Awareness of Deficits in Persons with Traumatic Brain Injury

1. Awareness of Deficits in Persons with Traumatic Brain Injury Stephanie Fanale Brenda Wilson, Ph.D, CCC-SLP Eastern Illinois University Research supported by an undergraduate research grant at Eastern Illinois University

2. Introduction • Traumatic brain injury (TBI) affects the lives of approximately 1.7 million Americans each year (Faul, Xu, Wald, & Coronado, 2010) • Patients with TBI often present with symptoms of impaired awareness in regard to their injuries as well as the impact of their injuries on their daily functioning (Sherer, Bergloff, Boake, High, & Levin, 1998) • Due to the individualized nature of awareness, developing a general, yet adequate assessment tool of awareness has proven difficult • There is limited information available about the validity of most assessments, as well as the rehabilitation implications of awareness of deficits in people with TBI

3. Introduction Roberts et al. (2006) found that individuals who received a one-on-one neurological consultation increased their levels of self-awareness Proctor, Wilson, Sanchez, and Wesley (2000) found a direct relationship between having the skills required to complete functional tasks successfully and the ability to set realistic goals Proctor et al. (2000) also found a direct relationship between having the skills required to complete functional tasks successfully and the awareness required to self-monitor behavior

4. Purpose of this study The purpose of this study was to determine the relationship between two awareness measures and a functional measure of communication.

5. Research Questions • What is the relationship between awareness of deficit scores and functional communication outcome scores after TBI? • Does severity of the brain injury impact the relationship between awareness of deficit scores and functional outcome scores after TBI? • What are speech-language pathologists’ clinical preferences in regard to awareness assessments?

6. Subjects Mean age of injury = 16;9 SD = 1.51 Mean age of testing = 16;11 SD = 1.69

7. Assessments • 2 awareness assessments were given: • Awareness Questionnaire • Functional Assessment of Verbal and Executive Strategies (FAVRES)

8. Awareness Questionnaire Composed of three forms: a patient form, a significant other form, and a clinician form On each form, the abilities of the person with TBI to perform various tasks after the injury as compared to before the injury are rated on a five point scale ranging from "much worse" to "much better” Awareness of deficits is determined by subtracting the significant other’s score and the clinician score from the self-rating of the participant, resulting in a discrepancy score

9. FAVRES • A standardized test designed to measure the use of executive strategies to complete tasks specifically for those individuals 18 or older with acquired brain injuries. • Consists of four tasks made to replicate everyday cognitive demands. The current study measured awareness of deficits using the rationale score for two tasks: • Task One: “Planning an Event”—requires the participant to analyze several options presented in a newspaper listing and choose which event was most appropriate within the constraints of time, money, and appropriateness. • Task Two: “Scheduling”—requires the participant to analyze a “things to do” list and various telephone messages in order to organize and prioritize activities based on importance and time.

10. Functional Independence Measure (FIM) Expression Social interaction No Helper • 7: Complete Independence • 6: Modified Independence Helper • 5: Standby Prompting • 4: Minimal Prompting • 3: Moderate Prompting • 2: Maximal Prompting • 1: Total Assistance No Helper • 7: Complete Independence • 6: Modified Independence Helper • 5: Supervision • 4: Minimal Direction • 3: Moderate Direction • 2: Maximal Direction • 1: Total Assistance

11. Question 1 • There was a tendency for increased awareness of deficit, as measured by the AQ discrepancy scores, to be associated with a lower communication outcomes, as measured by the FIM. • Participant 1: • FIM score: 6 out of 14 • Lowest AQ discrepancy score: 5

12. Question 1

13. Question 1:Relationship between the AQ and the FIM

14. Question 1 • There was a tendency for increase awareness of deficits, as measured by the FAVRES rationale score, to be associated with a higher communication outcome, as measured by the FIM. • Participant 1: • FIM score: 6 out of 14 • FAVRES rationale score: 4

15. Question 1

16. Question 1: Relationship between the FAVRES rationale score and the FIM

17. Possible Explanations: Physical limitations were included on the AQ Participant 1 was injured last summer. Other participants were tested directly after discharge.

18. Question 2: The Impact of Severity • FIM ratings were used to measure severity of injury, with lower ratings indicating increased severity • Participant 1: • Lowest FIM score—indicating greatest severity • Lowest AQ discrepancy score—indicating highest awareness • Lowest FAVRES rationale score—indicating lowest awareness

19. Question 2: The Impact of Severity and the AQ

20. Question 2: The Impact of Severity and the FAVRES rationale

21. Question 3: Clinical Preferences Based on the clinical preferences rating of the clinician, the AQ was ranked the better than the FAVRES for time efficiency and for accuracy. Both assessments were given the highest ratings for ease of administration .

22. Summary • The AQ was the most accurate assessment of awareness of deficit. • Awareness of deficit as measured by the AQ does not show a strong relationship with the FIM expression and social interaction scales.

23. Summary The rationale score of the FAVRES was not an accurate assessment of awareness of deficit The rationale score of the FAVRES was moderately related to communication outcome as measured by the FIM In this small sample, increased severity as measured by the FIM was not associated with increased awareness of deficit. However, it was associated with the FAVRES rationale score.

24. Future Direction Increased sample size will increase validity of results. Since awareness of deficit is an important factor in rehabilitation after TBI, various measures of awareness should be evaluation in terms of rehabilitation outcome.

25. References Faul, M., Xu, L., Wald, M. M., & Coronado, V. G. (2010, March 17). Traumatic Brain Injuries in the United States. Retrieved from http://www.cdc.gov/TraumaticBrainInjury/statistics.html Proctor, A., Wilson, B., Sanchez, C., and Wesley, E. (2000). Executive function and verbal working memory in adolescents with closed head injury (CHI). Brain Injury, 14(7), 633-647. doi:10.1080/02699050050043999 Roberts, C. B., Rafal, R., & Coetzer, B. R. (2006). Feedback of brain-imaging findings: Efects on impaired awareness and mood in acquired brain injury. Brain Injury, 20(5), 485-497. doi: 10.1080/02699050600664665 Sherer, M., Bergloff, P., Boake, C., High, W., & Levin, E. (1998). The Awareness Questionnaire: Factor structure and internal consistency. Brain Injury, 12(1), 63-68. doi: 10.1080/026990598122863