Excerpts

Self-Awareness

We have already described methods to assess self-awareness. Assessment of most other areas described in Table 3.2 uses methods that require either observing the individual directly in real-life or simulated real-life environments, or obtaining such observational information from family, friends, or others who have the opportunity to observe the patient’s functioning in real-life environments.

Disability

Several functional scales have been developed that measure disability due to a medical condition or illness. Hall (1992) provides a review of scales commonly used in inpatient settings to measure disability due to brain injury. However, these scales focus on more basic activities and physical status, and often do not capture the nature of disability present in ambulatory brain injured populations in the postacute phase. Crewe and Dijkers (1995) review a variety of scales used with disabled populations, including several suited to outpatient settings that assess functional changes due to brain injury. Of these, the Mayo–Portland Adaptability Inventory (MPAI; Malec et al., 1997), the Craig Handicap Assessment and Reporting Technique (CHART; Whiteneck, Charlifue, Gerhart, Overholser, & Richardson, 1992), and the Community Integration Questionnaire (CIQ; Willer, Rosenthal, Kreutzer, Gordon, & Rempel, 1993) seem to capture many of the activity and participation changes often present in individuals with brain injury in the postacute phase of recovery. These scales have demonstrated reliability and validity. The Web site of the Center for Outcome Measurement of Brain Injury (COMBI; www.tbims.org/combi) provides extensive information about psychometric and other properties of these and other scales that are useful in brain injury rehabilitation. Unfortunately, these scales are not familiar to most neuropsychologists and are most often used in rehabilitation settings as part of an overall team assessment. As we argue later, a team approach provides the best means of assessment in patients with this injury.

Compensation

Evaluating compensation for cognitive, physical, and emotional deficits, of course, requires identification of such deficits through neuropsychological, psychological, rehabilitation, or other types of formal assessments. However, evaluation in this functional domain also requires identifying methods that persons use to manage such impairments. Such compensation techniques for cognitive deficits may include calendars, notebooks, and personal digital assistants, as well as systems of prompts and cues that depend on other people. Emotional coping techniques may include both overlearned, internalized coping responses and systems such as “time out” that require assistance from other people. Physical compensation methods include orthoses, prostheses, and modifications of the physical environment.

Self-Esteem and Self-Confidence

These characteristics are best assessed as part of comprehensive clinical interview and observation of the patient. Limited self-awareness and defenses may interfere with accurate self-reporting of negative self-statements that nonetheless obviously interfere in actual behavioral performance settings. Congruence between goals and abilities, probably also best assessed behaviorally, is an aspect of self-awareness that goes beyond a verbal reporting of strengths and weaknesses to include the capacity to use information about strengths and weaknesses in selecting activities and making plans. Crosson and colleagues (1989) describe this as the anticipatory level of self-awareness.

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