Coelho_ Ylvisaker_ Turkstra non-stand assess Sem 2005.pdf

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Nonstandardized Assessment Approachesfor Individuals with Traumatic Brain Injuries

CarlCoelho, Ph.D.,1Mark Ylvisaker, Ph.D.,2 andLynS. Turkstra,Ph.D.3

ABSTRACT

Nonstandardized assessment procedures serve a variety of purposes,

including determining competencies in domains for which there are nostandardized tests, describing performance in the context of real-worldsettings and activities, and exploring the effects of systematic changes incommunication and cognitive demands and partner supports. This articlereviews evidence on the use of nonstandardized procedures for the assess-ment of individuals with traumatic brain injury and offers recommendationsfor the use of the procedures that are supported by the available evidence.

KEYWORDS: Traumatic brain injury, assessment, nonstandardized,

functional, cognition, communication, discourse, social cognition,

pragmatics

Learning Outcomes:Upon completion of this article, the reader will be able to (1) define terminology associated

with the assessment of individuals with traumatic brain injury (TBI), (2) summarize the rationale for the use of

nonstandardized assessment procedures for individuals with TBI, (3) identify which discourse analyses should be

included when monologic or conversational discourse is examined in individuals with TBI, (4) summarize the use

of collaborative contextualized hypothesis testing for individuals with TBI, and (5) summarize the key limitations of

nonstandardized assessment procedures.

This is one of two articles devoted toreviewing clinical practice for the assessmentof cognitive-communicative disorders follow-ing traumatic brain injury (TBI). The firstassessment article (Turkstra et al,1 in this issue)pertained to use of standardized tests. Thepresent article reviews nonstandardized assess-ment procedures. These articles are part of a

series devoted to examining evidence-basedclinical practice in neurogenic communicationdisorders, initiated in 1997 by the Academy ofNeurologic Communication Disorders andSciences (ANCDS) (see www.ancds.org).

Several assessment purposes are currentlybest served by nonstandardized procedures.

These include (1) determining competencies

Evidence-Based Practice for Cognitive-Communication Disorders after Traumatic Brain Injury; Editors in Chief, Audrey

L. Holland, Ph.D., and Nan Bernstein Ratner, Ed.D.; Guest Editor, Lyn S. Turkstra, Ph.D. Seminars in Speech andLanguage, volume 26, number 4, 2005. Address for correspondence and reprint requests: Carl Coelho, Ph.D., Communica-tion Sciences, University of Connecticut, Unit 1085, Storrs, CT 06269-1085. E-mail: [email protected]. 1CommunicationSciences, University of Connecticut, Storrs, Connecticut; 2College of St. Rose, Albany, New York; 3Department ofCommunicative Disorders, University of Wisconsin, Madison, Wisconsin. Copyright # 2005 by Thieme MedicalPublishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0734-0478,p;2005,26,04,223,241,ftx,en;ssl00250x.

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in domains for which there are no standardizedtests (e.g., discourse), (2) describing perform-ance in the context of real-world settings andactivities, (3) identifying cognitive and commu-

nication demands of relevant real-world con-texts, (4) describing the communication andsupport competencies of everyday communica-tion partners, and (5) exploring the effectsof systematic changes in communicationand cognitive demands and partner supports.

Thus, there are compelling reasons to examinethe evidence for nonstandardized assessmentapproaches.

First, the relevant terminology is defined.The sections that follow address nonstandar-dized procedures and their rationales. Theinformation included in this summary is de-rived from studies of nonstandardized proce-dures, published expert opinion, and a surveyof speech-language pathologists who work withindividuals with cognitive-communicationdisorders.

DEFINITIONS

Discussions of assessment are often plagued bya lack of clarity regarding the purpose of theassessments under discussion and by a lack ofprecise definitions of relevant terminology. Inthis section we offer operational definitions ofkey types of assessment.

Standardized versus NonstandardizedA standardized assessment is one in which the

procedures for administering test items areprescribed and well defined. All other assess-ments are nonstandardized.

Norm Referenced versus Criterion

ReferencedA norm-referenced test is one that yields resultsthat can be quantitatively compared with per-formance of a normative sample (e.g., age-corrected scores and standard scores basedon a normal comparison group). A criterion-referenced test is one that yields results that arecompared with a standard other than perform-ance of a normative sample. For example,results of a Piagetian test of cognitive develop-

ment may place a child in a developmentalcategory defined by Piagetian theory but not

yield a score that relates a childs performanceto age norms. The Western Aphasia Battery is

another example of a criterion-referenced test.The goal is to identify individuals with aphasiaand determine aphasia severity rather than toplace individuals with aphasia on a continuum

with a normal comparison group.

Formal versus InformalAlthough these terms are used in a variety ofsenses, we define a formal assessment tool asone that has systematically applied procedures,

whereas an informal assessment lacks definedprocedures. In this sense, the broad category offormal measures includes both standardizedmeasures with specifically prescribed adminis-tration procedures and other systematic assess-ments such as functional behavior assessment.

Static/Descriptive versus Dynamic/

Experimental

A static or descriptive measure yields a descrip-tion of performance, participation, or contextconditions without attempting to identify thefactors that influence (positively or negatively)the quality of performance or the success ofparticipation. The term dynamic assessmenthas been used in many senses, including flexibleassessment and test-teach-test assessment.2 As

we use the term, dynamic assessment is exper-imentalin the sense that it attempts to identify

the effects of factors (e.g., strategies, taskmodifications, context factors, environmentalsupports) that may influence performance.Dynamic assessment can be used for diagnosticpurposes (e.g., process assessment as de-scribed by Kaplan3) but typically has the goalof generating an effective and efficient inter-

vention plan. For the purposes of this article,the term static includes measures that are de-scriptive and the term dynamic includes meas-ures that are experimental.

Initial versus OutcomeInitial assessments are used to document base-line abilities, performance, and participation

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prior to intervention. Ongoing assessmentsare used to document progress in relation togoals and to refine the intervention plan inan ongoing manner. Outcome assessment

is used to document the final effects of inter-vention (or passage of time) at a discretetime.

RELATED TERMINOLOGY

World Health Organization

International Classification

of Functioning CategoriesIn its most recent iteration, the World HealthOrganization (WHO)4 proposed three broadcategories for describing diseases and injuriesand their effects: body structure and functions(generally corresponding to the previous termimpairment), activities and participation(corresponding to disability and handicap),and context (environmental and attitudinal). Inthe case of each of the three categories, thereexists the possibility of static/descriptive anddynamic assessments, thus yielding a total six

categories of assessment within the WHOsystem. A functional measure, as we use theterm, may document strengths and weaknessesat the level of personally relevant everydayactivities, participation in relevant contexts oflife, and relevant factors outside the person(context factors) that affect performance andparticipation in those contexts. For example,for a static measure at the level of context, onemight wish to document the effects of partners

communication styles on the performanceand participation of the individual with dis-ability. At the same level, a dynamic measuremay explore effects of strategies and contextsupports. For example, one could examineexperimentally the degree to which a partnersstyle can be modified to become more sup-portive and the effects of proposed modifica-tions on the individuals performance andparticipation.

In this article, our focus is primarily onassessments that are functional; at the level ofactivity, participation, or context; and imple-mented for purposes of planning and monitor-ing intervention. It should be noted that oneand the same assessment could be functional or

not, depending on its use and interpretation.For example, performance on the Cookie

Theft Picture stimulus item from the BostonDiagnostic Aphasia Examination5 could be

used to judge perceptual skills, organizationalskills, syntax and word-finding abilities, and thelike. Alternatively, it can be used to judge apersons ability to communicate effectively andefficiently relevant information to a communi-cation partner in an organized manner underrelatively supportive communication condi-tions. In the latter case, it would be considereda functional measure.

Subjective and Objective Quality

of LifeResearch on social outcome after TBI hasincorporated both subjective and objectivemeasures of quality of life (QOL). SubjectiveQOL measures are insider-defined measuresof outcome,6 focusing on the individuals per-ceptions of well-being. By contrast, objectiveQOL measures focus on markers of social well-being in the individuals culture, including

outcomes such as employment, marriage, andindependence.

PURPOSES OF ASSESSMENT

The multidimensional nature of assessment hasled to substantial confusion in clinical practiceas well as in the literature associated with themanagement of individuals with TBI. Withoutconsideration of the terminology just discussed,

interpretation of assessment findings is mis-leading at best. Assessments can be designedto serve several distinct purposes, includingdiagnosis, prognosis, acquisition of services,legal testimony, research, planning interven-tion, or monitoring intervention. The presentarticle is focused on assessment proceduresdesigned to facilitate functional and individu-alized intervention planning and monitoringof progress for persons with TBI. It considersnonstandardized measures that target bodystructures and functions, activities, participa-tion, or contexts; are formal or informal, staticor dynamic; and are used for an initial, ongoing,or outcome assessments. All of these assess-ments share the characteristic of not having

NONSTANDARDIZED ASSESSMENT/COELHO ET AL 225


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been standardized on a normal or clinicalsample.

RATIONALE FORNONSTANDARDIZED

ASSESSMENT

The importance of nonstandardized, func-tional, and context-sensitive assessment is sup-ported by extensive research demonstratingthe shortcomings of standardized, office-boundlanguage and neuropsychological testing forindividuals with TBI.710 Indeed, Andersonand colleagues11 describe the dissociation be-tween test performance and everyday function-ing as a defining feature of frontal lobe injury,noting that the dissociation between severedysfunction in daily activities and good per-formances on standardized cognitive tests pro-

vides both an important diagnostic indicator aswell as a major challenge in the evaluation ofpersons with prefrontal dysfunction (p. 289).Similarly, Ewing-Cobbs and colleagues12

found that in a cohort of children with TBI,although standardized achievement test scores

had returned to normal by 6 months afterinjury, 79% had either repeated a grade or re-quired special education assistance at a 2-yearfollow-up. Perrott and colleagues13 observedthat among children with moderate to severe

TBI, poor behavioral outcome was associatedwith only one of six IQ variables (digit span)and only one of nine neuropsychological tests(the Contingency Naming Test14). Further-more, the TBI group did worse than sibling

controls on behavioral measures but not onneuropsychological tests.Functional or situational assessments have

also been compared with testing conducted inclinical settings for purposes of predicting voca-tional and community reentry for adults

with TBI. LeBlanc and colleagues15 comparedneuropsychological assessment findings withsituational vocational assessments for 127 in-dividuals with TBI. The results indicated thatsituational assessments were more effectivethan standardized testing at predicting voca-tional success. In addition, the authors foundrelatively weak correlations between the situa-tional evaluations and the neuropsychologicalassessments. They emphasized that situational

evaluations are critical, particularly for the as-sessment of executive functions. Starch andFalltrick16 reached similar conclusions in areport of three case studies. These authors

observed that in all three cases, skills identifiedas being important for successful communityreentry and judged to be intact in the clinicalsetting were noted to be impaired in homesettings. They concluded that because rehabil-itation and adjustment to brain injury are on-going, assessment and intervention should becommunity based.

In a review of the ecological validity of neu-ropsychological tests, Chaytor and Schmitter-Edgecombe17 noted that although severalstudies found statistically significant relation-ships between standardized tests and measuresof everyday cognitive skills, the magnitude ofthese relationships was typically weak. Theylisted a variety of factors that could limit a testspredictive and ecological validity, includingthe test environment (e.g., the distraction-freeenvironment and supportive behavior of theexaminer may mask functional cognitive andemotional problems), constructs that a test

measures (e.g., there is disagreement aboutthe definition of executive functioning andhow it should be measured), behavior sampling(e.g., the testing process may collect a smallsample of a persons range of behavior and maynot stress attentional, memory, and organiza-tional skills to their point of functional weak-ness), compensatory strategies (e.g., a personmay successfully employ a compensatory strat-egy to accomplish a task in everyday life but be

prevented from using it in the testing environ-ment), and noncognitive factors (i.e., manypersons with brain injury have behavioral andemotional deficits that may compound theircognitive deficits). The authors concludedthat it no longer seemed appropriate to asksimply are neuropsychological tests ecologi-cally valid? but rather one should ask whichtests have the most ecological validity and in

which circumstances?The general conclusion that can be drawn

from the evidence just discussed is that whenthe primary goals of assessment are to identifyreal-world disability and to plan and monitorintervention, office-bound language and neuro-psychological testing must be supplemented



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by nonstandardized, real-world assessmentprocedures.

NONSTANDARDIZED ASSESSMENTPROCEDURES CURRENTLY IN USE

FOR INDIVIDUALS WITH

TRAUMATIC BRAIN INJURY

The authors began by surveying speech-language pathologists regarding their assess-ment practices. Thirty individuals working ina variety of clinical settings completed a surveyon their use of informal, nonstandardized,or functional measures for the assessment ofindividuals with TBI. Detailed results are avail-able on the ANCDS Web site (www.ancds.org). These clinicians reported using 28 differ-ent tasks or procedures ranging from observa-tion to discourse analysis to administration ofsubtests from published assessment batteries,

with a high proportion of the reported fallingin the last category. This preliminary evidencesuggested that nonstandardized techniques

were common among clinicians working inthis area. As noted in the introduction, the

nonstandardized use of standardized tests isnot discussed here. Rather, this review focuseson the nonstandardized procedures that havebeen described in the research literature orpublished expert opinion.

DISCOURSE ANALYSIS

The communicative deficits of individualswith TBI are frequently difficult to delineate.

Performance on aphasia batteries may give theimpression that their communicative skills areintact. However, interactions with many ofthe same individuals leave the listener withthe sense that they are off target, tangential,and disorganized or, in some cases, have verylittle to say. The overestimated communicativeperformance of these individuals is a function ofthe limited scope and ceiling effect of aphasiabatteries, which were never intended to assessthe subtle types of deficits many individuals

with TBI demonstrate. Most aphasia batteriesassess language function at the single word orsentence level, at which most individuals with

TBI have little difficulty.18 Recent investigatorsof communicative ability in brain-injured adults

have instead applied discourse analyses to de-scribe these deficits. In the sections that follow,several discourse studies of children and adults

with TBI are reviewed. Two primary types of

discourse are described, monologic or nonin-teractive (e.g., descriptive, narrative, proce-dural) and conversational.

Monologic DiscourseThe authors reviewed 19 studies pertaining tomonologic discourse sampling. These studiesincluded over 400 children, adolescents, andadults ranging in age from 7 to 69 years. With

regard to elicitation tasks employed for dis-course sampling, the most common were nar-ratives, such as story retelling, story generation,and personal event retelling,1931 followedby procedural discourse26,28,3234 and finallypicture description.30,35,36 A variety of analysis procedures were employed. Themost commonly applied were measures ofcohesion, that is how meaning is tied acrosssentences,2325,27,29,31,32,37 and sentence-level

grammatical complexity.

2022,26,27,29,30,38

Sixstudies used analyses of coherence, the thematicunity of a text,22,25,27,31,37 amount and accuracyof information or content20,28,33,34,36; and storygrammar.2123,29 Additional analyses includedmeasures of productivity and effici-ency,22,26,30,34 propositional analyses,19,21,25,34

and lexical selection.27,28

Identification of Useful AnalysisProceduresAlthough discourse analyses are useful for iden-tifying subtle communicative deficits in indi-

viduals with TBI, the broad array of tasks andanalyses that have been described in the liter-ature has resulted in confusion when attempt-ing to select the best discourse sampling andanalysis procedures. However, because dis-course analysis can be extremely time consum-ing, it is important that clinicians who chooseto invest their time in such procedures obtainthe biggest return for their efforts. In aneffort to address this issue, the authors eval-uated three factors in the 19 studies reviewed:interjudge reliability, consistency of findings



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across studies, and potential to distinguishimpaired from normal discourse.

INTERJUDGE RELIABILITY

Of the 19 studies reviewed, 15 reported inter-judge reliability scores, with most falling withinan acceptable range of 0.80 or above. The twostudies reporting reliability scores below 0.80

were those of Glosser and Deser,27 who re-ported a reliability of 0.79 for thematic coher-ence, and Hartley and Jensen,28 who reportedreliability of 0.76 for lexical selection and 0.60for substitution and ellipsis combined. It shouldbe noted that other investigators have encoun-tered similar difficulties with scoring reliabilityof cohesive categories.29 These investigatorshave opted instead to judge the adequacy ofeach occurrence of a cohesive tie and calculate acohesive adequacy score (i.e., complete tiesdivided by total number of cohesive ties). In-terjudge reliability for this measure is typicallymuch higher.23 Overall, these findings suggestthat other than the difficulty in identifyingspecific cohesive devices, interjudge reliabilityis not a limiting factor in choosing a discourse

analysis procedure.

CONSISTENCY OF FINDINGS

A consistent finding in many studies is thatindividuals with TBI have less verbal outputduring monologic discourse tasks2022,28,30 andthat the overall efficiency of their discourse isdiminished.20,26,30,34,35 Coherence is anotherdiscourse measure in which there is generalagreement regarding impairments noted after

TBI,25,27,37

although Van Leer and Turkstra31

noted that their participants with TBI were noworse than a matched group of normal teens.Measures of content accuracy and organizationalso show consistent impairments in the de-scriptive, procedural, and story narratives ofindividuals with TBI21,22,24,26,28,30,34 as wellas an increased number of irrelevant pro-positions.34,37 Along similar lines, there isagreement in several reports that TBI resultsin problems with story components andgrammar.2022,24,36,38

By contrast, mixed findings have beenreported with regard to syntactic analyses,

with some studies reporting decreased gram-matical complexity21 or increased grammatical

errors27 and others finding sentence-levelgrammar to be comparable to that of normalcontrols.22,29 Similarly, although there is evi-dence that TBI disrupts the use of cohesive

devices,24,25,28,29,39

other studies have notedcohesion to be relatively intact.23,27 Deficits ofcohesion appear to be influenced by the elic-itation task, with some individuals demonstrat-ing impairments in story generation but not instory retelling29 and others with impairmentsin story retelling.25 Task or condition effectshave also been reported for coherence measures,

with better coherence being noted in a personalversus a current events narration.31 Overall,the measures of verbal productivity and effi-ciency, content accuracy and organization, storygrammar, and coherence were all noted to besensitive measures of impaired discourse per-formance after TBI.

DISTINGUISHING IMPAIRED

PERFORMANCE FROM NORMAL

Without question, the primary limitation to theuse of discourse analyses, particularly for indi-

viduals with TBI, is the lack of normative data.

One may argue that normative data are notimportant if the goal is to document progress asopposed to making a diagnosis, but in eithercase it is important to have confidence that thediscourse performance that is being labeledimpaired is distinctly different from that ofindividuals without brain injury. In a follow-upstudy, discriminant function analyses (DFA)

were employed to determine the accuracy ofselected measures of narrative discourse for

classifying participants into their respectivegroups.40 The participants consisted of 32adults with TBI and 43 noninjured adults.

The measures that contributed most to thediscrimination procedure included story gram-mar (in story generation and retelling), sentencelength (in story generation), and grammaticalcomplexity (in story retelling). The results in-dicated that the story narrative measures cor-rectly classified 70% of the participants, 64.5%of the TBI group and 74.4% of the noninjuredgroup. The overlap in the performance of the

TBI and control groups may be due in partto the broad range of education representedin both groups. A greater degree of overlapin discourse performance has been reported



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by other investigators. For example, Body andPerkins20 derived composite scores from severaldiscourse measures including content organiza-tion for 20 adults with TBI and 20 controls,

and although there were significant group dif-ferences, only 3 individuals with TBI fell out-side the normal range. These studies need tobe replicated in a prospective manner, but itappears that measuring the amount and organ-ization of content was more important in dis-tinguishing impaired from normal discoursethan measures of language form.

CONVERSATIONAL DISCOURSE

Twelve studies of conversational discourse wereidentified, involving 200 children and adultsranging in age from 6 to 61 years. Among themany analysis procedures used, the most com-mon was a rating scale, such as Damicos41

Clinical Discourse Analysis42,43 or Pruttingand Kirchners44 Pragmatic Protocol.45,46

More objective analyses examined such dimen-sions as prompt frequency and turn duration,47

topic management,38,39,48 response appropri-

ateness,38,48 intonation units,39,49 compensa-tory strategies,50 and phonologic and lexicalproduction, syntax, and productivity.51,52

Pragmatic rating scales are typically em-ployed during live or videotaped interac-tions.41,44,45,5356 Although there is overlapamong dimensions rated within these scales,each scale has a rather novel approach to look-ing at conversation. For example, some scalesrate both nonverbal behaviors (e.g., intonation,

facial expression, eye contact, gesture) andverbal communication (conversation initiation,turn taking, topic maintenance, responselength, presupposition, and referencing),54

whereas others focus on specific aspects ofthe verbal message, such as intelligibility, sen-tence formation, and coherence of narrative.45

The Pragmatic Protocol, a theoretically basedscale developed for children, focuses on aspectsof pragmatics such as utterance acts (e.g.,

vocal intensity, voice quality, prosody), propo-sitional acts (e.g., lexical selection, word order,stylistic variations), and illocutionary and per-locutionary acts (e.g., speech acts, topic, turntaking).44,46 Other scales, such as DamicosClinical Discourse Analysis, are questionnaires

that are completed during an observation orfrom personal knowledge. They ask questionssuch as, Does [the] client make rapid andinappropriate changes in conversational topic

without clues to the listener, or fail to attend tocues for conventional turns, interrupting fre-quently or failing to hold up his or her end ofthe conversation? Although these scales arepotentially useful tools for rating communica-tive behaviors, most require training to achieveacceptable reliability, many are not well definedand have checklist items that do not representcontinuous variables, and none are supported byadequate data on normal performance.

Identification of Useful Analysis

ProceduresThe sampling and analysis of conversationaldiscourse are often more appealing to manyclinicians because of the interactive nature ofconversation and the fact that it occurs on adaily basis. However, like analysis of monologicdiscourse, analysis of conversational discoursecan be time consuming. Consequently, it is

important to identify the most useful analysisprocedures. To address this, the authors exam-ined the 12 studies on conversational discoursefor interjudge reliability, consistency of find-ings, their potential to distinguish normal fromimpaired conversational performance, and theinfluence of context.

INTERJUDGE RELIABILITY

Interjudge reliability was reported for seven ofthe eight studies that described objective meas-

ures of conversation and ranged from 0.67 to1.0. The measures that fell below 0.80 includedaspects of Mentis and Pruttings39very complexanalysis of topic management and Jordan andcolleagues51 measures of frequency and type ofdisruptions within conversation. Reliabilityscores for the four studies that used rating scalesranged from .75 to 1.0, with the lower scores forErhlich and Barrys45 scale. These resultssuggest that, in general, adequate interjudge

reliability can be achieved for conversationalanalysis procedures.

CONSISTENCY OF FINDINGS

Although few of the studies used the samemeasures, the results could be classified into



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two broad categories: (1) decreased initiation48

and maintenance of conversational topics39,48

and (2) errors of content conveyed during con-versation, including findings of verbal disrup-

tions and problems with word finding,51

errorsin the transfer of information,33 and decreasedresponse adequacy.38,48 Conversations of indi-

viduals with TBI were characterized by moreturns and shorter, less complex utterances.48,52

Overall, measures of content and topic manage-ment appeared most useful for identifying con-

versational impairments.Two studies using pragmatic rating scales

identified subtle communication impairmentsin the presence of near-normal scores on stand-ardized language batteries.45,46 In addition,these two studies revealed that, regardless ofinjury severity, individuals with TBI demon-strated a higher incidence of pragmatic errorsthat normal controls. It is important to notethe scales limitations, however, as discussedpreviously.

DISTINGUISHING IMPAIRED

PERFORMANCE FROM NORMAL

Coelho and colleagues40 applied DFA tonarrative discourse data to examine how accu-rately various measures of conversation couldidentify group membership of the 32 adults

with TBI and 43 noninjured adults. The twoprimary measures that contributed most to thebetween-groups discrimination were comments(utterances that were not necessarily directresponses to questions but kept the conversa-tion flowing) and response-plus utterances (ut-

terances that provided more information thanwas requested). The TBI group had fewercomments and more response-plus utterancesthan the controls. The results indicated that theconversational measures correctly classifiedmore than 77% of the participants, 78% of the

TBI group and 72% of the noninjured group.40

Once again, it is important to note that theperformance of the noninjured group over-lapped that of the TBI group. The two meas-ures that made the greatest contribution to theDFA procedure, comments and adequate-plusutterances, are consistent with the two generalcategories of results presented earlier for theobjective conversational measures. The measurecomments fits within the category of de-

creased initiation and maintenance of conversa-tional topic, and the number of adequate-plusutterances fits into the category related torelevance of conversational content.

EVALUATION OF COMMUNICATION

CONTEXT

Togher and colleagues5759 have written exten-sively about the potential influences of variousdimensions of the communicative context onconversational performance. As described bythese authors, context is a combination of threecomponents: field, mode, and tenor. Fieldpertains to the nature of the social interactiontaking place (e.g., a speech versus a conversa-tion with friends). Mode refers to the modalityby which the discourse is produced (e.g., writ-ten or oral). Tenor describes those who areinvolved in the interaction, their relationshipto each other, and their roles or status (e.g.,teacher and student, two strangers, clerk andcustomer).58 Two additional components aregenre, which pertains to the influence of cultureon language (i.e., the step-by-step structure

that is followed to achieve goals), and ideology,which is the participants biases and personalperspectives. As a speaker produces an utter-ance, he or she makes choices about what is tobe said and how it will be said, and this isinfluenced by the listener and situation. Togherand colleagues stated that these contextualfactors should be considered in the analysis ofconversational exchanges.

GENERAL CONCLUSIONS

REGARDING DISCOURSE

ANALYSES

1. The review of 18 studies of monologicdiscourse in individuals with TBI identifiedanalysis procedures for which consistentfindings of impairment have been reported.

These included analyses of productivityand efficiency of verbal output, contentaccuracy and organization, story grammar,and coherence. Analyses of syntax, gram-matical complexity, and cohesion yieldedinconsistent findings across the studiesreviewed.



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2. The review of 12 studies of conversationaldiscourse following TBI indicated thatfew of the studies used similar measures.

The variety of measures employed could

be grouped into two categories: measuresof initiation and measures of manipulationof content. Overall, measures of contentand topic management appeared mostuseful for identifying conversationalimpairments.

3. Pragmatic rating scales are useful in thatthey may capture real-world communicationdifficulties. However, most scales require aperiod of training before they can be usedreliably and many scales are weak in basicpsychometric properties.

4. The interpretation of discourse analysesmust consider context factors.

5. Measures of conversational discourse appearbetter able to discriminate TBI and nonbrain-injured groups than measures ofmonologic discourse. This may be accountedfor by the interactive nature of conversationas well as social factors that appear to makethis genre more sensitive to the cognitive-

communicative impairments of individualswith TBI.

6. There is a need for further research toestablish the ecological validity of discoursemeasures outside the experimental settingsin which data are typically collected.

NONSTANDARDIZED ASSESSMENT

OF SOCIAL COGNITION

As is evident from the preceding review, therehave been many studies focusing on productionaspects of communication. By contrast, therehas been considerably less attention to measur-ing comprehension, particularly for pragmaticaspects of communication. This aspect of com-munication falls within the domain of socialcognition, which includes the cognitive proc-esses required for the perception and compre-hension of social stimuli and the ability touse the products of these processes to makesocial decisions. There are no norm-referencedtests of social cognition, so typically it is as-sessed with either nonstandardized measures(e.g., clients responses to what if. . . socialscenarios) or standardized tasks from the re-

search literature. The latter are primarilyfrom the area of autism,6062 although a fewtasks have been standardized for individuals

with TBI63,64 and other neurogenic communi-

cation disorders.6568

This is a relatively newarea of clinical assessment in TBI, and muchwork remains to be done before it is possibleto establish an evidence base for clinicalpractice.

CONTEXTUALIZED HYPOTHESIS

TESTING

In several publications, Ylvisaker and col-leagues69,70 proposed the use of an assessmentprocess referred to as collaborative contextual-ized hypothesis testing. This process has itsconceptual roots in three distinct traditions:(1) the dynamic assessment movement in edu-cational psychology dating back to the work ofVygotsky71 and elaborated by Feuerstein,72

Lidz,2 and others; (2) process assessment aspracticed in adult neuropsychology3; and (3)functional behavior assessment as practiced bybehavioral psychologists. Dynamic assessment

has been validated as a procedure used to deriveinstructional methods and supports for individ-ual students.73

Functional behavior assessment has longbeen used to derive effective behavioral inter-

ventions.74,75 Indeed, functional behavior as-sessment is considered an integral and criticalcomponent of behavioral interventions, includ-ing most of those reviewed by Ylvisaker andcolleagues (this issue). What follows is a ration-

ale for each component of collaborative, con-textualized hypothesis-testing assessment whenthe goal is creation and monitoring of a pro-gram of cognitive, behavioral, communication,and/or educational/vocational interventionsand supports.

Why Test Hypotheses?When complex individuals experience aca-demic, vocational, or social difficulty, thereare inevitably alternative possible explanationsfor their difficulty and alternative possible in-terventions or supports that might help.Failure to perform any given real-worldtask effectively (e.g., reading a chapter and



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answering questions, maintaining a social con-versation, effectively organizing a work task)can be explained by reference to a wide varietyof possible breakdowns. As a corollary, a variety

of modifications and supports hold the poten-tial to improve performance. In the case ofindividuals with TBI, this variety is exaggeratedby the potentially bewildering pattern of dam-aged and preserved parts of the brain, oftenaccompanied by complex emotional and behav-ioral reactions after the injury and frequently bysome type of disability before the injury. There-fore, without experimentation it is never possi-ble to know with certainty how to interpretfailure on a test or other task or what recom-mendation would be most effective in improv-ing performance. In Table 1, failure on areading task is used to illustrate the need fordynamic experimentation.

Why Collaborate in Testing

Hypotheses?Ideally, educational, vocational, and social-communication assessments include contribu-

tions from all of the members of the professio-nal team (including assistants) as well as familymembers, the person with disability, andpossibly others. The most obvious reason topromote collaboration in assessment is that itincreases the number of people available tointeract with and observe the individual in

varied contexts, to brainstorm about hypothesesthat need to be tested, to test those hypotheses,and to apply the results of the experimentsto planning and implementing intervention.Related to this advantage, collaborative assess-ment in this shared professional territory helpsto promote collegiality and cohesion withinteams of professionals.

Table 1 Potential Hypotheses That Might Explain Failure on a Reading Comprehension Task.Hypothesis-Testing Assessment Is Designed to Rule in or Rule out Potential Hypotheses

Physical Problems

Fatigue, hunger, pain, illness, overmedication, undermedication, subclinical seizures

Sensory/Perceptual Problems

Visual acuity impairment, visual perceptual impairment, problem with tracking/scanning

Cognitive/Executive Function Problems

Attention: Inadequate sustained attention, distractibility/weak filtering, inability to divide attention, difficulty

shifting from the previous task (stuck in set)

Orientation: Unclear orientation to task

Working Memory: Insufficient space in working memory to hold the task instructions, reading strategies,

and information from the paragraph

Self-Monitoring: Failure to recognize that the task is difficult and requires special strategic effort

Organization/Integration: Difficulty organizing information to comprehend the text, to understand how

details relate to each other, to understand how the questions relate to the text, or to formulate an

organized answer

Cognitive Problems

Memory: Difficulty encoding the information for subsequent storage and retrieval, storing information long

enough to answer the questions, or retrieving information from storage to answer the questions

General Speed of Information Processing: Slow processing of information

Knowledge Base: Insufficient background knowledge to comprehend the passage

Language Problems

Unable to comprehend the vocabulary or syntax of the text or questions; difficulty retrieving words to

answer the questionsAcademic (Decoding) Problems

Impaired or nonfluent decoding of printed language

Emotional/Motivational/Behavioral Problems

Depression, anxiety, fear, anger, general lack of motivation, oppositionality, or euphoria



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In addition, if staff and family memberswho interact with the person on a daily basis areactive collaborators in identifying what causesbreakdowns in functioning and what can be

done to improve performance, the likelihood oftheir compliance with the recommendationsthat emerge from this assessment is increased.In contrast, when staff and family members aresimply told what to do by a specialist who hasunilaterally completed an assessment (whichmay appear mysterious to other staff and familymembers), they often understandably resistthese instructions and follow their own in-stincts. This may be due to a genuine differenceof opinion, a lack of understanding, or simpleoppositionality. Collaborative assessments holdthe promise of diminishing all of these sourcesof noncompliance, much as they do in the fieldof applied behavior analysis.

Finally, collaborating with individuals withdisability in assessment serves two purposes:(1) it helps them understand their disabilityand its connection to the intervention andsupport program and (2) in some cases, ithelps to overcome the persons oppositionality.

Ylvisaker, Szekeres, and Feeney76 offered a toolfor student self-assessment and participation indeveloping educational intervention and sup-port plans.

Why Test Hypotheses in the Real

Contexts of the Individuals Life?Hospital personnel, educators, parents, andothers often observe that the behavior of

many individuals with TBI is inconsistent,varying from day to day and situation to sit-uation. The contributors to this inconsistencyare often elusive. However, factors that arerelatively predictable in their negative effecton performance include fatigue, cognitive orsocial stress, anxiety, depression, complexityand novelty of the task, organizational demandsof the task, environmental interference, lack ofmotivation, and others. It is in part for thiscomplex of reasons that many individuals withfrontal lobe injury perform better on stand-ardized tests in a controlled testing environ-ment than in stressful real-world contexts. Thesupportive interactive manner of the examiner,clear orientation to the tasks, elimination of

environmental distractions, use of relativelyshort tasks, and use of tasks that do not requireintegration of multiple sources of informationor retention from day to day combine to elevate

performance in a person who may have diffi-culty performing effectively on real-world tasksin a busy classroom or workplace or in astressful or novel social situation.

Furthermore, formal testing situationsrarely require that individuals initiate behavioron their own (they are told when to start andstop), inhibit irrelevant behavior (the examinergenerally keeps the individual on task), monitorand evaluate performance (the examiner eval-uates the results), or think of clever ways tosucceed that may be outside the limits of thetest (e.g., asking to take notes when listeningto a paragraph during a test of auditory com-prehension). It is for these reasons that manyclinicians have characterized examiners asprosthetic frontal lobes and have questionedthe validity of test results for persons withfrontal lobe injury. Alternatively, people with

TBI may perform poorly on test tasks thatare unfamiliar or unmotivating and proceed to

perform surprisingly well in real-world educa-tional or vocational settings, given the supportprovided by familiar routines and motivatingtasks.

Therefore, it is critical that educationaland vocational assessments include proceduresdesigned to identify carefully and systematicallystrengths and weaknesses of the individualsperformance in relation to a variety of contex-tual variables, including settings, people,

times of day, activities, materials, instructions,and supports. It is especially important forrehabilitation hospital staff to simulate aneducational or vocational setting and activ-ities prior to making educational or vocationalrecommendations.

Procedures that enhance sensitivity to con-text can include the primary evaluator makingstructured and unstructured observations in

varied settings and also obtaining reports fromothers through standardized questionnaires orinformal interviews. It is most useful, however,to engage everyday people in the individualslife (e.g., family members, therapists, teachers,assistants) in the process of collaborative hy-pothesis testing. In addition to ensuring that



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the assessment is relevant to planning interven-tion, this practice has the other advantagesassociated with collaboration and hypothesistesting (listed earlier).

Why Continue the Exploration in an

Ongoing Manner?Following severe TBI, neurologic change maycontinue for months and often longer. Becausethis change can be rapid in the early monthsafter the injury, the results of formal assess-ments may be invalid (for purposes of planninginstruction or intervention) by the time thetesting is completed and interpreted and thereports are written and disseminated. Second,even in the absence of neurologic change, in-dividuals with TBI often have very complexprofiles of ability and need, necessitating fre-quent modification and refinement of theirrehabilitation, vocational, and educational pro-grams. Ongoing dynamic assessment contrib-utes to this process. Third, it is well known that

TBI in children and adolescents, especially withprefrontal injury, is associated with consequen-

ces that may not be noted for months or yearsafter the injury.

Fourth, the individuals psychological re-actions after a life-altering injury are nevercompletely predictable and can vary over time.

Therefore, ongoing assessment of emotionalreactions to the injury and life after the injuryis a responsibility of the intervention team.Finally, the persons response to placements,supports, and specific intervention plans can

vary over time. For example, one-on-one sup-port may be a useful during the early weeks afteran individuals return to work or school butlater may become unnecessary (or a possiblecontributor to learned helplessness). For all ofthese reasons, a system for ongoing dynamicassessment is preferable to (or at least supple-ments) an assessment that captures only one ora small number of discrete points in the indi-

viduals life after the injury.

COMMUNICATION CHECKLISTS

The checklists developed by Hartley77 are ex-amples of tools designed to evaluate communi-cation in everyday contexts. In this section, we

report on the interjudge reliability, consistencyof findings, and discrimination ability of severalof these checklists. The first considered was theGeneral Behavioral Observation Form,77(p. 234)

which asks raters to characterize an individualscognitive functions (e.g., attention, executivefunctions/metacognition, processing and re-sponse speed, emotional control, drive andmotivation, and memory) as within normallimits, not able to judge, or area of needand provide comments. Each cognitive skill isdivided into subskills or characteristics. Forexample, there are three items for memory:repetition needed, reauditorization, and con-fabulation/intrusions.

Hartley created an Environmental NeedsAssessment checklist (also reproduced in refer-ence 77) for the evaluation of living/family,general community, work, and educational en-

vironments. This checklist asks respondents toevaluate current and projected environmentalcharacteristics, such as type of setting andactivities that will be expected of that individualor provided by others (e.g., meal planning,home repairs, going to restaurants or social

service agencies, note taking in class), and tocomment on the social interactions of theexaminee (e.g., appropriateness, responsivenessto needs of others). A regular contact person isidentified, and there is space to add informationabout current and projected educational plansas well as work placement information. Foreach activity, the respondent is asked to ratethe individuals level of independence on a five-point scale from totally independent to totally

dependent.A third assessment tool is the Checklist ofListening Behaviors.77 This checklist asks therespondent to rate the frequency of a list oflistening behaviors in conversation. The check-list items include maintaining a proper level ofarousal, inhibiting thoughts, maintaining eyegaze toward the speaker, refraining from inter-rupting, and asking for clarification when un-sure of a message. Judgments are made on afive-point scale from almost never to alwaysand the respondent is given space to providecomments on each item.

Hartley77 also reviewed checklists pub-lished by others, such as the Pragmatic Proto-col,32 and presented tables of skill and cueing



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hierarchies that could be adapted as checklistsfor evaluation. For example, she created atable relating communication behaviors tounderlying cognitive functions that could serve

as framework for evaluation of cognitive-communication ability.


Procedures

Interjudge reliability. No interjudge reliabilityscores were reported for any of Hartleyschecklists.

Consistency of findings. There are insufficientstudies of Hartleys checklists to report onthe consistency of findings.

Potential to distinguish impaired from normalfunctioning. Once again, although no studieshave been published that used Hartleyschecklists to distinguish participants with

TBI from noninjured participants, the facevalidity of these procedures appears high.

COMMUNICATIVE PROFILINGSYSTEM

The Communicative Profiling System (CPS)78

was developed to describe and analyze commu-nicative and social interaction and to assist inorganizing management planning for individ-uals with aphasia. Although the CPS has neverbeen described as a measure for individuals with

TBI, this procedure has great potential fordocumenting decreased socialization, a real-

world consequence of TBI frequently neglectedin treatment programs. The procedures involvea stepwise and cyclical system that moves from abroad description of behaviors, people, andsituations to a more narrow focus on commu-nicative behaviors and contexts deemed impor-tant to the individual being profiled. Data arederived from ethnographic interviews supple-mented by participant observations. These dataare then used to plot profiles of the individualssocial network and create a general behavioralinventory, affective inventory, and participationinventory. Using these procedures, Damico andSimmons-Mackie have profiled participantssocial networks before and after the onsetof aphasia. What is typically seen after onset

is a network that has shrunk and lost nodes.The nodes represent either social situationsthe individual no longer feels comfortableparticipating in or people the individual no

longer sees or interacts with socially. Thesepre- and postonset social network profiles arethen used to plan intervention activities di-rected toward reexpanding an individuals socialnetworks.


Procedures

Interjudge reliability.The CPS has not yet beenpublished as a formal scale, so no data re-garding its interjudge reliability are currentlyavailable.

Consistency of findings.There are few publishedreports on the use of the CPS; therefore, theconsistency of findings cannot be ascertained.

Potential to distinguish impaired from normalfunctioning. The CPS was not designed todiscriminate impaired from normal function-ing. Rather, it is intended to be used to

obtain baseline information to comparechanges in an individuals social networkover time.

ANALYSIS OF COMMUNICATION

PARTNER COMPETENCIES

Ylvisaker and colleagues79 presented a list ofcommunication partner competencies derivedfrom an extensive literature on parent-child

interaction in developmental cognitive psychol-ogy. Studies of normal cognitive developmentin children have shown that parents who con-

verse with their children using a responsiveand supportive style of interaction facilitatethe cognitive development of their childrenin domains that include memory, organizedthinking, problem solving, and organized lan-guage.8085 Landry and colleagues86,87 showedthat a positive parental style of interactionfacilitated cognitive and executive system de-

velopment in normal and high-risk childrenand that this style can be taught to parents

who do not possess it naturally. All of thestudies were conducted within a generallyVygotskyan framework in which facilitative



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conversations are considered scaffolding forcognitive growth or recovery.

Many of these studies have focused onsocially coconstructed (i.e., parent-child) narra-

tive conversations about jointly experiencedpast events. However, the facilitative effects ofthis style can be associated with conversationsabout any topic, including problem-solvinginteraction. Conversely, a nonsupportive, per-formance-oriented style of interaction can elicitnegative behavior from individuals who feelthreatened by ongoing tests. Furthermore, astyle of interaction that is disjointed and poorlyorganized around extended topics can contrib-ute to fragmentation in the thinking of cogni-tively challenged individuals.

Ylvisaker organized the checklist of com-petenciesassociated with an interactive stylethat is known to facilitate cognitive develop-mentunder two headings: elaboration andcollaboration. An elaborative style is one in

which the partner shows the child or personwith cognitive impairment how to remember,organize, reflect, and problem solve at a higherlevel. A collaborative style is one in which the

conversational relationship is symmetrical andreciprocal and not performance oriented.

This list of competencies has been used inassessing communication partners (e.g., directcare staff in residential or community-basedrehabilitation programs) and in the training ofpartners of both children and adults with TBI.However, neither the validity of the assessmentnor the effectiveness of the training has beensystematically studied with these populations.

Thus, supportive data are available only fromstudies of other populations.Blosser and Neidecker88 created the Com-

munication Style Identification Checklist toprovide a systematic method for helpingpeople analyze and describe their own interac-tive communication manner and style.89(p. 131)

Blosser and DePompei89 recommended its useeither as a format for discussion or for a pro-fessional to use independently. The scale invitesthe respondent to characterize his or her com-munication style in several categories, includingspeech rate, length and complexity of sentences,

word choice, attentiveness during conversa-tions, organization of conversations, and pa-tience while waiting for a response. The

respondent then evaluates how each character-istic might affect the communication of thepartner with a communication disorder.

A useful companion to the Communica-

tion Style Identification Checklist is a work-sheet for a child or adolescent to complete,titled Let Us Know How to Help You.89

This worksheet appeals to the childs expertiseas the best judge of how other people can causeproblems for you or help you do better(p. 133). It includes 10 questions that lead thechild to identify problems at home, school, or

work; reactions to those problems; problemclassroom situations (e.g., noise); and whatteachers and classmates can do to help or

what they do that causes problems. The work-sheet ends with a request for three skills thatchild would like to improve and a request totell five things that are great about you that you

wish other people would know (p. 133).Systemic Functional Linguistics (SFL)

describes language as a series of choices.90,91

Togher and colleagues5759 studied whetherparticipants with TBI and a comparison groupof uninjured adults altered their communicative

behavior with different conversational partnerswho varied in terms of familiarity (e.g., aninformation operator at a bus station, a police-man, their mother, or a therapist). The authorsfound that therapists and mothers gave lessinformation to those with TBI, therapists askedfewer questions of those with TBI and gener-ated more clarifications and checking utteran-ces with this group, and the police asked morequestions of the TBI group than the compar-

ison group. In regard to individuals with TBIversus their uninjured peers, the results were asfollows: (1) the TBI group produced moreinformation in the police encounter and someof the information offered was inappropriate(i.e., more information than was requested);(2) they provided more information in theirinteractions with the police than in those withthe therapists or the operators at the bus sta-tion, in part because of the greater number ofquestions produced by the police; (3) TBIgroup participants provided less informationto their mothers, as the mothers did not requestmuch information from them; (4) they re-quested more information from the therapistsand generated more requests for clarifications



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than did their uninjured peers; and (5) theyasked for clarifications more with the policethan with their mothers or the operators at thebus station. Overall, the results indicated that

the discourse performance of the participantswith TBI varied according to their conversa-tional partner. These and other findings of

Togher and colleagues illustrate the promiseof SFL for revealing competencies and limita-tions in individuals with TBI in a variety ofreal-world contexts.


ProceduresInterjudge reliability. No interjudge reliabilityscores have been reported for either the

Ylvisaker et al79 or Blosser and Neidecker88

checklists. Togher and colleagues have reportedintra- and interjudge reliability scores for theSFL procedures ranging from 82 to 96%.

Consistency of findings. There are insuffi-cient studies of the Ylvisaker et al79 and Blosserand Neidecker88 checklists to report on theconsistency of findings. Togher and colleagues

have been the only group to report on theapplication of SFL procedures to the study ofdiscourse impairments. Their findings havedemonstrated that the elaborate SFL analysisprocedures are useful for delineating the com-plex interactions of participants and context indiscourse.

Potential to distinguish impaired from nor-mal functioning. No studies have been publishedthat used the Ylvisaker et al79 or Blosser and

Neidecker88

checklists to distinguish partici-pants with TBI from uninjured participants;however, the checklists appear to have strongface validity. The SFL analyses have consis-tently documented group differences between

TBI and matched control groups for variousdimensions of interactional discourse.

SUMMARY AND

RECOMMENDATIONS

Nonstandardized, functional, and context-sen-sitive assessment is an important component ofthe evaluation of individuals with TBI. Thisconclusion is based on the observation thatindividuals with TBI often demonstrate limi-

tations in everyday activities despite goodperformance on standardized cognitive andlanguage tests. When the primary goals ofassessment are to identify real-world disability

and plan and monitor intervention, office-bound language and neuropsychological testingmust be supplemented by nonstandardized,functional assessment procedures. Evidencefor the use of nonstandardized assessment pro-cedures was compiled from a review of studiesand published expert opinion as well as a surveyof speech-language pathologists working withindividuals with TBI. On the basis of thisevidence, the following recommendations areoffered:

1. For individuals with cognitive-communica-tive disorders after TBI, there is substantialevidence to support the assessment of com-munication beyond what is included instandardized aphasia or child language bat-teries. Whenmonologicdiscourse is assessed,the literature to date supports inclusion ofanalyses of productivity and efficiency of

verbal output, content accuracy and organi-

zation, story grammar, and coherence. Forconversationaldiscourse, analyses should in-clude measures of initiation and manipula-tion of content during interactions. In allinstances, it is critical to consider the poten-tial influences of context (i.e., nature of thesocial interaction, modality by which thediscourse is produced, and the relationshipand roles of participants in the interaction).

2. Impairments of social cognition present sig-

nificant barriers to community reintegra-tion. Ongoing research is needed todevelop measures that address how indivi-duals with TBI make social decisions in real-life situations.

3. There is extensive evidence in the TBIliterature that collaborative contextualizedhypothesis testing should be used for plan-ning behavioral interventions and supports.Further, dynamic assessment applied toother related populations supports the no-tion of applying this technique for TBI indomains other than behavior. Finally, colla-boration and context sensitivity have content

validity in relation to the characteristics ofthe population when the goal is planning



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behavioral interventions and supports,although no specific procedures have been

validated.4. Limited research has been conducted on the

competencies of communication partnerswho interact with individuals with TBI.Application of exchange structure and gen-eric structure analyses have been shown to beuseful for delineating complex interactionalpatterns. Various checklists related to theassessment of communication partners haveapparent content validity but need addi-tional study and should be used judiciously.

5. Checklists pertaining to the communicationenvironment and environmental demandshave face validity; however, they requireongoing study and findings should be inter-preted with caution.

ACKNOWLEDGMENTS

This work was supported by funding from theAmerican Speech-Language-Hearing Associa-tion (ASHA), ASHA Division 2: Neurophysi-ology and Neurogenic Speech and Language

Disorders, and the Department of VeteransAffairs.

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