Communication partner training facilitates everyday outcomes for people with acquired communicationdisability

Leanne Togher1, Skye Mcdonald2, Robyn Tate3,4, Emma Power1 & Rachel Rietdijk1,5

1 Speech Pathology, Faculty of Health Sciences, the University of Sydney, Sydney

2 School of Psychology, the University of New South Wales, Sydney

3 Rehabilitation Studies unit, Northern Clinical School, Faculty of Medicine, University of Sydney

4 Royal Rehabilitation Centre, Sydney

5 Brain Injury Rehabilitation Unit, Liverpool Health Service, Sydney

Westmead Brain Injury Unit

Acknowledgements

› NH&MRC project Grant 402687

› We are grateful to study participants as well as staff from:

› Liverpool Brain Injury Unit, including Dr Grahame Simpson, Dr Adeline Hodgkinson, Manal Nasreddine, Kasey Metcalf

› Westmead Brain Injury Unit and speech pathology department, including Dr Kathy McCarthy, Anna Jones, Dr Alex Walker, Dr Ian Baguley, Dr Joe Gurka, Rod Gilroy

› Royal Rehab Centre Sydney Brain Injury Unit, including Audrey McCarry, Vanessa Aird, Alanna Huck and Dr Clayton King

› Gaye Murrills, private speech pathologist

Approaches to improve communication in TBI

Train the person with TBI (Flanagan, McDonald & Togher, 1995, Medd & Tate, 2000, Tate, 1987,

Cannizzaro & Coelho, 2002; Cramon et al, 1992, Helffenstein & Wechsier, 1982 ; Dahlberg et al., 2007)

Train communication partners (Togher, McDonald, Code & Grant, 2004)

Train both

NH&MRC Clinical trial (Togher, McDonald & Tate, 2007-2009)

3 arm trial which compares:

1. Treating communication deficits of person with TBI directly

(TBI SOLO)

2. Training everyday communication partners (ECP) along with the person with TBI (TBI JOINT)

3. A delayed treatment control group (CTRL)

TBI Participants

44 participants with TBI recruited from Liverpool, Royal Ryde and Westmead Brain Injury Units,

Sydney Australia

Mean age = 36 years (SD=14, range=18-68)

Mean education = 12 years (SD=3, range=7-20 )

Mean time post injury = 8 years (SD=7.2, range=1-25)

Mean PTA = 83.15 days (SD=61, range=6-182)

38 males: 6 females

Everyday communication partner (ECP) participants

44 communication partners of person with TBI

Mean age = 50 years (SD = 15.5, range = 17-79)

Mean education = 13 years (SD = 2.7, 9-19)

80% were female

80% knew the person before the TBI

The majority were partners or parents, however siblings and friends also participated in the study

Study Participants

Allocated to TBI JOINT - Communication partner treatment

n=14 ( 1 dropout = 13)

TBI SOLO - Person with TBI alone treatment

n=15 ( 1 dropout = 14)

CTRL - Delayed treatment control

n=15 ( 1 dropout = 14)

93 % retention rate at post assessment and 87.5% retention at 6 mo f/up

ANOVA comparison across groups ‘ns’ for: Age, education

Time post onset, PTA

Cognitive-linguistic impairment (SCATBI)

ECP age

ECP education

Treatment – Communication Partner training

Group and individual training for TBI JOINT group Group of 4-5 people with TBI & their communication partners

2.5 hr weekly group sessions (+ morning tea/social break)

1 hour weekly individual sessions for each pair

10 week program

Manualised approach

• Interpersonal communication skills

• Collaborative and elaborative conversational strategies (Ylvisaker et al 1998)

• Enhancing / supporting communication of person with TBI/ question asking

Treatment – TBI only training

Group and individual training TBI SOLO group

Group of 4-5 people with TBI

No communication partners

2 therapists

2.5 hr weekly group sessions (with morning tea/social break)

1 hour weekly individual sessions

10 week program

Manualised approach – parallels JOINT contents

Control condition

Waitlist groupdeferred treatment

Conversation assessment

Outcome measures were collected at: Initial assessment,

1-3 weeks after group intervention and

6 months after assessment

2 discourse samples were collected:Casual conversation

Purposeful conversation

Primary outcome measures

Adapted Kagan scale

(Kagan et al., 2001,2004; Togher et al, in press)

Measure of Participation in Conversation (MPC)(TBI)

La Trobe Communication Questionnaire (LCQ)

(Douglas, O’Flaherty & Snow, 2000)

Self report

Other report

Primary outcome measure

Adapted Kagan scale (Kagan et al., 2001,2004; Togher et al, in press)

Measure of Participation in Conversation (TBI)

level and quality of conversational participation

Ability to interact and socially connect (Interaction scale)

Ability to respond to and/or initiate content (Transaction scale)

videotaped interactions rated by 2 blind assessors

9-point Likert scales, presented as a range of 0 to 4 with 0.5 levels for ease of scoring

The Adapted Kagan scales for TBI Interactions

Scales ranged from 0 (no participation) through 2 (some) participation to 4 (full participation) in conversation

Inter-rater reliability scores for both the Adapted MPC scales were excellent

(MPC: ICC = 0.84-0.89). Over 90% of ratings scored within 0.5 on a 9 point scale

Intra-rater agreement was also strong

(MPC: ICC = 0.81-0.92). Over 90% of ratings scored within 0.5 on a 9 point scale

(Togher et al., 2010, Aphasiology)

Secondary measures

Adapted Measure of Support in Conversation (MSC)(Kagan et al., 2001,2004; Togher et al, in press)

Global ratings of communication (Bond & Godfrey, 1997) Appropriate Effortful Interesting/engaging Rewarding

on a 9 point scale, 0-4

Social perception ability: The Awareness of Social Inference Test (McDonald, Flanagan & Rollins, 2002)

Social participation: Sydney Psychosocial Reintegration Scale (Tate et al., 1999)

Confidence and self esteem: Rosenberg Self Esteem Scale (Rosenberg, 1965)

Caregiver satisfaction: Modified Care Burden Scale (Machamer et al., 2002) Discourse analysis measures

Initial analysis compared amount of change across the 3 groups with repeated measures ANOVA pre and post treatment in purposeful and casual conversation conditions

Intention to treat analysis used

Analysis

RESULTS

No statistically significant differences between the three groups at baseline on MPC ratings

Significant treatment effect measured on the MPC

Interaction scale in both casual conversation and

purposeful conversation conditions

i.e., the JOINT group improved relative to the other two

19

Casual conversation: Interaction scale

20

CC = Casual conversation

Purposeful conversation: Interaction scale

21

PC = Purposefulconversation

Results

Significant treatment effect was also found on the MPC Transaction Scale in both casual conversation and purposeful conversation conditions

Casual conversation: Transaction scale

23

CC = Casualconversation

Purposeful interaction: Transaction scale

24

PC = Purposefulconversation

Discussion

Training communication partners was more efficacious than training the person with TBI alone

Success was due to key training principles including: Communication being a collaborative and elaborative process (Ylvisaker

et al., 1998)

Training the ECP to reveal the competence of the disabled speaker (Kagan et al., 2004)

Sensitively targeting behaviours of the ECP (eg test questions, speaking for the person with TBI) led to a significant change in everyday interactions

Discussion

Communication partners were challenged to change THEIR OWN communication behaviours

Eliminating “testing” questions to which they already knew the answer

Reducing questions which checked the accuracy of the person with TBI’s contribution

Speaking to the person with TBI as an adult and not a child

Conclusions in the context of the World Disability Report

A person’s communication environment will significantly impact on their ability to engage in daily living activities

Building capacity within the family unit will promote good psychosocial outcomes for both the person with brain injury and their family members

Training everyday communication partners is an important complementary treatment for people with TBI and their families to facilitate and promote improved communication outcomes