1. INTRODUCTION Early after injury, persons with mild traumatic brain injury (TBI) have been shown to experience physical, cognitive, and emotional difficulties. 1-4 Several studies have shown that, for most persons, these symptoms resolve by approximately 3 months following injury. 5-7 However, other studies have shown persistence of symptoms at periods ranging from 3 to 6 months. 8,9 There has been some evidence that persistence of symptoms following a mild TBI is related to a pre-injury history of depression and/or anxiety 10-12 and/or to pre- existing personality or coping styles. 12-14 Depression following mild TBI has been shown to be associated with increased report of subjective cognitive complaints, 15-17 as well as with decreased cognitive test performance. 17-19 Depression may directly lead to impairments in attention, memory, and processing speed, but may also contribute indirectly by impacting a person’s self-efficacy regarding performance. Expectancies regarding cognitive performance have been shown to be related to actual performance in normal persons 20 and in alcoholics. 21 PURPOSE The purpose of the current study was to examine expectancies for cognitive performance in persons with mild TBI, as well as to investigate the relationship of expectancies to cognitive performance, stress, self-efficacy, and depression. METHOD Participants: 104 persons with mild TBI who were consecutively admitted to a Level I trauma center emergency room (ER). The majority of participants (n=68) had sustained a complicated mild TBI, as defined by a Glasgow Coma Scale (GCS) score of 13 to 15 upon admission, but with the presence of abnormal findings on neuroimaging. 22 The remainder (n=36) had sustained uncomplicated mild TBI, as defined by a GCS score of 13 to 15 and no abnormalities on neuroimaging. 22 The majority of participants were male (67%), with a mean age of 34 (SD=14.46). Recruitment from a County Level I trauma center resulted in a sample composed primarily of minorities (44% Black, 30% White, 24% Hispanic, 1% Asian) and relatively low education (Mean yrs.=12; SD=2.6; Range=4 to 20). Expectancies for Performance in Persons With Mild Traumatic Brain Injury Angelle M. Sander, Ph.D., Margaret A. Struchen, Ph.D., Allison N. Clark, Ph.D., Walter M. High, Jr., Ph.D., H.J. Hannay, Ph.D. METHOD, CONT. Procedure and Measures: Within 1 week of injury, participants completed a battery of tests and questionnaires that included those shown in Table 1. After instructions for each cognitive measure, but prior to beginning the task, participants rated on a 5- point scale how they expected to perform compared to others of similar age and education. All scores on cognitive measures were converted to standardized T-scores. Mean T-scores were calculated for each cognitive domain. For each domain, a participant was classified into one of the following categories: below average (mean T-score 60). Mean expectancy ratings for each of the cognitive domains were also calculated. For each domain, each participant’s expectancy rating was coded as (1) worse compared to peers or (2) the same or better compared to peers. Expectancy Question How do you think you will perform on this test compared with people who are of the same age and educational level as yourself? (1=much worse; 2=somewhat worse; 3=about the same; 4=somewhat better; 5=much better) Table 1. Cognitive and Self-Report Measures Administered Learning/Memory Measures: Buschke Verbal Selective Reminding Test 23 Long-term storage scoreLong-term storage score Continuous long-term retrieval scoreContinuous long-term retrieval score 30-minute delayed recall score30-minute delayed recall score Rey-Osterrieth Complex Figure Test 24 Immediate recall scoreImmediate recall score 30-minute delayed recall score30-minute delayed recall score Processing Speed Measures: Controlled Oral Word Association Test 25 Trailmaking Test Part A 26 Paced Auditory Serial Addition Task 27 Trials 1-4 Executive Functioning Measures: Trailmaking Test Part B 26 Wisconsin Card-Sorting Test 28 Number of errorsNumber of errors Number of perseverative responsesNumber of perseverative responses Self-Report Measures: Self-Efficacy Scale 29 Stressful Life Events Questionnaire 30 Center for Epidemiolgic Studies- Depression Scale 31 RESULTS Cognitive performance did not differ between persons with complicated and uncomplicated mild TBI for any of the cognitive domains. Mean expectancy ratings for each of the cognitive domains are shown in Figure 1. Persons with complicated mild TBI expected to perform worse than persons with uncomplicated mild TBI on measures of learning and memory (t=-2.4, p<.05). For the complicated mild group, number of stressful life events was inversely related to expectancies for learning/memory (r=-.50, p<.01) and speed of processing performance (r=-.47, p<.01). For the uncomplicated mild group, self- efficacy was positively correlated with expectancies for performance on executive functioning measures (r=.29, p<.05). Depressive symptoms, as assessed by the CES-D, were not related to cognitive performance. For the entire sample, expectancies added significantly to the variance in performance on learning/memory tasks (R2 change=.10, p<.01) and processing speed tasks (R2 change=.05, p<.05) after accounting for injury severity and self- efficacy scores. *p<.05 Figure 1. Pre-Test Expectancies By Cognitive Domain DISCUSSION/CONCLUSIONS It is possible that within the time limit of one week after injury, persons with complicated mild TBI have greater daily experience with learning and memory problems than with problems in speed of processing or executive functioning. While the actual performance did not differ between persons with complicated and uncomplicated mild injury, it is possible that persons with complicated mild injury experienced greater everyday changes in learning and memory, leading them to have lower expectancies for performance. Experience with previous stressful life events and/or low self-efficacy can decrease one’s perception of their abilities, and thus lower their expectancies for cognitive performance. The relationship between self-efficacy and expectancies for the uncomplicated mild group suggests that their feelings of general self-esteem can impact their predictions of performance on cognitive tests. Expectancies contribute to cognitive performance on tasks of learning/memory and processing speed, even after accounting for injury severity and self-efficacy. This should not be taken to mean that expectancies cause performance, as this is a correlational design. It is possible that persons who have cognitive difficulties in these areas develop realistic expectancies regarding their abilities. Future studies should look at discrepancies between expectancies and performance. It would also be beneficial to assess post-test perceptions of performance, in order to assess whether appraisal of performance is impacted after experience with the task. Depression was not related to expectancies for this sample. However, total scores on the CES-D were used and future studies should investigate this relationship for the subset of persons who show depression. The results have implications for education and intervention in persons with mild TBI, since altering expectations of performance has the potential to impact performance. References Available on Handout Physical Medicine and Rehabilitation