The acquisition, maintenance, and generalization of problem-solving skills by closed head-injured adults

BEHAVIOR THERAPY 20, 61-76, 1989

The Acquisition, Maintenance, and Generalization of Problem-Solving Skills by Closed Head-Injured Adults

R.M. Foxx

Anna Mental Health and Developmental Center

RONALD C. MARTELLA

NANCY E. MARCHAND-MARTELLA

Southern Ilhnots Umverslty

This study developed and evaluated a program for teaching a problem-solving strategy to closed head-injured adults Four general areas were targeted for training: Commu- nity Awareness and Transportation; Medication, Alcohol, and Drugs; Stating One's Rights; and Emergencies, Injuries, and Safety. The program featured cue cards, response- specific feedback, modeling, self-momtoring, positive reinforcement, response practice, self-correction, and individualized performance criterion levels. The experimental group (N = 3) received baseline, training, probes, and pre/posttrainlng generalization assessments, whereas the contrast group (N = 3) received only the pre/posttraining assessments. The generalization assessments were conducted via interviews and staged interactions and contained situations that were both similar and dissimilar to the training situations. The six-month posttraining results revealed that the experimental subjects' problem-solving skills had generalized to both types of situations whereas the contrast group showed little change. Furthermore, the experimental group's six-month scores were comparable to those of a group of normal individuals. The program appears to offer promise as a means of teaching problem-solving since it uses standardized training procedures, is socially valid, and produces effects that generalize.

The most common method of teaching problem-solving skills has been to use a generation of alternatives approach (e.g., Castles & Glass, 1986; D'Zurilla & Goldfried, 1971; Spivack, Platt & Shure, 1976) wherein the subject is taught to select a solution to a problem situation after first generating several alternative solutions. For example, Castles and Glass (1986) chose situations that represented real-life problems experienced by mentally retarded adults in the

We would like to thank Brenda Mooney, Randy Allnatt, Scott Bullen, Sean Carey, Ehsabeth Garrettson, Tom Huffman, Theresa Krankowskl, Lori Kubes, Martha Kyle, Lisa Litsey, Debra Braunhng-McMorrow, and Don Vogenthaler for their assistance, and Gerry Faw for his com- ments on an earlier version of the paper. Reprint requests should be sent to Richard M Foxx, Anna Mental Health and Developmental Center, 1000 North Main Street, Anna, IL 62906.

61 0005-7894/89/61-7651 00/0 Copyright 1989 by AssooaUon for Advancement of Behavior Therapy

All rights of reproducUon m any form reserved.

62 voxx ET AL.

community and had them "brain-storm" alternative solutions, select the most effective one, and list the steps necessary to implement the chosen solution. Although this approach has proven to be quite effective in teaching problem- solving to a variety of populations such as alcoholics (Intagliata, 1978), psychiatric inpatients (Edelstein, Couture, Cray, Dickens, & Lusebrink, 1980), mentally retarded adults (Castles & Glass, 1986), and distressed families (Robin, 1981), there are apparently no published studies in which it has been used with head-injured individuals.

Another approach to teaching problem-solving skills emphasizes the content of the solution by having the subject choose a single solution to a problem situation (Ross & Ross, 1978). This was the approach which Foxx, Marchand- Martella, Martella, Braunling-McMorrow, and McMorrow (1988) used in a program designed to teach a problem-solving strategy to head-injured adults. Although the program was successful, Foxx et al. reported that subjects sometimes became bored and inattentive during training. They attributed this behavior to the fact that each subject was only required to respond to 25°70 of the situations each session. A greater disappointment was that a generalization assessment one month after training revealed that the trained group had only improved 19.4070 from its pre-generalization assessment.

The present study sought to develop a problem-solving skills training program for head-injured adults that would overcome the problem of subject boredom and produce effects that would generalize and be maintained across situations, settings, and time (e.g., see D'Zurilla & Nezu, 1982; Tisdelle & St. Lawrence, 1986). This was accomplished in several ways. First, a modified generation of alternatives approach was used wherein each subject was required to provide either an initial solution or an alternative one to each problem situation presented in training. This active participation requirement was designed to ensure that the subjects would remain attentive throughout the session and enhance the effects of response practice (Kent-Udolf, 1984). Second, the subjects were encouraged to interact and provide feedback to each other to further involve them in training. Third, probes with untrained problem situations were used throughout the program to assess whether generalization was oc- curring. Fourth, a six-month posttraining generalization assessment was conducted. This was important since many head-injured individuals exhibit memory deficits that may severely limit the entry of information into long- term storage (Gianutsos, 1980). Fifth, because the program was designed to teach problem-solving skills to individuals being targeted for transition from supervised living arrangements to independent ones, social validity was an important consideration. It was assessed by comparing the experimental subjects' problem-solving abilities with those of a normal group of individuals (see Kazdin, 1977).

METHOD Subjects

The three experimental subjects were referred by a private rehabilitation center for head-injured adults. Each had sustained a closed head injury at

PROBLEM-SOLVING SKILLS TRAINING 63

least 3 years prior to the study. Although they were targeted for transition to independent living, each displayed specific problem-solving deficits. None had received any previous problem-solving training.

John was a 28-year-old male who was injured in an automobile accident at the age of 20. He had decreased peripheral vision and right hemianopsia. He exhibited decreased strength and range of motion in both right extremities and used a cane for ambulation. He lived in a transitional living center that served as an intermediate step to independent living. His WAIS scores were 108, 77, and 93 for verbal, performance, and full scale, respectively. John displayed a limited ability to generate and evaluate multiple solutions to problems and was inflexible to altering his initial or incorrect solutions. He relied heavily on Center staff for support in problem-solving.

Robert was a 24-year-old male who was injured in an automobile/train accident at the age of 15. He had severe muscle tone disturbances in both upper extremities and exhibited moderate ataxic movements. He lived in an apartment complex with 24-hour supervision. His WAIS verbal, performance, and full scale scores were 113, 88, and 102, respectively. His clinical records indicated that he had difficulty organizing information in order to make compar- isons and generate solutions. He also lacked strategies for coping with problem situations in the community.

William was a 31-year-old male who was injured in an automobile accident at the age of 28. He developed a seizure disorder as a result of the injury. He lived in the same apartment complex as Robert. His WAIS verbal, performance, and full scale scores were 98, 95, and 97, respectively. He lacked flexi- bility and organization in problem solving and displayed a decreased ability to solve problems when confronted with new information. He attempted to solve problems quickly, rarely checked himself for accuracy, and displayed deficits in identifying the details of a problem situation. William was involved in an earlier problem-solving study as a contrast group member (Foxx et al., 1988), but had received no training.

The three contrast group subjects were also referred by the rehabilitation center. Each had sustained a closed head injury at least 7 years prior to the study. Two lived in the same apartment complex as Robert and William, and the other lived in the same transitional living center as John.

Lisa was a 29-year-old female who was injured in an automobile accident at the age of 17. She was left hemiparetic and confined to a wheelchair. Her WAIS scores were 102, 77, and 90 for verbal, performance, and full scale, respectively. She exhibited a decreased ability to solve problems and identify essen- tial elements in a problem. She required memory cues for some tasks.

Jill was a 26-year-old female who was struck by an automobile at the age of 17. She had impairments of her left lower extremity due to decreased strength and hypersensitivity. Testing on the WAIS revealed verbal, performance, and full scale scores of 94, 76, and 84. Jill had difficulty maintaining attention to a task and controlling her impulsive responses. She displayed deficits in solving complex problems, explaining abstract concepts, and sequencing tasks.

Chris was a 31-year-old male who was injured in an automobile accident at the age of 24. He exhibited a wide-based gait with ataxic movements as

64 FOXX ET AL.

well as excessive upper body and arm motion. Chris was assisted by a staff member approximately 10 hours per week so that he could participate in community activities. Testing revealed WAIS verbal, performance, and full scale scores of 113, 101, and 108. Chris displayed difficulties in forming new concepts and planning and organizing daily living tasks. He was unable to generate alternative solutions to a problem and would provide the same solution for several different situations.

Although the subjects were not randomly assigned to groups, a number of subject variables and the group's pretest scores (described later) strongly suggested that the groups were comparable (see Kazdin, 1980). For example, the mean WAIS verbal, performance and full scale scores were 106, 87, and 97 for the experimental group and 103, 85, and 94 for the contrast group. In addition, the experimental group's mean age was 27, with a mean post-injury of 6.6 years while the contrast group's mean age was 28, with a mean post injury of 9.3 years. Lastly, all six subjects were categorized as functioning within the moderate range of disability according to the Glasgow Outcome Scale (Jen- nett, 1976).

Expertmental Design A nonrandomized pretest-posttest control group design was used (Kazdin,

1980). The experimental group received baseline, probes, training, and pre- post assessments whereas the contrast group only participated in the pre and post-assessments.

Materials Forty-eight problem-solving situations were developed. This was accom-

plished by asking six direct care staff at the living center to separately generate a list of problems that Center clients frequently encountered. They were asked to categorize the problems according to the four general problem situational areas related to successful community placement and adjustment that had been identified by Foxx et al. (1988). These areas were Community Awareness and Transportation; Medication, Alcohol and Drugs; Stating One's Rights; and Emergencies, Injuries, and Safety. The problem situations which the individual staff generated were then incorporated into a master list and each was asked to rate the solutions according to their importance and relevance to independent living and frequency of occurrence. Their rating was based on a scale of 1 (somewhat relevant) to 3 (most relevant). The problem situations with the highest averages were then selected until there was an equal number of problem situations (12) for each area.

Sixteen situations were used for training, eight for the probes, and 24 for the pre/post generalization tests (described later). Each training and probe situation was printed on a 6 x 4" index card. Twelve training situation cards were used in each session. Four of the 16 cards were removed on a rotating basis prior to each session for use in the following session. Each subject offered four initial solutions and eight alternative solutions per session. Thus, after four training sessions each subject had offered an initial solution to all 16 situ-


ations and alternative solutions to each of these situations twice (i.e., each subject was exposed to 12 situations per sessions).

Control procedures included: (a) staggering the starting card on a session- by-session basis (for example, starting with card four in one session and card eight in the next session); (b) having a different subject begin each session; and (c) removing four different cards each session. These procedures were designed to ensure that the subjects could not predict the sequence of the cards.

An 8 ½ x 5" card (index card) that listed the four problem-solving criterion questions to be taught was given to each subject during the training with cue card phase.

Setting All baseline and training sessions were videotaped and conducted in a large

conference room at the rehabilitation center. The subjects and trainer sat at one end of the table facing each other. The probe sessions were conducted and videotaped in a separate office at the center. Subjects met individually with the trainer during the probes. They were aware that they were being videotaped. The trainer in all sessions was a male graduate student who had no previous experience in training problem-solving skills. The adequacy of his training efforts was assessed on four occasions by either the senior author or a trainer (third author) from our earlier study (Foxx et al., 1988). Two assessments were done by directly observing sessions and two by reviewing the training videotapes.

Date Collection Target Behaviors. As noted earlier, Foxx et al. (1988) identified four general

problem situational areas related to successful community placement and adjustment: Community Awareness and Transportation; Medication, Alcohol, and Drugs; Stating One's Rights; and Emergencies, Injuries, and Safety. Four training problem situation cards were developed for each area. Because the subjects were sometimes defensive regarding their inability to solve problems, all situations were posed as being a problem encountered by a friend rather than by the subject. For example, one of the Emergencies, Injuries, and Safety situations was, "Your friend took his medication and thirty minutes later he broke out with a severe rash. How would you help?"

Responses to four criterion questions were used for scoring, providing feedback, and as cues during training (see Foxx et al., 1988): 1) When will the problem be solved?, 2) Where would you look for help?, 3) Who would you talk to?, and 4) What would you say?. For six of the 16 situations, only three of the questions were relevant to the situation and thus, the irrelevant question was not used in scoring. For example, there was no need to address the question "Where would you look for help?" in the situation, "A neighbor in- vites your friend to a party, but she does not feel like going. She tells the neighbor that she does not want to go, but he repeatedly asks her to attend. How would you help?"

In order to provide a fine grain analysis of the subjects' problem-solving

66 FOXX ET AL.

skills, each criterion question was scored separately. Thus, a subject could correctly state where he would look for help but incorrectly state who he would talk to or what he would say. There were 42 to 45 possible correct criterion questions for any particular set of 12 situations. 1 In general, the first response was the one that was scored except when the subject responded in a vague or incomplete manner. In such cases, the subject was asked for clarification or more information before the response was scored.

Social Validation

The content of training and probe situations was validated prior to training by questioning three counselors at the apartment complex where four of the subjects lived. The counselors were asked to provide written answers to the situations as well as rate them for their appropriateness and usefulness to the problems which head-injured individuals would encounter in independent living. A detailed analysis of their written responses was then conducted using the scoring criteria. These responses were used to develop the sample correct responses used by the trainer when he gave feedback during training sessions. The 24 pre/post assessment situations (described later) were validated in the same fashion. 2 The counselors were naive as to the design and intent of the study.

In an attempt to socially validate the training effect, a normal contrast group was created. This was done by asking three staff members at the rehabilitation center and one counselor not involved with the facility to provide written answers to all training, probe, and pre/post situations and scoring their responses according to the aforementioned criteria. All were naive as to the design and the intent of the study. The data from this group was compared with the experimental group's posttraining data (see Smith, 1986).

Procedures

Baseline. The subjects took turns offering initial solutions to the problem situations in a clockwise fashion. On his turn, a subject was instructed to choose the top card from the card deck, read the situation aloud, and provide a solution. The other two subjects were asked to listen to this situation and also think of a solution. After a subject finished providing a solution, the other two were each asked in turn to offer an alternative solution. The order of who was to generate the first alternative was randomly determined during the session. The trainer did not provide any feedback and simply recorded the subjects' responses. After the second alternative was generated, the trainer simply requested that the next subject take his turn providing the initial solution to a new situation. Twelve solutions were provided by each subject each session (four initial solutions and eight alternative ones). After each session, all sub-

t A copy of the 16 training and 8 probe situations and sample correct responses can be ob- tained by writing the senior author.

2 A copy of the 24 pre/post assessment situations and sample correct responses can be ob- tained by writing the semor author.


jects received a fifty-cent coupon redeemable at a fast food restaurant regard- less of their performance.

Probe Condition. All conditions remained the same as the baseline except: (a) the subjects met individually with the trainer; (b) eight situations were used that were not used in any other condition; and (c) no positive consequences were given for participation. These situations were validated in the same fashion as the training and pre/post assessment situations. The purpose of the probes was to determine the extent to which each subject had learned the problem- solving strategy. The probes were conducted after every sequence of four sessions.

Problem-Solving Training (With Cue Cards). All conditions were the same as baseline except: (a) cue cards listing the four criterion questions for solving problems were given to the subjects prior to each session and they were told to refer to these cards when formulating their solutions; (b) the trainer provided feedback and prompted and coached the subjects to provide a correct solution if one or more of the criterion questions in their solution was incorrect or missing. The trainer indicated which questions had been addressed correctly and which had not. The trainer provided a sample correct response(s) only if the subject could not, after he had been prompted and coached, and after his initial response had been scored. If a correct response was given, the trainer simply stated "good answer" or "you've addressed all the questions"; (c) subjects received a scorecard on which to record their number of correctly solved situations; and (d) $1.00 was given to subjects who met their individualized performance criteria. In addition, subjects earned a $1.00 bonus for surpassing this criterion.

The criterion for all subjects in the first training session was set at four situations addressed correctly. Once a subject met or passed this criterion, his following session's criterion was increased by 33 °70 (i.e., to five situations). There- after, each time a subject met or passed his individualized criterion, the following session's criterion was increased by 33°70 of his previous session's score. For example, if a subject addressed eight situations correctly, the next session's criterion was set at eleven.

To aid the subjects in determining their individualized criteria, their criterion numbers (from 4 to 12) were circled on their scorecards. The trainer frequently asked them during the session how many situations they had to address correctly to meet their criteria.

Problem-Solving Training (No Cue Card). The only difference between this condition and the previous one was that the cue cards were not used.

Pretest/Posttest Generalization. Subjects from both groups received the 24 generalization situations individually. The four general problem areas were equally represented (i,e., six situations each). The situations were presented in two ways: (a) in interviews conducted by a female graduate student one month before (pretest) and 1, 3, and 6 months after training (posttests), and (b) in staged interactions conducted in the natural environment by center staff members 1 month before and after training.

The situations were designed to be either similar or dissimilar to the training situations. The dissimilar situations were included to provide a stringent anal-

6 8 FOXX ET AL.

ysis of generalization to untrained situations since our earlier study (see Foxx et al., 1988) had only assessed untrained situations that were somewhat similar to the trained ones. Eight interview and staged situations (two per problem area) were similar to the training situations and four of each type (one per problem area) were dissimilar. The similar situations were similar in content to the training situations. For example, one of the training situations was "Your friend is tired of picking up the tab when he goes out to lunch with a friend." The corresponding similar situation was "Your friend is tired of always paying the fare for a cab he shares with a friend when they go to the laundromat." In contrast, the dissimilar situations presented novel problems that shared no content with the training situations.

The interviews were conducted at the subjects' residences and all 12 situations were presented (i.e., eight similar and four dissimilar). The interviewer used a script and audio-recorded the interview.

The 12 staged situational interactions were conducted either at the center or in the community. Staff members presented the situations to each subject and shortly thereafter recorded the subject's responses verbatim. Situations were presented over a two-week period and were conducted during natural and ongoing interactions. For example, in one situation a therapist limped into a room and said to a subject, "I just slipped and I think I twisted my ankle" and asked the subject for assistance in obtaining treatment. Both the interviewer and staff were naive regarding whether the situations were similar or dissimilar to the training ones.

Three criterion questions were used in scoring the subjects' responses: "Where would you look for help?," "Who would you talk to?," and "What would you say?." "When will the problem be solved?" was not used because the validators (i.e., counselors) had not provided this information when they satisfactorily responded to the situations. However, as noted earlier, this criterion was used during training as a means of teaching problem identification.

Recording and Reliability All baseline, probe, and training sessions were scored during the session by

the trainer and later from videotapes by the primary rater. Reliability was calculated by dividing agreements by agreements plus disagreements, and mul- tiplying by 100. Reliability was calculated on one session from each four-session sequence in the baseline and training conditions and for all probe sessions. A secondary rater, who was naive as to the design and intent of the study also scored the reliability sessions. The raters were instructed to listen to the subjects' responses on the videotape and then fast-forward through the trainer's feedback so that they could not hear it. The trainer was present during this scoring to ensure the raters' compliance with the instructions.

For the baseline session (session three), the mean interobserver reliabilities were 81.4070 between the trainer and the primary rater, 86.8°70 between the trainer and the secondary rater, and 80.6O7o between the primary and secondary raters. The mean interobserver reliability in the training with cue cards (session eight) was 97.70/o between the trainer and primary rater, 93.1o70 between the trainer and secondary rater, and 93.9O7o between the primary and secondary raters.


In the training without cue cards (session 11), the mean interobserver reliability was 99.2% between the trainer and primary rater, 94.6% between the trainer and secondary rater, and 93.8% between the primary and secondary raters. The mean interrater reliability for the three probe sessions was 89.3 % (range 87.8 to 91.7%) between the trainer and primary rater, 79.8% (range 72.7 to 88.9%) between the trainer and secondary rater, and 82.1°-/0 (range 77.3 to 87.8%) between the primary and secondary raters.

The pretest and posttest generalization assessments for both groups were scored by the trainer and the primary rater from verbatim transcripts recorded by staff or from transcripts of audiotapes. Responses were scored using the aforementioned criteria.

Reliability on the pretest assessments for the experimental group was 86.4 % between the trainer and primary rater, 83.6% between the trainer and secondary rater, and 82.5% between the primary and secondary raters. These figures for the contrast group were 86.4, 81.4, and 87.0%, respectively. Mean reliability on the three postassessments (I, 3, and 6 months) for the experimental group was 85.5% between the trainer and the primary rater, 86.7% between the trainer and secondary rater, and 86.3 % between the primary and the secondary raters. These figures for the contrast group were 81.2, 73.6, and 72.1 percents, respectively.

Reliability for the normal contrast group's responses on all training and probe situations was 76.6% between the trainer and primary rater, 81.5 % between the trainer and secondary rater, and 76.8% between the primary and secondary raters. The mean interrater reliability on pre/post situations was 76.7% between the trainer and primary rater, 81.4% between the trainer and secondary rater, and 78.8°-/0 between the primary and secondary raters.

RESULTS Training

Figure 1 shows that the experimental group averaged 28.5 %o correct on the criterion questions during baseline, 92.2°70 correct during the training with cue cards, and 96%0 correct during the training without cue cards. The mean percentage of criterion questions correct increased during training in each of the four general problem situational areas, and this trend continued into the no cue card condition. A similar pattern occurred in the mean percentage correct for each of the four criterion questions. Only slight differences were ap- parent between the two types of responses, initial and alternative, with correctness on the alternative ones always being slightly higher across conditions. The greatest difference between the two was only 5.7%0 in the training with cue cards condition. It was expected that the alternative responses would be higher since they occurred after feedback had been given on the correctness of the initial response to a situation.

Probes The probes served as a form of generalization assessment. Figure 1 shows

that the experimental group scored 26.1070 in the probe following baseline,

70 FOXX ET AL.

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69.3°7o in the probe after training with cue cards and 93.007o in the probe that followed training without cue cards. The mean percentage of criterion questions correct increased across the probes in each of the general problem areas as did the mean percentage correct for each of the four criterion questions. The probes indicated that the subjects' problem-solving skills had generalized because over time they correctly responded at a high level to novel problem situations.

Generalization Recall that the one month pre- and postassessments were conducted via in-

terviews and staged interactions whereas the three- and six-month postassessments were conducted only via interviews. Figure 1 shows that the experimental group's criterion questions percent correct increased in the interviews from 26.9°7o in the pre to 97.8, 89.2, and 8607o, respectively, in the one-, three-, and six-month postassessments while the contrast group scored 36.6070 in the pre and 47.3, 43.0, and 40.9%, respectively, in the three postassessments. Figure 1 also shows that the experimental group increased in the staged interactions from 28.6070 in the pre to 69.1070 in the one-month postassessments whereas the contrast group scored 33.3 and 38.3070, respectively. In both types of assessments, the experimental group's gains were in all four general problem areas and in the three criterion questions. The overall generalization results (i.e., interview and staged assessments) revealed that the experimental group increased by 56.8070 from pre to one-month posttraining (i.e., from 27.7 to


84.5 070), and this effect was maintained in the interview assessments conducted 6 months after training where the group averaged 86°-/o correct (see Tables 1 and 2).

Tables 1 and 2 show that there was little difference in the experimental group's responding to the similar and dissimilar situations in both types of postassessments. The contrast group scored higher on the dissimilar situations in all of the interview assessments and higher on the similar situations in the staged interactions. However, there was little difference between its overall pre- and postassessment means on either type of assessment.

Anecdotal evidence of generalization came from two of the three experimental subjects. Before all of the posttraining interviews and prior to most of the posed situations, they verbally rehearsed by stating the four criterion questions from training. This suggested that they had retained the strategy and were verbally rehearsing it before they attempted to address the problem situations.

Normal Contrast Group

Recall that a group of normal individuals was given the training, probe, and pre/post situations, and their written answers were scored using the same criteria used for the subjects. Table 3 shows that the group's overall mean percentage correct was 85.6°7o. The scores ranged from 81.5070 on the training situations to 89.4°70 on the pre/post situations. Of particular interest was how the group's performance in the pre/post situations compared to that of the experimental group. The experimental group's overall mean percentage correct across interview and staged situations at the one-month posttest was 84.5 °7o versus the normal contrast group's mean of 89.4°7o. The normal contrast group's score on similar situations from the interview assessment was 85.7°7o whereas the experimental group scored 96.8, 88.9, and 87.3°-/o at the one-, three- and six-month posttraining interviews (see Tables 1 and 2). These figures for the dissimilar situations from the interview assessment were 90°-/o for the normal contrast group and 100, 90, and 83.3070, respectively, for the experimental group. The scores on the similar situations from the staged assessments were 95.6°-/o for the normal contrast group (recall that they were presented in written form) and 70.8°7o (one-month post) for the experimental group (see Table 1). The normal contrast group's dissimilar score from the staged assessment was 86.4 070 while the experimental group's was 66.707o (one-month post). The compar- ison of most interest was the experimental group's score on the interview situations at 6 months versus the normal contrast group's score on the same situations. It revealed that the scores were very similar since the experimental group scored 86°7o and the contrast group 87.10-/0 (see Tables 2 and 3).

DISCUSSION The training results showed that the program not only increased the problem-

solving skills of all experimental subjects when they used cues, but that this improvement continued when the cues were eliminated. This, of course, suggested that the subjects had learned and were using the problem-solving strategy

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TABLE 2 MEAN PERCENTAGE CRITERION QUESTIONS CORRECT ON THE SIMILAR AND DISSIMILAR THREE

AND SIX-MONTH POSTTEST INTERVIEW PROBLEM SITUATIONS PER GROUP (N = 3)

3 months Posttest 6 months

Experimental Contrast Experimental Contrast

Interviews Simdar 88.9 Dissimilar 90.0

89.2

Range ~ Range x Range ~ Range (76.2-100) 42.9 (38.1-47.6) 87.3 (81.0-90.5) 36.5 (23.8-47.6) (70.0-100) 43.3 (20.0-80.0) 83.3 (700-100) 50.0 (20.0-70.0) (74.2-100) 43.0 (35.5-58.1) 86.0 (77 4-93 5) 40.9 (22.9-54.8)

during the no cues condition. The subjects' probe results further verified the effectiveness of training and demonstration of the strategy since generalization across novel problem situations was demonstrated.

Although the training findings were of interest, the generalization that occurred was more so because training gains are of little value if the subjects' problem-solving skills do not generalize to untrained problem situations. This was important in the present case since the subjects were targeted for transition from supervised to unsupervised living arrangements (Zahara & Cuvo, 1984). The generalization results were especially encouraging given that Foxx et al. (1988) reported a considerably smaller increase in performance at a one- month follow-up across interview, staged, and phone call assessments.

A major goal of the present study was to ensure that the subjects could use their trained skills to solve problems different from those used to teach the skills (Reeve & Brown, 1985; Tisdelle & St. Lawrence, 1986). its achieve- ment was confirmed by the demonstration of generalization to untrained situations that were also dissimilar to the training situations, in fact, performance on the untrained dissimilar situations in interviews was virtually indistinguish- able from performance Ol~.untrained similar situations.

Another important finding was that the experimental group's post-training

TABLE 3 NORMAL CONTRAST GROUP'S (N - 4) MEAN PERCENTAGE OF CRITERION QUESTIONS

CORRECT ON THE PRE/PosT INTERVIEW AND STAGED ASSESSMENTS FOR SIMILAR

AND DISSIMILAR SITUATIONS AND THE PROBE AND TRAINING SITUATIONS

Similar Dissimilar Mean

Pre/Post x Range ~: Range ,x Interview 85.7 (76.2-100) 90.0 (70.0-100) 87.1 Staged 95.6 (82.4-100) 86.4 (72.7-100) 92.0

= 90.1 (78.9-100) 88.1 (71 4-95.2) 89.4 Probe 83.0 Training 81 5 Grand ~ = 85.6

Range (74.2-100) (78.6-100) (76.3-96.6) (68.2-100) (78.6-83.3) (78.9-90.2)

74 FOXX ET AL.

performance was quite similar to a group of normal individuals. For example, the experimental group's score on the interview situations at 6 months, 86~/0, was very similar to the normal contrast group's score on the same material, 87.1% (see Table 3), which suggested that three trained head-injured subjects correctly responded at the same level as a normal group of individuals 6 months after the former had received training.

In their excellent review of problem-solving skills training research, TisdeUe and St. Lawrence (1986) indicated that one crucial issue was whether the skills that were taught represented actual problem-solving processes. Accordingly, they suggested that training programs should begin empirically demonstrating the relevance of the program's skill objectives rather than simply using the standard practice of relying on clinical intuition. The social validity procedures employed here and previously (Foxx et al., 1988) appear to offer one such way of following this suggestion. Consider that the targeted criterion questions, ("Where would you look for help?," "Who would you talk to?," and "What would you say?") were validated in this and in the previous study by examining normal contrast groups' responses to problem situations and determining that the group members used them in solving the problems. This was why the same scoring criteria were used for both the subjects and the normal contrast groups. In the present case, the normal contrast group's high score on the problem situations represented a further substantiation of the validity of the criterion questions (skill components) or processes that were taught.

The overall results suggest that the modified generation of alternative solutions approach used in the present study was more successful than the single solution approach used previously (Foxx et al., 1988). The present study's subjects showed a significantly greater gain from pre to post at 6 months than the previous study's subjects showed at 1 month. Explanations for this dis- parity in results seem to be related to the following procedural differences between the two studies. First, the present approach increased the likelihood that the subjects would attend to each other's responses and feedback since they were required to respond to all of the situations in each session by providing either an initial solution or an alternative one. This led to increased interaction among them since they frequently gave each other corrective and positive feedback and kept them from becoming bored or inattentive (see Foxx et al., 1988). This requirement also enhanced the effects of response practice. In contrast, the previous study's subjects were only required to provide a solution to 25% of the situations each session. Thus, the present subjects had more opportunities to rehearse the strategy for each problem situation which may have reduced their errors and helped them retain new material (Kent-Udolf, 1984). Indeed, the present subjects were able to learn the strategy in only eight training sessions whereas the previous study's subjects required twelve. Second, in the previous study, participating and achieving individualized criteria were reinforced, whereas in the present study exceeding criteria was also reinforced. Third, because reinforcement was available for exceeding criteria, the present subjects became quite competitive. Although this resulted in each subject at- tempting to achieve the highest score each session, it did occasionally lead to arguments over whether or not someone had responded correctly. As a re-


suit, future training efforts should attempt to reduce the competitive aspects of the program by systematically reinforcing appropriate interaction (i.e., giving advice nicely) and/or by placing negative consequences on inappropriate interaction (i.e. arguing). These explanations seem plausible since other procedural factors were the same in both studies including the use of self-monitoring, response specific feedback from the trainer, monetary reinforcers, modeling, self-correction, individualized performance criteria, and cue cards. However, another factor that may have contributed to the difference in success and that must be mentioned is that the present subjects may have had fewer debilitating cognitive deficits. Consider that their mean WAIS verbal, performance, and full scale scores, were 106, 87, and 97, whereas the scores for the previous study's subjects were 83, 72, and 87, respectively. Unfortunately, we cannot pinpoint the deficits of the various subjects since no formal neuropsychological evaluations were performed.

The present program appears to offer several advantages for training head- injured individuals in problem-solving. One, it is cost-efficient since only one trainer is required and the setting of individalized performance criteria permits the simultaneous training of several persons with varying cognitive deficits. Two, its use of standardized procedures should facilitate its replication and extension (cf., Foxx & McMorrow, 1983). Three, it could possibly be used as an assessment tool to pinpoint problem-solving deficits prior to training such that the situation cards could be specifically designed for a given individual or group. Four, it facilitates cooperation, competition and assisting others. Finally, it trains socially valid skills as was demonstrated by the high corre- spondence between the scores of the normal contrast and experimental groups (Hansen, St. Lawrence, & Christoff, 1985).

In summary, although this study appears to demongtrate the generalization and maintenance of training gains over time and across settings, some caveats are in order. First, it would have been advantageous to have used an intrasubject- replication experimental design such as a multiple-baseline across subjects rather than a between-groups design so that all subjects could have been provided with training. Second, our descriptions of the subjects' problem- solving deficits were based on qualitative evaluations of the difficulties they experienced rather than on formal neuropsychological evaluations. Clearly, such formal evaluations would have been highly desirable and useful in both buttressing our descriptions of the subjects' various cognitive deficits and demonstrating the overall applicability of the training program. Finally, it is unknown just how predictive the generalization assessment data are of the subjects' ability to problem-solve in the natural environment (see Krasnor & Rubin, 1981), since they merely represent verbal responses to problem situations i.e., what the subjects would do, rather than their actual performance in those situations. Thus, future studies should concentrate on developing more rigorous and natural long-term evaluations of generalization (e.g., Foxx, McMorrow, Bittle, & Ness, 1986).

REFERENCES Castles, E. E., & Glass, C. R. (1986). Training in social and interpersonal problem-solving skills

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RECEIVED: April 25, 1988 FINAL ACCEPTANCE: May 8, 1988

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The acquisition, maintenance, and generalization of problem-solving skills by closed head-injured adults