Quality of life for individuals with traumatic brain injury: comparison with others living in the community

OBJECTIVES: To provide a conceptual overview of approaches to quality of life (QOL) measurement and an extensive review of research relating to QOL after TBI; to document subjective QOL of individuals with traumatic brain injury (TBI); to explore how subjective QOL differs for people with TBI in comparison to individuals with no disability (ND) and those with spinal cord injury (SCI); and to document the perceptions of unmet important needs and the relationship between such perceptions and subjective QOL. DESIGN: Interview-based data focusing on current perceptions of QOL and unmet important needs, obtained from individuals with TBI, SCI, or ND. Covariance and partial regression analyses were used to explore group differences and to document relationships between variables. SETTING: Individuals drawn from diverse communities across New York State. PARTICIPANTS: TBI group: 430 individuals who identified themselves as having TBI; SCI group: 101 individuals with spinal cord injury; ND group: 187 people who identified themselves as having no disability. Participants were recruited through recruitment ads in general circulation newspapers and newsletters and through contacting a wide variety of community agencies. MAIN OUTCOME MEASURES: Two summary QOL indicators: a Global QOL Measure based on two items tapping the individual's emotion-based view of QOL, and a summary score adapted from Flanagan"s Scale of Needs, reflecting the individual's perceptions of total unmet important needs. RESULTS: Both summary QOL indicators were correlated with demographic characteristics. Unmet important needs were stronger in the TBI group than in the SCI and ND groups. Most areas of unmet important need were moderately correlated with the summary QOL indicators. Analyses of covariance showed that severity of injury was a more powerful modulator of post-TBI QOL judgments than the mere fact of TBI. For example, those with the most severe injury (ie, loss of consciousness [LOC] >1 month) rated their QOL similar to that in the ND group, whereas individuals who had experienced only a brief LOC (<20 minutes) viewed their QOL as significantly lower than that in the ND and SCI groups and lower than other TBI severity subgroups. CONCLUSIONS: This exploration of subjective QOL strengthens the argument that after TBI, the insider"s reaction to injury varies greatly within the population. Thus, severity of injury strongly affects perceptions of QOL. The use of a multimethod approach for exploring the reactions and perceptions of QOL has proven useful in this study.     

The enigma of "hidden" traumatic brain injury

OBJECTIVE: To examine individuals with "hidden" traumatic brain injury (TBI), defined in this study as those who sustained a blow to the head, with altered mental status, and experienced a substantial number of the cognitive, behavioral, and emotional sequelae typically associated with brain injury but did not make the causal connection between the injury and its consequences. DESIGN: Comparison of four groups of individuals matched for age, gender, years of education, and duration of loss of consciousness. SETTING: This study of hidden TBI followed the identification of 143 individuals who, within a larger study of people with TBI who live in the community, identified themselves as "nondisabled" (they were to be part of the comparison sample) but who had experienced a blow to the head that left them at minimum dazed and confused. PARTICIPANTS: 21 of these 143 individuals also reported large numbers of symptoms (eg, headaches, memory problems) associated with TBI. This group (Hidden TBI-High Symptoms group) was compared to three other matched samples: one with known TBI (Known Mild TBI group) and one with no disability (No Disability group) (both of which were drawn from the larger study), and one group of individuals who identified themselves as having no disability but who had experienced a blow to the head that resulted in a few symptoms (Head Trauma-Low Symptoms group). MAIN OUTCOME MEASURES: All study participants were administered an interview that incorporated several existing instruments documenting levels of reported symptoms, emotional well-being/distress, and vocational/social handicaps. RESULTS: The Hidden TBI-High Symptoms group was found to be similar to the Known Mild TBI group in terms of the number and types of symptoms experienced, whereas the Head Trauma-Low Symptoms group was similar in this respect to the No Disability group. The two former groups also evidenced high levels of emotional distress, whereas the two latter groups did not. However, on measures of handicap, the Hidden TBI-High Symptoms and Head Trauma-Low Symptoms groups were similar to the No Disability group and dissimilar from the Known Mild TBI group in that the last group experienced vocational handicap, in particular, whereas the other groups did not. Conclusions: We conclude that hidden TBI occurs at a nontrivial level (7% of our nondisabled sample). Also, individuals with hidden TBI (with persistent symptoms), unlike those with known mild TBI, are likely to experience emotional distress but not vocational handicap following injury.     

The influence of memory beliefs in individuals with traumatic brain injury.

Objective: To explore metamemory (memory beliefs) and affective functioning in individuals with traumatic brain injury (TBI). Participants: Twenty-six individuals with mild TBI (MTBI), 16 individuals with severe TBI (STBI), and 42 uninjured adults. Outcome Measures: Metamemory in Adulthood questionnaire, Postconcussion Syndrome Checklist, Perceived Stress Scale, Beck Depression Inventory (2nd ed.), Beck Anxiety Inventory. Results: The control group endorsed higher memory self-efficacy, fewer depressive symptoms, fewer memory strategies, and fewer postconcussion symptoms than the MTBI or STBI group. The MTBI group placed high importance on success in memory tasks. Memory self-efficacy and memory-strategies use mediated the relation between TBI and depression. Conclusion: Individuals with brain injury hold negative beliefs about their memory functioning, and such beliefs contribute to depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I psychopathology in individuals with traumatic brain injury

OBJECTIVES: To assess the incidence, comorbidity, and patterns of resolution of DSM-IV mood, anxiety, and substance use disorders in individuals with traumatic brain injury (TBI). DESIGN: The Structured Clinical Interview for DSM-IV Diagnoses (SCID) was utilized. Diagnoses were determined for three onset points relative to TBI onset: pre-TBI, post-TBI, and current diagnosis. Contrasts of prevalence rates with community-based samples, as well as chi-square analysis and analysis of variance were used. Demographics considered in analyses included gender, marital status, severity of injury, and years since TBI onset. SETTING: Urban, suburban, and rural New York state. PARTICIPANTS: 100 adults with TBI who were between the ages of 18 and 65 years and who were, on average, 8 years post onset at time of interview. MAIN OUTCOME MEASURES: SCID Axis I mood diagnoses of major depression, dysthymia, and bipolar disorder; anxiety diagnoses of panic disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and phobia; and substance use disorders. RESULTS: Prior to TBI, a significant percentage of individuals presented with substance use disorders. After TBI, the most frequent Axis I diagnoses were major depression and select anxiety disorders (ie, PTSD, OCD, and panic disorder). Comorbidity was high, with 44% of individuals presenting with two or more Axis I diagnoses post TBI. Individuals without a pre-TBI Axis I disorder were more likely to develop post-TBI major depression and substance use disorders. Rates of resolution were similar for individuals regardless of previous psychiatric histories. Major depression and substance use disorders were more likely than were anxiety disorders to remit. CONCLUSION: TBI is a risk factor for subsequent psychiatric disabilities. The need for proactive psychiatric assessment and timely interventions in individuals post TBI is indicated.     

Blame attribution in intentional and unintentional traumatic brain injury: Longitudinal changes and impact on subjective well-being.

Objective: Examine longitudinal changes in attribution of blame to self and others, and concern over cause of injury, in both intentional (violence-related) and unintentional (accidental) traumatic brain injury (TBI); investigate the relation of these factors to subjective well-being outcomes at 1 year post-TBI. Study Design: Prospective, multicenter, observational study with longitudinal component. Participants: 99 men with unintentional TBI and 25 men with intentional TBI who sustained moderate to severe injuries, received inpatient rehabilitation, and provided data in both acute rehabilitation and 1-year follow-up. Measures: Blame Attribution Questionnaire, General Health Questionnaire-30, Neurobehavioral Functioning Inventory-Revised Depression Scale, Satisfaction With Life Scale, community participation measures. Results: At both time points, participants with intentional TBI blamed others more while those with unintentional TBI blamed themselves more (trend). Other-blame at 1 year predicted depression but not life satisfaction. Self-blame was not a significant predictor of depression or life satisfaction. Increasing concern over cause/blame for injury from acute rehabilitation to follow-up was associated with high levels of emotional distress. Conclusion: Blame attribution issues may be markers of TBI-related emotional distress regardless of injury etiology, particularly when others are blamed for the injury and/or concerns over cause of injury do not resolve over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The psychological effects of employment after traumatic brain injury: Objective and subjective indicators.

Objectives: This study examines the effects of objective (level of engagement) and subjective (discrepancy between importance of work and the degree to which work needs are met) indicators of employment on self-reported psychological well-being, quality of life (QoL), and depression for individuals with traumatic brain injury (TBI). Design: Cross-sectional. Setting: Community-based research and training center. Participants: 317 individuals with self-reported TBI under the age of 65 were included in analysis. Main Outcome Measures: Living Life After Traumatic Brain Injury (LLATBI; 1998), Flanagan Scale of Needs (J. C. Flanagan, 1982), Beck Depression Inventory-II (BDI-II; A. T. Beck, R. Steer, & G. Brown, 1996). Results: Only 21% of the present sample experienced similar levels of pre- and postinjury employment. Multiple regressions revealed significant relationships between demographic, objective, and subjective employment indicators and perceived QoL and depression. In addition, significant increments in QoL and depression variance were accounted for by subjective indicators of employment per se. Conclusions: Subjective indicators are additional important measures when assessing the rehabilitation needs and planning treatment for individuals with TBI, as they contribute to further improvements in their QoL and mood. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The reliability and validity of the Community Integration Measure in persons with traumatic brain injury.

Objective: To investigate the psychometric properties of the Community Integration Measure (CIM), a scale that assesses self-perceived quality of community integration, among persons with traumatic brain injury (TBI). Method: Persons (N = 279) with TBI completed the CIM, as well as other measures of community integration and quality of life, and were followed up to 15 years postinjury. Results: The CIM was found to be a reliable instrument with adequate internal consistency. Validity was demonstrated in its relationship to other measures of community integration and life satisfaction. Utility was evident in its prediction of perceived social support. Conclusion: Results suggest that the CIM is an adequate measure of community integration for persons with histories of TBI of up to 15 years. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Characteristics of drivers and driving record after traumatic and nontraumatic brain injury

OBJECTIVE: To determine whether individuals with a traumatic brain injury (TBI) or stroke (cerebrovascular accident [CVA]) have an increased risk of subsequent motor vehicle crash or moving violation. DESIGN: A retrospective study comparing the driving records of four cohorts hospitalized with TBI, CVA, isolated extremity fractures (FX), and appendicitis (APPY) with the records of four age-matched, gender-matched, and zip code-matched nonhospitalized cohorts. SETTING: Eligible drivers in the state of Washington, 1991 to 1993. PARTICIPANTS/METHODS: Four cohorts hospitalized in 1992 with TBI, CVA, FX, or APPY were identified from Washington state hospital discharge data. The state driver's license database identified patients with drivers' licenses. Each hospitalized cohort was compared with its own age-matched, gender-matched, and zip code-matched nonhospitalized cohort. MAIN OUTCOME MEASURES: Crashes and citations for moving violations 12 months after hospitalization adjusted for age, gender, and prior driving record. RESULTS: The relative risks (RRs) of any subsequent crash or receipt of citation were not greater for those with either CVA or TBI than for nonhospitalized individuals, nor were the risks of experiencing two or more of these events in the 12 months after hospitalization significantly elevated. After adjustment for prior driving record, modest elevations were observed only for the risks of subsequent driving violation among those with TBI (RR=1.3, 1.0-1.7) and among patients with FX (RR=1.2, 1.1-1.4). CONCLUSIONS: The results do not support the hypothesis that individuals who have sustained a brain injury are at increased risk of motor vehicle crashes. Although patients with TBI were more likely to subsequently receive citations than nonhospitalized individuals, a similar increase was observed among patients without brain injury who had FX, suggesting an inability to completely control for driver characteristics that may be related to risk-taking behavior and that are also associated with an increased risk of driving violation.     

The WRAT-3 Reading Subtest as a Measure of Premorbid Intelligence Among Persons With Brain Injury.

Objective: To examine whether the Wide Range Achievement Test-3 (WRAT-3) Reading subtest (S. Jastak & G. S. Wilkenson, 1984; G. S. Wilkinson, 1993) measures premorbid intelligence in persons with traumatic brain injury (TBI). Participants: Sixty individuals (63% male, 78% Caucasian, mean age = 38 years) tested during acute rehabilitation hospitalization following TBI and 1 year later. Results: Slight (4.4 points) increase in WRAT-3 Reading scores was observed but with greater, although nonsignificant (p = .12), increase for those with greater injury severity. Conclusions: The WRAT-3 Reading subtest is a better hold test for individuals who sustain mild TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients with traumatic brain injury referred to a rehabilitation and re-employment programme: social and professional outcome for 508 Finnish patients 5 or more years after injury

We studied influence of age and educational level before injury on the social and vocational outcome among a group of traumatic brain injury (TBI) patients with post-injury problems in their education and employment. Patients with TBI, followed up for at least 5 years, and who were admitted to a rehabilitation and re-employment programme, were selected for evaluation of long-term outcome. We used the Glasgow Coma Scale (GCS) scores at the time of emergency admission to the hospital to measure brain injury severity. Age at the time of TBI and educational status before TBI were correlated with the outcome measures at the end of follow-up separately in each category of brain injury severity. The study was carried out at the Kauniala outpatient neurological clinic, which specializes in brain injuries in Finland; it works closely with the Departments of Neurology and Neurosurgery at the Helsinki University Central Hospital. Main outcome measures were functional outcome measured by the Glasgow Outcome Scale (GOS), the educational level reached, and post-injury occupation, as well as the incapacity for work at the end of follow-up. In the severe category of brain injuries, children 7 years or younger at the time of injury suffered severe disability as measured by the GOS scores more often than did the older age groups (p = 0.010, chi 2). They were less often capable of independent employment (p = 0.011, chi 2) than the children injured at the age of 8-16. Patients with a higher education usually had a better outcome. In the category of mild brain injuries the majority of the patients, regardless of age, recovered well according to the GOS, and were capable of independent employment at the end of follow-up. Our patients were selected from the TBI population as survivors with problems in education and re-employment. Those with severe injury sustained early in life (childhood and early teens) coupled with poor educational attainment had relatively worse social and vocational outcome; better outcomes were enjoyed by those severely injured individuals whose injuries were sustained later (late teens or early adulthood). In the groups of patients with moderate and mild brain injuries such a relationship was not found between age or pre-injury education and outcome.     

Parent-child interactions during the initial weeks following brain injury in young children.

Objective: To understand how traumatic brain injury (TBI) affects parent-child interactions acutely following injury. Participants: Young children hospitalized for TBI (n = 80) and orthopedic injuries (OI; n = 113). Method: Raters coded videotaped interactions during free play and structured tasks for parental warmth/responsiveness and negativity and child warmth, behavior regulation, and cooperation. Raters also counted parental directives, critical/restricting statements, and scaffolds. Results: Parents of children with TBI exhibited less warm responsiveness and made more directive statements during a structured task than parents in the OI group. Children with TBI displayed less behavior regulation than children with OI. Parental warm responsiveness was more strongly related to child cooperativeness in the OI group than in the TBI group. Child behavior also mediated group differences in parental responsiveness and directiveness. TBI accounted for as much variance in parental behaviors as or more than did sociodemographic factors. Conclusion: TBI-related changes in child behavior may negatively influence parent-child interactions and disrupt the reciprocity between parent and child. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Age differences in a sample of state vocational rehabilitation clients with traumatic brain injury.

Objective: To examine the relations among age, neuropsychological functioning, and vocational rehabilitation following traumatic brain injury (TBI). Study Design and Participants: Prospective study of 78 adults (18-57 years) who qualified for services with the Missouri Division of Vocational Rehabilitation (DVR), based on a history of TBI followed from enrollment to case closure. Group differences based on age were examined for neuropsychological and vocational outcome with multivariate analysis of variance and nonparametric methods. Main Outcome Measures: Neuropsychological test data and DVR data regarding vocational placement. Results: Age-related differences were present for a measure of mental flexibility, isolated demographic characteristics, and 1 DVR service category. Contrary to hypotheses, there were no age-related differences in vocational outcome. Conclusions: In contrast to hospital-based samples, age does not appear to be a negative indicator for individuals admitted to a state DVR program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Trajectories of life satisfaction in the first 5 years following traumatic brain injury.

Objectives: The trajectories of life satisfaction for 609 individuals who sustained a traumatic brain injury (TBI) were studied. Hierarchical linear modeling analysis examined individual level growth trends over the first 5 years following TBI using gender, functional independence, age, and time to estimate life satisfaction trajectories. Measures: Participants completed the Functional Independence Measure and the Life Satisfaction Inventory at years 1, 2, 4, and 5 after sustaining TBI. Results: Participants who reported higher functional independence at year 1 also had higher life satisfaction at year 1. Participants with lower functional independence across the 5-year period had life satisfaction trajectories that decreased at significantly greater rates than the individuals with more functional independence. The life satisfaction trajectory declined for the sample, but participants reporting lower cognitive and motor functional independence had significantly greater declines in life satisfaction trajectories. Age and gender were not significant factors in predicting life satisfaction trajectories following TBI. Implications: Individuals with greater cognitive and motor impairments following TBI are likely to experience significant declines in life satisfaction within 5 years of living with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effect of valued activity disability, social comparisons, and satisfaction with ability on depressive symptoms in rheumatoid arthritis.

This longitudinal study identified a model through which function affects the psychological well-being of individuals with rheumatoid arthritis (RA). Results of hierarchical linear regression analyses (N = 436) demonstrated that greater physical impairment resulted in greater disability in valued activities and engagement in unfavorable social comparisons. All 3 factors--greater physical impairment, greater disability in valued activities, and unfavorable comparison evaluations--predicted low satisfaction with abilities. Low satisfaction with abilities was the most important predictor of higher depressive symptoms and mediated the impact of physical impairment, valued activity disability, and unfavorable comparisons on depressive symptoms. Results highlight the role of personal meaning attached to changes in functional status in predicting the long-term psychological well-being of individuals with chronic illnesses such as RA. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Measurement properties of the neurobehavioral cognitive status examination (Cognistat) in traumatic brain injury rehabilitation.

Objective: Evaluate measurement properties of the Neurobehavioral Cognitive Status Examination (Cognistat) using Rasch analysis. Design: Calibration of item responses from 120 individuals admitted to a rehabilitation medicine service for traumatic brain injury (TBI) and 296 community-dwelling adults with TBI. Results: Three strata of performance were differentiated despite a skewed distribution toward high performance among the community sample. Elimination of easier items created a better targeted instrument (i.e., generated more spread among individuals) without a significant increase in error. Memory and verbal reasoning were the most difficult domains for each sample; however, analyses indicated significant measurement error. Conclusions: As a screening instrument, the Cognistat reliably classifies multiple levels of cognitive status in both acute and postacute TBI settings; however, this measure is unsuitable for generating a profile of neurocognitive strengths and weaknesses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Explanatory Style and Perception of Recovery in Symptomatic Mild Traumatic Brain Injury.

Objective: To examine perception of injury and explanatory style in symptomatic mild traumatic brain injury (MTBI). Study Design: Cross-sectional comparisons. Setting: Outpatient brain injury rehabilitation clinic. Participants: Twenty-two adults with MTBI and 11 with moderate/severe traumatic brain injury (TBI). Measures: Questionnaires addressing self-perception of injury severity and recovery and explanatory style. Results: MTBI patients reported greater injury severity and poorer cognitive recovery and rated their brain injury as affecting more areas of life than the moderate/severe TBI group. Pessimistic explanatory style was associated with poorer perceived recovery. Conclusions: The results provide a stimulus for future research on self-perception and explanatory style as significant psychological variables and should be considered as relevant for interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anosognosia and denial: Their relationship to coping and depression in acquired brain injury.

Objective: To evaluate relations among denial, anosognosia, coping strategies, and depression in persons with brain injury. Study Design: Correlational. Setting: A Midwest residential, post-acute brain injury rehabilitation center. Participants: Twenty-seven adults with brain injury. Measures: Clinician's Rating Scale for Evaluating Impaired Self-Awareness and Denial of Disability After Brain Injury, COPE, Beck Depression Inventory-I. Results: Denial and anosognosia were related and co-occurred. Use of process coping strategies was associated with greater use of problem-focused coping strategies. Higher levels of denial were associated with greater use of avoidant coping strategies, and greater use of these coping strategies was related to higher levels of depression. Conclusions: Individuals primarily in denial and individuals primarily anosognosic differ in the coping strategies they institute. Avoidant coping strategies are used more frequently by individuals in denial, and use of these strategies is associated with higher levels of clinical depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The efficacy of the generation effect in improving new learning in persons with traumatic brain injury.

Objective: To evaluate the usefulness of the generation effect in improving learning and memory abilities in neurologically impaired individuals. The generation effect is the observation that items self-generated by participants are better remembered than items provided by the examiner. Although this effect has shown to be relatively robust in healthy adults, few studies have examined the usefulness of the generation effect in neurological populations. Participants: 18 individuals with moderate-severe traumatic brain injury (TBI) and 18 healthy adults. Main Outcome Measure: The measure was the generation effect protocol. Results: Results indicated recall and recognition of generated information was significantly higher than that of provided information across testing conditions. However, healthy adults showed greater benefit from the generation effect than did individuals with TBI. As expected, recall and recognition performance diminished over time (i.e., immediate recall, 30 min, 1 week) however, rates of forgetting did not differ between groups. Conclusion: Self-generation significantly improved verbal learning and memory in individuals with TBI. The results of self-generation in improving learning suggest that applying that technique may be beneficial in the cognitive rehabilitation of persons with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive outcome in children and adolescents following severe traumatic brain injury: influence of psychosocial, psychiatric, and injury-related variables

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than psychiatric or psychosocial factors as correlates of cognitive outcomes. We addressed this concern by recruiting a consecutive series (N = 24) of children age 5 through 14 years who suffered a severe TBI, a matched group who sustained a mild TBI, and a second matched group who sustained an orthopedic injury. Standardized intellectual, memory, psychiatric, family functioning, family psychiatric history, neurological, and neuroimaging assessments were conducted at an average of 2 years following injury. Severe TBI, when compared to mild TBI and orthopedic injury, was associated with significant decrements in intellectual and memory function. A principal components analysis of independent variables that showed significant (p < .05) bivariate correlations with the outcome measures yielded a neuropsychiatric factor encompassing severity of TBI indices and postinjury psychiatric disorders and a psychosocial disadvantage factor. Both factors were independently and significantly related to intellectual and memory function outcome. Postinjury psychiatric disorders added significantly to severity indices and family functioning and family psychiatric history added significantly to socioeconomic status in explaining several specific cognitive outcomes. These results may help to define subgroups of children who will require more intensive services following their injuries.     

Use of the Neuropsychiatric Inventory in traumatic brain injury: A pilot investigation.

Objective: The goal of this investigation was to pilot the Neuropsychiatric Inventory (NPI) among individuals with traumatic brain injury (TBI) and their caregivers, assessing its screen-metric approach. Design and Participants: Using the NPI, caregivers rated neurobehavioral disturbances in 51 individuals with moderate-to-severe TBI. The NPI was completed 1 or 2 years after the individuals were injured. Results: Caregivers reported the highest symptom levels for participants on Irritability/Lability, Apathy, and Agitation/Aggression, and rated greater levels of distress tied to those domains and to Dysphoria. Caregivers endorsing domain screening items endorsed significantly more metric items (vs. screen non-endorsers) within that domain, as would be expected if the screen accurately measured the psychopathology under consideration. In addition, the screen-metric yielded extremely low false-positive rates, although 5 of the 12 domains had elevated false-negative rates. Conclusions: Findings provide preliminary support for the accuracy of the NPI's screen-metric in this population and are consistent with prior work detailing common problematic neurobehavioral consequences of TBI. These results lay groundwork for research and clinical use of this measure in populations with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)