UBC Theses and Dissertations

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UBC Theses and Dissertations

Social skills training for head injured adults Pope, Dorothy Mae 1987

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SOCIAL S K I L L S TRAINING FOR HEAD INJURED ADULTS by DOROTHY MAE POPE • S.W., The U n i v e r s i t y o f B r i t i s h Co 1umbia,1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTER OF SOCIAL WORK i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l o f S o c i a l Work) We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA J u n e 1987 D o r o t h y Mae Pope,1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of £tec£ <-6tJe>'>£. • The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date DE-6(3/81) i i ABSTRACT S o c i a l S k i l l s T r a i n i n g f o r Head I n j u r e d A d u l t s R e s e a r c h h a s d e m o n s t r a t e d n u m e r o u s p e r s o n a l i t y a n d b e h a v i o r a l d i s t u r b a n c e s r e s u l t i n g f r o m h e a d i n j u r y ( L e z a k , 1 9 7 8 ) . I t i s t h e s e c h a n g e s r a t h e r t h a n t h e p h y s i c a l d i s a b i l i t i e s t h a t c r e a t e t h e s t r e s s , i n t h e l o n g t e r m f o r t h e r e l a t i v e s o f t h e h e a d i n j u r e d ( M e K i n l e y , 1 9 8 1 ) . T h e r e f o r e , s o c i a l s k i l l s t r a i n i n g i s a i m p o r t a n t p a r t o f i n t e r v e n t i o n w i t h t h i s p o p u l a t i o n . T h i s s t u d y e v a l u a t e s a s o c i a l s k i l l s t r a i n i n g p r o g r a m " S t a c k i n g t h e D e c k " ( B r a u n 1 i n g - M c M o r r o w e t a l 1986 ) w h i c h h a s b e e n m o d i f i e d t o i n c l u d e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . T h i s i s a s i n g l e c a s e e v a l u a t i o n (A - B a s e l i n e , B - T r e a t m e n t ) w i t h r e p l i c a t i o n . The s u b j e c t s a r e f o u r m a l e s w i t h s e v e r e h e a d i n j u r i e s , a g e s 1 9 , 2 2 , 3 4 , a n d 3 6 . S o c i a l s k i l l s w e r e d e s c r i b e d a s r e q u i r i n g an a c t i o n o r r e a c t i o n w i t h i n s i x s k i l l a r e a s : c o m p l l m e n t s , s o c i a l i n t e r a c t i o n , p o 1 i t e n e s s , c r i t i c i s m , s o c i a l c o n f r o n t a t i o n , a n d q u e s t i o n s / a n s w e r s . M e a s u r e s i n c l u d e t h e b a s e l i n e d e v e l o p e d i n t h e " S t a c k i n g t h e D e c k " p r o g r a m , S t a f f Q u e s t i o n n a i r e on S o c i a l B e h a v i o r ( S p e n c e , 1 9 7 9 ) a n d t h e S o c i a l S k i l l s A s s e s s m e n t C h a r t ( S p e n c e , 1 9 8 0 ) . R e s u l t s i n d i c a t e t h a t t h i s i s a n e f f e c t i v e p r o g r a m f o r s o c i a l s k i l l s t r a i n i n g w i t h t h e a d u l t h e a d i n j u r e d p o p u l a t i o n . i i i TABLE OF CONTENTS INTRODUCTION 1 CHAPTER i . THE CONSEQUENCES OF HEAD INJURY 3 P s y c h o s o c i a l F u n c t i o n i n g and Head I n j u r y 11 CHAPTER 2. RESEARCH PROBLEM 22 S u b j e c t s 34 CHAPTER 3. RESEARCH DESIGN 39 P r o c e d u r e 50 CHAPTER 4. METHODOLOGICAL ISSUES 74 P r e v i o u s Work i n S o c i a l S k i l l s T r a i n i n g 84 CHAPTER 5. FINDINGS 92 CHAPTER 6. IMPLICATIONS AND CONCLUSIONS 125 APPENDIX 138 REFERENCES 160 L i s t o f T a b l e s T a b l e 1 I m p o r t a n t V a r i a b l e t o C o n s i d e r i n E v a l u a t i n g L i k e l y Outcome of R e h a b i l i t a t i o n o f Head I n j u r e d A d u l t s 9 T a b l e 2 C r i t e r i a F o r D e t e r m i n i n g C o r r e c t R e s p o n s e s 53 T a b l e 3 I n t e r - r a t e r R e l i a b i l i t y i n " S t a c k i n g t h e Deck" 72 T a b l e 4 I n t e r - r e a t e r R e l i a b i l i t y - A s s e s s m e n t C h a r t 73 T a b l e 5 P l a y e r P r o g r e s s G r a p h S u b j e c t 1 93 T a b l e 6 S o c i a l S k i l l s A s s e s s m e n t C h a r t S u b j e c t 1 94 T a b l e 7 A v e r a g e Number o f Words p e r R e s p o n s e 99 T a b l e 8 P l a y e r P r o g r e s s G r a p h S u b j e c t 2 103 T a b l e 9 S o c i a l S k i l l s A s s e s s m e n t C h a r t S u b j e c t 2 104 T a b l e 10 S t a f f Q u e s t i o n n a i r e S u b j e c t 2 110 T a b l e 11 P l a y e r P r o g r e s s G r a p h S u b j e c t 3 I l l T a b l e 12 S o c i a l S k i l l s A s s e s s m e n t C h a r t S u b j e c t 3 112 T a b l e 13 S t a f f Q u e s t i o n n a i r e S u b j e c t 3 116 T a b l e 14 P l a y e r P r o g r e s s G r a p h S u b j e c t 4 . 118 T a b l e 15 S o c i a l S k i l l s A s s e s s m e n t C h a r t S u b j e c t 4 119 T a b l e 16 S t a f f Q u e s t i o n n a i r e S u b j e c t 4 121 V ACKNOWLEDGMENTS I w o u l d l i k e t o e x p r e s s my a p p r e c i a t i o n t o my t h e s i s c o m m i t t e e , P r o f . J o h n C r a n e , P r o f . Nancy Wax 1 e r - M o r r i s o n , and Mr. B e r t Forman, D i r e c t o r o f S o c i a l S e r v i c e s , G.F. S t r o n g R e h a b i l i t a t i o n C e n t r e , f o r t h e i r g u i d a n c e and e n c o u r a g e m e n t . A s p e c i a l t h a n k you t o Mr. D a v i d K a b o o l , S o c i a l W o r k e r , G.F. S t r o n g R e h a b i l i t a t i o n C e n t r e , f o r h i s a s s i s t a n c e and f o r s h a r i n g h i s k n o w l e d g e and e x p e r t i s e on head i n j u r i e s . I am e s p e c i a l l y g r a t e f u l t o t h e s t a f f , p a t i e n t s and r e s i d e n t s o f G.F. S t r o n g R e h a b i l i t a t i o n C e n t r e and K i n g Edward House f o r t h e i r c o - o p e r a t i o n w i t h t h i s p r o j e c t . 1 INTRODUCTION A f t e r a s e v e r e head i n j u r y , t h e r e i s a c r i t i c a l p e r i o d when s u r v i v a l i s t h e m a i n i s s u e . Due t o i m p r o v e m e n t s i n m e d i c a l t e c h n o l o g y i t i s i n c r e a s i n g l y l i k e l y t h a t p a t i e n t s w i t h s e v e r e head i n j u r i e s w i l l s u r v i v e . However, a c o n s i d e r a b l e number w i l l r e m a i n h a n d i c a p p e d and t h e s e w i l l p l a c e a b u r d e n on t h e i r f a m i l i e s and a demand on r e h a b i l i t a t i o n s e r v i c e s . T h e r e i s no q u e s t i o n t h a t head i n j u r y i s a m a j o r h e a l t h p r o b l e m a l t h o u g h t h e p r e c i s e r a t e o f o c c u r r e n c e i s d i f f i c u l t t o o b t a i n . B a s e d on r e c e n t p o p u l a t i o n and p r e v a l e n c e s t a t i s t i c s , a u t h o r i t i e s e s t i m a t e 200-300 new head i n j u r i e s p e r .100,000 p o p u l a t i o n i n t h e U n i t e d S t a t e s ( H a b e r m a n n , 1 9 8 2 ) . L y n c h r e p o r t s t h a t one p e r s o n i n 200 i n t h e U n i t e d S t a t e s w i l l r e q u i r e m e d i c a l c a r e f o r head i n j u r y . S i n c e many of t h e s e v i c t i m s a r e young and w i l l p r o b a b l y s u r v i v e 30 t o 40 y e a r s b e y o n d t h e i n i t i a l t r a u m a ( J e n n e t t , 1 9 7 5 ) t h e r e i s an i n c r e a s i n g number of i n d i v i d u a l s s u f f e r i n g l a t e e f f e c t s o f t r a u m a t i c head i n j u r y . F i g u r e s a r e n o t as r e a d i l y a v a i l a b l e f o r C a n a d i a n s s u f f e r i n g f r o m head i n j u r i e s b u t t h e numbers a l t h o u g h p r o b a b l y n o t as l a r g e as i n t h e U n i t e d S t a t e s a r e s t i l l s i g n i f i c a n t . 2 The h i g h e s t p e r c e n t a g e of r e p o r t e d head i n j u r i e s i n Canada, U n i t e d S t a t e s and i n A u s t r a l i a a r e t h e r e s u l t o f r o a d a c c i d e n t s w h i c h i n c l u d e m o tor v e h i c l e s , p e d e s t r i a n s , and c y c l i s t s . S c o t l a n d , w i t h i t s h i g h e r r a t e o f a l c o h o l i s m , has as many head i n j u r i e s f r o m a s s a u l t as f r o m r o a d a c c i d e n t s i n t h e young male p o p u l a t i o n ( H a b e r m a n n , 1 9 8 2 ) . Head i n j u r i e s may a l s o r e s u l t f r o m s t r o k e , f a l l s and work r e l a t e d a c c i d e n t s . Head i n j u r y r e s u l t s i n b o t h m e n t a l and p h y s i c a l d e f i c i t s i n w h i c h r e c o v e r y c a n t a k e many y e a r s . S e r v i c e s h ave n o t k e p t up w i t h t h e n e e d s of t h i s n e w l y d i s a b l e d p o p u l a t i o n t h a t has v e r y s p e c i a l n e e d s . As a r e s u l t , h e a d i n j u r e d p e r s o n s w i t h b e h a v i o r p r o b l e m s a r e o f t e n p l a c e d i n p s y c h i a t r i c o r g e r i a t r i c h o s p i t a l s , n o t b e c a u s e s u c h p l a c e m e n t s a r e s e e n as a p p r o p r i a t e , b u t b e c a u s e o t h e r s e t t i n g s a r e n o t a b l e t o cope w i t h t h e b e h a v i o r d i s o r d e r s (Eames & Wood,1985). I t i s o f t e n t h e l a c k o f a p p r o p r i a t e s o c i a l s k i l l s t h a t c a u s e t h e most p r o b l e m s f o r b o t h t h e p a t i e n t and h i s f a m i l y . T h i s s t u d y a t t e m p t s t o a d d r e s s t h e a p p a r e n t l a c k o f s o c i a l c o m p e t e n c e i n t h i s p o p u l a t i o n and e v a l u a t e s a p r o g r a m d e s i g n e d f o r t h e t e a c h i n g o f s o c i a l s k i l l s t o t h e a d u l t head i n j u r e d p o p u l a t i o n . 3 CHAPTER 1 THE CONSEQUENCES OF HEAD INJURY T h e r e a r e d i f f e r e n t t e r m s u s e d t o d e s c r i b e t h e c o n d i t i o n o f head i n j u r y , " b r a i n i n j u r e d " , "head i n j u r e d " , and " b r a i n damaged". F o r t h e p u r p o s e o f t h i s s t u d y , t h i s p o p u l a t i o n w i l l be r e f e r r e d t o as t h e 'head i n j u r e d ' , ' t h e p a t i e n t ' o r ' t h e i n d i v i d u a l ' . Many m i l d l y head i n j u r e d p e r s o n s r e t u r n t o t h e i r f o r m e r l i f e s t y l e s a f t e r o n l y a v e r y b r i e f s t a y i n t h e h o s p i t a l . M i l d l y i n j u r e d p a t i e n t s t e s t e d on s i m p l e m e a s u r e s o f l e a r n i n g and memory may show a r a p i d r e t u r n t o c o m p l e t e r e c o v e r y w i t h i n s i x months of i n j u r y . F o r t h e more s e v e r e l y i n j u r e d p a t i e n t s r e c o v e r y o f c o g n i t i v e f u n c t i o n s a p p e a r s t o be a t a maximum w i t h i n t h e f i r s t s i x months o f i n j u r y , b u t t h e r e a f t e r t h e y show s l o w e r r a t e s o f c h a n g e . However, i n d i v i d u a l r e c o v e r y c u r v e s show l a r g e v a r i a n c e i n p a t t e r n s o f r e c o v e r y ( B r o o k s e t a l . 1 9 8 4 ) . T h i s s t u d y i s c o n c e r n e d w i t h t h o s e p a t i e n t s who r e m a i n e d i n a coma f o r s e v e r a l d a y s o r weeks w h i c h i s t h e n f o l l o w e d by i n t e n s i v e c a r e i n an a c u t e c a r e h o s p i t a l and l a t e r by an o f t e n l o n g e r s t a y i n a r e h a b i l i t a t i o n h o s p i t a l . 4 T y p e s o f Head i n j u r y Head i n j u r y o r t r a u m a i s t h e r e s u l t o f e i t h e r an open o r c l o s e d i n j u r y . In open head i n j u r y t h e s k u l l and d u r a have been p e n e t r a t e d and d i r e c t t i s s u e damage o c c u r s . In t h i s i n j u r y t h e r i s k o f i n f e c t i o n i s h i g h . C l o s e d head i n j u r y ( CHI) i s more common and h e r e t h e s k u l l and d u r a have n o t b e e n p e n e t r a t e d , however, t h e b r a i n c e l l s a r e a f f e c t e d i n d i r e c t l y by p r e s s u r e r e s u l t i n g f r o m s w e l l i n g o r by an i n t e r r u p t i o n i n t h e b1ood f1ow. Head i n j u r i e s c a n c r e a t e d i f f u s e o r f o c a l b r a i n damage f r o m t h e i n i t i a l i m p a c t and f r o m s e c o n d a r y b r a i n damage. Habermann (1982) s t a t e s t h a t t h e i n i t i a l i m p a c t o f t e n i n c l u d e s : a) a f r a c t u r e o f t h e s k u l l w h i c h o c c u r s i n 80 p e r c e n t o f t h e c a s e s ( b a s i l a r f r a c t u r e s most common), b) c o n t u s i o n s o f g r e y m a t t e r ( o c c u r s a t t h e f o c a l p o i n t o f i m p a c t and on t h e u n d e r s u r f a c e o f t h e t e m p o r a l and f r o n t a l l o b e s ( r e g a r d l e s s o f t h e s i t e of i m p a c t ) , c ) d i f f u s e w h i t e m a t t e r l e s i o n s ( r e s u l t i n g f r o m t o r n n e r v e f i b e r s a t t i m e o f i m p a c t ) . 5 S e c o n d a r y b r a i n damage i s t h e r e s u l t o f : a) r a i s e d i n t r a c r a n i a l p r e s s u r e b) i n t r a c r a n i a l hematoma and c) i s c h e m i c b r a i n damage w h i c h c a n be e i t h e r f o c a l o r w i d e s p r e a d (Habermann, 1 9 8 2 ) . Newcombe s t a t e s t h a t many o f t h e symptoms s e e n a f t e r c l o s e d head i n j u r y a r e due t o c o n t u s i o n s o f t h e f r o n t a l l o b e s . M i d - b r a i n i n j u r y m i g h t a c c o u n t f o r some c a s e s o f p e r m a n e n t i n t e l l e c t u a l and e m o t i o n a l d i s a b i l i t y , w h i l e damage t o t h e f l o o r o f t h e t h i r d v e n t r i c l e may p r o v o k e d i s t u r b a n c e s i n s l e e p and s e x u a l a c t i v i t y , s e q u e l a e t h a t a r e d i f f i c u l t t o q u a n t i f y b u t a r e of m a j o r i m p o r t a n c e t o t h e p a t i e n t (Newcombe,1981). S t u d i e s o f t h e e f f e c t s o f a n g l e o f i m p a c t upon c e r e b a l i n j u r y h ave r e v e a l e d t h a t a g r e a t e r amount o f t i s s u e damage o c c u r s f o l l o w i n g a r o t a t i o n a l ( o b l i q u e ) r a t h e r a l i n e a r ( f r o n t - t o - b a c k and b a c k - t o - f r o n t ) m o t i o n . The s h e a r i n g e f f e c t s i n r o t a t i o n a l i m p a c t s r e s u l t i n more s u b s t a n t i a l damage t o b o t h c o r t i c a l and b r a i n s t e m s t r u c t u r e s ( L y n c h , 1 9 8 4 ) . S t r o k e , g u n s h o t and o t h e r s u c h wounds u s u a l l y p r o d u c e c o n f i n e d e f f e c t s and t h e r e f o r e , damage i s n o t a s w i d e s p r e a d as i n t h e c a s e o f c l o s e d head i n j u r y . 6 A n o x i a , p o i s o n i n g and e n c e p h a l i t i s may have s i m i l a r e f f e c t s and t h e r e f o r e p e o p l e s u f f e r i n g f r o m t h e s e c o n d i t i o n s have t h e same n e e d s as t h e head i n j u r e d p e r s o n . T h i s i s b e c a u s e g r o u p s of b r a i n c e l l s a r e d e s t r o y e d and n e u r o n a l c o n n e c t i o n s a r e d i s r u p t e d t h u s i n t e g r a t i o n o f d i f f e r e n t b r a i n p r o c e s s e s i s i m p a i r e d . As a - r e s u l t t h e e f f e c t s a r e c o m p l e x and s u b t l e and p s y c h o s o c i a l and e m o t i o n a l c h a n g e s d o m i n a t e o v e r p h y s i c a l o n e s . C o g n i t i v e and e m o t i o n a l h a n d i c a p s a r e t h e m a i n f a c t o r s i n l o n g t e r m d i s a b i l i t y . Newcombe r e p o r t s t h a t most of t h e r e c o v e r y t a k e s p l a c e i n t h e f i r s t few months and t h a t r e c o v e r y a f t e r t h i s t i m e may be r e l a t e d t o new ways of d o i n g t h i n g s . A s o c i a l l e a r n i n g model of r e h a b i l i t a t i o n t h e r e f o r e makes more s e n s e t h a n a p h y s i c a l r e s t o r a t i o n m o d e l . The G l a s g o w Coma S c o r e (GCS) i s u s e d t o d e f i n e head i n j u r y and i s b a s e d on t h e p o s t - t r a u m a t i c a m n e s i a (PTA) p e r i o d . The PTA i s d e f i n e d as t h e t i m e f r o m i n j u r y t o r e c o v e r y o f f u l l o r i e n t a t i o n t o t i m e , p l a c e and p e r s o n . The PTA i s b e l i e v e d t o c o r r e l a t e w i t h t h e r e - e s t a b l i s h m e n t of c o n t i n u o u s memory. T h i s s c a l e p r o v i d e s a s t a n d a r d i z e d manner o f c a t e g o r i z i n g e v e n t u a l outcome of t r e a t m e n t of p a t i e n t s w i t h head i n j u r i e s . The G l a s g o w Outcome S c a l e c o n s i s t s of f i v e l e v e l s o f o utcome, e a c h of w h i c h has c e r t a i n d e f i n i n g 7 c h a r a c t e r i s t i c s ( J e n n e t t , 1 9 7 6 ) : 1. D e a t h 2. P e r s i s t e n t V e g e t a t i v e S t a t e 3. S e v e r e D i s a b i l i t y : The p a t i e n t i s d e p e n d e n t upon o t h e r s f o r s u r v i v a l due t o p h y s i c a l o r m e n t a l d i s a b i l i t y o r b o t h . T h e s e p a t i e n t s a r e u s u a l l y ( b u t n o t n e c e s s a r i l y ) h o s p i t a l i z e d . 4. M o d e r a t e D i s a b i l i t y : A t t h i s l e v e l , t h e p a t i e n t i s i n d e p e n d e n t i n h i s / h e r d a i l y f u n c t i o n i n g , c a n use p u b l i c t r a n s p o r t a t i o n and i s a b l e t o work i n p r o t e c t e d s e t t i n g s . D e f i c i t s e x p e r i e n c e d i n t h i s s t a g e a r e : d y s p h a s i a , h e m i p a r e s i s , memory d e f i c i t s , c o g n i t i v e d e f i c i t s and p e r s o n a l i t y d i s o r d e r s . 5. Good R e c o v e r y : The p a t i e n t i s a b l e t o r e t u r n t o n o r m a l l i f e and f u n c t i o n s a t o r n e a r t h e p r e m o r b i d 1 eve 1. A c c o r d i n g t o L y n c h ( 1 9 8 4 ) , r e c o v e r y f r o m head i n j u r y i s r e l a t e d t o : a) L o c a t i o n of t h e i n j u r y . A p e r s o n w i t h a l o c a l i z e d o r r e l a t i v e l y c i r c u m s c r i b e d t r a u m a t i c l e s i o n has a b e t t e r p r o g n o s i s t h a n one w o u l d have i f t h e l e s i o n was of a b i l a t e r a l o r d i f f u s e d n a t u r e . L y n c h r e p o r t s t h a t a r e c e n t s t u d y of M i l l e r & M i y a m o t o ( 1 9 7 9 ) i n d i c a t e s t h a t b r a i n l e s i o n s t h a t a r e deep o r c e n t r a l 8 ( u s i n g a h o r i z o n t a l f r a m e of r e f e r e n c e ) a r e more l i k e l y t o r e s u l t i n g r e a t e r and l a s t i n g d e f i c i t s t h a n l e s i o n s t h a t a r e s u p e r f i c i a l o r p e r i p h e r a l . L e s i o n s i n v o l v i n g t h e b r a i n stem c a n r e s u l t i n i m p a i r m e n t s of c o n s c i o u s n e s s , a l e r t n e s s and a t t e n t i o n w h i l e l e s i o n s i n v o l v i n g t h e l a n g u a g e c e n t e r s c a n make c o m m u n i c a t i o n w i t h t h e p a t i e n t d i f f i c u l t . b) C h r o n i c i t y o f l e s i o n . S t u d i e s i n d i c a t e t h a t most r e c o v e r y o c c u r s i n t h e f i r s t s i x months f r o m t h e d a t e of o n s e t . H o w e v e r , t h i s i s n o t t o s a y t h a t r e c o v e r y d oes n o t o c c u r a f t e r t h i s s i x month p e r i o d , b u t s i g n i f i c a n t r e c o v e r y t h a t w o u l d r e s u l t i n a movement t o a n o t h e r l e v e l i n t h e G l a s g o w Outcome S c a l e i s u n l i k e l y . However, t h e GOS c a t e g o r i e s a r e r a t h e r b r o a d and p a t i e n t s may i m p r o v e w i t h i n t h e s e c a t e g o r i e s . c ) Age of p a t i e n t . S t u d i e s i n d i c a t e t h a t t h e y o u n g e r p a t i e n t d e m o n s t r a t e s a g r e a t e r and more r a p i d i m p r o v e m e n t a f t e r c e r e b r a l t r a u m a t h a n do o l d e r p a t i e n t s . d) P r e s e n c e of O t h e r D i s a b i l i t i e s . O t h e r d i s o r d e r s t h a t may o r may n o t be d i r e c t l y r e l a t e d t o t h e t r a u m a a l s o have a b e a r i n g on t h e p a t i e n t ' s r e c o v e r y and d i r e c t l y a f f e c t t h e t y p e of a c c o m m o d a t i o n t h a t may be a v a i l a b l e f o r t h e p a t i e n t . T h e s e m i g h t i n c l u d e s u c h t h i n g s as p a r a p l e g i a , q u a d r i p 1 eg I a, h e m i p a r e s i s , a n d 9 s u b s t a n c e a b u s e ( d r u g s a n d / o r a l c o h o l ) . e) L e v e l of m o t i v a t i o n . L y n c h s t a t e s t h a t t h e l e v e l o f m o t i v a t i o n t h a t t h e p a t i e n t s b r i n g s t o t h e r e h a b i l i t a t i o n i s an i m p o r t a n t f a c t o r i n t h e r e c o v e r y p r o c e s s . H i s t a b l e i d e n t i f i e s v a r i a b l e s t o c o n s i d e r i n t h e r e h a b i l i t a t i o n p r o c e s s ( L y n c h , 1 9 8 4 p.278) TABLE 1 Some I m p o r t a n t V a r i a b l e s t o C o n s i d e r i n E v a l u a t i n g L i k e l y Outcome of R e h a b i l i t a t i o n of Head I n j u r e d A d u l t s Outcome t e n d s t o be V a r i a b l e More f a v o r a b l e L e s s f a v o r a b l e A n g l e o f i m p a c t Type of i n j u r y L o c a t i o n of i n j u r y B r a i n s t e m i n vo1vement C e r e b r a l d o m i n a n c e C h r o n i c i t y of l e s i o n Age P r e s e n c e of o t h e r d i sab i 1 i t i es Mot i v a t i on 1 i n e a r c 1 o s e d f o c a 1 m i n i ma 1 o r none mi xed r e c e n t u n d e r 65 none h i g h o b 1 i que p e n e t r a t i n g d i f f u s e s i g n i f i c a n t / p e r m a n e n t l a t e r a l i z e d o 1 d / r e m o t e o v e r 65 any 1 ow 10 An i m p o r t a n t v a r i a b l e t h a t p l a y s a m a j o r r o l e i n t h e p a t i e n t ' s r e c o v e r y t h a t was n o t m e n t i o n e d by L y n c h i s t h e q u a l i t y of t h e b r a i n ( r e l a t e d t o s o c i a l i z a t i o n ) p r i o r t o t h e i n j u r y (Newcombe,1981). O b v i o u s l y , l e v e l s of p o s t - i n j u r y p s y c h o l o g i c a l f u n c t i o n s w i l l n o t o r d i n a r i l y e x c e e d t h o s e o f p r e - i n j u r y f u n c t i o n . I n d e e d , t h e s e p r e - e x i s t i n g c i r c u m s t a n c e s may have c o n t r i b u t e d t o t h e i n j u r y , and may i n c r e a s e t h e i n d i v i d u a l ' s c h a n c e of a r e c u r r e n t i n j u r y . S t u d i e s i n d i c a t e d t h a t i t i s o f t e n t h e young male r i s k t a k e r s t h a t a r e o f t e n i n c l u d e d i n t h i s p o p u l a t i o n . A c c o r d i n g t o M c L a u g h l i n and S h a f f e r ( 1 9 8 5 ) , t h e t y p i c a l head i n j u r e d p e r s o n i s b e t w e e n 19 and 30 y e a r s o l d , m a l e , s i n g l e , and i n j u r e d i n an a u t o m o b i l e a c c i d e n t . In t h e i r s t u d y o f 63 head i n j u r e d a d u l t s , t h e y r e p o r t e d t h a t 5 5 % were i n v o l v e d w i t h d r u g s o r a l c o h o l a t t h e t i m e of t h e a c c i d e n t , 3 8 % had s i g n i f i c a n t r e l a t i o n s h i p s o r m a r i t a l p r o b l e m s and 5 1 % had a h i s t o r y of d i s r u p t i v e o r a c t i n g o u t b e h a v i o r i n m u l t i p l e a r e a s . T h i s p o p u l a t i o n a l s o i n c l u d e s an o v e r r e p r e s e n t a t i o n of t h e l o w e r s o c i o e c o n o m i c c l a s s . ( M c K i n 1 a y , 1 9 8 1 ) . 11 P s y c h o s o c i a l F u n t l o n i n g and Head I n j u r y I n v e s t i g a t o r s i n t h e a r e a o f t r a u m a t i c head i n j u r y a g r e e t h a t t h e most c o n s i s t e n t and d i s a b l i n g c o n s e q u e n c e s o f head i n j u r y a r e t h e i m p a i r m e n t s i n p s y c h o s o c i a l f u n c t i o n i n g (McLean e t a l . 1 9 8 4 ) . R e p o r t s have s t r e s s e d t h e i m p o r t a n c e o f m e n t a l c h a n g e s and i n p a r t i c u l a r p e r s o n a l i t y c h a n g e s . F a h y e t a l . (1967) f o u n d " p s y c h i a t r i c symptoms" i n 17 o u t of 22 c a s e s who had PTA of more t h a n t h r e e d a y s . Thomsen (1974) n o t o n l y f o u n d p e r s o n a l i t y c h a n g e s i n 42 o u t of 50 c a s e s b u t n o t e d t h a t p a t i e n t s o f t e n l a c k e d i n s i g h t , and f o r t h i s r e a s o n r e s e a r c h e r s have o f t e n i n t e r v i e w e d r e l a t i v e s t o o b t a i n i n f o r m a t i o n a b o u t c h a n g e s i n t h e p a t i e n t . F o r d y c e e t a l . ( 1 9 8 3) f o u n d t h a t i n c r e a s e d e m o t i o n a l d i s t r e s s o f t e n p a r a l l e l s t h e p a t i e n t ' s i n c r e a s e d a w a r e n e s s o f c o g n i t i v e , and s o c i a l and v o c a t i o n a l l i m i t a t i o n s , w h i c h o c c u r as o v e r a l l c o g n i t i v e c o n f u s i o n l e s s e n s . S i m i l a r l y , M c K i n l e y f o u n d , i n h i s s t u d y o f r e l a t i v e s o f 55 s e v e r e l y head i n j u r e d a d u l t s (PTA g r e a t e r t h a n o r e q u a l t o 2 d a y s ) , t h a t s t r e s s e x p e r i e n c e d by t h e r e l a t i v e s a f t e r t h r e e , s i x , and t w e l v e months 12 p o s t i n j u r y was a s s o c i a t e d w i t h m e n t a l , and b e h a v i o r a l c h a n g e s i n t h e p a t i e n t . Romano (1974, i n R o s e n t h a 1 , 1 9 8 4 ) r e p o r t e d t h e u s e of d e n i a l a s a d e f e n s i v e s t r a t e g y f o r f a m i l i e s o f 13 head i n j u r e d a d u l t s . R e l a t i v e s d e n i e d t h e p r e s e n c e o f t h e d i s a b i l i t y and t h e p o t e n t i a l permanence of d e f i c i t s . He f o u n d t h a t i n i t i a l l y t h i s was a c o p i n g s t r a t e g y b u t i f d e n i a l c o n t i n u e d i t c o u l d r e s u l t i n t h e f a m i l y ' s f a i l u r e t o e f f e c t i v e l y a s s i s t t h e i r r e l a t i v e i n r e g a i n i n g a p r o d u c t i v e r o l e i n s o c i e t y . The p e r s o n a l i t y and b e h a v i o r c h a n g e s t h a t a f f e c t t h e p a t i e n t ' s a b i l i t y t o f u n c t i o n w i t h i n t h e f a m i l y and community s y s t e m s may be t h e r e s u l t o f : a) P r e s e n c e o f c o g n i t i v e d e f i c i t s . S h o r t t e r m memory l o s s i s more common t h a n l o n g t e r m memory l o s s and a f f e c t s t h e p a t i e n t ' s a b i l i t y t o r e - l e a r n t a s k s and r e - a c q u i r e k n o w l e d g e . T h e r e a l s o may be p r o b l e m s i n m a i n t a i n i n g a t t e n t i o n , p r o c e s s i n g c o m p l e x i n f o r m a t i o n and i n s t o r i n g and r e t r i e v i n g i n f o r m a t i o n . P r o b l e m s o l v i n g and a b s t r a c t t h i n k i n g c a n c r e a t e d i f f i c u l t i e s f o r t h i s p o p u l a t i o n . b) Change i n a f f e c t . Damage t o t h e f r o n t a l l o b e s may r e s u l t i n a v a r i e t y o f b e h a v i o r s : a s p o n t a n e i t y l e t h a r g y , f l a t o r d u l l a f f e c t , i r r i t a b i l i t y , l o s s o f 13 i n i t i a t i v e , l a c k of g o a l d i r e c t e d n e s s and a l o o s e n i n g o f i n h i b i t i o n s . c) L o s s o f s o c i a l c o n t a c t s . T h i s may r e s u l t f r o m t h e l o n g p e r i o d s of h o s p i t a l i z a t i o n a s s o c i a t e d w i t h head i n j u r y . The p a t i e n t may w i t h d r a w on h i s own b e c a u s e of a l o w e r i n g of s e l f - e s t e e m and b e c a u s e of p h y s i c a l o r m e n t a l d e f i c i t s . On t h e o t h e r hand, s o c i a l i s o l a t i o n may r e s u l t f r o m t h e w i t h d r a w a l of f r i e n d s b e c a u s e o f i n a p p r o p r i a t e s o c i a l b e h a v i o r and e g o - c e n t r i c i t y on t h e p a r t o f t h e p a t i e n t . d) D e p r e s s i o n . R e c o v e r y a c c o m p a n i e d by g r a d u a l a w a r e n e s s c a n r e s u l t i n d e p r e s s i o n . F o r d y c e e t a l . ( 1 9 8 3 ) f o u n d t h a t i n c r e a s e d e m o t i o n a l d i s t r e s s o f t e n p a r a l l e l s t h e p a t i e n t ' s i n c r e a s e d a w a r e n e s s of c o g n i t i v e , s o c i a l and v o c a t i o n a l l i m i t a t i o n s , w h i c h o c c u r as o v e r a l l c o g n i t i v e c o n f u s i o n l e s s e n s . The r e s t o r a t i o n of m o tor s k i l l s may r e t u r n h owever, t h e i n d i v i d u a l may be u n a b l e t o p a r t i c i p a t e i n s t r e n u o u s p h y s i c a l e x e r c i s e s u c h a s a t h l e t i c a c t i v i t i e s . D e p r e s s i o n may a l s o r e s u l t f r o m t h e i n a b i l i t y t o d r i v e an a u t o m o b i l e , t h e r e s t r i c t i o n o f a l c o h o l , t h e s c a r s and c r a n i a l d e f e c t s t h a t a l t e r t h e body image and s e l f c o n c e p t . L e a r n i n g d i s a b i l i t i e s r e l a t e d t o t h e s l o w 14 p r o c e s s i n g o f i n f o r m a t i o n may be d e p r e s s i n g and may i n t e r f e r e w i t h t h e r e s u m p t i o n o f a c a d e m i c p u r s u i t s . T h i s has a s i g n i f i c a n t c o n s e q u e n c e f o r t h e i n d i v i d u a l s i n c e t h e age of head i n j u r y ( 1 5 - 3 0 ) o f t e n c o i n c i d e s w i t h t h e p e r i o d o f e d u c a t i o n and c a r e e r d e v e l o p m e n t . T h i s i s d e p r e s s i n g and f r u s t r a t i n g f o r t h e f a m i l y as w e l l b e c a u s e o f t h e i n d i v i d u a l ' s i n a b i l i t y t o resume t h e p r e m o r b i d r o l e i n t h e f a m i l y . The b r e a d w i n n e r may now be d e p e n d e n t and t h e a s s e r t i v e p a r t n e r may now be p a s s i v e , o r t h e c h i l d who i s r e a c h i n g i n d e p e n d e n c e may r e m a i n d e p e n d e n t . Many of t h e s e p r o b l e m s become more o b v i o u s a f t e r t h e p a t i e n t has r e t u r n e d home and c o n t a c t w i t h t h e h e a l t h c a r e team has d i m i n i s h e d . The f a m i l y i s o f t e n r e l u c t a n t t o c o n t a c t t h e team and t h e r e f o r e i s a l o n e t o d e a l w i t h t h e s e o v e r w h e l m i n g p r o b l e m s . S c a r c e r e s o u r c e s may a l s o c o n t r i b u t e t o t h e f a m i l y ' s d e p r e s s i o n and f r u s t r a t i o n . e) I n a p p r o p r i a t e s o c i a l b e h a v i o r . The b e h a v i o r o f t h e head i n j u r e d a d u l t i s o f t e n c h i l d - l i k e . They a r e o f t e n unaware o f t h e c o n s e q u e n c e s and i m p l i c a t i o n s of t h e i r b e h a v i o r . S o metimes t h e s e b e h a v i o r s r e p r e s e n t n o t so much a cha n g e o f p e r s o n a l i t y b u t r a t h e r an e x a g g e r a t i o n o f p r e v i o u s a d v e r s e t r a i t s . They may engage i n v e r b a l o r motor p e r s e v e r a t i o n , p a t h o l o g i c a l 15 l a u g h t e r and i n a p p r o p r i a t e s e x u a l b e h a v i o r . G i v e n t h e s e c o n s e q u e n c e s i t i s n o t s u p r i s i n g t h a t f a m i l i e s and s o c i e t y as a w h o l e have d i f f i c u l t i e s i n d e a l i n g w i t h t h e head i n j u r e d p e r s o n . In t h e b e g i n n i n g , when t h e p a t i e n t r e q u i r e s t o t a l c a r e , t h e p a r e n t s may see t h i s as an o p p o r t u n i t y t o r e p e a t t h e p a r e n t i n g r e 1 a t i o n s h i p. However, w i v e s have g r e a t e r d i f f i c u l t y c o p i n g w i t h t h e i r head i n j u r e d h u s b a n d s a s t h e y a r e o f t e n n o t w i l l i n g t o e x c h a n g e t h e i r p r e v i o u s r o l e f o r a p a r e n t i n g r o l e . I t i s d i f f i c u l t t o m a i n t a i n a f u l l m a r i t a l r e l a t i o n s h i p u n d e r t h e s e c o n d i t i o n s and as a r e s u l t a s p o u s e may c h o o s e t o d i s t a n c e h e r s e 1 f / h i m s e 1 f o r d i v o r c e may be t h e o p t i o n ( M c L a u g h i n & S h a f f e r , 1 9 8 5 ) . T h i s has b e e n d e m o n s t r a t e d by r e s e a r c h as m o t h e r s o f head i n j u r e d a d u l t s a r e b e t t e r a b l e t o c o p e w i t h t h e b u r d e n o f c a r i n g f o r t h e i r a d u l t c h i l d t h a n w i v e s a r e a b l e t o c a r e f o r t h e i r head i n j u r e d h u s b a n d s . S i m i l a r l y , Rosenbaum & N a j e s o n (1976) s t u d i e d t h e r e a c t i o n s of w i v e s o f head i n j u r e d s o l d i e r s i n I s r a e l and f o u n d t h a t w i v e s o f head i n j u r e d s o l d i e r s had a more r e s t r i c t e d s o c i a l l i f e t h a n e i t h e r w i v e s of i n d i v i d u a l s w i t h s p i n a l c o r d i n j u r i e s o r of c o n t r o l s u b j e c t s . 16 I m p l i c a t i o n s f o r S o c i a l Work I n t e r v e n t i o n P s y c h o s o c i a l i n t e r v e n t i o n i s n e c e s s a r y s i n c e i t i s t h e p s y c h o s o c i a l c h a n g e s r a t h e r t h a n t h e p h y s i c a l c h a n g e s t h a t c r e a t e t h e p r o b l e m s f o r b o t h t h e p a t i e n t and f a m i l y i n t h e l o n g t e r m . More a t t e n t i o n s h o u l d be g i v e n t o b e h a v i o r m o d i f i c a t i o n f o r t h e head i n j u r e d p e r s o n and o n g o i n g c o u n s e l l i n g and s u p p o r t s h o u l d be a v a i l a b l e f o r t h e p a t i e n t and f a m i l y . In g e n e r a l , s o c i e t y has been u n c a r i n g and unaware of t h e n e e d s of t h e head i n j u r e d p o p u l a t i o n . T h i s p o p u l a t i o n has o f t e n b e e n e q u a t e d w i t h t h e m e n t a l l y r e t a r d e d , e m o t i o n a l l y d i s t u r b e d and p h y s i c a l l y c r i p p l e d ( R o s e n t h a l e t a l . 1 9 8 3 ) . T h e s e o t h e r p o p u l a t i o n s r e c e i v e s p e c i a l i z e d a t t e n t i o n w h i l e t h e head i n j u r e d p e r s o n does n o t . P a r a d o x i c a l l y t h e r e a r e many r e s o u r c e s a v a i l a b l e f o r c h i l d r e n b o r n w i t h " b r a i n damage" b u t i f t h i s o c c u r s l a t e r i n l i f e , r e s o u r c e s a r e n o t as r e a d i l y a v a i l a b l e . T h i s m i g h t r e s u l t f r o m t h e f a c t t h a t t h i s p o p u l a t i o n as p r e v i o u s l y m e n t i o n e d i s o f t e n t h e y o u n g male r i s k t a k e r s who have been d r i n k i n g and d r i v i n g . B u t t h e n t h e e t h i c a l i s s u e a r i s e s , does s o c i e t y have t h e r i g h t t o 17 p u n i s h t h i s g r o u p f o r t h e r e m a i n d e r of t h e i r l i v e s b e c a u s e of a m i s t a k e made i n t h e i r y o u t h ? T h i s p o p u l a t i o n b e c a u s e of t h e n a t u r e of t h e i r d i s a b i l i t y a r e n o t a b l e t o l o b b y on t h e i r own b e h a l f . S i m i l a r l y , t h e f a m i l i e s o f t h e head i n j u r e d o f t e n l a c k i n i t i a t i v e b e c a u s e of t h e s t r e s s of c a r i n g f o r t h e i r f a m i l y member. B e c a u s e t h i s i s a r e l a t i v e l y new and i n c r e a s i n g p o p u l a t i o n , t h e Head I n j u r y A s s o c i a t i o n i s a l s o new and t h e r e f o r e does n o t have t h e same s u p p o r t ( f i n a n c i a l o r p o l i t i c a l ) as do o t h e r a s s o c i a t i o n s . The r o l e of t h e s o c i a l w o r k e r t h e n becomes one of an a d v o c a t e . In o r d e r f o r p r o g r a m s t o be s u c c e s s f u l t h e r e must be s o c i a l and c o m m u n i t y s u p p o r t . T h e r e i s a need f o r a p e r s o n t o a c t as a c o - o r d i n a t o r who c a n f o l l o w a p a t i e n t and f a m i l y f r o m t h e t i m e o f t h e a c c i d e n t t h r o u g h r e c o v e r y (2 t o 3 y e a r s ) and who, w i t h a f u l l k n o w l e d g e o f t h e p a t i e n t ' s h i s t o r y , w o u l d be a b l e t o m o b i l i z e t h e a p p r o p r i a t e r e s o u r c e s r e q u i r e d ( M e r r y _ P a n t i n g , 1 9 8 2 ) . T h i s r o l e w o u l d a p p r o p r i a t e l y be f i l l e d by a s o c i a l w o r k e r who c o u l d a c t as a c o - o r d i n a t o r , c o u n s e l l o r and e d u c a t o r and a t t h e same t i m e p r o v i d e 1 i a s o n s e r v i c e w i t h t h e c o mmunity r e s o u r c e s . S i n c e i t i s d e s i r a b l e f o r t h e p a t i e n t t o r e t u r n t o h i s f a m i l y and c o m m u n i t y , i t i s n e c e s s a r y t o p r o v i d e some 18 t y p e o f s o c i a l s k i l l s t r a i n i n g t o i n c r e a s e t h e c h a n c e s f o r s u c c e s s i n t h i s a d j u s t m e n t p e r i o d . The l a c k of s o c i a l s k i l l s c a n a f f e c t t h e r e h a b i l i t a t i o n p r o c e s s , l i m i t t h e p l a c e m e n t p o s s i b 1 i t i e s , a n d i n t e r f e r s w i t h v o c a t i o n a l and s o c i a l p r o c e s s e s . T h e r e f o r e , s o c i a l s k i l l s t r a i n i n g i s an i m p o r t a n t s t e p i n s o c i a l work i n t e r v e n t i o n w i t h t h i s p o p u l a t i o n . S o c i a l S k i l l s T r a i n i n g S o c i a l s k i l l s t r a i n i n g p r o g r a m s have been e m p l o y e d w i t h v a r i o u s p o p u l a t i o n s i n c l u d i n g t h e m e n t a l l y h a n d i c a p p e d , c h r o n i c s c h i z o p h r e n i c s and s h y p e o p l e ( B r a m s t o n & S p e n c e , 1985, W a l l a c e & L i b e r m a n , 1985; H a y n e s - C 1 e m e n t s & A v e r y , 1 9 8 4 ) . C o n s i d e r i n g t h e f a v o u r a b l e o u t c o m e s of t h e s e s t u d i e s and t h e n e e d s of t h e head i n j u r e d p e r s o n i t i s s u r p r i s i n g t h a t t h e r e i s r e l a t i v e l y l i t t l e r e s e a r c h i n t h e s o c i a l s k i l l s t r a i n i n g o f head i n j u r e d a d u l t s . However, McMorrow, L l o y d & F r a l i s h ( 1 9 8 5 ) a p p l i e d , w i t h some s u c c e s s , an a d a p t e d v e r s i o n o f t h e p r o g r a m f o r t e a c h i n g s o c i a l s k i l l s t o m e n t a l l y h a n d i c a p p e d a d u l t s c a l l e d " S t a c k i n g t h e Deck" and t h i s p r o g r a m w i l l be a d d r e s s e d l a t e r i n t h i s s t u d y . 19 What i s S o c i a l S k i l l s T r a i n i n g ? S o c i a l s k i l l s t r a i n i n g has become a m a j o r t h e r a p y f o r p e o p l e w i t h i n t e r p e r s o n a l p r o b l e m s . A c c o r d i n g t o P e t e r T r o w e r , s o c i a l s k i l l s a r e t h e component n o r m a t i v e b e h a v i o r s t h a t a p e r s o n n e e d s i n h i s r e p e t o i r e and i t i s t h e p r o c e s s by w h i c h t h e i n d i v i d u a l p r o d u c e s a p p r o p r i a t e s o c i a l b e h a v i o r ( T r o w e r , 1 9 8 2 ) . The a c q u i s i t i o n o f s o c i a l s k i l l s ( s o c i a l c o m p e t e n c e ) i s a c o m p l e x p r o c e d u r e . I t i n v o l v e s m o n i t o r i n g t h e i m m e d i a t e s o c i a l e n v i r o n m e n t , m a k i n g c o g n i t i v e d e c i s i o n s a b o u t a p p r o p r i a t e r e s p o n s e s a c c o r d i n g t o t h e i n f o r m a t i o n r e c e i v e d and t h e i n d i v i d u a l ' s g o a l , and t h e n p e r f o r m i n g t h e c h o s e n a c t i o n s k i l l f u l l y . The f i n a l p r o c e s s i n v o l v e s t h e f e e d b a c k t h e i n d i v i d u a l r e c e i v e s on h i s a c t i o n , i f he i s on t a r g e t he p r o c e e d s t o h i s n e x t a c t i o n . A p o l o g i e s a r e make a t t h i s t i m e i f t h e s e a c t i o n s have o f f e n d e d a n y o n e . S o c i a l s k i l l s a r e l e a r n e d by d i r e c t e x p e r i e n c e , o r v i c a r i o u s l y t h r o u g h m o d e l s t h e r e f o r e , t h e y c a n be t a u g h t t o p e o p l e who l a c k them. The f o r m o f i n s t r u c t i o n c a n v a r y b u t f o r t h e p u r p o s e o f t h i s r e s e a r c h t h e f o l l o w i n g methods w i l l be e m p l o y e d : 20 I n s t r u c t i o n : A p a r t i c u l a r s k i l l i s b r o k e n down i n t o a s e q u e n c e of b e h a v i o r a l e l e m e n t s so t h a t t h e i n d i v i d u a l c a n s e e e x a c t l y what i s t o be done. M o d e l i n g : A s k i l l i s l e a r n e d by o b s e r v i n g o t h e r s . In t h i s s t u d y , t h e f a c i l i t a t o r m o d e l s t h e a p p r o p r i a t e b e h a v i o r b a s e d on B a n d u r a ' s s o c i a l l e a r n i n g t h e o r y . M o d e l i n g t h u s c o n s i s t s o f l e a r n i n g by i m i t a t i o n . R e h e a r s a l : T h i s g i v e s t h e i n d i v i d u a l t h e o p p o r t u n i t y t o t r y o u t new o r r e - l e a r n e d b e h a v i o r s . R e i n f o r c e m e n t was p r o v i d e d t h r o u g h c o a c h i n g and p r a i s e . The o b j e c t i v e s of t h i s s t u d y a r e t o e n h a n c e t h e s e n d i n g and r e c e i v i n g s k i l l s o f head i n j u r e d a d u l t s i n s i x a r e a s : c o m p l i m e n t s , s o c i a l i n t e r a c t i o n , p o 1 i t e n e s s , c r i t i c i s m , s o c i a l c o n f r o n t a t i o n , and q u e s t i o n s and a n s w e r s . Summary R e c e n t a d v a n c e s i n m e d i c a l t e c h n o l o g y have l e d t o an i n c r e a s e i n t h e number of p e o p l e s u r v i v i n g s e v e r e head i n j u r y . However, i t i s t h e p e r s o n a l i t y and b e h a v i o r a l d i s t u r b a n c e s r e s u l t i n g f r o m s e v e r e head 21 i n j u r y t h a t c r e a t e t h e p r o b l e m s , i n t h e l o n g t e r m , f o r t h e r e l a t i v e s o f t h e head i n j u r e d and t h e head i n j u r e d p e r s o n h i m s e l f . T h e s e c h a n g e s i n p e r s o n a l i t y a r e t h e r e s u l t o f : an i m p a i r e d c a p a c i t y f o r s o c i a l p e r c e p t i v e n e s s ( i . e . The p a t i e n t ' s p owers of s e l f c r i t i c i s m a r e d i m i n i s h e d and t h e r e i s an i n c r e a s e i n e g o c e n t r i c i t y and a l o s s o f e m p a t h y . ) ; an i m p a i r e d a b i l i t y t o i n i t i a t e c o n v e r s a t i o n and a c t i v i t i e s o f d a i l y l i v i n g ; and a d e c r e a s e d a b i l i t y t o b e n e f i t f r o m e x p e r i e n c e . The c o n s e q u e n c e s o f head i n j u r y a f f e c t t h e p a t i e n t , t h e p a t i e n t ' s f a m i l y and t h e community. The l a c k of a p p r o p r i a t e s o c i a l s k i l l s c a n make r e h a b i l i t a t i o n and r e t u r n t o t h e f a m i l y and community d i f f i c u l t . T h e r e f o r e , s o c i a 1 s k i l l s t r a i n i n g t h a t may a s s i s t i n t h e r e - i n t e g r a t i o n o f t h e head i n j u r e d p e r s o n i n t o t h e f a m i l y and community i s a n e c e s s a r y p a r t of s o c i a l work i n t e r v e n t i o n and r e h a b i l i t a t i o n i n g e n e r a l . 22 C h a p t e r 2 R e s e a r c h P r o b l e m The c o n s e q u e n c e s o f head i n j u r y h ave a p r o f o u n d e f f e c t upon t h e i n d i v i d u a l and h i s f a m i l y . As p r e v i o u s l y m e n t i o n e d , t h e s e p r o b l e m s a r e r e l a t e d t o p e r s o n a l i t y and b e h a v i o r a l c h a n g e s and a r e o f t e n m a n i f e s t e d i n i n a p p r o p r i a t e s o c i a l b e h a v i o r . The h y p o t h e s i s o f t h i s s t u d y i s t h a t s o c i a l s k i l l s t r a i n i n g w i l l h e l p t o l e s s e n t h i s i n a p p r o p r i a t e b e h a v i o r . Much of t h e r e s e a r c h t o d a t e i n t h i s a r e a has been q u a n t i t a t i v e d e s c r i p t i v e , i n t h a t t h e c o n s e q u e n c e s o f head i n j u r y have b e e n d e s c r i b e d i n d e t a i l . The l a c k o f s o c i a l s k i l l s has been i d e n t i f i e d as an o n g o i n g p r o b l e m f o r t h i s p o p u l a t i o n . The work o f Eames and Wood (1985) i n t h e U n i t e d Kingdom i s one o f t h e few p r o g r a m s t h a t a d d r e s s t h e i n a p p r o p r i a t e s o c i a l b e h a v i o r of t h i s popu1 a t i on. The s o c i a l s k i l l t r a i n i n g p r o g r a m s d e v e l o p e d f o r o t h e r p o p u l a t i o n s a r e n o t e a s i l y a d a p t e d t o t h e head i n j u r e d p o p u l a t i o n b e c a u s e t h e i r n e e d s a r e q u i t e d i f f e r e n t . One m a j o r p r o b l e m i n w o r k i n g w i t h t h e head i n j u r e d p o p u l a t i o n i s t h e i r d e n i a l . T h i s a f f e c t s m easurement as s e l f m e a s u r e s a r e n o t r e l i a b l e and i t 2 3 a l s o a f f e c t s m o t i v a t i o n ; i f t h e r e i s no p e r c e i v e d p r o b l e m t h e r e i s no need f o r s o c i a l s k i l l s t r a i n i n g . T h e r e a r e v a r i o u s m o d e l s u s e d i n e x p l a i n i n g and r e m e d i a t i n g s o c i a l i n a d e q u a c i e s . T h e s e m o d e l s d i f f e r i n t h e i r c o n c e p t u a l i z a t i o n o f t h e c e n t r a l d i f f i c u l t y t h a t i s c h a r a c t e r i s t i c o f s o c i a l i n a d e q u a c y . T h e s e m o d e l s a r e : a) s o c i a 1 - s k i 11s d e f i c i t , i n w h i c h t h e c e n t r a l d i f f i c u l t y i s t h o u g h t t o be an i n a d e q u a t e r e p e r t o i r e of s o c i a l s k i l l s . b) c o n d i t i o n e d a n x i e t y , i n w h i c h t h e c e n t r a l d i f f i c u l t y i s t h o u g h t t o be c o n d i t i o n e d a n x i e t y t h a t i n t e r f e r e s w i t h t h e p e r f o r m a n c e o f an a d e q u a t e r e p e r t o i r e o f s o c i a l s k i l l s . c ) c o g n i t i v e o r s o c i a l p e r c e p t i o n m o d e l s , i n w h i c h t h e c e n t r a l d i f f i c u l t y i s t h o u g h t t o be r e l a t e d t o c o g n i t i v e p r o c e s s e s , s u c h as o v e r l y n e g a t i v e s e 1 f - e v a 1 u a t i o n s of s o c i a l p e r f o r m a n c e , n e g a t i v e c o v e r t s e 1 f - s t a t e m e n t s and i n a d e q u a t e p r o c e s s i n g o f r e l e v a n t i n t e r p e r s o n a l s t i m u l i , and d) p h y s i c a l a t t r a c t i v e n e s s , i n w h i c h t h e c e n t r a l d i f f i c u l t y i s t h o u g h t t o be n e g a t i v e j u d g m e n t s t h a t o t h e r s make a b o u t one's a p p e a r a n c e ( A r k o w i t z , 1 9 7 7 ; M o r r i s o n and B e l l a c k , 1 9 8 1 i n N e l s o n e t a l . 1 9 8 3 ) . 24 T h i s s t u d y assumes t h a t t h e s o c i a l s k i l l s d e f i c i t s of t h e head i n j u r e d a r e r e l a t e d t o an i n a d e q u a t e r e p e r t o i r e o f s o c i a l s k i l l s and d i f f i c u l t i e s r e l a t e d t o c o g n i t i v e o r s o c i a l p e r c e p t i o n s . Much of t h e s o c i a l s k i l l s t r a i n i n g has been u s e d w i t h t h e s e v e r e l y a f f e c t e d and w i t h d r a w n i n d i v i d u a l s s u c h as c h r o n i c s c h i z o p h r e n i c s , t h e n o n - d a t e r , t h e e x t r e m e l y s h y , and t h e a g g r e s s i v e p e r s o n . As a r e s u l t t h r e e t y p e s o f s o c i a l s k i l l t r a i n i n g p r o g r a m s have been d e v e l o p e d t o meet t h e s e n e e d s b u t t h e y do n o t n e c e s s a r i l y meet t h e n e e d s of t h e head i n j u r e d popu1 a t i on. The most p o p u l a r f o r m of s o c i a l s k i l l s t r a i n i n g i n t h e U n i t e d S t a t e s i s a s s e r t i o n t r a i n i n g . T h i s a p p r o a c h i s recommended f o r t h o s e who a r e u n a s s e r t i v e , i n c l u d i n g s c h i z o p h r e n i c s , t h e e x c e s s i v e l y s h y , u n l i b e r a t e d women (and men) and d e p r e s s i v e s who b e l i e v e t h e m s e l v e s t o be h e l p l e s s . A s s e r t i o n i s c o n c e p t u a l i z e d as b e h a v i o r f a l l i n g on a m i d p o i n t b e t w e e n s u b m i s s i o n and a g g r e s s i o n . Thus t h i s p r o g r a m i s a l s o u s e d w i t h t h e o v e r a g g r e s s i v e v i o l e n t p e r s o n . T h i s t y p e of s o c i a l s k i l l t r a i n i n g w o u l d n o t be s u i t a b l e f o r t h e head i n j u r e d p e r s o n b e c a u s e i t d o es n o t a d d r e s s t h e i r p a r t i c u l a r n e e d s . A l t h o u g h , i t does a d d r e s s i s s u e s of d e p r e s s i o n and v i o l e n c e w h i c h a r e o f t e n a s s o c i a t e d w i t h head i n j u r y 25 i t d o e s n o t a d d r e s s t h e more common p r o b l e m s p e c u l i a r t o head i n j u r y s u c h as p r o b l e m s i n m a i n t a i n i n g a t t e n t i o n , l e t h a r g y , f l a t o r d u l l a f f e c t and l o s s of i n i t i a t i o n . H e t e r o s o c i a l s k i l l s t r a i n i n g i s g e n e r a l l y d e f i n e d as t r a i n i n g f o r s k i l l s r e l e v a n t t o i n i t i a t i n g , m a i n t a i n i n g and t e r m i n a t i n g a s o c i a l a n d / o r s e x u a l r e l a t i o n s h i p w i t h a member of t h e o p p o s i t e s e x . T h e s e s k i l l s may be n e eded by t h e head i n j u r e d p e r s o n , however t h i s p a r t i c u l a r p r o g r a m does n o t a d d r e s s t h e more b a s i c n e e d s o f t h i s p o p u l a t i o n t h a t a r e r e q u i r e d b e f o r e t h i s t y p e o f t r a i n i n g c a n t a k e p l a c e . More b a s i c s o c i a l s k i l l s t r a i n i n g p r o g r a m s have b e e n d e v e l o p e d f o r t h e most s o c i a l l y d i s a b l e d , p a r t i c u l a r l y t h e c h r o n i c s c h i z o p h r e n i c , m e n t a l l y r e t a r d e d and l o n g t e r m p r i s o n e r . However, t h e m e a s u r e s u s e d i n t h e s e p r o g r a m s a r e n o t s u i t a b l e f o r t h e head i n j u r e d p o p u l a t i o n . I t i s a l s o i m p o r t a n t t o n o t e t h a t a l t h o u g h t h i s p o p u l a t i o n has b r a i n damage t h e y a r e n o t " m e n t a l l y r e t a r d e d " . T h e r e f o r e t h e s e p r o g r a m s w o u l d have t o be a d a p t e d t o s u i t t h e n e e d s of t h i s p o p u l a t i o n . As a r e s u l t t h e r e a r e n o t many p r o g r a m s t o c h o o s e f r o m t h a t w i l l a d d r e s s t h e n eeds of t h e head i n j u r e d i n d i v i d u a l . T h e r e f o r e , t h i s r e s e a r c h e v a l u a t e s one of t h e few p r o g r a m s t h a t was d e s i g n e d t o t e a c h s o c i a l s k i l l t o t h e head i n j u r e d p e r s o n . However, t h i s r e s e a r c h i s t o be 26 e x p l a n a t o r y and w i l l e v a l u a t e t h e u s e f u l n e s s o f t h e m o d i f i e d " S t a c k i n g t h e Deck" p r o g r a m i n t e a c h i n g s o c i a l s k i l l s t o head i n j u r e d a d u l t s . The e v a l u a t i o n o f t h e p r o g r a m i n c l u d e d : a) an i n - d e p t h a n a l y s i s o f w h e t h e r t h e s k i l l s were a c q u i r e d i n t h e t h e r a p e u t i c i n t e r v e n t i o n . b) w h e t h e r n o n - v e r b a l s k i l l s I m p r o v e d . c) w h e t h e r t h e s k i l l s were d i s p l a y e d i n an u n t r a i n e d s e t t i n g . d) an i n - d e p t h a n a l y s i s o f t h e s u i t a b i l i t y o f t h e use o f t h i s p r o g r a m f o r " l o w e r f u n c t i o n i n g " head i n j u r e d i n d i v i d u a l s (most s p e c i f i c a l l y where r e s p o n s e t i m e i s s l o w and t h e r e i s an o b v i o u s l a c k o f i n i t i a t i o n ) . T h i s p a r t i c u l a r p r o g r a m was c h o s e n b e c a u s e i t i s b e l i e v e d i t w i l l a d d r e s s some s p e c i f i c b e h a v i o r a l and p e r s o n a l i t y c h a n g e s t h a t a r e a s s o c i a t e d w i t h head i n j u r y ; p r o b l e m s i n m a i n t a i n i n g a t t e n t i o n , p r o b l e m s i n i n i t i a t i o n , l a c k o f g o a l d i r e c t e d n e s s , w i t h d r a w a l f r o m s o c i a l c o n t a c t s , r e d u c e d a b i l i t y f o r p r o b l e m s o l v i n g and a b s t r a c t t h i n k i n g . The p r o b l e m o f m a i n t a i n i n g a t t e n t i o n and l a c k o f i n i t i a t i o n s i s a d d r e s s e d by t h e game f o r m a t . I t i s assumed t h a t t h e p r o c e d u r e o f r e s p o n d i n g t o q u e s t i o n s and m o v i n g game p i e c e s a r o u n d t h e b o a r d w i l l i n c r e a s e t h e a t t e n t i o n o f t h e p l a y e r s . T h i s s h o u l d a l s o h e l p 27 i n i t i a t i o n b e c a u s e t h e p l a y e r i s q u e s t i o n e d and movement a r o u n d t h e b o a r d d e p e n d s upon a c o r r e c t a n s w e r . A prompt answer i s d e s i r e d so t h a t o t h e r p l a y e r s do n o t have t o w a i t u n n e c e s s a r i l y f o r t h e i r t u r n . E a c h s i t u a t i o n ( c a r d ) g i v e s t h e i n d i v i d u a l an o p p o r t u n i t y t o p r o b l e m s o l v e . The s t r u c t u r e d l e a r n i n g a s s i g n m e n t s p r o v i d e a d d i t i o n a l o p p o r t u n i t i e s t o p r a c t i c e p r o b l e m s o l v i n g s k i l l s . The p r e - d e t e r m i n e d i n d i v i d u a l g o a l s (number o f c o r r e c t r e s p o n s e s r e q u i r e d ) may h e l p t o a d d r e s s t h e l a c k of g o a l d i r e c t e d n e s s . I t i s assumed t h a t t h e s u b j e c t s w i l l want t o c o n t i n u e p l a y i n g t h e game t o i n c r e a s e t h e i r number o f c o r r e c t r e s p o n s e s . The r e w a r d s (gum and c a n d y ) may a l s o a d d r e s s t h i s i s s u e . The w i t h d r a w a l f r o m s o c i a l c o n t a c t s was p r e v i o u s l y m e n t i o n e d as a p r o b l e m f o r t h i s p o p u l a t i o n . T h i s i s o f t e n t h e c o m b i n e d r e s u l t of s e l f c e n t e r e d n e s s and t h e i r r e m o v a l f r o m t h e i r s o c i a l s e t t i n g due t o h o s p i t a l i z a t i o n . The game i t s e l f and c o f f e e a f t e r w a r d s p r o v i d e s a s o c i a l s e t t i n g where c o - o p e r a t i o n i s e n c o u r a g e d and i t p r o v i d e s an o p p o r t u n i t y f o r t h e s u b j e c t s t o p r a c t i c e l e a r n e d s o c i a l s k i l l s . I t i s assumed t h a t t h e s o c i a l c o n t a c t o f t h e game and presumed i n c r e a s e i n s o c i a l s k i l l s w i l l i n c r e a s e s e l f e s t e e m and t h e r e b y work t o l e s s e n d e p r e s s i o n 28 a s s o c i a t e d w i t h head i n j u r y . K n o w l e d g e B u i l d i n g F u n c t i o n o f R e s e a r c h The i n t e n t o f t h i s r e s e a r c h i s t o p r o v i d e b u i l d i n g i b l o c k s f o r f u r t h e r l a r g e b e t w e e n - g r o u p s t u d i e s . The s i n g l e s y s t e m d e s i g n w i l l p r o v i d e a n e e d e d s p e c i f i c k n o w l e d g e on t h e e f f e c t s of t h e i n t e r v e n t i o n and i t s h o u l d i n d i c a t e a r e a s o f i n t e r v e n t i o n t h a t may be i m p r o v e d upon. T h i s s t u d y s h o u l d p r o v i d e i n f o r m a t i o n on t h e p o s s i b i l i t y o f t e a c h i n g s o c i a l s k i l l s t o t h e head i n j u r e d i n d i v i d u a l s who l a c k them. The g e n e r a l i z a t i o n o f many s o c i a l s k i l l t r a i n i n g p r o g r a m s have b e e n q u e s t i o n a b l e (Twentyman & Z i m e r i n g , 1 9 7 9 , i n T r o w e r , 1 9 8 2 ) and t h i s s t u d y may be f u r t h e r e v i d e n c e o f t h i s . However, i t i s b e l i e v e d t h a t t h i s s t u d y w i l l g e n e r a t e h y p o t h e s i s f o r f u t u r e s t u d i e s ( i . e . i s a s t r u c t u r e d l e a r n i n g p r o c e s s ( s o c i a l l e a r n i n g t h e o r y ) more e f f e c t i v e t h a n a c o g n i t i v e a p p r o a c h t o s o c i a l s k i l l s t r a i n i n g w i t h head i n j u r e d a d u l t s . T h i s s t u d y may a l s o s u g g e s t t h a t f u r t h e r r e s e a r c h i s needed i n t o ways o f m a i n t a i n i n g and g e n e r a l i z i n g l e a r n e d s k i 1 I s . 29 R e a s o n s f o r C o n c e p t u a l Model S i n c e t h e s i n g l e s y s t e m d e s i g n p r o v i d e s an o p p o r t u n i t y f o r an i n - d e p t h e v a l u a t i o n o f t h e i n t e r v e n t i o n , i t was e m p l o y e d i n t h i s s t u d y . A s c o r e i s o b t a i n e d e a c h t i m e t h e game i s p l a y e d so t h e r e i s i m m e d i a t e f e e d b a c k on p e r f o r m a n c e . A l t h o u g h i t i s n o t p o s s i b l e t o e v a l u a t e t h e e f f e c t s o f t h e i n t e r v e n t i o n i n t h e game s e p a r a t e f r o m t h e i n t e r v e n t i o n o f t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s , i t i s b e l i e v e d t h a t t h e s e i n t e r v e n t i o n s s h o u l d be c o m b i n e d b e c a u s e t h e y b o t h a d d r e s s d i f f e r e n t a s p e c t s o f s o c i a l s k i l l s t r a i n i n g . However, t h e i m p o r t a n t a s p e c t o f t h e i n t e r v e n t i o n i s n o t w h i c h p a r t w o r k s t h e b e s t b u t r a t h e r i s t h e i n t e r v e n t i o n s u c c e s s f u l i n i m p r o v i n g t h e s o c i a l s k i l l s o f t h e head i n j u r e d i n d i v i d u a l . The " S t a c k i n g t h e Deck" p r o g r a m was e m p l o y e d b e c a u s e ; i t was p r o v e n e f f e c t i v e i n t e a c h i n g s o c i a l s k i l l s t o t h i s p o p u l a t i o n , i t e m p l o y e d s t a n d a r d i z e d t r a i n i n g p r o c e d u r e s , i t was c o s t e f f e c t i v e , and i t a l l o w e d f o r an i n - d e p t h a s s e s s m e n t o f s k i l l a c q u i s i t i o n i n a number o f s o c i a l s k i l l component a r e a s . T h e o r e t i c a l O r i e n t a t i o n The m a j o r c o n c e p t i n t h i s s t u d y i s t h a t s o c i a l s k i l l s a r e l e a r n e d b e h a v i o r and t h e r e f o r e , i t i s assumed t h a t s o c i a l s k i l l s c a n be t a u g h t t o t h o s e who l a c k them. 30 Good s k i l l s a r e a d a p t i v e t o t h e s o c i a l e n v i r o n m e n t w h i l e bad s k i l l s o r l a c k o f s k i l l s a r e m a l a d a p t i v e . The o r i e n t a t i o n s u s e d t o p r o v i d e t h e b a s i s of s o c i a l s k i l l s t r a i n i n g p r o g r a m s u s u a l l y e m p l o y b e h a v i o r m o d i f i c a t i o n , l e a r n i n g t h e o r y o r c o g n i t i v e t h e o r y . T h i s s t u d y , w h i c h i n c l u d e s a l l a s p e c t s of t h e i n t e r v e n t i o n , i s b a s e d on s o c i a l l e a r n i n g t h e o r y . A l b e r t B a n d u r a ( McConne11,1980) b e l i e v e s t h a t t h e p r i m a r y mechanisms of s o c i a l l e a r n i n g may be o b s e r v i n g and m o d e l i n g . M o d e l i n g i s a s o c i a l i z a t i o n p r o c e s s i n w h i c h yo u l e a r n s o c i e t y ' s " r u l e s and r e g u l a t i o n s " by b e i n g t o l d what t o do ( a n d r e w a r d e d f o r d o i n g s o , o r p u n i s h e d i f you d i s o b e y ) and by i m i t a t i n g t h e b e h a v i o r o f "model c i t i z e n s " . M o d e l i n g t h u s c o n s i s t s of l e a r n i n g by i m i t a t i o n . A c c o r d i n g t o B a n d u r a , t h e r e a r e f o u r i n t e r - r e 1 a t e d p r o c e s s e s i n v o l v e d i n o b s e r v a t i o n a l l e a r n i n g . B e f o r e t h e o b s e r v e r c a n l e a r n much f r o m a model he must a c t i v e l y a t t e n d t o t h e m o d e l ' s b e h a v i o r . T h i s a t t e n t i o n i s a f f e c t e d by c h a r a c t e r i s t i c s of b o t h t h e model and t h e o b s e r v e r . S i n c e head i n j u r e d i n d i v i d u a l s have p r o b l e m s i n m a i n t a i n i n g a t t e n t i o n t h i s a s p e c t of t h e t r a i n i n g p r o c e s s was a d d r e s s e d a c c o r d i n g t o t h e i n d i v i d u a l ' s n e eds ( q u e s t i o n s may have t o be r e p e a t e d , d i s t r a c t i o n s removed o r l e s s e n e d w h e r e v e r p o s s i b l e ) . 31 B a n d u r a s t a t e s t h a t memory and m o t o r i c p r o c e s s e s a r e a l s o i n v o l v e d i n l e a r n i n g ( P a p a l i a & O l d s , 1 9 7 9 ) . B e h a v i o r s a r e l e a r n e d by w a t c h i n g o t h e r s b u t a r e p e r f e c t e d t h r o u g h p r a c t i c e . In t h i s s t u d y t h e f a c i l i t a t o r i s t h e model who d i s p l a y s t h e c o r r e c t b e h a v i o r and g i v e s t h e a p p r o p r i a t e r e s p o n s e t o t h e s i t u a t i o n c a r d s . U s i n g t h e same s i t u a t i o n c a r d s o v e r and o v e r a g a i n g i v e s t h e s u b j e c t t h e o p p o r t u n i t y t o p e r f e c t t h e s k i l l t h r o u g h p r a c t i c e . F i n a l l y , t h e r e i s a m o t i v a t i o n a l a s p e c t t o o b s e r v a t i o n a l l e a r n i n g . The p e r f o r m a n c e of a b e h a v i o r d e pends upon w h e t h e r o r n o t we e x p e c t t o be r e i n f o r c e d o r p u n i s h e d f o r d o i n g s o . R e i n f o r c e m e n t s u s e d i n t h e game and s t r u c t u r e d l e a r n i n g a s s i g n m e n t s were s o c i a l r e i n f o r c e m e n t s ( p r a i s e and a p p r o v a l ) and r e w a r d s ( s u g a r l e s s gum and c h o c o l a t e b a r s ) . I t i s assumed t h a t t h e s o c i a l l e a r n i n g t h e o r y w i l l be a u s e f u l o r i e n t a t i o n w i t h t h i s p o p u l a t i o n b e c a u s e i t p r o v i d e s a s t r u c t u r e t h a t a d d r e s s t h e s p e c i f i c p r o b l e m s o f t h e head i n j u r e d i n d i v i d u a l n a m e l y ; a t t e n t i o n , memory, m o t i v a t i o n and t h e o p p o r t u n i t y t o p r a c t i c e t h e s k i l l ( m o t o r i c p r o c e s s ) . 32 L i m i t a t i o n s o f t h e R e s e a r c h The most o b v i o u s l i m i t a t i o n o f t h i s r e s e a r c h i s i t s s m a l l s a m p l e s i z e . However, t h e s m a l l number of a v a i l a b l e s u b j e c t s n e c e s s i t a t e d t h e u s e o f t h e s i n g l e s y s t e m d e s i g n . G e n e r a l i z a t i o n s a r e l i m i t e d by t h e AB d e s i g n and t h e s e a r e d i s c u s s e d i n C h a p t e r 3. However t h e more c o n t r o l l e d ABA d e s i g n was n o t p o s s i b l e h e r e b e c a u s e i t i s a l m o s t i m p o s s i b l e t o remove t h e e f f e c t s o f t h e i n t e r v e n t i o n and r e t u r n t o t h e b a s e l i n e A. The w h o l e i s s u e o f t h e g e n e r a l i z a t i o n of s o c i a l s k i l l s may a l s o be a l i m i t a t i o n o f t h i s r e s e a r c h . In t h e p a s t , r e s e a r c h e r s have had m i x e d o p i n i o n s o f t h e g e n e r a l i z a t i o n o f s o c i a l s k i l l s t r a i n i n g . Some b e l i e v e t h a t homework a s s i g n m e n t s i n c r e a s e t h e p o t e n t i a l f o r g e n e r a l i z a t i o n s . As a r e s u l t homework a s s i g n m e n t s were i n c l u d e d i n t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . O t h e r s b e l i e v e t h a t s o c i a l s k i l l s t r a i n i n g a p p e a r s t o l e a d t o a r e a s o n a b l e g e n e r a l i z a t i o n t o t h e n a t u r a l e n v i r o n m e n t when m e a s u r e d by s e 1 f - m o n i t o r i n g ( U r b a n & S c h w a r z e n b e r g , 1 9 8 0 ) . However, t h i s i s n o t p o s s i b l e i n t h i s s t u d y b e c a u s e of t h e d e n i a l a s p e c t s t h a t a r e a s s o c i a t e d w i t h head i n j u r y . A l t h o u g h , f u r t h e r l i m i t a t i o n s o f t h i s d e s i g n a r e d i s c u s s e d i n C h a p t e r 3 on R e s e a r c h D e s i g n , t h e s i n g l e 33 s y s t e m d e s i g n was c h o s e n b e c a u s e t h e p o s i t i v e f e a t u r e s of t h e d e s i g n o u t w e i g h any n e g a t i v e f e a t u r e s o f t h e d e s i g n . Summary In c o n c l u s i o n t h i s e v a l u a t i o n w i l l c o n c e n t r a t e o n: 1. The p r o b l e m s r e l a t e d t o s o c i a l i n t e r a c t i o n t h a t r e s u l t f r o m t h e b e h a v i o r a l and p e r s o n a l i t y c h a n g e s t h a t a r e a s s o c i a t e d w i t h head i n j u r y . 2. The u s e f u l n e s s o f s o c i a l s k i l l s t r a i n i n g w i t h t h i s p o p u l a t i o n and g e n e r a l i z a t i o n o f t h e s k i l l s w i t h p a r t i c u l a r r e f e r e n c e t o t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . 3. The u s e f u l n e s s o f t h e " S t a c k i n g t h e Deck" p r o g r a m as a measure and a t r a i n i n g p r o g r a m . 4. L i m i t a t i o n s o f t h i s r e s e a r c h and t h e i m p l i c a t i o n s f o r f u r t h e r r e s e a r c h i n t o s o c i a l s k i l l s t r a i n i n g w i t h t h i s p o p u l a t i o n . 34 Sub j e c t s The s u b j e c t s were s e l e c t e d f r o m t h e i n - p a t i e n t p o p u l a t i o n a t G.F. S t r o n g R e h a b i l i t a t i o n C e n t r e and t h e o u t - p a t i e n t p o p u l a t i o n w h i c h r e s i d e d a t a g r o u p home ( K i n g Edward H o u s e ) . They had t o be a t l e a s t s i x months p o s t i n j u r y and had t o r e m a i n i n t h e V a n c o u v e r a r e a u n t i l t h e c o m p l e t i o n o f t h e s t u d y . The s u b j e c t s had t o be be t w e e n t h e a g e s o f 19 and 40. A l l s u b j e c t s c h o s e n were male b e c a u s e t h e r e were no f e m a l e s u b j e c t s t h a t f i t t h e abo v e c r i t e r i a a t t h e t i m e t h e s t u d y was c o n d u c t e d . S u b j e c t 1 B i r t h d a t e : J u n e 30,1967 D a t e o f A c c i d e n t : J u n e 30,1986 G l a s g o w Outcome S c a l e (GOS): S e v e r e , coma 6 t o 8 weeks As a r e s u l t of a f a l l , S u b j e c t 1 s u f f e r e d a d i f f u s e c l o s e d head i n j u r y w i t h s e c o n d a r y c o g n i t i v e d e f i c i t s , l e f t p o s t e r i o r p o l a r v i t r e o u s h e m o r r h a g e , m i 1d l e f t a f f e r e n t p u p i l d e f e c t , d e n s e l e f t homomymous h e m i a n o p s i a , and p o s s i b l e m i l d r i g h t u p p e r e x t r e m i t y r e f l e x s y m p a t h e t i c d y s t r o p h y . 35 S u b j e c t 1 was a d m i t t e d t o a r e h a b i l i t a t i o n f a c i l i t y f r o m an a c u t e c a r e h o s p i t a l - He s p e n t t h r e e months i n t h e r e h a b i l i t a t i o n f a c i l i t y . P s y c h o l o g i c a l t e s t i n g was n o t c a r r i e d o u t a t t h i s t i m e b e c a u s e o f h i s v e r y s i g n i f i c a n t a t t e n t i o n a 1 d e f i c i t s . I t was c o n s i d e r e d n o t p o s s i b l e t o do o b j e c t i v e n e u r o p s y c h o l o g i c t e s t i n g t o s e r v e as a b a s e l i n e r e c o r d . P r i o r t o t h e a c c i d e n t he w o r k e d as a l o t man f o r a c a r d e a l e r s h i p . He was known t o consume a l c o h o l f r e q u e n t l y and a l s o u s e d m a r i j u a n a . H i s s i s t e r d e s c r i b e d him as s h y and c o n s e r v a t i v e , p r i o r t o t h e a c c i d e n t , b u t she r e p o r t e d t h a t t h i s was no l o n g e r t h e c a s e . P e r s o n a l i t y and b e h a v i o r a l p r o b l e m s were r e p o r t e d as i n a p p r o p r i a t e s o c i a l b e h a v i o r , 1 a c k o f i n i t i a t i o n , memory p r o b l e m s and l a c k o f i n s i g h t . S u b j e c t 2 D a t e o f B i r t h : November 8,1952 D a t e o f A c c i d e n t : May 14,1985 G l a s g o w Outcome S c a l e (GOS): s e v e r e , coma 4 t o 6 weeks S u b j e c t 2 s u f f e r e d a b r a i n stem and p o s s i b l e a n o x i c c e r e b a l i n j u r i e s r e s u l t i n g i n a s p a s t i c q u a d r i p a r e s i s and i n t e l l e c t u a l d e f i c i t s as a r e s u l t o f a m o t o r c y c l e a c c i d e n t . He was a d m i t t e d t o a r e h a b i l i t a t i o n f a c i l i t y f r o m an a c u t e c a r e h o s p i t a l . He r e m a i n e d i n t h e 36 r e h a b i l i t a t i o n f a c i l i t y f o r e i g h t months and was d i s c h a r g e d t o a g r o u p home f o r head i n j u r e d p e r s o n s . He had g r a d e 10 e d u c a t i o n , a n d was e m p l o y e d as a h e a v y d u t y m a c h i n e o p e r a t o r . He was s e p a r a t e d f r o m h i s w i f e p r i o r t o t h e a c c i d e n t and has two p r e - s c h o o l c h i l d r e n who l i v e w i t h h i s w i f e . P r i o r t o h i s a c c i d e n t he was a h e a v y d r i n k e r and smoker and was r e p o r t e d t o have u s e d a v a r i e t y o f d r u g s . H i s p r e - m o r b i d l i f e s t y l e was d e s c r i b e d as s e 1 f - c e n t e r e d machismo and he was known f o r h i s r i s k t a k i n g b e h a v i o r . P e r s o n a l i t y and b e h a v i o r a l p r o b l e m s r e s u l t i n g f r o m t h e head i n j u r y a r e r e p o r t e d a s ; memory d e f i c i t s , v e r b a l a b u s i v e b e h a v i o r , l a c k o f i n s i g h t , p r o b l e m s o l v i n g d i f f i c u 1 t i e s , e a s i 1 y f r u s t r a t e d , l a c k o f c o n f i d e n c e , and p o o r i n t e r p e r s o n a l s k i l l s . P s y c h o l o g i c a l t e s t i n g r e p o r t e d a s c o r e o f 75-79 f o r t h e W e c h s l e r A d u l t I n t e l l i g e n c e S c a l e R e v i s e d and a s c o r e o f 64 i n t h e W e c h s l e r memory s c a l e . S u b j e c t 3 D a t e of B i r t h : May 15,1950 D a t e of A c c i d e n t : May 19,1985 G l a s g o w Outcome S c a l e ( G O S ) : S e v e r e coma 26 d a y s S u b j e c t 3 s u f f e r e d a c l o s e d head i n j u r y , a b d o m i n a l 37 i n j u r i e s , f r a c t u r e o f t h e p e l v i s , and m u l t i p l e f r a c t u r e s of l o w e r e x t r e m i t i e s as a r e s u l t o f a motor v e h i c l e a c c i d e n t . He was d i v o r c e d f r o m h i s w i f e p r i o r t o t h e a c c i d e n t . H i s two c h i l d r e n l i v e w i t h h i s e x - w i f e . He has g r a d e 12 e d u c a t i o n and w o r k e d f o r t h e r a i l w a y . H i s f e l l o w w o r k e r s d e s c r i b e d h i s as a l i k e a b l e man w i t h a t e n d e n c y n o t t o f o l l o w o r d e r s a t t i m e s . He was r e p o r t e d t o have a t e n d e n c y t o o v e r i n d u l g e i n a l c o h o l w h i c h r e s u l t e d i n b e l i g e r a n t b e h a v i o r . B e h a v i o r a l and p e r s o n a l i t y p r o b l e m s r e s u l t i n g f r o m t h e a c c i d e n t a r e r e p o r t e d a s ; l a c k o f i n s i g h t , l a c k o f i n i t i a t i o n , d i f f i c u l t y i n p r o b l e m s o l v i n g , d i f f i c u l t y i n p l a n n i n g , memory p r o b l e m s , i n a p p r o p r i a t e s t e r e o t y p e d r e s p o n s e s . However, S u b j e c t 3 r e p o r t s t h a t he b e l i e v e s h i s memory i s e s s e n t i a l l y n o r m a l and t h a t c o g n i t i v e l y he i s much t h e same as p r i o r t o t h e a c c i d e n t . In p s y c h o l o g i c a l t e s t i n g , he r e c e i v e d a s c o r e o f 86 i n t h e W e c h s l e r A d u l t I n t e l l i g e n t S c a l e R e v i s e d and 72 W e c h s l e r Memory S c a l e . He was r e p o r t e d t o have m a j o r p r o b l e m s i n l o g i c a l e x p r e s s i o n and s o c i a l j u d g e m e n t f r o m a c o n c e p t u a l s t a n d p o i n t . S u b j e c t 4 D a t e o f B i r t h : O c t o b e r 20,1964 38 D a t e o f A c c i d e n t : May 5,1985 G.O.S: M o d e r a t e ( l e n g t h o f coma n o t a v a i l a b l e ) S u b j e c t 4 s u f f e r e d a c l o s e d head i n j u r y ( d i f f u s e ) w i t h l e f t f r o n t a l l o b e and l e f t t h a l a m i c and r i g h t t e m p o r a l h e m o r r h a g e s , as t h e r e s u l t o f a motor v e h i c l e a c c i d e n t . He was a d m i t t e d t o a r e h a b i l i t a t i o n f a c i l i t y f r o m an a c u t e c a r e h o s p i t a l and r e m a i n e d t h e r e f o r f o u r months. He was d i s c h a r g e d home and l a t e r t o a g r o u p home f o r head i n j u r e d p e r s o n s . He had a g r a d e 12 e d u c a t i o n and w o r k e d as a c o o k p r i o r t o t h e a c c i d e n t . The b e h a v i o r a l and p e r s o n a l i t y p r o b l e m s r e s u l t i n g f r o m t h e head i n j u r y were r e p o r t e d a s ; memory p r o b l e m s , i m p a i r e d s p e e c h (monotone and n a s a l q u a l i t y , s l i g h t s l u r r e d ) , s l o w i n f o r m a t i o n p r o c e s s i n g , p r o b l e m s o l v i n g d i f f i c u l t i e s and p o o r i n t e r - p e r s o n a 1 s o c i a 1 s k i l l s . I n p s y c h o l o g i c a l t e s t i n g he s c o r e d 70-79 on t h e W e c h s l e r Memory S c a l e R e v i s e d and 69 on t h e W e c h s l e r Memory S c a l e . T h e r e was a g e n e r a l d e c r e a s e i n o v e r a l l i n t e l l e c t u a l c a p a b i l i t i e s . 39 C h a p t e r 3 R e s e a r c h D e s i g n T h i s r e s e a r c h i s an e x p l o r a t o r y - d e s c r i p t i v e s t u d y w h i c h s e e k s t o t h o r o u g h l y d e s c r i b e a p a r t i c u l a r phenomenon. The m a j o r p u r p o s e of t h i s t y p e of s t u d y i s t o r e f i n e and d e v e l o p c o n c e p t s and h y p o t h e s i s . The e x p e r i m e n t a l m a n i p u l a t i o n of t h e i n d e p e n d e n t v a r i a b l e ( i n t e r v e n t i o n p r o g r a m ) i s u s e d t o d e m o n s t r a t e t h e p l a u s i b i l i t y o f t h i s s p e c i f i c p r o g r a m . However, t h i s i s d i f f e r e n t f r o m e x p e r i m e n t s i n t h a t i t does n o t u s e r a n d o m i z a t i o n p r o c e d u r e s o r e x p e r i m e n t a l and c o n t r o l g r o u p s ( F e l l i n , T r i p o d i , M e y e r , 1 9 6 9 ) . In t h i s s t u d y , t h e s i n g l e s y s t e m d e s i g n was u s e d t o a d d r e s s t h e q u e s t i o n s t h a t t h e e x p l o r a t o r y - d e s c r i p t i v e d e s i g n c a n c ope w i t h . T h e s e a r e : 1. Can t h e d e s i g n be d e v e l o p e d i n o p e r a t i o n a l f o r m and i m p l e m e n t e d ? 2. Can t h e d e s i g n be a p p l i e d i n n o r m a l p r a c t i c e ? 3. Can t h e c h a n g e be r e l i a b l y m e a s u r e d ? A. Does ch a n g e o c c u r ? 5. What v a r i a t i o n i n c h a n g e e x i s t s o v e r t h e c u r r e n t t r e a t m e n t p o p u l a t i o n ? 40 The r e s e a r c h e r ' s c o n t r o l o v e r t h e phenomena s t u d i e d i s l i m i t e d by t h e t y p e o f d e s i g n e m p l o y e d . I n t h i s s t u d y , as m e n t i o n e d , t h e s i n g l e s u b j e c t d e s i g n was u s e d t o e v a l u a t e t h e e f f e c t s o f an i n t e r v e n t i o n on a s i n g l e i n d i v i d u a l . I t i s o f t e n c a l l e d s i n g l e c a s e d e s i g n , e x p e r i m e n t a l s i n g l e c a s e r e s e a r c h d e s i g n , o r t h e N =1 d e s i g n . In t h i s d e s i g n e a c h s u b j e c t s e r v e s as h i s / h e r own c o n t r o l . P r o p e r t i e s o f t h i s d e s i g n g i v e v a l i d i t y t o t h e i r u s e w i t h an i n d i v i d u a l who i s a b l e t o s e r v e b o t h e x p e r i m e n t a l and c o n t r o l f u n c t i o n s ( K r a t o c h w i 1 1 , M o t t , & Dobson i n B e l l a c k _ H e r s e n , 1 9 8 4 ) . The b a s e l i n e (A) p h a s e i s t h e c o n t r o l a s p e c t of t h i s d e s i g n and t h e i n t e r v e n t i o n <B) i s t h e e x p e r i m e n t a l f u n c t i o n o f t h e d e s i g n . A c h a n g e I n b e h a v i o r w h i c h i s n o t c o n s i s t e n t w i t h t h e b a s e l i n e and w h i c h i s a s s o c i a t e d w i t h t h e i n t e r v e n t i o n s t r e n g t h e n s t h e c o n c l u s i o n o f t h e c a u s a l r e l a t i o n s h i p b e t w e e n t h e t a r g e t b e h a v i o r c h a n g e and t h e i n t e r v e n t i o n . The s i n g l e s u b j e c t d e s i g n has b een a t t a c k e d as a l e s s r i g o r o u s method of r e s e a r c h . However, t h e r e has b e en i m p o r t a n t m e t h o d o l o g i c a l and c o n c e p t u a l a d v a n c e s i n t h i s a r e a o f r e s e a r c h r e c e n t l y . T h i s d e s i g n has a dded t o t h e d e v e l o p m e n t of m e a s u r e s t h a t c a n be u s e d r e p e a t e d l y o v e r t h e t h e r a p e u t i c p r o c e s s , s u c h as d i r e c t o b s e r v a t i o n , r a t i n g s c a l e s , c h e c k l i s t s , s e 1 f - m o n i t o r i n g 41 and v a r i o u s p s y c h o p h y s i c o 1 o g i c a 1 r e c o r d i n g s . A c c o r d i n g t o B e l l e e k and H e r s e n , t h e s e r e p e a t e d m e a s u r e s t a k e n o v e r t i m e a l l o w f o r an a n a l y s i s o f i n d i v i d u a l v a r i a b i l i t y as w e l l as m o n i t o r i n g o f p o t e n t i a l r e s p o n s e c o v a r i a t i o n w i t h i n a s i n g l e c l i e n t . I n c r e a s i n g l y , r e s e a r c h e r s and o t h e r s c h o l a r s i n t h e f i e l d a r e r e c o g n i z i n g t h e i m p o r t a n c e o f s i n g l e c a s e d e s i g n f o r t h e d e v e l o p m e n t o f a k n o w l e d g e b a s e i n t h e f i e l d ( B e l l a c k & H e r s e n , 1 9 8 4 ) . The s i n g l e s y s t e m d e s i g n i s an i m p o r t a n t a d d i t i o n t o r e s e a r c h f o r many r e a s o n s . I t p r o v i d e s an i m p o r t a n t k n o w l e d g e b a s e t h a t i s u n o b t a i n a b l e t h r o u g h t h e l a r g e N-between g r o u p d e s i g n i n r e s e a r c h . I t i s u n i q u e l y s u i t e d t o t h e e v a l u a t i o n o f t r e a t m e n t s i n v o l v i n g a s i n g l e c l i e n t and t h u s i s p a r t i c u l a r l y u s e f u l i n t h e f i e l d s o f s o c i a l work and c l i n i c a l p s y c h o l o g y . The s i n g l e s u b j e c t d e s i g n i s u s e f u l when g r o u p c o m p a r i s o n s a r e n o t p o s s i b l e b e c a u s e o f t h e l a c k of a l a r g e number of s u b j e c t s w i t h a p a r t i c u l a r p r o b l e m o r d i s o r d e r . The d e s i g n i s a l s o u s e f u l f o r c o n d u c t i n g r e s e a r c h s t u d i e s on c l i n i c a l p r o b l e m s t h a t do n o t match t h e t y p e o f c l i e n t s r e c r u i t e d f o r c o m p a r a t i v e g r o u p outcome s t u d i e s . T h i s d e s i g n a d d r e s s e s t h e e t h i c a l and l e g a l c o n s i d e r a t i o n s t h a t a r e o f t e n r a i s e d a b o u t t h e n o - t r e a t m e n t g r o u p o f c l a s s i c a l d e s i g n r e s e a r c h . 42 The s i n g l e s y s t e m d e s i g n u s e s r e p e a t e d m e a s u r e s t o e s t a b l i s h t r e n d s and a n a l y z e c h a n g e . T h e s e m u l t i p l e d a t a p o i n t s p r o v i d e d e t a i l e d d a t a on how t h e i n t e r v e n t i o n a f f e c t s t h e t a r g e t b e h a v i o r s o v e r t i m e . U n l i k e c l a s s i c a l e x p e r i m e n t a l d e s i g n s w h i c h t y p i c a l l y e v a l u a t e t h e s t r e n g t h of t h e i n t e r v e n t i o n e f f e c t s a f t e r t h e i n t e r v e n t i o n i s o v e r , t h e s i n g l e s u b j e c t d e s i g n p r o v i d e s on g o i n g , c o n t i n u o u s f e e d b a c k on t h e s e e f f e c t s and t h i s i n t u r n s h a p e s i n t e r v e n t i o n s t r a t e g i e s ( P o l s t e r & L y n c h , 1 9 8 2 ) . G r i n n e 1 1 ( 1 9 8 1 ) s t r e s s e s i n o r d e r t o o b t a i n r e l i a b l e d a t a e x t r a n e o u s c i r c u m s t a n c e s must be c o n t r o l l e d by m a i n t a i n i n g s t a b l e e n v i r o n m e n t a l c o n d i t i o n s , e m p l o y i n g r e p e a t e d and r e l i a b l e m e a s u r e m e n t s t h r o u g h o u t t h e s t u d y , and by c h a r t i n g a s t a b l e b a s e l i n e . He p o i n t s o u t t h a t t h e r e must be a s y s t e m a t i c and r e p e a t e d i n t r o d u c t i o n of t h e i n t e r v e n t i o n and t h a t t h e r e must be a s t a b l e r a t e of b e h a v i o r d u r i n g e a c h i n t r o d u c t i o n o f t h e i n t e r v e n t i o n . The s t a b l e b a s e l i n e i s one i n w h i c h t h e f r e q u e n c y of b e h a v i o r i s s t e a d y and r e m a i n s a t a c o n s t a n t l e v e l o v e r t i m e , u s u a l l y t h r e e o r f i v e s e s s i o n s o r e l s e t h e f r e q u e n c y i s c h a n g i n g i n some i d e n t i f i a b l e o r d e r l y manner. No p l a n n e d i n t e r v e n t i o n o c c u r s i n t h e b a s e l i n e , r a t h e r o n l y p l a n n e d o b s e r v a t i o n of t h e t a r g e t p r o b l e m . S i n c e t h e s e s t e p s were f o l l o w e d i n t h i s s t u d y we c a n 43 h y p o t h e s i z e t h a t t h e c h a n g e s i n b e h a v i o r a r e a s s o c i a t e d w i t h t h e i n t e r v e n t i o n s and a r e n o t t h e r e s u l t of n o r m a l f l u c t u a t i o n s i n t h e f r e q u e n c y of b e h a v i o r . In a d d i t i o n t o d i s t i n g u i s h i n g d i f f e r e n c e s t h a t o c c u r b e t w e e n b a s e l i n e and i n t e r v e n t i o n , t h e s i n g l e s u b j e c t d e s i g n o f f e r s t h e p o s s i b i l i t y o f m a k i n g c a u s a l i n f e r e n c e s - d i d t h e i n t e r v e n t i o n p r o d u c e t h e o b s e r v e d o u tcome? However, Bloom and F i s h e r ( 1 9 8 2) p o i n t o u t t h a t s e v e r a l c r i t e r i a a r e n e e d e d f o r i n f e r r i n g c a u s a l i t y i n s i n g l e s y s t e m d e s i g n s . The c h a n g e i n t h e t a r g e t p r o b l e m must o c c u r a f t e r t h e i n t e r v e n t i o n . T h i s c a n be v e r i f i e d by c h a r t i n g b a s e l i n e and i n t e r v e n t i o n d a t a . T h e r e must be a r e p e a t e d c o - p r e s e n c e of t h e a p p l i c a t i o n of i n t e r v e n t i o n and d e s i r e d c h a n g e of t h e t a r g e t p r o b l e m and t h i s p r o b l e m c a n n o t c h a n g e f o r t h e b e t t e r i n a b s e n c e of t h e i n t e r v e n t i o n . T h e r e must n o t be any o t h e r c o n t i n u o u s l y c o - p r e s e n t f a c t o r s t h a t c o u l d be c a u s a l l y r e l a t e d t o t h e outcome. F i n a l l y , Bloom and F i s h e r s t a t e t h a t t h e c o n c e p t u a l and p r a c t i c a l p l a u s i b i l i t y o f t h e i n f e r e n c e s h o u l d be g r o u n d e d i n s c i e n t i f i c k n o w l e d g e o r a t l e a s t n o t c o n t r a r y t o i t . S i n g l e s y s t e m d e s i g n i s c r i t i c i z e d f o r w e a k n e s s i n g e n e r a l i z a t i o n . A l t h o u g h some i n t e r v e n t i o n w o r k s w i t h one c l i e n t , i t i s h a r d t o p r o v e t h a t i t w i l l l i k e l y be t r u e f o r a n o t h e r c l i e n t . However, t h e r e i s s t i l l 44 s u f f i c i e n t b a s i s f o r a s s e r t i n g a l i m i t e d f o r m o f g e n e r a l i z a b i l i t y w i t h t h i s d e s i g n , b u t t h e g e n e r a l i z a t i o n must be b a s e d on how much a l i k e t h e e s s e n t i a l c l i e n t d i m e n s i o n s a r e . R e p l i c a t i o n w i t h t h e s i n g l e s y s t e m d e s i g n i s a c h i e v e d t h r o u g h c a r e f u l s p e c i f i c a t i o n o f : t h e s e t t i n g , t h e c l i e n t c h a r a c t e r i s t i c s t h a t o c c u r d u r i n g t h e e x p e r i m e n t , and t h e i n d e p e n d e n t and d e p e n d e n t v a r i a b l e s . I t i s a l s o n e c e s s a r y t o i s o l a t e t h e t h e r a p e u t i c ' c o mponents i n o r d e r t o e s t a b l i s h a f u n c t i o n a l r e l a t i o n s h i p b e t w e e n t h e i n d e p e n d e n t and d e p e n d e n t v a r i a b l e s . I n t e r n a l v a l i d i t y i s a c h i e v e d by t h e r e p l i c a t i o n of e f f e c t s a c r o s s c l i e n t s . However, t h e number of r e p l i c a t i o n s has b een d e b a t e d . A c c o r d i n g t o B loom and F i s h e r , a t l e a s t two and p r o b a b l y f o u r r e p l i c a t i o n s a r e n e c e s s a r y t o t e s t t h e h y p o t h e s i s t h a t t h e i n d e p e n d e n t v a r i a b l e i s r e s p o n s i b l e f o r t h e c h a n g e i n t h e d e p e n d e n t v a r i a b l e . T h i s r e p l i c a t i o n i s c r i t i c a l i f r e s u l t s a r e t o be g e n e r a l i z e d b e y o n d t h e i n d i v i d u a l c a s e . U n l i k e c l a s s i c a l e x p e r i m e n t a l d e s i g n s , t h e p r i m a r y e m p h a s i s i n t h e s i n g l e s y s t e m d e s i g n s i s n o t t h e p r o o f o r d i s p r o o f of h y p o t h e s e s , b u t on t h e o b s e r v a t i o n and a n a l y s e s of t h e e f f e c t of i n t e r v e n t i o n on s p e c i f i c t a r g e t b e h a v i o r s . H o w e v e r , b o t h s i n g l e s y s t e m d e s i g n and .45 g r o u p d e s i g n s s t r e s s t h e s e l e c t i o n and d e f i n i t i o n o f t a r g e t b e h a v i o r s w h i c h i s a c r i t i c a l s t e p i n t h e r e s e a r c h p r o c e s s . In t r a d i t i o n a l g r o u p d e s i g n s , t h e e v a l u a t i o n of i n t e r v e n t i o n p r o g r a m s u s u a l l y means t h a t t h e i n t e r v e n t i o n c a n n o t be c h a n g e d once t h e s t u d y has begun. However t h e s i n g l e s u b j e c t d e s i g n i s more f l e x i b l e and t h e i n t e r v e n t i o n c a n be c h a n g e d d e p e n d i n g on t h e needs o f e a c h c a s e . The m a j o r d i s t i n g u i s h i n g c h a r a c t e r i s t i c o f s i n g l e s y s t e m d e s i g n s i n v o l v e s t h e p l a n n e d c o m p a r i s o n o f a p r e - i n t e r v e n t i o n o r b a s e l i n e p e r i o d o f o b s e r v a t i o n w i t h o b s e r v a t i o n s o f t h e i n t e r v e n t i o n p e r i o d and p o s t - i n t e r v e n t i o n p e r i o d s i n some c a s e s . U n l i k e c l a s s i c a l e x p e r i m e n t a l c o n t r o l g r o u p d e s i g n s i n w h i c h c o m p a r i s o n i s made b e t w e e n g r o u p s , s i n g l e s y s t e m d e s i g n i n v o l v e s a c o m p a r i s o n b e t w e e n t i m e p e r i o d s f o r t h e same c l i e n t . The u n d e r l y i n g a s s u m p t i o n h e r e i s t h a t i f t h e i n t e r v e n t i o n had n o t o c c u r r e d t h e b a s e l i n e b e h a v i o r w o u l d c o n t i n u e . However, e v e n t h o u g h s i n g l e s u b j e c t d e s i g n and c l a s s i c a l r e s e a r c h a r e q u i t e d i f f e r e n t t h e y complement e a c h o t h e r . As m e n t i o n e d p r e v i o u s l y , t h e s i n g l e s u b j e c t d e s i g n i s u s e f u l f o r f o r m a t i v e p r o g r a m e v a l u a t i o n as r e s e a r c h i s f o c u s e d on e v a l u a t i n g and i m p r o v i n g a s p e c i f i c p r o g r a m . C l a s s i c a l r e s e a r c h i s more u s e f u l f o r s u m m a t i v e e v a l u a t i o n r e s e a r c h f o c u s e d on e v a l u a t i o n t h a t 46 c a n be g e n e r a l i z e d t o a p p l y t o o t h e r p r o g r a m s o r s i t u a t i o n s t o a f f e c t d e c i s i o n m a k i n g ( S c r i v e n , 1 9 6 7 i n Bloom _ F i s h e r , 1 9 8 2 ) . T h e r e I s an i n t e r - r e 1 a t i o n s h i p b e t w e e n s i n g l e s u b j e c t d e s i g n and c l a s s i c a l r e s e a r c h as s e v e r a l s u c c e s s f u l r e p l i c a t i o n s o f t h e s i n g l e s y s t e m d e s i g n c a n be u s e d t o f o r m t h e b a s i s f o r l a r g e g r o u p r e s e a r c h . The s i n g l e s u b j e c t d e s i g n c a n be u s e d t o p r o v i d e b a s i c d a t a f o r g e n e r a t i n g h y p o t h e s e s f o r more c o m p l e x c l a s s i c a l d e s i g n s . The A B D e s i g n The A ( b a s e l i n e ) B ( i n t e r v e n t i o n ) i s t h e b a s i c s i n g l e s y s t e m d e s i g n and i s w i d e l y a p p l i c a b l e t o many t y p e s o f p r o b l e m s and s e t t i n g s as w e l l a s t o a l l l e v e l s o f i n t e r v e n t i o n . The s i m p l e l o g i c a l s t r u c t u r e p e r m i t s a p l a n n e d c o m p a r i s o n b e t w e e n two e l e m e n t s . I t c l e a r l y d e m o n s t r a t e s when t h e t a r g e t b e h a v i o r s have c h a n g e d . The d i f f e r e n c e s t h a t emerge b e t w e e n t h e b a s e l i n e and a f t e r t h e i n t e r v e n t i o n p r o v i d e a t e n t a t i v e l o o k a t p o s s i b l e c a u s a l f a c t o r s . T h i s d e s i g n p r o v i d e s an o n g o i n g f e e d b a c k on t h e b e h a v i o r d u r i n g b a s e l i n e and i n t e r v e n t i o n p e r i o d s and p e r m i t s an a p p r a i s a l o f t h e e f f e c t i v e n e s s o f t h e i n t e r v e n t i o n . T h e r e a r e o t h e r more r i g o r o u s s i n g l e s y s t e m d e s i g n s b u t t h e y a r e n o t f e a s i b l e f o r t h i s s t u d y and t h e r e f o r e 47 w i l l n o t be d i s c u s s e d h e r e . L i m i t a t i o n s o f t h e A B D e s i g n T h i s d e s i g n c a n o n l y p r o v i d e c l e a r i n f o r m a t i o n on c h a n g e b e t w e e n b a s e l i n e and i n t e r v e n t i o n . I t does n o t p e r m i t c o n t r o l o f any a l t e r n a t e e x p l a n a t i o n s f o r why r e s u l t s o c c u r r e d as t h e y d i d . However, m u l t i p l e m e a s u r e s o f t h e p r o b l e m c a n h e l p t o o v e r c o m e t h i s . T h e r e i s a t e n d e n c y f o r p r a c t i t i o n e r s and r e s e a r c h e r s t o down p l a y t h e A B d e s i g n b e c a u s e i t does n o t p e r m i t t h e f u n c t i o n a l a n a l y s i s t h a t more c o m p l e x d e s i g n s do. T h e r e a r e two t e c h n i q u e s i n t h e i n t e r v e n t i o n - t h e game and t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s , b u t t h e A B d e s i g n does n o t d i s t i n g u i s h w h i c h one o r w h i c h c o m b i n a t i o n s were more e f f e c t i v e . However t h i s s i m p l e d e s i g n c a n be r e a d i l y e m p l o y e d by any p r a c t i t i o n e r and p r o v i d e s v i t a l i n f o r m a t i o n t h a t c a n n o t be o b t a i n e d i n any o t h e r way. A c c o r d i n g t o Bloom and F i s h e r i t p r o v i d e s t h e b a s i c f o u n d a t i o n and t h e f u n d a m e n t a l b u i l d i n g b l o c k s f o r a l a r g e a r r a y of l o g i c a l ways of i n f e r r i n g c a u s a l e f f i c a c y o f t h e i n t e r v e n t i o n s . However, by f o l l o w i n g t h e p r e v i o u s m e n t i o n e d c r i t e r i a f o r i n f e r r i n g c a u s a l i t y i n s i n g l e s y s t e m d e s i g n s t h e s e l i m i t a t i o n s c a n be r e d u c e d and e a c h s u c c e s s f u l r e p l i c a t i o n f u r t h e r s u p p o r t s t h e 48 e f f e c t i v e n e s s of t h e i n t e r v e n t i o n . A d v a n t a g e s o f S i n g l e S y s t e m D e s i g n Some of t h e a d v a n t a g e s have been m e n t i o n e d and w i l l o n l y be s u m m a r i z e d h e r e . A l t h o u g h t h i s d e s i g n c a n r e f u t e o r o f f e r s u p p o r t f o r t h e h y p o t h e s i s t h a t t h e i n t e r v e n t i o n e f f e c t e d c h a n g e , i t c a n n o t c o n f i r m i t . The r e s u l t c a n l e a d t o a b e t t e r f o r m u l a t e d h y p o t h e s i s . T h i s d e s i g n i s u s e d t o e v a l u a t e t h e e f f e c t s of an i n t e r v e n t i o n on a s i n g l e i n d i v i d u a l o r g r o u p . I n t e r v e n t i o n f a i l u r e c a n be q u i c k l y o b s e r v e d d u r i n g m o n i t o r i n g of d a t a and c h a n g e s c a n be made. I f t h e a d d i t i o n a l i n t e r v e n t i o n l e a d s t o s u c c e s s H e r s e n and B a r l o w ( 1 976) s t a t e t h e y c a n be f u r t h e r r e p l i c a t e d f o r t r a n s f e r a b i l i t y . I f n o t s u c c e s s f u l t h e d i s t i n c t i v e c h a r a c t e r i s t i c s of t h a t c l i e n t c a n be s t u d i e d t o t r y t o d i s c o v e r e l e m e n t s t h a t may have c a u s e d t h e r e s u l t and t h i s i n f o r m a t i o n c a n be u s e d i n r e p l i c a t i o n s t u d i e s . S i n g l e s y s t e m d e s i g n p r o v i d e s an i m p o r t a n t k n o w l e d g e b a s e t h a t I s u n o b t a i n a b l e w i t h t r a d i t i o n a l c l a s s i c a l d e s i g n s . I t o v e r c o m e s t h e e t h i c a l p r o b l e m s of w i t h h o l d i n g t r e a t m e n t . 49 The s i m p l e l o g i c a l p r o c e s s p r o v i d e s o p t i o n s f o r p r a c t i t i o n e r s t o be i n v o l v e d i n r e s e a r c h . The s i n g l e s y s t e m d e s i g n p l a y s an i m p o r t a n t r o l e i n t h e i n v e s t i g a t i o n i n d i v e r s e a r e a s of p s y c h o l o g y , e d u c a t i o n , s o c i a l work and o t h e r r e l a t e d f i e l d s . T h i s d e s i g n i s c o m p a t i b l e w i t h any f o r m o f p r a c t i c e , a t a l l l e v e l s o f i n t e r v e n t i o n and a c r o s s a b r o a d r a n g e o f t h e o r e t i c a l o r i e n t a t i o n s . The u l t i m a t e g o a l of s i n g l e s y s t e m d e s i g n i s t o i m p r o v e p r a c t i c e w h i c h i s c o m p a t i b l e w i t h t h e g o a l of t h i s s t u d y w h i c h i s t o e v a l u a t e t h e e f f e c t i v e n e s s o f a s p e c i f i c p r o g r a m . Summary In summary, t h e d e s i g n i s n o t a p r o b l e m i f : r e p e a t e d m e a s u r e s a r e e m p l o y e d , e x t r a n e o u s c i r c u m s t a n c e s a r e c o n t r o l l e d , a s t a b l e b a s e l i n e i s c h a r t e d p r i o r t o t h e i n t r o d u c t i o n o f t h e i n d e p e n d e n t v a r i a b l e and r e p l i c a t i o n s a r e made f o r g e n e r a l i z a t i o n s t o o t h e r s i m i l a r i n d i v i d u a l s . C o n s e q u e n t l y when t h i s t y p e o f d e s i g n i s e m p l o y e d a l o n g w i t h a h i g h i n t e r - r a t e r r e l i a b i l i t y and when e r r o r s i n ju d g m e n t a r e c o n t r o l l e d f o r , t h e n t h e r e s u l t i n g d a t a c o n t r i b u t e s t o r e s e a r c h and p r a c t i c e . 50 PROCEDURE B e f o r e t h e b a s e l i n e m e a s u r e m e n t s a r e d i s c u s s e d i t i s n e c e s s a r y t o l o o k a t t h e measure o r game " S t a c k i n g t h e Deck" b e c a u s e i t i s u n i q u e . " S t a c k i n g t h e Deck" i s p l a y e d by i n c o r p o r a t i n g g e n e r a l s o c i a l s k i l l s i t u a t i o n s i n t o t h e t a b l e game " S o r r y " . T h i s game i n v o l v e s s u c c e s s i v e t u r n s and p r o g r e s s i v e movement a r o u n d t h e game b o a r d t o w a r d s "home". The r e l a t i v e l y s i m p l e r u l e s were m o d i f i e d so t h a t no p l a y e r m i s s e d a t u r n and no e x t r a t u r n s were a l l o w e d . P l a y e r s were o n l y a l l o w e d t o move when t h e y r e s p o n d e d c o r r e c t l y . T h e r e f o r e , game r u l e s t h a t r e q u i r e d an e x a c t number i n o r d e r t o move ( e . g . d r a w i n g a c a r d w i t h a p a r t i c u l a r number t o move o u t of " s t a r t " o r i n t o "home") were d r o p p e d so t h a t movement was p e r m i t t e d on any c a r d . A game of " s t a c k i n g t h e d e c k " ends when a l l t h e c a r d s i n t h e c u r r i c u l u m d e c k have been u s e d . Thus, t h e l e a d p l a y e r i s d e c l a r e d t h e w i n n e r , r e g a r d 1 e s s o f w h e t h e r h i s p i e c e s r e a c h e d t h e g o a l . R e a c h i n g "home" was n o t t h e p r i m a r y o b j e c t o f " s t a c k i n g t h e d e c k " . T h i s p r o g r a m i s u n i q u e b e c a u s e i t i s b o t h an a s s e s s m e n t t o o l and a t h e r a p y p r o g r a m . 51 D e v e l o p i n g a B a s e l i n e o f S o c i a l S k i l l s " S t a c k i n g t h e Deck" was u s e d a s an a s s e s s m e n t t o o l t o d e t e r m i n e e a c h p l a y e r ' s b a s e l i n e l e v e l of s o c i a l c o m p e t e n c y . T h i s was a c c o m p l i s h e d by p l a y i n g a s e r i e s of f o u r o r f i v e games a t t h e b e g i n n i n g , i n w h i c h t h e f a c i l i t a t o r p r o v i d e d no f e e d b a c k r e g a r d i n g t h e p l a y e r s ' r e s p o n s e s . P l a y e r s were a l l o w e d t o move t h e i r game p i e c e s w h e t h e r t h e y r e s p o n d e d c o r r e c t l y o r i n c o r r e c t l y . A l t h o u g h t h e f a c i l i t a t o r u s e d t h e F a c i l i t a t o r R e c o r d i n g S h e e t and S c o r i n g S h e e t d u r i n g b a s e l i n e games, t h e p l a y e r s d i d n o t r e c o r d r e s p o n s e s on t h e P l a y e r S c o r e c a r d s o r p l o t t h e i r own p r o g r e s s on t h e P l a y e r P r o g r e s s G r a p h s u n t i l t h e t r a i n i n g b e g a n. U s i n g t h e p r o g r a m i n t h i s manner p e r m i t t e d t h e f a c i l i t a t o r t o e v a l u a t e e a c h p l a y e r ' s e n t r y l e v e l o f s k i l l and p r o v i d e d a b a s e l i n e measure a g a i n s t w h i c h t o compare i m p r o v e m e n t s d u r i n g t r a i n i n g . PLAYING THE GAME E s t a b l i s h i n g C r i t e r i a f o r t h e Game Once t h e p l a y e r s were s e a t e d a t t h e game t a b l e , t h e f a c i l i t a t o r i n f o r m e d e a c h p l a y e r how many c o r r e c t r e s p o n s e s he ne e d e d f o r t h a t game. To keep t r a c k o f 52 c o r r e c t r e s p o n s e s , e a c h p l a y e r was g i v e n a P l a y e r ' s S c o r e c a r d numbered f r o m 1 t o 12 ( c o r r e s p o n d i n g t o h i s 12 game t u r n s ) on w h i c h t h e f a c i l i t a t o r c i r c l e d t h e number ne e d e d t o w i n . T h i s number was d e t e r m i n e d i n d i v i d u a l l y on a game-by-game b a s i s so t h a t a p l a y e r ' s r a t e o f c o r r e c t r e s p o n s e s i n c r e a s e d . T h i s p r o g r e s s i v e s e q u e n c e was u s e d t o m o t i v a t e t h e p l a y e r s t o i m p r o v e as t h e y c o n t i n u e d t o p l a y t h e game. The f a c i l i t a t o r b e g an e a c h game by s h u f f l i n g t h e deck and s e l e c t i n g a p l a y e r t o s t a r t . P l a y e r s t h e n t o o k t u r n s i n a c l o c k w i s e f a s h i o n a r o u n d t h e b o a r d . E a c h t u r n b e gan w i t h t h e f a c i l i t a t o r r e a d i n g t h e c a r d , f r o m t h e t o p of t h e d e c k , t o t h e p l a y e r and gave him a p p r o x i m a t e l y 10 s e c o n d s t o b e g i n a r e s p o n s e ( w i t h t h e e x c e p t i o n o f S u b j e c t 1 who was g i v e n more t i m e t o r e s p o n d and t h e q u e s t i o n was r e p e a t e d up t o t h r e e t i m e s i f he was d i s t r a c t e d by a c t i v i t y a r o u n d h i m ) . P l a y e r s were n o t a l l o w e d t o a s s i s t o t h e r s w i t h a r e s p o n s e . The f a c i l i t a t o r c h e c k e d t h e F a c i l i t a t o r ' s S c o r i n g g u i d e t o d e t e r m i n e w h e t h e r t h e p l a y e r ' s r e s p o n s e s a t i s f i e d t h e c o r r e c t r e s p o n s e t o t h a t t y p e o f s i t u a t i o n . (See T a b l e No.2 ). 53 TABLE 2 CR I T E R I A FOR DETERMINING CORRECT RESPONSES S k i l l a r e a C a t e g o r y C h a r a c t e r i s t i c s of a C o r r e c t R e s p o n s e (C) Comp1iments (A) a c t o r 1 (B) r e a c t o r 1. 2. T e l l s t h e o t h e r p e r s o n what you l i k e a n d / o r How y o u f e e l a b o u t i t . A c k n o w l e d g e s t h e c o m p l i m e n t a n d / o r R e l a t e s b a c k t o t h e o t h e r p e r s o n . ( S I ) S o c i a l I n t e r a c t i o n (A) a c t o r (B) r e a c t o r (P) P o l i t e n e s s (A) a c t o r 1. 2. 1. 1. 2. (B) r e a c t o r 1. 2. (CR) C r i t i c i s m (A) a c t o r 1. 2. (B) r e a c t o r 1. 2. I n i t i a t e s a c o n v e r s a t i o n a n d / o r H e l p s k e e p t h e c o n v e r s a t i o n g o i n g . L e t s t h e o t h e r p e r s o n know y o u a r e l i s t e n i n g a n d / o r H e l p s k e e p t h e c o n v e r s a t i o n g o i n g . A d d r e s s e s t h e i s s u e a n d / o r Uses a p p r o p r i a t e 1 a n g u a g e ( e . g . Thank y o u , e x c u s e me e t c . ) Us e s a p p r o p r i a t e l a n g u a g e a n d / o r O f f e r s an e x p l a n a t i o n . T e l l s t h e o t h e r p e r s o n what y o u d o n ' t l i k e a n d / o r S a y s s o m e t h i n g n i c e ( e . g . "You l o o k b e t t e r i n r e d " ) . T e l l s t h e o t h e r p e r s o n what y o u t h i n k a n d / o r S a y s s o m e t h i n g n i c e . ( S O S o c i a l C o n f r o n t a t i o n (A) a c t o r (B) r e a c t o r i , T e l l s t h e o t h e r p e r s o n what t h i n k a b o u t t h e p r o b l e m a n d / o r How y o u f e e l a b o u t i t . T e l l s t h e o t h e r p e r s o n what t h i n k a b o u t t h e p r o b l e m a n d / o r What c a n be done a b o u t i t . y o u y o u (Q) Q u e s t i o n s / A n s w e r s (A) a c t o r 1. A s k s an a p p r o p r i a t e p e r s o n ( i f a p p l i c a b l e ) a n d / o r 2. S t a t e s t h e q u e s t i o n c o m p l e t e l y . 1. A n s w e r s t h e q u e s t i o n and 2. I f t h e answer i s no, g i v e s an e x p 1 a n a t i on. (B) r e a c t o r 54 E a c h c a r d c o n t a i n e d a two o r t h r e e l e t t e r c o d e k e y e d t o t h e g u i d e t h a t s p e c i f i e d w h i c h s k i l l a r e a t h e p o s e d s i t u a t i o n i s i n and w h e t h e r a n a c t i o n o r r e a c t i o n was r e q u i r e d . I f t h e f a c i l i t a t o r d e t e r m i n e d t h a t t h e r e s p o n s e was c o r r e c t , t h e p l a y e r was p r a i s e d ( g o o d a n s w e r , o u t s t a n d i n g j o b , g r e a t , e t c . ) and was a l l o w e d t o move one o f h i s game p i e c e s t h e number o f s p a c e s i n d i c a t e d by t h e l a r g e number i n t h e m i d d l e o f t h e c a r d . T h e n t h e p l a y e r was t o l d t o mark h i s P l a y e r S c o r e c a r d by p u t t i n g a l i n e o r " x M t h r o u g h t h e a p p r o p r i a t e n u m b e r . A s s i s t a n c e was p r o v i d e d i f n e c e s s a r y . I f t h e a n s w e r d i d n o t s a t i s f y t h e c r i t e r i a on t h e F a c i l i t a t o r S c o r i n g G u i d e , t h e f a c i l i t a t o r s i m p l y i n f o r m e d t h e p l a y e r t h a t t h e a n s w e r i s i n c o r r e c t ( i n a n e u t r a l , n o n a p o l o g i c t o n e ) a n d r e r e a d t h e s i t u a t i o n on t h e c a r d a n d m o d e l e d a s a m p l e c o r r e c t a n s w e r f r o m t h e c o r r e s p o n d i n g F a c i l i t a t o r R e s p o n s e S h e e t . The p l a y e r was n o t a l l o w e d t o move a n y o f h i s game p i e c e s . The same c o r r e c t r e s p o n s e was m o d e l e d u n t i l t h e p l a y e r s w e r e r e s p o n d i n g c o r r e c t l y t o t h a t c a r d on a r e g u l a r b a s i s . A t t h a t p o i n t t h e f a c i l i t a t o r b e g a n t o v a r y t h e c o r r e c t r e s p o n s e s g i v e n . The f a c i l i t a t o r t h e n u s e d t h e F a c i l i t a t o r R e c o r d i n g S h e e t t o r e c o r d w h e t h e r t h e r e s p o n s e was c o r r e c t o r i n c o r r e c t . A game was f i n i s h e d 55 when a l l t h e 48 c a r d s were u s e d . A t t h a t p o i n t , t h e p l a y e r w i t h , t h e most p i e c e s i n "home" o r c l o s e s t t o "home" was d e c l a r e d t h e game w i n n e r . The p r i z e was u s u a l l y a p a c k a g e o f s u g a r l e s s gum o r a c h o c o l a t e b a r . The s t r u c t u r e d l e a r n i n g a s s i g n m e n t s ( G o l d s t e i n , S p r a f k i n & G e r s h a w , 1 9 7 6 ) were i n c o r p o r a t e d i n t o t h e p r o g r a m i n o r d e r t o i m p r o v e t h e n o n - v e r b a l b e h a v i o r and t o i n c r e a s e t h e c h a n c e o f g e n e r a l i z a t i o n t o t h e n a t u r a l e n v i r o n m e n t . The a u t h o r s of t h e s t r u c t u r e d l e a r n i n g p r o g r a m d e v e l o p e d t h e i r p r o g r a m t o a s s i s t m e n t a l l y i l l p a t i e n t s r e t u r n i n g t o t h e community. The s t r u c t u r e d l e a r n i n g t h e o r y e m p l o y s m o d e l i n g , r o l e p l a y , and s o c i a l r e i n f o r c e m e n t t o e n h a n c e l e a r n i n g . A c c o r d i n g t o G o l d s t e i n e t a l . , t h e r e a r e t h r e e s t a g e s t o m o d e l i n g ; a t t e n t i o n , r e t e n t i o n and r e p r o d u c t i o n . The a t t e n t i o n and r e t e n t i o n a s p e c t s were a d d r e s s e d by l i s t e n i n g t o t a p e s , and t h e n e v a l u a t i n g t h e t a p e s by f o l l o w i n g e a c h s p e c i f i c l e a r n i n g p o i n t . E a c h s u b j e c t had a c a r d o f l e a r n i n g p o i n t s and e a c h had a c h a n c e t o d e t e r m i n e i f t h e l e a r n i n g p o i n t s were f o l l o w e d . T h e s e same c a r d s w i t h l e a r n i n g p o i n t s were u s e d t o e n a c t a g i v e n s i t u a t i o n , e a c h s u b j e c t t o o k t u r n s r o l e p l a y i n g a s i t u a t i o n . E v e r y o n e had t h e o p p o r t u n i t y t o p a r t i c i p a t e i n a r o l e p l a y and e v a l u a t e a r o l e p l a y a c c o r d i n g t o l e a r n i n g p o i n t s f o l l o w e d . S o c i a l r e i n f o r c e m e n t s o f 56 p r a i s e and a p p r o v a l were g i v e n , by t h e f a c i l i t a t o r , a c c o r d i n g 1y. E a c h s u b j e c t p a r t i c i p a t e d i n t h r e e s t r u c t u r e d l e a r n i n g s e s s i o n s w i t h t h e e x c e p t i o n o f s u b j e c t 4 who o n l y p a r t i c i p a t e d i n one of t h e s e s e s s i o n s b e c a u s e o f o t h e r c o m m i t t m e n t s . T h e s e s e s s i o n s were i n t e r s p e r s e d b e t w e e n games. The game was n o t p l a y e d d u r i n g t h e s e s e s s i o n s . The l e a r n i n g p o i n t s o f t h e s k i l l s s t u d y a r e : S k i l l 1. S t a r t i n g a C o n v e r s a t i o n 1. C h o o s e t h e r i g h t p l a c e and t i m e . 2. G r e e t t h e o t h e r p e r s o n . 3. Make s m a l l t a l k . 4. J u d g e i f t h e o t h e r p e r s o n i s l i s t e n i n g and w a n t s t o t a l k w i t h y o u . 5. Open t h e ma i n t o p i c y o u want t o t a l k a b o u t . S k i l l 2. C a r r y i n g on a C o n v e r s a t i o n 1. Open t h e m a i n t o p i c y o u want t o t a l k a b o u t . 2. P r e s e n t y o u r t h o u g h t s and f e e l i n g s on t h e t o p i c . 3. Ask f o r t h e o t h e r p e r s o n ' s r e a c t i o n s . 4. R e s p o n d t o t h e o t h e r p e r s o n ' s r e a c t i o n s . 57 S k i l l 3. E n d i n g a C o n v e r s a t i o n 1. Summarize y o u r ' s and t h e o t h e r p e r s o n ' s main p o i n t s . 2. Draw a c o n c l u s i o n . 3. Ask f o r t h e o t h e r p e r s o n ' s r e a c t i o n . 4. R e s p o n d t o t h e o t h e r p e r s o n ' s r e a c t i o n . 5. Make a c l o s i n g r e m a r k . S k i l l 4. L i s t e n i n g 1. Look a t t h e o t h e r p e r s o n . 2. Show y o u r i n t e r e s t i n t h e o t h e r ' s s t a t e m e n t - e.g. nod y o u head e t c . 3. Ask q u e s t i o n s on t h e same t o p i c . 4. Add y o u r t h o u g h t s and f e e l i n g on t h e t o p i c . S k i l l 13. E x p r e s s i n g A n g e r 1. Pay a t t e n t i o n t o t h o s e body s i g n a l s w h i c h h e l p y o u know what y o u a r e f e e l i n g . 2. D e c i d e w h i c h o u t s i d e e v e n t s may have c a u s e d you t o have t h e s e f e e l i n g s . 3. D e c i d e i f y o u a r e f e e l i n g a n g r y a b o u t t h e s e e v e n t s . 4. D e c i d e how y o u c a n b e s t e x p r e s s t h e s e a n g r y f e e l i n g s . 5. E x p r e s s y o u r a n g r y f e e l i n g s i n a d i r e c t and h o n e s t manner. 58 S k i l l 22. R e s p o n d i n g t o Anger 1. L i s t e n o p e n l y t o t h e o t h e r p e r s o n ' s a n g r y s t a t e m e n t . 2. Show t h a t you u n d e r s t a n d what t h e o t h e r i s f e e l i n g . 3. Ask t h e o t h e r p e r s o n t o e x p l a i n a n y t h i n g y o u d o n ' t u n d e r s t a n d a b o u t what he s a i d . 4. Show t h a t y o u u n d e r s t a n d why he i s f e e l i n g a n g r y . 5. I f a p p r o p r i a t e , e x p r e s s y o u r t h o u g h t s and f e e l i n g s a b o u t t h e s i t u a t i o n . T h e s e p a r t i c u l a r s k i l l s were c h o s e n b e c a u s e t h e c o n v e r s a t i o n and l i s t e n i n g s k i l l s a p p e a r e d t o a d d r e s s some of t h e n o n - v e r b a l and c o g n i t i v e f u n c t i o n s o f c o m m u n i c a t i o n . The s k i l l s on e x p r e s s i n g and r e s p o n d i n g t o a n g e r were c h o s e n b e c a u s e t h i s was i d e n t i f i e d as a p a r t i c u l a r p r o b l e m f o r some of t h e s u b j e c t s . S u b j e c t 1 o n l y w o r k e d on t h e c o n v e r s a t i o n and l i s t e n i n g s k i l l s and S u b j e c t 4 was o n l y a b l e t o a t t e n d one o f t h e s t r u c t u r e d l e a r n i n g s e s s i o n s . R e s e a r c h C o n t r o l o v e r Phenomena S t u d i e d The r e s e a r c h e r ' s c o n t r o l o v e r t h e t i m i n g o f d a t a c o l l e c t i o n i n r e l a t i o n t o t h e o c c u r r e n c e o f t h e i n d e p e n d e n t v a r i a b l e i s i m p o r t a n t . In a l l c a s e s t h e i n d e p e n d e n t v a r i a b l e ( t h e s i t u a t i o n c a r d s i n t h e deck a c c o m p a n i e d by t h e f a c i l i t a t o r ' s r e s p o n s e as t o a 59 c o r r e c t o r i n c o r r e c t a n s w e r ) o c c u r r e d o n l y a f t e r a b a s e l i n e was e s t a b l i s h e d . T h e r e f o r e , i t i s assumed t h a t t h e p a t t e r n o f b e h a v i o r i n t h e b a s e l i n e w o u l d c o n t i n u e i f t h e r e was no i n t e r v e n t i o n . D a t a Co 1 1 e c t i o n The " S t a c k i n g t h e Deck" p r o g r a m p r o v i d e d f o r t h e m a j o r i t y o f t h e d a t a c o l l e c t e d . S p e n c e ' s S o c i a l S k i l l s A s s e s s m e n t C h a r t and t h e S t a f f Q u e s t i o n n a i r e on S o c i a l B e h a v i o r were u s e d as p r e and p o s t i n t e r v e n t i o n m e a s u r e s . In d e v e l o p i n g t h e " S t a c k i n g t h e Deck " p r o g r a m , Foxx e t a l . ( 1 9 8 3 ) i n d e n t i f i e d s i x s o c i a l s k i l l component a r e a s : c o m p l i m e n t s , s o c i a l i n t e r a c t i o n , p o l i t e n e s s , c r i t i c i s m , s o c i a l c o n f r o n t a t i o n and q u e s t i o n s / a n s w e r s . A r e v i s e d s e t of t r a i n i n g c a r d s were d e v e l o p e d f o r t h e u s e w i t h t h e head i n j u r e d p o p u l a t i o n ( B r a u n l i n g - M c M o r r o w e t a l . 1986) a f t e r ; r e v i e w i n g t h e s o c i a l s k i l l s l i t e r a t u r e t h a t p e r t a i n s t o head i n j u r y , p o l l i n g t h e p r o f e s s i o n a l and p a r a p r o f e s s i o n a 1 s t a f f a t a r e h a b i l i t a t i o n c e n t r e , and a f t e r o b s e r v i n g i n t e r a c t i o n a l b e h a v i o r among game p l a y e r s . 60 E i g h t game c a r d s were d e v e l o p e d f o r e a c h s i x component a r e a s ( a t o t a l o f 48 c a r d s ) , w i t h f o u r c a r d s f o r e a c h a r e a d e p i c t i n g " a c t o r " s i t u a t i o n s and f o u r c a r d s f o r " r e a c t o r " s i t u a t i o n s . The " a c t o r " s i t u a t i o n c a r d s r e q u i r e d s u b j e c t s t o i n i t i a t e an i n t e r a c t i o n ( e . g . t o g i v e a c o m p l i m e n t ) w h e r e a s " r e a c t o r " s i t u a t i o n s r e q u i r e d them t o r e s p o n d t o an i n t e r a c t i o n i n i t i a t e d by someone e l s e ( e . g . r e s p o n d t o a c o m p l i m e n t ) . The f a c e v a l i d i t y o f t h e s i t u a t i o n c a r d s a p p e a r e d t o be h i g h . However, two s i t u a t i o n s were c h a n g e d b e c a u s e t h e y were n o t r e l e v a n t t o a g r o u p home s i t u a t i o n . The new q u e s t i o n s t h a t were s u b s t i t u e d a d d r e s s e d t h e same s k i l l a r e a . Q u e s t i o n 5, " You n e e d e d t o u s e t h e e l e v a t o r and t h e p e r s o n u s i n g i t l a s t d i d n o t s h u t t h e d o o r so i t w o u l d n ' t work. What do you d o ? " T h i s was c h a n g e d t o "You s a y s o m e t h i n g t h a t makes y o u r f r i e n d a n g r y . What s h o u l d you d o ? " . Q u e s t i o n 1 1 , " You a r e i n a s e s s i o n and a t h e r a p i s t w a l k s by t h e d o o r . You have w a n t e d t o t a l k t o t h a t t h e r a p i s t a l l day. What do you d o ? " was c h a n g e d t o : "You a r e i n a s t o r e and ne e d t o f i n d a g i f t f o r y o u r m o t h e r . How w o u l d y o u a s k f o r h e l p ? " Q u e s t i o n 4 8 , " You a r e i n y o u r room and s p i l l a g l a s s of w a t e r and need someone t o h e l p you c l e a n i t up. What do y o u s a y ? " was c h a n g e d t o : " l t ' s y o u r f i r s t day on a j o b and y o u a r e i n t r o d u c e d t o t h e s u p e r v i s o r you 61 m i g h t s a y h e l l o and . " T h i s c h a n g e was u s e d w i t h s u b j e c t s 2,3,and 4 and t h e o r i g i n a l s i t u a t i o n was u s e d w i t h s u b j e c t 1. I n t e r - r a t e r r e l i a b i l i t y f o r t h e b a s e l i n e and t r a i n i n g "games" r a n g e d f r o m 91.6 p e r c e n t t o 100 p e r c e n t ( s e e T a b l e No.3 ) S o c i a l S k i l l s A s s e s s m e n t C h a r t ( S p e n c e , 1 9 7 9 ) The S o c i a l S k i l l s A s s e s s m e n t C h a r t was u s e d as a f u r t h e r measure of e a c h s u b j e c t ' s s o c i a l c o m p e t e n c e . T h i s s c a l e was d e s i g n e d t o e s t a b l i s h an i n d i v i d u a l ' s s k i l l l e v e l on 32 s p e c i f i c s o c i a l s k i l l s . S k i l l s a r e c a t e g o r i z e d i n t o s u b g r o u p s , s u c h as p e r c e p t i o n of e m o t i o n s , b a s i c n o n - v e r b a l s k i l l s , q u a l i t y o f s p e e c h , c o n t e n t o f s p e e c h , l i s t e n i n g s k i l l s and b a s i c c o n v e r s a t i o n . E a c h b e h a v i o r ( e . g . eye c o n t a c t , s o c i a l d i s t a n c e , p o s t u r e ) was r a t e d on a 5 - p o i n t s c a l e a c c o r d i n g t o w r i t t e n d e s c r i p t o r s . A c c o r d i n g t o S p e n c e ( 1 9 7 9 ) , t h i s s c a l e was f o u n d t o have good i n t e r r a t e r r e l i a b i l i t y and c o n t e n t r e l i a b i l i t y . B u t s p e c i f i c i n f o r m a t i o n on t h e d e v e l o p m e n t of t h i s s c a l e was n o t a v a i l a b l e b e c a u s e i t i s i n an u n p u b l i s h e d D o c t o r a l T h e s i s . T h e r e f o r e , f o r t h e p u r p o s e of t h i s s t u d y t h i s s c a l e c a n o n l y be a s s e s s e d on i t s f a c e v a l i d i t y . T h i s 6 2 s c a l e was c h o s e n b e c a u s e of i t s a p p a r e n t f a c e v a l u e . T h i s s c a l e was u s e d t o a s s e s s e a c h s u b j e c t p r e and p o s t i n t e r v e n t i o n . B e c a u s e t h i s s c a l e i s so s p e c i f i c i t s h o u l d p r o v i d e an a c c u r a t e p i c t u r e of e a c h s u b j e c t ' s l e v e l o f s o c i a l s k i l l s . The p a r t o f t h e s c a l e on p e r c e p t i o n o f e m o t i o n s was n o t u s e d w i t h any of t h e s u b j e c t s . The i n t e r - r a t e r r e l i a b i l i t y r a n g e d f r o m 80 p e r c e n t t o 100 p e r c e n t ( s e e T a b l e no.4 ) ' S t a f f Q u e s t i o n n a i r e on S o c i a l B e h a v i o r T h i s q u e s t i o n n a i r e was u s e d t o a s s e s s g e n e r a l s o c i a l c o m p e t e n c e d u r i n g d a y - t o - d a y i n t e r a c t i o n s w i t h i n t h e i n s t i t u t i o n a l s e t t i n g . I t was d e s i g n e d f o r u s e w i t h a d o l e s c e n t o f f e n d e r s w i t h i n an i n s t i t u t i o n a l s e t t i n g and r e f e r s t o b o t h b a s i c and c o m p l e x s o c i a l s k i l l s d u r i n g i n t e r a c t i o n s w i t h p e e r s and a d u l t s . The 24 i t e m s a r e r a t e d on a 5 - p o i n t s c a l e . The v a l i d i t y o f t h e t e s t was e s t a b l i s h e d by S p e n c e (1979) who d e m o n s t r a t e d s i g n i f i c a n t c o r r e l a t i o n s of t e s t i t e m s w i t h a g e n e r a l r a t i n g o f s o c i a l - s k i 11s p e r f o r m a n c e . S p e n c e r e p o r t s t h a t 10 i n s t i t u t i o n a l s t a f f r a t e d t h e f a c e v a l i d i t y o f e a c h i t e m as b e i n g a p p l i c a b l e t o an i n t e l l e c t u a l l y h a n d i c a p p e d p o p u l a t i o n . She s t a t e s t h a t a l l i t e m s were f o u n d t o be of r e l e v a n c e . T h i s measure was c h o s e n 63 b e c a u s e of i t s f a c e v a l i d i t y and i t s e a s e of u s e . I t was assumed t h a t s t a f f c o u l d i m p l e m e n t t h i s w i t h o u t any p r e v i o u s b e h a v i o r a l t r a i n i n g . A l t h o u g h t h i s measure may n o t p r o v i d e an a c c u r a t e measure of g e n e r a l i z a t i o n of s k i l l s , i t w i l l be u s e d b e c a u s e i t does p r o v i d e some g l o b a l i n f o r m a t i o n . The same s t a f f p e r s o n u s e d t h i s s c a l e t o r a t e s u b j e c t s 2,3,and 4 one week p r i o r t o t r a i n i n g and one week a f t e r t h e t r a i n i n g was c o m p l e t e d . D a t a A n a l y s i s R e s u l t s f r o m t h e " S t a c k i n g t h e Deck" i n t e r v e n t i o n w i l l be p r e s e n t e d i n g r a p h f o r m w i t h t h e b a s e l i n e s e p a r a t e d f r o m t h e i n t e r v e n t i o n p h a s e by a b r o k e n l i n e . E a c h game i s p l o t t e d s e p a r a t e l y on t h e g r a p h . The s t a t i s t i c a l a n a l y s i s e m p l o y e d t h e p r o p o r t i o n / f r e q u e n c y a p p r o a c h t h a t c o m p a r e s a " t y p i c a l " p a t t e r n of e v e n t s d u r i n g b a s e l i n e w i t h t h e outcome e m e r g i n g f r o m t h e i n t e r v e n t i o n u s i n g e x p a n d e d b i n o m i a l d i s t r i b u t i o n t a b l e s ( o n e - t a i l e d t - t e s t ) . The number o f b a s e l i n e o b s e r v a t i o n s i s t o o s m a l l t o u s e B a r t l e t t ' s t e s t f o r a u t o c o r r e l a t i o n . However Bloom and F i s h e r ( 1 9 8 2) s t a t e t h a t we c a n assume t h a t t h e d a t a i s n o t a u t o c o r r e 1 a t e d i f t h e r e i s no i n c r e a s i n g o r d e c r e a s i n g t r e n d i n t h e b a s e l i n e . S i n c e none of t h e b a s e l i n e s i n t h i s s t u d y i n d i c a t e d any i n c r e a s i n g o r d e c r e a s i n g t r e n d , i t was 64 assumed, on v i s u a l i n s p e c t i o n , t h a t t h e y were n o t a u t o c o r r e 1 a t e d and t h e e x p a n d e d b i o n o m i n a l d i s t r i b u t i o n t a b l e s were u s e d . The s i g n i f i c a n t l e v e l o f .05 was s e l e c t e d f o r t h i s s t u d y . Summary t a b l e s were u s e d f o r t h e number o f words p e r r e s p o n s e a t b a s e l i n e and a t t h e l a s t game. The number of words p e r r e s p o n s e were r e c o r d e d f o r t h i s p e r i o d f o r e a c h s u b j e c t . T h i s was done f r o m a v i d e o r e c o r d i n g of e a c h s e s s i o n . A l l words were c o u n t e d , w i t h c o n t r a c t i o n s b e i n g c o u n t e d as a s i n g l e word. C o u n t i n g was done by two r a t e r s and 100 p e r c e n t a g r e e m e n t was r e a c h e d . A l t h o u g h words p e r r e s p o n s e were c o n s i d e r e d t o be a c o r o l l a r y measure b e c a u s e i t w o u l d r e f l e c t t h e c o m p l e x i t y of t h e s u b j e c t ' s r e s p o n s e , i t was n o t t h e t a r g e t o f t r a i n i n g . R e s p o n s e t i m e ( t i m e r e q u i r e d t o b e g i n r e s p o n s e ) f o r s u b j e c t 1 was m e a s u r e d t h r o u g h t o u t t h e b a s e l i n e and i n t e r v e n t i o n . The r e s p o n s e t i m e was m e a s u r e d f r o m t h e v i d e o r e c o r d i n g u s i n g a s t o p w a t c h . Two m e a s u r e s were t a k e n and t h e a v e r a g e t i m e f o r e a c h r e s p o n s e was r e c o r d e d . The t i m e s r e p o r t e d a r e t h o s e of t h e f i r s t and l a s t i n t e r v e n t i o n s e s s i o n s . I t was assumed t h a t r e s p o n s e t i m e w o u l d i m p r o v e i n e a c h s e s s i o n . A v a r i e t y o f r e s p o n s e s f r o m e a c h s u b j e c t a r e g i v e n f r o m t h e b a s e l i n e and i n t e r v e n t i o n p h a s e s . I t i s 65 assumed t h a t more a p p r o p r i a t e r e s p o n s e w i l l be g i v e n as t h e t r e a t m e n t p r o g r e s s e s . O b s e r v a t i o n s on e a c h s u b j e c t ' s b e h a v i o r w i l l be r e p o r t e d b e c a u s e i t i s assumed t h a t t h e game w i l l p r o v i d e an o p p o r t u n i t y f o r i n t e r - p e r s o n a 1 c o m m u n i c a t i o n ( i . e . c o - o p e r a t i o n , c o m p e t i t i o n , f r i e n d l y c o n v e r s a t i o n s ) . The p r e and p o s t i n t e r v e n t i o n m e a s u r e s w i l l be p r e s e n t e d on t h e S o c i a l S k i l l s A s s e s s m e n t C h a r t . E a c h p o r t i o n o f t h e c i r c l e r e p r e s e n t s a s c o r e on a 5 - p o i n t s c a l e a c c o r d i n g t o v e r y s p e c i f i c c a t e g o r i e s . The v a l u e a t t h e c e n t r e of t h e c i r c l e i s 1 and i t i n c r e a s e s f r o m t h e r e t o w a r d s t h e o u t e r edge o f t h e c i r c l e w h i c h i s v a l u e d a t 5. The p r e - m e a s u r e s a r e marked i n g r e e n and p o s t - m e a s u r e s a r e marked i n r e d . I f t h e p r e and p o s t m e a s u r e s r e c e i v e t h e same v a l u e t h e n t h e a p p r o p r i a t e a r e a s i s s h a d e d i n g r e e n and r e d s t r i p e s . T h i s c h a r t i s v e r y u s e f u l b e c a u s e t h e p r e and p o s t m e a s u r e s c a n be d i s p l a y on t h e same c h a r t . T h i s p r o v i d e s a q u i c k v i s u a l a s s e s s m e n t of t h e s u b j e c t ' s p r o g r e s s . S t a f f Q u e s t i o n n a i r e on S o c i a l B e h a v i o u r T h i s q u e s t i o n n a i r e i s d i v i d e d i n t o t h r e e s e c t i o n s ; p e e r r e l a t i o n s h i p s , s t a f f r e l a t i o n s h i p s , and g e n e r a l s o c i a l b e h a v i o r . The sum of t h e s c o r e s i n e a c h s e c t i o n was r e c o r d e d f o r b o t h t h e p r e and p o s t m e a s u r e s . In 66 p e e r r e l a t i o n s h i p s , t h e r e a r e 8 i t e m s t h e r e f o r e , a maximum s c o r e i s 40. A s c o r e b e l o w 25 was c o n s i d e r e d t o i n d i c a t e a s i g n i f i c a n t l a c k of s o c i a l s k i l l s . A s c o r e b e t w e e n 25-34 i n d i c a t e d t h a t i m p r o v e m e n t was n e c e s s a r y and a s c o r e o f 35 o r more r e f l e c t e d a d e q u a t e s o c i a l c o m p e t e n c e w i t h p e e r s . In s t a f f r e l a t i o n s h i p s t h e r e a r e 7 i t e m s t h e r e f o r e a maximum s c o r e i s 35. A s c o r e b e l o w 20 was c o n s i d e r e d t o i n d i c a t e a s i g n i f i c a n t l a c k o f s o c i a l c o m p e t e n c e I n t h i s a r e a . A s c o r e b e t w e e n 21-29 i n d i c a t e d t h a t i m p r o v e m e n t was needed w h i l e a s c o r e o f 30 o r more r e f l e c t e d a d e q u a t e s o c i a l c o m p e t e n c e i n s t a f f r e 1 a t i o n s h i p s . In g e n e r a l r e l a t i o n s h i p s , t h e r e a r e 9 i t e m s t h e r e f o r e t h e maximum s c o r e i s 45. A s c o r e b e l o w 28 was c o n s i d e r e d t o i n d i c a t e a s i g n i f i c a n t l a c k o f s o c i a l c o m p e t e n c e i n t h i s a r e a . A s c o r e b e t w e e n 29-39 i n d i c a t e d i m p r o v e m e n t was needed w h i l e a s c o r e of 40 o r more r e f l e c t e d a d e q u a t e s o c i a l c o m p e t e n c e i n t h i s a r e a . O t h e r s o c i a l s i t u a t i o n s i n w h i c h t h e s u b j e c t s had d i f f i c u l t y were a l s o r e p o r t e d f o r t h e p r e and p o s t m e a s u r e s . The d e s i r e d outcome m e a s u r e d u s i n g t h i s s c a l e w o u l d be a i n c r e a s e i n t h e p o s t t e s t s c o r e and a d e c r e a s e i n t h e number o f s o c i a l s i t u a t i o n s i n w h i c h t h e s u b j e c t had d i f f i c u l t y w i t h . As p r e v i o u s l y m e n t i o n e d , 67 t h e g e n e r a l s o c i a l s k i l l s p e r f o r m a n c e was n o t r e p o r t e d b e c a u s e t h i s p o r t i o n of t h e s c a l e was n o t c o m p l e t e d . T h i s s c a l e was n o t u s e d w i t h s u b j e c t 1. A n a l y s i s M e t hods The i n t e r v e n t i o n w i l l be e v a l u a t e d i n t e r m s of e f f o r t , e f f e c t i v e n e s s and e f f i c i e n c y . To e s t a b l i s h t h e e f f e c t i v e n e s s of t h e i n t e r v e n t i o n , t h e p o s i t i v e i m p a c t t h a t t h e i n t e r v e n t i o n has on e a c h s u b j e c t ' s l e v e l of s o c i a l s k i l l s w i l l be e v a l u a t e d . E f f e c t i v e n e s s i s p r e s e n t e d as t h e c o m p a r i s o n made a b o u t t h e l e v e l of s o c i a l s k i l l s b e f o r e and a f t e r t h e i n t e r v e n t i o n . The f o c u s i s on outcome of t r a i n i n g , p a r t i c u l a r l y t h e a n a l y s i s of o b s e r v a b l e c h a n g e s , i n r e l a t i o n t o t h e t r a i n i n g p r o g r a m and o t h e r e x t r a n e o u s i n f l u e n c e s . In e v a l u a t i n g t h e e f f e c t i v e n e s s of t h e i n t e r v e n t i o n i t i s n e c e s s a r y t o l o o k a t e f f o r t and e f f i c i e n c y . E f f o r t r e f e r s t o t h e amount of work t h a t goes i n t o t h e p r o g r a m w h e r e a s , e f f i c i e n c y r e f e r s t o how much e f f e c t i v e n e s s was a t t a i n e d g i v e n t h e amount o f e f f o r t and t i m e r e q u i r e d ( B l o o m & F i s h e r , 1 9 8 2 ) . E f f i c i e n c y i s a r a t i o t h a t c o m p a r e s c o s t s and b e n e f i t s , i t r e f e r s t o g e t t i n g t h e b e s t outcome f o r t h e l e a s t c o s t ( i n t e r m s of p e r s o n a l and m a t e r i a l c o s t s ) . 68 I n f e r e n c e s E x p e c t e d f r o m t h e D a t a A l t h o u g h t h e s i n g l e s y s t e m d e s i g n i s n o t a b l e t o c o n t r o l a l l v a r i a b l e s t h a t a c t upon t h e s u b j e c t , Bloom and F i s h e r r e p o r t t h a t i n f e r e n c e s c a n be made i f t h e s p e c i f i c i n t e r v e n t i o n was c h o s e n b e c a u s e i t was l i k e l y t o a f f e c t t h e p r o b l e m . R e p l i c a t i o n s i n c r e a s e b o t h i n t e r n a l and e x t e r n a l v a l i d i t y . W i t h t h e s e t h i n g s i n mind i t i s e x p e c t e d t h a t t h e d a t a g e n e r a t e d w i l l p r o v i d e t h e b a s e s f o r a d e t a i l e d e v a l u a t i o n o f t h e e f f e c t i v e n e s s of t h e i n t e r v e n t i o n . I t i s e x p e c t e d t h a t e a c h s u b j e c t ' s s o c i a l s k i l l s w i l l i m p r o v e , t h e number o f words s p o k e n w i l l i n c r e a s e and r e s p o n s e t i m e w i l l l e s s e n . However, i t i s i m p o r t a n t t o n o t e t h a t i n f e r e n c e s c a n o n l y be made t o o t h e r head i n j u r e d i n d i v i d u a l s when t h e i r c i r c u m s t a n c e s a r e s i m i 1 a r . P i l o t T e s t i n g o f P r o g r a m T h i s p r o g r a m was p i l o t t e s t e d i n o r d e r t o become f a m i l i a r w i t h t h e p r o g r a m and m e a s u r e s and t o c h e c k on t h e v a l i d i t y o f t h e m e a s u r e s . The s i t u a t i o n c a r d s were c o n s i d e r e d t o be an a d e q u a t e s a m p l e of s i t u a t i o n s t h a t c o u l d a r i s e i n t h e day t o day f u n c t i o n i n g o f t h e s u b j e c t s i n a r e h a b i l i t a t i o n s e t t i n g o r i n a g r o u p home. S t a f f f r o m b o t h o f t h e s e s e t t i n g c o n c u r r e d . 69 T h i s p r o g r a m was t e s t e d w i t h f o u r s u b j e c t s , t h r e e m a l e s and one f e m a l e . The male s u b j e c t s were o n l y f i v e and f o u r months p o s t i n j u r y and t h e r e f o r e i t i s d i f f i c u l t t o r e l a t e t h e i r g a i n s t o t h e i n t e r v e n t i o n . However, t h e y were c h o s e n b e c a u s e t h e y r e p r e s e n t e d t h e head i n j u r e d p o p u l a t i o n and were l i k e l y t o r e m a i n i n t h e r e h a b i l i t a t i o n f o r t h e t i m e r e q u i r e d t o t e s t t h e p r o g r a m . The f e m a l e s u b j e c t was a b l e t o answer a l l t h e s i t u a t i o n c a r d s c o r r e c t l y i n t h e b a s e l i n e and t h r o u g h o u t t h e i n t e r v e n t i o n . She c o n t i n u e d t o p a r t i c i p a t e a p p a r e n t l y b e c a u s e she e n j o y e d t h e game and she a l s o was e a g e r t o p a r t i c i p a t e i n t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . I n t e r e s t i n g l y she e n j o y e d p l a y i n g t h e game as much as t h e o t h e r s u b j e c t s and d i d n o t a p p e a r t o become b o r e d w i t h i t . A l l s u b j e c t s p l a y e d 13 games, f o u r o f w h i c h were b a s e l i n e games, and t h e r e m a i n d e r were i n t e r v e n t i o n games. M a l e s u b j e c t A had an a v e r a g e b a s e l i n e s c o r e o f 6.2 and by t h e f i f t h game of t h e i n t e r v e n t i o n he a n s w e r e d a l l 12 s i t u a t i o n s c o r r e c t l y . M a l e s u b j e c t B had an a v e r a g e b a s e l i n e s c o r e of 7.2 and by t h e t h i r d game o f t h e i n t e r v e n t i o n he a n s w e r e d 11 s i t u a t i o n s c o r r e c t l y . M a l e s u b j e c t C had an a v e r a g e b a s e l i n e s c o r e of A.5 and by t h e f i f t h game of t h e i n t e r v e n t i o n he had 70 a n s w e r e d 11 s i t u a t i o n s c o r r e c t l y . By t h e s e v e n t h game of t h e i n t e r v e n t i o n he a n s w e r e d a l l 12 s i t u a t i o n s c o r r e c t 1y. A l l s u b j e c t s a l s o a t t e n d e d t h r e e s t r u c t u r e d l e a r n i n g s e s s i o n s where t h e game was n o t p l a y e d . T h e s e p i l o t s u b j e c t s were v i d e o e d and t h e i n t e r - r a t e r r e l i a b i l i t y was s i m i l a r t o t h a t o f t h e s t u d y . Two of t h e male s u b j e c t s were a l s o r a t e d on t h e S o c i a l S k i l l s A s s e s s m e n t C h a r t . T h i s c h a r t was f o u n d t o be an a d e q u a t e r e p r e s e n t a t i v e o f s o c i a l f u n c t i o n i n g and was t h e r e f o r e i n c l u d e d i n t h e s t u d y . S i n c e a l l o f t h e s e s u b j e c t s s i g n i f i c a n t l y i m p r o v e d t h e i r s o c i a l s k i l l l e v e l and a p p e a r e d t o e n j o y t h e game, t h e p r o g r a m was e m p l o y e d w i t h t h e f o u r male s u b j e c t s o f t h e s t u d y . E t h i c a 1 I s s u e s I t i s assumed t h a t p a r t i c i p a t i o n i n t h i s p r o g r a m w i l l l e a d t o i m p r o v e d s o c i a l c o m p e t e n c e and t h u s w i l l f a c i l i t a t e t h e r e i n t e g r a t i o n of t h e head i n j u r e d p e r s o n i n t o t h e f a m i l y and community. T h e r e a r e no r i s k s i n v o l v e d i n t h i s p r o g r a m . However, as i n a l l r e s e a r c h t h e r e i s a l w a y s t h e p o s s i b i l i t y t h a t t h e t r e a t m e n t may n o t work b u t i f t h i s was t o be t h e c a s e t h e s u b j e c t s w o u l d n o t s u f f e r any p s y c h o l o g i c a l o r p h y s i c a l s t r e s s 71 f r o m h a v i n g t a k e n p a r t i n t h i s p r o g r a m . The i d e n t i t y of t h e s u b j e c t s w i l l be known o n l y t o t h e r e s e a r c h e r and one o t h e r r a t e r . The i d e n t i t y o f t h e s u b j e c t s b e y o n d t h i s p o i n t w i l l be s a f e g u a r d e d . 72 T A B L E 3 I N T E R - R A T E R R E L I A B I L I T Y O c c a s i o n S u b j e c t 1 S u b j e c t IN " S T A C K I N G 2 S u b j e c t 3 THE DECK" S u b j e c t 4 i 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 9 1 . 6 % 100% 9 1 . 6 % 100% 100% 9 1 . 6% 9 2 . 3% 9 1 . 6% 100% 100% 100% 9 1 . 6 % 100% 100% 100% 100% 100% 100% 100% 100% • 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 9 1 . 6% 9 1 . 6% 9 2 . 3% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 9 1 . 6% 100% 100% 100% 100% 100% 100% 100% 9 1 . 6% 100% 100% 9 1 . 6% 9 1 . 6% 100% 100% T A B L E 4 I N T E R - R A T E R R E L I A B I L I T Y - ASSESSMENT CHART S U B J E C T : 1 2 3 4 O c c a s i o n p r e - p o s t p r e - p o s t p r e - p o s t p r e !-pOS Vo i c e q u a 1 i t y t o n e 1 0 0 - 8 0 % 8 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% v o l u m e 8 0 - 1 0 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 8 0 - 100% r a t e 1 0 0 - 1 0 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% B a s i c N o n - V e r b a l e x p r e s s i o n 8 0 - 8 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% p o s t u r e 1 0 0 - 8 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% g e s t u r e s 1 0 0 - 8 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% e y e c o n t a c t 1 0 0 - 1 0 0 % 8 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% N o n - v e r b a l Re s p o n s e s f i d d l i n g 8 0 - 1 0 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% s m i 1 i n g 1 0 0 - 8 0 % 100 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% h e a d 1 0 0 - 1 0 0 % 100 - 8 0 % 8 0 - 1 0 0 % 1 0 0 - 100% Q u a l i t y o f S p e e c h amount 1 0 0 - 1 0 0 % 100 - 8 0 % 1 0 0 - 8 0 % 80 - 8 0 % r e s p o n s e 1 0 0 - 8 0 % 80 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% p a u s e s 1 0 0 - 8 0 % 80 - 8 0 % 8 0 - 8 0 % 80 - 8 0 % d y s f 1 u e n c i es 1 0 0 - 1 0 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% C o n t e n t o f S p e e c h r e p e t i t i o n s 1 0 0 - 8 0 % 100 - 8 0 % 1 0 0 - 1 0 0 % 1 0 0 - 100% i n t e r r u p t i o n s 1 0 0 - 8 0 % 1 0 0 - 100% 8 0 - 1 0 0 % 8 0 - 100% i n t e r e s t 1 0 0 - 8 0 % 80 - 8 0 % 1 0 0 - 8 0 % 100 - 8 0 % r e 1 e v a n c y 1 0 0 - 8 0 % 1 0 0 - 100% 1 0 0 - 1 0 0 % 1 0 0 - 100% L i s t e n i n g S k i 1 1 s d i s c i o s u r e 1 0 0 - 1 0 0 % 8 0 - 100% 1 0 0 - 8 0 % 1 0 0 - 100% Q / a n s w e r s 1 0 0 - 8 0 % 80 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% r e f 1 e c t i o n s 1 0 0 - 1 0 0 % 100 - 8 0 % 1 0 0 - 8 0 % 100 - 8 0 % a c k n o w l e d g e 8 0 - 1 0 0 % 100 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% B a s i c C o n v e r s a t i o n l e n g t h r e p l y 1 0 0 - 1 0 0 % 80 - 8 0 % 1 0 0 - 8 0 % 100 - 8 0 % i n f o c o n t e n t 1 0 0 - 8 0 % 80 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% Q / A f r e q u e n c y 1 0 0 - 1 0 0 100 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% f / i n i t i a t i o n s 1 0 0 - 8 0 % 100 - 8 0 % 1 0 0 - 8 0 % 1 0 0 - 100% 74 C h a p t e r 4 M e t h o d o l o g i c a l I s s u e s The s e l e c t i o n of a method o f measurement f o r t h e p u r p o s e of m e a s u r i n g t h e l e v e l o f s o c i a l s k i l l s t h a t t h e head i n j u r e d a d u l t p o s s e s s i s d i f f i c u l t b e c a u s e of t h e c o n s e q u e n c e s of head i n j u r y . S e l f r e p o r t i n g was n o t c o n s i d e r e d as a s u i t a b l e m easure f o r e v a l u a t i n g t h e s o c i a l s k i l l s o f t h e head i n j u r e d p o p u l a t i o n b e c a u s e t h e head i n j u r e d p e r s o n ' s power of s e l f - c r i t i c i s m i s d i m i n i s h e d and t h e r e i s an i n c r e a s e i n e g o c e n t r i c i t y ( B o n d , 1 9 8 4 ) . The l a c k of i n s i g h t and d e n i a l o f d i s a b i l i t y a l s o make s e 1 f - r e p o r t i n g u n r e l i a b l e . T h e r e a r e m e t h o d o l o g i c a l p r o b l e m s i n a s s e s s i n g s o c i a l , e m o t i o n a l and b e h a v i o r a l s e q u e l a e of head i n j u r y and t h e e f f e c t t h e s e have on t h e f a m i l y and s o c i a l l i f e b e c a u s e a c c o u n t s g i v e n by t h e r e l a t i v e s and p a t i e n t d i f f e r . The p a t i e n t may l a c k i n s i g h t and r e l a t i v e s , who a r e u n d e r c o n s i d e r a b l e s t r e s s , may g i v e d i s t o r t e d a c c o u n t s . The a c c o u n t s g i v e n by p a t i e n t s and r e l a t i v e s n o t o n l y d i f f e r b u t do so s e l e c t i v e l y w i t h e m o t i o n a l / b e h a v i o r a l d i f f i c u l t i e s o f t e n a l l e g e d by r e l a t i v e s and d e n i e d by p a t i e n t s . The e x t e n t t o w h i c h t h e p a t i e n t d e n i e s d i f f i c u l t y , w h i c h r e l a t i v e s r e p o r t as b e i n g p r e s e n t i n t h e p a t i e n t , was n o t f o u n d t o 75 be r e l a t e d t o c o g n i t i v e d e f i c i t s ( M c K i n l a y & B r o o k s , 1 9 8 4 ) . R e l a t i v e s o f a head i n j u r e d p e r s o n were f o u n d t o have s i g n i f i c a n t and p e r s i s t e n t p s y c h i a t r i c and s o c i a l d s y f u n c t i o n as a r e s u l t o f t h e h i g h b u r d e n i n c a r i n g f o r t h i s f a m i l y member ( L i v i n g s t o n , B r o o k s &< Bond, 1985) and t h u s t h e i r e v a l u a t i o n may n o t be r e l i a b l e . B e c a u s e o f t h e s e c o n c e r n s n e i t h e r s e l f - r e p o r t s o r f a m i l y e v a l u a t i o n s were e m p l o y e d i n t h e e v a l u a t i o n o f t h e head i n j u r e d ' s s o c i a l c o m p e t e n c e . T h i s i s n o t t o s a y t h a t f a m i l i e s a r e unaware o f t h e i r f a m i l y member's l a c k o f a p p r o p r i a t e s o c i a l s k i l l s b u t r a t h e r t h a t t h e i r o p i n i o n s were n o t u s e d as p a r t of t h e measure. S i n c e t h e p a t i e n t and f a m i l y members may have a d i s t o r t e d v i e w o f t h e a c t u a l l e v e l o f s o c i a l c o m p e t e n c e t h e head i n j u r e d p e r s o n p o s s e s s e s , t r a i n e d o b s e r v e r s were u s e d t o a s s e s s t h e s o c i a l s k i l l l e v e l o f t h e head i n j u r e d p e r s o n . However, t h e use of t r a i n e d r a t e r s d oes n o t e n s u r e t h a t t h e r e s u l t s w i l l be f r e e o f e r r o r s i n j u d g m e n t . To r e d u c e e r r o r s i n o b s e r v a t i o n , t h e r a t e r s were i n s t r u c t e d t o be aware of some p o t e n t i a l e r r o r s . The e r r o r of l e n i e n c y i s c a u s e d when r a t e r s t e n d t o r a t e t h o s e p a t i e n t s whom t h e y know w e l l , o r i n whom t h e y a r e e g o - i n v o 1 v e d , h i g h e r t h a n t h e y s h o u l d be ( G i 1 f o r d , 1 9 5 4 ) . The r a t e r may r a t e t o o e a s y o r t o o 76 h a r d . The l e n i e n c y e r r o r t h e n , i s t h e c o n s t a n t t e n d e n c y f o r a r a t e r t o r a t e t o o h i g h o r t o o low f o r w h a t e v e r r e a s o n s . In o r d e r t o d e c r e a s e e r r o r s o f l e n i e n c y r a t e r s were i n s t r u c t e d t o f o l l o w t h e f a c i l i t a t o r ' s s c o r i n g g u i d e and t h e f a c i l i t a t o r ' s r e s p o n s e s h e e t . D u r i n g t h e c o u r s e o f t h e s t u d y , p e r i o d i c r e t r a i n i n g s e s s i o n s were c o n d u c t e d as r e q u i r e d . The e r r o r o f c e n t r a l t e n d e n c y i s c a u s e d when r a t e r s h e s i t a t e t o g i v e e x t r e m e j u d g m e n t s and t h u s t e n d t o d i s p l a c e i n d i v i d u a l s i n t h e d i r e c t i o n o f t h e mean of t h e t o t a l g r o u p ( G i l f o r d , 1 9 5 4 ) . T h i s i s p e r h a p s more common i n r a t i n g i n d i v i d u a l s whom t h e r a t e r s do n o t know v e r y w e l l . S i n c e r a t e r s u s e d i n t h i s s t u d y know t h e s u b j e c t s and s i n c e t h e s c o r i n g f o r r e s p o n s e s i s s p e c i f i c a l l y o u t l i n e d , t h e e r r o r s o f c e n t r a l t e n d e n c y s h o u l d be c o n t r o l l e d . The h a l o e f f e c t i s t h e r e s u l t o f t h e r a t e r ' s g e n e r a l m e n t a l a t t i t u d e t o w a r d s t h e i n d i v i d u a l . One r e s u l t o f t h e h a l o e f f e c t i s t o f o r c e t h e r a t i n g o f any t r a i t i n t h e d i r e c t i o n o f t h e g e n e r a l i m p r e s s i o n o f t h e i n d i v i d u a l s r a t e d and t o t h a t e x t e n t t o make t h e r a t i n g s o f some t r a i t s l e s s v a l i d . A n o t h e r r e s u l t i s t o i n t r o d u c e a s p u r i o u s amount of p o s i t i v e c o r r e l a t i o n b e t w e e n t h e t r a i t s t h a t a r e r a t e d . I t i n v o l v e s i r r e l e v a n t c r i t e r i a w i t h w h i c h j u d g m e n t s a r e 77 c o n t a m i n a t e d . A c c o r d i n g t o G i l f o r d , h a l o e f f e c t s a r e more p r e v a l e n t i f t r a i t s a r e n o t e a s i l y o b s e r v a b l e , n o t s i n g l e d o u t o r n o t c l e a r l y d e f i n e d . However, s o c i a l s k i l l s o r l a c k o f them a r e e a s i l y o b s e r v e d and s i n c e e a c h s k i l l and r e q u i r e d r e s p o n s e i s c l e a r l y d e f i n e d e r r o r s r e l a t e d t o t h e h a l o e f f e c t s h o u l d be c o n t r o l l e d . G i l f o r d s t a t e s t h a t l o g i c a l e r r o r s i n r a t i n g a r e due t o t h e f a c t t h a t o b s e r v e r s a r e l i k e l y t o g i v e s i m i l a r r a t i n g s f o r t r a i t s t h a t seem l o g i c a l l y r e l a t e d i n t h e minds of t h e r a t e r s . T h e s e e r r o r s c a n be a v o i d e d i n p a r t by c a l l i n g f o r j u d g m e n t s of o b j e c t i v e l y o b s e r v a b l e a c t i o n s r a t h e r t h a n a b s t r a c t o n e s . S i n c e s o c i a l c o m p e t e n c e i s o b s e r v a b l e and b e c a u s e t h e s p e c i f i c t y p e o f r e s p o n s e i s o u t l i n e d f o r e a c h s i t u a t i o n , l o g i c a l e r r o r s i n r a t i n g s s h o u l d be c o n t r o l l e d i n t h i s s t u d y . The c o n t e n t e r r o r o c c u r s when a r a t e r has a t e n d e n c y t o r a t e o t h e r s i n t h e same o r o p p o s i t e d i r e c t i o n f r o m h i s / h e r s e l f i n a t r a i t . T h i s i s a g e n e r a l c l a s s of e r r o r s i n v o l v i n g t h e r a t e r ' s a t t i t u d e t o w a r d s s p e c i f i c t r a i t s . I t may r e s u l t f r o m a b i a s o f one c o n t r a s t o r a n o t h e r . The r a t e r s were i n s t r u c t e d t o t a k e p r e c a u t i o n s t o a v o i d t h e s e e r r o r s . G i l f o r d s t a t e s t h a t t h e p r o x i m i t y e r r o r i n j e c t s undue c o v a r i a n c e s among r a t e d t r a i t v a r i a b l e s . The r e a s o n f o r t h i s s o u r c e of s p u r i o u s c o r r e l a t i o n i s 78 t h e n e a r n e s s i n s p a c e o r i n t i m e f o r t h e r a t i n g o f two t r a i t s . T h i s e r r o r m i g h t be c o u n t e r a c t e d t o some e x t e n t by p l a c i n g s i m i l a r t r a i t s f a r t h e r a p a r t and t h e more o b v i o u s l y d i s p a r a t e ones c l o s e r . I t w o u l d be b e t t e r t o r a t e one t r a i t a t a t i m e . T h i s c a n e a s i l y be a c c o m p l i s h e d i n t h e game by s t a c k i n g t h e s i t u a t i o n s a c c o r d i n g l y i n t h e deck and by r a t i n g one t r a i t a t a t i m e i n t h e s o c i a l s k i l l s a s s e s s m e n t c h a r t . C o n s e q u e n t l y t h e r a t e r s were i n s t r u c t e d t o a v o i d t h e s e e r r o r s when e v e r p o s s i b l e . I n t e r - r a t e r r e l i a b i l i t y i s u s e d t o v e r i f y t h e r e l i a b i l i t y o f t h e d a t a by h a v i n g a s e c o n d p e r s o n i n d e p e n d e n t l y o b s e r v e t h e t a r g e t b e h a v i o r . T h i s was a c c o m p l i s h e d by h a v i n g a s e c o n d r a t e r r a t e a v i d e o r e c o r d i n g of e a c h s e s s i o n . F r e q u e n c y m e a s u r e s a r e t h e most common m e a s u r e s e m p l o y e d and i n v o l v e c o u n t i n g t h e number of t i m e s a s p e c i f i c b e h a v i o r o c c u r s . In o r d e r t o do a f r e q u e n c y c o u n t t h e b e h a v i o r must be o b s e r v a b l e ( h a v e a c l e a r b e g i n n i n g and e n d i n g so as a s e c o n d b e h a v i o r may be c o u n t e d ) . I t must t a k e a r e l a t i v e l y c o n s t a n t amount of t i m e when i t o c c u r s so t h a t t h e u n i t s c o u n t e d a r e s i m i l a r ( B l o o m & F i s h e r , 1 9 8 2 ) . F r e q u e n c y m e a s u r e s a r e n o t a l w a y s u s e f u l . When t h e m a j o r i s s u e i s t h e l e n g t h of t i m e a b e h a v i o r o c c u r s , d u r a t i o n m e a s u r e s a r e u s e d . T h e s e a r e s i m p l e t o use and r e q u i r e r e c o r d i n g t h e l e n g t h of t i m e t h a t t h e b e h a v i o r o c c u r s . The b e g i n n i n g and e n d i n g of t h e b e h a v i o r must be c l e a r as w e l l as t h e t i m e f r a m e i n w h i c h t h e b e h a v i o r o c c u r s. I n t e r v a l m e a s u r e s c o m b i n e b o t h f r e q u e n c y and d u r a t i o n m e a s u r e s and were u s e d i n t h i s s t u d y . They p r e s e n t a c l e a r e r o v e r a l l p i c t u r e o f t h e b e h a v i o r . H e r e t h e o b s e r v a t i o n i s d i v i d e d i n t o i n t e r v a l s and t h e r a t e r s t a t e s w h e t h e r o r n o t t h e s p e c i f i c b e h a v i o r o c c u r r e d i n e a c h i n t e r v a l . T h i s i s a f l e x i b l e r a t i n g s y s t e m t h a t c a n be u s e d w i t h any t y p e of b e h a v i o r ( B l oom & F i s h e r , 1 9 8 2 ) . I n t e r - r a t e r r e l i a b i l i t y f o r i n t e r v a l m e a s u r e s i s d e t e r m i n e d by c o m p a r i n g t h e p r o p o r t i o n of i n t e r v a l s i n w h i c h two r a t e r s a g r e e on t h e o c c u r r e n c e and non o c c u r r e n c e of t h e b e h a v i o r . An a g r e e m e n t i s an i n t e r v a l i n w h i c h b o t h o b s e r v e r s a g r e e t h a t a b e h a v i o r o c c u r r e d o r d i d n o t o c c u r . And e a c h i n t e r v a l i n w h i c h o n l y one o b s e r v e r s c o r e d a b e h a v i o r i s c o n s i d e r e d t o be a d i s a g r e e m e n t . R e l i a b i l i t y i s d e t e r m i n e d by d i v i d i n g t h e number of i n t e r v a l s i n w h i c h b o t h r a t e r s a g r e e d by t h e number of a g r e e m e n t s p l u s d i s a g r e e m e n t s and m u l t i p l y i n g by 100. T h e r e a r e no c l e a r f i g u r e s f o r i n t e r - r a t e r r e l i a b i l i t y b u t a good o r h i g h r e l i a b i l i t y i s c o n s i d e r e d 80 t o be b e t w e e n 80 p e r c e n t and 100 p e r c e n t . T y p e s of O b s e r v a t i o n s A g r e e m e n t b e t w e e n t h e o b s e r v e r s o r r a t e r s i s i m p o r t a n t and t h e t y p e of o b s e r v e r a t i o n u s e d i s a l s o a m e t h o d o l o g i c a l c o n c e r n . The r e s e a r c h e r must d e t e r m i n e i f t h e p r o c e s s o f o b s e r v i n g and r e c o r d i n g has an e f f e c t on t h e p e o p l e b e i n g o b s e r v e d . A t t h e same t i m e t h e d a t a c o l l e c t i o n s must be b o t h r e l i a b l e and v a l i d . T h r e e t y p e s of o b s e r v a t i o n a r e ; t h e c o m p l e t e p a r t i c i p a n t , t h e p a r t i c i p a n t - a s - o b s e r v e r , and t h e c o m p l e t e o b s e r v e r . The o b s e r v e r t h a t t a k e s t h e r o l e o f t h e c o m p l e t e p a r t i c i p a n t i n t e r a c t s as n a t u r a l l y as p o s s i b l e w i t h t h o s e b e i n g o b s e r v e d . However, t h e r e s e a r c h w o r k e r ' s i d e n t i t y and p u r p o s e a r e n o t r e v e a l e d t o t h e s u b j e c t s . I t i s p o s s i b l e t o l o s e o b j e c t i v i t y as t h e o b s e r v e r becomes p a r t o f t h e g r o u p . B u t t h i s method does o f f e r p o s s i b 1 i 1 1 1 i e s f o r l e a r n i n g a b o u t a s p e c t s o f b e h a v i o r t h a t m i g h t o t h e r w i s e e s c a p e t h e f i e l d o b s e r v e r ( A r k a v a , _ L a n e , 1 9 8 3 ) . In t h e p a r t i c i p a n t - a s - o b s e r v e r r o l e , t h e s u b j e c t s a r e a ware of t h e o b s e r v e r ' s r o l e . T h i s method a l l o w s f o r f o r m a l o b s e r v a t i o n b u t t h e s u b j e c t s a r e aware o f t h i s p r o c e s s and may t e n d t o mask some b e h a v i o r s . On 81 t h e o t h e r h a n d , i n t h e c o m p l e t e o b s e r v e r r o l e t h e r e i s no i n t e r a c t i o n w i t h t h e s u b j e c t s . The b e h a v i o r i s o b s e r v e d and i n t e r p r e t e d . F o r t h e p u r p o s e o f t h i s s t u d y t h e o b s e r v e r ' s r o l e was t h a t o f t h e c o m p l e t e o b s e r v e r as t h e b e h a v i o r was o b s e r v e d and i n t e r p r e t e d . However, i n t h e " S t a c k i n g t h e Deck" p r o g r a m t h e r e i s t h e o p p o r t u n i t y f o r t h e o b s e r v e r ( f a c i l i t a t o r ) t o a c t u a l l y p l a y t h e game w i t h t h e p a r t i c i p a n t s . T h i s method was u s e d w i t h S u b j e c t No. 1 on one o c c a s i o n . In t h i s c a s e , t h e o b s e r v e r a c t e d as a p a r t i c i p a n t i n t h a t t h e q u e s t i o n s were a n s w e r e d and t h e . game p i e c e s were moved a c c o r d i n g l y . However, a t t h i s t i m e t h e b e h a v i o r o f S u b j e c t No. 1 was a l s o o b s e r v e d and i n t e r p r e t e d . B e h a v i o r s u s e d as an outcome measure have a p a r t i c u l a r l y good c h a n c e o f b e i n g o b j e c t i v e l y r e c o r d e d b e c a u s e t h e y l e n d t h e m s e l v e s t o c l e a r , p r e c i s e and s p e c i f i c d e f i n i t i o n s . B e h a v i o r must be o b s e r v a b l e and c o u n t a b l e by someone. F o r t h e p u r p o s e s o f t h e s t u d y b e h a v i o r i n c l u d e d t a l k i n g , g e s t u r e s , v o i c e , c o n t e n t o f s p e e c h and o b s e r v a b l e n o n - v e r b a l a s p e c t s a d d r e s s e d i n S p e n c e ' s S o c i a l S k i l l s A s s e s s m e n t C h a r t w h i c h a r e c l e a r l y o u t l i n e d . A c c o r d i n g t o Bloom and F i s h e r , r e c o r d i n g t h e b e h a v i o r i s n o t an end i n i t s e l f . They s t a t e t h a t t h e 82 r e c o r d i n g p r o c e s s s h o u l d be a r e l a t i v e l y s i m p l e p r o c e s s t h a t e n h a n c e s t h e i n t e r v e n t i o n p r o g r a m by i n c r e a s i n g t h e m o t i v a t i o n of t h o s e i n v o l v e d . The s e l e c t i o n o f an i n s t r u m e n t d e pends upon t h e n a t u r e of t h e p r o b l e m , t h e c a p a b i l i t i e s and m o t i v a t i o n of t h e r e c o r d e r and t h e c o m p l e x i t y of t h e s i t u a t i o n s . They add t h a t t h e method of r e c o r d i n g s h o u l d be p o r t a b l e enough t o be u s e d where t h e b e h a v i o r o c c u r s . I t s h o u l d be u n o b t r u s i v e as t o n o t d i s t r a c t o r e m b a r r a s s t h o s e b e i n g o b s e r v e d . The method must a l s o be l i k e l y t o be u s e d and be p l e a s a n t o r e n j o y a b l e t o u s e . B o t h t h e "game" and t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s f i t t h e s e g u i d e l i n e s . The r e c o r d i n g p r o c e s s was s i m p l e t o use and e m p l o y e d s p e c i f i c s c o r i n g g u i d e s . The p l a y e r s ' m o t i v a t i o n was i n c r e a s e d w i t h t h e use of t h e p l a y e r ' s s c o r e c a r d . S i n c e e a c h p l a y e r was r e c o r d i n g h i s own s c o r e , t h e y were n o t d i s t r a c t e d by t h e f a c i l i t a t o r ' s r e c o r d i n g . The e a s y f o r m a t of t h e r e c o r d i n g e n s u r e d i t s u s e . The e a g e r n e s s and e n t h u s i a s m of t h e p l a y e r s e a c h s e s s i o n t e s t i f i e d t o t h e p l e a s a n t n e s s of t h i s p r o c e s s . A n a l o g u e M e a s u r e s A n o t h e r m e t h o d o l o g i c a l i s s u e i n t h i s s t u d y i s t h e u s e of a n a l o g u e m e a s u r e s . An a n a l o g u e measure i s 83 d e s c r i b e d as a measure t h a t r e q u i r e s a c l i e n t t o r e s p o n d i n a c o n t r i v e d o r c o n t r o l l e d s e t t i n g t o s i t u a t i o n s t h a t a r e f o u n d i n t h e n a t u r a l e n v i r o n m e n t . B o t h t h e s i t u a t i o n s i n t h e "game" and t h e r o l e p l a y s of t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s were e x a m p l e s o f t h i s . The d a n g e r w i t h a n a l o g u e m e a s u r e s a c c o r d i n g t o Ney ( 1 9 7 7 ) , i s t h a t t h e r e i s no c l e a r e v i d e n c e t h a t t h e y t a p t h e a c t u a l b e h a v i o r s t h a t a p e r s o n w o u l d engage i n i n r e a l l i f e ( B l o o m & F i s h e r , 1 9 8 2 ) . However, t h e use of a n a l o g u e m e a s u r e s may be s u p p o r t e d i n t h i s s t u d y b e c a u s e t h e s i t u a t i o n s i n t h e " S t a c k i n g t h e Deck" p r o g r a m were d e v e l o p e d f r o m r e a l l i f e s i t u a t i o n s and more i m p o r t a n t l y b e c a u s e t h e use of t h e game i t s e l f p r o v i d e d a r e a l l i f e s i t u a t i o n t h a t r e q u i r e d t h e a p p r o p r i a t e u s e of s o c i a l sk i 1 I s . S t a f f Q u e s t i o n n a i r e on S o c i a l B e h a v i o r A m e t h o d o l o g i c a l i s s u e i n t h i s s t u d y i n v o l v e d t h e use o f t h e S t a f f Q u e s t i o n n a i r e f o r two r e a s o n s ; t h e c a t e g o r i e s were n o t c l e a r l y d e f i n e d and t h e r e may be some e r r o r s i n r e c o r d i n g . S p e n c e n o t e d some p r o b l e m s w i t h t h i s s c a l e . She f o u n d t h a t d e s p i t e c h a n g e s i n t h e use o f a w i d e r a n g e o f b a s i c s o c i a l s k i l l s w i t h i n t h e n a t u r a l s e t t i n g , t h e g e n e r a l i z a t i o n measure o f g e n e r a l s o c i a l c o m p e t e n c e on t h e s t a f f q u e s t i o n n a i r e f a i l e d t o 84 d e m o n s t r a t e s i g n i f i c a n t c h a n g e s o v e r t i m e . However, i n s p i t e o f h e r f i n d i n g s i t was b e l i e v e d t h a t t h i s s c a l e may s t i l l have some p o t e n t i a l i n t h e g r o u p home s e t t i n g . Use of V i d e o E q u i p m e n t The o b s e r v a t i o n s h o u l d n o t be o b t r u s i v e , d i s t r a c t o r e m b a r r a s s t h o s e b e i n g o b s e r v e d . The p r e s e n c e o f a v i d e o c a m e r a c a n do a l l o f t h e s e t h i n g s and t h e r e f o r e i t must be u s e d w i t h c a r e . In t h i s p a r t i c u l a r s t u d y , t h e use o f t h e v i d e o c a m e r a d i d n o t a p p e a r t o have an e f f e c t on t h e s u b j e c t s b e c a u s e t h i s was o f t e n p a r t o f t h e i r r o u t i n e I n t h e r e h a b i l i t a t i o n c e n t r e and i n t h e g r o u p home. P r e v i o u s Work i n S o c i a l S k i l l s T r a i n i n g B r a u n 1 i n g - M c M o r r o w e t a l . ( 1 9 8 6 ) s t a t e t h a t t h e t h r e e s u b j e c t s i n t h e i r s t u d y i m p r o v e d i n t h e i r s o c i a l a p p r o p r i a t e r e s p o n s e s and t h a t t h i s was g e n e r a l i z e d t o t h e n a t u r a l s e t t i n g . However, t h e House S t a f f e v a l u a t i o n s i n d i c a t e d t h a t r a t i n g s d i d n o t change and t h a t one p e r s o n ' s s c o r e was l o w e r f o l l o w i n g t r a i n i n g . The a u t h o r s a r e u n c e r t a i n as t o why t h e s t a f f r e p o r t e d 85 no i m p r o v e m e n t i n any of t h e s u b j e c t ' s s k i l l l e v e l s . T h e s e e v a l u a t i o n s were b a s e d on a f i v e p o i n t L i k e r t - t y p e s c a l e w h i c h r a t e d e a c h s u b j e c t on 15 b e h a v i o r s . U n f o r t u n a t e l y t h e s c a l e i s n o t r e p r o d u c e d i n t h e a r t i c l e and t h e r e f o r e i t i s d i f f i c u l t t o a s c e r t a i n i f t h e s c a l e i s a t f a u l t o r i f i n f a c t t h e g e n e r a l i z a t i o n i s n o t as good as t h e a u t h o r s i n d i c a t e . The a u t h o r s ' g e n e r a l i z a t i o n s were b a s e d on p e r f o r m a n c e d u r i n g d i n n e r w h i c h was r e c o r d e d on v i d e o . S i m i l a r l y , S p e n c e (1985) f o u n d t h a t d e s p i t e c h a n g e s i n t h e u s e of a w i d e r a n g e o f b a s i c s o c i a l s k i l l s w i t h i n t h e n a t u r a l s e t t i n g , t h e g e n e r a l i z a t i o n m e a s ure o f g l o b a l s o c i a l c o m p e t e n c e on t h e s t a f f q u e s t i o n n a i r e f a i l e d t o d e m o n s t r a t e s i g n i f i c a n t c h a n g e s o v e r t i m e . In s p i t e o f t h e s e p r o b l e m s t h i s s c a l e was u s e d i n t h i s s t u d y w i t h S u b j e c t s 2,3, and 4. The same s t a f f p e r s o n a s s e s s e d e a c h s u b j e c t a t t h e g r o u p home on b o t h t h e p r e and p o s t m e a s u r e s b u t t h e p o s t measure was n o t c o m p l e t e d ( t h e o v e r a l l a s s e s s m e n t r a t i n g was o m i t t e d ) . O t h e r m e t h o d o l o g i c a l p r o b l e m s a s s o c i a t e d w i t h t h i s s c a l e i n c l u d e d many e r a s e r marks w h i c h may i n d i c a t e t h a t t h e r e was a p r o b l e m d e c i d i n g on w h i c h l e v e l t o g r a d e t h e s u b j e c t . T h e r e f o r e t h i s s c a l e may n o t p r o v i d e an a c c u r a t e measure o f s o c i a l s k i l l s b e c a u s e i t l a c k s s p e c i f i c i t y and b e c a u s e t h e p o s t measure was n o t 86 c o m p l e t e d . However, as p r e v i o u s l y s t a t e d t h e r e a r e n o t many s u i t a b l e m e a s u r e s t h a t a d d r e s s s o c i a l s k i l l s t r a i n i n g w i t h t h e head i n j u r e d p o p u l a t i o n and t h e r e f o r e t h i s m easure was i n c l u d e d . R e s u l t s f r o m t h i s measure must be r e g a r d e d a c c o r d i n g l y . B e h a v i o r a t d i n n e r may p r o v i d e a n a t u r a l s e t t i n g i n w h i c h t o o b s e r v e s o c i a l b e h a v i o r b u t i t i s l i k e l y t h a t more t i m e w i l l be s p e n t e a t i n g and as a r e s u l t may o n l y p r o v i d e an o p p o r t u n i t y f o r p o l i t e d i n n e r t i m e c o n v e r s a t i o n . C o n s e q u e n t l y f o r t h i s s t u d y a g r o u p d i s c u s s i o n s e s s i o n was c h o s e n i n o r d e r t o e v a l u a t e s o c i a l s k i l l s . P a r t o f t h e r e a s o n f o r c h o o s i n g t h i s g r o u p d i s c u s s i o n f o r m a t was b e c a u s e some of t h e s t a f f a t t h e g r o u p home s t a t e d t h a t t h i s was an a r e a o f d e f i c i t . As a r e s u l t a v i d e o of a g r o u p d i s c u s s i o n c o n d u c t e d one week p r i o r t o t h e c o l l e c t i o n o f b a s e l i n e d a t a was u s e d f o r t h e p r e measure and a g r o u p s e s s i o n c o n d u c t e d one week f o l l o w i n g t r a i n i n g was u s e d as a p o s t measure f o r s o c i a l s k i l l s a c q u i s i t i o n . I t was n o t p o s s i b l e t o o b t a i n a p r e - b a s e l i n e v i d e o on s u b j e c t N o . l , t h e r e f o r e h i s b e h a v i o r i n t h e b a s e l i n e was u s e d as a measure f o r t h e S o c i a l S k i l l s A s s e s s m e n t C h a r t . I t was b e l i e v e d t h a t h i s b e h a v i o r h e r e was an a d e q u a t e e x a m p l e o f h i s s o c i a l b e h a v i o r . T h i s i s b e c a u s e t h e b a s e l i n e d a t a c o l l e c t i o n s e s s i o n was i n d e e d 87 a s o c i a l s i t u a t i o n . A v i d e o of a p o s t g r o u p s e s s i o n was u s e d t o e v a l u a t e g e n e r a l i z a t i o n f o r S u b j e c t No. 1. In t h e " S t a c k i n g t h e Deck P r o g r a m " t h e r e was a l a c k of a t t e n t i o n t o n o n - v e r b a l s o c i a l s k i l l s and t h e r e f o r e t h i s p r o g r a m was m o d i f i e d t o i n c l u d e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . M e a s u r e m e n t s were added t o a d d r e s s n o n - v e r b a l b e h a v i o r s ( S o c i a l S k i l l s A s s e s s m e n t C h a r t ) . T h e s e m e a s u r e s i n c l u d e d b a s i c n o n - v e r b a l s k i l l s ( f a c i a l e x p r e s s i o n , p o s t u r e , g e s t u r e s , eye c o n t a c t , s o c i a l d i s t a n c e , f i d d l i n g movements, s m i l i n g and l a u g h t e r , head movements) w h i c h were m e a s u r e d p r e and p o s t t r a i n i n g . The " S t a c k i n g t h e D e c k " p r o g r a m d i d n o t p r o v i d e s p e c i f i c i n s t r u c t i o n s f o r i m p l e m e n t a t i o n w i t h " l o w e r f u n c t i o n i n g " i n d i v i d u a l s . F o r e x a m p l e , i f a s u b j e c t has a p r o b l e m w i t h i n i t i a t i o n c a n t h e q u e s t i o n be r e p e a t e d ? Can t h e q u e s t i o n be r e p e a t e d i f t h e s u b j e c t was d i s t r a c t e d f o r any r e a s o n ? F o r t h e p u r p o s e of t h i s s t u d y , q u e s t i o n s were r e p e a t e d 2 o r 3 t i m e s i f t h e s u b j e c t was d i s t r a c t e d o r i f no r e s p o n s e was g i v e n w i t h i n t e n s e c o n d s f o r s u b j e c t No. 1 o n l y ( n o t e t h a t s u b j e c t No. 1 p l a y e d t h e game w i t h two o t h e r s who were n o t c o n s i d e r e d f o r t h i s s t u d y b e c a u s e t h e y were n o t s i x months p o s t i n j u r y ) . I f o t h e r s u b j e c t s (No. 2, 3, o r 88 4) were d i s t r a c t e d i t was due t o o t h e r t a l k i n g , and t h e f a c i l i t a t o r s t o p p e d and a s k e d t h o s e t a l k i n g t o p l e a s e be q u i e t and g i v e a c h a n c e t o r e s p o n d t o t h e q u e s t i o n . The q u e s t i o n was r e p e a t e d a t t h i s t i m e . T h i s work o f B r a u n 1 i n g - M c M o r r o w e t a l (1986) i s r e l a t i v e l y new and n o t as w e l l know as t h e work o f Eames _ Wood ( 1 9 8 1 , 1 9 8 5 ) . Eames and Wood made use o f a t o k e n economy t o r a d i c a l l y c h a n g e t h e i n a p p r o r i a t e b e h a v i o r o f many head i n j u r e d i n d i v i d u a l s . However, t h e i r s u c c e s s i s b a s e d on e x t e n s i v e t r e a t m e n t p e r i o d s o f a y e a r o r more. In t h e i r work, " R e h a b i l i t a t i o n a f t e r s e v e r e b r a i n i n j u r y : a f o l l o w - u p s t u d y o f a b e h a v i o r m o d i f i c a t i o n a p p r o a c h " (1985) t h e y e v a l u a t e d 24 p a t i e n t s w i t h s e v e r e head i n j u r y t h a t had d i s t u r b e d b e h a v i o r s p r e v e n t i n g r e h a b i l i t a t i o n o r c a r e i n o r d i n a r y s e t t i n g s and t h u s were t r e a t e d i n a t o k e n economy. T h e i r l o n g - t e r m f o l l o w - u p s t u d y i n d i c a t e d t h a t p o s t - t r a u m a t i c b e h a v i o r d i s o r d e r s c a n be l a s t i n g l y i m p r o v e d , and t h a t l e n g t h y r e h a b i l i t a t i o n c a n have s u r p r i s i n g l y good e f f e c t s . T h e i r K e m s l e y U n i t i s a v e r y s t r u c t u r e d e n c l o s e d u n i t o r g a n i z e d as a t o k e n economy, and u s e s a w i d e r a n g e of p h y s i c a l , c o g n i t i v e , b e h a v i o r , o c c u p a t i o n a l and s o c i a l t e c h n i q u e s f o r t r e a t m e n t and t r a i n i n g . The b e h a v i o r a l t r e a t m e n t i s b a s e d on t h e p o s i t i v e r e i n f o r c e m e n t ( w i t h t o k e n s , g o o d i e s , p r i v i l e g e s , and 89 a b o v e a l l , i n t e r e s t , a t t e n t i o n and p r a i s e ) o f a l l a p p r o p r i a t e and a d a p t i v e b e h a v i o r s . The Eames and Wood s t u d y d e m o n s t r a t e d t h a t s e v e r e l y b r a i n - i n j u r e d p a t i e n t s who were p r e v i o u s l y n o t a c c e p t e d i n r e h a b i l i t a t i o n p r o g r a m s c o u l d be s u c c e s s f u l l y t r e a t e d by c o m b i n i n g f o r m a l r e h a b i l i t a t i o n w i t h b e h a v i o r m o d i f i c a t i o n t e c h n i q u e s . However, b e h a v i o r m o d i f i c a t i o n n e e d s v e r y l e n g t h y a p p l i c a t i o n t o a c h i e v e c h a n g e s t h a t a r e l i k e l y t o e n d u r e . As a r e s u l t t h e i r r e h a b i l i t a t i v e t r e a t m e n t s were a b l e t o c o n t i n u e f o r much l o n g e r t h a n u s u a l , and e x t e n d e d i n t o s o c i a l , l e i s u r e and e v e n o c c u p a t i o n a l a r e a s . T h e i r r e s u l t s s u g g e s t t h a t a p e r i o d of 15 t o 18 months i s o p t i m a l f o r most (Eames & Wood,1985). The l e n g t h of t i m e n e c e s s a r y i n t h e i r p r o g r a m makes t h e r e h a b i l i t a t i o n p r o c e s s more e x p e n s i v e and t h e r e f o r e may n o t be f e a s i b l e . On t h e o t h e r hand, t h e a p p e a l o f t h e " S t a c k i n g t h e D e c k " p r o g r a m i s i t s a p p a r e n t c o s t e f f e c t i v e n e s s , i n t h a t s e v e r a l i n d i v i d u a l s c a n be t r a i n e d s i m u l t a n e o u s l y by one f a c i l i t a t o r . I t a l s o p r o v i d e s an i n d e p t h a s s e s s m e n t of s k i l l a c q u i s i t i o n i n a number of s o c i a l s k i l l component a r e a s . T h i s p r o g r a m was a d a p t e d f o r t h i s s t u d y b e c a u s e of t h e s e f a c t o r s . However a m e t h o d o l o g i c a l c o n c e r n i n t h i s s t u d y t h a t has n o t been a d d r e s s e d as y e t i s t h e d e s i g n i t s e l f . 90 The s i n g l e s u b j e c t d e s i g n was c h o s e n b e c a u s e of t h e s m a l l number of s u b j e c t s i n v o l v e d and b e c a u s e t h e c h a r a c t e r i s t i c s o f t h i s d e s i g n f i t t h e p u r p o s e o f t h i s s t u d y . T h e s e i s s u e s were a d d r e s s e d i n c h a p t e r 3 on R e s e a r c h D e s i g n and w i l l n o t be r e p e a t e d h e r e . Summary I n t e r - r a t e r r e l i a b i l i t y and r e d u c t i o n o f e r r o r s i n Judgment a r e m a j o r m e t h o d o l o g i c a l i s s u e s i n t h i s s t u d y . R a t e r s were i n f o r m e d o f p o t e n t i a l e r r o r s and p r e c a u t i o n s were t a k e n t o a v o i d p r o x i m i t y e r r o r s , c o n t e n t e r r o r s , t h e h a l o e f f e c t , e r r o r s o f c e n t r a l t e n d e n c y , and l e n i e n c y e r r o r s w h e r e v e r p o s s i b l e . I t was assumed t h a t t h e ma i n m e t h o d o l o g i c a l i s s u e may be t h e p r o b l e m s o f t r a n s f e r r i n g t h e l e a r n e d b e h a v i o r t o t h e " r e a l w o r l d " . C o n s e q u e n t l y t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s w h i c h p r o v i d e d homework were e m p l o y e d t o h e l p o v e r come t h i s p r o b l e m . T h e r e a r e a l s o some m e t h o d o l o g i c a l p r o b l e m s w i t h t h e g l o b a l S t a f f Q u e s t i o n n a i r e b u t i t does a d d r e s s t h e i s s u e of m a i n t a i n i n g s k i l l s . The Eames & Wood's b e h a v i o r m o d i f i c a t i o n , a l t h o u g h v e r y s u c c e s s f u l , was n o t c o n s i d e r e d b e c a u s e of t h e h i g h c o s t and l e n g t h y t r e a t m e n t t i m e r e q u i r e d . The " S t a c k i n g t h e Deck" p r o g r a m was m o d i f i e d t o i n c l u d e s t r u c t u r e d 91 l e a r n i n g a s s i g n m e n t s i n o r d e r t o a d d r e s s some of t h e n o n - v e r b a l a s p e c t s of s o c i a l s k i l l s and t o i n c r e a s e t h e p o s s i b i l i t y of g e n e r a l i z a t i o n . I t i s b e l i e v e d t h a t t h e t y p e of o b s e r v a t i o n and t h e r e c o r d i n g methods u s e d i n t h i s s t u d y w i l l a s s i s t i n t h e k n o w l e d g e b u i l d i n g p r o c e s s . 92 CHAPTER 5 FINDINGS  S u b j e c t 1 T a b l e no.5 shows t h a t s u b j e c t 1's c o r r e c t r e s p o n s e s t o t h e s i t u a t i o n c a r d s i n t h e " S t a c k i n g t h e Deck" p r o g r a m r a n g e d f r o m one t o f i v e i n t h e b a s e l i n e . D u r i n g t h e i n t e r v e n t i o n p h a s e he was a b l e t o i m p r o v e h i s number of c o r r e c t r e s p o n s e s u n t i l he o b t a i n e d a p e r f e c t s c o r e i n t h e f i n a l game. P< = .001 ( t - t e s t ) S o c i a l S k i l l s A s s e s s m e n t C h a r t ( T a b l e No.6) In v o i c e q u a l i t y , c l a r i t y and r a t e were s c o r e d as 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . Volume and t o n e and p i t c h r e c e i v e d 3 i n t h e p r e t e s t and 4 i n t h e p o s t t e s t . In n o n - v e r b a l r e s p o n s e s , s o c i a l d i s t a n c e was n o t s c o r e d w i t h t h i s s u b j e c t b e c a u s e he was o f t e n i n a wheel c h a i r s i t t i n g a t a t a b l e . H i s s o c i a l d i s t a n c e was a l w a y s a p p r o p r i a t e b u t i t w o u l d be d i f f i c u l t t o s a y i f h i s a p p r o p r i a t e b e h a v i o r was r e l a t e d t o good s o c i a l s k i l l s o r t h e s e a t i n g a r r a n g e m e n t . In f i d d l i n g movements he r e c e i v e d a s c o r e of 2 i n t h e p r e measure and 4 i n t h e p o s t m e a s u re. In t h e p r e t e s t s m i l i n g and TABLE 5 P L A Y E R PROGRESS GRAPH S U B J E C T 1 93 S 3 S N C M S 3 - J O U 3 8 W 0 N THE QUALITY OF THIS MICROFICHE IS HEAVILY DEPENDENT UPON THE QUALITY OF THE THESIS SUBMITTED FOR MICROFILMING. UNFORTUNATELY THE COLOURED ILLUSTRATIONS OF THIS THESIS CAN ONLY YIELD DIFFERENT TONES OF GREY. LA QUALITE DE CETTE MICROFICHE DEPEND GRANDEMENT DE LA QUALITE DE LA THESE SOUMISE AU MICROFILMAGE. MALHEUREUSEMENT, LES DIFFERENTES ILLUSTRATIONS EN COULEURS DE CETTE THESE NE PEUVENT DONNER QUE DES TEINTES DE GRIS. TABLE NO. 6 SOCIAL SKILLS ASSESSMENT CHART SUBJECT 1 94 ss i t O n O p Sfi green red - p r e - t e s t - p o s t - t e s t 95 l a u g h t e r , and head movements were s c o r e d a t 3 and r e c e i v e d 4 i n t h e p o s t t e s t . In t h e b a s i c n o n - v e r b a l s k i l l s , f a c i a l e x p r e s s i o n , p o s t u r e , g e s t u r e s and eye c o n t a c t were r a t e d as 2 i n t h e p r e t e s t and g e s t u r e s and eye c o n t a c t r e c e i v e d 3 i n t h e p o s t t e s t . F a c i a l e x p r e s s i o n and p o s t u r e r e c e i v e d 4 i n t h e p o s t t e s t . In t h e b a s i c c o n v e r s a t i o n s k i l l s , s u b j e c t 1 r e c e i v e d a s c o r e of 1 i n f r e q u e n c y of i n i t i a t i o n s and f r e q u e n c y of q u e s t i o n a s k i n g i n t h e p r e t e s t and t h e s c o r e i n e a c h o f t h e s e c a t e g o r i e s i n t h e p o s t t e s t was 3. I n f o r m a t i o n c o n t e n t and l e n g t h of r e p l y t o q u e s t i o n s s c o r e d 2 i n t h e p r e t e s t and i n f o r m a t i o n c o n t e n t went t o 4 i n t h e p o s t t e s t and l e n g t h of r e p l y t o q u e s t i o n s went t o a s c o r e of 3. In l i s t e n i n g s k i 1 1 s , a c k n o w 1 e d g m e n t s were s c o r e d as 2 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t . R e f l e c t i o n s r e c e i v e d 1 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t . Q u e s t i o n - t y p e f e e d b a c k and p e r s o n a l s e 1 f - d i s c 1 o s u r e s r e c e i v e d 1 i n t h e p r e - t e s t and 3 i n t h e p o s t t e s t . In c o n t e n t of s p e e c h , r e l e v a n c y of c o n v e r s a t i o n went f r o m 3 i n t h e p r e t e s t t o 4 i n t h e p o s t t e s t , i n t e r e s t c o n t e n t and r e p e t i t i o n s went f r o m 2 i n t h e p r e t e s t t o 4 i n t h e p o s t t e s t and i n t e r r u p t i o n s r e m a i n e d a t 4 i n t h e p r e and p o s t t e s t s . 96 R e s p o n s e s t o " S t a c k i n g t h e Deck" In t h e b a s e l i n e p e r i o d , s u b j e c t 1 a v e r a g e d 5.3 words p e r r e s p o n s e and i n c r e a s e d t o 11.12 i n t h e l a s t s e s s i o n ( s e e T a b l e n o . 7 ) . The r e s p o n s e t i m e ( t i m e i t t o o k t o r e s p o n d t o s i t u a t i o n ) d u r i n g t h e b a s e l i n e p e r i o d was 29.15 s e c o n d s and t h e r e s p o n s e t i m e i n t h e l a s t s e s s i o n was 2.47 s e c o n d s . In t h e s e s s i o n s a t t h e b e g i n n i n g of i n t e r v e n t i o n , q u e s t i o n s had t o be r e p e a t e d as many as 2 o r 3 t i m e s , however, t o w a r d s t h e f i n a l s e s s i o n s t h e s i t u a t i o n s were o n l y s t a t e d o nce and t h e r e p l y was i m m e d i a t e . The r e s p o n s e s t o t h e s i t u a t i o n c a r d s n e v e r d i s p l a y e d any r o t e p a t t e r n . The r e s p o n s e s o f t e n v a r i e d and showed i m p r o v e m e n t i n s o c i a l c o m p e t e n c e as t r a i n i n g s e s s i o n s p r o g r e s s e d . In t h e b e g i n n i n g S u b j e c t 1 s p e n t much o f h i s t i m e b l o w i n g on h i s hand and r o c k i n g b a c k and f o r t h i n h i s w h e e l c h a i r . He e i t h e r s t a r e d s t r a i g h t a h e a d o r k e p t h i s head down and s t a r e d a t h i s l a p . In t h e t h i r d i n t e r v e n t i o n s e s s i o n (game 7) h i s b e h a v i o r began t o show some i m p r o v e m e n t . However, eye c o n t a c t was n o t good, he c o n t i n u e d t o l o o k down and r o c k back and f o r t h i n h i s c h a i r . B u t he b l e w on h i s hand l e s s . He began t o r e s p o n d more and a s k e d q u e s t i o n s h i m s e l f (how much i s 97 t h i s one w o r t h ? ) . He was most e a g e r t o r e c e i v e a l a r g e number so he c o u l d move h i s game p i e c e a c c o r d i n g l y . R e s p o n s e s became more a p p r o p r i a t e as t h e i n t e r v e n t i o n p r o g r e s s e d . In t h e b e g i n n i n g i n c o r r e c t r e s p o n s e s were o f t e n t h e r e s u l t o f no r e s p o n s e and c o r r e c t r e s p o n s e s were o f t e n a few w o r d s . E x a m p l e s of q u e s t i o n s and r e s p o n s e s a r e : A n o t h e r r e s i d e n t t e l l s y o u t h a t he f e l l t h i s m o r n i n g and h u r t h i s l e g . What w o u l d y o u s a y ? A n s w e r s were as f o l l o w s : ( i n o r d e r of o c c u r r e n c e ) 1. " H i t t h e r o a d t h e r e Wayne." 2. " I ' d s a y l i f e ' s a b i t c h and t h e n y o u m a r r y one e h ! " You a r e on an a c t i v i t y w i t h an a c t i v i t y t h e r a p i s t and he s a y s i t s t i m e t o go b a c k t o t h e c e n t r e , y o u want t o s t a y l o n g e r . What do y o u s a y ? 1. "What's w i t h y o u t h e r e d u d e ? " 2. " I w o u l d s a y why do we have t o go, I want t o s t a y l o n g e r . 3. " I w o u l d s a y e x c u s e me t h e r e - b u t do we have t o go r i g h t now b e c a u s e I am h a v i n g a good t i m e . " A n o t h e r r e s i d e n t t e l l s y o u t h a t t h e y a p p r e c i a t e y o u r o p e n i n g t h e d o o r f o r them. What do y o u s a y ? 1. "Don't t h a n k me j u s t buy me s o m e t h i n g . " 2. "Don't t h a n k me j u s t buy me s o m e t h i n g . " 98 3. "No p r o b l e m - any t i m e . " 4. " I p r o b a b l y s a y y o u a r e v e r y welcome. You a r e o u t on an a c t i v i t y and a n o t h e r r e s i d e n t l o o k i n g a t a g i r l w a l k i n g down t h e s t r e e t s a y s , "She's n o t bad l o o k i n g f o r a f a t p e r s o n . " What do y o u s a y ? 1. " I s n ' t she e h " 2. "Yah, s h e ' s n o t bad l o o k i n g : 3. " I t i s n o t v e r y n i c e t o s a y t h a t a b o u t f a t p e o p 1 e . " 4. " T h a t ' s n o t v e r y n i c e t o s a y - what i f y o u were f a t . " By game 9 ( s i x t h game o f i n t e r v e n t i o n ) q u e s t i o n s d i d n o t have t o be r e p e a t e d . S u b j e c t 1 a n s w e r e d a l l q u e s t i o n s u n l e s s he was d i s t r a c t e d . However, q u e s t i o n s were n o t r e p e a t e d a t t h i s p o i n t . I f a n s w e r s were n o t prompt t h e y were marked as i n c o r r e c t . Eye c o n t a c t was b e t t e r . He no l o n g e r b l e w on h i s hand o r r o c k e d b a c k and f o r t h i n h i s c h a i r . In game 15, h i s mother was p r e s e n t f o r p a r t o f t h e s e s s i o n . She s a t a t t h e bac k o f t h e room b e h i n d s u b j e c t 1. He d i d n o t a p p e a r t o be d i s t r a c t e d by t h i s . Games 15 and 16 were p l a y e d i n a d i f f e r e n t room and a g a i n t h i s d i d n o t d i s t r a c t t h e sub j e c t . TABLE NO.7 AVERAGE NUMBER OF WORDS PER RESPONSE Words i n Words i n S u b j e c t B a s e l i n e L a s t Game S u b j e c t 1 5.3 11.12 S u b j e c t 2 10.13 14.86 S u b j e c t 3 5.5 11.21 S u b j e c t 4 4.0 8.7 100 S t r u c t u r e d l e a r n i n g A s s i g n m e n t s T h e s e a s s i g n m e n t s were t o be c o m p l e t e d as homework. However, s i n c e t h e f i r s t a s s i g n m e n t was n o t r e t u r n e d t h e r e m a i n d e r were c o m p l e t e d i n t h e i n t e r v e n t i o n s e s s i o n . L i s t e n i n g s k i l l s and c o n v e r s a t i o n s k i l l s were t h e t o p i c s c o v e r e d i n t h r e e s e s s i o n s . In s t a r t i n g a c o n v e r s a t i o n , s u b j e c t 1 had d i f f i c u l t y g e t t i n g p a s t t h e s m a l l t a l k . He was a b l e t o j u d g e i f t h e o t h e r p e r s o n was l i s t e n i n g , h o w e v e r , t h e m a i n t o p i c was o f t e n s i m i l a r t o t h e s m a l l t a l k w h i c h he o p ened t h e c o n v e r s a t i o n w i t h . A t f i r s t he c o u l d n o t s u p p l y h i s own t o p i c of c o n v e r s a t i o n and i t e m s had t o be s u g g e s t e d f o r him, s u c h as h i s f a m i l y , and t h e town where he grew up. S u b j e c t 1 had no d i f f i c u l t y c a r r y i n g on a c o n v e r s a t i o n w i t h h i s p e e r s . He c o u l d a l s o end t h e c o n v e r s a t i o n w i t h no d i f f i c u l t y . However, he was t h e b e s t a t t h e L i s t e n i n g S k i l l s . The i m p r o v e m e n t h e r e was i n l o o k i n g a t t h e o t h e r p e r s o n and s h o w i n g i n t e r e s t by n o d d i n g h i s h e a d . T h e s e two p a r t i c u l a r s k i l l s d i d a p p e a r t o c a r r y o v e r t o t h e game s i t u a t i o n . The w r i t t e n p a r t o f t h e a s s i g n m e n t s was d i f f i c u l t f o r him and he r e q u i r e d a s s i s t a n c e . P h r a s e s were u s e d r a t h e r t h a n s e n t e n c e s . He a l w a y s r a t e d h i s p e r f o r m a n c e as good. He a p p e a r e d t o e n j o y t h e i n t e r a c t i o n and r o l e p l a y w i t h h i s p e e r s. 101 S u b j e c t 2 R e s p o n s e I n t h e b a s e l i n e ( S t a c k i n g t h e Deck p r o g r a m ) f o r S u b j e c t 2 was v a r i a b l e and t h i s c o n t i n u e d i n t o t h e i n t e r v e n t i o n p h a s e u n t i l game 9. D u r i n g t h e b a s e l i n e p h a s e c o r r e c t r e s p o n s e s r a n g e d f r o m 4 t o 11 w i t h an a v e r a g e o f 7. However, I n t h e m i d d l e o f t h e i n t e r v e n t i o n p h a s e t h e c o r r e c t r e s p o n s e s r e m a i n e d c o n s i s t a n t a r o u n d 11 and 12 ( s e e T a b l e No.8 ) P< =.01 ( t - t e s t ) . The number o f words p e r r e s p o n s e a v e r a g e d a t 10.13 d u r i n g t h e b a s e l i n e p h a s e and a v e r a g e d a t 14.86 p e r r e s p o n s e i n game 18 ( s e e T a b l e N o . 7 ) . S o c i a l S k i l l s A s s e s s m e n t C h a r t ( s e e T a b l e no. 9 ) In v o i c e q u a l i t y t h e r e was no r e c o r d e d i m p r o v e m e n t i n c l a r i t y , r a t e , v o l u m e , and t o n e and p i t c h . C l a r i t y and r a t e s c o r e d 5 i n b o t h t h e p r e and p o s t t e s t s . , w h i l e v o l u m e , and t o n e and p i t c h s c o r e d 4 i n t h e p r e and p o s t t e s t s . I n n o n - v e r b a l r e s p o n s e s head movements s c o r e d 4 i n b o t h p r e and p o s t t e s t s . S m i l i n g and l a u g h t e r were marked a t 3 i n t h e p r e t e s t and 4 i n t h e p o s t t e s t . A s c o r e o f 5 was a s s i g n e d t o f i d d l i n g movements i n b o t h t h e p r e and p o s t t e s t s . In b a s i c n o n - v e r b a l s k i l l s , f a c i a l e x p r e s s i o n was r e c o r d e d as 3 i n b o t h t h e p r e and p o s t t e s t s . P o s t u r e 102 was r a t e d as 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . G e s t u r e s and eye c o n t a c t r e c e i v e d a s c o r e o f 4 i n b o t h t h e p r e and p o s t t e s t s . In t h e b a s i c c o n v e r s a t i o n s k i l l s , t h e l e n g t h o f r e p l y t o q u e s t i o n s r e m a i n e d a t 3 f o r b o t h t h e p r e and p o s t t e s t s and i n f o r m a t i o n c o n t e n t r e m a i n e d a t 2 f o r b o t h t e s t s . F r e q u e n c y o f q u e s t i o n a s k i n g was s c o r e d as 1 i n t h e p r e t e s t and 2 i n t h e p o s t t e s t . F r e q u e n c y of i n i t i a t i o n r e c e i v e d 2 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t . In l i s t e n i n g s k i l l s , a c k n o w l e d g m e n t s were 2 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t and r e f l e c t i o n s r e c e i v e d 1 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t . Q u e s t i o n - t y p e f e e d b a c k r e m a i n e d t h e same w i t h a s c o r e o f 3 and p e r s o n a l s e 1 f - d i s c 1 o s u r e s r e m a i n e d t h e same a t 2. In t h e c o n t e n t o f s p e e c h , r e l e v a n c y o f c o n v e r s a t i o n s c o r e d 2 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . I n t e r e s t c o n t e n t r e c e i v e d 3 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . I n t e r r u p t i o n s r e m a i n e d t h e same a t 4. R e p e t i t i o n s were s c o r e d a t 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . In t h e q u a l i t y o f s p e e c h , d y s f l u e n c i e s r e m a i n e d t h e same a t 5 i n b o t h t e s t s and h e s i t a t i o n s and p a u s e s r e m a i n e d t h e same a t 4 i n b o t h t e s t s . L a t e n c y o f TABLE 8 P L A Y E R PROGRESS GRAPH S U B J E C T 2 103 s a s N O d s a u l o a m i o o AO ^HHWON 104 TABLE NO.9 SOCIAL SKILLS ASSESSMENT CHART SUBJECT 2 green - p r e - t e s t red - p o s t - t e s t 105 r e s p o n s e r e c e i v e d 2 i n t h e p r e t e s t and 4 i n p o s t t e s t . The amount s p o k e n r e m a i n e d a t 3 i n b o t h t e s t s . R e s p o n s e s i n " S t a c k i n g t h e Deck" S u b j e c t 2 was a v e r b a l l y a g g r e s s i v e p e r s o n b u t t h e q u a l i t y of r e s p o n s e s i m p r o v e d t h r o u g h o u t t h e i n t e r v e n t i o n . Some e x a m p l e s o f t h i s f o l l o w , w i t h t h e q u e s t i o n g i v e n f i r s t and t h e r e s p o n s e s i n o r d e r of o c c u r r e n c e : You a r e w a t c h i n g TV and y o u r roommate comes i n and c h a n g e s t h e c h a n n e l . What do y o u s a y ? 1. " T u r n t h a t t h i n g b a c k . I am w a t c h i n g i t - i f he d o e s n ' t do t h a t he w o u l d wear t h e c a n e . " 2. " E x c u s e me, c a n y o u p u t t h a t b a c k . I was w a t c h i n g t h a t . You c a n ' t come i n h e r e and c h a n g e i t . I f y o u want t o w a t c h s o m e t h i n g e l s e y o u s h o u l d have been h e r e e a r 1 i e r . " 3. " I ' d s a y s w i t c h t h a t damn t h i n g b a c k . I'm w a t c h i n g a show. You s h o u l d have been h e r e h a l f an h o u r ago. " 4. "Hey I was w a t c h i n g t h a t show. What t h e heck do y o u t h i n k y o u a r e d o i n g . " 5. " T e l l him t o t u r n i t b a c k I was w a t c h i n g t h a t show." 106 A n o t h e r r e s i d e n t u s e s a l o t o f d i r t y words when he t a l k s , and you do n o t l i k e i t . What c a n y o u do? 1. " T e l l him t o s h u t h i s f u c k i n g mouth - i f he w a n t s t o u s e d i r t y w o rds I c a n . " 2. "Ask him i f t h e d i r t y words a r e n e c e s s a r y a l l t h e t i m e b e c a u s e y o u w o u l d r a t h e r n o t h e a r them b e c a u s e y o u c a n u s e enough y o u r s e l f - y o u d o n ' t n e e d t o h e a r them." 3. " T e l l him i f y o u c a n ' t s t o p t h a t s w e a r i n g I won't t a l k t o him any more - i t i s as s i m p l e as t h a t . " 4. "Ask him t o s t o p s w e a r i n g - t h e r e i s no r e a s o n f o r a l l t h o s e d i r t y w o r d s . " A r e s i d e n t r e p e a t e d l y a s k s y o u t o g e t h i s c i g a r e t t e s f o r him. You know he c a n g e t them h i m s e l f . What do y o u s a y ? 1. " N o t h i n g p r i n t a b l e . Who was y o u r b u s h y o u know what l a s t y e a r - g e t them y o u r s e l f . " 2. "Your c i g a r e t t e s a r e r i g h t where y o u l e f t them - I'm n o t g o i n g t o g e t them f o r y o u . " 3. "No, I'm n o t g o i n g t o g e t y o u r c i g a r e t t e s - y o u c a n g e t them y o u r s e l f . " 4. *?Get them y o u r s e l f . " 5. "You know where y o u r c i g a r e t t e s a r e and I'm n o t y o u r s l a v e , c a n y o u g e t them y o u r s e l f p l e a s e ? " 107 You o v e r h e a r someone s a y t o a s t a f f member, "Get me t h a t a s h t r a y . I n e e d i t . " What m i g h t y o u s a y t o y o u r f r i end? 1. " N o t h i n g p r i n t a b l e - What t h e h e l l i s a m a t t e r w i t h y o u ? Do y o u have a b o a r d t i e d t o y o u r a s s ? " 2. " I f y o u ne e d i t c a n ' t you g e t i t y o u r s e l f . You a r e t a l k i n g t o a r e s i d e n t who has a memory p r o b l e m , and t h e y a s k y o u what y o u a r e m a k i n g i n a r t . T h i s p e r s o n a s k e d y o u t h e same q u e s t i o n y e s t e r d a y . What do y o u s a y ? 1. "The same t h i n g I was m a k i n g y e s t e r d a y - I t o l d y o u y e s t e r d a y . " 2. "The same t h i n g I was m a k i n g y e s t e r d a y . " 3. " I t o l d y o u what I was m a k i n g y e s t e r d a y . " 4. " I t o l d y o u what I was m a k i n g y e s t e r d a y - I'm m a k i n g t h e same t h i n g i f y o u c a n ' t remember w r i t e i t down." 5. " E x c u s e me, I know y o u have t r o u b l e r e m e m b e r i n g I ' l l t e l l y o u a g a i n b u t p l e a s e w r i t e i t down so y o u w i l l remember." Someone a s k s y o u r f r i e n d how t h e y a r e d o i n g t o d a y , and y o u r f r i e n d g i v e s them a l o n g e x p l a n a t i o n . What do you s a y t o y o u r f r i e n d ? 1. "My g o o d n e s s he j u s t a s k e d how you a r e d o i n g n o t f o r a two ho u r s t o r y . " 108 2. " C o u l d you p l e a s e s h o r t e n t h a t up w e ' l l be h e r e f o r h a l f an h o u r . " 3. " C o u l d y o u p l e a s e - y o u c a n t e l l him how y o u a r e b u t c o u l d y o u p l e a s e make i t a l i t t l e s h o r t e r . " S u b j e c t 2 a p p e a r e d t o e n j o y t h e game f o r m a t . He j o k e d a b o u t a low p o i n t he r e c e i v e d a f t e r he had g i v e n a l o n g a n s w e r . He e s p e c i a l l y l i k e d t h e p r a i s e g i v e n f o r a c o r r e c t a n s w e r . He w o u l d a l w a y s t r y t o g e t a few e x t r a p o i n t s by s l i d i n g on s p a c e s meant f o r o t h e r p l a y e r s . He. w o u l d t h e n l a u g h and j o k e a b o u t i t . He showed c o - o p e r a t i o n i n m o v i n g o t h e r p l a y e r s m a r k e r s when t h e y were n e a r him and by h e l p i n g t o p u t t h e game away a f t e r t h e s e s s i o n was o v e r . However, h i s b e h a v i o r t o w a r d s o t h e r p e o p l e d e p e n d e d on what he t h o u g h t o f them. He e x p r e s s e d t h i s on a few o c c a s i o n s and d e m o n s t r a t e d i t i n some o f h i s r e p l i e s . F o r e x a m p l e t h e q u e s t i o n , You a r e i n a s t o r e and a l i t t l e k i d comes up and a s k s what i s wrong w i t h y o u ( e i t h e r b e c a u s e o f y o u r w h e e l c h a i r , c a n e , o r t h e way y o u w a l k ) . What do you s a y ? He r e p l i e d , " A l i t t l e k i d i f i t was anyone e l s e t h e y w o u l d h e a r a b o u t i t . " H e s t a t e d t h a t i f he d i d n ' t l i k e someone he w o u l d n ' t t a l k t o them and t h a t i f he d i d n ' t l i k e someone he d i d n ' t have t o be n i c e t o them. Some of t h e s e c o n c e r n s were a d d r e s s e d i n t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . 109 S t r u c t u r e d L e a r n i n g A s s i g n m e n t s S u b j e c t 2 e v a l u a t e d o t h e r s a c c o r d i n g t o t h e l e a r n i n g p o i n t s t o be f o l l o w e d and t h e n f o l l o w e d t h e s e same l e a r n i n g p o i n t s when he r o l e p l a y e d a s i t u a t i o n . He p r o v i d e d e x a m p l e s f o r r o l e p l a y s . He r a t e d h i m s e l f as e x c e l l e n t i n t h e c o n v e r s a t i o n s k i l l s and l i s t e n i n g s k i l l s and o n l y f a i r i n e x p r e s s i n g a n g e r . However, he had d i f f i c u l t y w i t h t h e w r i t t e n p a r t o f t h e e x e r c i s e , ( w r i t i n g and s p e l l i n g p o o r ) . S t a f f Q u e s t i o n n a i r e In p e e r r e l a t i o n s h i p s , S u b j e c t 2 s c o r e d 29 i n t h e p r e t e s t and 28 i n t h e p o s t t e s t . In s t a f f r e l a t i o n s h i p s , he s c o r e d 19 i n t h e p r e t e s t and 23 i n t h e p o s t t e s t . In g e n e r a l s o c i a l b e h a v i o r , he s c o r e d 34 i n t h e p r e t e s t and 35 i n t h e p o s t t e s t , ( s e e t a b l e no. 10) The comments r e c o r d e d i n w h i c h t h e s u b j e c t had d i f f i c u l t y i n t h e p r e t e s t w e r e : r e p e t i t i v e s t o r i e s , low f r u s t r a t i o n t o l e r a n c e , and a b u s i v e a t t i t u d e . The comments on t h e p o s t t e s t w e r e : i n i t i a t i n g o u t s i d e t h e h o u s e . 110 TABLE NO. 10 STAFF QUESTIONNAIRE S u b j e c t 2 P r e P o s t P e e r r e l a t i o n s h i p 29 28 S t a f f r e l a t i o n s h i p 19 23 G e n e r a l s o c i a l b e h a v i o r 34 35 S u b j e c t 3 D u r i n g t h e b a s e l i n e p h a s e i n t h e S t a c k i n g t h e Deck p r o g r a m , S u b j e c t 3 s c o r e d b e t w e e n 5 and 8 c o r r e c t r e s p o n s e s and by game 7 was g e t t i n g 11 o f t h e 12 r e s p o n s e s c o r r e c t . In game 16 he had a p e r f e c t s c o r e . T h i s went down t o 11 i n games 17 and 18. P< = .01 ( t - t e s t s e e T a b l e No.11) In t h e b a s e l i n e p h a s e S u b j e c t 3 a v e r a g e d 5.5 words p e r r e s p o n s e . T h i s c h a n g e d s i g n i f i c a n t l y t o an a v e r a g e of 11.21 words p e r r e s p o n s e i n game 18. ( s e e T a b l e No.7) sasNo_S3_ J ,o:-nnico AO uanwnN TABLE NO. 12 112 SOCIAL SKILLS ASSESSMENT CHART SUBJECT 3 green - p r e - t e s t red - p o s t - t e s t 113 S o c i a l S k i l l s A s s e s s m e n t C h a r t (See T a b l e No.12) In q u a l i t y o f s p e e c h , d y s f 1 u e n c i e s r e c e i v e d 5 i n t h e p r e and p o s t t e s t s and h e s i t a t i o n s and p a u s e s r e m a i n e d a t 4 f o r t h e p r e and p o s t t e s t s . L a t e n c y of r e s p o n s e and amount s p o k e n r e c e i v e d a s c o r e of 3 i n t h e p r e t e s t and a s c o r e of 4 i n t h e p o s t t e s t . In v o i c e q u a l i t y , c l a r i t y and r a t e r e m a i n e d a t 5 f o r b o t h t e s t s . Volume r e c e i v e d 4 i n t h e p o s t t e s t and 5 i n t h e p r e t e s t w h i l e t o n e and p i t c h r e m a i n e d a t 4 f o r b o t h t e s t s . In n o n - v e r b a l r e s p o n s e s , head movements r e c e i v e d a s c o r e o f 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . S m i l i n g and l a u g h t e r r e c e i v e d 3 i n t h e p r e t e s t and 4 i n t h e p o s t t e s t . F i d d l i n g movements r e m a i n e d a t 5 f o r b o t h t e s t s . In b a s i c c o n v e r s a t i o n s k i l l s , t h e l e n g t h of r e p l y t o q u e s t i o n s r e m a i n e d t h e same a t 3 f o r b o t h t h e p r e and p o s t t e s t s . W h i l e i n f o r m a t i o n c o n t e n t , f r e q u e n c y o f q u e s t i o n a s k i n g , and f r e q u e n c y of i n i t i a t i o n s were s c o r e d as 2 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t . In l i s t e n i n g s k i l l s , a c k n o w l e d g e m e n t s r e c e i v e d 3 i n t h e p r e t e s t and 4 i n t h e p o s t t e s t . R e f l e c t i o n s were s c o r e d as 1 i n t h e p r e t e s t and 4 i n t h e p o s t t e s t . Q u e s t i o n - t y p e f e e d b a c k and p e r s o n s e 1 f - d i s c 1 o s u r e s s c o r e d 3 i n t h e p r e t e s t s and 4 i n t h e p o s t t e s t s . In c o n t e n t of s p e e c h , r e l e v a n c y of c o n v e r s a t i o n and 114 i n t e r e s t c o n t e n t r e c e i v e d 4 i n t h e p r e t e s t s and 5 i n p o s t t e s t s . I n t e r r u p t i o n s r e m a i n e d a t 4 f o r b o t h t e s t s . R e p e t i t i o n s s c o r e d 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . R e s p o n s e s i n " S t a c k i n g t h e Deck" The r e s p o n s e s t o t h e s i t u a t i o n c a r d s i n t h e S t a c k i n g t h e Deck p r o g r a m i m p r o v e d w i t h i n t e r v e n t i o n . Some e x a m p l e s o f t h i s f o l l o w . You a r e t a l k i n g t o a r e s i d e n t who has a memory p r o b l e m , and t h e y a s k y o u what y o u a r e m a k i n g i n a r t . T h i s p e r s o n a s k e d y o u t h e same q u e s t i o n y e s t e r d a y . What do y o u s a y ? 1. " Y o u r memory's bad and I t h i n k y o u ' r e d e a f t o o . " 2. " E x c u s e me b u t y o u a s k e d me t h e same q u e s t i o n y e s t e r d a y do y o u mind w r i t i n g i t down so y o u won't f o r g e t i t . " 3. " E x c u s e me y o u a s k e d me t h e same q u e s t i o n y e s t e r d a y , why d o n ' t y o u w r i t e i t down so y o u won't f o r g e t . " You a r e o u t on an a c t i v i t y and a n o t h e r r e s i d e n t l o o k i n g a t a g i r l w a l k i n g down t h e s t r e e t s a y s , "She's n o t bad l o o k i n g f o r a f a t p e r s o n . " What do y o u s a y ? 1. " Y o u ' r e b l i n d " . 115 2. " Y o u ' r e n o t bad l o o k i n g f o r a s k i n n y k i d . " 3. " I w o u l d t e l l h im n o t t o be so b l o o d y r u d e " . 4. " B e a u t y d o e s n ' t go i n s i z e s . " You a r e w a t c h i n g TV and y o u r roommate comes i n and c h a n g e s t h e c h a n n e l . What do y o u s a y ? 1. " P u n c h him i n t h e f a c e " . 2. " E x c u s e me I was w a t c h i n g t h a t show do y o u mind t u r n i n g i t b a c k ? " 3. " E x c u s e me b u t 1 was w a t c h i n g t h a t show." 4. " I was w a t c h i n g t h a t show do y o u mind t u r n i n g i t b a c k ? " A r e s i d e n t r e p e a t e d l y a s k s y o u t o g e t h i s c i g a r e t t e s f o r him. You know he c a n g e t them h i m s e l f . What do y o u s a y ? 1. " E x c u s e me b u t do y o u have a p i a n o t i e d t o y o u a s s . " 2. " I know y o u c a n g e t them y o u r s e l f so why d o n ' t y o u g e t them y o u r s e l f . " S u b j e c t 3 a p p e a r e d t o e n j o y t h e game f o r m a t . He was a l w a y s t h e f i r s t t o a r r i v e . He c o - o p e r a t e d i n t h e game by m o v i n g game p i e c e s f o r o t h e r p l a y e r s and he h e l p e d s e t t h e game up and and he h e l p e d p u t t h e game away a t t h e end of t h e s e s s i o n s . 116 S t r u c t u r e d L e a r n i n g A s s i g n m e n t s S u b j e c t 3 p a r t i c i p a t e d i n 3 s t r u c t u r e d l e a r n i n g a s s i g n m e n t s . He f o l l o w e d t h e l e a r n i n g p o i n t s i n e v a l u a t i n g o t h e r s and i n h i s own r o l e p l a y . In t h e b e g i n n i n g he had d i f f i c u l t y w i t h t h e r o l e p l a y and p r o v i d i n g e x a m p l e s f o r s t a r t i n g a c o n v e r s a t i o n . However by t h e s e c o n d s e s s i o n he p r o v i d e d many e x a m p l e s and had no d i f f i c u l t y s t a r t i n g , c a r r y i n g on o r e n d i n g a c o n v e r s a t i o n . T h i s was t h e same f o r r e s p o n d i n g t o and e x p r e s s i n g a n g e r . He a l w a y s r a t e d h i s p e r f o r m a n c e as good. S t a f f Q u e s t i o n n a i r e T h e r e was no ch a n g e i n p e e r r e l a t i o n s h i p s t h e y r e m a i n e d a t 32 f o r t h e p r e and p o s t t e s t s . He s c o r e d 23 i n t h e p r e t e s t f o r s t a f f r e l a t i o n s h i p s and 27 f o r t h e TABLE NO.13 STAFF QUESTIONNAIRE S u b j e c t 3 p r e p o s t P e e r r e l a t i o n s h i p s S t a f f r e l a t i o n s h i p s G e n e r a l s o c i a l b e h a v i o r 32 23 36 32 27 36 117 p o s t t e s t . The g e n e r a l s o c i a l b e h a v i o u r r e m a i n e d a t 36 i n t h e p r e and p o s t t e s t s . The comments on t h e p r e t e s t w h i c h i d e n t i f i e d s o c i a l s i t u a t i o n s i n w h i c h t h e s u b j e c t had d i f f i c u l t y w e r e : a s s e r t 1 v e n e s s , and h a n d l i n g c o n f l i c t . A s s e r t i v e n e s s and i n i t i a t i n g o u t s i d e t h e house were r e p o r t e d as d i f f i c u l t a r e a s i n t h e p o s t t e s t . S u b j e c t 4 S u b j e c t 4 s c o r e d b e t w e e n 8 and 10 d u r i n g t h e b a s e l i n e p h a s e . T h i s went up t o 11 i n games 6,7 and 8 and up t o 12 i n games 9 and 10. The number o f c o r r e c t r e s p o n s e s d r o p p e d t o 6 i n game i i and r o s e t o 12 i n games 12 and 13. P< = .01 ( s e e T a b l e N o . 1 4 ) . The a v e r a g e number o f words p e r s i t u a t i o n d u r i n g t h e b a s e l i n e p h a s e was 4 and i n game 13 t h e a v e r a g e number o f words p e r r e s p o n s e was 8.7 ( s e e T a b l e N o . 7 ) . S o c i a l S k i l l s A s s e s s m e n t C h a r t ( s e e T a b l e No.15) In t h e q u a l i t y of s p e e c h , d y s f l u e n c i e s r e m a i n e d a t 5 f o r b o t h t h e p r e and p o s t t e s t s . L a t e n c y o f r e s p o n s e , h e s i t a t i o n s and p a u s e s , and amount s p o k e n r e m a i n e d a t 4 f o r b o t h t h e p r e and p o s t t e s t s . In v o i c e q u a l i t y , c l a r i t y and r a t e were s c o r e d a t 5 TABLE 15 P L A Y E R PROGRESS GRAPH S U B J E C T 4 o CD CO T CO — r CM sasNOdsan j - o a m i o o J O uamMDN 119 TABLE NO. 15 SOCIAL SKILLS ASSESSMENT CHART SUBJECT 4 green - p r e - t e s t red - p o s t - t e s t 120 i n b o t h t h e p r e and p o s t t e s t s . Volume was s c o r e d a t 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . Tone and p i t c h r e m a i n e d a t 4 i n b o t h t e s t s . In n o n - v e r b a l r e s p o n s e s , h e a d x movements and f i d d l i n g movements r e m a i n e d a t 5 i n b o t h t h e p r e and p o s t t e s t s . S m i l i n g and l a u g h t e r r e m a i n e d a t 4 i n b o t h t h e p r e and p o s t t e s t s . In b a s i c n o n - v e r b a l s k i l l s , f a c i a l e x p r e s s i o n r e m a i n e d a t 4 i n b o t h t h e p r e and p o s t t e s t s . P o s t u r e was s c o r e d as 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . G e s t u r e s r e c e i v e d 5 i n b o t h t e s t s . Eye c o n t a c t was s c o r e d a s 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . In b a s i c c o n v e r s a t i o n s k i l l s , l e n g t h o f r e p l y t o q u e s t i o n s , i n f o r m a t i o n c o n t e n t , and f r e q u e n c y o f q u e s t i o n a s k i n g were s c o r e d a t 3 f o r b o t h p r e and p o s t t e s t s . F r e q u e n c y of i n i t i a t i o n s r e c e i v e d 2 i n t h e p r e t e s t and 3 i n t h e p o s t t e s t . In l i s t e n i n g s k i l l s , a c k n o w l e d g e m e n t s , q u e s t i o n - t y p e f e e d b a c k and p e r s o n a l se 1 f - d i s c 1 o s u r e s , were s c o r e d as 3 i n t h e p r e t e s t and 4 i n t h e p o s t t e s t . R e f l e c t i o n s were r e c o r d e d as 1 i n p r e t e s t and 4 i n t h e p o s t t e s t . In t h e c o n t e n t o f s p e e c h , r e l e v a n c y o f c o n v e r s a t i o n , and i n t e r e s t ' c o n t e n t were r e c o r d e d as 3 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . I n t e r r u p t i o n s 121 r e m a i n e d a t 4 i n b o t h t h e p r e and p o s t t e s t s . R e p e t i t i o n s r e c e i v e d 4 i n t h e p r e t e s t and 5 i n t h e p o s t t e s t . S t a f f Q u e s t i o n n a i r e In p e e r r e l a t i o n s h i p s S u b j e c t 4 s c o r e d 27 i n t h e p r e t e s t and 28 i n t h e p o s t t e s t . In s t a f f r e l a t i o n s h i p s , he s c o r e d 22 i n t h e p r e t e s t and 21 i n t h e p o s t t e s t . In g e n e r a l s o c i a l b e h a v i o u r he r e c e i v e d 34 i n t h e p r e t e s t and 33 i n t h e p o s t t e s t . TABLE NO.16 STAFF QUESTIONNAIRE S u b j e c t 4 p r e p o s t P e e r r e l a t i o n s h i p 27 28 S t a f f r e l a t i o n s h i p 22 21 G e n e r a l s o c i a l b e h a v i o r 34 33 The s o c i a l s i t u a t i o n s i n w h i c h S u b j e c t 4 had 122 d i f f i c u l t y w i t h i n t h e p r e t e s t were r e p o r t e d as j u d g m e n t a l , d i s t r u s t i n g , and r e l a t e s p o o r l y t o women. The r e m a r k s i n t h e p o s t t e s t were i n t e r f e r e n c e w i t h o t h e r s and s a r c a s m . S u b j e c t 4 a n s w e r e d most q u e s t i o n s c o r r e c t l y e v e n i n t h e b a s e l i n e . The more s i g n i f i c a n t r e s u l t s i n t h i s c a s e were t h e number of words s p o k e n p e r r e s p o n s e . In t h e b a s e l i n e r e s p o n s e t h e number of words f o r e a c h r e s p o n s e was v e r y l i m i t e d . Many of t h e r e s p o n s e s were two o r t h r e e words ( " I a g r e e . " "Get i t y o u r s e l f . " " I t r i e d . " Thank y o u . " " Y o u r welcome." "Thank t h e c o o k . " " T e l l him".) However, l a t e r I n t h e i n t e r v e n t i o n s e n t e n c e s became l o n g e r . The r e s p o n s e t o some o f t h e s i t u a t i o n s f o l l o w s . A n o t h e r r e s i d e n t t e l l s y o u t h a t he f e l l t h i s m o r n i n g and h u r t h i s l e g . What do y o u s a y ? He r e p l i e d , " S o r r y t o h e a r t h a t I hope y o u r l e g i s b e t t e r . " You a r e i n a r e s t a u r a n t and t h e p e r s o n y o u a r e w i t h t e l l s t h e w a i t r e s s t h a t she i s b e a u t i f u l . What do you s a y ? He r e p l i e d , "Would y o u mind k e e p i n g y o u r comments t o y o u r s e I f . " A r e s i d e n t r e p e a t e d l y a s k s y o u t o g e t h i s c i g a r e t t e s f o r him. You know he c a n g e t them h i m s e l f . What do you s a y ? He r e p l i e d , " I w o u l d be more t h a n happy t o g e t them b u t p l e a s e i n t h e f u t u r e g e t them y o u r s e I f . " 123 However i n game 11 S u b j e c t 4 r e p l i e d t o t h i s s i t u a t i o n I n c o r r e c t l y . Someone i s w e a r i n g a new s h i r t t h a t y o u do n o t l i k e . He a s k s y o u how y o u l i k e h i s new s h i r t . What do y o u s a y ? He r e p l i e d , "Thank y o u " and o n l y a n s w e r e d one more q u e s t i o n c o r r e c t l y i n t h i s game. As a r e s u l t h i s s c o r e was 6. T h i s i s an e x c e l l e n t e x a m p l e o f t h e a d v a n t a g e o f a i m m e d i a t e e v a l u a t i o n t h a t i s i n v o l v e d i n t h e s i n g l e s y s t e m d e s i g n . I t i s e v i d e n t t h a t t h i s s c o r e i s v e r y d i f f e r e n t f r o m a l l h i s o t h e r s c o r e s . As m e n t i o n e d p r e v i o u s l y , t h i s d e s i g n c a n n o t c o n t r o l i n t e r v e n i n g v a r i a b l e s b u t i t does s u g g e s t t h a t s o m e t h i n g u n u s u a l i s h a p p e n i n g . The f i r s t t h o u g h t was t h a t he was b o r e d w i t h t h e game and d i d n o t want t o p l a y any more. However, he s t a r t e d t h i s s e s s i o n v e r y k e e n and w i l l i n g t o p a r t i c i p a t e . He e v e n j o k e d a t t h e b e g i n n i n g o f t h e game s a y i n g whoever won t h e gum had t o s h a r e i t w i t h a l l t h e o t h e r s . He a l s o r e t u r n e d f o r two more games a f t e r t h i s s e s s i o n and r e c e i v e d p e r f e c t s c o r e s . T h e r e f o r e , h i s c o n t i n u e d p a r t i c i p a t i o n and r e s u l t i n g s c o r e s d i s c o u n t s t h i s t h e o r y o f boredom. I m m e d i a t e l y a f t e r t h i s s e s s i o n I c h e c k e d w i t h t h e house s t a f f t o s e e i f a n y t h i n g u n u s u a l was h a p p e n i n g w i t h S u b j e c t 4 . They r e v e a l e d t h a t he had been e x p e c t i n g a l a r g e i n s u r a n c e s e t t l e m e n t f r o m h i s a c c i d e n t 124 and t h a t he had j u s t r e c e i v e d word e a r l i e r t h a t m o r n i n g t h a t t h e r e was t o be no s e t t l e m e n t . C o n s e q u e n t l y he was r a t h e r "down" and t h i s may have i n f l u e n c e d h i s b e h a v i o r i n t h e game. S u b j e c t 4 a l s o e x p r e s s e d a g r e a t d e a l o f d e n i a l . He b e l i e v e d t h a t h i s s o c i a l s k i l l s were j u s t f i n e . He a l s o b e l i e v e d t h a t he was more i n t e l l i g e n t t h a n t h e o t h e r s i n t h e g r o u p . The o t h e r p l a y e r s e x p l a i n e d t o him t h a t i t was n o t h i s s h i r t t h a t t h e q u e s t i o n was t a l k i n g a b o u t and b e i n g c o r r e c t e d by them may have been d i f f i c u l t f o r him t o a c c e p t . The b e h a v i o r o f S u b j e c t 4 may have been t h e r e s u l t of a l l o r any of t h e s e f a c t o r s and any o t h e r f a c t o r s t h a t a r e known o n l y t o him. However, t h e a d v a n t a g e o f t h e s i n g l e s y s t e m d e s i g n i s t h a t i t i m m e d i a t e l y i d e n t i f i e s any ch a n g e i n t h e d e p e n d e n t v a r i a b l e and f u r t h e r i n v e s t i g a t i o n and i n t e r v e n t i o n c a n be made a c c o r d i n g 1y. 125 C h a p t e r 6 I m p l i c a t i o n s and C o n c l u s i o n s The t a s k now i s t o l o o k a t t h e r e s u l t s of t h i s s t u d y as t h e y r e l a t e t o t h e o b j e c t i v e s s p e c i f i e d i n C h a p t e r 2 on R e s e a r c h P r o b l e m s . The o b j e c t i v e s were t o e n h a n c e t h e s e n d i n g and r e c e i v i n g s k i l l s o f head i n j u r e d a d u l t s i n s i x a r e a s ; c o m p l i m e n t s , s o c i a l i n t e r a c t i o n , p o l i t e n e s s , c r i t i c i s m , s o c i a l c o n f r o n t a t i o n and q u e s t i o n s and a n s w e r s . T h i s e v a l u a t i o n was t o c o n s i d e r t h e p r o b l e m s t h a t head i n j u r e d p e o p l e have w i t h s o c i a l i n t e r a c t i o n , t h e u s e f u l n e s s of s o c i a l s k i l l s t r a i n i n g w i t h t h i s p o p u l a t i o n , t h e u s e f u l n e s s o f t h e m o d i f i e d " s t a c k i n g t h e d e c k " p r o g r a m , and l i m i t a t i o n s and i m p l i c a t i o n s f o r f u r t h e r r e s e a r c h . S e n d i n g and R e c e i v i n g S k i l l s E a c h s u b j e c t c l e a r l y e n h a n c e d h i s s e n d i n g and r e c e i v i n g s k i l l s as s p e c i f i e d i n t h e " s t a c k i n g t h e d e c k " p r o g r a m and e a c h was a b l e t o o b t a i n a p e r f e c t s c o r e . 126 P r o b l e m s o f S o c i a l I n t e r a c t i o n T h i s i n t e r v e n t i o n was s u c c e s s f u l i n d e a l i n g w i t h some b e h a v i o r a l and p e r s o n a l i t y p r o b l e m s a s s o c i a t e d w i t h head i n j u r y . I n i t i a t i o n was i n c r e a s e d i n t h e c a s e o f S u b j e c t 1 as h i s r e s p o n s e t i m e was r e d u c e d f r o m 29.15 s e c o n d s t o 2.47 s e c o n d s . The i n c r e a s e i n t h e number of words p e r r e s p o n s e may a l s o be an i n d i c a t i o n of i n c r e a s e d i n i t i a t i o n on t h e p a r t o f a l l s u b j e c t s . P a r t i c i p a t i o n m i g h t be u s e d as an i n d i c a t i o n o f m o t i v a t i o n . A t t e n d a n c e was v o l u n t a r y and i n a l l c a s e s s u b j e c t s came t o a l l s e s s i o n s w i t h t h e e x c e p t i o n o f S u b j e c t 4 who had a j o b t r a i n i n g p r o g r a m t h a t c o n f l i c t e d w i t h t h i s s t u d y on t h r e e o c c a s i o n s . However, S u b j e c t 4 made e v e r y e f f o r t t o a t t e n d when he c o u l d . H i s r e t u r n a f t e r h i s p o o r p e r f o r m a n c e i n game 11 may be f u r t h e r i n d i c a t i o n o f h i s m o t i v a t i o n t o c o n t i n u e w i t h t h e t r e a t m e n t . The game f o r m a t w o r k e d w e l l i n m a i n t a i n i n g t h e a t t e n t i o n o f e a c h s u b j e c t . T h i s was e v i d e n t as e a c h p e r s o n n o t o n l y p a i d a t t e n t i o n d u r i n g h i s t u r n b u t a l s o r e m a i n e d a t t e n t i v e t h o u g h o u t t h e game. They w a t c h e d e a c h o t h e r ' s moves and c o u n t e d s p a c e s moved t o make s u r e no c h e a t i n g was i n v o l v e d . T h i s s t u d y a t t e m p t e d t o r e d u c e t h e s e l f 127 c e n t e r e d n e s s t h a t i s o f t e n a s s o c i a t e d w i t h head i n j u r y . T h i s was t o be a c c o m p l i s h e d by e n c o u r a g i n g c o - o p e r a t i o n . C o - o p e r a t i o n was d i s p l a y e d as t h e s u b j e c t s a s s i s t e d i n m o v i n g t h e o t h e r p l a y e r ' s game p i e c e a t t i m e s . C o - o p e r a t i o n was a l s o d i s p l a y e d i n p u t t i n g t h e game away and i n t h e s h a r i n g o f t h e r e w a r d a t t h e end of t h e game. The i n t e r v e n t i o n p r o v i d e d an e q u a l s o c i a l o p p o r t u n i t y f o r a l l s u b j e c t s . They seemed t o e n j o y t h e game f o r m a t and e x p r e s s e d a p p r e c i a t i o n o f t h e p r o g r a m a t our l a s t s e s s i o n and m i g h t have c o n t i n u e d t o p l a y i n d e f i n i t e l y . Two s u b j e c t s i n v o l v e d i n t h e p i l o t t e s t i n g were most w i l l i n g t o p a r t i c i p a t e and e v e n a s k e d on d i s c h a r g e i f t h e y were g o i n g t o p l a y t h e game any more. T h i s was p a r t i c u l a r l y i n t e r e s t i n g b e c a u s e t h e y were n a t i v e I n d i a n and t h e " S t a c k i n g t h e Dec k " p r o g r a m r e f l e c t e d w h i t e m i d d l e c l a s s v a l u e s . A l t h o u g h t h e s i t u a t i o n c a r d s and e x p e c t e d r e s p o n s e s r e f l e c t e d a w h i t e m i d d l e c l a s s e n v i r o n m e n t , t h e y c o u l d be e a s i l y a d a p t e d t o r e p r e s e n t any c u l t u r e . I t i s i m p o r t a n t t o be aware o f t h e s u b j e c t ' s c u l t u r e b e c a u s e t h e p u r p o s e o f t h e i n t e r v e n t i o n i s t o a s s i s t w i t h t h e r e i n t e g r a t i o n o f t h e head i n j u r e d p e r s o n i n t o h i s / h e r f a m i l y and communi t y . However, i t a p p e a r s t h a t t h e game f o r m a t p r o v i d e d a d e s i r a b l e s o c i a l i n t e r a c t i o n . 128 D e n i a l has been i d e n t i f i e d as one of t h e b i g g e s t b l o c k s t o s u c c e s s f u l r e h a b i l i t a t i o n o f t h e t r a m a t i c a l l y head i n j u r e d p e r s o n . S u b j e c t 4 e x p r e s s e d t h e most d e n i a l and he b e l i e v e d t h a t he f u n t i o n e d b e t t e r t h a n t h e o t h e r p a r t i c i p a n t s . However, h i s s c o r e s p r o v e d t h i s t o be o t h e r w i s e . T h i s c o n f r o n t a t i o n w i t h r e a l i t y may have been d i s t u r b i n g t o him and h e n c e h i s p o o r e r s h o w i n g on t h e S t a f f Q u e s t i o n n a i r e . The a d v a n t a g e o f t h e i n t e r v e n t i o n i s t h a t i t r e a d i l y i n d i c a t e d t h a t o t h e r v a r i a b l e s may be o p e r a t i n g and t h e r e f o r e s t e p s c a n be t a k e n t o a d d r e s s them. The i n t e r v e n t i o n p r o v i d e d t h e o p p o r t u n i t y f o r p r o b l e m s o l v i n g b u t t h e r e was no d i r e c t m easure t o i n d i c a t e t h a t t h e s u b j e c t s a c t u a l l y i m p r o v e d i n t h i s s p e c i f i c s k i l l . However, a l l s u b j e c t s ' r e s p o n s e s t o t h e s i t u a t i o n c a r d s i m p r o v e d i n c o m p l e x i t y and no s u b j e c t p r o v i d e d a r o t e r e s p o n s e . S u b j e c t 2 and S u b j e c t 3 b e g a n t o u s e t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s t o a d d r e s s t h e i r p r o b l e m a t i c i s s u e s , s u c h as how t o c o m p l a i n t o a s t a f f p e r s o n a b o u t t h e c h o i c e of a r e s t a u r a n t f o r a d i n n e r o u t i n g . I t was assumed t h a t an i n c r e a s e i n p e r f o r m a n c e w o u l d l e a d t o an i n c r e a s e i n s e l f - e s t e e m . The s u b j e c t s i n d i c a t e d t h a t t h e y were p r o u d of t h e i r i m p r o v e m e n t i n t h e i r s c o r e s . The p e r s o n a l g o a l f o r e v e r y o n e was t o 129 a n s w e r a l l t h e s i t u a t i o n s c o r r e c t l y . C o n s e q u e n t l y t h e r e c o r d i n g and d i s p l a y o f t h e i n d i v i d u a l ' s p r o g r e s s ( p r o g r e s s c h a r t s and p r a i s e ) may have i n c r e a s e d t h e s u b j e c t ' s s e l f - e s t e e m ( t h i s i s assumed as t h e r e i s no d i r e c t m e a sure of t h i s ) . T h i s a p p e a r e d t o have w o r k e d t o t o l e s s e n d e p r e s s i o n t h a t i s a s s o c i a t e d w i t h head i n j u r y as a l l s u b j e c t s were e a g e r and c h e e r f u l t h r o u g h o u t t h e game. E v e n S u b j e c t 4 came bac k c h e e r f u l and w i l l i n g t o c o n t i n u e w i t h t h e i n t e r v e n t i o n a f t e r h i s p o o r s h o w i n g i n game 11. In summary t h i s i n t e r v e n t i o n a d d r e s s e d t h e p r o b l e m s of s o c i a l i n t e r a c t i o n a s s o c i a t e d w i t h head i n j u r y name 1 y ; s o c i a 1 i s o l a t i o n , d e n i a l , l o s s o f s e l f e s t e e m , d e c r e a s e d a b i l i t y f o r p r o b l e m s o l v i n g and an i n c r e a s e i n e g o - c e n t r i c i t y . U s e f u l n e s s o f S o c i a l S k i l l s T r a i n i n g The i d e a o f s o c i a l s k i l l s t r a i n i n g f o r t h e head I n j u r e d a d u l t i s e x c i t i n g b e c a u s e t h e n e e d i s so g r e a t . However, t h e t r a i n i n g must show some c h a n c e of s u c c e s s o r c a r r y o v e r i f i t i s t o be of v a l u e . In t h i s s t u d y e a c h s u b j e c t s i g n i f i c a n t l y i n c r e a s e d h i s s o c i a l s k i l l s r e p e r t o i r e . They were a b l e t o a c t o r r e a c t t o e a c h of t h e s i x s k i l l a r e a s . However, k n o w i n g t h e a p p r o p r i a t e s o c i a l s k i l l d oes n o t n e c e s s a r i l y mean 130 t h e s e s k i l l s w i l l be u s e d i n t h e n a t u r a l s e t t i n g . The S o c i a l S k i l l s A s s e s s m e n t C h a r t i n d i c a t e d t h a t t h e r e was i m p r o v e m e n t i n many s k i l l s . B u t t h e g e n e r a l i z a t i o n o f many S o c i a l S k i l l s T r a i n i n g p r o g r a m s i s q u e s t i o n a b l e as p r e v i o u s l y m e n t i o n e d and t h i s s t u d y r a i s e d s i m i l a r d o u b t s . E v e n t h o u g h t h e S o c i a l S k i l l s C h a r t i n d i c a t e d t h a t t h e r e was i m p r o v e m e n t one week a f t e r i n t e r v e n t i o n t h i s i s a v e r y l i m i t e d f o l l o w up. A more e x t e n s i v e f o l l o w up i s n e c e s s a r y t o e n s u r e g e n e r a l i z a t i o n . S i m i l a r l y , S p e n c e (1984) and McMorrow e t a l l ( 1 9 8 6) had d i f f i c u l t y w i t h g e n e r a l i z a t i o n i n t h e i r s t u d i e s . T h e r e f o r e t h e weak g e n e r a l i z a t i o n may be t h e r e s u l t of t h i s p a r t i c u l a r i n t e r v e n t i o n b u t i t may a l s o be r e l a t e d t o a w e a k n e s s o f s o c i a l s k i l l s t r a i n i n g i n g e n e r a l . T h i s w e a k n e s s i n g e n e r a l i z a t i o n may i n d i c a t e a need f o r c o n t i n u e d i n t e r v e n t i o n . I t may be n e c e s s a r y t o i n c o r p o r a t e t h e i n t e r v e n t i o n i n t o t h e r e g u l a r r o u t i n e o f t h e head i n j u r e d p e r s o n . E x a m p l e s o f t h i s c o n t i n u e d i n t e r v e n t i o n a r e d i s c u s s e d l a t e r u n d e r i m p l i c a t i o n s f o r p r a c t i c e . O t h e r p r o b l e m s r e l a t i n g t o g e n e r a l i z a t i o n s o f b e h a v i o r e x p e r i e n c e d i n t h i s s t u d y may be r e l a t e d t o t h e s e l f - f u l f i l l i n g p r o p h e c y . I t i s n e c e s s a r y t o e x p l a i n t h i s c o n c e p t b r i e f l y and how i t may be r e l a t e d h e r e . The s e l f - f u l f i l l i n g p r o p h e c y , by w h i c h p e o p l e a c t 131 as t h e y a r e e x p e c t e d t o , has been d o c u m e n t e d i n many d i f f e r e n t s i t u a t i o n s . In t h e i r "Oak S c h o o l " e x p e r i m e n t ( R o s e n t h a l & J a c o b s o n , 1 9 6 8 ) , s o m e t e a c h e r s were t o l d a t t h e b e g i n n i n g o f t h e t e r m t h a t some o f t h e i r p u p i l s had shown u n u s u a l p o t e n t i a l . However, t h e s e " b l o o m e r s " had a c t u a l l y been c h o s e n a t random. S e v e r a l months l a t e r t h e s e c h i l d r e n showed u n u s u a l g a i n s i n IQ. and t h e t e a c h e r s seemed t o l i k e t h e " b l o o m e r s " b e t t e r . R o s e n t h a l and J a c o b s o n b e l i e v e t h a t t h e s t u d e n t s i m p r o v e d b e c a u s e t h e t e a c h e r s e x p e c t e d them t o o . T h i s p r i n c i p a l c a n a l s o work i n a n e g a t i v e way. The s e l f - f u l f i l l i n g p r o p h e c y c a n a c t n e g a t i v e l y i n t h i s s t u d y i f t h e s t a f f e v a l u a t i o n and c o r r e s p o n d i n g i n t e r a c t i o n s were b a s e d on t h e b e h a v i o r e x p e c t e d . S i m i l a r l y i n t h i s v e i n , I was t o l d t h a t S u b j e c t 1 was n o t s u i t a b l e f o r t h i s s t u d y b e c a u s e he w o u l d n o t be a b l e t o p a r t i c i p a t e . In t a l k i n g w i t h h i s mother a f t e r game 15, she was amazed by h i s p e r f o r m a n c e and i n d i c a t e d t h a t she t o o had d o u b t s a b o u t h i s a b i l i t i e s t o p a r t i c i p a t e . The p o i n t h e r e i s t h a t p e o p l e w i t h head i n j u r i e s may be e x c l u d e d f r o m p r o g r a m s b e c a u s e t h e y a r e p e r c e i v e d as i n c a p a b l e . I t must be e m p h a s i z e d t h a t t h e s o c i a l s k i l l s i n t h i s s t u d y were l e a r n e d t h r o u g h c o n s t a n t r e p e t i t i o n i n b o t h t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s and i n t h e game. 132 U s e f u l n e s s o f M o d i f i e d " S t a c k i n g t h e Deck" P r o g r a m As p r e v i o u s l y m e n t i o n e d , t h e game f o r m a t was u s e f u l b e c a u s e i t a d d r e s s e d t h e s p e c i f i c n e e d s o f t h e head i n j u r e d p e r s o n ; p r o b l e m s i n m a i n t a i n i n g a t t e n t i o n , l a c k of i n i t i a t i o n , d e n i a l , d e p r e s s i o n , low s e 1 f - e s t e e m , 1 a c k of o p p o r t u n i t i e s f o r s o c i a 1 i z a t i o n , a n d d e c r e a s e d a b i l i t y i n p r o b l e m s o l v i n g . The f a i l u r e of many s o c i a l s k i l l s t r a i n i n g p r o g r a m s t o r e p o r t g r e a t e r g e n e r a l i z a t i o n o f b e h a v i o r s i s a r e s u l t o f t h e l a c k o f s i m i l a r i t y b e t w e e n t h e t r a i n i n g and t h e n a t u r a l s e t t i n g ( F o x x e t a l , 1 9 8 3 ) . A l t h o u g h t h i s p r o g r a m u s e d a n a l o g u e s i t u a t i o n s , t h e n a t u r e o f t h e t a b l e game i t s e l f s i m u l a t e d r e a l l i f e s i t u a t i o n s and e n c o u r a g e d p e e r i n t e r a c t i o n , c o - o p e r a t i o n , c o m p e t i t i o n and p r o b l e m s o l v i n g . P e e r i n t e r a c t i o n was e v i d e n t as t h e s u b j e c t s c o n g r a t u l a t e d e a c h o t h e r on a good r e s p o n s e and l a u g h e d when a c o r r e c t c o m p l e x r e s p o n s e o n l y r e c e i v e d one o r two p o i n t s . The e n c o u r a g i n g r e s u l t s of t h i s s t u d y a r e n o t t h e o n l y a d v a n t a g e s o f t h i s p r o g r a m . O t h e r a d v a n t a g e s a r e : 1) t h e a v a i l a b i l i t y o f s t a n d a r d i z e d t r a i n i n g p r o c e d u r e s 2) t h e c o s t e f f i c i e n c y o f g r o u p t r a i n i n g i n t h a t i t o n l y r e q u i r e s one p e r s o n t o do t h e t r a i n i n g and t h r e e o r f o u r i n d i v i d u a l s c a n be t r a i n e d a t one t i m e . 133 3) t h e u s e of a t r a i n i n g s e s s i o n t h a t a p p r o x i m a t e s a n a t u r a l e n v i r o n m e n t 4) t h e a b i l i t y t o t r a i n i n d i v i d u a l s t h a t have v a s t l y d i f f e r e n t s k i l l l e v e l s a t one t i m e . The a s s e s s m e n t a s p e c t of t h e p r o g r a m ( b a s e l i n e ) was u s e f u l b e c a u s e i t p r o v i d e d a s t a n d a r d w i t h w h i c h t o m e a sure i m p r o v e m e n t . C o n s e q u e n t l y c h a n g e s i n b e h a v i o r c o u l d be i m m e d i a t e l y n o t e d as i n t h e c a s e of S u b j e c t 4. I t was u s e f u l f o r i n d i c a t i n g c o g n i t i v e p r o b l e m s t h a t may have been d e n i e d o r n o t r e a d i l y a p p a r e n t as d e m o n s t r a t e d w i t h s u b j e c t 4 and t h e q u e s t i o n of t h e s h i r t . The i n t e r v e n t i o n c a n be s u c c e s s f u l w i t h " l o w e r f u n c t i o n i n g " p e o p l e i f q u e s t i o n s a r e r e p e a t e d and t h e s u b j e c t i s g i v e n t i m e t o r e s p o n d as i n t h e c a s e of S u b j e c t 1. L i m i t a t i o n s o f S t u d y T h i s s t u d y e m p l o y e d t h e s i n g l e s y s t e m d e s i g n and c o n c l u s i o n s a r e l i m i t e d b e c a u s e of t h e l i m i t s o f t h e d e s i g n . However, t h e r e p l i c a t i o n s (4 c a s e s w i t h s i m i l a r r e s u l t s ) s t r e n g t h e n t h e g e n e r a l i z a t i o n o f t h e f i n d i n g s . The i n t e r v e n t i o n d i d i n c r e a s e t h e s o c i a l s k i l l s o f a l l f o u r s u b j e c t s . 134 The g e n e r a l i z a t i o n m e a s u r e s a r e weak b e c a u s e t h e r e was o n l y one f o l l o w up measure one week a f t e r t r e a t m e n t . The two m e a s u r e s ( S o c i a l S k i l l s A s s e s s m e n t C h a r t & S t a f f Q u e s t i o n n a i r e ) u s e d t o a s s e s s t h e g e n e r a l i z a t i o n s s h o u l d have s t r e n g t h e n e d t h e f i n d i n g s b u t t h e a p p l i c a t i o n and t h e u s e of t h e S t a f f Q u e s t i o n n a i r e i t s e l f i s q u e s t i o n a b 1 e . I m p l i c a t i o n s f o r P r a c t i c e The f a v o u r a b l e r e s u l t s s u g g e s t t h a t t h i s c o u l d be an e f f e c t i v e p r o g r a m f o r t e a c h i n g s o c i a l s k i l l s t o head i n j u r e d a d u l t s . The s i t u a t i o n c a r d s c o u l d be a d a p t e d t o a d d r e s s t h e s p e c i f i c d e f i c i t o f t h e i n d i v i d u a l . The c a r d s c o u l d be c h a n g e d f r e q u e n t l y t o e n s u r e m a i n t a i n e n c e of s k i l l s . The s t a f f c o u l d s u g g e s t s i t u a t i o n s f o r t h e c a r d s b a s e d on day t o day p e r f o r m a n c e o f t h e i n d i v i d u a l . I t i s d i f f i c u l t t o d e t e r m i n e why t h e s u b j e c t s b e h a v e d d i f f e r e n t l y f o r me and t h e s t a f f . I t c o u l d be t h e r e s u l t o f t h e s e l f - f u l f i l l i n g p r o p h e c y o r t h e s u b j e c t s may have r e s p o n d e d more a p p r o p r i a t e l y f o r me b e c a u s e 1 s p e n t t i m e w i t h them and demanded and e x p e c t e d c o r r e c t r e s p o n s e s . T h e r e f o r e i n o r d e r t o e n s u r e t h a t t h e s k i l l s a r e m a i n t a i n e d and t r a n s f e r r e d t o o t h e r s e t t i n g s i t may be n e c e s s a r y t o have t h e c o - o p e r a t i o n of t h e s t a f f . I f a l l c o n c e r n e d were t o c o n s t a n t l y r e m i n d 135 t h e head i n j u r e d p e r s o n what a p p r o p r i a t e b e h a v i o r i s e x p e c t e d and t h e n e x p e c t t h i s b e h a v i o r t o be f o r t h c o m i n g , t h e s k i l l s may be r e t a i n e d . The l e a r n i n g and m a i n t a i n i n g o f s k i l l s c o u l d be f a c i l i t a t e d by h a v i n g a l l t h e s t a f f aware of t h e i n t e r v e n t i o n and by w o r k i n g as a team t o p r a i s e o r r e w a r d good s o c i a l s k i l l s and t o n o t e i n a p p r o p r i a t e s k i l l s on a d a i l y b a s i s . The s t r u c t u r e d l e a r n i n g s e s s i o n s c o u l d be r e c o r d e d on v i d e o and e a c h p e r s o n c o u l d e v a l u a t e d t h e i r p e r f o r m a n c e a c c o r d i n g t o t h e l e a r n i n g p o i n t s . The s t r u c t u r e d l e a r n i n g a s s i g n m e n t s c a n be u s e d t o p r o v i d e a d d i t i o n a l t r a i n i n g i n a r e a s t h a t a r e p a r t i c u l a r l y weak. T h i s was p a r t i c u l a r l y e f f e c t i v e i n i m p r o v i n g t h e n o n - v e r b a l b e h a v i o r o f S u b j e c t 1. T h e s e weak a r e a s c o u l d be i d e n t i f i e d by t h e s i t u a t i o n c a r d s and by t h e s t a f f w o r k i n g w i t h t h e i n d i v i d u a l . C o n s e q u e n t l y t h i s s t u d y i n d i c a t e d t h a t t h e s t r u c t u r e d l e a r n i n g a s s i g n m e n t s c a n e n h a n c e t h e " S t a c k i n g t h e Deck" s o c i a l s k i l l s t r a i n i n g p r o g r a m . T h i s c o u p l e d w i t h t h e a p p a r e n t p a r t i c i p a n t s ' e n j o y m e n t o f t h e p r o g r a m make t h i s a d e s i r a b l e f o r m o f i n t e r v e n t i o n . I m p l i c a t i o n s f o r f u r t h e r R e s e a r c h 136 W i t h i n t h e l i m i t s o f t h e d e s i g n and s a m p l i n g method, t h i s s t u d y c o n f i r m e d t h e f i n d i n g s of t h e B r a u n 1 i n g - M c M o r r o w , L l o y d _ F r a l i s h s t u d y o f 1986. The a r e a s o f c o n t i n u i n g c o n c e r n s a r e s i m i l a r , i n t h a t t h e r e i s a n e e d f o r c o n t i n u e d s t u d y i n t h e g e n e r a l i z a t i o n and m a i n t e n a n c e o f l e a r n e d b e h a v i o r s . The r e p l i c a t i o n o f e f f e c t s i n t h i s s t u d y s u g g e s t t h a t f u r t h e r r e s e a r c h m a k i n g u s e of l a r g e g r o u p e x p e r i m e n t a l d e s i g n s t o c o n f i r m t h e e f f e c t s o f t h e i n t e r v e n t i o n a r e n e c e s s a r y . In o r d e r t o d e t e r m i n e t h e l o n g t e r m c o n s e q u e n c e s o f t h e i n t e r v e n t i o n a d d i t i o n a l o b s e r v a t i o n s o f t h e s u b j e c t ' s b e h a v i o r i n a n a t u r a l s e t t i n g c o u l d be b u i l t i n t o a f u r t h e r s t u d y and f o l l o w up o b s e r v a t i o n p e r i o d s c o u l d be i n c l u d e d . S i n c e t h e e x p l o r a t o r y - d e s c r i p t i v e d e s i g n does n o t a d d r e s s some i m p o r t a n t q u e s t i o n s , t h e r e i s a need f o r f u r t h e r r e s e a r c h t h a t w o u l d make use of o t h e r d e s i g n s . The q u e s t i o n s t h a t t h i s d e s i g n i s n o t a b l e t o a d d r e s s a r e : 1. To what e x t e n t i s t h e cha n g e a r e s u l t o f t h e i n t e r v e n t i o n ? 2. What c o m p o n e n t s i n t h e i n t e r v e n t i o n l e a d t o t h e c h a n g e ? 3. I s t h e r e s u l t i n f l u e n c e d by t h e p l a c e b o e f f e c t 137 o r t h e c h o i c e o f t h e t h e r a p i s t ? P o s s i b l e f u t u r e d e s i g n s t h a t c o u l d be u s e d a r e r e v e r s a l d e s i g n s and m u l t i p l e b a s e l i n e d e s i g n s . E x a m p l e s o f t h e s e d e s i g n s a r e d e s c r i b e d i n B l oom and F i s h e r ( 1 9 8 2) and c o n s e q u e n t l y w i l l n o t be d e s c r i b e d h e r e . T h i s s t u d y a l s o c o n f i r m e d t h a t t h e e f f e c t s o f s o c i a l s k i l l s t r a i n i n g c a n be r e l i a b l y m e a s u r e d . C o n s e q u e n t l y t h i s has i m p l i c a t i o n s t h a t c a n be g e n e r a l i z e d t o o t h e r t y p e s of i n t e r v e n t i o n a t t h e s o c i a l / b e h a v i o r a l / a f f e c t i v e l e v e l t h a t a r e u s u a l l y c o n s i d e r e d t o o d i f f i c u l t t o m e a s u re. S i m i l a r l y t h i s s t u d y d e m o n s t r a t e d t h e e a s e a t w h i c h t h e s i n g l e s y s t e m d e s i g n c a n be i n c o r p o r a t e d i n t o p r a c t i c e and t h i s has i m p l i c a t i o n s f o r t h e i n t e g r a t i o n o f r e s e a r c h and p r a c t i c e . 138 APPENDIX S o c i a l S k i l l S i t u a t i o n s NOTE: The s u g g e s t e d r e s p o n s e h e r e i s t o be u s e d a l o n g w i t h t h e c r i t e r i a f o r d e t e r m i n i n g t h e c o r r e c t r e s p o n s e ( T a b l e 2) . 1. A n o t h e r r e s i d e n t i s h a v i n g a b i r t h d a y . You l i k e t h e new s h i r t he was j u s t g i v e n . What w o u l d y o u s a y ? (C, A) T h a t ' s a n i c e l o o k i n g s h i r t . 2. Someone t e l l s y o u t h a t he l i k e s y o u r s h o e s , b u t y o u d o n ' t l i k e them y o u r s e l f . What do y o u s a y ? (C,R) Thank y o u . I do n o t r e a l l y c a r e f o r them m y s e l f . 3 . A r e s i d e n t t e l l s y o u t h a t t h e y j u s t had a w o n d e r f u l v a c a t i o n . What do y o u s a y ? ( S I , R ) T h a t ' s g r e a t . What d i d y o u do? 4. Someone t e l l s y o u t h e y d o n ' t l i k e t h e way y o u a r e s t a r i n g a t them. What do y o u s a y ? (CR.R) I am s o r r y ; I d i d n ' t r e a l i z e t h a t I was s t a r i n g . 5. You s a y s o m e t h i n g t h a t makes y o u r f r i e n d a n g r y . What s h o u l d y o u do? (SC,A) I am s o r r y y o u a r e a n g r y , b u t t h a t ' s how I f e e l a b o u t i t . 6. You a r e i n a r e s t a u r a n t and when o r d e r i n g , t h e w a i t r e s s s a y s she c a n ' t u n d e r s t a n d you. What do y o u do? (CR,R) I am s o r r y ; I w i l l r e p e a t m y s e l f . 7. You a r e b u s y t r y i n g t o g e t some work done and a n o t h e r r e s i d e n t comes up t o y o u and wants t o t a l k . What do y o u s a y ? (P,A) E x c u s e me, I need t o f i n i s h t h i s . Can we t a l k l a t e r ? 8. You have an a p p o i n t m e n t w i t h a t h e r a p i s t and when you g e t t h e r e on t i m e she i s t a l k i n g t o someone e l s e . What do y o u do? (P,A) Say, " E x c u s e me, a r e you r e a d y f o r o u r s e s s i o n ? " 9. You a r e on an a c t i v i t y w i t h an A c t i v i t y T h e r a p i s t and he s a y s i t ' s t i m e t o go b a c k t o t h e C e n t r e ( o r H o u s e ) . You want t o s t a y l o n g e r . What do you s a y ? (Q, A) I w o u l d l i k e t o s t a y l o n g e r , may we? 139 APPENDIX 10. A r e s i d e n t r e p e a t e d l y a s k s y o u t o g e t h i s c i g a r e t t e s f o r him. You know he c a n g e t them h i m s e l f . What do y o u s a y ? (CR,A) I know y o u c a n g e t them y o u r s e l f , so I w i s h y o u wouId. 11. You a r e i n a s t o r e and ne e d t o f i n d a g i f t f o r y o u r m o t h e r . How w o u l d y o u a s k f o r h e l p ? (Q_,A) Would y o u p l e a s e h e l p me f i n d a g i f t f o r my m o t h e r . 12. A r e s i d e n t l a u g h s a t a n o t h e r r e s i d e n t who j u s t t r i p p e d o v e r h i s c a n e . What m i g h t y o u s a y t o t h e p e r s o n l a u g h i n g ? (SC,R) I do n o t t h i n k i t ' s v e r y n i c e t o l a u g h a t o t h e r p e o p l e ' s p r o b l e m s . 13. You a r e o u t w i t h a g r o u p and a n o t h e r r e s i d e n t l o o k i n g a t a g i r l w a l k i n g down t h e s t r e e t s a y s , "She's n o t bad l o o k i n g f o r a f a t p e r s o n . " What do y o u s a y ? (SC,A) I do n o t l i k e i t when y o u c a l l someone f a t . P l e a s e do n o t s a y t h a t when I am a r o u n d . 14. You a r e i n a s t o r e and a l i t t l e k i d comes up and a s k s what i s wrong w i t h y o u ( e i t h e r b e c a u s e o f y o u r w h e e l c h a i r , c a n e o r t h e way y o u w a l k ) . What do y o u s a y ? (Q, R) I was i n a bad a c c i d e n t . 15. You s e e a n o t h e r r e s i d e n t a c c i d e n t l y dump o u t e v e r y t h i n g i n h i s w a l l e t . What do y o u do? (P,A) O f f e r t o h e l p p i c k i t up. 16. You a r e w a t c h i n g TV and y o u r roommate comes i n and c h a n g e s t h e c h a n n e l . What do y o u s a y ? (SC,R) E x c u s e me, I was w a t c h i n g t h e o t h e r c h a n n e l . 17. You need t o a s k a s t a f f member a q u e s t i o n and s e e him i n h i s o f f i c e a l o n e . What do y o u s a y ? (Q,A) E x c u s e me, may I t a l k w i t h you? 18. You a r e i n a g r o u p o f p e o p l e , and t h e r e i s a p a u s e i n t h e c o n v e r s a t i o n . What do y o u s a y t o g e t t h e c o n v e r s a t i o n g o i n g a g a i n ? ( S I , A ) Hey, I h e a r i t ' s s u p p o s e d t o r a i n l a t e r t o d a y . 19. You a r e a t t h e d i n n e r t a b l e and a n o t h e r r e s i d e n t has j u s t g i v e n y o u t h e s a l t t h a t y o u a s k e d f o r . What do 140 APPENDIX you s a y ? (P,R) Thank y o u . 20. You a r e t a l k i n g t o a r e s i d e n t who has a memory p r o b l e m , and t h e y a s k y o u what y o u a r e m a k i n g i n a r t . T h i s p e r s o n a s k e d y o u t h e same q u e s t i o n y e s t e r d a y . What do y o u s a y ? <Q_,R) 1 am m a k i n g a c e r a m i c p o t . 21. Someone i s w e a r i n g a new s h i r t t h a t y o u do n o t l i k e . He a s k s y o u how y o u l i k e h i s s h i r t . What do y o u s a y ? (CR,R) I t i s n o t one o f my f a v o r i t e s . I l i k e y o u r b l u e one b e t t e r . 22. Someone t e l l s y o u t h a t t h e y l i k e y o u r new s t e r e o . What do y o u s a y ? (C,R) Thank y o u , I r e a l l y l i k e i t t o o . 23. You a r e a t d i n n e r and r e a l l y l i k e what i s b e i n g s e r v e d . What m i g h t y o u do? To t h e cook - I r e a l l y l i k e t h e d i n n e r . (C,A) 24. A n o t h e r r e s i d e n t u s e s a l o t o f d i r t y words when he t a l k s , and y o u do n o t l i k e i t . What c a n y o u do? (SC,A) I r e a l l y do n o t l i k e t o h e a r f o u l l a n g u a g e . Would yo u n o t u s e i t i n f r o n t o f me? 25. A n o t h e r r e s i d e n t i s a l w a y s b r a g g i n g a b o u t t h i n g s he does o r h a s . What do y o u do when he s t a r t s t o t e l l y o u a n o t h e r s t o r y ? (CR,A) I do n o t mean t o o f f e n d y o u , b u t I am g e t t i n g t i r e d of a l l t h e s e s t o r i e s . 26. A r e s i d e n t a s k s y o u why y o u a r e a t t h e C e n t r e . What do y o u s a y ? (Q_,R) S i n c e my a c c i d e n t , t h e r e a r e a l o t o f t h i n g s I need t o l e a r n how t o do a g a i n . 27. A n o t h e r r e s i d e n t t e l l s y o u t h a t t h e y a p p r e c i a t e y o u r o p e n i n g t h e d o o r f o r them. What do you s a y ? (C,R) You a r e welcome. 28. A n o t h e r r e s i d e n t l o o k i n g v e r y s a d s a y s he j u s t g o t some bad news f r o m home. What do y o u s a y ? ( S I , R ) Ask i f he w o u l d l i k e t o t a l k a b o u t i t . 29. You a r e d r i v i n g b a c k f r o m a movie and a n o t h e r r e s i d e n t a s k s t h e a c t i v i t y t h e r a p i s t t o s t o p f o r i c e cream. You do n o t want t o s t o p . What do you s a y ? 141 APPENDIX (SC,R) I do n o t f e e l l i k e h a v i n g i c e c r e a m ; p l e a s e d r o p me o f f a t t h e C e n t e r b e f o r e y o u go. 30. You a r e i n a r e s t a u r a n t and t h e p e r s o n y o u a r e w i t h t e l l s t h e w a i t r e s s t h a t she i s b e a u t i f u l . What do y o u s a y ? (CR,A) I t e m b a r a s s e s me when you s a y t h o s e k i n d o f t h i n g s t o p e o p l e y o u do n o t know. P l e a s e do n o t s a y them when I am, w i t h y o u . 31 . You want t o t a l k t o a c e r t a i n p e r s o n , b u t when you see them t h e y a r e t a l k i n g t o someone e l s e . What do you s a y ? (Q,A) E x c u s e me, may I t a l k t o y o u when y o u a r e f i n i s h e d . 32. You see a r e s i d e n t t a k e a pack o f gum o u t and t a k e a p i e c e . You w o u l d a l s o l i k e t o have a p i e c e . What do y o u s a y ? (Q_,A) May I have a p i e c e o f gum? 33. You o v e r h e a r someone s a y t o a s t a f f member, "Get me t h a t a s h t r a y I need i t . " What m i g h t y o u s a y t o y o u r f r i e n d ? (CR,A) You may w i s h t o a s k t h a t i n a n i c e r way. 34. Someone t e l l s y o u t h a t t h e y a r e u n c o m f o r t a b l e t a l k i n g t o y o u b e c a u s e t h e y f e e l as t h o u g h you a r e e x a m i n i n g them f r o m head t o t o e . What do you s a y ? (CR,R) I am s o r r y I d i d n o t r e a l i z e t h a t I was d o i n g t h a t . 35. You w a l k i n t o t h e d i n i n g room and two p e o p l e a r e t a l k i n g . You w o u l d l i k e t o j o i n them. What do y o u s a y ? ( S I , A ) E x c u s e me,I t h o u g h t I m i g h t j o i n y o u r c o n v e r s a t i o n . 36. A n o t h e r r e s i d e n t t e l l s y ou t h a t he f e l l t h i s m o r n i n g and h u r t h i s l e g . What w o u l d y o u s a y ? ( S I . R ) I am s o r r y t o h e a r t h a t , a r e y o u o k a y ? 37. Someone a s k s y o u r f r i e n d how t h e y a r e d o i n g t o d a y , and y o u r f r i e n d g i v e s them a l o n g e x p l a n a t i o n . What do you s a y t o y o u r f r i e n d ? (SC,R) I am n o t s u r e t h a t t h a t p e r s o n w a n t e d t o know a l l t h a t . Maybe n e x t t i m e y o u s h o u l d make i t s h o r t e r . 38. You were i n t h e b a t h r o o m f o r a l o n g t i m e . When y o u come o u t you n o t i c e someone has been w a i t i n g t o u s e t h e b a t h r o o m . You t h i n k i t ' s n i c e t h a t t h e y w a i t e d . What APPENDIX 142 do y o u s a y ? (C,A) I am s o r r y I t o o k so l o n g . Thank y o u f o r w a i t i n g . 39. A n o t h e r r e s i d e n t has bumped i n t o y o u and s a y s t h a t he i s s o r r y . What do y o u s a y ? (P,R) T h a t ' s o k a y . 40. You meet a g i r l downtown and w o u l d l i k e t o g e t t o know h e r b e t t e r . What m i g h t you s a y t o h e r ? ( S I , A ) I was w o n d e r i n g i f y o u w o u l d l i k e t o go o u t w i t h me. 41. Someone you do n o t l i k e a s k s y o u i f y o u a r e g o i n g away t h i s weekend. What do y o u s a y ? (Q_,R) Y e s , I am g o i n g o u t o f town on S a t u r d a y . 42. You a r e i n a c r o w d e d r e s t a u r a n t , and t h e w a i t r e s s who i s b u s y t a k e s s e v e r a l m i n u t e s b e f o r e c o m i n g t o y o u r t a b l e f o r y o u r o r d e r . What do you s a y when she does come and a p o l o g i z e f o r t a k i n g so l o n g ? (P,R) I u n d e r s t a n d t h a t t h i n g s a r e r e a l l y b u s y ; we w o u l d l i k e t o o r d e r now. 43. A r e s i d e n t t e l l s y o u t h e y a r e r e a l l y a n x i o u s a b o u t c a l l i n g home t o n i g h t . What do y o u s a y ? ( S I , R ) I am s u r e t h e y w i l l be happy t o h e a r f r o m y o u . How l o n g has i t b e e n s i n c e y o u have t a l k e d w i t h them? 44. A r e s i d e n t t e l l s y o u t h a t t h e y a r e happy t h a t y o u have s t o p p e d u s i n g f o u l l a n g u a g e a r o u n d them. What w o u l d y o u s a y ? (C,R) Thank y o u . I am t r y i n g . 45. You a r e a t a p a r t y and someone o f f e r s t o go g e t y o u a b e e r . What do y o u s a y ? (P,R) Thank y o u , b u t I do n o t c a r e f o r one r i g h t now. 46. A f r i e n d j u s t g o t a h a i r c u t t h a t y o u l i k e . What do you s a y ? (C,A) I r e a l l y l i k e t h a t h a i r c u t on y o u . 47. Someone down t h e h a l l i s m a k i n g a l o t of n o i s e , and you want t o r e s t . What do y o u s a y ? (SC,A) E x c u s e me, b u t 1 am t r y i n g t o g e t some s l e e p ; w o u l d y o u be a l i t t l e more q u i e t ? 48. You a r e i n y o u r room and s p i l l a g l a s s o f w a t e r and n e e d someone t o h e l p y o u c l e a n i t up. What do y o u s a y ? ( S I , A ) F i n d someone and s a y , " I s p i l l e d some w a t e r i n my 143 APPENDIX room. Would you h e l p me c l e a n i t u p ? " OR 48. I t ' s y o u r f i r s t day on t h e j o b and y o u a r e i n t r o d u c e d t o t h e s u p e r v i s o r . You m i g h t s a y h e l l o and ? ( S I , A ) I t ' s n i c e t o meet y o u . APPENDIX SOCIAL SKILLS ASSESSMENT CHART 145 APPENDIX SOCIAL SKILL 1 PER FORM AN 2 CE RAT1NC .. 3 5 voict: QUALITY Tone and Pitch Extremely unpleasant, high p i t c h -ed, Bqueaky v o i c e or t o t a l l y l a c k i n g i n expression. Very mono-tonous and boring. High f r e -quency of high p i t c h or monotonic speech, but l e s s severe. Unpleasant to l i s t e n t o . Sometimes becomes squeaky, p a r t i c u l a r l y i f e x c i t e d , or inade-quate v a r i -a t i o n i n p i t c h and tone. Usually shows appropriate v a r i a t i o n i n p i t c h and tone. V a r i a t i o n i n voice accept able. V a r i a t i o n i n pi t o h and tone appro-p r i a t e . Used f o r emphasis. Pleasant to l i s t e n to. Volume Voice a l -ways excess-i v e l y loud or excess-i v e l y quiet. Unpleasant loud or hard to hear. Voice i s fr e q u e n t l y e x c e s s i v e l y loud or ex c e s s i v e l y q u i e t . Sometimes speaks too lo u d l y , or very q u i e t l y when inappro-p r i a t e . Usually appropriate to s i t u a t i o n but volume i s occasion-a l l y rather too loud or s o f t . Volume always appropriate to s i t u a t i o n . E a s i l y audible Can shout when necess-ary, quiet when appro-p r i a t e -Rate Always speak e x c e s s i v e l y f a s t or ex-c e s s i v e l y slowly. Very hard to fo l l o w . Often speak ex c e s s i v e l y f a 6 t or slow when inappro— p r i a t e -Tends to speak s l i g h t l y too q u i c k l y or slowly when i n -appropriate. Rate us— u s a l l y appropriate but occas-i o n a l l y speaks too slowly or quickly. Rate of speech always' appropriate to s i t u a t i o n . C l a r i t y Speech a l -ways ex-tremely hard to under-stand. Words extremely mumbled and poor pro-nounced. Always quite hard to under-stand. High frequency of quite severe mum— b l i n g and poor pro-nunciation. O c c a s i o n a l l y hard to understand. Sometimes mumbles, t u t not severe. Usually easy to understand, but occas-ional s l i g h t muabling or poor pro-nunciation. Very c l e a r speech. Easy to understand Well pro— 1 nounced. PERFORMANCE RATING SOCIAL SKILL 1 2 3 4 5 NON-VERBAL RESPONSES Social Distance Extremely inappropriate to situation. Is always excessively close or distant in interactions. Frequently stands or sits very close or distant during interactions. Makes others feel uncomfortable. Sometimes shows inappropriate social distance. Not severe. Usually appropriate. May increase social distance excessively in stressful or intimate social situations. Maintains appropriate social distance according to the situation. Fiddling Movements Extremely inappropriate. Constant shifting o( position, movements of arms and legs. Constant touching of face, hair, hands etc. Frequent and excessive body movements. Tends to show excess fiddling and fidgeting during conversations particularly in stressful interactions. Body movements usually appropriate, but occasional inappropriate hand movements e.g. fiddling with objects, clothes, etc. Slight excess shifting of position. Body movements appropriate to situation. Shifts position when necessary for comfort. Hands and arms relaxed or involved in gestures. Smiling and Laughter Total absence of smiling or laughing, or continuous, inappropriate smiling. Rarely smiles in situations which cue smiling. Sometimes fails to smile when appropriate or often smiles when inappropriate. Usually appropriate, but face slightly tense during conversations. Occasional failure to smile when appropriate. Smiles and laughs when appropriate, during conversations, e.g. in response to jokes, comments or smiles from others Head Movements Total absence of appropriate head movements or continuous head nodding or shaking. Rarely uses appropriate head movements Moderate under or excessive usage of head movements. Usually appropriate. Slight under use of head movements. Appropriate use of head movements to agree or disagree. Also uses head nods while listening to others. PERFORMANCE RATING SOCIAL SKILL 1 2 3 4 5 PERCEPTION OF EMOTIONS (SC ORES FROM TESTS C )F PERCEPTION OF E MOTIONAL EXPRESS!! DN) Facial Expression 1-2 3-4 5-6 7-8 3-10 Posture 1-2 3-4 5-6 7-6 S-10 Gestures 1-2 3^1 5-6 7-S 3-10 Voice Quality 1-2 3-4 5-6 7-6 3-10 BASIC NON-VERBAL SKILLS Facial Expression Extremely inappropriate to situation. Excessive glaring, grinning or frowning. Continuous Frequently inappropriate. Little change in expression with situation neutral or blank. Usually appropriate but occasional excess in frowning etc. Always appropriate to situation. Relaxed and changes with situation. Posture Extremely inappropriate to situation. Severe and continuous slouching, shoulders drooped etc. Frequent slouching or excessively tense and rigid, with arms and legs tightly folded. Posture sometimes too casual or tense. Usually appropriate but slightly too casual or relaxed. Always appropriate to situation. Well poised but relaxed. Arms down, back straight, head up. Slight lean forwards. Gestures Total absences or severe excess of gestures. Frequent excessive or inadequate usage Gross hand movements. Moderate excess or inadequate usage of growth. Slight excess or inadequate usage. Uses gestures for emphasis and information during conversations. Used appropriately and not excessively. Eye Contact Total aversion of gaze during conversations, or intense, continuous staring. High frequency of gaze aversion or inappropriate staring. Moderately inadequate eye contact, or excessive staring. Usually appropriate but occasional avoidance of eye contact or excessive staring in stressful situations. Appropriate to situation. Engages eye contact at intervals while others are speaking, and as a cue for others lo speak. PERFORMANCE RATING SOCIAL SKILL 1 2 3 4 5 BASIC CONVERSATION SKILLS i Length ol Reply to Questions Always gives extremely briel answers to questions. Usually gives one word answers. Usually gives very brief replies to questions. Answers sometimes very brief or usually excessively long. Answers usually lull and of appropriate length but occasionally rather brief or rather too long. Answers questions fully, providing the information required Qualifies answers with extending statements Length of reply appropriate to situation Information Content Conversation always contains minimal information. Content is generally unrelated to the topic of concern. Conversation usually provides lirtle information to the listener, or Information is usually inappropriate Sometimes fails to provide adequate and appropriate information. Information content ol conversation usually appropriate. Always contains uselul and appropriate information, relevant to the topic of concern. Frequency of Question Asking Always total absence of question asking during general conversation or when trying to gain information or to hand ovtr conversation. Infrequent and extremely inadequate question asking. Moderate frequency of question asking. Not adequate. Usually high frequency of question asking when taking lead or major roles, but frequency slightly inadequate. Frequency of question asking always appropriate to the situation. High frequency during general conversation, or when trying to gain information or to hand over conversation. Frequency of Initiations Always total absence of initiations during conversation. Falls to Initiate statements or questions to maintain conversation. Very low frequency of initiations. Fails to maintain conventions when taking lead role. Uncomfortable for those taking minor role Moderate frequency ol initiations, but inadequate. Sometimes falls to initiate, leading to conversation breakdown, when in the lead role. Usually high but occasional inadequacy e.g. with Strangers. Frequency of initiations always appropriate to situation. Initiates conversations with strangers when necessary or to maintain conversation if taking the lead role. PERFORMANCE RATING SOCIAL SKILL 1 2 3 4 5 LISTENING SKILLS Personal Self-disclosures Total absence of personal self-disclosure statements or excessive extremely personal self-disclosure, e.g. about illness or sexual activities. Frequent lack of excess of personal self-disclosure. May embarrass others with Inappropriate self statements. Moderate inadequacy or excess of disclosures relating to personal experiences, history, feelings, or personality. Frequency and content usually appropriate, but is occasionally inadequate or excessive. Level of personal self-disclosure appropriate to situation. Makes others feel at ease when taking the listening role. Question-type Feedback Total absence of question-type feedback while other person is talking or questioning responses are Inappropriate and irrelevant to conversation. Very low frequency of question-type feedback, or rarely appropriate. .Sometimes provides question-type feedback while in the listening role, but frequency not adequate. Slight inadequacy in level of appropriate question-type feedback. High frequency of appropriate question-type responses when in the listening role, e.g. 'Oh? Really ? Did you ?' Reflections Total absence of reflections while in the listening role. Very low frequency of reflections when in the listening role. Inadequate but occasional use of accurate reflections. Frequent use of reflections in listening role, but tend to be slightly inaccurate. Frequent use of reflections appropriate to the content of conversation, while in the listening role. Acknowledge-ments Total absence of acknowledgements, when in the listening role. Very low frequency of acknowledgements when in the listening role Inadequate but occasional use of acknowledgements Frequent use of acknowledgements in listening role but slightly inadequate. Frequent use of acknowledgements, appropriate to the content of conversations, while in the listening role. e.g. mm, ahh, 1 see. PERFORMANCE RATING SOCIAL SKILL 1 2 3 3 5 CONTENT OF SPEECH Repetitions Excessive and inappropriate repetition of statements or information during conversations. Frequent, inappropriate repetitions. Sometimes repeats information or phrases when Inappropriate. Repetitions usually only when appropriate, but slight excess during clarification. Repeats information or phrases only when appropriate. Interruptions Very high frequency of persistent and irritating butting in, while other people are speaking. Frequent, inappropriate interruptions. Occasional inappropriate interruptions. Infrequent interruptions. Usually allows other person to complete speech before taking the lead. Never interrups unless appropriate, and makes excusing statements first. Interest Content Always extremely boring and uninformative. Or may be totally preoccupied with self. Excessive talking about self. Content is often very boring. Fails to select appropriate topics of conversation according to interests of listener. Content of speech is occasionally boring to the listener. Content is usually quite interesting. Selects appropriate topics of interest to listener. Always interesting and informative. Selects topics appropriate to situation. Relevancy of Conversation Always wanders off the topic of conversation. Extreme digressions. Rapid switching of topics without apparent connection. Frequently wanders off the subject. Frequent discussion of topics inappropriate to situation. Occasional inappropriate digressions and irrelevant topics during conversations. Content usually relevant and appropriate to situation. Very occasional digressions. AJways sticks to relevant and appropriate topic of conversation. PERFORMANCE RATING SOCIAL SKILL 1 2 3 4 5 QUALITY OF SPEECH Amouni Spoken Extremely minimal. Mainly one word replies and very brief statements. Hardly speaks at all. Very minimal or excessive. Fails to give others opportunity to speak. Monopolizes conversation. Moderate excess or inadequate quantity of speech. Usually appropriate amount of speech. Occasional slight excess or inadequate amount. Amount spoken always appropriate to situation Appropriate length and frequency of utterances. Does not monopolize conversation. Latency of Response Always extremely slow in responding. Long, abnormal delay in response to questions or initiations. Frequently very slow In responding during conversations. Makes others feel awkward. Sometimes rather slow In response during conversations. May be slight delay in response, but infrequent and not very obvious or may tend to rush response and become muddled. Fails to allow adequate time for formulation. Rapid response during speech. Formulates words quickly. No obvious delay. Hesitations and Pauses Frequent and excessive pauses or hesitations In speech. Sounds extremely jerVy and broken. Hard to follow. Frequent moderately severe pauses or hesitations, or infrequent but very prolonged pauses or hesitations. Occasional moderate pauses or hesitations. Ooesn't seriously Impair flow. Speech usually unbroken but occasional minor pauses or hesitations. Speech flows well No obvious pauses or hesitations in speech Dysfluencies Continuous severe dysfluencies e.g. stuttering, stammering, umms, ahhs, etc. Very difficult to understand. Frequent dysfluencies. Speech quite hard to understand. Sometimes shows dysfluencies, of moderate severity. Occasional slight dysfluencies, particularly in stressful situations. No obvious dysfluencies. Speech easy to understand. APPENDIX 152 SOCIAL SKILLS TRAINING WITH CHILDREN AND ADOLESCENTS by Sue Spence STAFF QUESTIONNAIRE: ON SOCIAL BEHAVIOUR Name: Staff Member: Date: Please observe the above named closely and circle your opinion of the level of social functioning in the following areas: — R a t i n g Situation 1 2 3 4 5 Peer relationships 1. Has friends amongst none no close one close several many friends peers friends friend friends at at least two least one good ones close 2. Talks freely with peers never rarely sometimes usually always 3. Jo ins in activities never rarely sometimes often very often with peers 4. Is bullied by others very often often sometimes rarely never 5. Wi l l volunteer in never rarely sometimes often very often group situations 6. Avoids peer interaction always often sometimes rarely never 7. Becomes aggressive or always often sometimes rarely never loses temper when teased by peers 8. Wi l l stan up a never rarely sometimes often very often conversation with peers appropriately Staff relationships 9. Initiates conversations never rarely sometimes often very often with staff at appropriate times 10. Approaches staff never rarely sometimes often very often appropriately with requests or questions 11. Talks freely to members never rarely sometimes often very often of staff about general topics 12. Is verbally aggressive always often sometimes rarely never towards staff 13. Becomes angry when always usually sometimes rarely never criticised by staff APPENDIX 153 Rating Situation 1 2 3 4 5 14. Refuses staff requests always often sometimes rarely never and instructions 15. Argues inappropriately always usually sometimes rarely never with staff if prevented from doing something he/she wants to do General Social Behaviour 16. Engages/disengages very poor poor moderate good very good eye contact appropriately in conversation 17. Facial expression is never. rarely sometimes usually always appropriate to situation 18. Response to questions excessively poor moderate adequate detailed brief 19. Posture terrible poor moderate good excellent 20. Uses tone and pitch very poor poor moderate good very good for emphasis monoton-ous 21. Clarity of speech very poor poor moderate good very good 22. Fidgets and fiddles all the often sometimes rarely never with hands during time conversation 23. Laughs and smiles never or rarely sometimes usually when always appropriately continuous appropriate appropriate appropriate grinning 24. Fluency of speech extremely very poor moderate good excellent poor hesitant/ Stuttering Please state any other social situations in which the above named has difficulty: 25. Please rate the above named on a 10 point scale of general social skills performance: — 1 2 3 4 5 6 7 8 9 10 I I I extremely moderate excellent poor PLAYER PROGRESS GRAPH 12 - i Baseline Games 11 H 10 H 9 H 6 H 5 H 4 H 2 -\ 1 ^ 2 3 > W 'i—i 10 11 12 13 14 15 16 17 18 155 APPENDIX F A C I L I T A T O R S C O R I N G S H E E T This form shows the sequence of card numbers and the players who should receive them over a series of four games. Write the name of the curriculum and each player's name in the spaces provided. Under each number, mark a plus ( + ) if the response was correct or a minus (—) if the response was incorrect. Record the number of correct responses for each player when each game is over. NAME Game One NUMBER CORRECT Facilitator Card 1 5 9 13 17 21 25 29 33 37 41 45 Score Player 1 Card 2 6 10 14 18 22 26 30 34 38 42 46 Score Player 2 Card 3 7 11 15 19 23 27 31 35 39 43 47 Score Player 3 Card 4 8 12 16 20 24 28 32 36 40 44 48 Score Game Two Player 1 Card 13 17 21 25 29 33 37 41 45 1 5 9 Score Player 2 Card 14 18 22 26 30 34 38 42 46 2 6 10 Score Player 3 Card 15 19 23 27 31 35 39 43 47 3 7 11 Score Facilitator Card 16 20 24 28 32 36 40 44 48 4 8 12 Score Game Three Player 2 Card 25 29 33 37 41 45 1 5 9 13 17 21 Score Player 3 Card 26 30 34 38 42 46 2 6 10 14 18 22 Score Facilitator Card 27 31 35 39 43 47 3 7 11 15 19 23 Score Player 1 Card 28 32 36 40 44 48 4 8 12 16 20 24 Score Game Four Player 3 Card 37 41 45 1 5 9 13 17 21 25 29 33 Score Facilitator Card 38 42 46 2 6 10 14 18 22 26 30 34 Score Player 1 Card 39 43 47 3 7 11 15 19 23 27 31 35 Score Player 2 Card 40 44 48 4 8 12 16 20 24 28 32 36 APPENDIX Curriculum 156 FACILITATOR RECORDING SHEET This form is used to score player responses when the game is played by shuffling the cards. Write the name of the curriculum, the number of the game, and each player's name in the spaces provided. On each player's turn, mark a plus (+) if the response is correct and a minus (—) if the response is incorrect. Record the number of correct responses for each player when each game is over. Game TURNS NUMBER PLAYER 1 2 3 4 5 6 7 8 9 10 11 12 CORRECT Game TURNS NUMBER PLAYER 1 2 3 4 5 6 7 8 9 10 11 12 CORRECT Game TURNS NUMBER PLAYER 1 2 3 4 5 6 7 8 9 10 11 12 CORRECT Game TURNS NUMBER PLAYER 1 2 3 4 5 6 7 8 9 10 11 12 CORRECT APPENDIX PLAYER SCORECARD 157 NAME THE NUMBER CIRCLED IS THE NUMBER YOU NEED TO WIN. PUT AN "X" IN A BOX WHEN YOU ANSWER RIGHT. GAME ONE 1 2 3 4 5 6 7 8 9 10 11 12 TWO 1 2 3 4 5 6 7 8 9 10 11 12 THREE 1 2 3 4 5 6 7 8 9 10 11 12 FOUR 1 2 3 4 5 6 7 8 9 10 11 12 PLAYER SCORECARD NAME THE NUMBER CIRCLED IS THE NUMBER YOU NEED TO WIN. PUT AN "X" IN A BOX WHEN YOU ANSWER RIGHT. GAME ONE 1 2 3 4 5 6 7 8 9 10 11 12 TWO 1 2 3 4 5 6 7 8 9 10 11 12 THREE 1 2 3 4 5 6 7 8 9 10 11 12 FOUR 1 2 3 4 5 6 7 8 9 10 11 12 PLAYER SCORECARD NAME THE NUMBER CIRCLED IS THE NUMBER YOU NEED TO WIN. PUT AN "X" IN A BOX WHEN YOU ANSWER RIGHT. GAME ONE 1 2 3 4 5 6 7 8 9 10 11 12 TWO 1 2 3 4 5 6 7 8 9 10 11 12 THREE 1 2 3 4 5 6 7 8 9 10 11 12 FOUR 1 2 3 4 5 6 7 8 9 10 11 12 158 APPENDIX Homework Report Name: Date F i l l i n during t h i s c l a s s 1- Homework assignment: 2. Learning p o i n t s to be -followed: F i l l i n BEFORE next c l a s s 3. Describe what happened when you d i d the homework assignment. 4. Learning p o i n t s you a c t u a l l y -followed: 5. Rate y o u r s e l f on how w e l l you used the s k i l l (check one) a. E x c e l l e n t b. Good . c. F a i r d. Poor 6 . Describe what y o u f e e l s h o u l d be y o u next homework assignment. 160 REFERENCES B e l l a c k , A l a n A . , H e r s e n , M i c h e l ( E d s ) R e s e a r c h M e t h o d s  i n C l i n i c a l P s y c h o l o g y . New Y o r k : Pergamon P r e s s 1984. B r a m s t o n , P a u l and S p e n c e , S u s a n H. (1985) " B e h a v i o r a l v e r s u s C o n g i t i v e S o c i a l S k i l l s T r a i n i n g w i t h i n t e l l e c t u a l l y H a n d i c a p p e d A d u l t s " . Behav. Res. T h e r . V o l 28 No 1 . B r a u n 1 i n g - M c M o r r o w , D e b r a , L l o y d , K a r e n , and F a l i s h , K a t h l e e n . " T e a c h i n g S o c i a l S k i l l s t o Head I n j u r e d A d u l t s " J o u r n a l o f R e h a b i l i t a t i o n . J a n u a r y / F e b r u a r y / M a r c h 1986. Bloom, M a r t i n , F i s h c h e r , J o e l . E v a l u a t i n g P r a c t i c e ;  G u i d e l i n e s f o r t h e A c c o u n t a b l e P r o f e s s i o n a l . New J e r s e y : P r e n t i c e - H a l l I n c . 1982. B r o o k s , D.N. e t a l . ( 1 9 8 4 ) " P r o b l e m s i n M e a s u r i n g C o g n i t i v e R e c o v e r y a f t e r A c u t e B r a i n I n j u r y " . J o u r n a 1  of C l i n i c a l N e u r o p s y c h o l o g y 6,71-85. B r o o k s , D.N., M c K i n l a y , W. (1983) " P e r s o n a l i t y and B e h a v i o r a l Changes a f t e r S e v e r e B l u n t Head I n j u r y - a r e l a t i v e ' s v i e w " . J o u r n a l o f N e u r o l o g y , N e u r o s u r g e r y  and P s y c h i a t r y 4 8 : 6 1 3 - 6 1 9 . Eames, P e t e r , Wood, R o d g e r . ( 1 9 8 5 ) " R e h a b i l i t a t i o n a f t e r s e v e r e b r a i n i n j u r y : a f o l l o w - u p s t u d y o f a b e h a v i o r m o d i f i c a t i o n a p p r o a c h " J o u r n a 1 of N e u r o 1 ogy. N e u r o s u r g e r y and P s y c h i a t r y 4 8:613-619. Fahy e t a l . " R e c o v e r y f o r m Head I n j u r y " . B r i t i s h M e d i c a l  J o u r n a 1 . F e b r u a r y 1967. F e l l i n , P h i l l i p , T r i p o d i , Tony and M e y e r , H e n r y . E x a m p l a r e s of S o c i a l R e s e a r c h . 111.: P e a c o c k P r e s s , U n i v e r s i t y of M i c h I g a n , 1 9 6 9 . F o r d y c e , D a v i d J . ; Roueche,James R.; P r I g a t a n o , G e o r g e P. ( 1 9 8 3 ) " E n h a n c e d e m o t i o n a l r e a c t i o n s i n c h r o n i c head t r a u m a p a t i e n t s " . J o u r n a 1 of N e u r o 1 ogy, N e u r o s u r g e r y , and P s y c h i a t r y 46: 620-624. Foxx.R.M., McMorrow, M.J. & S c h l o s s , C.N. ( 1 9 8 3 ) . " S t a c k i n g t h e d e c k : T e a c h i n g s o c i a l s k i l l s t o r e t a r d e d a d u l t s w i t h a m o d i f i e d t a b l e game." J o u r n a l o f A p p l i e d 161 B e h a v i o r A n a l y s i s , 1 6 , 1 5 7 - 1 7 0 . F o x x , R.M. & MCMorrow, M.J. ( 1 9 8 3 ) . " S t a c k t h e d e c k : a S p e c i a l s k i l l s t r a i n i n g game f o r r e t a r d e d a d u l t s . " C h a m p a i g n , I L : R e s e a r c h P r e s s . G e n t i l l i n i , M assimo e t a l . ( 1 9 8 5 ) " N e u r o p s y c h o l o g i c a l e v a l u a t i o n s of m i l d head i n j u r y " . J o u r n a 1 o f N e u r o l o g y , N e u r o s u r g e r y , and P s y c h i a t r y 4 8 : 1 3 7 - 1 4 0 . G l o a g , Daphne. (1985) " R e h a b i l i t a t i o n a f t e r head i n j u r y - 1: C o g n i t i v e P r o b l e m s " . B r i t i s h M e d i c a l J o u r n a l . Volume 290 :834-836. G 1 o a g , D a p h n e . ( 1 9 8 5 ) " Needs and O p p o r t u n i t i e s i n R e h a b i l i t a t i o n - R e h a b i l i t a t i o n a f t e r head i n j u r y : 2 B e h a v i o r and e m o t i o n a l p r o b l e m s , l o n g t e r m n e e d s , and t h e r e q u i r e m e n t s f o r s e r v i c e s " . B r i t i s h M e d i c a l J o u r n a 1 . 290: 9 1 3 - 9 1 5 . G o l d s t e i n , A r n o l d P. S p r a f k i n , R o b e r t P. Gershaw, N. J a n e . S k i l l T r a i n i n g f o r Community L i v i n g . New Y o r k : Pergamon P r e s s / S t r u c t u r e d L e a r n i n g A s s o c i a t e s . 1979. Goodman-Smith,Ann; T u r n b u l l , J a k k i . "A B e h a v i o r a l A p p r o a c h t o R e h a b i l i t a t i o n o f S e v e r e l y B r a i n - i n j u r e d A d u l t s " . ( 1 9 8 3 ) P h y s i o t h e r a p y 6 9 : 3 9 3 - 3 9 6 . G r i n n e l l , R i c h a r d M. S o c i a l Work R e s e a r c h and  E v a 1 u a t i o n . I t a s c a : F.E. P e a c o c k P u b l i s h e r s , I n c . 1981. G u i l f o r d , J . P . P s y c h o m e t r i c M e t h o d s . New Y o r k : M cGraw-Hi11,1954. Habermann, B a r b a r a . ( 1 9 8 2 ) " C o g n i t i v e D y s f u n c t i o n and S o c i a l R e h a b i l i t a t i o n i n t h e S e v e r e l y H e a d - I n j u r e d P a t i e n t " . J o u r n a l of N e u r o s u r g i c a l N u r s i n g . O c t o b e r V o l . 1 4 No.5: 220-224. H a l l , K a r y l ; C o p e , D . N a t h a n ; R a p p a p o r t , M a u r i c e . ( 1 9 8 5 ) " G l a s g o w Outcome S c a l e and D i s a b i l i t y R a t i n g S c a l e : C o m p a r a t i v e U s e f u l n e s s i n F o l l o w i n g R e c o v e r y i n T r a u m a t i c Head I n j u r y " . A r c h P h y s Med R e h a b i 1 6 6 : 3 5 - 3 7 . H a y n e s - C 1 e m e n t s , L i n d a A . ; A v e r y , A r t h u r W. ( 1 9 8 4) "A C o g n i t i v e - B e h a v i o r a l A p p r o a c h To S o c i a l S k i l l s T r a i n i n g w i t h Shy P e r s o n s . " J o u r n a l of C l i n i c a l P s y c h o l o g y . V o l . 4 0 . No.3. 162 H e r s e n , M. and D.H. B a r l o w . S i n g l e C a s e E x p e r i m e n t a l  D e s i g n s : S t r a t e g i e s f o r S t u d y i n g B e h a v i o r Change. New Y o r k : Pergamon.1976. J e n n e t t , B.; and Bond, M. (1975) " A s s e s s m e n t o f Outcome a f t e r S e v e r e B r a i n Damage". L a n c e t 1:480-484. L i b e r m a n , R o b e r t P a u l ; M u e s e r , KimT.; W a l l a c e , C h a r l e s J . " S o c i a l S k i l l s T r a i n i n g f o r S c h i z o p h r e n c i I n d i v i d u a l s a t R i s k f o r R e l a p s e " Am J P s y c h i a t r y 143:523-526. L i n d e n , W o l f g a n g , W r i g h t , J o h n . (1979) " P r o g r a m m i n g G e n e r a l i z a t i o n T h r o u g h S o c a i 1 S k i l l s T r a i n i n g i n t h e N a t u r a l E n v i r o n m e n t " Behav. Ana 1. Modi f . 4 ( 1 9 8 0 ) 2 3 9 - 2 5 1 . L i v i n g s t o n , M a r t i n G.; B r o o k s , D . N e i 1 ; Bond, M i c h a e l R. ( 1 9 8 5 ) " T h r e e months a f t e r s e v e r e head i n j u r y : p s y c h i a t r i c and s o c i a l i m p a c t on r e l a t i v e s . J o u r n a l o f  N e u r o l o g y , N e u r o s u r g e r y , and P s y c h i a t r y 4 8 : 8 7 0 - 8 7 5 . L i v i n g s t o n , M a r t i n G . ; B r o o k s , D . N e i l ; Bond, M i c h a e l R. ( 1 9 8 5 ) " P a t i e n t outcome i n t h e y e a r f o l l o w i n g s e v e r e head i n j u r y and r e l a t i v e s ' p s y c h i a t r i c and s o c i a l f u n c t i o n i n g " . J o u r n a l o f N e u r o l o g y . N e u r o s u r g e r y , and P s y c h i a t r y . 4 8 : 8 7 6 - 8 8 1 . L y n c h , W i l l i a m J . "A R e h a b i l i t a t i o n P r o g r a m f o r B r a i n I n j u r e d A d u l t s " . i n B a r r y A. E d e l s t e i n , Eugene T. C o u t u r e ( E d s ) B e h a v i o r a l A s s e s s m e n t and R e h a b i l i t a t i o n  o f t h e T r a u m a t i c a 1 Iy B r a i n Damaged. New Y o r k : P l e n u m P r e s s 1984. McConne11, James V. U n d e r s t a n d i n g Human B e h a v i o r . New Y o r k : H o l t , R i n e h a r t , and W i n s t o n 1980. M c K i n l a y e t a l (1984) "The s h o r t - t e r m outcome of s e v e r e b l u n t head i n j u r y as r e p o r t e d by r e l a t i v e s of i n j u r e d p e r s o n s " J o u r n a l o f N e u r o l o g y N e u r o s u r g e r y , and P s y c h i a t r y . 6:87-99. McLean, A l v i n J r . , T e m k i n , Nancy R.,Dikmen, S u r e y y a , W y l e r , A l l e n R. ( 1983) " B e h a v i o r a l S e q u e l e of Head I n j u r y " J o u r n a l of C l i n i c a l N e u r o p s y c h o l o g y . 5:361-376. McLean e t a l (1984) " P s y c h o s o c i a l F u n c t i o n i n g a t 1 Month a f t e r Head I n j u r y " N e u r o s u r g e r y . V o l . 14. No 4. 163 Newcombe, F r e d a . ( 1 9 8 1 ) "The p s y c h o l o g i c a l c o n s e q u e n c e s of c l o s e d head i n j u r y : a s s e s s m e n t and r e h a b i l i t a t i o n . " I n j u r y . 14. 11-136. Oddy, M i c h a e l , Humphrey, M i c h a e l , U t t 1 e y , D a v i d . ( 1 9 78) " S u b j e c t i v e i m p a i r m e n t and s o c i a l r e c o v e r y a f t e r c l o s e d head i n j u r y . " J o u r n a l o f N e u r o s u r g e r y and P s y c h i a t r y 4 1 : 1 6 6 - 6 1 6 . Oddy, M i c h a e l , C o u c h l a n , Tony, Tyerman, Andrew, J e n k i n s , D a v i d . ( 1 9 8 5 ) " S o c i a l a d j u s t m e n t a f t e r c l o s e d head i n j u r y : a f u r t h e r f o l l o w - u p s e v e n y e a r s a f t e r i n j u r y " . J o u r n a l of N e u r o l o g y , N e u r o s u r g e r y , and P s y c h i a t r y 4 8 : 5 6 4-568. P a p a l i a , D i a n e E., O l d s , S a l l y Wendkos. A C h i I d ' s Wor1d  I n f a n c y t h r o u g h A d o l s e c e n c e . New Y o r k : M c G r a w - H i l l I n c . 1979. P a r s o n s , O s c a r A. , P r i g a t a n o , G e o r g e P. ( 1 9 7 8) " M e t h o d o l o g i c a l C o n s i d e r a t i o n s i n C l i n i c a l N e u r o p s y c h o l o g i c a l R e s e a r c h " J o u r n a l o f C o n s u l t i n g and  C l i n i c a l P s y c h o l o g y . 4 6 : 6 0 8 - 6 1 9 . R o s e n t h a l , M i t c h e 1 1 . ( 1 9 8 4 ) " S t r a t e g i e s f o r I n t e r v e n t i o n w i t h F a m i l i e s of B r a i n - I n j u r e d P a t i e n t s " i n B a r r y A. E d e l s t e i n ; Eugene T. C o u t u r e ( E d s ) B e h a v i o r a l A s s e s s m e n t and R e h a b i l i t a t i o n of t h e T r a u m a t i c a l l y B r a i n  Damaged. New Y o r k : 2 7 7 - 2 4 6 . T a r v e r , S a r a G. ( 1 9 8 6) " C o g n i t i v e B e h a v i r o M o d i f i c a t i o n , D i r e c t I n s t r u c t i o n and H o l i s t i c A p p r o a c h e s t o t h e E d u c a t i o n of S t u d e n t s w i t h L e a r n i n g D i s a b i l i t i e s " . J o u r n a l of L e a r n i n g D i s a b i l i t i e s . 19:368-375. T r o w e r , P e t e r . ( 1 9 8 2 ) "The what, who, and how of s o c i a l s k i l l s t r a i n i n g . " B r i t i s h J o u r n a l o f H o s p i t a l M e d i c i n e . J u n e 1982. 608-614. Thomsen, E.V. ( 1 9 7 4) "The P a t i e n t w i t h S e v e r e Head I n j u r y and h i s F a m i l y " . S c a n d i n a v i a n J o u r n a l of  R e h a b i 1 i t a t i o n M e d i c i n e . ( 6 ) 180-183. W a l l a c e , C h a r l e s J . , L i b e r m a n , R o b e r t P a u l . ( 1 9 8 5) " S o c a i l S k i l l s T r a i n i n g f o r P a t i e n t s w i t h S c h i z o p h r e n c i a : A C o n t r o l l e d C l i n i c a l T r i a l " . P s y c h i a t r y R e s e a r c h . 1985 15: 239-247. 

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