Volume 82, Issue 1 , Pages 49-56, January 2001
Levels of self-awareness after acute brain injury: How patients' and rehabilitation specialists' perceptions compare☆☆☆★
Article Outline
Abstract
Abreu BC, Seale G, Scheibel RS, Huddleston N, Zhang L, Ottenbacher KJ. Levels of self-awareness after acute brain injury: how patients' and rehabilitation specialists' perceptions compare. Arch Phys Med Rehabil 2001;82:49-56. Objective: To examine self-awareness regarding performance on 4 daily living tasks and to test theoretical predictions for a model of self-awareness in persons with acquired brain injury. Design: A comparative design examining the level of self-awareness recorded by patients and actual patient performance as judged by rehabilitation clinicians. Setting: A community-based residential center providing comprehensive rehabilitation services to persons with acquired brain injury. Participants: Fifty-five persons with acquired brain injury and the identified potential to return to independent function in the community. Ten subjects without brain injury provided comparison data. Intervention: Information was collected by using patient self-report, clinician rating of patient performance, patient rating of non-brain-injured subjects, and clinician rating of non-brain-injured subjects. Main Outcome Measures: Three self-awareness criteria were examined: intellectual, emergent, and anticipatory. Self-awareness was rated for 3 tasks: dressing, meal planning, and money management. Results: Statistically significant differences (p < .05) were found for all levels of self-awareness across the 3 tasks. Persons with brain injury judged their abilities higher than clinician ratings of actual performance. No statistical support was found for a hierarchy among intellectual, emergent, and anticipatory self-awareness. Conclusions: No evidence was found supporting a hierarchy among levels of self-awareness as defined and measured in the present study. New methods for operationally defining intellectual, emergent, and anticipatory self-awareness are necessary to examine the relationship between self-awareness and performance. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Keywords: Brain injuries, Disability evaluation, Rehabilitation
INDIVIDUALS WITH acquired brain injury frequently display unrealistic expectations regarding their physical, sensory, and cognitive abilities.1, 2, 3 Patients who are aware of their deficits tend to perform better in rehabilitation,4 are more motivated to participate in treatment,5 and achieve better vocational and community adjustment outcomes.6, 7, 8, 9 Conversely, a lack of self-awareness may result in a failure to employ appropriate compensatory strategies and may produce behavior that is dangerous or ineffective.10, 11 The lack of self-awareness regarding high-risk behavior is recognized as a common impediment to successful rehabilitation of persons with brain injury12, 13 and has been identified as an important area for research.14 No consensus exists, however, regarding an empirically based definition of self-awareness,6 how best to measure the phenomenon,8 or a theoretical framework to guide treatment and research efforts in this area.15, 16, 17, 18, 19
In the present investigation, self-awareness was defined as the subjective acknowledgment, observation, or recognition of one's own actions and the drawing of subjective inferences about their effects.6, 12, 20 Self-awareness relies on knowledge from the present and the past, as well as information inferred about the future. This knowledge must be coordinated and interpreted so that appropriate interaction occurs in the natural environment.8
Measuring awareness deficits typically involves comparing patients' estimates of their performance with the ratings of family members or rehabilitation professionals.7, 8, 21, 22 Other methods have used objective personality measures to assess the presence of distress21, 22 and have compared differences between patients' estimates of their performance on neuropsychologic tests with actual test scores.23 Scales used to measure impaired awareness include the Awareness Questionnaire, Patient Competency Rating Scale, Awareness Interview, Self-Awareness Questionnaire, and the Self-Awareness of Deficits Interview.6 However, only the Patient Competency Rating Scale and the Awareness Questionnaire have been subjected to psychometric investigation. Sherer et al6 found that patients and family members did not differ in their estimates of the patient's degree of impairment when asked specific questions rather than general or open-ended questions. This finding confirmed previous studies by Gasquoine24 and Deaton.23
Although there is no consensus on a theoretical framework to explain deficits in self-awareness, 3 primary models exist: (1) the cognitive, (2) psychodynamic, and (3) neurophysiologic. Respectively, these models examine deficits in self-awareness as: (1) a distinct cognitive system or subsystems including attention, memory, or executive functions14, 19, 21, 25; (2) denial as a defense mechanism23; or (3) specific deficits in awareness relating to lesion site.19, 26
Any theoretical approach to describing self-awareness must include classification of performance. Crosson et al27 proposed a classification of self-awareness for postacute rehabilitation of persons with brain injury that includes the categories of intellectual awareness, emergent awareness, and anticipatory awareness. Intellectual awareness is a basic understanding by patients that an impairment or deficit exists. Emergent awareness is a more detailed awareness of the impairment that develops as one is engaged in performing a task. Emergent awareness also involves the realization that one may be unable to perform a specific task because of an impairment. Crosson's final classification27 of self-awareness is anticipatory awareness, which is the ability to reflect on future consequences of impairment.
The typology proposed by Crosson is essentially linear, suggesting that development of anticipatory awareness requires the prior establishment of intellectual and emergent awareness (fig 1).27
Fig. 1.
The 3 levels of self-awareness. (Reprinted/Adapted with permission from Crosson et al,27 “Awareness of Compensation in Postacute Head Injury Rehabilitation,” J Head Trauma Rehabil 1989;4(3):46-54 © 1989, Aspen Publishers, Inc.)
The present investigation examined the self-awareness typology proposed by Crosson.27 Specifically, we wanted to evaluate 4 research questions: (1) Are the levels of self-awareness hierarchic as proposed by Crosson?; (2) Is there a difference between patients' rated self-awareness of their ability to complete a task and their actual performance of that task as rated by a rehabilitation professional?; (3) Are persons with brain injury able to rate accurately the ability of persons without brain injury?; and (4) Do clinician ratings of brain-injured persons differ from their ratings of non-brain-injured persons?
Methods
Subjects
Forty-five subjects with traumatic brain injury who received rehabilitation services participated in the first phase of the study, which was designed to answer research questions 1 and 2 stated earlier. All subjects were capable of independent mobility (using of a wheelchair if necessary) and were judged by the professional staff at the participating facility as potentially capable of independent living. They ranged in age from 17 to 58 years (mean age ± standard deviation [SD], 29.46 ± 9.02yr). Thirty-one subjects were Caucasian, 7 African American, and 7 Hispanic. Twenty-two subjects completed high school, 12 had some college, and 6 had graduate or professional degrees. Three subjects did not complete high school. Information on educational level was not available for 2 subjects.
All subjects had a medical diagnosis of closed head injury. Twenty-nine had been in motor vehicle accidents, 6 had been injured during falls, and 4 had been hit by cars. Two had been injured in other types of accidents. Four subjects had been assaulted or injured as a result of domestic violence. Twenty-six had experienced coma after their injury. The mean coma length was 17.29 ± 10.32 days. Severe coma length was defined as loss of consciousness for more than 24 hours. The mean Glasgow Coma Scale (GCS) score was 5.67 ± 2.85 (SD).28 Severe GCS score was defined as score of 8 or less. The average period of medical inpatient management was 43.10 ± 30.41 days). The postinjury period before the most recent admission to the rehabilitation facility ranged from 9 days to 119 months.
Results from neuropsychologic testing were available for 32 participants. The tests provided a comprehensive cognitive profile and helped identify the client's potential to function independently in the community. Two subjects were not tested because they were too impaired to cooperate with some assessment procedures, and the other untested subjects had participated in the study before neuropsychologic assessment was added to the study protocol. Of the 32 subjects who were administered neuropsychologic tests,29, 30, 31, 32 a few were unable to obtain reliable scores on 1 or more measures because of motor, language, or cognitive impairment. Thus, the number of subjects completing the different neuropsychologic tests varied.
The mean ± SD Full Scale IQ for subjects who were assessed with the Wechsler Adult Intelligence Scale-Revised (WAIS-R)29 was 81.6 ± 11.7 (n = 30). Mean ± SD for Performance IQ was 77.5 ± 12.6 (n = 32), and Verbal IQ was 86.3 ± 12.3 (n = 30); these scores from the WAIS-R were within the low average range. Academic skills were assessed with the Wide Range Achievement Test-3rd Edition,30 and mean ± SD standard scores for the overall sample were at the upper end of the low average range for reading (90.9 ± 16.4; n = 30), at the lower end of the average range for written spelling (87.8 ± 17.6; n = 32), and the higher end of the borderline range for written arithmetic (75.0 ± 16.8; n = 32). The mean ± SD number of perseverative errors (27.2 ± 16.3; n = 30) on the Wisconsin Card Sorting Test,31 a measure of problem solving, was within the low average range when compared with published normative data. However, the mean score from the long-term delayed free recall trial of the California Verbal Learning Test (CVLT)32 was consistent with severe memory impairment. On average, the mean ± SD delayed free recall was 4.8 words out of 15 ± 3.8 (n = 32), and this level of memory performance falls well below the first percentile of the CVLT normative sample.
Scores of the Disability Rating Scale (DRS) were available for 28 of the study participants. The DRS ratings ranged from 2 to 10 with a mean of 4.93 ± 1.9. The mean DRS score indicated that the patients had a moderate level of disability based on the suggested interpretation for the DRS.33 No significant difference (p > .05) existed in age, gender, or other demographic characteristics between the 28 patients with DRS scores and the 17 without DRS scores. The 17 patients without DRS scores were enrolled in this investigation before a separate study that used the DRS began.
Ten subjects with brain injury and 10 without were included in the second phase of the investigation, which was designed to answer research questions 3 and 4. The 10 subjects with brain injury included 5 men and 5 women with an age range (mean ± SD) from 19 to 51 years (32.7 ± 9.64). They did not differ in any significant way from the 45 subjects with brain injury included in the first phase of the investigation. Ten subjects without brain injury also participated in the second phase of the investigation. The non-brain-injured subjects were staff members at the participating facility or student volunteers. They were 5 men and 5 women ranging in age (mean ± SD) from 21 to 40 years (29.89 ± 8.34) who did not have any physical or cognitive impairments preventing them from engaging in the full range of normal social and work activities. They served as a comparison group for assessing the ability of clinicians and patients to evaluate self-awareness and actual performance in self-awareness tasks. The research protocol was approved by the appropriate human subjects review committees, and informed consent was obtained from each subject or from the subject's legal guardian.
Test instrumentation
Self-awareness was tested by asking subjects to perform 4 different tasks: dressing, meal planning, simple math calculations used in daily activities, and checkbook reconciliation. In the dressing task, subjects were asked to put on a sweatshirt independently. For the meal planning exercise, subjects were asked to write independently 3 meal plans (breakfast, lunch, dinner) that were nutritionally balanced. For the simple math calculation task, subjects were given a form and asked to complete 5 addition and 5 subtraction equations. When subjects completed the calculations, they were asked to check the answers with a calculator. During the math calculation exercise, subjects were timed. For checkbook reconciliation, subjects were given a bank statement, a reconciliation form, a checkbook register, and canceled checks. The therapist explained that the balance on the reconciliation form and the balance on the checkbook should match after the exercise was completed.
Subjects were asked 4 self-awareness questions regarding their ability to complete the 4 tasks. The first question, asked before patients performed the task, was, “Are you aware of any changes in your ability to perform the following task since your injury?” Patients provided a yes or no response to this question for each of the 4 tasks. The second question, also asked before engaging in each task, was, “How well do you think you will do on the following task?” Each task was verbally presented, and patients ranked their ability to complete the task on a 7-point Likert scale, in which 7 = 100% confidence that the task could be completed and 1 = less than 25% likelihood of completing the task.
After completing the 4 tasks, 2 additional questions were asked of the patients. The first was, “How well do you think you did on the task?” Again, the 7-point scale was used, with 7 = 100% successful, and 1 = less than 25% successful. The final question asked was, “How do you think your performance for each of the following might affect your ability to live independently, work, and have fun?” This question was also rated on a 7-point Likert scale.
A graphic of the Likert response scale was provided for the latter 3 questions to help patients complete their individual ratings. This scale provided a visual supplement to the verbal instructions. A copy of the visual response scale and instruction sheet can be obtained from the first author. To ensure face and content validity, the questions were reviewed by a panel of 3 rehabilitation professionals, each of whom had more than 10 years' experience working with persons with disabilities. There was 100% agreement among these panelists that the questions were related to self-awareness as described in the theoretical model proposed by Crosson et al.27 There was also 100% agreement that the questions were appropriate for the persons with brain injury being tested.
Methods for research questions 1 and 2
In the first phase of the study, 2 rehabilitation therapists familiar with patients and responsible for providing therapy in dressing and meal preparation completed the awareness rating scale for the 45 brain-injured subjects based on their task performance. The clinicians completing the performance assessment had extensive experience (> 10yr) in treating persons with acquired brain injury and were not aware of the patients' own ranking of their ability on any of the 4 tasks. The test-retest reliability of the therapist ratings was examined for 10 patients who completed the task twice over a period of 7 to 10 days. Intraclass correlation coefficients (ICCs; model 3,1) ranged from .80 to .97. All individual items produced ICC values of .80.
To examine the model proposed by Crosson et al,27 the questions were categorized into 3 groupings: intellectual awareness, emergent awareness, or anticipatory awareness. The questions were assigned as follows: “How well do you predict that you will do on the following task?” (intellectual awareness), “How well do you think you did on the task?” (emergent awareness), and “How do you think your performance on the task might affect your ability to live independently, work, and have fun?” (anticipatory awareness). Participants answered these questions on a Likert response scale.
The first question, asked before subjects completed any of the tasks—“Are you aware of any changes in your ability to perform the following task since your injury?—was considered in the intellectual awareness category. This question was answered with a yes or no response and was used to group clients for future analysis (see description that follows).
Methods for research questions 3 and 4
The second phase of the study was designed to ensure that self-awareness deficits did not simply reflect a general inability of brain-injured persons to make accurate judgments regarding task performance of activities of daily living (ADLs) and activities required for independent living (IADLs). We were also interested in determining the accuracy of clinician ratings of performance ability across persons with and without brain injury. This phase of the study had 20 subjects: 10 with brain injury receiving services at the participating facility and 10 without brain injury. The following rating conditions were created across the 4 tasks: (1) the brain-injured person's self-rating of ability; (2) the clinician's rating of the brain-injured subject's ability to complete each task (these 2 conditions were similar to those described earlier for phase 1 of the study); (3) the non-brain-injured person's self-rating of ability to complete each task; (4) the clinician's rating of the non-brain-injured subject's ability to complete each task; and (5) the brain-injured person's rating of the non-brain-injured person's ability to complete each of the 4 tasks. The wording of the tasks for presentation to the study participants was modified as appropriate; ie, references to the person's injury were omitted. All other procedures were identical to the first phase of the study for patient self-rating, the clinician's rating of the patient, the non-brain-injured person's self-rating, and the clinician's rating of the non-brain-injured person. The same clinicians who rated the persons with brain injury also rated the persons without brain injury. Some modifications in the procedure were made for the final comparison, the brain-injured patient's rating of a non-brain-injured person's ability to complete the tasks. Each of the 10 patients with brain injury was asked to rate the ability of 1 of the professional staff (an occupational therapist) to complete each of the 4 tasks. All patients were familiar with the occupational therapist from previous therapy sessions. The patients were asked to use the same scale (7-point Likert scale) they had used in completing their own self-rating of the 4 tasks.
Data analysisData were analyzed with descriptive statistics and a nonparametric statistical test (Wilcoxon's signed-rank test) appropriate for the sample size, and ordinal rankings produced by the awareness scale. Percentage agreement statistics were completed for each level of self-awareness: intellectual, emergent, and anticipatory. The limits of agreement plots proposed by Bland and Altman34 were also computed to provide a graphic comparison of the levels of awareness across the tasks for the 45 brain-injured subjects who participated in the first phase of the study.
Results
Results for research questions 1 and 2
The study design produced a matrix of responses based on self-awareness level and task type. Analysis of the descriptive statistics for simple mathematical calculations and balancing a checkbook revealed that performance on these 2 tasks was highly correlated. For purposes of further analysis, responses on these 2 tasks were collapsed into 1 category, referred to as money management. Thus, there were 3 levels of awareness: intellectual, emergent, and anticipatory, and 3 functional tasks: dressing (basic ADL), meal planning, and money management. Table 1 shows the median and mean awareness scores for the 3 tasks, along with information on the variability of the scores and the values reported by the patients and the actual performance as rated by the rehabilitation clinician. The patient's self-awareness and actual performance scores were analyzed with a Wilcoxon's signed-rank nonparametric test. The z of the summed ranks and p values for the Wilcoxon's signed-rank test for each comparison are also included. A statistically significant discrepancy existed between all but 1 of the comparisons (emergent awareness: basic ADL). In every case with a statistically significant difference, patients rated their ability to complete the task more positively than their actual performance, as recorded by the rehabilitation clinicians. The largest discrepancy between self-rating by brain-injured persons and clinician rating was consistently associated with money management (table 1), which was the most cognitively difficult task.
Table 1: Comparison of Patient Self-Awareness Scores and Actual Patient Performance for 3 Levels of Awareness using Wilcoxon's Signed-Rank Test
| Task | Patient Awareness | Patient Performance | z | p |
|---|---|---|---|---|
| Intellectual Awareness | ||||
 Basic ADL | ||||
| Median (range) | 97 (85-100) | 93 (80-100) | ||
| Mean | 96.34 | 92.11 | −2.96 | <.05 |
| SD | 10.23 | 13.19 | ||
| Mean Planning | ||||
| Median (range) | 93 (80-100) | 88 (60-100) | ||
| Mean | 92.01 | 86.15 | −2.36 | <.05 |
| SD | 14.23 | 17.91 | ||
| Money management | ||||
| Median (range) | 88 (60-100) | 78 (30-100) | ||
| Mean | 86.10 | 75.87 | −2.50 | <.05 |
| SD | 18.79 | 24.76 | ||
| Emergent Awareness | ||||
| Basic ADL | ||||
| Median (range) | 99 (90-100) | 95 (85-100) | ||
| Mean | 97.63 | 94.49 | −0.88 | .37 |
| SD | 7.62 | 12.87 | ||
| Mean Planning | ||||
| Median (range) | 95 (85-100) | 86 (60-100) | ||
| Mean | 93.43 | 84.64 | −2.54 | <.05 |
| SD | 10.35 | 13.66 | ||
| Money management | ||||
| Median (range) | 86 (60-100) | 75 (30-100) | ||
| Mean | 84.22 | 74.84 | −2.45 | <.05 |
| SD | 22.33 | 27.31 | ||
| Anticipated Awareness | ||||
| Basic ADL | ||||
| Median (range) | 97 (90-100) | 93 (80-100) | ||
| Mean | 96.34 | 92.34 | −2.43 | <.05 |
| SD | 18.43 | 20.39 | ||
| Meal Planning | ||||
| Median (range) | 90 (80-100) | 88 (70-100) | ||
| Mean | 92.49 | 86.87 | −2.16 | <.05 |
| SD | 23.57 | 21.43 | ||
| Money management | ||||
| Median (range) | 83 (60-100) | 72 (30-100) | ||
| Mean | 81.38 | 70.54 | −2.91 | <.05 |
| SD | 27.30 | 33.76 |
The comparison between patient self-ratings and ratings by rehabilitation clinicians was further examined by calculating and graphing the “limits of agreement” as defined by Bland and Altman. Bland and Altman34 argued that traditional statistical procedures using pooled data can be misleading when the goal is to make individual patient comparisons across raters or assessment instruments. They proposed the limits of agreement approach to supplement traditional statistical methods. To produce the graphic component of the limits of agreement method for the present study, we computed the mean difference values for all pairs of measurements (ie, patient self-rating and clinician rating). The standard deviation of the difference scores was also calculated. In plotting the difference scores (fig 2), Patient minus Clinician were placed on the y axis and the mean (Patient plus Clinician divided by 2) were placed on the x axis.
Fig. 2.
Limits of agreement between patients' versus clinician's ratings of anticipatory self-awareness for 3 tasks: (A) basic ADL, (B) meal planning, and (C) money management. Ratings in perfect agreement would fall on the mean (dashed) line. In these 3 plots, the patients' ratings are consistently higher than the clinician's.
Percent agreement statistics were computed for basic ADL, meal planning, and money management by using the formula (agreement/agreement + disagreement) × 100. The percentage agreement between client awareness and therapist observation of performance was highest for the basic ADL task of dressing: 82% for intellectual awareness, 73% for emergent awareness, and 82% for anticipatory awareness. For the task of meal planning, the percentages of agreement for each awareness level were 71% for intellectual awareness, 51% for emergent awareness, and 64% for anticipatory awareness. For the final task, money management, the agreement percentages were 66% for intellectual awareness, 58% for emergent awareness, and 61% for anticipatory awareness. The average agreement across all tasks for intellectual awareness was 73%, for emergent awareness the level of agreement was 61%, and for anticipatory awareness the mean percentage agreement across all tasks was 69%.
To examine the model proposed by Crosson et al,27 2 groups were created based on responses to the question: “Are you aware of any changes in your ability to perform the following task since your injury?” If patients responded negatively, ie, verbally indicated no awareness of any changes in ability to perform at least 2 of the 4 tasks, then they were placed in the group labeled “unaware.”
The Crosson27 model predicts that self-awareness must be achieved at the lower levels of intellectual and emergent awareness before anticipatory awareness can develop. Based on this prediction, the aware group (n = 19) should have more agreement with therapists for anticipatory awareness questions than the unaware group (n = 26). The agreement rate for the anticipatory questions for the clients in the aware group for the 3 tasks were 76% (basic ADL), 60% (meal planning), and 69% (money management). For the unaware group, the percentage agreement rates were 73% (basic ADL), 64% (meal planning), and 70% (money management). A chi-square analysis showed no statistically significant (p < .05) differences in percentage of agreement between the 2 groups on any of the tasks.
Results for research questions 3 and 4
Figure 3 displays the numerical ratings for each of the 5 comparisons across the levels of awareness (intellectual, emergent, anticipatory) for each of the 3 tasks (dressing, meal planning, money management).
Fig. 3.
Comparisons of patient versus clinician ratings for 3 ADL-IADL tasks across 3 levels of awareness: intellectual awareness (IA), emergent awareness (EA), and anticipatory awareness (AA). Abbreviations: P/P, patient self-rating of ability to complete each task; C/P, clinician rating of the brain-injured patient's ability to complete the tasks; N/N, the non-brain-injured person's self-rating of ability to complete each task; C/N, the clinician rating of the non-brain-injured person's ability to complete the tasks; P/N, the brain-injured patient's rating of the non-brain-injured person's ability to complete each task.
Discussion
The results from the present sample suggest that patients with acquired brain injury lack accurate self-awareness regarding their ability to perform basic ADLs. Twenty-six (58%) of the subjects included in phase 1 of the study indicated that they did not expect unusual difficulty in performing the ADL tasks examined. In contrast, rehabilitation clinicians consistently rated actual patient performance below the level of performance expected by the patient. The difference between the patient's expected or predicted level of performance and actual performance was statistically significant across all but 1 of the tasks examined (table 1).
In the second phase of the present study, multiple cross comparisons eliminated patient and clinician bias in the judgment of patients' task-performing abilities. The study confirmed that persons with brain injury consistently rated their ability to perform the ADL and IADL tasks higher than their actual ability, as judged by experienced rehabilitation clinicians. The second phase of the investigation showed a high rate of agreement between the self-ratings of persons without brain injury and the ratings of clinicians regarding their ability to accomplish the tasks. We also found that the brain-injured participants were able to judge accurately the ability of a non-brain-injured person with whom they were familiar to complete the ADL and IADL tasks. Of note is that the self-ratings of the patients and the patients' ratings of the non-brain-injured persons did not follow the same pattern. The patient self-ratings showed a decrease in confidence as tasks became progressively more cognitively difficult. For example, the patient's self-ratings for intellectual awareness ranged from 97% for dressing to 85% for money management, suggesting an awareness that the money management task would be more cognitively difficult. The patient self-ratings, however, were much higher than the performance ratings assigned by the rehabilitation clinicians. The patients rated the person without brain injury as consistently able to accomplish all 3 tasks at a similar level. This finding suggests that the patients were making some discrimination in their awareness ratings and were able to distinguish between self-awareness and the awareness of another person (without brain injury) to accomplish the selected tasks. More research is needed to distinguish further the ability of brain-injured persons to make these awareness discriminations.
The findings support previous investigations suggesting that lack of self-awareness is a substantial problem in the rehabilitation of persons who have experienced head injury.4, 5 Evidence for a hierarchy of intellectual, emergent, and anticipatory self-awareness was not found in the data we collected from our sample of 45 individuals with acquired brain injury. The Crosson27 model has a logical appeal in terms of the staged acquisition of self-awareness and the relationship between self-awareness and compensatory strategies. The inability to identify a hierarchy among intellectual, emergent, and anticipatory self-awareness in the present study may have resulted from questions that were not sensitive to the levels of self-awareness described by Crosson.27
The present investigation is a preliminary attempt to operationalize the variables described in the model proposed by Crosson.27 The levels of self-awareness are open to interpretation and other methods of operationally defining them must be examined.
Self-awareness in persons with acquired brain injury is an important and complex issue mediated by many factors. For example, it has been hypothesized that meta-cognition, the activity of self-regulation and self-monitoring of learning strategies, plays a critical role in self-awareness.35 Other researchers have pointed to executive functions such as anticipation, goal selection, preplanning, and monitoring as important mediating factors.36 Memory deficits have also been linked to impaired awareness.37, 38 Although self-awareness has been defined as a conscious function,39, 40 others have described it as having both conscious and unconscious components.40, 41 Indeed, the meta-cognitive functions of self-monitoring and self-regulation, which are essential components of self-awareness, have been shown to occur without conscious awareness.42
No single theoretical framework has emerged to predict or explain self-awareness in persons with acquired brain injury. Researchers have had difficulty connecting specific awareness deficits to particular subject groups or etiologies.43, 44, 45, 46, 47 For example, persons with Alzheimer's disease often display a lack of awareness of their impairment but not in a consistent or uniform manner.48, 49 Seltzer et al10 found that Alzheimer-related awareness deficits correlate positively with dementia severity and negatively with patient depression. Other researchers, however, have found no evidence of such correlations.48, 49
Conclusion
Individuals with acquired brain injury often show deficits in self-awareness, ranging from the dramatic, such as unawareness of hemiplegia or hemispatial visual neglect, to the subtle, such as lack of emotional control and inappropriate social interaction.1, 2, 50 To examine deficits in self-awareness, investigators must have methods that enable them to define and measure self-awareness behaviors.50 An established method of evaluating deficits in self-awareness behaviors and their consequences does not exist in medical rehabilitation. In the present investigation, we have attempted to frame such a method by using a specific theoretical model. This initial attempt, which should be viewed as a pilot investigation, has numerous limitations. The questions and tasks were attempts to operationalize levels of the Crosson27 model. Although the questions appear to have face validity, their ability to reflect levels of awareness as described by Crosson27 has not been verified. Additional means of operationalizing intellectual, emergent, and anticipatory awareness are clearly needed. Another limitation is the small sample size. We were limited to descriptive and nonparametric statistics that were not ideal procedures for testing theoretical models. With a larger sample size, more sophisticated statistical methods, such as structural equation modeling, could be used to examine the relationships hypothesized in the Corsson27 model. The tasks used in this study (dressing, meal planning, money management) are narrowly focused. Additional tasks representing a wider variety of skills with environmental and community relevance for persons with brain injury are needed to extend the findings of the current investigation.
It is possible to empirically examine levels of self-awareness in relation to a theoretical framework. The findings of the present study, however, must be viewed as preliminary, given the small sample, the heterogeneous nature of acquired brain injury, and the lack of previous research. A brain-injured person's ability to benefit from rehabilitation services requires a more complete understanding of patient self-awareness of disability and how it influences motivation and participation in therapeutic activities. We are optimistic that this initial investigation will encourage others to join us in continued research on this topic.
Acknowledgements
The authors thank Jane Keel, Cindy Hammecker, and Kim Luppens for assistance with data collection, and Dr. Brent Masel for his support.
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☆ Supported in part by the Moody Foundation and Moody Endowment.
☆☆ No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the author(s) is/are associated.
★ Reprint requests to Kenneth J. Ottenbacher, SAHS, Rm 4.202, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1028, e-mail: kottenba@utmb.edu
PII: S0003-9993(01)95199-8
doi:10.1053/apmr.2001.9167
© 2001 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Volume 82, Issue 1 , Pages 49-56, January 2001
