This article was downloaded by: [New York University] On: 17 October 2014, At: 21:10 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Clinical and Experimental Neuropsychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ncen19
Behavioral assessment of social competence following severe head injury a
Nigel V. Marsh & Robert G. Knight a
b
University of Waikato , Hamilton, New Zealand
b
University of Otago , Dunedin, New Zealand Published online: 04 Jan 2008.
To cite this article: Nigel V. Marsh & Robert G. Knight (1991) Behavioral assessment of social competence following severe head injury, Journal of Clinical and Experimental Neuropsychology, 13:5, 729-740, DOI: 10.1080/01688639108401086 To link to this article: http://dx.doi.org/10.1080/01688639108401086
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly
Downloaded by [New York University] at 21:10 17 October 2014
forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Clinical and Experimental Neuropsychology 1991, Vol. 13, NO. 5, pp. 729-740
0168-8634/9 1/1305-0729$3.00 0 Swets t Zeitlinger
Behavioral Assessment of Social Competence Following Severe Head Injury* Nigel V. Marsh University of Waikato, Hamilton, New Zealand
Downloaded by [New York University] at 21:10 17 October 2014
and Robert G. Knight University of Otago, Dunedin, New Zealand
ABSTRACT Eighteen community-dwelling adults who had suffered a very severe closed-head injury more than 18 months previously and required long-term rehabilitative support were compared with a closely matched control group on a number of behavioral measures of skill during social interaction. Results showed that during social interactions the head-injured patients exhibited impaired communication skills. They appeared disinterested, and their speech was characterized as lacking in fluency and clarity due to their difficulty in finding appropriate words, use of inappropriate expressions and inability to express ideas clearly. Attempts to fiid a relationship between the patients’ cognitive deficits and their impaired communication skills were unsuccessful. It is suggested that the often reported poor social adjustment of some head-injured patients is in part related to their inappropriate behavior during social interactions. This is particularly manifest in their poor language skills and speech delivery style.
It is well established that recovery from severe closed-head injury (CHI) is highly variable, For many patients, return to premorbid levels of functioning m a y b e relatively complete, however, for a small group of such patients there are lasting and disabling cognitive and psychosocial sequelae (Dodwell, 1988).Changes i n the social behavior and personality of C H I patients are often particularly distressing, not only for the patients themselves, but also for their families and caregivers (Brooks, Campsie, S y m i n g o n , Beattie, & McKinlay, 1986;Rosenbaum
* The authors wish to thank Bernadette Moroney, who served as an interactor, and Susan Cowie and Katrina Falconer, who served as raters. This research was funded in part by a grant from the University of Otago Research Committee. Requests for reprints and all correspondence should be addressed to: Nigel V. Marsh Ph.D., Department of Psychology, University of Waikato, Private Bag 3105, Hamilton, New Zealand. Accepted for publication: December 20, 1990.
Downloaded by [New York University] at 21:10 17 October 2014
730
NIGEL V .MARSH AND ROBERT G . KNIGHT
& Najenson, 1976). At the present time, a precise description of the social and behavioral deficits of poor outcome CHI patients is largely unavailable. There have recently been calls for a merging of behavioral technology and the practice of clinical neuropsychology (Marshall & Newcombe, 1984; Sunderland, 1990; Wilson, 1987). and a small number of studies have reported the application of behavioral techniques to the remediation of problem behaviors in head-injured patients (Eames & Wood, 1985; Horton & Howe, 1981; Johnson & Newton, 1987; Lewis, Nelson, Nelson, & Reusink, 1988; Schloss, Thompson, Gajar, & Schloss 1985; Turner, Hersen, & Bellack, 1978). However, reports of the use of behavioral observation to assess the social interaction skills of CHI patients are noticably lacking in the literature. An exception to this is the study by Newton and Johnson (1985), which described the social adjustment of 11 severely headinjured patients. As part of their assessment procedure the patients were videotaped during a 5-min conversation with a stranger. The performance of each patient was rated by two observers on a number of molar scales measuring aspects of verbal and nonverbal behavior. The head-injured patients were rated as significantly less socially skilled than the control subjects. Although Newton and Johnson’s (1985) findings are of value, there are a number of problems associated with the sole use of either a molar or molecular analysis of observational data (Bellack, 1983; Curran, Farrell, & Grunberger, 1984). As a comprise between molar and molecular systems, Wallander, Conger, and Conger (1985), proposed an intermediate level assessment system called the Behaviorally Referenced Rating System of Intermediate Social Skills (BRISS). This system provides a series of qualitative rating scales for the specific behavioral components of heterosocial skill that have potential practical value in the assessment of social interaction in CHI patients. The present report describes research conducted as part of a larger study on the long-term psychosocial functioning of a group of very severely injured CHI patients (Marsh, Knight, & Godfrey, 1990). Our aim was to investigate the cognitive, emotional, and social functioning of those very severely injured CHI patients, who remain in need of supportive care several years postinjury, in order to identify more precisely the factors that determine psychosocial reintergration into life in the community. In the present report we describe an analysis of the social interaction data, using the revised BRISS system (Farrell, Rabinowitz, Wallander, & Curran, 1985), which permitted an informative and detailed view of the patients’ deficits in social behavior. We also investigated the relationship between the patients’ cognitive performance and their social skill deficits.
METHOD Subjects
The CHI group comprised all the male, community-dwelling, former patients of the neurosurgery unit of Dunedin Hospital living in the greater Otago area, who had sustained a very severe CHI, (i.e., posttraumatic amnesia, PTA. greater than 7 days; Russell & Smith,
731
Downloaded by [New York University] at 21:10 17 October 2014
SOCIAL COMPETENCE
1961). more than 18 months previously ( M =70.17 months, SD = 42.15, range = 20-146), and who were still in contact with the hospital's social and rehabilitation services. The nature of this contact varied from weekly family sessions to monthly support group meetings. The rehabilitation process involved primarily counselling support for the patient and caregivers, and some vocational assessment and assistance. No cognitive retraining or formal social skills exercises were involved. Of the 27 patients tested, the results from nine were discarded for various reasons including incomplete hospital records of the length of PTA, evidence from hospital records of PTA less than 7 days, or because the etiology of the patient's disorder proved to be complicated by factors other than CHI (e.g., subsequent infection or concurrent penetrating wounds). The CHI'S of 14 patients had resulted from motor vehicle accidents, 2 from sports accidents, 1 from an industrial accident, and 1 from an accident in the home. Five patients had a PTA of between 7 and 28 days (very severe injury), and the remaining 13 had PTA's of greater than 28 days (extremely severe injury). Fourteen of the CHI patients were single, 3 were married, and 1 was separateddivorced. Ten were unemployed and eight were in full-time paid employment. Premorbid IQ was estimated using the National Adult Reading Test (NART; Nelson, 1982). This test requires the subject to read a list of 50 words with irregular pronunciation and an estimate of WAIS IQ (Wechsler, 1955), is derived from the number of errors. The assumption underlying this measure is that reading is a skill unlikely to be impaired in nonaphasic brain-injured or dementing subjects. All CHI patients were found to perform within normal limits on a shortened version of the Minnesota Differential Diagnosis of Aphasia Test (Powell, Bailey, & Clark, 1980). A matched group of 27 male, normal control (NC) subjects were also tested. The NC group were either friends/relatives of the CHI patients or volunteer process workers from a local factory. From this group, a total of 18 NC subjects were selected who had no history of CHI or other neurological disorder, and who best matched the CHI sample on the variables of age, years of education, and premorbid IQ. Thirteen of the NC subjects were married, and the remaining five were single. Fourteen were in paid employment, three were unemployed, and one was a student. There were no significant differences between the two groups on the matching variables of age, r (34) = 0.50, years of education, r (34) = -0.85, and NART estimated premorbid IQ, r (34) = -1.26. The data on these matching variables are presented in Table 1. Measures
Both the CHI patients and the NC subjects completed the same series of interviews, cognitive tests, self-report questionnaires, and videotaped naturalistic assessment procedures. Results from three of the videotaped social interaction tasks are reported here. The results
Table 1 . Matching variables of age, years of education, and premorbid IQ, for the CHI patient and NC groups.
CHI Age Education NART IQ
NC
M
SD
Range
M
30.44 11.17 103.06
10.47 1.30 8.37
18-54 9-13 91-124
28.78 11.50 106.28
SD
Range
9.47 1.04 6.86
18-56 10-14 96-116
Note: CHI = closed-head injury; NC = normal control; NART = National Adult Reading Test.
732
NlGEL V . MARSH AND ROBERT G . KNIGHT
Downloaded by [New York University] at 21:10 17 October 2014
from the cognitive tests, and self-report questionnaires have been reported in detail elsewhere (Marsh et al., 1990). Briefly, compared to NC subjects, the CHI patients were found to have impaired intellectual, information processing, and memory abilities. CHI patients were also less socially adjusted than NC subjects. interaction with significant other: Each CHI and NC subject nominated a “significant other”, defined as someone who knew the subject well, preferably resided with them, and in the case of the CHI patients had known them prior to their injury. The subject and their significant other were presented with five problem-solving tasks which required them to interact and reach a consensus decision. The results from two of these five tasks consistently produced sufficient discussion between the subject and their significant other to allow detailed ratings of the interaction to be made. One task was the “picture” situation where subjects were presented with reproductions of eight different paintings. They were instructed: “Now that you have chosen the wallpaper and carpet (previous task), I want you to choose the picture which you think would look best hanging in this room. You can only choose one picture, so you have to agree together which one it is going to be.” The other task was the “raffle” interaction in which subjects were presented with a list of 10 raffle prizes of equal monetary value. They were instructed: “Once again (as in a previous task), I want you to imagine that you have both gone halves in a raffle ticket which has won. I have here a list of prizes and you must choose together which one item you would take as your prize.” Interaction with opposite-sex stranger: This was conducted in the guise of a social break in the questionnaire administration. The subjects were instructed that the experimenter would be interviewing the significant other while the subject had a cup of tedcoffee bought into them by an assistant. The assistant, an experimental confederate, was instructed to introduce herself by her first name, to place the drinks on the table, take a seat, and say “How has everything been going this morning?” She was then to remain in the room for 10 minutes and converse with the subject. No other specific cues or prompts were used. The confederate was not informed of the subjects’ diagnostic status. A preliminary analysis of the subjects’ behavior in this situation has been reported elsewhere (Godfrey, Knight, Marsh, Moroney, & Bishara, 1989). It was found that molar ratings of social skill discriminated between the two groups, with the CHI patients performing significantly more poorly than the NC group.
Ratings Ratings were completed by two clinical psychologists. Raters were blind to group assignment but some CHI patients could be identified on the basis of physical handicap or content of speech. Raters were trained for approximately 24 hours to a criterion of interrater correlation greater than 0.70 on all scales, using a series of practice tapes, prior to undertaking the ratings. Ratings were completed using scales from the revised BRISS. The revised BRISS consists of 10 separate seven-point Likert-type rating scales with anchor points of I (very inappropriate), 4 (normal), and 7 (very appropriate), and behavioral referents distributed across the scale. Four of these scales assess nonverbal and six (Language, Speech Delivery, Conversation Structure, Conversation Content, Personal Conversational Style, and Partner-Directed Behavior) assess verbal component behaviors of social skill. A full description of this measure is available in Farrell et al. (1985). The nonverbal scales were not employed in this study because the camera angle and tape resolution prevented accurate assessment of these aspects of behavior. Rating Procedure During the ratings of the videotapes, CHI and NC subjects were presented in a random order. For the interactions with the significant others, raters viewed the first minute of
SOCIAL COMPETENCE
733
Downloaded by [New York University] at 21:10 17 October 2014
each interaction and then made independent ratings on the six verbal scales of the revised BRISS, they then viewed the next minute, and again completed the six ratings. The same procedure was followed in rating the opposite-sex stranger interaction, except that in this case, the first four minutes of the interaction were rated. Data Analysis Analyses of variance (ANOVA’s) were conducted as described below using the SAS GLM subprogram. As six subjects during the “picture” task and seven subjects during the “raffle” task completed their interactions with their significant other in less than two minutes, estimates of the missing ratings for the second minute were made by use of the BMDP AM subprogram, and these were used when group comparisons were undertaken using the SAS routine. Given the increased probability of Type I errors occurring because of multiple hypothesis testing. some adjustment to alpha levels was necessary. In this case the significance of families of hypotheses from each social interaction were assessed using a revision of the Bonferroni inequality proposed by Holm (1979). This method is demonstrably more powerful than the standard Bonferroni procedure (Holland & Copenhaver, 1988). Where relevant, exact probabilities have been reported below to allow the use of alternative Bonferroni procedures by other workers.
RESULTS
Rater Reliability Reliability of the rating procedures was estimated using a generalizability analysis (Cronbach. Gleser, Nanda, & Rajaratnam, 1972), for the combined CHI and NC samples. A detailed discussion of the application of generalizability theory is available in Farrell, Mariotto, Conger, Curran, and Wallander (1979). Full sample generalizability coefficients were obtained for the two raters on the revised BRISS scales for the two tasks where the subjects’ interacted with their significant other. These reliability estimates were calculated for three universes of generalization: Raters, Occasions, and Raters by Occasions. Rater reliability tended to be high, ranging from 0.53 to 0.92 (median = 0.85). Ratings tended to be constant across occasions with generally high coefficients being obtained for this factor (range = 0.60 - 0.91, median = 0.78). Again, the generalizability coefficients indicated a satisfactory level of reliability. The data from those subjects who completed their interaction in less than two minutes were excluded from the calculation of these generalizability coefficients. In a similar manner, full sample generalizability coefficients were calculated for the ratings of the subjects’ interactions with an opposite-sex stranger. Rater reliability estimates ranged from 0.75 to 0.93 with a median of 0.87, an acceptable level of reliability. Again, ratings were also constant across occasions (range = 0.75 - 0.95, median = 0.84).
BRISS ratings As described above, the subjects’ performance during the first two minutes of both the “picture” and “raffle” interactions were rated on the six verbal scales of the revised BRISS. The mean ratings of the two groups averaged across both
NIGEL V . MARSH AND ROBERT G . KNIGHT
Downloaded by [New York University] at 21:10 17 October 2014
734
raters, are presented in Table 2. Data from the two interactions were analyzed separately. For the “raffle” task a 2 x 2 (Groups, G x Time, T) ANOVA with repeated measures on the second factor was computed for each BRISS scale. The hypotheses tested were that there would be between group differences on the BRISS scales, reflecting the better performance of the NC group. Preliminary inspection of the ANOVA results revealed that none of the T x G interactions were significant at the 0.05 level. Accordingly, it was decided to proceed with testing the hypothesis by considering the F tests for the G main effects only, and computing Bonferroni inequalities using Holm’s (1979) procedure. This resulted in an alpha value of 0.01 defining the critical range of the F for these main effects. There were significant differences on two scales, the Language scale, F (1,34)=8.24,~=0.007, andtheSpeechDeliveryscale, F(1,34)=9.39,p=0.0043. On both scales, the ratings of the CHI group indicated greater impairment than those of the controls. An equivalent analysis was conducted on the “picture” data. The Bonferroni procedure was applied in the same manner to the G main effect F values, there being no G x T interactions significant at the 0.05 level. There were no significant group differences at the 0.0083 level of alpha. On three scales, Language, F
Table 2. Means and standard deviations, averaged across both raters. obtained by CHI and NC groups on the BRISS rating scales for the “picture” and “raffle” tasks. Raffle Task
Picture Task Time 1 Scale
M
SD
Language CHI 4.17 0.71 NC 4.58 0.60 Speech Delivery 3.44 0.94 CHI NC 4.08 0.88 Conversation Structure CHI 3.33 1.48 NC 4.19 0.97 Conversation Content 3.22 1.39 CHI NC 4.08 0.90 Personal Conversational Style CHI 3.17 1.34 NC 3.89 0.76 Partner-Directed Behavior 2.94 0.86 CHI NC 3.22 0.79
Time 2
M
SD
Time 1
M
SD
Time 2
M
SD
4.39 0.58 4.72 0.35
4.44 0.57 4.86 0.34
4.56 4.81
0.38 0.35
3.39 0.85 4.14 0.82
3.83 0.97 4.56 0.42
3.67 4.31
0.79 0.52
3.94 0.94 4.41 0.62
3.75 4.25
1.22 1.15
4.06 4.42
0.78 0.77
3.92 0.99 4.28 0.77
3.58 4.22
1.22 1.06
3.81 4.17
0.88 0.82
3.64 0.66 3.89 0.63
3.56 -1.03 3.86 0.95
3.83 3.86
0.62 0.56
3.06 0.68 3.31 0.60
3.11 0.83 3.44 0.75
3.28 3.53
0.69 0.50
735
Downloaded by [New York University] at 21:10 17 October 2014
SOCIAL COMPETENCE
(1,341 = 4.36, p = 0.0444, Speech delivery, F (1,34) = 6.37, p = 0.0164, and Conversation Structure, F (1,34) = 4.67, p = 0.0378, the G main effects approached significance. These trends are of note since they are consistent with results from the “raffle” task. The two raters also made ratings of the subjects’ performance on the six verbal scales of the revised BRISS for each of the first four minutes of the interaction with the opposite-sex stranger. Mean ratings obtained by both groups on this task, averaged across both raters, are presented in Table 3. A 2 x 4 (Groups, G x Time, T) ANOVA with repeated measures on the last factor was computed for each of the six scales. Of the 18 F tests computed only three were significant using the revised Bonferroni procedure. These were the G main effects for Language, F (1,34) = 19.37, p = 0.0001, and Speech Delivery, F (1,34) = 14.75, p = 0.0005; and the G x T interaction for Partner-Directed Behavior, F (3,102) = 5.86, p = 0.001. As in the previous analyses, consistent and significant differences emerged on the Language and Speech Delivery scales. The CHI group were also rated as significantly less appropriate on the scale assessing partner-directed behavior, and this emerged more strongly as the interaction progressed.
Table 3. Means and standard deviations, averaged across both raters, obtained by the CHI and NC groups on the BRISS rating scales for the “interaction with an opposite-sex stranger” task. Time 1 Scale
M
Time 2
Time 3
Time 4
SD
M
SD
M
SD
M
SD
0.69 0.38
4.42 5.03
0.65 0.44
4.42 4.94
0.65 0.51
4.31 5.08
0.71 0.26
1.05 0.86
3.75 4.81
1.10 0.73
3.69 4.81
1.05 0.57
3.78 4.94
1.24 0.59
4.44 4.86
0.71 0.72
4.17 4.64
0.87 0.61
4.42 4.50
0.75 0.69
4.08 4.64
0.69 0.66
3.94 4.64
1.01 0.56
4.03 4.67
1.13 0.64
0.93
3.97 4.50
0.81 0.87
3.83 4.25
0.75 0.73
3.94 4.22
0.68 0.65
Partner-Directed Behavior 3.67 1.26 CHI NC 3.31 0.86
3.06 4.00
1.01 0.87
3.17 3.75
1.14 0.86
2.97 3.72
1.23 0.81
Language 4.31 CHI NC 4.86 Speech Delivery CHI 3.72 NC
4.12
Conversation Structure CHI
4.53
0.80
NC 4.44 0.78 Conversation Content 4.06 0.91 CHI NC
4.39
0.81
Personal Conversational Style 4.17 0.62 CHI NC
4.25
Downloaded by [New York University] at 21:10 17 October 2014
736
NIGEL V .MARSH AND ROBERT G.KNIGHT
Relationship between Cognitive Performance and Social Skill As reported previously in Marsh et al. (1990), the cognitive performance of these patients was impaired relative to the NC group. These cognitive deficits were evident in the patients’ performance on the Standard Progressive Matrices test (Raven, Court, & Raven, 1977), the Selective Reminding Test (Buschke, 1973), and a task measuring speed of information processing for visual stimuli (Pashler & Badigo, 1985). For the 18 CHI patients, correlations between the BRISS ratings on the Language and Speech Delivery scales from the opposite-sex stranger interaction, and their performance on the Standard Progressive Matrices, Selective Reminding Test, and visual search task were calculated. To control for Type I errors, the significanceof the obtainedp-values was determined using amultistage Bonferroni procedure (Larzelere & Mulaik, 1977). None of these correlations reached significance .
DISCUSSION The objective of the research described in the present report is to identify barriers to the successful reintergration of very severe CHI patients into the community. To this end we have focussed on a specific subgroup of CHI patients: Those who require social support and rehabilitation services 18 or more months postinjury, and for whom most of the spontaneous recovery following CHI has already occurred (Bond, 1979). These patients are an important group to study in order to develop an understanding of the psychosocial consequences of CHI, because, for a variety of possible reasons, their return to an independent life in the community is less than complete. It is these patients or their families and caregivers, who are most likely to present to clinical neuropsychologistsfor assistance in the institution of appropriate management programs. One of the most significant impediments to successful readjustment to the community may be changes in the patients’ level of social skill (e.g., Godfrey et al., 1989; Johnson & Newton, 1987). In a previous report the finding that the present group of patients showed reduced molar social skill levels was detailed (Godfrey et al., 1989). The aim of this study was to examine the social interaction performance of the CHI patients in a greater variety of settings and more closely, using the revised BRISS. This was done in order to characterize these skill deficits with more precision. The most striking result to emerge from the BRISS ratings was the finding that the CHI patients were less appropriate in their use of language and their speech delivery than the comparison group. These differences were significant for the “raffle” task and opposite-sex stranger interaction, and approached significance for the “picture” task. The Language scale assessed the technical quality of the subject’s expressions, largely independent of the content of these expressions. Raters take into account the quality and appropriateness of vocabulary, ease of word finding, and ability to express ideas clearly, effectively, and in an
Downloaded by [New York University] at 21:10 17 October 2014
SOCIAL COMPETENCE
737
understandable fashion. The Speech Delivery scale refers to the sound of the subject’s speech or utterances, largely independent of the content of the speech, and is defined as consisting of the four components: Speech fluency, rate of speech, voice quality, and speech mannerism. The poor performance on both these scales indicates that the verbal behavior of the CHI patients was characterized by difficulty finding appropriate words, use of inappropriate expressions, and an inability to express ideas clearly. These problems were reflected in a speech style that lacked fluency, continuity, and clarity. In addition to these language deficits, there was also evidence for deficits in the patients’ pragmatic language behaviors (Wiig, Alexander, & Secord, 1988). Such behaviors include the use of appropriate reciprocal acts, which allow discourse to proceed smoothly. During the opposite-sex stranger interaction, the CHI patients were rated as more deficient on the Partner-Directed Behavior scale. This scale refers to behavior that facilitates the involvement of the partner in the conversation and is defined as consisting of three aspects: use of reinforcers, self-centered behavior, and partner involvement behavior. The performance of the CHI patients on this scale during the interaction with the opposite-sex stranger suggested that they failed to attend to, or show interest in their partners, and were generally more passive. As a result, they would not be reinforcing or stimulating people to converse with. It is also of note that there were no between-group differences on the ratings of three of the BRISS scales: Conversation structure, Conversation content, and Personal conversational style. Conversation structure requires the rater to evaluate conversational fluency (e.g., use of questions, extent of gaps in the flow of conversation) and the appropriateness of topic change. This component explicitly excludes difficulty in speech production, such as pauses within expressions or hesitation in delivery. Conversation content refers to the interest, substance, and appropriateness of the topics bought up by the subject. The general communication pattern of the subject, with a focus on the appropriate use of self-disclosure. humour, and social manners, is evaluated under the heading of personal conversational style. As is apparent in Tables 2 and 3, means of the CHI and NC subjects were equivalent across the time periods sampled. It is well known that traumatic head injury may result in reduced linguistic competence, particularly in the period immediately following the injury (e.g., Ehrlich, 1988; Sarno, 1988; Wiig et al., 1988). Such language deficits extend to include deficits in the pragmatic behaviors associated with maintaining an appropriate conversation (Holland, 1982). The results from the BRISS analysis suggest that underlying judgements of reduced social skill in head-injured patients may be qualitative differences in speech. The conversation of the CHI patients in this study was marked by a technical deficiency in language use, and further, their speech tended to sound different to observers. In contrast the content, style, and structure of their conversation was not noticeably dysfunctional. How they spoke, rather than what they said, was distinctly different to the raters. In addition, there was evidence in the interaction with a stranger, that the CHI
Downloaded by [New York University] at 21:10 17 October 2014
738
NIGEL V . MARSH AND ROBERT G . KNIGHT
patients had difficulty proving verbal indications of interest in the progress of the conversation It is not possible to do more than speculate on the underlying cognitive deficits that might be responsible for the language and pragmatic deficits that distinguished the CHI patients from the NC subjects. In this regard, results from the neuropsychological testing of our subjects were not helpful. Severity of memory impairment, current IQ, and performance on a complex visual search task did not predict either global skill (Godfrey et al., 1989) nor BRISS ratings. It must be acknowledged, however, that the tests used did not directly assess either aphasia nor frontal lobe functioning. One possible explanation for the language-related deficits displayed by our CHI patients is that they are evidence of a subclinical aphasia (Sarno, 1988). An alternative hypothesis is that the deficits in language use apparent in the conversation of the CHI patients were secondary to a disruption in the executive control system responsible for sequencing and organizing cognitive activities (Glosser & Goodlass, 1990; Hagen, 1982; Stuss & Benson, 1986). A dysfunction of the central executive processes is presumed to be a consequence of frontal or prefrontal lesions, but may also result from diffuse damage, because of the density of the interconnections between the frontal area and most other cerebral functional systems (Glosser & Goodlass, 1990). Diffuse or focal frontal lesions in CHI patients may lead to disruption of the executive control of language production. A similar explanation has been advanced to account for language disturbance in patients with Alzheimer’s disease, who also have a diffuse pattern of cortical damage (Murdoch, Chenery, Wilks, & Boyle, 1987). Demented patients have particular difficulty with tasks where language use is dependent on cognition, suggesting that the aphasia seen in Alzheimer’s disease may differ in quality to that resulting from the more focal lesions in other neurological conditions. A major obstacle to understanding language use in CHI, as in dementia, is the lack of a good theoretical basis for understanding the relationship between higher order cognitive processes and language use. The important implications of this study, however, are for understanding why some CHI patients have problems in achieving successful reintergration into their communities: Their speech is lacking in fluency and clarity, and they often fail to respond appropriately in conversations. This suggests that rehabilitation efforts directed towards enhancing the social interaction difficulties of poor outcome, community-dwelling, chronic CHI patients should focus on their speech delivery and language skills. There has been some success in executive strategy training for memory problems following CHI (e.g., Lawson & Rice, 1989). Similar rehabilitation efforts focused on the language problems of CHI patients could also be successful. Such success may have an influence in reducing the patients’ social isolation and improving their overall social adjustment.
SOCIAL COMPETENCE
739
Downloaded by [New York University] at 21:10 17 October 2014
REFERENCES Bellack, A.S. (1983). Recurrent problems in the behavioral assessment of social skill. Behaviour Research and Therapy, 21, 29-41. Bond, M.R. (1979). The stages of recovery from severe head injury with special reference to late outcome. International Rehabilitation Medicine, 1 , 155-159. Brooks, N., Campsie, L., Symington, C., Beattie, A., & McKinlay, W. (1986). The five year outcome of severe blunt head injury: A relative's view. Journal of Neurology, Neurosurgery, and Psychiatry, 49, 764-170. Buschke. H. (1973). Selective reminding analysis of memory and learning. Journal of Verbal Learning and Verbal Behaviour, 1 2 , 72-74. Cronbach, L.J.. Gleser, G.C., Nanda, H., & Rajaratnam, N. (1972). The dependability of behavioral measurements: Theory of generalizabilityfor scores andprofiles. New York: Wiley. Curran. J.P., Farrell, A.D., & Grunberger, A.J. (1984). Social skills: A critique and a rapprochement. In P. Trower (Ed), Radical approaches to social skills training (pp. 1646). London: Croom Helm. Dodwell, D. (1 988). The heterogeneity of social outcome following head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 51, 833-838. Eames, P., & Wood, R. (1985). Rehabilitation after severe brain injury: A follow-up study of a behaviour modification approach. Journal of Neurology, Neurosurgery, and Psychiatry, 48, 613-619. Ehrlich, J.S. (1 988). Selective characteristics of narrative discourse in head-injured and normal adults. Journal of Communication Disorders, 21, 1-9. Farrell, A.D., Mariotto, M.J.. Conger, A.J., Curran, J.P., & Wallander, J.L. (1979). Selfratings and judges' ratings of heterosexual social anxiety and skill: A generalizability study. Journal of Consulting and Clinical Psychology, 47, 164-175. Farrell, A.D., Rabinowitz, J.A., Wallander, J.L., & Curran,J.P. (1985). An evaluation of two formats for the intermediate-level assessment of social skills. Behavioral Assessment, 7 , 155-171. Glosser, G., & Goodlass, H. (1990). Disorders in executive control functions among aphasic and other brain-damaged patients. Journal of Clinical and Experimental Neuropsychology, 12, 485-501. Godfrey. H.P.D., Knight, R.G., Marsh,N.V., Moroney. B., & Bishara, S.N. (1989). Social interaction and speed of information processing following very severe head-injury. Psychological Medicine, 19, 175-182. Hagen, C. (1982). Language-cognitive disorganization following closed-head injury: A conceptualization. In L.E. Trexler (Ed.), Cognitive rehabilitation: Concepruafization and intervention (pp. 131-152). New York: Plenum Press. Holland, A.L. (1982). When is aphasia aphasia?: The problem of closed-head injury. In R.H. Brookshire (Ed.), Clinical aphasiology: Conferenceproceedings, 1982 (pp. 345349). Minneapolis: BRK Publishers. Holland, B.S., & Copenhaver, M.D. (1988). Improved Bonferroni-type multiple testing procedures. Psychological Bulletin, 104, 145-149. Holm, S . (1979). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6 , 65-70. Horton, A.M., & Howe, N.R. (1981). Behavioral treatment of the traumatically braininjured: A case study. Perceptual and Motor Skills, 53, 349-350. Johnson, D.A., & Newton, A. (1 987). Social adjustment and interaction after severe head injury: 11. Rationale and bases for intervention. British Journal ofClinical Psychology, 26,289-298. Larzelere, R.E., & Mulaik, S.A. (1977). Single-sample tests for many correlations. Psychological Bulletin, 84, 557-569.
Downloaded by [New York University] at 21:10 17 October 2014
740
NIGEL V . MARSH AND ROBERT G . KNIGHT
Lawson, M.J., & Rice, D.N. (1989). Effects of training in use of executive strategies on a verbal memory problem resulting from closed-head injury. Journal of Clinical and Experimental Neuropsychology, I I , 842-854. Lewis, F.D.. Nelson, I.. Nelson, C., Reusink, P. (1988). Effects of three feedback contingencies on the socially inappropriate talk of a brain-injured adult. Behavior Therapy, 19, 203-21 1. Marsh, N.V., Knight, R.G., & Godfrey, H.P.D. (1990). Long-term psychosocial adjustment following very severe closed-head injury. Neuropsychology, 4 , 13-27. Marshall, J.C., & Newcombe. F. (1984). Putative problems and pure progress in neuropsychological single-case studies. Journal of Clinical Neuropsychology, 6.65-70. Murdoch, B.E., Chenery, H.J., Wilks, V., & Boyle, R.S. (1987). Language disorders in dementia of the Alzheimer type. Brain and Language, 31, 122-137. Nelson, H.E. (1982). National Adult Reading Test (NART): Test Manual. Windsor, Berkshire: NFER-Nelson. Newton, A., & Johnson, J.A. (1985). Social adjustment and interaction after severe head injury. British Journal of Clinical Psychology, 24, 225-234. Pashler, H., & Badigo, P.C. (1985). Visual attention and stimulus identification. Journal of Experimental Psychology: Human Perception and Performance, 1I , 105- 121. Powell, G.E.. Bailey, S., & Clark, E. (1980). A very short version of the Minnesota Aphasia Test. British Journal of Social and Clinical Psychology, 19, 189-194. Raven, J.C., Court, J.H., & Raven, J. (1977). Manual for Raven's progressive matrices and vocabulary scales. London: H . K . Lewis. Rosenbaum, M., & Najenson, T. (1976). Changes in life patterns and symptoms of low mood as reported by wives of severely brain-injured soliders. Journal of Consultingand Clinical Psychology, 44, 881-888. Russell, W.R., & Smith, A. (1961). Post-traumatic amnesia in closed-head injury. Archives of Neurology, 5 , 4-17. Samo, M.T. (1988). Language and speech defects. ScandinavianJournal of Rehabilitation Medicine, (Suppl. 17), 55-64. Schloss, P.J., Thompson, C.K., Gajar, A.H., & Schloss, C.N. (1985). Influence of selfmonitoring on heterosexual conversational behaviors of head trauma youth. Applied Research in Mental Retardation, 6 , 269-282. Stuss, D.T., & Benson, D.F. (1986). The frontal lobes. New York: Raven Press. Sunderland, A. (1990). Single-case experiments in neurological rehabilitation. Clinical Rehabilitation, 4 , 181-192. Turner, S.M., Hersen, M. & Bellack, AS. (1978). Social skills training to teach prosocial behaviors in an organically impaired and retarded patient. Journal of Behavior Therapy and Experimental Psychiatry, 9, 253-258. Wallander, J.L., Conger, A.J., & Conger, J.C. (1985). Development and evaluation of a behaviorally referenced rating system for heterosocial skills. Behavioral Assessment, 7, 137-153. Wechsler, D. (1955). Manual for the Wechsler Adult Intelligence Scale. New York: The Psychological Corporation. Wiig. E.H., Alexander, E.W., & Secord, W. (1988). Linguistic competence and level of cognitive functioning in adults with traumatic closed-head injury. In H.A. Whitaker (Ed.), Neuropsychological studies of nonfocal brain damage: Dementia and trauma (pp. 186-201). New York Springer-Verlag. Wilson, B. (1 987). Single-case experimental designs in neuropsychological rehabilitation. Journal of Clinical and Experimental Neuropsychology, 9, 527-544.
Journal of Clinical and Experimental Neuropsychology Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ncen19
Behavioral assessment of social competence following severe head injury a
Nigel V. Marsh & Robert G. Knight a
b
University of Waikato , Hamilton, New Zealand
b
University of Otago , Dunedin, New Zealand Published online: 04 Jan 2008.
To cite this article: Nigel V. Marsh & Robert G. Knight (1991) Behavioral assessment of social competence following severe head injury, Journal of Clinical and Experimental Neuropsychology, 13:5, 729-740, DOI: 10.1080/01688639108401086 To link to this article: http://dx.doi.org/10.1080/01688639108401086
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly
Downloaded by [New York University] at 21:10 17 October 2014
forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Clinical and Experimental Neuropsychology 1991, Vol. 13, NO. 5, pp. 729-740
0168-8634/9 1/1305-0729$3.00 0 Swets t Zeitlinger
Behavioral Assessment of Social Competence Following Severe Head Injury* Nigel V. Marsh University of Waikato, Hamilton, New Zealand
Downloaded by [New York University] at 21:10 17 October 2014
and Robert G. Knight University of Otago, Dunedin, New Zealand
ABSTRACT Eighteen community-dwelling adults who had suffered a very severe closed-head injury more than 18 months previously and required long-term rehabilitative support were compared with a closely matched control group on a number of behavioral measures of skill during social interaction. Results showed that during social interactions the head-injured patients exhibited impaired communication skills. They appeared disinterested, and their speech was characterized as lacking in fluency and clarity due to their difficulty in finding appropriate words, use of inappropriate expressions and inability to express ideas clearly. Attempts to fiid a relationship between the patients’ cognitive deficits and their impaired communication skills were unsuccessful. It is suggested that the often reported poor social adjustment of some head-injured patients is in part related to their inappropriate behavior during social interactions. This is particularly manifest in their poor language skills and speech delivery style.
It is well established that recovery from severe closed-head injury (CHI) is highly variable, For many patients, return to premorbid levels of functioning m a y b e relatively complete, however, for a small group of such patients there are lasting and disabling cognitive and psychosocial sequelae (Dodwell, 1988).Changes i n the social behavior and personality of C H I patients are often particularly distressing, not only for the patients themselves, but also for their families and caregivers (Brooks, Campsie, S y m i n g o n , Beattie, & McKinlay, 1986;Rosenbaum
* The authors wish to thank Bernadette Moroney, who served as an interactor, and Susan Cowie and Katrina Falconer, who served as raters. This research was funded in part by a grant from the University of Otago Research Committee. Requests for reprints and all correspondence should be addressed to: Nigel V. Marsh Ph.D., Department of Psychology, University of Waikato, Private Bag 3105, Hamilton, New Zealand. Accepted for publication: December 20, 1990.
Downloaded by [New York University] at 21:10 17 October 2014
730
NIGEL V .MARSH AND ROBERT G . KNIGHT
& Najenson, 1976). At the present time, a precise description of the social and behavioral deficits of poor outcome CHI patients is largely unavailable. There have recently been calls for a merging of behavioral technology and the practice of clinical neuropsychology (Marshall & Newcombe, 1984; Sunderland, 1990; Wilson, 1987). and a small number of studies have reported the application of behavioral techniques to the remediation of problem behaviors in head-injured patients (Eames & Wood, 1985; Horton & Howe, 1981; Johnson & Newton, 1987; Lewis, Nelson, Nelson, & Reusink, 1988; Schloss, Thompson, Gajar, & Schloss 1985; Turner, Hersen, & Bellack, 1978). However, reports of the use of behavioral observation to assess the social interaction skills of CHI patients are noticably lacking in the literature. An exception to this is the study by Newton and Johnson (1985), which described the social adjustment of 11 severely headinjured patients. As part of their assessment procedure the patients were videotaped during a 5-min conversation with a stranger. The performance of each patient was rated by two observers on a number of molar scales measuring aspects of verbal and nonverbal behavior. The head-injured patients were rated as significantly less socially skilled than the control subjects. Although Newton and Johnson’s (1985) findings are of value, there are a number of problems associated with the sole use of either a molar or molecular analysis of observational data (Bellack, 1983; Curran, Farrell, & Grunberger, 1984). As a comprise between molar and molecular systems, Wallander, Conger, and Conger (1985), proposed an intermediate level assessment system called the Behaviorally Referenced Rating System of Intermediate Social Skills (BRISS). This system provides a series of qualitative rating scales for the specific behavioral components of heterosocial skill that have potential practical value in the assessment of social interaction in CHI patients. The present report describes research conducted as part of a larger study on the long-term psychosocial functioning of a group of very severely injured CHI patients (Marsh, Knight, & Godfrey, 1990). Our aim was to investigate the cognitive, emotional, and social functioning of those very severely injured CHI patients, who remain in need of supportive care several years postinjury, in order to identify more precisely the factors that determine psychosocial reintergration into life in the community. In the present report we describe an analysis of the social interaction data, using the revised BRISS system (Farrell, Rabinowitz, Wallander, & Curran, 1985), which permitted an informative and detailed view of the patients’ deficits in social behavior. We also investigated the relationship between the patients’ cognitive performance and their social skill deficits.
METHOD Subjects
The CHI group comprised all the male, community-dwelling, former patients of the neurosurgery unit of Dunedin Hospital living in the greater Otago area, who had sustained a very severe CHI, (i.e., posttraumatic amnesia, PTA. greater than 7 days; Russell & Smith,
731
Downloaded by [New York University] at 21:10 17 October 2014
SOCIAL COMPETENCE
1961). more than 18 months previously ( M =70.17 months, SD = 42.15, range = 20-146), and who were still in contact with the hospital's social and rehabilitation services. The nature of this contact varied from weekly family sessions to monthly support group meetings. The rehabilitation process involved primarily counselling support for the patient and caregivers, and some vocational assessment and assistance. No cognitive retraining or formal social skills exercises were involved. Of the 27 patients tested, the results from nine were discarded for various reasons including incomplete hospital records of the length of PTA, evidence from hospital records of PTA less than 7 days, or because the etiology of the patient's disorder proved to be complicated by factors other than CHI (e.g., subsequent infection or concurrent penetrating wounds). The CHI'S of 14 patients had resulted from motor vehicle accidents, 2 from sports accidents, 1 from an industrial accident, and 1 from an accident in the home. Five patients had a PTA of between 7 and 28 days (very severe injury), and the remaining 13 had PTA's of greater than 28 days (extremely severe injury). Fourteen of the CHI patients were single, 3 were married, and 1 was separateddivorced. Ten were unemployed and eight were in full-time paid employment. Premorbid IQ was estimated using the National Adult Reading Test (NART; Nelson, 1982). This test requires the subject to read a list of 50 words with irregular pronunciation and an estimate of WAIS IQ (Wechsler, 1955), is derived from the number of errors. The assumption underlying this measure is that reading is a skill unlikely to be impaired in nonaphasic brain-injured or dementing subjects. All CHI patients were found to perform within normal limits on a shortened version of the Minnesota Differential Diagnosis of Aphasia Test (Powell, Bailey, & Clark, 1980). A matched group of 27 male, normal control (NC) subjects were also tested. The NC group were either friends/relatives of the CHI patients or volunteer process workers from a local factory. From this group, a total of 18 NC subjects were selected who had no history of CHI or other neurological disorder, and who best matched the CHI sample on the variables of age, years of education, and premorbid IQ. Thirteen of the NC subjects were married, and the remaining five were single. Fourteen were in paid employment, three were unemployed, and one was a student. There were no significant differences between the two groups on the matching variables of age, r (34) = 0.50, years of education, r (34) = -0.85, and NART estimated premorbid IQ, r (34) = -1.26. The data on these matching variables are presented in Table 1. Measures
Both the CHI patients and the NC subjects completed the same series of interviews, cognitive tests, self-report questionnaires, and videotaped naturalistic assessment procedures. Results from three of the videotaped social interaction tasks are reported here. The results
Table 1 . Matching variables of age, years of education, and premorbid IQ, for the CHI patient and NC groups.
CHI Age Education NART IQ
NC
M
SD
Range
M
30.44 11.17 103.06
10.47 1.30 8.37
18-54 9-13 91-124
28.78 11.50 106.28
SD
Range
9.47 1.04 6.86
18-56 10-14 96-116
Note: CHI = closed-head injury; NC = normal control; NART = National Adult Reading Test.
732
NlGEL V . MARSH AND ROBERT G . KNIGHT
Downloaded by [New York University] at 21:10 17 October 2014
from the cognitive tests, and self-report questionnaires have been reported in detail elsewhere (Marsh et al., 1990). Briefly, compared to NC subjects, the CHI patients were found to have impaired intellectual, information processing, and memory abilities. CHI patients were also less socially adjusted than NC subjects. interaction with significant other: Each CHI and NC subject nominated a “significant other”, defined as someone who knew the subject well, preferably resided with them, and in the case of the CHI patients had known them prior to their injury. The subject and their significant other were presented with five problem-solving tasks which required them to interact and reach a consensus decision. The results from two of these five tasks consistently produced sufficient discussion between the subject and their significant other to allow detailed ratings of the interaction to be made. One task was the “picture” situation where subjects were presented with reproductions of eight different paintings. They were instructed: “Now that you have chosen the wallpaper and carpet (previous task), I want you to choose the picture which you think would look best hanging in this room. You can only choose one picture, so you have to agree together which one it is going to be.” The other task was the “raffle” interaction in which subjects were presented with a list of 10 raffle prizes of equal monetary value. They were instructed: “Once again (as in a previous task), I want you to imagine that you have both gone halves in a raffle ticket which has won. I have here a list of prizes and you must choose together which one item you would take as your prize.” Interaction with opposite-sex stranger: This was conducted in the guise of a social break in the questionnaire administration. The subjects were instructed that the experimenter would be interviewing the significant other while the subject had a cup of tedcoffee bought into them by an assistant. The assistant, an experimental confederate, was instructed to introduce herself by her first name, to place the drinks on the table, take a seat, and say “How has everything been going this morning?” She was then to remain in the room for 10 minutes and converse with the subject. No other specific cues or prompts were used. The confederate was not informed of the subjects’ diagnostic status. A preliminary analysis of the subjects’ behavior in this situation has been reported elsewhere (Godfrey, Knight, Marsh, Moroney, & Bishara, 1989). It was found that molar ratings of social skill discriminated between the two groups, with the CHI patients performing significantly more poorly than the NC group.
Ratings Ratings were completed by two clinical psychologists. Raters were blind to group assignment but some CHI patients could be identified on the basis of physical handicap or content of speech. Raters were trained for approximately 24 hours to a criterion of interrater correlation greater than 0.70 on all scales, using a series of practice tapes, prior to undertaking the ratings. Ratings were completed using scales from the revised BRISS. The revised BRISS consists of 10 separate seven-point Likert-type rating scales with anchor points of I (very inappropriate), 4 (normal), and 7 (very appropriate), and behavioral referents distributed across the scale. Four of these scales assess nonverbal and six (Language, Speech Delivery, Conversation Structure, Conversation Content, Personal Conversational Style, and Partner-Directed Behavior) assess verbal component behaviors of social skill. A full description of this measure is available in Farrell et al. (1985). The nonverbal scales were not employed in this study because the camera angle and tape resolution prevented accurate assessment of these aspects of behavior. Rating Procedure During the ratings of the videotapes, CHI and NC subjects were presented in a random order. For the interactions with the significant others, raters viewed the first minute of
SOCIAL COMPETENCE
733
Downloaded by [New York University] at 21:10 17 October 2014
each interaction and then made independent ratings on the six verbal scales of the revised BRISS, they then viewed the next minute, and again completed the six ratings. The same procedure was followed in rating the opposite-sex stranger interaction, except that in this case, the first four minutes of the interaction were rated. Data Analysis Analyses of variance (ANOVA’s) were conducted as described below using the SAS GLM subprogram. As six subjects during the “picture” task and seven subjects during the “raffle” task completed their interactions with their significant other in less than two minutes, estimates of the missing ratings for the second minute were made by use of the BMDP AM subprogram, and these were used when group comparisons were undertaken using the SAS routine. Given the increased probability of Type I errors occurring because of multiple hypothesis testing. some adjustment to alpha levels was necessary. In this case the significance of families of hypotheses from each social interaction were assessed using a revision of the Bonferroni inequality proposed by Holm (1979). This method is demonstrably more powerful than the standard Bonferroni procedure (Holland & Copenhaver, 1988). Where relevant, exact probabilities have been reported below to allow the use of alternative Bonferroni procedures by other workers.
RESULTS
Rater Reliability Reliability of the rating procedures was estimated using a generalizability analysis (Cronbach. Gleser, Nanda, & Rajaratnam, 1972), for the combined CHI and NC samples. A detailed discussion of the application of generalizability theory is available in Farrell, Mariotto, Conger, Curran, and Wallander (1979). Full sample generalizability coefficients were obtained for the two raters on the revised BRISS scales for the two tasks where the subjects’ interacted with their significant other. These reliability estimates were calculated for three universes of generalization: Raters, Occasions, and Raters by Occasions. Rater reliability tended to be high, ranging from 0.53 to 0.92 (median = 0.85). Ratings tended to be constant across occasions with generally high coefficients being obtained for this factor (range = 0.60 - 0.91, median = 0.78). Again, the generalizability coefficients indicated a satisfactory level of reliability. The data from those subjects who completed their interaction in less than two minutes were excluded from the calculation of these generalizability coefficients. In a similar manner, full sample generalizability coefficients were calculated for the ratings of the subjects’ interactions with an opposite-sex stranger. Rater reliability estimates ranged from 0.75 to 0.93 with a median of 0.87, an acceptable level of reliability. Again, ratings were also constant across occasions (range = 0.75 - 0.95, median = 0.84).
BRISS ratings As described above, the subjects’ performance during the first two minutes of both the “picture” and “raffle” interactions were rated on the six verbal scales of the revised BRISS. The mean ratings of the two groups averaged across both
NIGEL V . MARSH AND ROBERT G . KNIGHT
Downloaded by [New York University] at 21:10 17 October 2014
734
raters, are presented in Table 2. Data from the two interactions were analyzed separately. For the “raffle” task a 2 x 2 (Groups, G x Time, T) ANOVA with repeated measures on the second factor was computed for each BRISS scale. The hypotheses tested were that there would be between group differences on the BRISS scales, reflecting the better performance of the NC group. Preliminary inspection of the ANOVA results revealed that none of the T x G interactions were significant at the 0.05 level. Accordingly, it was decided to proceed with testing the hypothesis by considering the F tests for the G main effects only, and computing Bonferroni inequalities using Holm’s (1979) procedure. This resulted in an alpha value of 0.01 defining the critical range of the F for these main effects. There were significant differences on two scales, the Language scale, F (1,34)=8.24,~=0.007, andtheSpeechDeliveryscale, F(1,34)=9.39,p=0.0043. On both scales, the ratings of the CHI group indicated greater impairment than those of the controls. An equivalent analysis was conducted on the “picture” data. The Bonferroni procedure was applied in the same manner to the G main effect F values, there being no G x T interactions significant at the 0.05 level. There were no significant group differences at the 0.0083 level of alpha. On three scales, Language, F
Table 2. Means and standard deviations, averaged across both raters. obtained by CHI and NC groups on the BRISS rating scales for the “picture” and “raffle” tasks. Raffle Task
Picture Task Time 1 Scale
M
SD
Language CHI 4.17 0.71 NC 4.58 0.60 Speech Delivery 3.44 0.94 CHI NC 4.08 0.88 Conversation Structure CHI 3.33 1.48 NC 4.19 0.97 Conversation Content 3.22 1.39 CHI NC 4.08 0.90 Personal Conversational Style CHI 3.17 1.34 NC 3.89 0.76 Partner-Directed Behavior 2.94 0.86 CHI NC 3.22 0.79
Time 2
M
SD
Time 1
M
SD
Time 2
M
SD
4.39 0.58 4.72 0.35
4.44 0.57 4.86 0.34
4.56 4.81
0.38 0.35
3.39 0.85 4.14 0.82
3.83 0.97 4.56 0.42
3.67 4.31
0.79 0.52
3.94 0.94 4.41 0.62
3.75 4.25
1.22 1.15
4.06 4.42
0.78 0.77
3.92 0.99 4.28 0.77
3.58 4.22
1.22 1.06
3.81 4.17
0.88 0.82
3.64 0.66 3.89 0.63
3.56 -1.03 3.86 0.95
3.83 3.86
0.62 0.56
3.06 0.68 3.31 0.60
3.11 0.83 3.44 0.75
3.28 3.53
0.69 0.50
735
Downloaded by [New York University] at 21:10 17 October 2014
SOCIAL COMPETENCE
(1,341 = 4.36, p = 0.0444, Speech delivery, F (1,34) = 6.37, p = 0.0164, and Conversation Structure, F (1,34) = 4.67, p = 0.0378, the G main effects approached significance. These trends are of note since they are consistent with results from the “raffle” task. The two raters also made ratings of the subjects’ performance on the six verbal scales of the revised BRISS for each of the first four minutes of the interaction with the opposite-sex stranger. Mean ratings obtained by both groups on this task, averaged across both raters, are presented in Table 3. A 2 x 4 (Groups, G x Time, T) ANOVA with repeated measures on the last factor was computed for each of the six scales. Of the 18 F tests computed only three were significant using the revised Bonferroni procedure. These were the G main effects for Language, F (1,34) = 19.37, p = 0.0001, and Speech Delivery, F (1,34) = 14.75, p = 0.0005; and the G x T interaction for Partner-Directed Behavior, F (3,102) = 5.86, p = 0.001. As in the previous analyses, consistent and significant differences emerged on the Language and Speech Delivery scales. The CHI group were also rated as significantly less appropriate on the scale assessing partner-directed behavior, and this emerged more strongly as the interaction progressed.
Table 3. Means and standard deviations, averaged across both raters, obtained by the CHI and NC groups on the BRISS rating scales for the “interaction with an opposite-sex stranger” task. Time 1 Scale
M
Time 2
Time 3
Time 4
SD
M
SD
M
SD
M
SD
0.69 0.38
4.42 5.03
0.65 0.44
4.42 4.94
0.65 0.51
4.31 5.08
0.71 0.26
1.05 0.86
3.75 4.81
1.10 0.73
3.69 4.81
1.05 0.57
3.78 4.94
1.24 0.59
4.44 4.86
0.71 0.72
4.17 4.64
0.87 0.61
4.42 4.50
0.75 0.69
4.08 4.64
0.69 0.66
3.94 4.64
1.01 0.56
4.03 4.67
1.13 0.64
0.93
3.97 4.50
0.81 0.87
3.83 4.25
0.75 0.73
3.94 4.22
0.68 0.65
Partner-Directed Behavior 3.67 1.26 CHI NC 3.31 0.86
3.06 4.00
1.01 0.87
3.17 3.75
1.14 0.86
2.97 3.72
1.23 0.81
Language 4.31 CHI NC 4.86 Speech Delivery CHI 3.72 NC
4.12
Conversation Structure CHI
4.53
0.80
NC 4.44 0.78 Conversation Content 4.06 0.91 CHI NC
4.39
0.81
Personal Conversational Style 4.17 0.62 CHI NC
4.25
Downloaded by [New York University] at 21:10 17 October 2014
736
NIGEL V .MARSH AND ROBERT G.KNIGHT
Relationship between Cognitive Performance and Social Skill As reported previously in Marsh et al. (1990), the cognitive performance of these patients was impaired relative to the NC group. These cognitive deficits were evident in the patients’ performance on the Standard Progressive Matrices test (Raven, Court, & Raven, 1977), the Selective Reminding Test (Buschke, 1973), and a task measuring speed of information processing for visual stimuli (Pashler & Badigo, 1985). For the 18 CHI patients, correlations between the BRISS ratings on the Language and Speech Delivery scales from the opposite-sex stranger interaction, and their performance on the Standard Progressive Matrices, Selective Reminding Test, and visual search task were calculated. To control for Type I errors, the significanceof the obtainedp-values was determined using amultistage Bonferroni procedure (Larzelere & Mulaik, 1977). None of these correlations reached significance .
DISCUSSION The objective of the research described in the present report is to identify barriers to the successful reintergration of very severe CHI patients into the community. To this end we have focussed on a specific subgroup of CHI patients: Those who require social support and rehabilitation services 18 or more months postinjury, and for whom most of the spontaneous recovery following CHI has already occurred (Bond, 1979). These patients are an important group to study in order to develop an understanding of the psychosocial consequences of CHI, because, for a variety of possible reasons, their return to an independent life in the community is less than complete. It is these patients or their families and caregivers, who are most likely to present to clinical neuropsychologistsfor assistance in the institution of appropriate management programs. One of the most significant impediments to successful readjustment to the community may be changes in the patients’ level of social skill (e.g., Godfrey et al., 1989; Johnson & Newton, 1987). In a previous report the finding that the present group of patients showed reduced molar social skill levels was detailed (Godfrey et al., 1989). The aim of this study was to examine the social interaction performance of the CHI patients in a greater variety of settings and more closely, using the revised BRISS. This was done in order to characterize these skill deficits with more precision. The most striking result to emerge from the BRISS ratings was the finding that the CHI patients were less appropriate in their use of language and their speech delivery than the comparison group. These differences were significant for the “raffle” task and opposite-sex stranger interaction, and approached significance for the “picture” task. The Language scale assessed the technical quality of the subject’s expressions, largely independent of the content of these expressions. Raters take into account the quality and appropriateness of vocabulary, ease of word finding, and ability to express ideas clearly, effectively, and in an
Downloaded by [New York University] at 21:10 17 October 2014
SOCIAL COMPETENCE
737
understandable fashion. The Speech Delivery scale refers to the sound of the subject’s speech or utterances, largely independent of the content of the speech, and is defined as consisting of the four components: Speech fluency, rate of speech, voice quality, and speech mannerism. The poor performance on both these scales indicates that the verbal behavior of the CHI patients was characterized by difficulty finding appropriate words, use of inappropriate expressions, and an inability to express ideas clearly. These problems were reflected in a speech style that lacked fluency, continuity, and clarity. In addition to these language deficits, there was also evidence for deficits in the patients’ pragmatic language behaviors (Wiig, Alexander, & Secord, 1988). Such behaviors include the use of appropriate reciprocal acts, which allow discourse to proceed smoothly. During the opposite-sex stranger interaction, the CHI patients were rated as more deficient on the Partner-Directed Behavior scale. This scale refers to behavior that facilitates the involvement of the partner in the conversation and is defined as consisting of three aspects: use of reinforcers, self-centered behavior, and partner involvement behavior. The performance of the CHI patients on this scale during the interaction with the opposite-sex stranger suggested that they failed to attend to, or show interest in their partners, and were generally more passive. As a result, they would not be reinforcing or stimulating people to converse with. It is also of note that there were no between-group differences on the ratings of three of the BRISS scales: Conversation structure, Conversation content, and Personal conversational style. Conversation structure requires the rater to evaluate conversational fluency (e.g., use of questions, extent of gaps in the flow of conversation) and the appropriateness of topic change. This component explicitly excludes difficulty in speech production, such as pauses within expressions or hesitation in delivery. Conversation content refers to the interest, substance, and appropriateness of the topics bought up by the subject. The general communication pattern of the subject, with a focus on the appropriate use of self-disclosure. humour, and social manners, is evaluated under the heading of personal conversational style. As is apparent in Tables 2 and 3, means of the CHI and NC subjects were equivalent across the time periods sampled. It is well known that traumatic head injury may result in reduced linguistic competence, particularly in the period immediately following the injury (e.g., Ehrlich, 1988; Sarno, 1988; Wiig et al., 1988). Such language deficits extend to include deficits in the pragmatic behaviors associated with maintaining an appropriate conversation (Holland, 1982). The results from the BRISS analysis suggest that underlying judgements of reduced social skill in head-injured patients may be qualitative differences in speech. The conversation of the CHI patients in this study was marked by a technical deficiency in language use, and further, their speech tended to sound different to observers. In contrast the content, style, and structure of their conversation was not noticeably dysfunctional. How they spoke, rather than what they said, was distinctly different to the raters. In addition, there was evidence in the interaction with a stranger, that the CHI
Downloaded by [New York University] at 21:10 17 October 2014
738
NIGEL V . MARSH AND ROBERT G . KNIGHT
patients had difficulty proving verbal indications of interest in the progress of the conversation It is not possible to do more than speculate on the underlying cognitive deficits that might be responsible for the language and pragmatic deficits that distinguished the CHI patients from the NC subjects. In this regard, results from the neuropsychological testing of our subjects were not helpful. Severity of memory impairment, current IQ, and performance on a complex visual search task did not predict either global skill (Godfrey et al., 1989) nor BRISS ratings. It must be acknowledged, however, that the tests used did not directly assess either aphasia nor frontal lobe functioning. One possible explanation for the language-related deficits displayed by our CHI patients is that they are evidence of a subclinical aphasia (Sarno, 1988). An alternative hypothesis is that the deficits in language use apparent in the conversation of the CHI patients were secondary to a disruption in the executive control system responsible for sequencing and organizing cognitive activities (Glosser & Goodlass, 1990; Hagen, 1982; Stuss & Benson, 1986). A dysfunction of the central executive processes is presumed to be a consequence of frontal or prefrontal lesions, but may also result from diffuse damage, because of the density of the interconnections between the frontal area and most other cerebral functional systems (Glosser & Goodlass, 1990). Diffuse or focal frontal lesions in CHI patients may lead to disruption of the executive control of language production. A similar explanation has been advanced to account for language disturbance in patients with Alzheimer’s disease, who also have a diffuse pattern of cortical damage (Murdoch, Chenery, Wilks, & Boyle, 1987). Demented patients have particular difficulty with tasks where language use is dependent on cognition, suggesting that the aphasia seen in Alzheimer’s disease may differ in quality to that resulting from the more focal lesions in other neurological conditions. A major obstacle to understanding language use in CHI, as in dementia, is the lack of a good theoretical basis for understanding the relationship between higher order cognitive processes and language use. The important implications of this study, however, are for understanding why some CHI patients have problems in achieving successful reintergration into their communities: Their speech is lacking in fluency and clarity, and they often fail to respond appropriately in conversations. This suggests that rehabilitation efforts directed towards enhancing the social interaction difficulties of poor outcome, community-dwelling, chronic CHI patients should focus on their speech delivery and language skills. There has been some success in executive strategy training for memory problems following CHI (e.g., Lawson & Rice, 1989). Similar rehabilitation efforts focused on the language problems of CHI patients could also be successful. Such success may have an influence in reducing the patients’ social isolation and improving their overall social adjustment.
SOCIAL COMPETENCE
739
Downloaded by [New York University] at 21:10 17 October 2014
REFERENCES Bellack, A.S. (1983). Recurrent problems in the behavioral assessment of social skill. Behaviour Research and Therapy, 21, 29-41. Bond, M.R. (1979). The stages of recovery from severe head injury with special reference to late outcome. International Rehabilitation Medicine, 1 , 155-159. Brooks, N., Campsie, L., Symington, C., Beattie, A., & McKinlay, W. (1986). The five year outcome of severe blunt head injury: A relative's view. Journal of Neurology, Neurosurgery, and Psychiatry, 49, 764-170. Buschke. H. (1973). Selective reminding analysis of memory and learning. Journal of Verbal Learning and Verbal Behaviour, 1 2 , 72-74. Cronbach, L.J.. Gleser, G.C., Nanda, H., & Rajaratnam, N. (1972). The dependability of behavioral measurements: Theory of generalizabilityfor scores andprofiles. New York: Wiley. Curran. J.P., Farrell, A.D., & Grunberger, A.J. (1984). Social skills: A critique and a rapprochement. In P. Trower (Ed), Radical approaches to social skills training (pp. 1646). London: Croom Helm. Dodwell, D. (1 988). The heterogeneity of social outcome following head injury. Journal of Neurology, Neurosurgery, and Psychiatry, 51, 833-838. Eames, P., & Wood, R. (1985). Rehabilitation after severe brain injury: A follow-up study of a behaviour modification approach. Journal of Neurology, Neurosurgery, and Psychiatry, 48, 613-619. Ehrlich, J.S. (1 988). Selective characteristics of narrative discourse in head-injured and normal adults. Journal of Communication Disorders, 21, 1-9. Farrell, A.D., Mariotto, M.J.. Conger, A.J., Curran, J.P., & Wallander, J.L. (1979). Selfratings and judges' ratings of heterosexual social anxiety and skill: A generalizability study. Journal of Consulting and Clinical Psychology, 47, 164-175. Farrell, A.D., Rabinowitz, J.A., Wallander, J.L., & Curran,J.P. (1985). An evaluation of two formats for the intermediate-level assessment of social skills. Behavioral Assessment, 7 , 155-171. Glosser, G., & Goodlass, H. (1990). Disorders in executive control functions among aphasic and other brain-damaged patients. Journal of Clinical and Experimental Neuropsychology, 12, 485-501. Godfrey. H.P.D., Knight, R.G., Marsh,N.V., Moroney. B., & Bishara, S.N. (1989). Social interaction and speed of information processing following very severe head-injury. Psychological Medicine, 19, 175-182. Hagen, C. (1982). Language-cognitive disorganization following closed-head injury: A conceptualization. In L.E. Trexler (Ed.), Cognitive rehabilitation: Concepruafization and intervention (pp. 131-152). New York: Plenum Press. Holland, A.L. (1982). When is aphasia aphasia?: The problem of closed-head injury. In R.H. Brookshire (Ed.), Clinical aphasiology: Conferenceproceedings, 1982 (pp. 345349). Minneapolis: BRK Publishers. Holland, B.S., & Copenhaver, M.D. (1988). Improved Bonferroni-type multiple testing procedures. Psychological Bulletin, 104, 145-149. Holm, S . (1979). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6 , 65-70. Horton, A.M., & Howe, N.R. (1981). Behavioral treatment of the traumatically braininjured: A case study. Perceptual and Motor Skills, 53, 349-350. Johnson, D.A., & Newton, A. (1 987). Social adjustment and interaction after severe head injury: 11. Rationale and bases for intervention. British Journal ofClinical Psychology, 26,289-298. Larzelere, R.E., & Mulaik, S.A. (1977). Single-sample tests for many correlations. Psychological Bulletin, 84, 557-569.
Downloaded by [New York University] at 21:10 17 October 2014
740
NIGEL V . MARSH AND ROBERT G . KNIGHT
Lawson, M.J., & Rice, D.N. (1989). Effects of training in use of executive strategies on a verbal memory problem resulting from closed-head injury. Journal of Clinical and Experimental Neuropsychology, I I , 842-854. Lewis, F.D.. Nelson, I.. Nelson, C., Reusink, P. (1988). Effects of three feedback contingencies on the socially inappropriate talk of a brain-injured adult. Behavior Therapy, 19, 203-21 1. Marsh, N.V., Knight, R.G., & Godfrey, H.P.D. (1990). Long-term psychosocial adjustment following very severe closed-head injury. Neuropsychology, 4 , 13-27. Marshall, J.C., & Newcombe. F. (1984). Putative problems and pure progress in neuropsychological single-case studies. Journal of Clinical Neuropsychology, 6.65-70. Murdoch, B.E., Chenery, H.J., Wilks, V., & Boyle, R.S. (1987). Language disorders in dementia of the Alzheimer type. Brain and Language, 31, 122-137. Nelson, H.E. (1982). National Adult Reading Test (NART): Test Manual. Windsor, Berkshire: NFER-Nelson. Newton, A., & Johnson, J.A. (1985). Social adjustment and interaction after severe head injury. British Journal of Clinical Psychology, 24, 225-234. Pashler, H., & Badigo, P.C. (1985). Visual attention and stimulus identification. Journal of Experimental Psychology: Human Perception and Performance, 1I , 105- 121. Powell, G.E.. Bailey, S., & Clark, E. (1980). A very short version of the Minnesota Aphasia Test. British Journal of Social and Clinical Psychology, 19, 189-194. Raven, J.C., Court, J.H., & Raven, J. (1977). Manual for Raven's progressive matrices and vocabulary scales. London: H . K . Lewis. Rosenbaum, M., & Najenson, T. (1976). Changes in life patterns and symptoms of low mood as reported by wives of severely brain-injured soliders. Journal of Consultingand Clinical Psychology, 44, 881-888. Russell, W.R., & Smith, A. (1961). Post-traumatic amnesia in closed-head injury. Archives of Neurology, 5 , 4-17. Samo, M.T. (1988). Language and speech defects. ScandinavianJournal of Rehabilitation Medicine, (Suppl. 17), 55-64. Schloss, P.J., Thompson, C.K., Gajar, A.H., & Schloss, C.N. (1985). Influence of selfmonitoring on heterosexual conversational behaviors of head trauma youth. Applied Research in Mental Retardation, 6 , 269-282. Stuss, D.T., & Benson, D.F. (1986). The frontal lobes. New York: Raven Press. Sunderland, A. (1990). Single-case experiments in neurological rehabilitation. Clinical Rehabilitation, 4 , 181-192. Turner, S.M., Hersen, M. & Bellack, AS. (1978). Social skills training to teach prosocial behaviors in an organically impaired and retarded patient. Journal of Behavior Therapy and Experimental Psychiatry, 9, 253-258. Wallander, J.L., Conger, A.J., & Conger, J.C. (1985). Development and evaluation of a behaviorally referenced rating system for heterosocial skills. Behavioral Assessment, 7, 137-153. Wechsler, D. (1955). Manual for the Wechsler Adult Intelligence Scale. New York: The Psychological Corporation. Wiig. E.H., Alexander, E.W., & Secord, W. (1988). Linguistic competence and level of cognitive functioning in adults with traumatic closed-head injury. In H.A. Whitaker (Ed.), Neuropsychological studies of nonfocal brain damage: Dementia and trauma (pp. 186-201). New York Springer-Verlag. Wilson, B. (1 987). Single-case experimental designs in neuropsychological rehabilitation. Journal of Clinical and Experimental Neuropsychology, 9, 527-544.
