Psychometric evaluation of the Self-Awareness in Daily Life-3 Scale (SADL-3) for the assessment of self-awareness after acquired brain injury

Figures & data

Figure 1. Levels and patient types of self-awareness of deficits.

Table 1. Patient characteristics (n = 89).

Gender, n male	65
Mean age in years (SD; range)	53 (23–74)
Education level*, n
Low	32
Intermediate	31
High	13
Missing	12
Setting, n
Interaktcontour	54
Stichting Gehandicaptenzorg Limburg	19
Reinaerde	16
Mean time since acquired brain injury in years (SD; range)	16 (0–52)
Type of acquired brain injury, n
Traumatic	35
Cerebrovascular	36
Hypoxia	1
Encephalopathy	2
Tumor	6
Mixed**	5
Missing	4

*Low = no education, primary education or lower vocational education; intermediate = intermediate general secondary education, intermediate vocational education or higher general secondary education; high = higher vocational education or university.

**n = 1 cerebrovascular and encephalopathy; n = 1 traumatic, cerebrovascular and tumor; n = 1 hypoxia and encephalopathy; n = 2 traumatic and cerebrovascular.

Table 2. Score distributions of SADL-3, AQ, PCRS and CRS-ISA at T0.

	SADL-3 (n = 76)	AQ (n = 83)	PCRS (n = 84)	CRS-ISA (n = 67)
Statistic
Items, n	7	17	30	10
Scale range	7.00 to 21.00	−68.00 to 68.00	−120.00 to 120.00	0.00 to 10.00
Mean (SD)	13.68 (4.22)	8.96 (11.33)	14.07 (20.20)	5.38 (2.81)
Median	13.50	8.00	15.00	6.00
Score range	7.00 to 21.00	−20.00 to 35.00	−62.00 to 57.07	0.00 to 10.00
% with lowest score	7.9 (n = 6)	1.2 (n = 1)	1.2 (n = 1)	1.2 (n = 1)
% with highest score	11.8 (n = 9)	1.2 (n = 1)	1.2 (n = 1)	6.2 (n = 5)
% more than 25% missing items	17.1 (n = 13)	Patient form: 0 (n = 0) Clinician form: 7.2 (n = 6)	Patient form: 1.2 (n = 1) Clinician form: 4.8 (n = 4)	27.16 (n = 22)

SADL-3 = Self-Awareness in Daily Life-3; AQ = Awareness Questionnaire; PCRS = Patient Competency Rating Scale; CRS-ISA = Clinician’s Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability-ISA subscale.

Table 3. Inter-rater reliability: Intra class correlations for SADL-3.

SADL-3	n	ICC
Total score	56	.64**
Family relations	67	.37**
Friends and social contacts	63	.38**
Intimacy and sexuality	34	.46**
Leisure time	63	.42**
Work and daytime activities	64	.43**
Housing situation and living conditions	65	.42**
Health and appearance	66	.60**

ICC = Intra Class Correlation coefficient

SADL-3 = Self-Awareness in Daily Life-3

** = p < .01

Table 4. Test-retest reliability: associations between SADL-3 scores at T0 and T1.

SADL-3	n	ρs
Total score	40	.93**
Family relations	50	.82**
Friends and social contacts	48	.78**
Intimacy and sexuality	35	.87**
Leisure time	44	.87**
Work and daytime activities	47	.81**
Housing situation and living conditions	49	.87**
Health and appearance	47	.91**

ρ_s = Spearman correlation coefficient

SADL-3 = Self-Awareness in Daily Life-3

T0 = baseline; T1 = 2 weeks after T0

** = p < .01

Table 5. Usability of the SADL-3: responses to open-ended questions.

Questions	Responses
Do you think using the SADL-3 can be of additional value for everyday clinical practice?	Yes (63%) No (28%) Not answered (9%)
What do you consider weaknesses of the SADL-3 and suggestions for improvement?	– Not every area of daily life is relevant for every patient – Staff members do not always have knowledge about a patient’s functioningin all life areas – Life areas are broad; for some life areas patients can be twodifferent types of patients
Does using the SADL-3 help you make decisions about ways to deal or interact with patients?	Yes (46%) No (32%) Not answered (22%)
Does using the SADL-3 improve communication between staff members?	Yes (41%) No (37%) Not answered (22%)

Table

Passer-by	Searcher	Buyer
Has no awareness of his deficits. Significant others are usually the ones who experience problems and ask for help or treatment (the way the passer-by experiences the world differs from the way significant others experience the world)	Agrees that brain damage is part of his life but does not fully understand the consequences of the brain damage for everyday functioning His requests are vague, and/or Has no overview of his problems, and/or Has little confidence that his problems will be solved Often cancels his own requests (both the searcher and significant others experience the same problems; they differ in the way they want to deal with the problems)	Understands the fact that his brain damage affects his life Knows that he needs others to help him deal with his deficits Is willing to cooperate in search for solutions (both the buyer and significant others experience the same problems and agree on solving the problems)

Table

Daily life area	Passerby	Searcher	Buyer
Family relations
Examples of abilities or tasks that fit in this area of daily life: make appointments about housekeeping, making up after a quarrel, tell the other one that you need time on your own, divide your time between family and other important issues, show interest in your family	My relationship with my partner and children has not changed (in reality both the partner and children experience many changes in behaviour). The only thing that has changed is the fact that my wife thinks that I have changed (in reality both partner and children experience the patient as a completely different person).	I want to improve my relationship with my kids; unfortunately you (=professional) can’t help me with that. Something has changed in my relationship with my spouse, I don’t know what exactly. In early days I could get along well with my kids, nowadays it’s harsh.	I quarrel a lot with my spouse and I would like your (=professional) help to discuss what I can do about it. Since I moved to a group home, my relationship with my wife has become better.
Friends and social contacts
Get in touch with friends on a regular basis, tell someone that he is crossing a line, be interested in someone else’s emotional life, know the difference between friends and acquaintances, expressing to one another what you want	My old buddies visit me often (in reality old friends don’t visit on a regular basis). I do have many friends (in reality the patient says hello to other people and he only has superficial acquaintances).	My friends don’t come over to my place anymore. I don’t know why. Things have changed in my relationship with my friends, but I can’t help it.	Would you (=professional) help me to get in touch with my neighbours? I don’t see my best friend very often; would you help me to restore contact?
Intimacy and sexuality
Knowing the difference between what you like and what you don’t like, get in touch with someone you like, knowing how to get pregnant or not, understand that someone might not like something you want, knowing what your spouse likes	It’s not my fault that my partner and I are not intimate anymore (in reality the patient doesn’t take the wishes of his spouse into account).	My wife and I are not intimate anymore. I don’t know why that is I would like to have a relationship. How do you get one?	I would like to have a relationship, would you help me with that? For example in making an online profile? Recently there has been little intimacy in my relationship. Could you help me to discuss this with my spouse?
Leisure time
Finding a balance between stressful activities and relaxing activities, being aware of time, thinking of something to do when you are bored, knowing what your limitations are, knowing how long an activity will take	I still have the same hobbies (in reality the patient doesn’t pick up his former hobbies). I know how to fill in my days (in reality the patient is often bored and goes to bed early).	I cannot practise my former hobby anymore. It doesn’t matter, I don’t like it anymore. I would like to relax more often, I don’t know how. I’ve got fewer hobbies than I used to have. But that’s the way it is. You (=professional) cannot help me with that.	I would like to practise my old hobbies again. Will you help me with that? I would like to relax more often, could you help me with that? Housekeeping costs me so much time, I don’t have time to relax. Could you help me with that?
Work and daytime activities
Asking for advice when you don’t understand something, accept that something is not possible, being proud of your work and showing it, orienting in a room, finish what you started	Soon I will get back to work (in reality significant others think that going back to work is unrealistic). I ‘m going to a day activity centre because my wife wants me to. I’d rather stay home. I don’t belong here (=day activity centre).	My boss says I don’t have to come back to work anymore. I don’t get it. I really would like to work again, but in fact I’ve got brain damage, so that is impossible.	I’m not able to pick up my former work, so I really would like to go to a day activity centre. Could you help me with that? I have adjusted my work to my disabilities. Is it possible to adjust my work in an even better way?
Housing situation and living conditions
To set up a home in a pleasant way, clean your house, knowing where grocery shopping is cheap, to keep up maintenance, divide your money over the month	Cleaning my apartment is easy to do (in reality the apartment is disorderly and dirty. I see a lot of pressure for payments. It’s a mistake, I don’t have debts (in reality the debts are for real).	What should I do with this? (the patient opens a drawer which contains all the letters he received in the last 1.5 years) I really would like to organize my housekeeping in a different way. However, I don’t know where to start.	Can you help me to organise my administration? I cannot do it by myself. I would like to prepare easy meals. Can you help me with that?
Health and appearance
Use medication according to prescription, develop your own style of clothing, eat regularly and healthily, knowing what your physical disabilities are, to have physical fitness.	I don’t reek (in reality the patient smells bad). I can manage my own medication (in reality the patient doesn’t know which pill to take at what time).	I have so many pills, I don’t understand why I’m taking them. Laundry keeps on building up. I don’t know how to manage that.	I’ve got so many pills; when do I have to take this yellow one? Could you help me to make a laundry schedule?

Table

Daily life area	Passer-by (experiences no problems; significant others do) (score = 1)	Searcher (requests are vague, no overview of his problems, little trust his problems will be solved, cancels his requests) (score = 2)	Buyer (experiences problems, requests are clear, willing to cooperate, view of life matches the view of life of significant others) (score = 3)	Don’t know	Not applicable
Family relations (making up after a quarrel, showing interest in your family)
Friends and social relations (get in touch with friends on a regular basis, be interested in someone else’s emotional life)
Intimacy and sexuality (understand that someone might not like something you want, knowing what your spouse likes, Getting in touch with someone you like)
Leisure time. (thinking of something to do when you are bored)
Work and daytime activities (asking for advice when you don’t understand something; finishing what you started)
Housing situation and living conditions (cleaning your house, dividing your money over the month)
Health and appearance (using medication according to prescription, eating regularly and healthily, being physically fit)