Social adjustment scale assessments in traumatic brain injury.

The long term social and consequences of traumatic brain injury are receiving an increased amount of attention. Oddy and Humphrey (1980) report decreased social functioning up to 2 years post-trauma, and McKinlay, Brooks, Bond, Martinage, and Marshall (1981) report an increase in emotional problems during the year after injury while physical problems are decreasing. Lezak (1987) reports social and behavioral problems up to 5 years post-trauma, and Thomsen (1984) found persisting emotional lability and disturbed behavior over a 10-year period. Burton and Volpe (1988) found a distress syndrome marked by significant depression and impulsivity in traumatically brain injured men but not women at an average of two and one half years post-trauma. Thus, the social and emotional impact of head injury is long-lasting.

Several reports suggest that depression after head injury may actually increase with time. Cartlidge and Shaw (1981) report that depression doubled between discharge and 6-month follow-up, and stayed at the higher level of incidence at one- and two-year follow-up. Glenn and Rosenthal (1985) report that a reactive depression is most common in the months or even years following head injury. Fordyce, Roueche, and Prigatano (1983) report significant depression measured by the MMPI in patients tested 6 months or more since injury, but not in patients tested within 6 months of injury.

Wood, Novack, and Long (1984) feel that a series of difficulties in relationships, work, and leisure activities may be one cause of the depression. The changes in the head injured person obviously affect the people in his or her life also, setting up a complex interaction. Lezak (1978) reported that families of head injured persons may feel more isolated and may be the focus of the injured person's frustration. McKinlay, Brooks, and Bond (1983) reported that families may perceive the patient as more of a burden as time passes. Divorce is a frequent outcome of head injury if the disabilities are moderate to severe (Levin, Benton, and Grossman, 1982).

The head injured person is part of the same complex network of social relationships that he or she was involved in before injury. The impact on this network is substantial, and the interactions between the head injured person and others change. Every person functions in many roles simultaneously, and the changes in specific roles of the head injured person is the subject of the present study. The specific social roles were investigated using the Social Adjustment Scale (SAS) of Weissman and colleagues (1974, 1976, 1978), and included Work, Social and Leisure, Extended Family, Marital, Parental, and Family Unit roles.

Method

Subjects

The current group consists of 24 men and 9 women receiving treatment as outpatients (this group is that of Burton and Volpe, 1988). They are people who had responded to a mail request to complete an MMPI sent to 71 of 92 head injured persons for whom current addresses were available; the 92 had been consecutively admitted. All people receiving treatment in the Out-patient Department must be able to undergo physical therapy, occupational therapy, or speech therapy. This group was pre-screened from their charts to have an IQ greater than 65, no premorbid psychiatric history. no indication that they were unable to read, and no indication of severe visual impairment.

In terms of the demographics of the 33-member group, the mean age was 29.9 years (SD of 8.7), the mean time since trauma was 2.6 years (SD of 1.7), the mean WAIS-R IQ was 89.5 (SD of 13.9), and the mean Wechsler Memory Quotient was 89.9 (SD of 22.8). Forty-two percent were involved in their premorbid occupations (school, job, housework) on a full time basis, 12% on a part time basis, and 46% were not involved at all. Initial Glasgow Coma Scale Scores (within 24 hours of injury) were available for 28 of the 33 members, and yielded a mean score of 7 (SD of 4.2).

Procedure

A packet was sent to each person within 2 months of receipt of the MMPI (discussed in Burton and Volpe, 1988), consisting of an introductory letter, a stamped envelope, a self-administered SAS scale for the injured Person to complete, and a SAS for a significant other to complete about the Injured Person.

Instrument

The SAS of Weissman and colleagues (1974, 1976, 1978) was derived from The Structured and Scaled Interview to Assess Maladjustment (SSIAM; Gurland, Yorkston, Stone, Frank, and Fleiss, 1972) and has been widely used in psychiatric and non-psychiatric groups. In the self-report form, a 2-week period is assessed with 42 questions rated on a 5 point scale (higher numbers indicate greater impairment). This scale was used because it covers a broad range of social functions, TABULAR DATA OMITTED with specific subscales for Work, Social and Leisure, Extended Family, Marital, Parental, and Family Unit roles. The Work scale assesses time lost, impaired performance, and feelings of inadequacy. The Social and Leisure scale investigates decrease in contact with friends, leisure activities, romantic relationships, and increase in reticence, hypersensitivity, and loneliness. The Extended Family scale pertains to relationships with parents, siblings, in-laws, and children not living at home, and measures withdrawal, reticence, attachment, guilt, and resentment. The Marital scale rates sexual problems such as decreased intercourse, reticence, dependency, disinterest, affection, and impaired communication. The Parental scale assesses lack of involvement, affection, and impaired communication. The Family Unit scale assesses economic inadequacy, guilt, and resentment.

The self-report form of this scale was used. This test appears to have good discriminative validity with other groups investigated. Weissman and Bothwell (1976) report significant correlations between depressed patients and informants for all scales during acute illness. Further, the self-report form of the SAS significantly discriminated patients during acute depression and recovery, and discrimination of community non-patients and psychiatric patients has also been reported (Weissman, Prosoff, Thompson, Harding, and Myers, 1978). Inter-rater reliability is reported for the interview form of the test (Weissman, Paykel, Siegel, and Klerman, 1971; Paykel, Weissman, Prusoff, and Tonks, 1971), for which a mean correlation of .83 was found.

Results

The SAS scores for the 33-member group are shown in Table 1. The initial Glasgow Coma Scale score did not correlate significantly with either the Injured Person's or Informant's SAS overall rating. The deviation scores in Table 1 were calculated by dividing the difference between the present Injured Person's or Informant's SAS score and the Weissman et al. (1978) community sample means by the standard deviation of the Weissman et al. (1978) sample. As can be seen, the Work, Extended Family, and Parental scores and the overall SAS scores were elevated by greater than one standard deviation.

The Informants consisted of 2 husbands, 6 wives, and 2 live-in girlfriends, which accounted for the 10 Injured Person-Informant pairs who answered the Marital questions. The other Informants were 16 parents (12 mothers, 4 fathers), 2 brothers, 1 cousin, and 4 friends. All Informants did not complete all the subscales, hence the difference between the number of Injured Person-Informant pairs for the scales. It should also be noted that all roles were not filled by every person, thus decreasing the sample size for some of the scales, and thus weakening the findings.

The overall SAS ratings of the Injured Person and Informant correlated significantly (r=.62, p.01). Significant correlations were also found for the Work (r=.76, p.01), Social and Leisure (r=.71, p.01), and Extended Family (r=.40, p.05) scales. However, the Parental (r=.08, ns), Family Unit (r=.52, ns), and especially the Marital (r=-.02, ns) scales reflected little agreement between the Injured Persons and Informant's report.

Discussion

The greatest impairment (over one standard deviation) was seen in performing Work, Extended Family, and Parental roles, as reported by both the informant and the injured person. Difficulty with work performance is consistently reported in the literature, and difficulty performing parental responsibilities would seem to be an extension into the home of these same performance difficulties. The extended family difficulties have not been frequently reported. Oddy and Humphrey (1980) did report a deterioration in relationships with siblings at 12 months post-injury, but they found that these seemed to resolve at 2 years. Clearly, more investigation of the extended family relationships is needed, since head injury survivors are often relatively young and may have much contact with, and may live with, parents and siblings.

The lack of agreement between head injury survivors and informants for the Parental, Family Unit, and Marital scales is notable. These 3 categories pertain to roles for which the injured person's decreased ability to perform may result in an increased work load as well as decreased satisfaction for the informant. The literature cited earlier highlights the increased tensions that are possible between the injured person and partner, and at the same time, the present data (indicating poor agreement in perception) seems to reflect a decrease in communication.

Two obvious recommendations emerge from the present findings. First, it is clearly important to simply monitor the social and emotional functioning of the injured person at intervals that extend long past injury, social and emotional "check-ups", given the vulnerability of this group. Second, psychotherapeutic treatment must be offered as indicated by these check-ups, and must not only include individual counseling, but must also include family therapy as needed. It must be recognized that the individual is part of a complex interactive system, and the whole system may need treatment when one part changes.

The present data suggest three likely recipients for psychotherapeutic treatment: the head injured person, the partner, and the extended family. Rosenthal (1984) discusses the importance of family intervention, and recommends inclusion of an education component for both the injured person and family, as well as psychotherapy; he also stresses the importance of family support groups. The time to achieve a new homeostasis or level of adjustment for the family is not clear for head injury, and thus another area of needed research. Bray (1977) reports that families with spinal cord injured members require about 2 years to adjust, whereas families of people with strokes need half that amount of time. Bray (1987) suggests that the time to adjust depends on many things, including the magnitude and nature of disabilities, and the coping skills of both the injured person and the other family members.

Thus, the impact of head injury reverberates throughout the entire family system. The effects of head injury on the multiple roles of the head injured person needs to be more systematically monitored, and treatment must be made available to both the injured person and the affected family members.

References

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Leslie Burton, Ph.D., Neurology Department, Cornell University Medical College, 1300 York Ave., New York, NY 10021.