The Drivers' Neuropsychological Rating Scale

Neurological, Medical, and Psychiatric Disorders and Motor Vehicle Operations

Two Competing Interests

With recent advances in medicine and rehabilitation, increasing numbers of injury survivors as well as an aging population have led to a dramatic expansion in the number of individuals who may return to motor vehicle operations after injury or illness, or who continue driving to an advanced age. At the same time, all American legal jurisdictions place substantial restrictions upon the ability of some individuals with disabilities to procure or to maintain an unrestricted driver's license. The result is that two strongly competing interests are at stake when a legal jurisdiction imposes driving limitations.

First of all, such restrictions reflect the need to protect the public from the consequences and acts of persons who are incompetent to drive or who demonstrate an unacceptable level of driving risk as well as the need to protect such persons from themselves. On the other hand, driving in our society has become the predominant means toward independence, the ability to earn a living, and the fulfillment of a significant number of personal goals. The freedom to work, travel, shop, and seek recreational outlets contributes sign)ficantly to our independence. The importance of this aspect of our independence is demonstrated by the fact that persons who are institutionalized on the basis of mental disability inquire more frequently about their driving status than about the effect of their commitment on any of their other rights. And finally, recent advances in technology and rehabilitation indicate that it is possible to:
The decrease in independence after neurological illness or injury or psychiatric illness creates new problems for the individual with a disability, for the family, and for rehabilitation agencies. In particular, the increased emphasis on rehabilitation as well as advances in psychotropic medications in recent years has made it possible for large numbers of neuropsychologically and psychiatrically impaired individuals to return to some level of community functioning. The rehabilitation of the potential motor vehicle operator, however, is not to be treated in the same fashion as the routine physical therapy of the same disabled individual. Resuming a cognitively impaired individual to motor vehicle operation is not the same as simply helping him or her to walkl This is mentioned because, in the author's experience with scores of rehabilitation programs in the United States, Europe, and Latin America, some programs take this simplified Uphysical therapy" type of approach.

Other than questions relating to mental competency in general, it is hard to imagine questions of a more practical applied, or important nature which address the "neuropsychology of everyday life" than those questions related to mness to operate a motor vehicle. It is also hard to imagine questions which are more difficult for a rehabilitation professional to address given the current state of our knowledge. This current drivers' rating scale is therefore intended to present practical and current knowledge of driving after neurological illness, injury, psychiatric illness, or aging. It also will provide a functional decision model for sequential judgments regarding adaptive driving, rather than a single "test battery" which by itself will predict driving ability.

Traumatic Brain Injury and Other Neuropsychiatric Disorders

For example, an increasing number of survivors of serious traumatic brain injury (TBI) in the United States as well as other countries are left permanently disabled as a result of their injuries. The National Brain Injury Association estimates that as many as 70,000 individuals each year are leR with intellectual impairment of such a degree as to prevent them from leading normal lives. These injuries also account for an estimated 4.1 million plus preretirement years of disability, more than from cancer, cardiac arrest, and stroke combined. This situation results in large numbers of young TBI victims being unable to perform many activities related to independent living, one of the most important being the operation of a motor vehicle.

Added to these statistics are the staggering numbers of individuals with mental illness, substance abuse, or neurological disorders from other etiologies which increase risk factors for driving. The literature, for example, has recently documented that young adults with diagnoses of Attention-Deficit Disorder (ADD) manifest a crash risk four times that of their peers. Other psychological or medical disorders which have been demonstrated to increase substantially driving risk are conditions such as the somnolent disorders, cardiac disorders, portasystemic dysfunction, and diabetes which can contribute to peripheral sensorimotor or vision difficulties.

In addition to those who may not be able to resume driving and other independent living functions after neurological or psychiatric illness, large numbers of brain-impaired drivers are already "back on the road again,H perhaps contributing to an unknown accident risk factor if inadequately prepared to resume such a responsibility. The Texas Brain Injury Association, for example, has estimated that as many as 64,000 TBI survivors alone may currently be operating vehicles on Texas roads and highways.



The Drivers' Neuropsychological Rating Scale

Being able to retum to driving may remain a "top priority" for clients who are seen by rehabilitation and psychiatric professionals. However, individuals with acquired neurological deficits may present with injuries and/or illness which result in substantial neurological deficit and which may contribute substantially to disorders of cognition, judgement, a lack of appreciation of the extent of one's own brain injury or limitations, executive/frontal lobe dysfunction, and disorders of personality functioning. Many times such deficits may be severe enough to preclude the resumption of motor vehicle operations altogether or to present an imminent danger to the client or to others due to the presence of these cognitive and/or neurobehavioral disturbances.

Such individuals may therefore well require continued professional assistance and/or legal assistance in order to reestablish their ability to cope with the demands and responsibilities of rehabilitation and to participate fully in a therapeutic rehabilitation environment. Such assistance many times also involves aid with the making of responsible decisions regarding the possibility of the resumption of motor vehicle operations. At the same time, all due care must be taken to respect and to promote the human and civil rights of individuals with neurological and /or behavioral impairments while helping them to achieve their maximum level of independence.

A number of cognitive as well a physical driving tests are currently available, and many of these provide guidelines for driving decisions for rehabilitation patients who may consider resumption of motor vehicle operations after severe illness or injury. However, especially in cases of neurological illness or injury which result in residual neurobehavioral and/or neurocognitive impairment, written and other driving tests have been found to be among the poorest predictors of actual driving potential and risk assessment. In addition, many such tests are given by professionals with backgrounds outside of mental health and rehabilitation. And finally, in their seminal review of the neuropsychological aspects of motor vehicle operation, Hopewell and van Zomeren (1990) voiced the opinion there was no single ~test" or "test battery" which was best at predicting driving risk. Instead, a earful neuropsychological examination combined with a sequential rehabilitation decision strategy was recommended in making such choices. Such a multidisciplinary multi-decision program now appears to be the consensus model for driving experts and neuropsychologists.

The Drivers' Neuropsychological Rating Sca/e was therefore designed to fulfill a need for the rating of risk assessment as well as the planning of rehabilitation strategies by rehabilitation teams working within a mental health, rehabilitation, or geriatric framework. It was not designed to be a precise psychometric instrument, but rather was intended to be a rating guide used by rehabilitation and mental health professionals with an understanding of psychiatric as well as medical and neurological disorders. As a rating guide, the Dr/vers' Neuro,osycho/ogical Rating Sca/e should not be used in a rigid manner, but should be used by rehabilitation teams as an ongoing aid to risk assessment, risk communication, decision making, and the development of rehabilitation and safety strategies. The Drivers' Neuro,osychological Rating Scale can therefore be used as a multidisciplinary assessment and can make use of practically any available testing measure, although it may also be used by individual clinicians. It is typically used by neuropsychologists and psychologists, physicians, nurses, mental health professionals, substance abuse counselors, and allied health professionals working with adaptive driving populations such as Occupational Therapists. The scale provides the following advantages not currently found in other available instruments:

Can be used by a number of medical or nonmedical professionals involved in the assessment of driving skills, risk, training, or rehabilitation;

Can be used with any driving population, to include those with medical, neurological, rehabilitation, aging, substance abuse, criminal, psychiatric, problems or other high risk factors or behaviors;

Allows for the use of and integration of findings from a variety of medical, psychological, psychiatric, social work, and historical assessment devices, instruments, or questionnaires;

Provides driving risk identification along with narrative prediction models; and

Provides driving risk management strategies

And finally, the multidisciplinary coordination which can be tapped by the Drivers' Neuropsychological Rating Scale, when combined with the extensive database provided, meets Joint Commission requirements that psychological assessments make use of external resource data and should be helpful for facilities seeking or maintaining Joint Commission accreditation.

The Drivers' Neuropsychological Rating Scale is the culmination of over twenty years of the author's experience in the neuropsychological assessment and management of motor vehicle operation risk, both with a military and civilian population, to include both flight as well as ground vehicle operations. The author first became interested in this area when asked to assess the fitness of operators intrusted with self-propelled nuclear weapons platforms as well as flight duties involving senior general staff in the European military theater. The attention given to driving after head injury received special award status from the American Psychological Association in 1987:


Motor vehicle operation guidelines vary from simple issues involving an unrestricted license with no limitations, to unrestricted or modified vehicular operations, to licensure revocation with concomitant complete restriction from the resumption of vehicular operations. Guidelines often vary widely from state to state. The Drivers. Neuropsychological Raking Scale is neither meant to be a psychometric test in and by itself nor is it meant to provide rigid categorizations independently of other medical and neuropsychological assessments related to the judgement of experienced clinicians. Rather, the Drivers' Neuropsychological Rating Scale is designed to be used in conjunction with proper medical and neuropsychological assessment and to serve as a guide for decision making by the clinician or the team. The Drivers' Neuropsychological Rating Sca/e is also not designed to supplant or replace decisions by legal bodies such as Departments of Public Safety or Medical Advisory Boards, but to aid these bodies with decision making. Final decisions regarding ground driving operations are vested in state Departments of Public Safety. Flight status decisions may be vested in a variety of flight surgeon and FM domains.

The Drivers' Neuropsychological Rating Sca/e is a rating tool which consists of 15 separate categories requiring specific rating by the clinician filling out the protocol. Each category presents varying factors to be rated. The categories include:


Some factors are scored with a numerical score and these are added to produce a cumulative total dfiving score, with higher scores suggesting increased risk. Other factors are scored with either an UA" or a HBH are titled caving constraints. Driving Constraints are assumed generally to preclude driving for the immediate future, and would include factors such as significantly low vision, medical conditions such as seizure disorder, or substantial substance abuse, regardless of competence with other factors such as sensorimotor coordination. High total driving scores represent increased risk on a variety of levels, the overall pattern resulting in an increased risk factor.

Two hundred and thirty-seven (237) consecutive KAS-R protocols were also rated on the Dnver's Neuropsycho/ogical Rating Scale by staff of the Dallas Neuropsychological Institute. Protocols were analyzed for intertester reliability, these being culled from a total pool of 284 protocols, the remainder being unusable for various reasons. Two groups of raters were used, the first being Ph.D. Ievel raters with several years' experience with brain injury and the second group being Master's and Bachelor's level psychology graduates, also with several years' experience with brain injury. Intertester reliability for the Ph.D. Ievel raters ranged from .71 to .84, while the intertester reliability for the Master's and Bachelor's level psychology graduates ranged from .57 to .78. Such results are seen to be similar to the results from reliability studies of the Neurobehavioral Rating Scale by Corrigan, Dickerson, Fisher and Meyer (1990), in which some consistent biases were found which may have been related to training or experiential levels of the raters.

Further analysis of this group of brain injured subjects also involved identification of those who had been allowed to return to motor vehicle operations or who had perhaps never stopped (driving cohort) and those whose driving privileges had been rescinded at the time of the examination (not driving). In addition to the KAS-R ratings, ratings were obtained on the Driver's Neuropsychological Rating Scale by two Ph.D. Ievel raters. A (X Square analysis = 67.10, which was significant for p < .0001, demonstrating a high degree of predictive validity for the Driver's Neuropsychological Rating Scale . Next, a cohort of 141 geriatric subjects (age 65 or more) was subjected to a similar analysis. All subjects lived in the community and none were in residential or nursing home placement. A (X Square analysis = 57.29, which was also significant for p < .0001, again demonstrating a high degree of predictive validity for the Driver's Neuropsychological Rating Scale for an aging population.

Failure to Warn and the Special Relationship of Health Care Providers

A Special Relationship

It should be noted that in recent U. S. cases the courts have increasingly taken up the issue of whether a health care provider should be held liable for negligent diagnosis and treatment and/or failure to warn third parties of a patient's potential danger to others in the operation of an automobile after psychiatric or brain injury rehabilitation treatment. Courts are therefore increasingly holding that a special relationship exists between rehabilitation professionals and the clients with whom they work, and the courts are increasingly holding rehabilitation professionals to a negligence standard.

Petersen v. State was among the first to extend a psychiatrist's liability for unintentional remote harm. The plaintiff, Cynthia Petersen, was injured when her car was struck by Larry Knox, a mental patient with drug-related problems. Knox had been diagnosed as psychotic, as noncompliant with treatment, as a substance abuser, and had been admitted to an inpatient facility after cutting off his left testicle with a knife. The day before hospital discharge he was apprehended driving his car recklessly on the hospital grounds, but he was discharged anyway with no driving restrictions.

In another case, the Delaware supreme court affirmed a $1.4 million jury verdict in a wrongful death action against a staff psychiatrist who discharged a psychotic patient who drove into the car of the plaintiffts husband, killing him (Naidu v. Buckley, 539, A.2d 1076 (Del. Sup. Ct. 1988). The patient had a long history of psychosis, including at one time demonstrating his "driving abilities't by having rammed a police vehicle with his car.

Cain v. RljPen involved a case in which a psychotic who had undergone a high speed chase with police vehicles, during which he drove at 80 miles an hour into oncoming traffic, was released and described in his discharge summary as "being able to drive.N He subsequently demonstrated his presumably newly-found ability to drive (newly-found since he had never previously demonstrated either mental stability or driving competence) by striking and killing an innocent motorist.

In a case in which the spouse and paralyzed daughter of a mental patient were plaintiffs, a psychotic driver was not committed, her medication was not changed, and her family was not warned of her dangerous condition. The psychotic driver subsequently killed herself and paralyzed her own daughter (Schuster v. Altenberg.)

In addition to increasing recognition of liability in the U.S. commensurate recognition of civil liability is seen in Europe. The Institute for Medical Law and Pharmaceutical Law, Universitat von Gottingen, (Fullmich) has recently addressed the physicians' liability for medication prescriptions which affect the ability to drive.

Upon completion of the Dfivers' Neuropsychological Rating Scale the scale is scored and the computer-generated narrative report is produced. Communication of the clinical information is insured as these categories also (a) provide a narrative description and (b) provide a narrative recommended prescript/'ve action, both of which lay the foundation for further rehabilitation and a strategy for returning to driving. Information provided by the narrative reports should be used by the clinician and/or the rehabilitation team to (a) communicate information and decisions to the client, to the family, to other health care and legal authorities on a need-to-know basis; (b) to communicate risk levels; (c) to formulate and implement a rehabilitation or safety management strategy; and (d) to reevaluate decision making if the client's clinical status changes.

The KAS-R Traumatic Brain Injury Narrative Report

Since the pioneering work of Jackson, Hopewell, Glass, Warburg, Dewey, & Ghadliali (1992) in the evaluation of personality functioning associated with head injury, there remains a pressing need to provide viable assessment devices and strategies for the psychosocial and personality sequelae of traumatic injury. Such an assessment has intrinsic value not only with respect to clinical and rehabilitation issues but also in the medico-legal field. As can be seen from the brief review of the literature presented here, problems of psychosocial adjustment and personality changes are seen as the greatest areas of concern by long-term caregivers (Brooks and McKinlay, 1983), and are often largely responsible for restricting return to work (Brooks, McKinlay, Symington, Beattie, and Campsie, 1987), probably more than any other consequence of the trauma. Therefore, comprehensive and proper neuropsychological assessment of these factors is critical to rehabilitation. Furthermore, without such assessment devices, studies examining the processes involved in personality and emotional problems can only hope to achieve results of restricted applicability. And finally, with increased rehabilitation treatment of traumatic brain injury along with the concomitantly ever growing restrictive impact of managed care, especially within the United States, proper and prompt assessment is critical to the planning of an adequate treatment program. It is still interesting to observe how the neighborhood mechanic or the household gardener would embark neither upon automotive repairs nor yard work without a thorough examination and determination of the cause of the problem and the formulation of a repair strategy which was based directly upon that evaluation; yet rehabilitation center after center will commence upon much more complicated treatment programs without a satisfactory neuropsychological evaluation of the injured patient, perhaps because staff feel that the patient "only needs PT," or "only needs his meds," or "only needs speech therapy!"

The Katz Social Adjustment Scale

The Katz Adjustment Scale-Relatives Form; KAS-R (Katz and Lyerly, 1963) has assumed prominence with respect to assessment of personality change following brain injury (Oddy and Humphrey, 1980; Newton and Johnson, 1985; Klonoff, Costa and Snow, 1986; Goodman, Ball and Peck, 1988). The KAS-R, form R1, was originally designed as a 127 item questionnaire which was to be completed by the relatives or a close friend. The inventory was designed to provide a record of the patient's symptomatology and social behavior during a period of several weeks prior to the report. The items were written to cover two major areas of behavior, the symptomatic (psychiatric) and the social areas. In attempting to measure within the symptomatic area, "the intention was to sample all psychiatric symptoms, minor and major, as comprehensively as possible" (p 511). Items reflecting the social aspects of behavior were derived to reflect both prosocial as well as maladaptive or dysfunctional symptoms or behaviors. Attempts were made to emphasize that the reported should record behavior through the use of terms such as "looks like," "acts if," and "says." Such as behavioristic set was intended to relieve the reported from being asked to judge the patient or "look too deeply into his feelings." Results from the original study were determined to reduce to twelve main factors. These included:
  1. Belligerence
  2. Verbal Expansiveness
  3. Negativism
  4. Helplessness
  5. Suspiciousness
  6. Anxiety
  7. Withdrawal and Retardation
  8. General Psychopathology
  9. Nervousness
  10. Confusion
  11. Bizarreness
  12. Hyperactivity.
The KAS-R has a number of advantages over other personality assessment devices:
  1. The majority of items are phrased in such a way that they clearly ask for ratings of overt behaviour. In this way, the possible effects of psychological denial by relatives are likely to be reduced.
  2. The items were designed such that they may be answered adequately by a nonprofessional rater.
  3. The items cover a wide range of social and emotional behaviour, psychiatric indices, and physical and cognitive performance measures value, appear relevant to the clinical observation of changes following traumatic brain injury.
  4. The items on the KAS-R were designed to assess behaviour in the community, whereas other rating scales have often been limited in this respect.
  5. The items have proven discriminatory validity with well adjusted and poorly adjusted patients.
  6. Extensive comparative data are available on psychiatric and normal populations (Hogarty, and Katz, 1971).

However, there were several disadvantages to the KAS-R in its original form. First, the KAS-R does not permit an evaluation of change, since pre-morbid indices are not requested. Secondly, the KAS-R factor structure was derived from a psychiatric population rather than a TBI population, and there is no guarantee that the factors used are meaningful to TBI survivors. Thirdly, two different factor structures have been produced for this scale; one from the Katz and Lyerly cluster analysis of the scale and another by Graham, Lilly, Paolino, Friedman and Konick (1972). Although a recent study (Goodman, Ball and Peck, 1988) has suggested that the original Katz and Lyerly factor structure is superior for TBI survivors in that it provided a greater degree of accuracy in classifying head injured and non-head injured subjects, there remains considerable doubt as to whether the factor scales are valid for TBI populations. For example, few factor scales from Katz and Lyerly's analysis clearly represent the major personality and emotional changes cited from clinical observations. Furthermore, many of the 127 items of the KAS-R do not load significantly on any of the Katz and Lyerly factors, and some of these appear highly pertinent to the expected emotional and personality sequelae of TBI. Finally, some of the KAS-R factors seem to represent complex factors which makes interpretation with respect to a

TBI population difficult. For example, the factor "Motor Retardation/Withdrawal" potentially confuses physical dysfunction with social withdrawal. There have also been disparate findings regarding which of the KAS factors are influenced by brain injury. For example, Newton and Johnson (1985) found elevated scores for head injury survivors on Belligerence, Negativism, Helplessness, Suspiciousness, Motor-Retardation/Withdrawal and Confusion. While Goodman et al. (1988) confirmed the elevations on the Helplessness, Suspiciousness, Withdrawal and Confusion factors, they could find no significant differences on Belligerence or Negativism. However, they did find elevations on Anxiety, General Psychopathology and Nervousness not identified in the Newton and Johnson study. This inconsistency may simply reflect sample differences between these particular studies. Alternatively, it may suggest that the factor structure of the KAS is not appropriate for TBI populations. Based on the KAS-R1 ratings completed by 88 relatives of clients who had enrolled in a post-acute rehabilitation program, Goran and Fabiano (1993) submitted the 10 component groups previously discerned by them to a classical analysis of tests. Seventy-nine items were found to contribute to the internal consistency of their respective component groups, resulting in alpha values ranging from 0.75 to 0.93 for the component groups. Intercorrelations between components suggested that while some degree of overlap existed between groups, they represented discrete categories of neurobehavioural functioning. Second-order components, as determined by principal-component analysis, discern two significant component groups. Goran and Fabiano, similarly to the previous Jackson et al. study, felth that such findings indicated that the revised KAS-R1 exhibits considerable potential for clinical utility.

The Modified KAS-R

With consideration to the above-mentioned shortcomings of the KAS-R, Jackson, Hopewell, Glass, Warberg, Dewey and Ghadiali (1990) re-analyzed the KAS-R on 463 patients with traumatic injuries (head injury and spinal injury). This study originally comprised patients from five head injury and spinal rehabilitation centers in the United Kingdom as well as an additional five head injury and spinal rehabilitation centers in the United States, the latter gathered by Dr. Hopewell. The investigation now comprises over 1000 head injury and spinal cord survivors, and constitutes the largest study of personality functioning after catastrophic injury of its kind.

Spinally injured survivors, traumatically brain injured survivors, and survivors of both etiologies are included within the sample because it was envisaged that the factors derived from these populations would provide a more detailed and comprehensive assessment device which would aid in the identification of factors (both neurological and non-neurological) involved in promoting emotional and personality change. From the 463 relatives used in the initial 1990 study, 247 subjects were derived from the U. K. and 216 subjects from the United States.

A demographic questionnaire requesting information regarding pre-morbid and post morbid information on the injured person, the relationship of the respondent to the injured person, and global estimates of impairment and change was attached to a 25 item Personality Questionnaire and the KAS-R questionnaire. This inventory (nominally called the International Trauma Inventory; ITI) was distributed, either by hand at clinics, meetings, interviews, etc., or by post, to the relatives of the traumatic injury survivors together with a brief letter explaining the purpose of the investigation and assurances that the information given would be treated confidentially. All spinally injured patients were also sent a similar questionnaire for completion by themselves. The informants were not asked to provide their name or the name of their injured relative. The KAS-R was modified such that two ratings on each item was required; one to rate the person as they were prior to the injury, and one as they are now. Ratings were made on a four point scale; 1 "Almost Never", 2 "Sometimes", 3 "Often", and 4 "Almost Always". A detailed description of the demographic characteristics of this population are provided in Chapter 3. Estimates of the duration of post-traumatic amnesia (PTA) were requested on the questionnaire. However, less than 38% of raters indicated that they were able to provide an estimate of PTA. Therefore, severity of injury was estimated by the respondent by reported loss of consciousness. An arbitrary cut-off of 5 hours of unconsciousness was adopted as the definition of ""milder"" or "severe" head injury. This allowed for reasonable group sizes for later analyses. In addition, one hundred ratings were obtained on spinal injury patients who reported no loss of consciousness at the time of their injury. Ratings on 130 spinal injury patients with a "milder' head injury, and 21 spinal injury patients with severe head injury were obtained. Of the non-spinal head injury patients included in the sample, 86 had a "milder" head injury and 126 had a severe head injury by our criteria.

Difference scores between pre-morbid and post-morbid ratings were calculated for each item by simply subtracting the rating score of how the person was perceived before injury from the rating score of how they were perceived at the time of rating. Inspection of the distribution of scores across all the variables revealed a normal distribution with only a slight skew towards "no-change".

In order to assist interpretation of the factors and also to insure adequate subject to variable ratio, items on the KAS-R were divided into three broad domains: Psychosocial/ Emotional; Physical/Intellectual; and Psychiatric. The difference scores for each category set of items were factor analyzed using varimax rotation. The number of factors extracted was determined by an eigenvalue criteria of greater than one. Although, it is acknowledged that this procedure often results in over-factoring, the aim of this study was to produce an assessment device to sensitive complex and subtle changes rather than seeking parsimonious factor solutions.

The criterion for significance of factor loading was accepted as 0.3. Ten clinical Psychologists with experience in working with traumatically brain injured patients were asked to interpret and suggest a suitable name for each factor derived from the three analyses.

Basic agreement on the nature of the factors was found, although differences in preference for nomenclature was noted. The loadings of the items from the KAS-R on the extracted factors are reported in the original Jackson et al. (1990) study along with the percentage of variance accounted for and the most commonly cited factor name. The numbers of the various items are taken from the original KAS-R scale. The factors, along with the accompanying domain, were determined to be:

Emotional/Psychosocial
Factor 1 :  Belligerence - 30.9% of variance
Factor 2 :Apathy/Amotivational Syndrome - 6.8% of variance
Factor 3 :Social Irresponsibility - 4.4% of variance
Factor 4 :Emotional Sensitivity - 4% of variance
Factor 5 :Nervousness - 3.3% of variance
Factor 6 :Social Withdrawal - 2.9% of variance
Factor 7 :Emotional Incongruity - 2.6% of variance
Factor 8 :Obstreperousness - 2.3% of variance
Factor 9 :Resentfullness - 30.9% of variance
Factor 10:Openness - 2% of variance
Factor 11:Uncooperativeness - 1.9% of variance
Factor 12:Determination - 1.7% of variance
Factor 13:Resistance - 1.7% of variance
Factor 14:Physical Independence - 1.6% of variance


Physical/Intellectual
Factor 1:  General Cognitive Dysfunction - 27.49% of variance
Factor 2:Speech Dysfunction - 7.8% of variance
Factor 3:Arousal Disorder - 6.4% of variance
Factor 4:Verbal Expansiveness - 5.7% of variance
Factor 5:Motor Retardation - 4.3% of variance
Factor 6:Orientation - 3.8% of variance
Factor 7:Abnormal Movement - 3.6% of variance
Factor 8:Rate of Speech - 2.9% of variance
Factor 9:Motor Tremor - 2.9% of variance


Psychiatric
Factor 1:  Paranoid Ideation - 28.3% of variance
Factor 2:Psychotic Anxiety - 7.7% of variance
Factor 3:Bizarreness - 6.8% of variance
Factor 4:Psychotic Depression - 6.3% of variance
Factor 5:Antisocial Behavior - 4.5% of variance
Factor 6:Suicidal Inclination - 4.3% of variance
Factor 7:Unrealistic Attitude - 4% of variance
Factor 8:Fear of Losing Control - 3.7% of variance


It is considered that the above factors show marked similarity to the clinical syndromes derived from clinical experience with TBI survivors. Factors of Belligerence, Nervousness, Psychotic Anxiety, General Cognitive Dysfunction, Verbal Expansiveness, Bizarreness and Fear of Losing Control are similar to factors from the Katz and Lyerly and/or the Graham et al. (1972) analyses. Others, however, such as Apathy/Amotivational Syndrome, Emotional Incongruity, Social Irresponsibility, Emotional Sensitivity, Speech Disturbance, Arousal Disturbance, Motor Tremor, and Unrealistic Attitude are unique to this factor analysis. Furthermore, the latter are among the factors felt best to represent the unique neuropsychological sequelae of TBI. In order to demonstrate the comparability of the derived factors from the Modified KAS-R with those generated from clinical impression of changes following head injury, they were then compared in the original study for correspondence with the items in the Neurobehavioral Rating Scale.

The high degree of correspondence between the Modified KAS-R factor structure and the "syndromes" derived from clinical impression and from validated rating scales such as the Neurobehavioral Rating Scale suggests that close relatives were able to respond to identify these "syndromes" in the behaviour of the traumatically injured person. In addition, relatives serving as raters were able to separate social withdrawal from physical retardation as well as provide discriminating judgments regarding different types of speech, cognitive, and physical disorders. The identification of "independence" as an unique factor is likely to be due to the inclusion of the spinal injury group; thus it was called Physical Independence. Interestingly, both positive and negative personality changes were identified, which perhaps provide for the investigation of adjustment and coping strategies using variables other than just those related to pathology.

Since a high percentage of the factors were found to be inter-correlated, second order factors were derived. Items whose factor loading was greater than 0. 5 were weighted by multiplying the difference score for that item by two in order to reflect their greater influence on the nature of that factor. Factor scores for each subject were then calculated by adding together the difference scores for each item contributing to the relevant factor. These results were subjected to a second factor analysis including factor scores from all three categories. Seven second-order factors were extracted, and are reported in the Jackson et al. study.

The second order factors were also readily interpretable. The two major factors which emerged were Social Maladjustment (which appears most related to emotional/psychosocial and psychiatric factors) and Functional Dependency (which is predominantly related to intellectual/physical factors). It is interesting to note that Social Irresponsibility and Apathy were the only emotional/psychosocial factors to load significantly on the Functional Dependency factor, which perhaps suggests that cognitive dysfunction may play an important role in the etiology of these "personality" factors.

A general factor of Withdrawal also emerged, which is influenced by "emotional' factors (eg. Nervousness, Emotional Sensitivity), "physical" factors' (eg. Motor Retardation, Motor Tremor), and less so by "psychiatric" factors (eg. Psychotic Anxiety, Bizarreness, Psychotic Depression).

Reactive Depression emerged as a factor which appeared to be positively related to the degree of insight and realistic appraisal by the individual, whereas Psychotic Depression loads on the general Social Maladjustment factor. A positive adjustment factor is maintained in the form of Problem Focused Behaviour, as is the factor for antisocial behaviour in the form of Asocial Behaviour, which now includes the inclination towards suicide . In order to compare the utility of the original Katz and Lyerly factors with both the first and second order factors extracted from the above analyses, a series of discriminant function analyses were performed on the factor scores derived from each scoring system. Since there were few spinal injury survivors in the present sample who had also incurred a severe head injury, these subjects were excluded from these further analyses. Thus, three functions were derived from each analysis which discriminated between the four remaining groups; severe head injured, "milder" head injured, spinally injured with "milder" head injury, and spinally injured. In all cases, the discriminant functions (Functions 1, 2 & 3) derived differentiated between the groups in the following way:

Function 1. - Severe head injured from the other groups;
Function 2. - "Milder" head injury - spinal from the less severe head injury group;
Function 3. - Spinal injury subjects from the spinal injury - severe head injury and "milder" head injury group.


The correlations of the discriminating variable with the discriminating function are reported in the Jackson et al. study together the percentage of variance accounted for by each discriminant function.

The above analyses show that the first order factors from the 1990 analysis presents a much more detailed discriminative profile than do the original Katz and Lyerly factors. Not surprisingly, the highest loadings on the function which discriminated between the severely head injured and the other groups derived from all the analyses were those factors which reflected cognitive impairment and language disturbance. However, it is also notable that socio-behavioural problems, especially those reflecting poor social judgment, paranoid or incongruent emotional behaviour also loaded highly. Apathy/Amotivational Syndrome correlated significantly with the discriminant function, which may have been expected given the points raised above. However, other factors which might have been assumed to be more related to a reactive type of syndrome (eg. Emotional Sensitivity, Nervousness, and Withdrawal) also correlated significantly on this discriminant function.

The spinally injured with "milder" head injury were discriminated from the other non-severe head injury groups in terms of their reaction to their injuries, with higher ratings of Resentfulness, Suicidal Inclination, and Psychotic Anxiety as the major discriminant variables amongst the primary factors and Asocial Behaviour and Reactive Depression amongst the second order factors. It seems likely that the presence of even a "milder" head injury in addition to a major physical handicap impedes psychological adjustment to that injury and increases potential for suicidal inclination, resentfulness and denial (ie. Unrealistic Attitude). If confirmed, this finding has significant implications for rehabilitation approaches in all spinal injury centers, and would logically suggest that the identification of such cases be pursued vigorously by means of neuropsychological assessment.

Function 3 discriminated spinal injury subjects from both "milder" head injury groups. The main factor-discriminant function correlation was Physical Independence, which supports the previous interpretation of this factor being most related to physical ability. The results of this discriminant analysis can be interpreted as reflecting the greater ability or tendency of the spinal injury group to take on personal responsibility for their own adjustment, hence the loadings of Un-cooperativeness (+), Openness (-), Fear of Losing Control (-) and the second order factor Frustration/Resistance (+) with the discriminant function.

Using these different discriminant functions, it was possible to classify each subject according to their factor scores into one of the four subject groups and compare hit and miss rates. The percentage classification results using the Katz and Lyerly factors were reported in the Jackson et al. (1990) study and indicate an overall improvement from 47.2 % correctly classified to a high of 73.1% correctly classified; the overall improvement was 60.9%.

The percentage of correct classification using the original Katz and Lyerly factors, although above chance, was quite low, with major errors being made in classifying the "milder" head injured and the spinal injured groups. There was a tendency for these factor scores to bias classification towards the spine and "milder" head injured group with nearly half the severe head injured being misclassified in this way.

The Jackson et al. (1990) study factors provide a much more accurate discrimination between the four traumatic injury groups, improving on the Katz and Lyerly factors by an increased overall accuracy. Furthermore, the considerable bias of the Katz and Lyerly factors was greatly reduced. The majority of errors made appeared to be the confusion of spinal injured subjects and "milder" head injured - spinal subjects or the confusion of "milder" head injured subjects with either spine or spine - "milder" head injured subjects. This may have been expected given that some subjects suffered very mild head injuries with only a brief loss of consciousness, and therefore probably little or no significant brain injury.

The KAS-R Traumatic Brain Injury Narrative Report

Clinical Adaptation

Upon completion of the Jackson, et al. study, the Dallas Neuropsychological Institute, which had coordinated the United States portion of the study, began compiling additional data and analyses. For enhanced clinical use, it was felt that a number of clinical needs would met by using the scale as a rating of current symptomatology which would lead directly to both risk assessment and risk management strategies as well as clinical treatment plans designed specifically for a brain-injured population. This adaptation therefore addressed a number of clinical needs:

  • The need for a rating of current symptomatology which made use of the richness of either clinical or family ratings and which avoided biases inherent in self-report;
  • Such ratings would lead directly to a variety of both risk assessment and risk management strategies which are important to this population;
  • Such ratings would lead directly to a variety of clinical treatment plans designed specifically for a brain-injured population;
  • Treatment plans designed specifically for a brain-injured population would aid with both managed care demands as well as comply with JCAHO and CARF standards; and
  • Ratings would be replicable, allow for serial assessment, and would be useful for outcome measurements.

Such an adaptation could be accomplished in a variety of ways. First, the KAS-R could be used in a manner similar to the method introduced by Katz and Lyerly in that close relatives or friends could rate the traumatically brain injured survivor, with clinical scores being generated by using the improved factor analyses of the Jackson, et al. study.

An additional method would be an adaptation of the Levin Neuropsychological Rating Scale and BPRS approaches in which the ratings would be done by the clinician himself or herself. Such uses would therefore combine the advantages of clinical experience with the observational and historical richness of observers with a wealth of first-hand knowledge of the person being rated. Furthermore, unlike either the Neuropsychological Rating Scale or the BPRS, which do not automatically provide either risk assessments, risk management strategies, or treatment plans designed specifically for a brain-injured population, our adaptation of the KAS-R Traumatic Brain Injury Narrative Report would allow for such risk assessments, risk management strategies, or treatment plans designed specifically for a brain-injured population. Therefore, for the first time with such populations, clinicians would not only be rating current syptomatology of a brain-injured client, but such ratings would lend themselves directly to empirically validated and practical risk management and treatment planning strategies.

The KAS-R Traumatic Brain Injury Narrative Report and Risk Management

In recent cases U.S. courts have increasingly taken up the issue of whether a clinician should be held liable for negligent diagnosis and treatment and/or failure to warn third parties of a patient's potential danger to others in the operation of an automobile after psychiatric or brain injury rehabilitation treatment (Borum, Swartz, and Swanson, 1996; Grisso and Tomkins, 1996). Courts are increasingly holding that a special relationship exists requiring rehabilitation professionals who work with TBI survivors who may return to motor vehicle operations to provide a duty to protect or warn others when high crash rates may be predicted, and courts are increasingly holding rehabilitation professionals to a negligence standard. Such standards may also well be applied to other issues, such as warning the community-based provider of a vocational trial that the client might sexually assault, mutilate, and attempt to murder a female teenager, warning family that a brain-injured client might commit suicide by gaining access to an unrestricted roof and jumping to his death, or warning that a client might develop irreversible tardive dyskinesia and deteriorate psychiatrically and physically due to inadequate environmental structure and prolonged chemical restraints (all of these are actual litigation or potential litigation cases, some already or in the process of court adjudication). In addition, as manged care practices increasingly impact upon the provision of rehabilitaiton and mental health services decision-makers for managed care may be held increasingly responsible for the reuslts of theirs decisions. Recent examples of thi include Texas efforts to have managed care denials of service held accountable for the practice of medicine as wel as recent challenges to the ERISA shield.

In the field of law and mental health, there has been an evolution in thinking about how to assess risk for vioIence pscyhiatric patients as well as after traumatic brain injury (TBI). Early writings referred to these tasks as "predictions of dangerousness" or "predictions of violence," and described them as being almost exclusively focused on the person as the determinant of violence potential. However the focus has now shifted much more to person-situation interactions that produce conditions of risk which can change over time. This current mode of thinking is often referred to as "risk assessment." At a very basic level, risk assessments are not (or at least arguably should not be) oriented toward dichotomous predictions of whether a given individual will or will not be "accident prone" or whether they are dangerous "enough" to justify legal sanctions; rather, they should provide clinical/behavioral descriptions and an analysis of behavioral correlates of accident recidi vism that result in a probabilistic statement of risk. Risk should be viewed as a dynamic, contextual, and continuous construct, as opposed to former conceptions of "dangerousness" which tended to be more static, dispositional, and dichotomous. The current approach to risk assessment separates the construct of "dangerousness" into its component parts:

  • Risk Factors: Variables used to predict risk
  • Harm: Amount and type of crash risk being predicted
  • Risk Level: Probability of harm.
The neuropsychological and rehabilitation assessment using the KAS-R Traumatic Brain Injury Narrative Report provide the basic data for the Risk Assessment, and this assessment then forms the basis for recommendations forRisk Management . The model used by the KAS-R Traumatic Brain Injury Narrative Report includes four categorical levels:
  • Category I: Low Risk;
  • Category II: Moderate Risk;
  • Category III: High Risk; and
  • Category IV: Extreme or Very High Risk.

Upon completion of the KAS-R Traumatic Brain Injury Narrative Report , the protocol is scored and the computer-generated narrative report is generated. Communication of the clinical information is insured as these categories also (a) provide a narrative description and (b) provide a narrative recommended prescriptive action, both of which lay the foundation for further rehabilitation and treatment strategies. Information provided by the narrative reports should be used by the clinician and/or the rehabilitation team to (a) communicate information and decisions to the client, to the family, to other health care and legal authorities on a need-to-know basis; (b) to communicate risk levels; (c) to formulate and implement a rehabilitation or safety management strategy; and (d) to reevaluate decision and treatment strategies if the client's clinical status changes.

Rating Instructions

Instructions for the KAS-R Traumatic Brain Injury Narrative Report are as follows:

"This form is a rating for either your relative or friend who has been injured or ill. In the case of clinical ratings, the form is designed to be completed by a clinical professional who is completing a clinical assessment of their client. It is to be filled out by you as a person or clinician who knows the client well. In the case of a relative or friend, you should have known the client for at least several weeks, if not longer. For a clinical professional, your knowledge should come from clinical observation, and should be correlated with other assessments which are obtainable such as existing medical, school, and work records, if any, and clinical case information obtained from other relevant sources. Please answer all 127 questions by putting a cross (X) in the box which best describes the client as he or she is now, after the injury or illness."

Although direct observation is preferable, the advantage of using the form as a standardized rating is that behavior which is not easily "captured" or observable during the laboratory setting may be rated if reliable information regarding the behavior is obtainable. This is especially true for the "high intensity, low frequency" disorders which may occur with some frequency in the outside environment but with less frequency in the clinic, eg.:
  • Executive Dysfunction - "Has periods where he/she stops moving or doing something" - Item 7
  • Affective Dysfunction - "Gets very excited for no reason" - Item 34
  • Behavior Disorders - "Threatens to injure certain people" - Item 112

In this regard, the rating form should be used similarly to the Neuropsychological Rating Scale and the Vineland Adaptive Behavior Scales. With the latter, for example, the rater may never directly observe whether or not a child can brush their teeth while in the clinic setting itself. However, parental, other familial, foster parent, or teacher reports that a child can do so without cueing and without assistance may be taken as an indication for positive scoring of the item. Individual items are scored for occurrence and severity simultaneously "by putting a cross (X) in the box which best describes the client as he or she is now, after the injury or illness. " Items are scaled for severity as follows:
  1. - Almost Never
  2. - Sometimes
  3. - Often
  4. - Almost Always


The Children's Emotional Intelligence Test

C. Alan Hopewell, Ph.D., ABPP


What is "Emotional Intelligence"?

Overview

Emotions are the biopsychological reactions of an individual to important events in his or her life. These reactions involve special kinds of feelings, widespread physiological changes, impulses to action, and, sometimes, overt behavior. This is just as true for children as it is for adults. In addition, the emotions which a child experiences and the emotional competencies which he or she learns early in life will determine their emotional and social paths into adulthood and will be critical in determining success or failure throughout life.

"Emotions" are a complex state or condition that affects the entire child and influences how successfully the child interacts with the environment. Emotions are reactions to important life issues, such as being confronted by danger or threat, competing for popularity or grades, making a friend, or losing a parent. Such reactions help the individual with problems, that is, by fighting, by running away, by falling in love, or by calling for help. Although emotion represents a change in a person's inner state, it is also a change in behavior; most importantly, the behavior is designed to have an effect on the people or events around the person.

These complex states called "emotions" are described in different ways. The language of introspection uses terms such as "happy," "sad," "angry," and "disgusted. " The language of behavior is illustrated by words such as "hitting," "running away, " "crying, " and "embracing." Emotions can also be described in terms of the effects of the emotional behavior on the environment; thus, running away in the face of danger has the effect of protecting the individual from harm. Attacking a threatening stimulus has the effect of destroying the stimulus. Crying for help often has the effect of bringing help.

Rarely, if ever, does a child experience one emotion alone. Secondary emotions are formed by the mixing of primary emotions, like the mixing of primary colors to form others. Interestingly enough, the names given secondary, or mixed, emotions are often the same as those used to describe personality: for example, a person who habitually experiences feelings of anger and disgust might be called a "sarcastic" person; someone who is accepting and joyful would be called "sociable. Investigators have shown that emotions are related not only to personality, but to psychiatric diagnoses and ego defenses as well. They are also closely related to MOTIVATION. Emotions are thus fundamental processes in all living organisms and are related to many aspects of functioning.

The Children's Emotional Intelligence Test is the result of the most up-to-date scientific research on Emotional Intelligence ("EQ" - for "Emotional Quotient"). The Children's Emotional Intelligence Test is a scientifically validated instrument and is the only psychological test available which measures Emotional and Social Intelligence manifested at home, demonstrated , and developed in the classroom, which is also able to incorporate ratings from those who know children best: their teachers, parents, and mental health experts.

The Children's Emotional Intelligence Test is an Inventory which combines both a performance component as well as a rating factor, which sets it apart from other purported tests of Emotional Intelligence which are simply self-report measures. A self-report test of intelligence would ask questions about what one believes one's intelligence to be The Children's Emotional Intelligence Test directly measures the performance of the child in the classroom, at home, and in the community by allowing teachers, parents, and mental; health experts on Emotional Intelligence tasks.

The theory of "Emotional Intelligence" is not new, although many people who think so are just now paying attention to this important , indeed, critical factor of our functioning. Emotional Intelligence allows us to think more creatively and to use our emotions as well as our social skills to solve real life problems which are critical to our success later in life. "Emotional Intelligence" in most people overlaps to some extent with general intelligence, although children with significant difficulties with Emotional and Social Intelligence demonstrate a "disconnection" between these two skills which cause substantial difficulties in real life situations.

We've all heard of IQ, but at one time or another most of us have met someone who's technically smart, perhaps even brilliant, but otherwise not very bright and perhaps a real "loser" in the game of life. Such individuals do not seem to be successful at work, cannot seem to keep relationships, and often do not know how to make themselves happy. That's probably because they have a high IQ but rank low on the emotional intelligence scale, demonstrating a significant "disconnection" between IQ and EQ. One startling example of such a disconnection is that of Theodore Kasinsky, a person described as having a near-genius IQ. And yet the notorious "Unabomber" was unable to figure out how to fix a broken bike, was unable to earn a living and existed in a hovel at subsistence level, and used his "intelligence" in extremely destructive ways which killed and injured people. For example, we know that IQ predicts academic achievement and occupational status, but it still only predicts about 20% of personal variation in these areas. Psychologists have yet to understand everything that predicts the other 80% of success in these areas of life, but are beginning to feel that the Emotional Intelligences are among the most important, if not the determining abilities which are related to life success,

The Components of Emotional Intelligence

The components of Emotional Intelligence measured in The Children's Emotional Intelligence Test include:
  • General Mood Management
We often have little control over when we are swept by emotion being able to manage our emotions helps us to deal with anxiety, aggressiveness, and other emotional problems. Being able to regulate one's emotions means that the child can use his or her feelings to make a better decision. Being emotional and being able to use emotions adequately also help children to understand how someone else feels.
  • Internal Mood Management
The first, and perhaps most basic, component of Emotional Intelligence, is being able to recognize one's own feelings as well as how others are feeling. That is why Identifying emotions in people, music, and art is part of Emotional Intelligence. Understanding Emotions refers to knowing what happens as emotions get stronger, or how people react to different emotions. Some emotions are more complex than others, being formed through the combination of simpler emotions. The ability to understand complex emotions is part of Emotional Intelligence. This component also understands emotional "chains," how emotions transition from one stage to another. Being able to manage one's internal moods also means being able to develop healthy levels of self esteem. self esteem and the achievement of healthy goals also requires the development of Positive Motivation. The marshaling of feelings of enthusiasm, zeal and confidence is critical for achievement.
  • General Stress Management
Stress is the most common cause of ill health in our society, probably underlying as many as 70% of all visits to family doctors. It affects children as well as adults. The causes of stress are multiple and varied but they can be classified in two general groups: external and internal. External stressors can include relatives getting sick or dying, poor work at school or in other projects, or people or adults criticizing or becoming angry. However, much the stress that many children have is self-generated (internal). Such stress may be increasing among today's children who seem to be increasingly susceptible to peer and social pressures.
  • Emotional Flexibility
The assessment of emotional flexibility continues to be a challenge in psychology, yet these are the very functions which are considered to interfere significantly with independent and productive functioning. Emotional flexibility is described as the ability to engage in independent, purposeful, self-directed behavior which is adaptable and resilient to change and stress. Disorders of emotional flexibility are generally manifested by irritability, rigidity, apathy, defective behavioral initiation, carelessness, poor judgement, and inappropriate social behavior. The problem can be described as an impairment in the starting, switching and stopping of behavior as well as impairments in problem solving, impairments in the ability to engage in emotional and social operations, and the lack of ability to self-monitor for mistakes or show insight.
  • People Skills
The capacity to know how another feels is important in school, on the job, in romance and friendship, and in the family. Children with defective people skills are frequently noted by teachers and parents to be somewhat "in their own world" and are often preoccupied with their own agenda. They are often deeply frustrated and disappointed by their social difficulties. Their problem may either be a lack of interaction or a lack of effectiveness in interactions. They seem to have difficulty knowing how to "make connections" socially. Gillberg has described this as a "disorder of empathy", the inability to effectively "read" others' needs and perspectives and respond appropriately. As a result, such children tend to misread social situations and their interactions and responses are frequently viewed by others as "odd". Children with severe conduct problems, severe difficulty with adults and authority figures, and defective empathy for others may be at risk for Conduct Disorde rs. Such disturbances generally result in significant impairments in social, academic, and occupational functioning.
  • Motor Skills
Many people might question what motor skills have to do with the establishment and development of Emotional Intelligence. First of all, the sensorimotor evolution of children closely parallels their intellectual and emotional development, and actually lays the foundation for this further growth. Secondly, the motor skills of children are greatly prized by both their peers and adults, who reward and reinforce the best football players, dancers, and basketball players. Children good at such motor skills are more likely to be accepted by their peers and develop higher levels of self esteem. Research done a few years ago by the author in conjunction with the Dallas Neuropsychological Institute established that effective motor skills were more important in being able to secure and maintain employment than was IQ, memory functioning, and speech fluency. The only other factor as important as a person's motor skills in being effective was - you guessed it! Their Emotional Intelligence.

Children with poor EQ often demonstrate what are termed "nonverbal learning disorders." Such a child commonly appears awkward and is, in fact, inadequately coordinated in both fine and gross motor skills. The child may have had difficulty learning to ride a bike or to kick a soccer ball, and is often ridiculed by peers as being a "klutz," "nerd," or a "dork". Such rejection certainly results in lowered self esteem. Fine motor skills, such as cutting with scissors or tying shoe laces, are often difficult for these children to master. The child may compensate by "talking his way through" even simple motor activities. A young child with NLD or low motor components of EQ is less likely to explore the environment motorically because they cannot rely upon kinesthetic processing and spatial perceptions. This child learns little from experience or repetition and is unable to generalize information.

In the early years, such a child may appear "confused" much of the time despite good intelligence and adequate scores on receptive and expressive language measures. Closer observation will reveal a social ineptness brought about by misinterpretations of body language and/or tone of voice. Such children are unable to "look and learn" and often does not perceive subtle cues in the environment such as: when something has gone far enough; the idea of personal "space"; the facial expressions of others; or when another person is registering pleasure (or displeasure) in a nonverbal mode. These are all social "skills" which have motor components that are normally grasped intuitively through observation, not directly taught.


The Role of Attention Deficit and Hyperactivity Syndromes

Children with attention deficit and/or hyperactivity syndromes (AD/HD) are often attracted to novel stimuli and can be easily distracted by the environment in conjunction with showing excessive motor activity. ADHD students have a greater likelihood of grade retention, school drop out, academic under-achievement and social and emotional adjustment difficulties. This is probably due to the fact that AD/HD makes children vulnerable to failure in the two most important arenas for developmental mastery, school and peer relations.

Recent research with children who were started at the beginning of the school year without medication trials until later in the year experienced social rejection and peer relationship problems which did not "catch up" even though medication was instituted later on during the school year. This was because the social and emotional problems begun at the beginning of the school year had become serious and chronic enough to prove resistant to later, delayed, therapy. Therefore, such children frequently demonstrate Emotional Intelligence shortcomings, and the improvement of Emotional Intelligence is critical for both their future scholastic as well as social success.

For example, making and keeping friends is a difficult task for children with AD/HD. A variety of behavioral excesses and deficits common to these children get in the way of friendships. They may talk too much, dominate activities, intrude in others' games, or quit a game before its done. They may be unable to pay attention to what another child is saying, not respond when someone else tries to initiate an activity, or exhibit inappropriate behavior.

Children and adolescents with AD/HD do not necessarily outgrow the condition when they become adults. The symptoms frequently lead to difficulties on the job, in relationships, and in daily living. AD/HD looks different in adults than it does in children. Most noteworthy is the lack of obvious hyperactivity in adults. Generally, by the time a person with ADHD reaches late-adolescence, he or she has learned to inhibit obvious signs of hyperactivity, such as not staying seated. These adolescents and later the adults do experience a form of hyperactivity which appears as mental restlessness and constant fidgeting. Adults with hyperactivity are often pencil twirlers, foot tappers, and often jaw clinchers.


The Role of the Conduct Disorders

The essential feature of Conduct Disorder is a repetitive and persistent pattern of behavior which the basic rights of others or major age-appropriate societal norms or rules are violated. Many children with defective Emotional Intelligence are either at risk or already manifest various traits suggestive of Conduct Disorder. These behaviors fall into four main groupings: aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive conduct that causes property loss or damage , deceitfulness or theft, and serious violations of the rules of society. Such Conduct Disorders are significantly related to violence in our schools, increased incidents of delinquency, drug abuse, and teen pregnancy, school failure, and a variety of juvenile criminal activities.

Children or adolescents with Conduct Disorders often initiate aggressive behavior and react aggressively to others. They may display bullying, threatening, or intimidating behavior; initiate frequent physical fights; use a weapon that can cause serious physical harm ; be physically cruel to people or animals ; steal while confronting a victim; or force someone into sexual activity. Physical violence may take the form of rape, assault, or in rare cases, homicide.

Deliberate destruction of others' property is a characteristic feature of this disorder and may include deliberate fire setting with the intention of causing serious damage or deliberately destroying other people's property in other ways .

Deceitfulness or theft is common and may include breaking into someone else's house, building, or car; frequently Iying or breaking promises to obtain goods or favors or to avoid debts or obligations (e.g., "conning" other people); or stealing items of nontrivial value without confronting the victim .

Characteristically, there are also serious violations of rules (e.g., school, parental) by individuals with this disorder. Children with this disorder often have a pattern, beginning before age 13 years, of staying out late at night despite parental prohibitions or running away. Children with this disorder may often be truant from school, and a history of school and later vocational and social failure is frequent.

Outcome of Emotional Intelligence Literacy and Training

A number of studies have not only shown that such Emotional Intelligence skills are at least equally important if not more important than traditional IQ in longer-term success in life, but that such skills can at least to some degree be trained , learned or at least managed. Youngsters demonstrating higher levels of "EQ" or who have been trained in a number of social skills learning programs have been shown to be:
  • More responsible
  • More assertive
  • More popular and outgoing
  • More prosocial and helping
  • Better understanding of others
  • More considerate, concerned
  • Able to demonstrates better prosocial problem solving
  • More harmonious
  • More "democratic"
  • Able to demonstrate better conflict resolution
  • Able to demonstrate better self control
  • More thinking prior to acting
  • More frustration tolerance
  • More task orientation
  • Able to demonstrate better peer relationships and sociability
  • More positive attachment to family and school
  • More able to resist drug use
  • More able to resist delinquency
  • Able to achieve better standardized test scores
  • Able to demonstrate less Impulsivity and self-destructive tendencies

The Children's Emotional Intelligence Test is the first Inventory of its kind which is designed to identify and rate "EQ" in children and to provide effective treatment and educational planning strategies fro improvement in Emotional Intelligence.


Therapeutic Programs Designed to Increase Emotional Intelligence

Recent research has well established that a variety of therapeutic programs designed to increase Emotional Intelligence "work." Such programs rely upon the assessment of Emotional Intelligence among students in a variety of regular and special education programs as well as the implementation of a diversity of therapeutic interventions and programs which result in substantially increased social skills and overall Emotional Intelligence, as summarized in Daniel Goleman's recent book,

Emotional Intelligence, Why it can matter more than IQ;
Daniel Goleman;
Bantam Books; New York; 1995


Other therapeutic programs designed to increase Emotional Intelligence such as the following have also documented the effectiveness of such programs:


Typical Goals for the Improvement of Emotional Intelligence May Include:


Goal: To Improve Communication and Socialization

  • Establish and maintain eye contact when speaking to teachers and peers.
  • Ask for help from teachers or aides when needed.
  • Be respectful of peer's opinions.
  • Be positive in communicating with teachers and peers.
  • Share expertise and special interests with peers.
  • Initiate discussions with peers.
  • Respond appropriately to peers in social situations.
  • Compliment peers when appropriate.
  • Accept the success of peers without making negative comments.
  • Attempt to learn the interests of peers.


Goal: To Succeed in the Regular Classroom

  • Stay focused on the instruction in the classroom.
  • Participate appropriately in class.
  • Notify the teacher/aide if you do not understand the material.
  • Notify the teacher/aide if you are distracted by sensory input.
  • Be positive as you approach your work and new tasks.
  • Establish methods by which the student can help himself/herself control anxiety.
  • Notify the teacher/aide if you find yourself becoming overly agitated or anxious and your own efforts to control the anxiety have not been successful.
  • Establish method by which the student can organize and keep organized.
  • Understand that, though teachers and aides will attempt to let you know of potential changes in schedule, etc., there will be times when such notice cannot be given. Work on accepting change without becoming emotionally unraveled.


The Role of The Children's Emotional Intelligence Test in Regular and Alternative Schools


The Children's Emotional Intelligence Test is designed to be used as both an initial as well as a serial assessment of a child's Emotional Intelligence and then to serve as the foundation for a variety of therapeutic programs which can increase social competence and overall "EQ." Schools will also find the use of the system as a good way to publicize the innovative and unique programs implemented by the Charter Schools which are designed to address the needs of this special population of children. Services offered by the International Mental Health Network (IMHN) may include:

  • Individualized computerized testing and scoring of Emotional Intelligence for each child upon admission to the school program;
  • Serial individualized computerized testing and scoring of Emotional Intelligence for each child during the school year to measure progress and outcome;
  • Generation of treatment programs and plans for the individual student;
  • "Turnkey" computer programs for these purposes;
  • Access to thousands of database resources for mental health interventions related to Emotional Intelligence;
  • Access to a national network of psychological experts to help in consultation for the therapeutic remediation of Emotional Intelligence


For information on The Children's Emotional Intelligence Test and other programs offered by Dallas Neuropsychological Institute, P.C., Psicologia Clinica Hispana, and the International Mental Health Network, contact:

Dallas Neuropsychological Institute
Psicologia Clinica Hispana

3401 Altamesa, Suite 116
Ft. Worth, Texas 76133
Voice: (817) 361 - 9747
Cellphone: (817) 919 - 2322

or

7515 Greenville Ave, Suite 407
Dallas, Texas 75231
Voice: (214) 373 - 8080
Fax: (817) 294 - 9420
 
E-mail: hopewell@airmail.net