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REVIEW
Abstract
Primary objective: Neurobehavioural disability (NBD) has a major impact on long-term psychosocial outcome: however,
measures used to identify characteristics of NBD have not been fully evaluated. This review therefore discusses issues
surrounding the concept and assessment of NBD following acquired brain injury (ABI) by examining the psychometric
properties and other qualities of some of the most well known instruments used to assess NBD. It is the authors intention to
use this review to encourage researchers to develop new NBD measurement tools.
Main outcomes: The review highlights a number of concerns with existing measures, including; the absence of a clear
theoretical framework, a failure to distinguish impairment, disability and handicap when measuring characteristics of NBD
and issues surrounding reliability and validity.
Conclusions: The authors propose, promote and encourage the development of further measures with improved reliability
and validity to help ensure that the unique characteristics of NBD are captured more effectively.
Keywords: Neurobehavioral, disability, handicap, reliability, validity, assessment,
Introduction
There are a variety of non-cognitive consequences of
acquired brain injury (ABI) which, through their
interaction with cognitive sequelae, can have
a devastating impact on social function. For example,
Oddy et al. [1] described how blunted emotions,
combined with inflexible and concrete thinking, can
result in difficulty understanding complex behaviour,
especially attempts at humour. These deficits in social
perception can act as a barrier to recognizing the
emotional states of others [24]. Patients may lose the
ability to interpret and express feelings in social
situations. As a result their behaviour can appear
inappropriate, self-focused and lacking in empathy,
Correspondence: Professor Rodger Ll. Wood, Department of Psychology, School of Human Sciences, Swansea University, Singleton Park, Swansea SA2 8PP,
UK. Tel: (44) 1792 295778. Fax: (44) 1792 295679. E-mail: r.l.wood@swansea.ac.uk
ISSN 02699052 print/ISSN 1362301X online 2008 Informa UK Ltd.
DOI: 10.1080/02699050802491271
906
rehabilitation efforts and the general social acceptability of patients; consequently, these have been
conceived as constituting positive disorders of
behaviour [18].
Consistent with this conceptualization, Prigatano
[19] has drawn attention to negative disorders,
such as the psychosocial problems associated with
a lack of motivation. Such patients are often
viewed as lazy or depressed because they can
appear tired and disinterested in their environment. The lack of awareness exhibited by many
individuals, coupled with other forms of cognitive
impairment, mean that they may become confused
as to why people get upset with them, then
withdraw and experience a breakdown in personal
relationships, becoming more isolated [20].
Weddell et al. [21] also reported that head-injured
people spend more time at home, have fewer
friends and make or receive fewer visits than prior
to injury. In addition, they may experience low
self-esteem and feel more dependent on others.
Changes in cognition, behaviour and personality
therefore contribute to social handicap, because
many individuals become increasingly dependent
on family for social support [22].
One approach to understanding the complex
nature of behaviour change after ABI has been to
conceptualize such changes as neurobehavioural
disability (NBD) [2224]. This term has gained
considerable acceptance over the last two decades
and is now used to describe the long-term constellation of problems associated with ABI. Kreutzer et al.
[25] directly attributed poor outcome to the
presence of NBD, construed as adverse changes
in physical well-being, personality, mood, initiative,
social skills and cognitive abilities. Wood [22]
elaborated on the composition of NBD and argued
that it comprises elements of executive and attentional dysfunction, poor insight, awareness and
social judgement, labile mood and problems with
impulse control. Furthermore, when these interact
with specific cognitive problems (such as memory
impairment) and are further influenced by a persons
pre-morbid personality characteristics, they result in
social handicap that undermines the capacity for
independent social behaviour.
Attempts to categorize the diverse range of ABI
characteristics has culminated in recognition of the
need to develop measures of altered emotion, mood,
personality and behaviour [26, 27]. It has also been
advocated that difficulties with executive dysfunction should be included alongside assessment
of behavioural and emotional characteristics
[28]. However, it could be argued that any attempt
to categorize the complex pattern of changes
associated with ABI into clearly defined classes is
too simplistic, because of the complex interactions
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Comparison of measures
The principal characteristics of these eight well
known instruments that have been used to describe
and measure NBD are shown in Table I. Half were
adopted from existing tools, which questions
whether measures not initially conceptualized as
specific to NBD can be sufficiently comprehensive
to reliably capture its characteristics. With regard to
clinical populations for whom various measures were
originally described, all but the NBAP were composed of people with acquired brain injury. This
particular tool was designed to capture psychological
changes in personality, affect and behaviour characteristic of neurological impairment, but was first
used to measure these consequences amongst people
with dementia rather than ABI. The RNBI was first
employed to study NBD across a wide range of
people and conditions, of which TBI was a subsample.
All the measures incorporate rating scales that
quantify the presence and/or extent of patients
difficulties. Ratings on the NRS and NRS-R are
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910
yes
yes
yes
no
no
yes
8
2
3
item analysis
PCA
EFA
64
20
243
66
66
no
yes
informant
self and informant
self
rating scale
rating scale
rating scale
no
no
no
KBCI
HIBS
RNBI
rating scale
rating scale
no
no
yes
yes
yes
yes
yes
4
5
yes
no
6
confirmatory
factor analysis
PCA
forced hand sort
70
TBI (520)
yes
NFI
no
yes
yes
5
EFA
29
TBI (286)
yes
NRS-R
clinician
no
no
yes
4
PCA
27
TBI (101)
clinician
yes
NRS
no
Validity
investigated
Number of factors
or sub-scales
Data reduction
method
Number
of items
Pre-morbid
function
Population
(sample size)
Respondent
Type
Adapted from
existing measure
Table I. Comparison of some of the characteristics described in the original reports of instruments used to measure NBD within ABI populations.
Reliability
investigated
correlation
ICC
Cronbachs alpha
Cronbachs alpha
Cronbachs alpha
Cronbachs alpha
Cronbachs alpha
Cronbachs alpha
4 factors
5 hypothetical factors
8 scales
2 factors
4 domains
Cronbachs alpha
5 factors
Cronbachs alpha
Neuropsychological measures MMPI
Severity (coma)
factors
factors
factors
factors
5
5
5
6
KPCI
HIBS
RNBI
NBAP
NFI-66
NFI
NRS-R
NRS
4 factors
911
% agreement
Pearsons r % agreement
Pearsons r % agreement
ICC
Cronbachs alpha
Cronbachs alpha
Inter-rater
Reliability
Internal
Concurrent/Predictive
Factorial
Measure
Validity
Validity issues
Table II. Summary of main validity and reliability analyses pertaining to instruments used to measure NBD within ABI populations.
Testre-test
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cognition/energy;
meta-cognition;
somatic concern/anxiety;
language
NRS-R
Vanier et al. [40]
intentional behaviour;
emotional state;
survival oriented behaviour;
arousal state;
language & speech problems
NFI
Kreutzer et al. [41]
cognitive; behavioural;
social problems;
somatic complaints;
communication
NFI-66
Kreutzer and
thinking; somatisation;
Devany (unpublished) [42] depression; aggression;
miscellaneous
NRS
NBAP
KPCI
HIBS
RNBI
indifference; inappropriateness;
depression; mania; pragnosia
inattention; unawareness of problems;
impulsivity; apathy; interpersonal problems;
communication problems;
somatic differences;
emotional adjustment
emotional regulation;
behavioural regulation
intrapersonal functions;
interpersonal functions;
quality of life
Reliability issues
In contrast to validity, a perfunctory examination of
Table II suggests that reliability properties have been
less extensively investigated amongst the eight
measures considered here. One property that was
determined in all the instruments reviewed was
internal consistency, defined as the extent to which
items thought to measure the same general construct
produce similar scores. Cronbachs alpha was
employed for this purpose in all cases and, using
Nunnallys [53] criteria, alpha coefficients for the
factors and scales that comprise these measures
generally exceed 0.70 and, as a consequence, have
acceptable reliability. However, there are exceptions.
For example, internal consistency on the NRS-R was
as low as 0.50 [40] and 0.49 on the NBAP [26]. In
contrast, knowledge concerning inter-rater and test
re-test reliability is lacking amongst the measures.
Where this has been investigated, Pearson correlations and percentage of agreement have predominantly been used to determine the extent of
agreement between different raters in a single
administration or its consistency amongst different
administrations. Use of these methods for both
purposes has been criticized: in the case of nominal
data, percentage agreement between raters does not
take into account the amount of agreement that
would be expected by chance; similarly for ordinal
data, Pearson correlations fail to take into account
differences between raters. Instead, calculation of
the Kappa statistic and Intraclass Correlation
Coefficient (ICC), respectively, are the appropriate
methods of determining reliability [54]. These data
are only known in the case of inter-rater reliability on
the NRS-R [40] and testre-test reliability on the
NBAP [26]. ICC values exceeded 0.92 on the
NBAP, suggesting it has good consistency over
time; values for the NRS-R were more variable
(0.560.85) which does raise some concerns regarding that particular instruments reliability between
raters.
Time since injury
Standardization of items and scoring do not appear
to have been influenced by time since injury,
although long-term follow-up studies suggest that
psychosocial outcome is influenced by length of time
post-injury [55, 56]. Those measures considered
here have utilised patient cohorts at various stages of
recovery, with most individuals being assessed 6
months or more after injury. Godfrey et al. [44] used
the HIBS to quantify change in patients over a
3-year period. It is not known whether factor
structures would change in the case of very longterm outcome, but, in the view of the authors, this is
unlikely. A core role of these measures and those that
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rehabilitation workers. As argued earlier, working from a clearly defined theoretical or conceptual framework will further ensure the scope
of items is sufficient.
Should an awareness/insight coefficient constitute an
ideal characteristic of any measure of NBD?
Threats to the validity and reliability of information
that relies totally on the patient as informant have
been discussed. The tendency to under-report
difficulties also casts doubt on the validity of selfreport measures to inform treatment [6771].
However, there is still value in obtaining ratings
from patients, because these self-perceptions can
be compared with ratings obtained from relatives
or carers to help determine characteristics such
as self-awareness/insight or social judgement.
Comparisons of this kind may be regarded as
an ideal characteristic of future NBD measures.
For example, the authors of the NFI advocated that
any discrepancy between informant and patient
ratings could be used to help assess the degree of
post-injury adjustment. This may be related to
experience as a function of time since injury. For
example, Godfrey et al. [44] noted from HIBS
ratings that patients tended to under-report the
severity of behaviour problems within the first
6 months after closed head injury compared to
those injured 13 years earlier. Those who were at
a later stage post-injury evidenced better insight into
emotional and behaviour difficulties, but presented
higher levels of emotional dysfunction.
Cooper-Evans et al. [72] found a similar relationship between greater awareness of deficit and
increased psychological distress, but this was not
a function of time since injury. Their sample had
suffered ABI a mean of 10 years earlier. The
cognitive function of patients with the lowest levels
of insight was much worse than the group whose
insight was better preserved. However, such patients
paradoxically rated themselves as having higher selfesteem than the insightful patients, highlighting an
ethical dilemma for clinicians regarding the management of reduced awareness of deficit, because this
research suggests that self-esteem and psychological
distress may be adversely affected by therapy, whose
goal is to improve insight.
An index of insight and awareness embedded
within NBD measures would be useful, but clinically
it would need to be interpreted with caution, within
a broader set of outcome measures. It cannot be
reliably predicted that insight and awareness will
improve with time, so a measure of reduced insight
will not pinpoint any particular stage of neurobehavioural recovery. Therefore, whilst it might be useful
to provide such an index, it will not be possible to
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Concluding remarks
ABI is one of the few clinical conditions for which
reliable long-term prognoses remain elusive. Current
assessment tools contain methodological problems of
definition, conceptualization and measurement of
NBD. Furthermore, many fail to use a conceptual
framework that distinguishes impairment and disability from handicap. As a consequence, scores from
assessment tools are difficult to use in a way that
is clinically or socially meaningful as an indication
of outcome. This study has proposed that ICIDH2
is a potential framework for the development of
new tools for quantifying NBD as it provides
a system that facilitates understanding and classifying neurobehavioural characteristics of ABI. Future
observational tools based on this framework could
overcome many of the issues with existing measures
discussed in this paper. Furthermore, maximizing
the reliability and validity of new tools will help
clinicians generate more robust understanding of the
nature and severity of neurobehavioural disability
and social handicap, whilst providing information
that is clinically and socially meaningful as an
indication of outcome. New and better measures
will improve formulations for rehabilitation of NBD,
planning and implementation of treatment goals,
discharge planning and knowledge about outcome.
Changes in scores over time should be capable
of reliable interpretation by clinicians as
reflecting meaningful change in levels of NBD
and social handicap, rather then perhaps being
a product of any poor statistical qualities of
a measurement tool.
This review has attempted to clarify some
issues that relate to the assessment of NBD which
need to be addressed in order to promote understanding of how its characteristics arise and how
these may subsequently impact on long-term psychosocial outcome. The authors hope that the
critical analysis presented in this paper will generate
further interest amongst researchers to develop
further measurement tools that will reliably inform
rehabilitation staff of those legacies of ABI that are
likely to have long-term psychosocial significance
and which need to be a focus of rehabilitation
interventions.
Acknowledgements
The information in this manuscript and the manuscript itself is new and original and has never been
published either electronically or in print.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
1. Oddy M, Coughlan T, Tyerman A, Jenkins D. Social
adjustment after closed head injury: A further follow-up
seven years after injury. Journal of Neurology, Neurosurgery,
and Psychiatry 1985;48:564568.
2. Cicerone KD, Tanenbaum LN. Disturbance of social
cognition after traumatic orbitofrontal brain injury. Archives
of Clinical Neuropsychology 1997;12:173188.
3. McDonald S, Flanagan SM, Rollins JB, Kinch JM. TASIT:
A new clinical tool for assessing social perception after
traumatic brain injury. Journal of Head Trauma
Rehabilitation 2003;18:219238.
4. Wood R Ll, Williams C. Neuropsychological correlates of
organic alexithymia. Journal of the International
Neuropsychological Society 2007;13:471479.
5. McDonald S, Flanagan S, Martin I, Saunders C. The
ecological validity of the TASIT: A test of social perception.
Neuropsychological Rehabilitation 2004;14:285302.
6. McDonald S, Saunders JC. Differential impairment in
recognition of emotion across different media in
people with severe traumatic brain injury. Journal of
the International Neuropsychological Society 2005;11:
392399.
7. Wood R Ll, Williams C. Inability to empathize following
traumatic brain injury. Journal of the International
Neuropsychological Society 2008;14:289296.
8. Starkstein SE, Robinson RG. Mechanisms of disinhibition
after brain lesions. Journal of Nervous and Mental Disease
1997;185:108114.
9. Stewart JL, Tannock R. Inhibitory control differences
following mild head injury. Brain and Cognition 1999;41:
411416.
10. McKinlay WW, Brooks DN, Bond MR, Martinage DP,
Marshall MM. The short-term outcome of severe blunt
head injury as reported by relatives of the injured person.
Journal of Neurology, Neurosurgery and Psychiatry 1981;44:
527533.
11. Prigatano GP. Personality disturbances associated with
traumatic brain injury. Journal of Consulting and Clinical
Psychology 1992;3:360368.
12. Mateer CA. The rehabilitation of executive disorders. In:
Stuss DT, Wincour G, Robertson IH, editors. Cognitive
neurorehabilitation. Cambridge: Cambridge University
Press; 1999. pp 314332.
13. Brewer TL, Metzger BL, Therrien B. Trajectories of
cognitive recovery following a minor brain injury. Research
in Nursing and Health 2002;25:269281.
14. Eslinger PJ, Grattan LM, Geder L. Impact of frontal lobe
lesions on rehabilitation and recovery from acute brain injury.
Neurorehabilitation 1995;5:161185.
15. Greve KW, Love J, Sherwin E, Stanford MS, Mathias C,
Houston R. Cognitive strategy usage in long term survivors
of severe traumatic brain injury with persisting impulsive
aggression. Personality and Individual Differences 2002;32:
639647.
917
918
64. Wood RL, Worthington AD. Neurobehavioural rehabilitation in practice. In: Wood RL, McMillan T, editors.
Neurobehavioral disability and social handicap after head
injury. Hove, UK: Psychology Press, Taylor & Francis; 2001.
65. Alderman N, Knight C, Morgan C. Use of a modified version
of the Overt Aggression Scale in the measurement and
assessment of aggressive behaviours following brain injury.
Brain Injury 1997;11:503523.
66. Knight C, Alderman N, Johnson C, Green S, BirkettSwan L, Yorston G. The St Andrews Sexual Behaviour
assessment (SASBA): Development of a standardised recording instrument for the measurement and assessment of
challenging sexual behaviour in people with progressive and
acquired neurological impairment. Neuropsychological
Rehabilitation 2008;18:129159.
67. Ezrachi O, Ben-Yishay Y, Kay T, Diller L, Rattock J.
Predicting employment in traumatic brain injury following
neuropsychological rehabilitation. Journal of Head Trauma
Rehabilitation 1991;6:7184.
68. Hillier SL, Metzer J. Awareness and perceptions of
outcomes after traumatic brain injury. Brain Injury
1997;11:525536.
69. Port A, Willmott C, Charlton J. Self-awareness following
traumatic brain injury and implications for rehabilitation.
Brain Injury 2002;16:277289.
70. Prigatano GP, Fordyce DJ. Cognitive dysfunction and
psychosocial adjustment after brain injury. In: Prigatano
GP, Fordyce DJ, Zeiner HK, Roueche JR, Pepping M, Wood
BC, editors. Neuropsychological rehabilitation after brain
injury. Baltimore, MD: Johns Hopkins University Press;
1998. pp 117.
71. Sbordone RJ, Seyranian R, Ruff RM. Are the subjective
complaints of traumatically brain injured patients reliable?
Brain Injury 1998;11:505515.
72. Cooper-Evans S, Alderman N, Knight C, Oddy M. Selfesteem and self-concept as predictors of mood and behaviour
during rehabilitation following severe brain injury: An
exploratory study. Neuropsychological Rehabilitation
2008;18:607626.