Ghana Journal International of Mental Health

Volume 1 Number 1 September 2009

EDITOR-IN-CHIEF C. Charles Mate-Kole University of Ghana

FOUNDER Samuel A. Danquah University of Ghana

ASSOCIATE EDITOR Adam Nyarko Danquah London

Copyright@ 2009 by Ghana international Journal of Mental Health. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form, or by any means of electrical, mechanical, photocopying, recording or otherwise without prior consent of the publishers.

Address: Professor C. Charles Mate-Kole Editor-in-Chief Ghana International Journal of Mental Health Department of Psychology University of Ghana P.O. Box LG 84 Legon, Accra Email: [email protected] / [email protected] Phone: +233-26-5158672

Publishers: Department of Psychiatry, University of Ghana Medical School

Department of Psychology, University of Ghana

Ghana Association of Clinical Psychologists

Sponsors: Progressive Life Centre Washington D.C.

Printed by: G-Pak Limited, Main subsidiary of Graphic Communication Group. P.O. Box 742, Accra, Ghana. Email: [email protected]

EDITOR-IN-CHIEF FOUNDER ASSOCIATE EDITOR C. Charles Mate-Kole Samuel A. Danquah Adam Nyarko Danquah University of Ghana University of Ghana London, UK

EDITORIAL BOARD

Nii Bonney Andrews Daudi Azibo Tema International NeuroCenter Grambling State Accra, Ghana Loiusiana, USA John F. Connolly John DeFrancesco McMaster University American International College Hamilton, Ontario, Canada Massachusetts, USA Vivian Dzokoto, Joel Harvey Virginia Commonwealth University of Cambridge University, Virginia, USA U.K. Fredrick W. Hickling David M. Ndetei The University of the West Indies University of Nairobi Jamaica, WI Kenya Angela Ofori-Atta Samuel Ohene University of Ghana Medical School University of Ghana Medical School Accra, Ghana Accra, Ghana Akwasi Osei Solomon Tshimong Rataemane Accra Psychiatric Hospital University of Limpopo (MEDUNSA Accra, Ghana CAMPUS), Pretoria, South Africa Maxwell Twum Araba Sefa-Dede Fayetteville State University University of Ghana Medical School North Carolina, USA Accra, Ghana Thaddeus Ulzen Shawn Utsey University of Alabama Virginia Commonwealth University Tuscaloosa, Alabama Richmond, Virginia, USA USA Ming Wai Wang Editorial Manager University of Manchester, Sheriffa Mahama Manchester, U.K. University of Ghana, Legon Frederick Philips Progressive Life Centre Washington D.C.

CONTENTS Editorial 5 Commentary: S. A. Danquah 7 Commentary: Akwasi Osei 8

The Effect of Patient Participation in Collaborative Goal Setting in Psychotherapy: A Clinical Psychology Approach in Therapy in Ghana Samuel A. Danquah and Mavis Asare 10

Do cultural identity and control perceptions have any bearing on how satisfied we are with our lives? Frances Emily Owusu-Ansah 22

Psychosocial factors associated with symptoms of depression among Ghanaian adolescent students in junior and senior high schools. Mabel Oti-Boadi 35

Efficacy of cognitive training intervention programs in patients with dementia Rachel Bieu, C. Charles Mate-Kole, Patti Said, Robert Fellows, Katherine Catayong, James Conway, Rebecca Wood & Jake McDougal 51

The effects of knowledge and health beliefs on coping amongst adult sickle cell patients Olive O.Okraku, Angela Ofori-Atta, S. A, Danquah, I. Ekem and J. K. Acquaye 64

Doll Choice in Young Children: Representing Self through Skin Color Sheriffa Mahama, Adam Nyarko Danquah, Ming Wai Wan 77

Recognition of Nonwords in Two Patients with Deep Dyslexia: Implications for Models of Reading Rebecca M. Wood and C. Charles Mate-Kole 86

Psychotropic Medicine Shortages in Ghana: A Situation Analysis Truelove Antwi-Bekoe 1 , Dominic N.W Deme-Der, Gordon M. Donnir, Shoba Raja, Badimak and Yaro Peter 112

Exposure to violence on television and video games and aggressive behavior among children: Wiafe-Akenten C.B. 121

Editorial Mental health continues to be a contentious issue in our society. It is considered a stigma even though at least one in three people would experience some kind of a mental illness in the course of their lives. Despite these figures mental illness appears to rouse negativity thus isolating the mentally ill to a sub human category. I recall an incident during the Ghana at 50 celebrations when comments were made about “removing the lunatics from the streets”. Comments which were both insensitive and derogatory. It demonstrates the lack of understanding about mental illness. The irony is the fact that mental health embraces all aspects of health, from general medicine, child health, internal medicine, hematology, oncology, gynecology and of course, neuropsychiatry. Our ignorance may be borne by the fact that mental illness is usually accompanied by negative media. Thus, there is an increasing need for a medium to engage in intellectual discourse on mental health issues.

The birth of this new journal is long overdue and we have made attempts to present mental health to reflect its diversity and complexity. The topics for the issue cover range of areas from depression, treatment approaches, cultural identity, dementia, acquired dyslexia, policy and aggression. The issue includes original articles as well as literature reviews. It is our hope to include a section on grand rounds, case studies and correspondence in future. The journal will be published bi-annually in April and November.

Many colleagues have been instrumental in ensuring the success of this new journal, and I would remiss if I did not acknowledge them; Professor Danquah, Sheriffa Mahama and Dr. Adam Danquah – they have worked tirelessly for a long time to develop this journal. They have provided such invaluable service; they all deserve our appreciation. We thank the members of the editorial board for reviewing the manuscripts and submitting their reviews expeditiously. The journal has received such an enthusiastic welcome that we cannot fail. As reflected in Dr. Osei’s commentary, “this new day has dawned on us “and we must ensure its s survival; we shall keep it current and alive for a long time to come; we will build on it. This journal, unlike some other African journals is here to stay. It will surpass us all and history will remember you, the Editorial Board for seeing to the sustainability of this auspicious journal.

We encourage and invite submissions related to all aspects of mental health; research, reviews, commentaries and short correspondence. Although we cannot promise to publish every work submitted, we will at the very least, work with you to maintain high standards. It is our hope that this new mouthpiece on mental health becomes part of any professional journals found anywhere in the world. I invite your participation of this worthy cause. C. Charles Mate-Kole Editor-In-Chief Professor of Psychology University of Ghana, Legon

Commentary The new Journal, Ghana International Journal of Mental Health will at least make possible the publication of papers in subject areas that have long been inadequately covered here in Ghana and other parts of Africa. In particular, the journal’s aim is to reflect on current mental health trends in many different countries, allowing mental health professionals the opportunity to become familiar with development elsewhere. The journal will devote more attention to mental health issues through research and other articles which are of outstanding historical or biographical interest and often remained unpublished.

Mental Health has been given a new dimension since the World Health Organization (WHO) defined health not as the absence of a disease or physical disability, but the existence of a state of complete physical, mental and social well being. The experience of western countries has shown that mental ill-health can assume an important position in health care services. The phenomenological increase in mental health problems in these countries has brought in its wake a concomitant phenomenal increase in the number of mental health professionals and mental health oriented research.

Developing countries have not as yet experienced a comparable upheaval in their mental experiences but the realities of the present mental health problems will demand more attention than it is getting now. However, the gradual increase in the research by psychologists, psychiatrists, social workers and mental health nurses and others in the developing countries will share this information with their counterparts in other developing countries through the use of this International Journal of Mental Health Publication.

I hope this journal will continue after this first publication to make available valuable and important contributions to mental health by publishing regularly materials in the field. This will provide subscribers with an unrivalled and comprehensive coverage in Mental Health issues. S. A. Danquah Founder Professor of Psychology University of Ghana, Legon

Commentary Welcome GIMHJ - A new day has dawned A situation analysis of mental health system and services in Ghana showed that there is very little research output in mental health in Ghana. Indeed from 2000 to 2005 it was found that only 1% of all articles on health in Ghana as identified on PubMed were on mental health (Osei, 2004; Doku et al. - unpublished). This is a very low rate indicating that there is very little research activity going on in mental health in Ghana. The story is not too different in other parts in Sub-Sahara Africa or indeed in all of Africa. Many factors account for that, for example work load among clinicians – so much to do by so few personnel who, therefore, have very little time for research work. In a country of 22 million there are only five psychiatrists in active practice in Ghana. There is no clinical psychologist in the public health sector even though in the whole country one can count at least 80 of them.

But another significant reason for the lack of adequate research may be the fact that there are not many outlets for publication. Of course, other international journals are open to all authors but without those which lay emphasis on local circumstances the chances that one can publish in these become slim, for what might be of interest to a researcher here might not be of interest to the journals. For example, while reputable journals may be looking for high-tech research with highly sophisticated instruments and statistical tools, the exigencies of our circumstances will permit less sophisticated but revealing research to have their findings published in locally based journals.

Few, if any, international journals will be interested in case reports today, unless it is an extremely rare case. Yet as we are now building our data in this part of the world, cases that have not yet been reported here become interesting. Again few journals will be interested in prevalence or epidemiological studies while we are yet to establish the epidemiology of most conditions here.

Obviously there is no lack of researchable material in the subregion. Indeed the lack of research activity gives the impression that not much is obtainable here which could be of interest to others. For instance I read in a textbook recently that multiple personality disorder has not been

8 reported in Africa and therefore it might be a non-existing condition here. Yet we have seen at least five such cases in the last ten years and published these in the Ghana Medical Journal (Osei, 2004).

It is in this light that the birth of this journal gladdens our hearts and adds to the indicators of a new day in the life of mental health care and research in Ghana and elsewhere in Africa. With this journal research of particular interests are welcome. While case reports and epidemiological studies are welcome, of course completely new and cutting edge information are similarly welcome but we shall not wait for such data alone to go to print.

It is hoped that all mental health workers of all categories, psychiatrists, clinical psychologists, social workers, clinical pharmacists in psychiatry, counselors, therapists, psychiatric nurses, administrators, researchers and teachers alike, etc, are all welcome to read and contribute. Let this be seen as the intellectual mouthpiece of all of us to share and promote knowledge.

Research has a big role to play in the modern day era of knowledge and information-based development and any discipline that relegates research and data to the background stands the risk of being left behind. Research comes to nothing if there is no outlet for sharing of the findings. It is hoped that this journal will add another impetus towards the development of mental health services in Ghana, Africa and elsewhere. Akwasi Osei, FWACP (Psych) Chief Psychiatrist, Ghana Health Service Accra, Ghana References Doku, V et al. Country Report: A situation analysis of mental health policy development and implementation in Ghana (unpublished) Osei, A. (2004). Multiple Personality Disorder – A Myth or a Reality? Case Reports and literature review, Ghana Medical Journal, 38 (1), 36-41 www.psychiatry.uct.ac.za/pmhp/

The Effect of Patient Participation in Collaborative Goal Setting in Psychotherapy: A Clinical Psychology Approach in Therapy in Ghana

Samuel A. Danquah1and Mavis Asare 2

1 Department of Psychology, University of Ghana, Legon, Ghana 2 Department of Psychology, Methodist University College, Accra, Ghana

Abstract The present study examined the application of mutual goal setting theory on patients’ compliance behaviors and outcome goals. 60 patients on admission to a private psychiatric clinic in Greater Accra in Ghana were recruited for the study. It comprised two groups; the experimental and control groups. The experimental group participated in their mutual goal setting while the control group did not participate. Participants were diagnosed with any of the following conditions; schizophrenia, depression and substance abuse. The groups were compared with respect to goal attainment, patient satisfaction with care, therapist satisfaction and responses to the follow-up community readjustment program.

Results indicated that patients who participated in the mutual goal setting scored significantly higher on goal attainment and patient’s satisfaction with care than those who were not involved. In addition, therapists whose patients participated in the mutual goal setting were more satisfied with care given compared to those whose patients did not participate in goal setting. The patients with internal locus of control who participated in mutual goal setting scored significantly higher on goal attainment than those internals who did not participate in mutual goal setting. The implications of the findings are discussed in the paper.

Correspondence: Samuel A. Danquah, Ph.D. Department of Psychology University of Ghana, Legon, P.O. Box LG84, Legon, Ghana Phone: +233-021-413921 - Email - [email protected]

INTRODUCTION

Patients’ active involvement in planning for their care has been recommended by many authors (Bensing, 1991; Cegala, 1997). Helping patients to assume greater responsibility for their own healthcare has been a major focus of many health care providers. Often, however, the emphasis has been on attempts to gain patient’s acceptance of, or compliance with the goals and methods set by the healthcare providers. Little attention has been directed towards establishing a “partnership in healthcare” whereby patient and therapist or healthcare personnel work together to establish health goals and methods. A collaborative approach is desirable from an ethical standpoint, i.e. patients should have a voice on issues regarding their own health and wellbeing (Kaplan & Ware, 1989)

Currently, the healthcare system in Ghana is facing serious problems of overcrowding in psychiatric hospitals. There is a greater need to emphasize rehabilitation and follow-up community programs. In addition to the regular in-patient care activities, patient teaching and after-care planning by the health team must be intensified. The health team must prepare the patients for transition from the hospital to community.

The potential problem areas which may lead to patients’ non-compliance need to be explored by the health team; utilizing realistic goals as well as fostering independent community reintegration. These issues should be done as means of finding some solutions to the patient re-adjustment to the community and possibly lessen the revolving door approach. There is a need therefore to improve the patient care on the ward by the health care team, as well as evaluating the effectiveness of the interventions.

The conceptual framework of this study was based on Rotter’s maladaptive behavior in the social learning theory (Rotter & Hochreich, 1975). Any persistent behavior that fails to move a person closer to a desired goal may result in maladaptive behavior. Setting goals too high is only one of several possible contributors to maladaptive behavior. Maladaptive individuals are characterized by unrealistic goals, inappropriate behaviors, inadequate skills or unreasonably low expectancies of being able to execute the behaviors necessary for positive reinforcement. Although the individuals have learned inadequate social context, they can learn these behaviors and also learn more appropriate ones within the controlled social environment provided by psychotherapy.

Locus of Health Control The Health Locus of Control, a theoretical construct that has its origin in social learning theory (Rotter, 1966) seems to play an important role in individual self-healthcare. Research demonstrates that differences in locus orientation lead to characteristically different health behavior among variety of people. Internal Health Locus of control for example, has been found to be related to more self- responsibility for health (Younger, Marsh & Grap, 1995). People who hold this orientation attempt to maintain their well being more than those with External Health Locus of Control.

Changing Goals Many patients are unable to solve life’s problems because they are pursuing skewed or distorted goals. The role of the therapist is to help these patients understand the nature of their goals and to teach them constructive means of striving toward realistic goals.

Studies of achievement motivation are concerned with how individuals establish goals and how established goals affect performance. The original work of McClelland and Winter (1969) regarding the motivation of economic achievement and the work by Houts and Scott (1975, 1976) on training achievement motivation strategies appear to offer some direct evidence bearing on the relationship between participation in goal setting and level of goal attainment. The theory chosen by many authors was Locke and Latham’s (1990, 2000) theory of goal setting. Studies have concluded that the theory is among the most valid and practiced theories of motivation in organizational psychology (e.g. Lee and Earley, 1992; Miner, 1984; Pinder, 1998). Among the tenets of this theory is that setting a specific goal, high goal, leads to higher performance than setting no goal or even an abstract goal such as urging people to do their best.

Houts and Scott (1976) applied the work of McClelland and Winter to ten severely handicapped individuals often described as lacking in motivation as well as mental patients with history of long-term hospitalization. They concluded that the same principles that led to increased economic achievement would, if applied to the field of mental health, led to increased goal attainment by patients in therapy. The recent work by Latham and Brown (2006) on effects of learning and outcome goals on self-efficacy, satisfaction and performance in a Master in Business Administration program appear to offer some evidence in support of participation in goal setting and level of goal attainment.

Historical review of Goal Setting and Achievement showed that Luenbeger (1972) indicated that clients who formulated goals for therapy exhibited more goal attainment, anxiety reduction and self actualization as a result of therapy than client who did not formulate goals. Studies indicated that persons who set performance goals for themselves perform better in certain tasks than those who did not set their own goals (Lock & Bryan 1966; Jones & Garwick, 1973; Calsyn, 1978). Studies by Smith (1996) suggested that client participation in goal setting results in increased treatment effectiveness.

Overall, these results offer support that treatment is more effective when collaborative goal setting is added to goal-oriented therapy than when goals are set for clients. However, in Ghana, most often, the health care givers tend to set goals for the clients. The results from these reviews suggest that the critical variable in increasing therapeutic effectiveness is client participation in goal setting rather than setting goals per se. Goal setting as a nursing process, psychotherapeutic approach, as well as medical approach has been part of regular practices in Ghana. However, to increase its therapeutic effectiveness it may require patient or client participation, which is the concern of the present study.

The aim of the study was to carry out experimental studies to examine the effect of patient participation in collaborative goal setting in psychotherapy- psychological intervention among in-patients on the psychiatric wards. The groups were compared with respect to the following variables; goal attainment score; patient satisfaction with care (treatment); the therapist satisfaction with care given and responses to the follow-up community readjustment.

It was hypothesized that patients/clients who would participate with clinicians /caregivers to formulate goals by means of goal attainment scaling would, when compared to control group (non-goal participation);

1. Would score significantly higher on goal attainment measures than non-goal participants; 2. The experimental group would be more satisfied with their care than the control group; 3. The experimental group would respond more favorably on the standard questionnaire for community adjustment than the control group; 4. Clinicians/ caregivers who would participate in the goal attainment scaling with patients would be more satisfied with the care given than those who do not participate

METHODS

Participants Sixty patients were recruited comprising 30 females and 30 males. The patients had remained stable and had passed the acute phase of their illness (as determined by the health team -psychiatrists, nurses and psychologists). Further, they were coherent and able to discuss their health goals. They were randomly assigned to either one of the two conditions; experimental and control, using random numbers. The patients who stayed between three to four weeks on the admission unit were included in the study whereas those who spent less than two weeks on admission were excluded for the final analysis. The mean age for the experimental group was 46 years and the mean age for the control group was 38 years. See Table 1 for the demographic details.

Procedure The study was a repeated measures design. In addition to group comparison, each patient served as his/her own control. Each patient on admission to the unit, after obtaining his/her consent to participate in the study, completed the locus of control questionnaire.

They were then randomly assigned to one of two groups; mutual goal setting group (i.e., therapists and patients collaborated in setting goals for treatment - experimental group) or non-patient participating goal setting group (i.e., only therapists set goals for treatment - control group The Locus of Control measure was included in the study to see if participation in the goal setting process would influence patients to develop a greater sense of internal control

Clinician orientation Before the commencement of the study, four clinicians received training in goal setting techniques. In addition, they were given series of staff development sessions aimed at reviewing the treatment plan and goal setting of the patients. The technique was facilitated by using Guide to Goals (Garwick, 1975), a manual designed to direct clinicians, the active process of constructing a Goal Attainment Follow-up Guide with treatment plan. The program took about three weeks to complete.

Data Collection Each patient had a constructed Attainment Follow-up Guide. The goals were communicated to all staff- clinicians providing the therapy. There were no changes in the methods of providing nursing care on the ward due to the study. The clinicians utilized whatever system of nursing care existed on the ward. While the control group continued with the regular care plan with goals set by the nurses and other staff, the experimental group, in addition to the usual regular care plan, actively participated in setting the specific therapy goals with the clinicians for his or her care. Each patient was evaluated at the end of the goal attainment period (i.e. when the patient was ready for discharge from the ward). The period varied in length by each patient. Each patient spent no less than three weeks and not more than four weeks in the ward. See Table 2.

At the goal attainment period (a day before discharge) a first year graduate student who has no knowledge of the patient group (i.e. experimental or control group), evaluated each patient care as an external assessor.

Each patient as well as the clinical therapist who participated in the study completed Patient’s Level of Satisfaction Questionnaire for the treatment received and the Clinician’s Level of Satisfaction for care given respectively. Again each patient was rated on “Observation for Symptoms Scale” on the ward. The patients also before discharge, completed the Locus of Health Control the second time.

DATA ANALYSIS

The goal attained score (GAS) for each patient was calculated by using the formula (Horsley, Crane, Haller & Reynolds, 1982)

10∑WiXi 50 + v .7Wi+3(∑Wi)2

Where W, refers to Scale weight X, refers to the outcome level.

Score for each group were calculated by summarizing the score for each patient in the respective group. The two groups were compared on mean goal attainment scores.

Results Table 2 provides details of the goals set by the two groups (Experimental & Control Groups).

Table 1 – PATIENTS DEMOGRAPHICS INPATIENTS INFORMATION FOR BOTH GROUPS

Experimental Control Number of Patients 30 30 Female 12 14 Male 18 16 Mean Age 46 (9.4) 38(10) Diagnosis: Schizophrenia 12 11 Depression 8 10 Substance Abuse 10 9 Number of Readmissions 3 3 ______

Table 2 – Goals set by the two groups Experimental Control Number of goals per group 32 22 Types of Goals: Temper and other behavioral problems 3 1 Medication compliance problems 7 4 Personal hygiene 8 7 Aggressive behavior 4 3 Ward and outside activities 6 5 Eating habits 3 2 Speech 1 -

Goal Attainment Scores Table 3 illustrates scores of both groups. The results demonstrate that patients in Group 1 who participated in the mutual goal setting obtained significantly higher scores than the control group.

TABLE 3 - MEAN GOAL ATTAINMENT SCORES FOR GROUP for the Experimental and Control groups

Group 1 (Experimental) Group 2 (Control) t N=30 N=30

Mean Goal Attainment Score 54.23 (17.95) 28.83 (9.8) 7.0*

*p<.05

Patient Satisfaction The satisfaction analysis was done in light of the hypothesis that patient in Group 1 would be more satisfied with care received than the Group 2. The result, as indicated in Table 4 confirmed the hypothesis (t(1, 59)=14.98; p<.05).

TABLE 4 - COMPARISON OF MEAN SATISFACTION SCORES FOR BOTH GROUPS

Group 1 (Experimental) Group 2 (Control) t N= 30 N=30

Mean score 46.1 (6.9) 19.1 (7.1) 14.98* ______*p < 0.05

Therapist Satisfaction The analysis of the Clinician score in Table 5 supported the hypothesis that therapists in mutual goal setting when compared to therapist in non-mutual goal setting would be more satisfied with the care given to their patients

TABLE 5 - COMPARISON OF MEAN SATISFACTION SCORES FOR THERAPISTS IN GROUP 1 AND GROUP 2

Group 1 (Experimental) Group 2 (Control) t N=5 N=5

Mean Satisfaction score 46.6 (5.1) 27.7 (5.8) 16.85*

______*p < 0.05

Analysis of individual Patient’s level of Performance with each patient serving as his or for own control is reported Appendix A. It showed that each patient’s goal score at the baseline or initial stage was compared to his or her post score at the end of the goal attainment period. The result indicated that each patient in Group 1 achieved significant goal attainment post-scores than his /her pre-scores. However, some patient’s post mean score when compared to the group mean score did not adequately reflect the patient’s true performances.

Results of Locus of Health Control Scores The results indicated that the pre-mean-scores differentiated the internals from the externals in both Group 1 and Group 2. The post scores of Locus of Health control indicated that the patients with internal Locus of Control in Group 1 scored significantly higher on internal control than those internals in Group 2. The externals in Group 1 scored higher on internal Locus of health Control (IHLC) than those

16 externals in Group 2. The score of the externals and internals in Group 2 remained the same as pre-scores or the baseline scores. However the externals in Group 2 scored significantly higher on the subscale of powerful other (PHLC).

DISCUSSION The hypotheses tested confirmed that patients who participated in mutual goal setting with therapists performed better in their mental health care than those who were not. In other words, significant goal attainment scores appeared to have a direct relationship with patients involved in goal setting. The results provide some demonstration that Ghanaian patients’ involvement in therapy is effective in motivating patients towards establishing a partnership in their healthcare. The findings are in line with other western studies (Latham and Brown, 2006; Horsely et al, 1982; Galano,1977). The study seems to provide an effective method for monitoring the performance and evaluation of each patient treatment thus making it possible for each patient to receive the necessary assistance by therapist/clinicians; an approach that can lead to increased satisfaction among both therapist and patients. The results also provide some evidence for the effective system of quantitative measure of outcome of psychotherapy. By having patients involved in goal setting with therapists /clinicians, the patients are able to learn as well as take an active part in their own treatment; this approach can have a long-term impact on Ghanaian patients after their discharge from the hospitals.

Analysis and results of the data on single-case design (each patient serving as his/her own control) in the study revealed patients who performed better or poorly in the goal attainment mean scores, a situation which was masked by the group analysis. The single case analysis also helped in identifying individual patients who did not benefit from treatment but who need to be considered for special attention. The comparisons between the group and individual goal attainment scores offer strong evidence to support the importance of clinical and statistical significance of mutual goal setting for clinicians/therapists. The quantitative measures of the outcome of psychotherapy can help mental health professionals to contribute meaningfully to demonstrate the patient’s progress and planning of therapy.

The result of the locus of health control analysis revealed the influence on patient participation or non participation in goal setting. The patients who were Internalizers in goal setting seemed to have developed more confidence, competence and satisfaction which could be linked to their ability to control their healthcare, thus, scoring significantly higher on the internal health locus of control (IHLC). Some Externalizers could also benefit from mutual goal setting by modifying dependency on others.

The significant scores on External Health Locus of Control especially the subscale (PHLC) by patients in Group two who were initially Externalizers, confirmed modification of dependency on staff for setting goals for them; a suggestion made by other authors (Lowery, 1982).

Conclusions Patient’s involvement in mutual goal setting was examined with respect to its effect on psychotherapy outcome measures. It was found that greater involvement of Ghanaian patients in setting goals led to significantly greater patients’ and therapists satisfaction and goal attainment. It suggests that the relationship of involvement in goal setting with satisfaction and goal attainment warrants its use in clinical practice.

These results show that goal setting or partnership in healthcare procedures can have substantial effect in accomplishing psychotherapy objectives for patients and clinicians. It will also have additional quantitative data to support their clinical practice during patient’s progress evaluation and planning for discharge to the community. The patients who are discharged to the community with the ability to take care of themselves would definitely remain in the community longer and reduce the “revolving door attitude”. It is necessary to identify individual patients with internal locus of control who would be more willing to participate in collaborative goal setting with possible benefits than those with external locus of control characteristics.

REFERENCES

Bensing, J. (1991), Doctor-patient communication and the quality of care, Social Science and Medicine, 11 (32): 1301-10.

Calsyn, R.J. & Ferrie, L.A (1976) A Study of Therapeutic effects of Goal Attainment Scaling, P.E.R.C. Newsletter, 7: 1-7.

Cegala, D.J. (1997). A study of doctors’ and patients’ patterns of information exchange and relational communication during primary care consultation: implications for communication skills training. Journal of Health Communication, 2 (3): 169-94.

Galano, J (1977). Treatment effectiveness as a function of client involvement in goal setting and goal planning. Goal Attainment Review, 3: 17-32.

Horsely J.A., Crane, B., Haller, D. & Reynolds, C.(1982). Mutual Goal Setting in Patient Care: CURN Project. Toronto: Grune & Stratton: Sub: Harcourt Brace Jovanovic Publishers.

Houts, P.S. & Scott, R.N. (1975). Goal planning in mental rehabilitation: an evaluation of the effectiveness of achievement motivation training for mental patients being rehabilitated to community. Goal Attainment Review, 2: 33-51.

Jones, S. & Garwick, G. (1973). Guide to Goals study; Goal Attainment Scaling as Therapy adjunct. P.E.P. Newsletter 4: 1-3.

Kaplan, S.H., & Ware, J.E. Jr. (1989). The patient’s role in health care and quality assessment. In N. Goldfield and D.B Nash (Eds.), Providing quality care. Philadelphia: American College of Physicians.

Latham, G.P and Brown, T. C (2006) The effect of learning vs. outcome on self-Efficacy, Satisfaction and Performance in an MBA programme . Applied Psychology: An International Review, 55(4): 606-623.

Lee. C., & Earley, P.C (1992) Comparative peer evaluation of organizational behaviour theories. Organizational Development Journal, 10: 37-42.

Lock E.A. & Latham, G.P (1990). A theory of goal setting and task performance. Englewood Cliffs, NJ: Prentice Hall.

Lock, E.A & Latham, G.P (2002. Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American Psychologist, 57: 705- 71.

Luenberger (1972). Therapeutic movement as a function of awareness of goals. University of California Press.

McClelland, D.C. & Winter, D.G. (1969). Motivating Economic Achievement. New York: Free Press.

Miner, J.B. (1984). The validity and usefulness of theories in emerging organizational science. Academy of Management Review, 9: 296-306.

Pinder, C.C.(1998). Work motivation in organizational behaviour. Upper Saddle River, NJ: Prentice Hall.

Rotter, J.B. (1966). Generalized Expectancies for internal versus external Control of reinforcement . Psychology Monograph 80(1): 7-28.

Rotter J. B and Hochreich, D. (1975) Personality. Glenview, I. L: Scott, Foresmon.

Smith, D. (1976). Goal Attainment Scaling as an adjunct to Counseling. Journal of Counseling Psychology, 28: 22-27.

Younger, J., Marsh, K.J & Grap, M.J, (1995). The relationship of health locus of control and cardiac rehabilitation to mastery of illness-related stress. Journal of Advanced Nursing, 22: 294-299.

APPENDIX A - COMPARISON OF INDIVIDUAL GOAL ATTAINMENT SCORES WITH THE GROUP’S MEAN ATTAINMENT SCORES Pre-Score/Baseline Mean Group Scores INDIVIDUAL MEAN PRESCORE Group1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 m prescore 24.4 24.4 24.1 28. 28. 30. 24.4 26.1 25. 28. 21. 20.0 24.3 27. 26. 21. 4 2 1 1 2 4 1 2 6

Group 1

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

28.0 23. 24.3 25. 27. 22.3 24.5 22. 23. 22. 21.0 24.3 26. 25. 2o.1 2 6 1 2 0 5 3 1

Post-Score INDIVIDUAL MEAN POSTSCORE Group 1 m 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 post-score

54.1 60.3 50.2 52. 60. 65. 30.1 50.2 74. 28. 60. 22.1 76.4 70. 26. 21. 3 1 1 1 1 1 3 2 6

Group 1 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

78.0 63. 54.3 65. 65. 62.4 54.6 72. 63. 62. 71.0 54.3 66. 25. 23. 2 6 7 3 0 5 3 1 1

Pre-Score/Baseline Mean Group Scores INDIVIDUAL MEAN PRESCORE

Group 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 m prescore

23.3 23.0 25.1 21. 23. 20. 24.1 28.1 30. 26. 23. 26.1 24.3 30. 27. 20. 2 3 1 1 2 4 1 2 0

Group 2

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

24.1 22. 23.3 25. 23. 24.3 22.5 21. 19.7 20. 20.3 18.9 21. 20. 22. 3 6 8 2 0 5 3 1 1

INDIVIDUAL MEAN POSTSCORE

Group 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 m postscore 28.0 24.1 26.1 22. 24. 12. 25.2 27.5 32. 27. 24. 27.2 32.1 40. 28. 62. 1 1 2 2 1 0 3 2 6 Post-Score

Group 2

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

25.0 24. 23.6 36. 45. 26.2 28.0 33. 30. 26. 28.9 19.8 26. 25. 26. 2 8 7 6 0 5 7 1 3

DO CULTURAL IDENTITY AND CONTROL PERCEPTIONS HAVE ANY BEARING ON HOW SATISFIED WE ARE WITH OUR LIVES?

Frances Emily Owusu-Ansah, 1 Ph.D.

1College of Health Sciences, Faculty of Medicine Department of Behavioral Sciences Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

ABSTRACT

The role of perceived control in well-being and its relation to age is well established. Much less understood is the relationship of subjective cultural orientation to well-being and control, particularly primary and secondary forms of control. This study examined the relationship among cultural orientation, age, and well-being to control. Two hundred and sixty-five ethnically diverse adults (ages 18 to 88) from Southeastern parts of the United States participated in the study. Results of correlation and multiple regression analyses indicated that cultural orientation, age, and well-being were significantly and differentially related to forms of primary and secondary control. Associations of forms of primary and secondary control to the collectivism and individualism constructs appear congruent with collectivism and individualism values. Older adults in this sample enjoyed higher life satisfaction, relative to younger adults, and used more secondary control coping strategies. In general, a greater life satisfaction was associated with selective primary control and positive reappraisal secondary control. Potential implications for clinical practice and further research are discussed.

Key words: collectivism, individualism, perceptions of control, primary control, secondary control, subjective well-being.

Correspondence: Frances Emily Owusu-Ansah, Ph.D. College of Health Sciences, Faculty of Medicine, Department of Behavioral Sciences Kwame Nkrumah University of Science and Technology, Kumasi Phone: 020-819-8270 or 024.308.2765 Email address - [email protected]

INTRODUCTION There is a plethora of literature that consistently suggests that a sense of control plays a critical role in people’s psychological and physical wellbeing. Greater perceived control has been associated with positive effects in several life spheres including academic achievement, self-concept, and attenuation of stress, healthy psychological functioning and constructive coping skills.

Perception and exercise of control can be categorized as primary or secondary. Primary control involves attempts to change the environment so that it fits with an individual’s needs and desires. It is assimilative and outwardly directed as the individual engages in ‘whatever means’ are necessary, direct or indirect, to persist in the pursuit of desired goals. Tenacious engagement of the environment through own efforts is referred to as selective primary control while the use of secondary resources to alter the environment to attain goals is compensatory primary control.

Unlike primary control, secondary control is accommodative and involves attempts to fit in with the environment. It focuses on cognitive or motivational changes within the self. Attempts to make sense of and/or find some positive meaning in an otherwise difficult or negative situation is interpretive or considered positive reappraisal secondary control. Disengagement from prior goals, rescaling or adjustment of values attached to unattainable goals also reflects secondary control processes referred to as lowering aspirations.

Age and Control Despite some gains, normal aging is accompanied by losses in physical and cognitive resources. Therefore aging persons may experience more constraints than younger persons. These limitations, physical or cognitive, influence perception and exercise of control so that differences in control perceptions for different ages are observed (Heckhausen & Schultz, 1995; 1999). Given the availability of numerous developmental pathways and opportunities in childhood through early adulthood, primary control increases (relative to secondary control) because it may be seen as most effective for the attainment of goals. With increasing age, primary control gradually declines and is replaced by an increase in secondary control to compensate for losses in primary control.

Although results of studies on aging and control are mixed, the general findings suggest that the strive for control per se continues throughout the life span but control-related behavior (primary or secondary) differs as a function of age and cultural orientation.

Cultural Orientation and Control Several studies attest to the important relationship between cultural orientation and control perceptions. Culture provides a framework within which individuals conceptualize their world, interpret experiences, and respond to the environment (Kambon, 1998). Cultural beliefs influence control perceptions because embedded are schemas that inform the individual about how the “world works” and forms the basis for the understanding and construction of “reality” as well as cause and effect relationships.

In the cross-cultural literature, cultures are broadly categorized and described as collectivist or individualist. Triandis (1995) suggests that collectivists and individualists are differentiated in four main areas: definition of self, priority of goals, nature of relationships, and determinants of social behavior.

These differences have social and individual implications that are importantly related to individuals’ perceptions of control.

Culture, age and control perceptions Only a few studies have investigated the relation of culture to control perceptions and aging. These studies suggest that socio-cultural context is essential in the choice of control and coping strategies. Individuals are significantly differentiated in their perception and choice of control strategies by their age and cultural orientation.

Although these studies provide useful information about culture, age, and control, some questions and inadequacies remain. Previous studies have focused on cross-national comparisons that are based on categorizations of countries as collectivist or individualist. Granted that some cross-national cultural differences have been found (Hofstede, 1980), investigation at the subjective level seems more appealing in view of modern technological advancements that facilitate rapid migration of peoples and ideas across societies and cultures turning the world into a ‘global village’24. Any country has a mix of collectivism and individualism and indeed healthy individuals exhibit both tendencies (Triandis, 1995; Vandello & Cohen, 1999). More importantly, it is individuals, not cultures, that behave and therefore insights at the subjective level would serve greater utility for clinical interventions.

The present study examined the relation of control to culture and well-being as may be moderated by age. Given the greater emphasis of independence among individualists and an emphasis of interdependence among collectivist (Triandis, 1995), control perceptions can be expected to differ as a function of cultural orientation. Individualists, relative to collectivists, may have a greater perception of primary control because of an emphasis on the individual as a separate entity (Hofstede, 1980) and a primary agent whose efficacy can change the environment. Collectivists, on the other hand, prioritize relationships, interdependence, and an emphasis on the collective (Triandis, 1995; Kambon, 1998). Maintaining relationships with others often require changes within the self; a characteristic that may arguably predispose collectivists, relative to individualists, to a greater perception of secondary control strategies. The assumed differential perception of primary and secondary control by individualist and collectivists can be further moderated by age as noted in previous findings. Primary and secondary control is both expected to be positively related to well-being given their adaptability.

Specifically three questions are explored: First, are there differences in the relationships between individualism/collectivism and forms of primary and secondary control? Second, are these relationships moderated by age? Third, what is the relationship between forms of primary and secondary control to well-being? In other words, the study examines: (a) whether cultural orientation is related to perceived control, (b) whether age moderates these associations, and (c) whether perceived control is associated with well-being. Based on the preceding theoretical and empirical review, individualism is expected to be positively related to forms of primary control and this relationship should be stronger for younger than older adults. A positive relationship is also expected between collectivism and forms of secondary control with the relationships stronger for older than younger adults. Since control is essential to well- being and both primary and secondary control can be adaptive, both forms of control should be positively related to well-being.

METHODS

Participants These consisted of 265 sampled adults from Southeastern United States who were mainly undergraduate psychology students and others from nearby social organizations. There were 192 women (73%) and 73 men (28%) with the age range of 18-88 (mean age of 32.5 years, SD = 21.4). Most participants were single (74%), or in a committed relationship (21%) or divorced/separated (3.%) and a few widowed (2.0%). Many of them had completed college (66.4%) or were still in college (24.2%) with a few High School graduates (9.4%). Caucasian (51.7%) and African-American (33.3%) ethnic backgrounds formed the larger portion of participants with a few others of Ghanaian (4.9%), Hispanic (4.9%) and Asian (3.4%) ethnic backgrounds.

Procedure Students from undergraduate psychology courses at the Florida State were randomly recruited by means of a detailed sign-up sheet at the Psychology Department in accordance with the requirements of its research and ethics committee. Other participants were similarly solicited from church and community organizations through their appropriate leaders. All were provided with adequate information about the study, had their questions answered, their consent sought and obtained before completing questionnaires. Questionnaires were administered in small group sessions (10-30 sizes). Particular effort was made to ensure consistency in data collection at all settings.

Measures Cultural orientation - Subjective cultural orientation was measured with Triandis’(1995) Individualism- Collectivism Scale that consists of 16 items with equal number of items assessing the two constructs. These were rated on a 9-point scale from 1 (strongly disagree) to 9 (strongly agree) with high scores indicating high collectivism or high individualism. The scale has good internal reliability and validity and found useful for assessing subjective cultural orientation cross culturally.

Well-being Subjective Well-Being was assessed using the Satisfaction With Life Scale (SWLS; Diener, Emmons, Larsen & Griffin, 1985). The scale consists of 5 statements assessing overall satisfaction with life and rated on a 7-point scale from strongly disagree (1) to strongly agree (7). Higher scores indicate higher satisfaction with life. The SWLS has good internal consistency and stability with desirable convergent and discriminate validity.

Primary and secondary control - Control perception was assessed with items from pre-existing control scales (Tenacious Goal Pursuit and Flexible Goal Adjustment Scales; Brandstadter & Renner, 1990; Peng, 1993; Wrosch et al., 2000) and additional constructed items. Items (primary and secondary control) were rated on a 7-point scale on how good or bad they perceived themselves in behaving in the indicated way (1 – very bad; 7 – very good). A mean score was computed with higher scores indicating higher perception of primary or secondary control. Descriptive statistics and internal consistency reliabilities for the control items (as well as culture items) are presented in Table 1.

RESULTS The first two research questions investigated the relationship of cultural orientation (i.e. individualism and collectivism) to forms of primary and secondary control and whether age moderated those relationships. Bivariate correlations, presented in Table 2 indicate, as expected, that individualism was positively correlated with selective primary control and collectivism was positively related to positive reappraisal secondary control. However, contrary to a priori expectations, there were significant positive relationships between individualism and some forms of secondary control and between collectivism and both forms of primary control.

Table 1: Descriptive Statistics and Internal Consistency Reliabilities for Perception of forms of Primary and Secondary Control and Culture Variables

Mean SD Median Range Possible Coefficient Range Alpha Primary Control Selective 5.15 .92 5.20 2-7 1-7 .72 Compensatory 4.67 1.11 4.75 1-7 1-7 .60 Secondary Control Positive Reappraisal 5.19 .98 5.17 3-7 1-7 .79 Social Comparison 3.84 1.74 4.00 1-7 1-7 .76 Lower Aspiration 3.59 1.15 3.67 1-7 1-7 .82

Culture Variables Collectivism 6.97 1.15 7.13 1.8-9.0 1-9 .71 Individualism 5.79 1.21 5.88 2.5-8.5 1-9 .64

Table 2 - Correlation among Culture Variables and Forms of Primary and Secondary Control

Individualism Collectivism Selective PC .14 (p = .026)a .42 (p = .000)b Compensatory PC -.01(p = .952)a .36 (p = .000)b Positive Reappraisal SC .05 (p = .412)a .44 (p =. 000)b Social Comparison SC .39 (p =. 000)a .01 (p = .972)b Lowering Aspirations SC .16 (p = .000)a .06 (p = .320)b Age -.20 (p =.000)a -.03 (p = .571)b

Note: PC = Primary Control; SC = Secondary Control

Information in parentheses indicates p-value for statistical significance test of the difference from correlation of zero. Within rows, coefficients with the same superscripts are not significantly different from each other at p< .05; those with different superscripts are significantly different at p< .01. The moderating effect of age was examined with hierarchical regression. Preliminary analyses were conducted for this and all subsequent multiple regression analyses to ensure that the data met assumptions for multiple regression analysis. Two-step hierarchical multiple regression analyses were conducted entering each predictor variable (e.g. individualism and age or collectivism and age) in step one (to test for the independent contribution of each main effect) and adding their cross-product in step two (to test for the interaction). Separate hierarchical regression analyses were conducted for each culture variable (i.e. individualism, collectivism) predicting each form of primary and secondary control.

Individualism was expected to be positively related to forms of primary control with the relationship being stronger for younger than older adults. The results indicated that individualism strongly predicted selective primary control, social comparison and lowering aspirations secondary control with standardized coefficients (beta) of 0.13, 0.40, and 0.23 respectively. No form of control was significantly predicted by the interaction of individualism and age.

Collectivism was expected to be positively related to secondary forms of control with the relationship being stronger for older than younger adults. The results indicated that collectivism scores were strong predictors of three forms of control: selective, compensatory, and positive reappraisal. Standardized coefficients (beta) were 0.42 for selective primary control, 0.35 for compensatory primary control, and 0.44 for positive reappraisal secondary control. Interaction between collectivism and age significantly predicted lowering aspirations secondary control, accounting for additional 3% of the variance with a standardized coefficient (beta) of 1.04. Other than this, age did not contribute a significant amount of variance to any of the outcome variables. Simple main effects of this interaction are presented in Table 3. The pattern of regression weights for this sample is consistent with the expectation that the relationship between collectivism and lowering aspiration secondary control would be more strongly positive for older than younger adults. The relationship between collectivism and lowering aspiration was significantly different from zero for older adults (ages 80 and above) but not for younger (ages 20-49) and middle aged adults (ages 50-79).

Table 3 - Simple Main Effects of Collectivism on Lowering Aspirations Age Effect of collectivism

20 -.03 50 .18 80 .39*

*p< .05

The final question investigated the relationship of perception of forms of primary and secondary control to well-being. Primary and secondary forms of control were predicted to be positively related to well- being. Partly consistent with expectation, life satisfaction had significant positive correlations with selective primary control and positive appraisal secondary control (see Table 4).

Table 4: Correlation of Life Satisfaction and Forms of Primary and Secondary Control Life Satisfaction Selective Primary Control .21 (p = .000)a Compensatory Primary Control .10 (p = .108)b Positive Reappraisal Secondary Control .25 (p = .000)a Social Comparison Secondary Control -.03 (p = .684)b Lowering Aspirations Secondary Control -.03 (p = .584)b

Note: Information in parentheses indicates p-value for statistical significance test of the difference from a correlation of zero. Coefficients with the same superscripts are not significantly different from each other at p< .05; those with different superscripts are significantly different at p< .01.

In other words, persons who were very satisfied with their lives also held greater perceptions of selective primary control and positive reappraisal secondary control. These correlations were significantly different from the relationship of life satisfaction to the other forms of primary (i.e. compensatory) and secondary control (i.e. social comparison and lowering aspirations).

DISCUSSION Limitations of the study include sample and method of analyses. Participants were solely residents of the United States and therefore results may not generalize to other, though similar, cultural groups outside of the United States and are therefore discussed with caution. Replication with a different sample, (preferably Ghanaian dominant sample) is necessary to ensure that results are not artifacts. Furthermore, the general pattern of results does not strongly support predictions. Instead more questions are raised. These include, for example, why do some of the results point in the opposite direction? Does the theory on the measured variables err? Or is it due to lack of adequate research examining the nomological network surrounding these constructs so that appropriate theoretical explanation of results is impeded? These questions warrant further investigation.

Limitations notwithstanding the significant relationships of individualism to the three forms of control (i.e. selective primary control, social comparison and lowering aspirations secondary control) appear consistent with individualist values. Individual uniqueness, independence, and competition are central to individualism. For persons with individualist cultural orientation, opportunities for individual ascendancy and distinctiveness are greatly desired and pursued. Personal ascendancy would be facilitated by both social comparison and a belief in the ability to bring about desired goals (selective primary control). Similarly the ability to adjust unattainable goals (lowering aspirations) can serve to reinforce a perception of the self as primary agent in the attainment of goals. This too would be consistent with a sense of independence central to individualist cultural orientation. Seen from this perspective, therefore, it makes 28 sense that individualism was significantly associated with these forms of control and not with compensatory primary control which is ‘other-centered’ in the attainment of ‘own’ goals. To the individualist, to be able to do it alone and with less help from others is better because in this way the sense of self as agentic is reinforced.

That high collectivism should be accompanied by high positive reappraisal appear reflective of underlying commonalities in the two constructs. A collectivist orientation is relatively less ‘self-centered’ and the role of others in the meaning-making of a person’s life is emphasized. The ‘other’ may include a spiritual source. Therefore collectivism has been suggested to have religious underpinnings that emphasize a more teleological, less linear, approach to understanding reality. Such worldview would motivate a tendency to search for meanings and purposes of events and an orientation that things happen because they are ‘meant to’; so that an otherwise illogical and negative or distressing event can be positively reappraised to enhance acceptance and acquiescence.

The significant positive relationship of collectivism to forms of primary control was unexpected and somewhat difficult to explain. Cautious speculations are in order. First, the association appears particular to the cultural context of the study. The American value system emphasizes self-determination. In a predominantly individualist society, such as the United States, where individual distinctiveness is emphasized and self-efficacy rewarded, a collectivist orientation may well be accompanied by the development of a strong sense of agency which may explain this finding. It appears that the nature of collectivism in the United States may be different from the nature of collectivism in a predominantly collectivist cultural context. Furthermore, this finding suggests that collectivism, with its interdependence and collective focus, is nether antithetical to primary control nor imply an unequivocal lack of it. A collectivist orientated person may be just as committed to personal advancement through the exercise of primary control as he or she is to the collective. Indeed self-reliance, long considered uniquely individualist attribute, has also been associated with collectivism. The relation of both individualism and collectivism to primary and secondary forms of control in unexpected directions underscore the issue of contentious dualism, and often erroneous assumptions, that pervade psychological investigation in which autonomy is pitted against interdependence and individualism against collectivism. Findings of this study suggest that persons who hold collectivist beliefs are not lacking in or less desirous of primary control relative to those who share individualist beliefs and values. Likewise, individualists do not solely use primary but secondary control strategies as well. Therefore, it is safe to say that the desire for control is indeed basic in all humans, though the form and behavioral expressions may differ as a function of cultural orientation.

Investigating the moderating effects of age in the relation of cultural orientation to forms of control, age was predictive of lowering aspirations over and above cultural orientation suggesting that this form of secondary control is common with increasing age. Goal adjustment in older adults (i.e. lowering aspirations) is consistent with Brandstadter and Rothermund’s (1994) suggestion that personal control and life satisfaction in later life are essentially influenced by the ability to accommodate goals and ambitions to personal resources and situational constraints.

Although not all forms of primary and secondary control were significantly related to subjective well- being, the significant positive correlations of well-being to selective primary control and positive

29 reappraisal secondary control are also consistent with previous research that suggests that both primary and secondary forms of control are adaptive. Specifically, this finding suggests that well-being will sometimes require changing the environment to suit needs (as in selective primary control) or making flexible changes within the self to suit environmental constraints (as in positive reappraisal secondary control) (Kyeong, 2003; Myers, 2000).

CONCLUSIONS The present study offers germinal insights for further research with potential clinical implications. First, control does not appear to be a unitary construct. The relationships of the forms of control (primary and secondary) to well-being need further investigation in this cultural context for greater understanding and delineation for a fruitful clinical utility. Second, it is not enough to know a person’s preferred form of control. Knowledge about the value (importance) that one attaches to a given form of control would provide more information about its implication for the one’s subjective well-being. In other words, the relationship of control appraisal to subjective well-being would be more interesting.

Third, the efficacy of treatment interventions can be informed and enhanced by a consideration of age and cultural orientation of the individuals seeking therapy on control-related issues. The findings of present study suggest that rescaling of goals is essential for greater subjective well-being in older adults. Likewise it appears that on control related issues the highly individualist would be more responsive to therapeutic interventions that enhance sense of personal agency and coping skills through affirmation of uniqueness relative to others. For the highly collectivist, encouragement toward positive reappraisal of difficult or negative life situations to effect acquiescence and acceptance might be more appealing and therapeutic. Though findings and conclusions from this study cannot be generalized to the Ghanaian context, given the sample, it is hoped that they will spur the necessary further research because happiness (otherwise referred to as subjective well-being) has social and economic implications given its impact on productivity (Kyeong, 2003). Society can only benefit from more context-specific research in this direction.

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PSYCHOSOCIAL FACTORS ASSOCIATED WITH SYMPTOMS OF DEPRESSION AMONG GHANAIAN ADOLESCENT STUDENTS IN JUNIOR AND SENIOR HIGH SCHOOLS.

Mabel Oti-Boadi1

1Regent University College of Science and Technology

ABSTRACT The present study examined psychosocial factors associated with depression among Ghanaian adolescent students in junior and senior high schools. Three hundred high school students were recruited comprising 150 males and 150 females. Tests administered evaluated depressive symptoms, self-esteem, and parental social support. The results revealed that female adolescents experienced more depressive symptoms than male adolescents. However, there was no significant difference in depressive symptoms of adolescents from separated/divorced families and adolescents from married families. Further, the results revealed a significant negative correlation between depressive symptoms and self-esteem, but no significant correlation between depressive symptoms and social support. Implications for further research are discussed.

Key Words: adolescents, depressive symptoms, gender, parent’s marital status, self-esteem, social support.

Correspondence: Mabel Oti-Boadi Regent University College of Science and Technology P. O. Box DS 1636 Dansoman Accra-Ghana Email: [email protected] – Phone: +233244985442

INTRODUCTION

Adolescence is a time of rapid biological, cognitive and psychosocial maturation (Arnette, 2000). According to Ingersoll (1989) adolescence is "a period of personal development during which a young person must establish a personal sense of individual identity and feelings of self worth which include an alteration of his or her body image, adaptation to more mature intellectual abilities, adjustments to society’s demands for behavioral maturity, internalizing a personal value system, and preparing for adult roles" (p. 2).

In spite of the significant developmental changes associated with the transitional period of adolescence, there are several difficulties and challenges that most adolescents confront. According to Waslick (2000), adolescence is a difficult transition, especially in societies with so many opportunities, temptations, and choices; hardly anyone gets through it without some anxiety and depression. Several studies have shown that adolescents difficulties (with their teachers, academic work, parents, establishing their self-identities, mood swings and self-esteem), are often the sources of depressive symptoms (Boadu, 2004; Early, 2002; Nair, Paul & John, 2004). Depression is present in about 1 percent of children and 5 percent of adolescents at any given time. Before puberty, boys and girls are at equal risk for depression, whereas after the onset of puberty, the rate of depression is about twice as high in girls (Brent & Birmaher, 2002).

In the past, researchers and health professionals doubted the existence of depression in children because they believed that children lacked the mature psychological and cognitive structure to experience these problems and that behaviors such as mood swings, boredom and hopelessness were transitory and not a reflection of a mental disorder (Santrock, 2001; Son & Kirchner, 2000). However, three decades of research have dispelled the myths of adolescents being incapable of experiencing and manifesting depressive symptoms similar to adults (Sarafolean, 2000; Son & Kirchner, 2000). Mental health professionals now acknowledge the occurrence and increase of depression among adolescents (National Institute of Mental Health [NIMH], 2001). Studies on adolescent depression consistently demonstrate that depression is occurring earlier in life today than in past decades and early onset depression often recurs and continues into adulthood (Lewinshon, Gotlib, Klein, Rhode, Seeley, 2000; Weismann, Wolk & Goldstein, 1999). According to Avenevoli and Steinberg (2000), about 25% of adolescents regularly feel depressed and about 5% experience symptoms at any one time. Depression has been predicted as the leading cause of global disability burden (World Health Organization (WHO; 2002). Recent evidence indicates that by the year 2020, childhood neuropsychiatric disorders including depression will become one of the five most common causes of morbidity, mortality and disability among children (WHO, 2002). Depression in adolescents has often led to serious difficulties in school, low self-esteem, substance use, and personal adjustment (Nunley, 2001). Common symptoms of depression among adolescents include poor performance in school, withdrawal from friends and activities, feelings of sadness and hopelessness, loss of interest and/or pleasure in previously enjoyed activities, lack of enthusiasm, energy, or motivation, sleep disturbance (reduced or increased sleep), low self-esteem, feelings of guilt, indecision, lack of concentration, or forgetfulness, restlessness and agitation, changes in eating or sleeping patterns, substance abuse, problems with authority, suicidal ideation (suicidal thoughts) or actions (National Mental Health Association, [NMHA], 2000). According

36 to the American Academy of Pediatrics (2000), adolescents who suffer from depression are at much greater risk of committing suicide than those without depression.

Much of the research on adolescent depression has been conducted with adolescents who attend mental health clinics and with patients who tend to have the severe and recurrent forms of depression (Birmaher, Brent & Benson 1998; NIMH, 2001). However, this may not be representative of all adolescents with symptoms of depression since several studies have documented that a substantial number of adolescents in the general population suffer from depression (Fombonne, Wostear, Cooper, Harrington & Rutter, 2001; Joslan, Wight & Aneshensel, 2000; Rey, Sawyer, Clark, & Bughurst, 2001).

To date, and to the knowledge of the author, only a few empirical studies have been done in Ghana (Assan, 1993; Boadu, 2004). Assan (1993) studied sex differences in depressive symptoms among secondary school students in Ghana. The results revealed that depression is prevalent among Ghanaian adolescents but found no significant sex differences in reported symptoms. Boadu (2004) found a positive relationship between locus of control and depression but found no significant gender differences on depression and locus of control.

Relationship between depression and gender has received significant attention in the past decade in particular. Females are reported to have higher rates of depression than males (Galombos, Leadbeater & Baker, 2004; Meadows, Brown, Elder, & Glen, 2006; Sarigiani & Petersen, 2000; Schraedley, Gotlib, & Hayward, 1999). Overall, studies reported that adolescent females are twice as likely to experience depression as adolescent males (Brent & Birmaher, 2002National Institute of Mental Health - NIMH; 2003).

One major explanation for gender differences in depression may be due to traditional gender role socialization. Traditional gender roles have been found to increase the risk for some disorders such as depression, anxiety, low self-esteem, and eating disorders in females (Hankin & Abramson, 2001; McHale, Crouter, & Whiteman, 2003). In many parts of the world including Ghana, females are usually socialized to be emotionally expressive, child-nurturing, and be domestic. However, men are usually socialized to be emotionally inhibited, assertive, and providers with responsibility for the welfare of all household members (Boateng, Adomako-Ampofo, Flanagan, Gallay & Yakah, 2006; Boohene, Kotey, & Folker, 2005; Dolphyne, 2000; Kimberling & Ouimette, 2002). Males are taught to lead and control females and a male whose lifestyle does not measure up to the prescribed expectations is branded “banyin-basia” in Akan, meaning “man-woman’. Conversely, females are taught to defer to males as stronger, wiser and responsible (Adomako-Ampofo, 2001; as cited in Boateng, Adomako-Ampofo, Flanagan, Gallay & Yakah, 2006). A female who changes the status quo and moves into domains prescribed for males is branded “babasia-kokonin”, in Akan, meaning “a woman-cock” or “male-woman” (Adomako-Ampofo, 2001; as cited in Boateng et al., 2006).

Clare (2000) and Pollack (1999) reported that that the way in which males are socialized to ‘mask’ their emotions might lead to an under-reporting of depressive symptoms. In a study among college students, Joiner, Alfano and Metalsky (1992) found that when depressed female students reached out to their roommates they were met with concerned and nurturing reactions. Depressed male students who did the same, however, were met with social isolation and in some cases, outright hostility. Other studies (Assan,

1993; Liu, Kurita & Tang 1999; Masten, Caldwell-Colbert, Williams, & Jerome 2003) found no variations in depressive symptoms between adolescent females and males. Masten et al. (2003) studied gender differences in depressive symptoms among Mexican adolescents. They reported that changes associated with their political, social, and economic conditions and the high levels of stress associated with the ‘Americanization’ of the American culture was a predictor of depression rather than gender. In another development, females are said to suffer from a higher prevalence of depression than males throughout their reproductive years. Female adolescents are often unprepared for the bodily and social changes that mark their lives during the pubertal period and these changes engender feelings of shame, guilt and inferiority (Angold, Costello, Erkanli, & Worthman, 1999; Carter, Joyce, Mulder, Luty, & McKenzie, 2000). There is accumulating evidence that certain reproductive-related hormonal changes place women at an increased risk of depression (Angold et al., 1999; Harter, 2002).

Parents’ marital status has also been implicated in the development of adolescent depression. In recent times, divorce has become increasingly common in many parts of the world including Ghana. A report from the Accra Metropolitan Assembly’s Register of Marriages on marriages and dissolutions (AMA Report, 1990-2007) shows that marriage dissolutions in Ghana have been increasing over the years. For instance, the report revealed that marriage dissolutions increased from 200 cases in the year 2000 to 425 cases in the year 2007. Although the figures relate to Accra, the most urbanized city in Ghana, it can be inferred to reflect the state of divorce in the rest of the country.

There is a consensus in the literature that children whose parents have divorced are at an increased risk of displaying a variety of behavioral problems such as depression, low-self-esteem, and sadness compared to children living in continuously intact families (Amato, 2000; Elegbeleye and Okeke 2004; Harvey & Fine, 2004; Hetherington & Kelly, 2002; Mahon, Yarcheski, & Yarcheski, 2003; Stephens, Nicholson, & Knoester, 2005; Wallerstein, Lewis, & Blakeslee, 2000). However, other researchers (Garber, 1991; Emery, 1999; Wu, 2000 as cited in Wu, Huang, & Chang, 2006) found no differences between children from separated/divorced and married/intact families. Further, they reported that parents’ marital status has no significant impact on adolescent depression. Other studies argued that potential stressful events such as divorce can have positive long-term consequence when people resolve their problems successfully (Thoits, 1995; Wheaton, 1990; as cited in Amato, 2000). Kirby and Dean (2002) and Richardson and McCabe (2001) reported that some children and adolescents from intact families with severe marital conflicts also experience emotional problems like depression.

Several researchers have examined the link between self-esteem and adolescent behavior (e.g. Marcotte, Fortin, Potvin & Papilon, 2002). According to Battle (1980), as depression rises, self-esteem tends to decline, and as self-esteem declines depression increases. For most adolescents however, low self-esteem is only a temporary emotional discomfort. In others, low self-esteem can translate into serious problems like depression, suicide, anorexia nervosa, delinquency, and other adjustment problems (Usher, Zahn- Waxler, Finch, & Gunlicks, 2000; Southhall and Roberts, 2002; O’Farrell, Flanagan, Bedford, James, & Howell 2005). In a study by McCabe and Ricciardelli (2001), females were found to be less satisfied with their bodies than males and were likely to adopt strategies to lose weight which could affect their depression scores (Erkolahti, IIonen, SaariJAorvi & Terho, 2003).

Studies of depressed adolescents and children confirm the importance of parental social support. There is substantial evidence that the perceived availability of social support buffers the effect of stress on psychological distress, depression, and anxiety (Kawachi & Berkman, 2001; Mahon and Yarcheski; 2001; Needham, 2008; Stice, Ragan, and Randall 2004). Access to social support is critical for the maintenance of health, well-being and symptoms of depression (Graber, 2004; Jacobson, 2007; Seroczynski, Jacquez, & Cole, 2003). However, Rowlison and Felner (1988) failed to find any interaction between social support and symptoms of depression.

The present study seeks to investigate the psychosocial factors associated with adolescent depression in Ghana since to date, majority of the studies have been conducted in Europe and the United States (Meadows, Brown, Elder, & Glen, 2006; Southhall & Roberts, 2002; Stice, Ragan, & Randall, 2004).

The aims of the present study are fourfold: To examine depressive symptoms between adolescent females and males. To determine whether adolescents from separated/divorced families would show more symptoms of depression than adolescents from married families. To examine any relationships between self-esteem and depressive symptoms. To determine any correlation between parental social support and depression.

METHODS

Participants Three hundred adolescents from five randomly selected Junior and Senior High Schools in the Greater Accra Region participated in the study. There were 150 males and 150 females with an age range of 12 to 20 years (M= 17.6, SD = 11.95). Adolescents from separated/divorced families represented 40% of the sample and adolescents from married families represented 60% of the total sample.

Materials /Measures Standardized questionnaires with acceptable psychometric properties were used in the study. These were the Center for Epidemiologic Studies Depression Scale (CES-D), Rosenberg Self-Esteem Scale (RSE) and Parental Social support for Adolescents (PSSA). They were used to assess the various psychosocial factors namely: depression, self-esteem and parental social support respectively. The questionnaires were compiled into a booklet. Depressive Symptoms - Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression Scale (CES-D) developed by Radloff (1977). It is a 20- item self- report scale that measures a range of symptoms (such as sleep disturbances, feelings of guilt, feelings of loneliness, depressed mood). Several reviews have addressed the psychometric properties of the CES-D and have recommended it as appropriate to measure depressive symptoms in the general population (Radloff, 1977; Gotlib & Hammen, 1992), and for use with high school populations (Radloff, 1991, Philips, Shadish, Murray, Kubik, Lytle, Birnbaum, 2006). Roberts (1980) found the CES-D to have good internal consistency of .80. The present study revealed an internal consistency of .72. The scale assesses the frequency of depressive symptoms. Respondents indicated on a four-point scale (0-3) how often they had experienced depressive symptoms in the previous week. Scores range from 0-60, with higher scores indicating greater depressive symptoms.

Self-Esteem - Rosenberg’s (1965 - RSE) self-esteem index was used. The test was developed by Rosenberg (1965). The items were rated on a 4-point Likert scale with responses ranging from strongly agree through to strongly disagree. Test-retest correlations range from .82 to .88, and Cronbach's alpha for various samples are in the range of .77 to .88 (Blascovich & Tomaka, 1993).

Parental Social Support for Adolescents (PSSA) scale was developed by Aneshensel and Sucoff (1996). This scale has been used to assess parental social support among adolescents. It has a reliability of .90 and internal consistency (Cronbach’s alpha) of .92 (Sneed, Morisky, Rotherram-Borus, Ebin, & Malotte, 2001).

Demographics form was used to collect information such as gender, parents’ marital status, self-esteem, parental social support and depressive symptoms.

Procedure Consent was sought from the Ghana Education Service, School boards and students for their participation in the study. Participants were briefed on the general purpose of the study. They were also assured of anonymity and confidentiality. Participants completed the questionnaires in a regular classroom setting under the supervision of the researcher and a research assistant who briefed them on how to fill the questionnaires. Participants were given a questionnaire booklet and requested to fill in approximately 50 minutes.

RESULTS All analyses were done using the Statistical Package for the Social Sciences (SPSS – windows version). The data analyses involved descriptive including means, standard deviations, independent t test statistics and Pearson product moment correlation tables.

Table 1 - Means and Standard Deviations of Depressive Symptoms and Gender of Adolescent Students in Junior and Senior High Schools in Ghana.

Test Male Female df t N=150 N=150

CED-S 34.31(8.72) 43.13(10.43) 298 7.95*

CED-S= Center for Epidemiologic Studies Depression Scale.

*p<.05

Table 1 shows significant difference between males and females on depression score (t (298), = 7.95, p<.05, with the mean score of depression obtained by females being significantly higher than males

Table 2 - Means and Standard Deviations of Depressive Symptoms and Parents’ Marital Status of Adolescent Students in Junior and Senior High Schools in Ghana.

Test Married Separated/Divorced df t p N=150 N=150

CED-S 38.82(10.69) 38.56(10.41) 298 0.84 n.s

Table 2 indicates the effect of parents’ marital status on symptoms of depression was not significant, t (298) = 0.84, p>.05. There was no significant difference in the depressive symptoms experienced by adolescents from separated/divorced families and adolescents from married families, 38.56 and 38.82 respectively. Mean depression score obtained by the participants was 38.72 with a standard deviation of 10.56. Mean score for Self-Esteem was 29.27 with a standard deviation of 5.80. Mean score for Social Support was 67.97 with a corresponding standard deviation of 9.48. Means of self-esteem and social support were correlated with mean score for depressive symptoms.

Table 3 - Pearson Correlations for Depressive Symptoms, Self-Esteem and Social Support measures (N=300) DE SE -.211** SS -.025 - **p<.01; DEP.S=Depressive Symptoms SE=Self-Esteem, SS=Social Support.

In table 3, correlation between self-esteem and depressive symptoms was significant (r = -.211; p<.01). However, there was no significant correlation between parental social support and depressive symptoms, r = .025, p=n.s).

DISCUSSION The results of the present study showed some consistencies and inconsistencies in contrast to previous studies. Females experienced significantly more depressive symptoms than males. This is consistent with findings of the National Institute of Mental Health (2003). Studies in most countries find significant higher levels of depressive symptoms among girls than boys and this pattern appears to generalize across cultures (Meadows, Brown, Elder, & Glen, 2006; Sarigiani & Petersen, 2000; Schraedley, Gotlib, & Hayward, 2001; Tomori, Martina, & Blanka, 2000). Research has found that traditional gender roles contribute substantially to females’ high susceptibility to depression (Thornicroft & Sartorius, 1993; Hankin & Abramson, 2001). According to Kimberling and Ouimette (2002), males and females are treated differently and are given different roles in almost all societies. In Ghana, females are generally socialized to do household chores like cooking, washing and sweeping, whiles males are socialized to believe that household chores is a preserve of females and that males are supposed to provide for the home and also be the head of the family (Boateng et al., 2006;

Boohene et al., 2005, Dolphyne, 2000). Other studies (Brown & Gilligan, 1996; Dolphyne, 2000) have found that females are socialized to ‘silence’ themselves, to be gentle, become less in expressing their opinion, to put the needs of others before theirs and never to be winners. This self-silencing behavior may contribute to a decline in self-esteem.

Other studies have found that males are usually socialized to ‘mask’ emotions, to be emotionally inhibited, assertive, and independent (Clare, 2000; Joiner, Alfano, and Metalsky, 1992; Pollack, 1999). Thus, it can be argued that and this behavior might lead to an under-reporting of depressive symptoms. The current results point to the fact that gender role socialization of Ghanaian children contributed immensely to the differences found in depressive symptoms experienced by males and females. However, the results of this study contradict other findings (Liu, Kurita & Tang, 1999; Assan, 1993; Masten, Caldwell-Colbert, Williams & Jerome, 2003) who report no significant gender differences in depression among adolescents.

Investigating whether adolescents from separated/divorced families would have more depressive symptoms than adolescents from married families, the results revealed no significant differences. This result is in contrast to studies conducted in many parts of the western world (Harvey & Fine, 2004; Hetherington & Kelly, 2002; Mahon, Yarcheski, & Yarcheski, 2003; Stephens, Nicholson, & Knoester, 2005; Wallerstein, Lewis, & Blakeslee, 2000). These studies have revealed that adolescents whose parents are separated or divorced are more likely to experience symptoms of depression than adolescents whose parents remain.

The usual negative impact of separation/divorce on children and adolescents was not observed among Ghanaian adolescents and this is consistent with other findings (Emery, 1999; Kirby & Dean, 2002; Richardson & McCabe, 2001) that the majority of children whose parents divorce show no lasting negative effects and that divorce might not be the only cause of depression among adolescents.

Results of the present study could also be explained in terms of the resolution of issues regarding separation/divorce because of the extended family system practiced in Ghana (Nukunya, 2003). The extended family system ensures that parents’ roles are shared by other members of the family and therefore in the absence of the mother or the father, the uncle and other members step in to play that role thereby mitigating the adverse effects that the absence as a result of separation/divorce may create (Nukunya, 2003). This is consistent with the studies by Thoits (1995) and Wheaton (1990) who argued that potential stressful events, such as divorce, can have positive long-term consequence when people resolve their problems successfully. Also, Garber (1991) and Wu (2000) found no differences between children from divorced and married families.

Self-esteem and depression were expected to be negatively correlated in this study. Results obtained revealed that adolescents with high self-esteem experience less symptoms of depression than those with low self-esteem. The results have been supported by previous findings (Usher, Zahn-Waxler, Finch, & Gunlicks, 2000). Further, Erkolahti, IIonen, SaariJAorvi, and Terho (2003) found significant negative correlation between self-image scores and depression scores.

In modern times the idea that "thin is beautiful" has become the socially accepted norm. The media publicizes what is beautiful; and more often females do not seem to equate to these looks (Kim & Kim, 2001). For instance in Ghana many obese females get teased by their male counterparts and some describe them as ‘obolo’ (meaning a fat person) which usually cast a slur on their self-image. These factors, if taken to the extreme, can result in feelings of depression and subsequent eating disorders. On the contrary, Shrier, Harris, Sternberg, and Beardslee (2001) believed that the fact that an adolescent feels low about him or herself does not guarantee the experience of depressive symptoms.

Parental social support revealed no significant negative correlation with depressive symptoms. This finding did not support previous studies (Mahon & Yarcheski, 2001; Shaw & Krause, 2004; Stice, Ragan, & Randall, 2004) that reported that children whose parents provide ample social support report fewer psychological and physical symptoms of depression during childhood and adolescence. The results showed that whether adolescents received parental social support did not have any significant impact on depression.

Despite the provision of some insights for further research in the area of adolescent depression, the present study is beset with some limitations. First, a diagnostic instrument for depression was not used; only self-report was adopted, thus, the severity of depression could not be ascertained. Future research should focus on identifying levels of adolescent’s depression with an appropriate depression instrument. Second, care must be taken in generalizing the results of this study which was based on self-reported data. Lewinshon, Rhode, Seeley and Hops (1991) have reported that the CES-D overestimates depression; clinical measures of depression yield a more valid assessment. Third, the sample size should be increased in future research to ensure a fair representation of all Ghanaian adolescents and accurate generalization of results. Fourth, future research should consider rural adolescents since they have a different social environment from that of urban adolescents.

Conclusions The present study revealed that Ghanaian adolescents do experience some depressive symptoms and this serves as a basis for further studies into the exact levels of depression among adolescents. Mental health promotion in schools and other intervention programs that seek to enhance adolescents’ self-esteem should be encouraged. Attention should address the impact of traditional gender role socialization on depression (Boateng et al., 2006). Commonly held attitudes and views of males such as ‘females are born to marry and give birth whilst men are to be breadwinners for the family should be discouraged. In addition, formal education should be considered equally important for males than for females to enable execution (Boohene et al., 2005; Dolphyne, 2000)

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EFFICACY OF COGNITIVE TRAINING INTERVENTION PROGRAMS IN PATIENTS WITH DEMENTIA

Rachel Bieu1, C. Charles Mate-Kole2, Patti Said3, Robert Fellows2, Katherine Catayong2, James Conway2, Rebecca Wood2 & Jake McDougal2

1Department of Psychology, Central Connecticut State University, New Britain, CT, US. 2Olin Neuropsychiatry Research Center, The Institute of Living, Hartford, CT, US. 3New England Cognitive Center, Hartford, CT, US.

Abstract Cognitive training has emerged as a potentially efficacious intervention in treating the symptoms associated with dementia (Ball et al., 2002). The present study was designed to examine the efficacy of two cognitive training programs (1) an individualized computer-based program and (2) a program combining individualized computer-based training with group-based interactive training in a population of individuals with a diagnosis of dementia. Forty participants were administered a battery of neuropsychological tests at baseline (T1) and then following 12 week, 24 session cognitive training program (T2). Both programs yielded gains and declines in cognitive and behavioral functioning. Individuals completing the individualized computer-based program showed gains in visual memory, global cognitive functioning, and self-report of cognitive failures and decline in visual motor speed and coordination. Individuals completing the combined program showed significant improvement in abstract reasoning, spatial orientation, and self-report of cognitive failures and decline in visual motor speed and coordination, visual motor tracking, attention, and cognitive flexibility. Effectiveness appeared to vary with training program design. However, it appears that for both groups verbal tasks improved while timed visual motor tasks declined.

CORRESPONDENCE: C. Charles Mate-Kole, Ph.D., Departments of Psychology and Psychiatry, University of Ghana, Legon P. O. Box LG 84, Legon, Ghana Tel: +233-26-515-8672 - Email: [email protected]

INTRODUCTION

Research indicates that some form of cognitive decline is almost universal in the elderly and is to be expected in the majority of the oldest old (Park, O’Connell & Thomson, 2003). Further, studies have revealed that cognitive decline in aging represents a continuum from successful aging with little cognitive decline, to noticeable cognitive decline associated with normal aging, to pre-clinical and cognitive changes linked to dementia (Foster, 2006).

In developed countries prevalence of dementia is estimated at 5% at age 65 with this figure doubling every four years reaching approximately 30% at 80 years (Ritchie & Lovestone, 2002). Overall prevalence increases with age, about 1% per year, and is low in people of African or Asian origin (Ritchie & Lovestone, 2002). Individuals with dementia have a considerably shortened life expectancy, with the average individual surviving approximately eight years post diagnosis (Ritchie & Lovestone, 2002). The most common cause of dementia is Alzheimer’s disease (AD) followed by vascular dementia (VaD). Alzheimer’s disease accounts for 50-60% of all cases of dementia (Elias & Saucier, 2006); vascular dementia accounts for 12-20% of all cases of dementia (Jellinger, 2005).

In 2000, 4.5 million individuals in the US alone were affected by AD (Hebert, Scherr, Bienias, Bennett & Evans, 2003). By 2050, as the population of baby boomers or individuals born between 1946 and 1964 continues to age, this number is expected to increase to approximately 13.2 million (Hebert, Beckett, Scherr & Evans, 2001; Hebert et al., 2003).

AD is characterized by progressive intellectual decline of cognitive function and functional abilities increasingly worsening until death with mortality being strongly associated with the rate of cognitive decline (Farina et al. 2002; Hui et al., 2003). Progression is relatively rapid with most individuals living from five to fifteen years post diagnosis (Elias & Saucier, 2006). Mild AD, occurring during the first two years following diagnosis, is characterized by deficits in a number of learning tasks, regardless of the measures (e.g. verbal, visual) and impaired memory at all levels, encoding, storage, and retrieval. Two to three years following diagnosis, as AD advances to moderate severity, a loss of more remote memories is evident. As a case becomes more severe all higher cognitive functions as well as many basic motor functions are lost (Elias & Saucier, 2006).

VaD is the second most common type of dementia (Looi & Sachdev, 2000). In comparison to AD, VaD has been rather understudied (Gorelick, 2004). VaD is often difficult to differentiate from AD as the two have cognitive impairments in common (Gold et al., 2002). These cognitive impairments may include memory impairment, deterioration in judgment and thinking such as planning and organization, a disturbance in executive functions, apraxia, agnosia or aphasia (Gold et al., 2002; Elias & Saucier, 2006). A diagnosis of VaD requires the presence of dementia, evidence of cerebrovascular disease or stroke(s), and a direct relation between the two (Gold et al., 2002).

In the absence of a cure, cognitive training has emerged as a potentially efficacious intervention in treating symptoms associated with dementia. Cognitive training typically entails guided practice on a group of standard tasks relating to specific cognitive functions such as memory, attention, or problem solving (Clare et al., 2001). The premise of such programs is that practice will help to improve or at least

52 maintain functioning in the area being practiced; it is thought that such effects will further generalize beyond the context of the initial training (Clare et al., 2001). Programs can be offered on an individual or group interactive basis with tasks being pencil and paper oriented or computerized.

Farina et al. (2002) investigated cognitive training effects in a population of individuals with AD. Individuals were assigned to one of two groups, a procedural memory group and a partially spared cognitive functions group (Farina et al., 2002). Those in the procedural memory group were trained in a kitchen on tasks including washing hands, setting and unsetting the table, preparing coffee, and a room on tasks including writing and sending a letter, opening and closing a door-lock, making a phone call. Those in the partially spared cognitive functions group were trained in attention, short-term memory, language, visual spatial tasks, and categorization. Each group was administered training three times weekly for five weeks (Farina et al., 2002). Results indicated that both groups improved substantially after training in a direct performance measure of everyday functioning (Farina et al., 2002). However, neuropsychological tests indicated that training in activities of daily living, supported by procedural memory, may be slightly more effective; those in this group evidenced greater improvement in tests of verbal fluency and selective attention (Farina et al., 2002). They noted that improvement in functional and cognitive abilities obtained following cognitive training was lost after three months; level of performance returned to baseline (Farina et al., 2002). Results of Farina et al. (2002) suggest that cognitive training may prove helpful for individuals with AD. However, it would seem that in order for results to be maintained training must be continuous; when training is not continuous beneficial results are not maintained.

A study by Doornhein and De Haan (1998) evaluated the effectiveness of memory training in a group of vascular dementia patients. Those in the treatment condition received twice weekly sessions for four weeks. The training intervention included six simple memory strategies applying to daily memory problems. Following training, significant improvement on the trained memory skills was found; no improvement on the control memory tasks was found indicating that those skills that were not specifically practiced were not significantly improved. This study suggests that individuals displaying vascular related cognitive difficulties might be helped by cognitive training (Doornhein & De Hann, 1998).

A meta-analytic study by Clare et al. (2001) challenged the previously discussed research pertaining to the effectiveness of cognitive training interventions used with AD and VaD patients. The overall aim of this meta-analytic study was to evaluate the effectiveness and impact of cognitive training and cognitive rehabilitation interventions aimed at improving memory functioning for individuals in the early stages of AD or VaD . Six studies which reported cognitive training interventions were included. The reported findings of this meta-analysis do not provide strong support for the use of cognitive training interventions for people with early stage AD or VaD (Clare et al., 2001). Specifically, none of the studies included in the meta-analysis demonstrated any statistically significant effects in any domain of cognitive functioning although there were indications of some meek, non-significant effects in various domains of cognitive functioning (Clare et al., 2001).

Computer-based Cognitive Training “Advances in computing technologies, telecommunications and the widespread prevalence and uptake of the Internet have offered a completely new paradigm to the way in which care can be provided” (Nugent, 2007; p473). As technology continues to advance, computer-based cognitive training programs

53 are being increasingly utilized in the field of cognitive rehabilitation (Gontkovsky, McDonald, Clark & Ruwe, 2002). Advocates of such training maintain that this treatment modality provides treatment at a level equivalent or superior to more traditional treatment modalities (Gontkovsky et al., 2002).

Hofmann et al. (2003) conducted a study investigating the effects of computer-based cognitive training using a population of individuals with Alzheimer’s disease. Participants included AD patients (n=9), age- and gender-matched participants with a major depressive episode (n=9), and healthy controls (n=10). All individuals were trained to use an interactive computer-based program simulating a shopping route; social competence tasks; and tests of memory and orientation were included (Hofmann et al., 2003). Cognitive training was administered three times weekly for four weeks. Following assessment three weeks later (i.e. week 7), task performance of AD patients was found to improve significantly (Hofmann et al., 2003). Performance of the depressed patients and the normal controls also improved with no difference found between the two groups (Hofmann et al., 2003).

Hofmann, Hock, Kuhler, and Muller-Spahn (1996) reported different findings on the effectiveness of computer-based programs. Ten patients, each with a diagnosis of probable AD participated in a computer-based training program on a voluntary basis . Four patients were trained in programs individually tailored to them; photographs of their own town and social environment were incorporated. The remaining six patients were trained in a complex computer program simulating a walk into the center of town and also involving social competence tasks and tests of orientation and memory (Hofman et al., 1996). Between 50 and 150 photos were taken for each training program; photos were scanned into the memory of a PC and integrated into presentation software program (Hofman et al., 1996). An everyday task of relevance to the patient (i.e. shopping) was simulated on a PC touch screen which the patient was trained to operate. Training occurred three to four times a week for a total of three weeks (Hofman et al., 1996). Results indicated no evidence of general cognitive improvement (Hofman et al., 1996).

Group-based Cognitive Training Much of the research pertaining to cognitive training focuses on individual treatment interventions. A review by Scott and Clare (2003) asked the question, “Do people with dementia benefit from psychological interventions offered on a group basis?” (p. 186). This review references several studies (Ermini-Funfschilling & Meyer, 1995; Gatz et al., 1998; De Vreese et al., 2001) done in an effort to gauge the effectiveness of group interventions, particularly with individuals having dementia. Scott and Clare (2003) suggested that perhaps the future lies in a combined program; a program offering individually designed cognitive rehabilitation interventions within a broader therapeutic context, taking into account emotional and social needs. In addition to the studies referenced in Scott and Clare (2003), a recently published study by Mate-Kole et al. (2007), while noting its modest sample size, also speaks to the potential of group-based training. Mate-Kole et al. (2007) administered a combined cognitive training program, part computer assisted and part interactive, to a group of moderate to severely demented individuals. Following a six week cognitive training program participants improved significantly on measures of overall cognitive function, including short-term memory and cognitive failures (Mate-Kole et al., 2007). Caregiver reports indicated significant improvement in behavioral signs and socialization. Also of note, these participants did not demonstrate significant decline on any of the measures from pre- test to post-test levels (Mate-Kole et al., 2007). That said, when tested four weeks after training cessation, participants showed a slight decline in the general cognitive measures including the RQCST, ADAS-Cog,

54 and the behavioral measures; caregiver reports expressed unease about participants’ decline (Mate-Kole et al., 2007).

Critique of Research to Date While there is a fair amount of research attesting to the potential of cognitive training interventions there is a lack of research suggesting that one program design is more effective. The research previously cited suggests that cognitive training programs in general, both interactive group-based programs and individualized (e.g. computer-based) programs, might be effectively applied in varying populations including individuals with dementia. What is lacking in the research is a study comparing differing program designs in an effort to determine which design is most effective. Is an interactive group-based program more effective than an individualized program or might a combination of the two prove most effective? It is difficult to compare program effectiveness across previously conducted studies as there appears to be a lack of uniformity with regard to the definition of cognitive training and the assessment batteries used to measure intervention effectiveness. Currently, a comparison study using a uniform training definition and uniform assessment(s) is needed.

The purpose of the present study is to examine the efficacy of two differing cognitive training programs; (1) an individualized computer-based program and (2) a program combining individualized computer- based training with group-based interactive training (combined program), in a population of individuals with a diagnosis of dementia, specifically Alzheimer’s disease or vascular dementia.

Methods

Participants

Forty older adults (N=40) with a neurological or dementia diagnosis assigned by their physician were included in this study. This group included individuals with diagnoses of Alzheimer’s disease (n=34) or vascular dementia (n=5), as well as one individual diagnosed with Parkinson’s dementia (n=1). Participants were divided into two groups. Group 1 completed the individualized computer-based program and Group 2 completed the combined program, a program integrating the individualized computer-based program with a group-based interactive program. Individuals in Group 1 (n = 29) ranged in age from 54 to 89 years and included 10 males and 19 females. Mean age was 76.10 (SD=10.53) years and the mean number of years of education was 14.41 (SD=3.20) years. Individuals in Group 2 (n = 11) ranged in age from 64 to 94 and included 2 males and 9 females. Mean age was 82.27 (SD=9.03) years and mean number of years of education was 14.45 (SD=2.51) years. See Table 1.

Table 1. Demographics: Means and Standard Deviations of the two groups ______Computer-based Combined ______n 29 11

Age 76.10 (10.53) 82.27 (9.03)

Education 14.41 (3.20) 14.45 (2.51)

Male 10 2

Female 19 9 (N=40)

Measures Participants were administered a battery of neuropsychological tests including the following: revised version of the Quick Cognitive Screening Test (RQCST; Mate-Kole, Major, Lenzer, & Connolly, 1994), Alzheimer Disease Assessment Scale-Cognitive subscale (ADAS-Cog; Rosen, Mohs, & Davis, 1984), Selective Reminding (Buschke & Fuld, 1974), Digit Symbol-Coding and Incidental Recall of the Wechsler Adult Intelligence Scale, Third Edition (WAIS-III; Wechsler, 1997), Grooved Pegboard (Klove, 1963; Matthews & Klove, 1967; Lezak, 1995), Trail Making Test (Reitan & Davidson, 1974; Lezak, 1995), Controlled Oral Word Association Test and Category Naming (Goodglass & Kaplan, 1972; Lezak, 1995), Mini-Mental Status Exam (MMSE; Folstein, Folstein, McHugh, 1975), Geriatric Depression Scale (GDS; Brink, Yesavage, Lum, Heersema, Adey, & Rose, 1982), Quality of Life (QOL; Spitzer, Dobson, Hall, et al., 1981), Functional Activities Questionnaire (FAQ; Pfeffer, Kurosaki, Harrah, Chance, & Filos, 1982), Cognitive Failures Questionnaire (CFQ; Broadbent, Cooper, Fitzgerald & Parkes, 1982).

The Revised Quick Cognitive Screening Test (RQCST) is a sensitive “mid-range” cognitive screening test used in detecting a broad range of cognitive deficits. This test, consisting of 48 items divided into 17 subtests, is designed to detect both global and specific areas of cognitive dysfunction. Areas assessed include orientation, attention and concentration, spatial neglect, arithmetic, memory, constructional praxis, vocabulary, naming, abstract reasoning, unusual views, spatial orientation, delayed memory, and memory for new learning (Mate-Kole et al., 1994).

The Alzheimer Disease Assessment Scale-Cognitive subscale (ADAS-Cog) is a standard measure of cognitive function in individuals with AD (Rosen, Mohs, & Davis, 1984). Like the RQCST, this measure generates subtest scores in addition to a global score. Areas assessed include language, comprehension of spoken language, recall of test instructions, word finding difficulty, following commands, naming objects and fingers, constructional praxis, ideational praxis, orientation, word recall, and word recognition.

The Mini-Mental Status Exam (MMSE), a shortened form of the MSE, is a brief measure assessing orientation to time and place, registration of 3 words, attention and calculation, recall of 3 words,

56 language functions, and visual construction abilities.

Digit Symbol-Coding assesses visual motor speed and coordination; the Incidental Recall portion of this test assesses incidental memory for visual material.

The Trail Making Test assesses visual motor tracking, divided attention, cognitive flexibility, and conceptual and visual tracking. The Grooved Pegboard assesses manual dexterity and complex coordination skills.

The remaining tests used consisted of behavioral measures. The Geriatric Depression Scale (GDS) measures level of depression. Participants are asked a number of questions pertaining to the way they feel on most days. The Quality of Life (QOL) assesses perceived quality of life and functional status in five domains including: physical activity, activities of daily living, mental health, social support, and outlook. The Cognitive Failures Questionnaire (CFQ) is a 25 item measure assessing the frequency of minor mistakes made on everyday tasks occurring in three cognitive areas (perception, memory, and motor function). The Functional Activities Questionnaire (FAQ) assesses performance on functional activities such as writing checks or shopping.

Procedure Participants were administered a battery of neuropsychological tests at baseline (T1). Following baseline assessment participants completed a twenty-four session cognitive training program (approximately three months in duration). Each individual participated in two one hour sessions each week. Sessions were administered by an assigned cognitive trainer with a background in psychology and/or education. Sessions were adapted to best cater to the abilities and needs of each client. Two differing cognitive training programs were offered: an individual-based computerized program and a combined program (individual-based computerized training plus group-based interactive training). Following the completion of their respective cognitive training program participants were administered the same battery of neuropsychological tests (T2). Time taken to complete a full test battery varied.

Cognitive Training Programs/Treatment Interventions Group-based Interactive Training Program. The group-based interactive training program is disseminated by a trainer with a background in psychology and/or education. The training exercises developed and utilized in this program include pen and paper tasks and other hands-on activities targeting memory, attention and concentration, problem solving, cognitive flexibility, and manual dexterity. Exercises included range from rolling or bouncing a ball across a table between participants to simple mathematical tasks. Each session includes visual, auditory, and kinesthetic tasks. Session design and pace is adjusted according to the needs of the group. Sessions are cost effective as each session may include ten or more participants to one trainer.

Individualized Computer-based Training Program. The computer-based program is an individualized cognitive training program utilizing a computer program comprised of 8 differing skills packages (Copyright by Psychological Software Services, Inc.). The Foundations I Skills Package is designed to rebuild attention, attention shifting initiation/inhibition skills, capacity to discriminate and capacity to respond differentially. The Foundations II Skills Package is an extension of Foundations I focusing on

57 basic attention, cognitive processing, and eye movement. The Visuospatial I Skills Package targets visual perception and visual-motor integration skills. The Visuospatial II Skills Package is an extension of Visuospatial I focusing on visual perception, orientation, spatial analysis, and perceptual/motor skills. The Memory II Skills Package is designed to target encoding, categorizing, and organizational skills while the Memory I Skills Package targets recall capacity. The Problem Solving I Skills Package requires the use of logic, reasoning, and strategy. The Problem Solving II Skills Package addresses logical thinking and deduction. Sessions include one participant and one trainer with a background in psychology and/or education. Session design and pace is tailored to the needs of the individual participant. Participants need only minimal knowledge of computers as these computerized tasks require only the use of a mouse. Combined program. The combined program is a combination of both the group-based interactive program and the individualized computer-based program. Participants work both in interactive groups and individually with the computerized programs.

Data Analysis A pre-test (baseline) post-test or T1 T2 design was used to measure the effectiveness of the two cognitive training programs. Paired-samples t-tests were used to determine pre-test and post-test differences. Effect size or η2 was calculated in an effort to determine the magnitude of each significant finding (How much of the variance in scores from T1 to T2 was due to the particular training intervention used).

Results Computed correlations between age, education, and test scores were not significant. T1 and T2 means and standard deviations of all variables can be found in Table 2.

Individualized Computer-based Training Program. For the individualized computer-based program, paired samples t-tests revealed significant improvement from pre-test to post-test on the RQCST Visual Memory Delayed Recall, t (28) = -2.14, p <. 05, η2 = .14, the RQCST Global, t (28) = -2.74, p < .05, η2 = .21, and the Cognitive Failures Questionnaire, t (23) = 2.96, p < .05, η2 = .28. Participants evidenced decline on the WAIS-R Digit Symbol Copy, t (28) = 2.46, p < .05, η2 = .18.

Combined program. For the combined program, paired-samples t-tests revealed significant improvement from pre-test to post-test on the RQCST Verbal Analogies, t (10) = -2.80, p < .05, η2 = .44, the RQCST Visual Spatial Orientation, t (10) = -2.95, p < .05, η2 = .47, and the Cognitive Failures Questionnaire, t (8) =2.99, p < .05, η2 = .53. Participants appeared to get significantly worse on the WAIS-R Digit Symbol Copy, t (7) =3.28, p < .05, η2 = .61 and the Trail Making Test B-A, t (10) = -2.37, p < .05, η2 = .36.

Table 2 - Means and Standard Deviations of pre- and post scores of the two groups

Computer-based (n = 29) Combined (n = 11) Pre (T1) Post (T2) t Pre (T1) Post (T2) T RQCST Verbal Ab. 3.07 (.88) 3.30 (.78) .87 1.45 (1.13) 2.45 (1.13) -2.80* Reasoning Analogy RQCST Total Verbal 23.28 (6.12) 23.79 (5.46) -.91 17.27 (9.34) 19.18 (6.15) -1.32

RQCST Visual 4.45(.83) 4.62 (.68) -1.31 3.27 (1.56) 4.45 (.82) -2.95* Spatial Orientation RQCST Visual Mem. 1.28 (2.22) 1.79 (2.24) -2.14* 1.09 (2.02) .91 (1.81) .80 Delayed Recall RQCST Total Visual 9.90 (5.51) 21.07 (5.72) -1.97 16.09 (8.06) 18.18 (6.52) .14

RQCST Global 51.00 (12.34) 53.34 (13.63) -2.74* 37.82 (18.56) 41.55 (13.71) -1.80 WAIS-Digit Symbol 22.83 (12.60) 20.07 (11.93) 2.46* 16.75 (10.25) 9.45 (8.97) 3.28* Copy †Trail Making Test 100.32 (58.00) 128.63 (128.85) -1.59 302.07 (247.41) 233.50 (196.02) 1.61 A+ †Trail Making Test 255.51 (179.74) 209.46 (155.62) 1.45 182.59 (183.70) 292.95 (191.64) -2.37* B-A+ ADAS-Cog Global 20.29 (9.35) 20.40 (10.72) .13 30.68 (12.21) 30.60 (9.88) .52 †Cognitive Failures 37.04 (14.28) 31.24 (13.43) 2.96* 27.09 (11.48) 15.78 (13.65) 2.99* Questionnaire † = decrease in score indicates improvement * = p<.05

RQCST VMDR is RQCST Visual Memory Delayed Recall; RQCST is RQCST Global Score; Cog. FQ is Cognitive Failures Questionnaire; Note: In the case of Cognitive Failures Questionnaire a decrease in score represents improvement; WAIS DSC is WAIS Digit Symbol Copy; T1 = Score on measure at baseline, T2 = Score on measure post training

Discussion Overall, the participants completing the individualized computer-based cognitive training program showed significant improvement on the RQCST Visual Memory Delayed Recall as well as the RQCST Global measure indicating gains in visual memory and global cognitive functioning. Scores on the Cognitive Failures Questionnaire reveal a reduction in self-reports of cognitive failures from pre-test to post-test indicating substantial behavioral improvement. Scores on the WAIS-R Digit Symbol Copy were significantly worse from pre-test to post-test, indicating a decline in visual motor speed and coordination. Individuals completing the combined cognitive training program showed significant improvement on two subtests of the RQCST, Verbal Analogies and Visual Spatial Orientation indicating gains in abstract reasoning and spatial skills. Scores on the Cognitive Failures Questionnaire reveal a reduction in cognitive failures from pre-test to post-test indicating substantial behavioral improvement. Like those completing the computer-based program, those completing the combined program also showed significant

59 worsening from pre-test to post-test on the WAIS-R Digit Symbol Copy indicating a decline in visual motor speed and coordination. Time utilized for Trail Making Test B-A increased significantly for pre- test to post-test indicating decline in visual motor tracking, psycho-motor speed, attention, and cognitive flexibility.

Participants in both programs showed both gains and losses. Note, where no gains or losses are noted participants maintained their baseline levels of functioning. It is also important to note that baseline (T1) scores for the combined group were markedly worse on the majority of measures suggesting that perhaps this group was more impaired to start. Those completing the individualized computer-based cognitive training program showed gains in visual memory, global cognitive functioning, and behavioral functioning and losses in visual motor speed and coordination. Those completing the combined program showed gains in analogies, spatial skills, and behavioral functioning and losses in visual motor speed, coordination, visual motor tracking, attention, and cognitive flexibility.

Effectiveness did appear to vary with program design. However, it appears that for both groups verbal tasks improved while timed visual motor tasks declined. Perhaps such results can be partially attributed to the crystallized or fluid nature, respectively, of each task. While verbal tasks are thought to be more crystallized, spatial tasks are considered more fluid. More specifically, crystallized intelligence is thought to increase in one’s 20s and 30s and then remain stable throughout the lifespan perhaps dropping off slightly in late age (Gardner et al., 2000). Conversely, fluid intelligence appears to peak during one’s 20s declining thereafter (Gardner et al., 2000).

The results of the present study suggest that cognitive training can elicit some improvement of cognitive and/or behavioral skills improvement in individuals with dementia. Relative success appears to be contingent, at least in part, on the particular program design used. That said, much previous research, particularly large meta-analytic studies, have provided inconclusive or unsupportive results with regard to cognitive training programs (Park et al., 2003; Clare et al., 2001). This is likely due, at least in part, to two inconsistencies in the literature. Firstly, there appears to be a lack of uniformity in the definition of cognitive training. Secondly, there appears to be a lack of uniformity in the assessment batteries used to gauge the effectiveness of such training interventions. It is difficult to compare and contrast research when uniformity is lacking. Implementing greater uniformity in both the definition of, and assessment of cognitive training programs, will likely lead to greater reliability of results.

Future research would do well to examine the effect of a solely group-based interactive cognitive training program in a group of individuals with dementia. The present study utilized a combined program, a program combining group-based interactive training with individualized computer-based training. What effects might an interactive group based only training program produce in a population of individuals with dementia?

The sample sizes utilized in the present research were limited. While there was a respectable 29 individuals included in the computer-based group, only 11 were included in the combined group. Subsequent research should increase the sample size in each treatment intervention. This increase in sample size would result in greater study power.

The present research might also be improved by implementing a control condition and thereby offering a group for comparison. Here, all individuals would be tested at baseline (T1). Following baseline assessment, a sample of the participants would be exposed to a cognitive training intervention while another like demographic sample would receive no treatment intervention. This would allow researchers to determine whether cognitive losses shown in the present study were due to the passage of time as opposed to the program. Finally, in an effort to determine whether cognitive gains are maintained long- term, individuals should be assessed again long-term, at 3, 6, and 12 months post training. Such a design would aid in determining how long and to what extent changes in cognitive function are maintained after training ceases.

Conclusions The results of the present research suggest that cognitive training can elicit cognitive and behavioral improvement or maintenance in individuals with dementia. Efficaciousness appears to vary with type of training intervention. These results should be interpreted with caution due to the limitations previously discussed. For example, the sample size used was limited and no control group was used. This limits the generalizability of the findings. Also, long-term benefits of these programs are not clear at this time.

Acknowledgements This study was partly funded by a grant from the State of Connecticut Department of Social Services to the New England Cognitive Center in Hartford, CT. We acknowledge the support of Dr. Louise Loomis, founder of the New England Cognitive Center, Dr. John Connolly, and the staff of Atria Health Hamilton Heights in West Hartford, Connecticut.

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THE EFFECTS OF KNOWLEDGE AND HEALTH BELIEFS ON COPING AMONGST ADULT SICKLE CELL PATIENTS

Olive O.Okraku,1 Angela Ofori-Atta,2 S. A, Danquah,1 I. Ekem3,4 and J. K. Acquaye 3,4

1Department of Psychology 2Department of Psychiatry 3Department of Haematology, University of Ghana, Legon 4Sickle Cell Clinic, Korle-Bu Teaching Hospital, Accra, Ghana

ABSTRACT The aims of the study are twofold. First, to investigate the effects of knowledge of Sickle Cell Disease (SCD) and health beliefs on how patients cope with SCD. Second, to examine the current trends of health beliefs and treatment choice in Ghana. The study adopted pre-test post-test design, comprising two groups; an experimental and a control group. 100 participants diagnosed with sickle cell disease (50 males and 50 female adults) were recruited from the Sickle Cell Clinic at a national hospital in Accra, Ghana. Measures administered assessed knowledge of SCD, health beliefs and coping. The experimental group received education on sickle cell disease while the comparison group received no education during the study. The results indicated a significant increase in knowledge and coping before and after the educational session for the experimental group. Patients used more traditional treatment (i.e., herbs, shrine for guidance) than medical treatment (routine medication, doctors’ reviews). Also, there was a significant positive correlation between socio-economic status and coping with SCD. Overall, the results have demonstrated that knowledge and coping of SCD increased significantly after the intervention. Further, the study revealed that Ghanaians continue to use more traditional treatment than western medical approach.

CORRESPONDENCE: Olive Okraku, Department of Psychology, University of Ghana, P.O. Box LG84, Legon, Ghana email: [email protected] +233-242069274

INTRODUCTION

Sickle cell disease (SCD) comprises a group of genetic red blood disorders affecting people mainly but not exclusively, of African, Caribbean and Asian origin. Sickle Cell Disease affects approximately 100 million people worldwide. Africa is the main birth place of sickle mutations with the highest prevalence affecting 200,000 newborns per year (Mohanty & Mukherjee, 2002). In Ghana, about 12 - 15% of the total population is affected with SCD, with 564 infants born each year (Korle-Bu Teaching Hospital Records, 2007). The disease had probably been recognized for generations in West Africa, where ‘cold season rheumatism’ was given the repetitive onomatopoeic names appropriate to a chronic, recurrent condition (Konotey-Ahulu, 1968). Thus the Ga ethnic group referred to SCD as “Chwecheechwe”, the Twi as “Ahututuo”, the Ewe as “Nuidudui”, and the Fante as “Nwiiwii”. Konotey-Ahulu (1968) also stated that some elders could trace back several generations, relatives who had died young from the disease.

Sickle cell disease (SCD) is one of the most prevalent genetic diseases. It is a chronic disease with potentially serious complications including; infections, cerebrovascular events or stroke and chronic pain. The predominant symptom is recurrent and unpredictable episodes of pain resulting from the blockage of blood vessels due to abnormally shaped ‘‘sickle’’ red blood cells, referred to as ‘‘vaso-occlusive crisis’’ (Anie, Steptoe & Bevan, 2002). Other complications include; acute chest syndrome (ACS), splenic sequestration, and priapism (Claster & Vichinsky, 2003; Karnon et al., 2000; Wethers, 2000b; Wilson et al., 2003). Acute chest syndrome (ACS) is a serious complication of SCD involving the development of infiltrates in the pulmonary system and may include infections. Splenic sequestration is characterized by a rapidly enlarged spleen which can lead to a decrease in hemoglobin production and an increased risk for infection. Approximately 10% of all SCD patients will have a stroke at some time in their lives, with the peak incidence occurring between the ages of 4 and 6. Priapism is a prolonged painful erections due to vaso-occlusion (Claster & Vichinsky et al., 2003). Renal complications can also be manifestations of SCD. Due to the fragility of the kidneys, these organs are prone to damage by the inflexible sickled red blood cells (Claster & Vichinsky et al., 2003).

SCD patients do not only experience the physiological problems elaborated, but they also face numerous psychosocial challenges. These include children slow in growth and development (Wethers, 2000). The social effects of missed school, limitations in activity, and repeated hospitalizations can also cause distress to an adolescent with SCD. In a study by Butler, Dennis, Beltran and Lou, (1997) in a group of adult sickle cell sufferers, they reported the following; pain, depression, developmental delays, drug dependence, death anxiety, disability, disruption of social relationships and disenfranchisement. Butler et al. (1997) further found that within the group, virtually all members had experienced periods of dysphoria, sadness, and depression.

Ohaeri, Wuraola, Akinlade and Dare (1995) in Ibadan, Nigeria highlighted the psychosocial problems and coping style of SCD patients. They reported that 13 complaints were predominant in at least a quarter of the population surveyed. These included; the limitations the illness placed on social life, depressive feelings on thinking about illness, abnormal habitus, irritability, suicidal ideation during inefficiency at work, feelings of inferiority, loss of useful opportunities, and the burden of illness in the family. Ohaeri et

65 al. (1995) did not offer explanations about patient’s difficulty in responding to measures they took to alleviate their worries and how they coped or used any structured measures or in depth quantitative method. Patients were only asked how they coped with their worries. Since the study was done on Nigerians, it is also important to note that culture, beliefs and religion could affect coping styles.

Thomas, Hambleton and Serjeant (2001) reported that sickle cell disease sufferers often experience severe illness, pain and the possibility of early sudden death. The disease may also have an impact on sufferers’ physical and emotional well-being, work, and sex resulting in disability, fear and uncertainty about the future. They further reported differences between Jamaican and UK SCD sufferers in their socioeconomic status and coping styles.

Gustafson (2006) used acceptance of genetic testing and improving knowledge of sickle cell disease (SCD) through brief five minute educational sessions in SCD patients. Gustafson (2006) concluded that the level of knowledge following education was significantly higher than knowledge of SCD prior to education. Utilizing the Health Belief Model, Gustafson (2006) surveyed forty-five African American women of childbearing age. Some of the participants commented that “sickle cell disease just does not run in my family”. Others believed that they were not at risk for the illness. Gustafson argued that future studies should take into account the emotional strongly embedded family histories and beliefs that may be influencing how those at-risk individuals perceive the health information they receive. She further suggested that, education materials should acknowledge these beliefs. Since African Americans are of African origin, their belief may be rooted in African tradition and culture which could influence their choice of treatment (Gustafson, 2006). Anie et al. (2007) investigated the psychosocial aspects of SCD in UK and Nigeria. The results indicated that active coping scores were significantly higher among Nigerian patients indicating that they tend to use these coping mechanisms more than the UK patients. Nigerian cohorts scored significantly higher on ‘‘Praying and Hoping’’ and ‘‘Powerful Others’’ than the British sample.

In the work of McInnis (2002), the emotional impact of SCD presented some of the emotional issues faced by adults with SCD. It focused on the emotional impact of Black people living in London, UK, with particular reference to religion as a way of coping as well as the impact of race and disability. McInnis (2002) reported that SCD could have a profound effect on friends and family. Lack of understanding amongst peers or a wider community can result in people with SCD being stigmatized; whilst at work they might be perceived as lazy. Furthermore, envy may develop between family members on the part of the persons who suffer from SCD. “Some of the family members might harbour thoughts of ‘why me’ and may experience feelings of hurt blaming their parents for “making them ill”, (McInnis, 2002). Mattis (2000; as cited in McInnis, 2002) claimed that it would seem logical that spirituality and religion could influence every domain of a Black person’s life. McInnis (2002) further suggested that lack of information on SCD stems from the fact that it is a condition that primarily affects Black people. As such and consistent with other disorders common among blacks, they are often under resourced, under researched and misunderstood. This, according to McInnis (2002), is further complicated by the differences such as class and country of the patients. Among those with religious beliefs, McInnis reported that their faith has helped them a lot in coping with SCD. One of the key practices is prayer not only during time of pain but on a daily basis.

Despite the problems reported, to date, only few studies have been done in Ghana. Based on the various reports, a pilot study was undertaken at the Department of Haematology Sickle Cell Unit at a national hospital in Accra, (Okraku, Ofori Atta, Ekem & Acquaye, 2007). 71 cases were seen by a psychologist at the Sickle Cell Unit. A questionnaire on the psychosocial problems of adult sickle cell disease patients was used for screening the patients.

Of the 71 cases, 45 were female and 26 were male with age range between 14-49 years. This pilot study revealed the responses presented in table 1 below;

Table 1- Psychosocial Problems of Adult Sickle Cell Disease Patients

Psychosocial Problems % of Responses

A problem with getting a job due to SCD status 12 Lost a job due to SCD status 12 Ended relationships because of SCD status 15 Felt they were treated differently due to SCD status 44 Missed school due to SCD crisis 43 Missed school for other illnesses 22 Had fears for crisis pain, short life spans 49.3 Have fears of having children with SCD 46 Were depressed 23.9 Have fears about money to finance health care 30.9

Interestingly, 61% of the sickle cell patients did not know how they got sickle cell disease and other relevant information. 10% of the parents denied they are trait carriers. Also 7.1% were angry, 24% had low self-esteem while 9.8% were unassertive. 19.7% reported they were unhappy in their marriage and 70% of the patients wanted information about the disease. Approximately 35% were non compliant to treatment and management skills 12% also perceived that SCD is not manageable. In addition, patients’ perceptions were assessed through interviews. Patients held many myths about the disease, its precipitants and treatment. Most patients evidenced poor understanding of SCD. This had an effect on their compliance, treatment and management of SCD. Based on the results of the pilot study, the present study examined the health beliefs as well as knowledge of SCD and how it affects coping among SCD patients. The purpose of the present study is threefold. First, to examine knowledge of SCD among sufferers. Second, to investigate patients’ knowledge and its effect on coping with SCD. Third, to determine whether current health beliefs affect coping skill and choice of treatment. Further, the study will address these issues such as African beliefs, culture, tradition, treatment choice.

Methods The study is a quasi experiment, pre-test -post-test design. The research design comprises two groups; the experimental group and the comparison group.

Participants The sample consisted of 50 males and 50 females with age range between 19-52 years (mean age= 29.04 for males; females = 26.44). Twenty four percent (24%) were SS (double sickle gene) 65% were SC (one sickle gene and a different variant of S B globin mutation) 8% were SB (sickle B- globin thalassemia ) and 3% were other. Among these patients, 15% were married, 72% were single and 13% were separated. With education, 11% had tertiary education, 34% had secondary, 35% had middle school or junior high, 19% had primary and 1% had no formal education. With regards to employment, 19% were students, 30% were unemployed, 36% were employed in the government sector while 15% were employed in the private sector. Of those employed, 15% were professionals, 16% were skilled workers, 20% were unskilled workers. Participants were selected from the adult Sickle Cell Clinic at a large national hospital in Accra, Ghana. Selection was by purposive sampling after consent has been obtained.

MEASURES Knowledge of Sickle Cell Disease Questionnaire, Knowledge assessment instrument made up of 25 Multiple Choice Questions modeled after a survey administered to school age children to assess knowledge of Sickle Cell Disease using 10 questions (Koontz, Short, Kalinyak & Noll, 2004). 15 questions were included to improve on reliability and to provide more in-depth information and knowledge. The 15 items added had questions on genetics which covered the biological inheritance of sickle cell disease management of the disease covered nutrition, hydration, self care, treatment and pain management. It also explores trigger factors precipitating crises. Correct answers to the questions were given a score of one (1) with a total of maximum score of 25 answers. An incorrect answer to the question was given a score of 0. The Knowledge of SCD Questionnaire was piloted using 10 SCD patients from two local hospitals. Results from the pilot study yielded an internal reliability of 0.66.

Health Belief Model (HBM) This instrument was developed in an attempt to explain the various factors influencing health behaviors, particularly preventive behaviors (Janz & Becker, 1984). On the HBM assessment, respondents were asked to indicate their level of agreement with particular statement on a five-point Likert-scale in measuring these factors; perceived severity, vulnerability/susceptibility, benefit and barriers. African concepts were developed and added to each scale to enable researcher elicit the information on African health beliefs and tradition. Three of such concepts were added to each scale of two items. For example, under Perceived Severity, items were added; “SCD is a demonic disease”. Under Perceived Vulnerability; “It is very likely to be at risk due to generational curses”. Under Perceived Benefits; “the use of herbs (traditional medicine) is a good way of reducing symptoms and crises”. Under Perceived Barriers; “It is difficult to find a good herbalist for treatment”. Items was scored from 1(strongly disagree) to 5 (strongly agree) with 5 indicating a high perception and 1 indicating a low perception as recommended by Champion, (1984): Champion & Scott, (1997)

Psychometric Properties The internal reliability (Cronbach’s Alpha) of the health beliefs scale are all above .70 and the discriminant validity calculated according to Bohrnstedt’s (1969) method is fairly good (i.e. covariation is less than .36 in all cases). A large number of studies have used HBM approach either in its entirety or with selected component. It has had moderate success in predicting some health behaviour with some components being more useful than others. Janz and Beck (1974) reviewed 46 studies and found that perceived barriers had a significant predictive value in 89% of studies, perceived vulnerability was predictive in 81% but perceived benefits and severity were only predicted in 79% and 65% of studies respectively.

COPE Questionnaires The full COPE is a 60-item measure developed by Carver, Scheier and Weintraub, (1989). It yields 15 factors that reflect active versus avoidant coping strategies. In the “trait like” version, respondents were asked to rate the degree to which they typically use each coping strategy when under stress. In the “state like” version, respondents rate the degree to which they use each coping strategy to deal with a particular stressful event. Ratings are made on a 4-point Likert-type scale that ranges from “1 (usually) don’t do this at all” (1) to “1 (usually) do this a lot” (4). The measure has good psychometric properties with alphas ranging from 45 to 92, test-retest reliabilities ranging from 46 to 86, and strong evidence of discriminant and convergent validity (Carver et al., 1989). Separate scores for each of the scales are computed simply by adding the scores on the four items that make up each scale. Since the scores for each item range from 1 (I usually don’t do this at all) to 4 (I usually do this a lot), the scores for each range from 4 to 16. Carver et al. (1989) found that the internal consistency (Cronbach’s alpha) of the COPE scales were high and exceeded 0.6, with the exception of one scale. This was the mental disengagement scale which is made up of a number of rather disparate items and is less likely to be internally consistent. This indicates that the coping tendencies measured by the COPE are reasonably stable.

Procedure Patients were all interviewed and administered the COPE, Health Belief and the Knowledge of SCD questionnaires during clinic appointment. They were given basic information about the study. There were two groups; the experimental group (A) and the control group (B). The knowledge of SCD questionnaire, Health Belief Model and the COPE, questionnaires were given to both groups. However, only the experimental group received education on the genetic, general knowledge and management of sickle cell disease. The assessment was done before educating the patients in order to avoid influencing the answers and to obtain a representative sample of the current state of knowledge of SCD, health beliefs and coping of Sickle cell patients in Ghana.

GROUP (A) (Pre test) + Education – (2wks) Post test – Measure The experimental group (A) was pre-tested and given education on sickle cell disease, and its management. After the education has been given to group A, they were given an appointment to return to the clinic after two weeks. The purpose was to conduct a post test on the same participants to measure the effects of the education on their coping behavior and to determine if knowledge of SCD had any effect on their health beliefs and coping with SCD.

GROUP (B) (Pre test) Waiting - (2wks) Post test + Education – Measure The comparison group (B) was pre-tested but were not given education on sickle cell disease the same day after the pre-test. Group B were also given an appointment to return to the clinic after two weeks. After 2 weeks both groups were retested. Groups were used in their intact categories and as a result of that there might be threats to internal validity; history and maturation. However, these threats were controlled because both groups went through the same maturation period. History was controlled with the pre test due to the fact that pre test was given to both groups before the intervention was given. The third test given to both groups ensured that both groups came on the same level.

RESULTS The General Model’s Repeated Measure was used to analyze Knowledge and Coping. This was due to the fact that the design was a pre and post test. Using the Pearson’s Product-Moment Correlation Coefficient the study examined the relationship in compliance between traditional treatment and medical treatment. A total of 100 cases were analyzed with 50 being males and 50 females.

Table 3 - Summary of Means of Knowledge of SCD before and after Educational session by Experimental and Control Groups

Condition Pre-test Post-test Post-test II Experimental 11.22 14.20 14.54 Control 10.82 11.34 12.36

Results from the Repeated Measures show that there was a significant effect of education on knowledge of SCD (F (1,49) =39.777, ρ<0.01) indicating that there was a significant difference in knowledge of SCD before intervention (M=11.22, SD=3.579) and after intervention (M=14.20, SD=2.548). Knowledge of SCD increased after the educational session for the experimental group. On the contrary, there was no significant difference in knowledge of SCD between pre-test and post-test among the comparison group

(F (1, 49) =2.583, ρ = ns).

Table 4 - Summary of Means of Coping with SCD before and after Educational session by Experimental and Control Groups

Condition Pre-test Post-test Post-test II Experimental 104.88 107.70 107.66 Control 102.52 102.66 114.28

Table 4 shows that among the experimental group, the mean of coping skills before the educational session (Pre-test) was 104.88 with an increase of 2.82 points to yield 107.70 after the educational section (Post-test). The difference of 11.62 observed among the comparison group between post test and post test II also attests to the positive impact of education on coping among these patients. 70

Table 5 -Within Subjects effects of Coping with SCD by Experimental and Comparison Groups.

Condition Source df F CP Experimental Factor 1 7.186 .010 Error 49 Control Factor 1 .088 .768 Error 49

Repeated Measures in Table 5 shows that there was a significant effect of education on coping with SCD

(F (1,49) =7.186, ρ<0.05). This means that there was a significant difference in coping with SCD before education (M=104.88, SD=25.853) and after education (M=107.70, SD=25.138). It can be concluded that there was an improvement in coping with SCD after the educational session. As indicated in Table 2, however, there was no significant difference in coping with SCD between pre-test and post-test among

the control group (F (1, 49) =0.088, ρ>0.05).

Health Belief Table 6 - Results of the Pearson Correlation Coefficient of Traditional and Medical Treatments Medical Treatment

Traditional Treatment -.39**

**ρ<0.01

The results above shows there was a significant negative correlation between traditional treatment and

compliance to medical treatment (r (98) = -0.399, ρ<0.01). This shows that as the belief in traditional treatment of SCD patients increases, their compliance to western medical treatment decreases. This result confirmed the prediction of the research.

Socioeconomic Status Results from the Pearson Correlation coefficient indicate that there was a significant positive correlation

between socioeconomic status and coping among SCD patients (r (98)= 0.188, ρ<0.05). This suggests that higher socioeconomic status increases with coping.

DISCUSSION The objectives of this study were to provide education as an intervention to improve knowledge and coping in adult SCD patients. It also investigated the current health beliefs of the Ghanaian SCD population including choice of treatment. Results of the study showed that knowledge and coping could be improved after a brief educational session and this was consistent with the work of Gustafson (2006). It was also found that the Ghanaian

SCD population prefers traditional treatment to the western type treatment. This finding is consistent with previous studies (e.g., Danquah, 2008). Socioeconomic status correlated positively with coping as reported by Thomas et al. (2001).

As hypothesized, knowledge and coping was improved after the educational session. Thus, it is argued that the educational session was effective in increasing knowledge of SCD and improves coping. This finding is consistent with Gustafson’s work (2006), who suggested that brief educational session is effective in increasing knowledge of SCD as well as increasing the level of acceptance of genetic screening. There was a significant difference in knowledge of SCD before, and after intervention. Comparing both groups, results on pre-test for experimental group was 38% and 28% for the control group. During the post test after giving educational intervention to the experimental group alone, their results increased to 72% while the control group showed minimal increase to 31%. However, at the end of the study when the control group received educational intervention, their results increased to 60%.

The result of the post-test could be due to the fact that within the given two weeks before the post-test, patients did apply the knowledge of Sickle Cell (Management section) to their lives and this could have influenced how they perceived and interpreted some of the difficulties they experienced. This could also be a result of redirecting negative attitudes such as anger towards parents, family, and God into a positive one by complying with treatment. In addition, they might add other forms of healing procedures such as turning to religion, praying and hoping.

This study has shown that educational session could help patients gather good and important information that will eventually improve their coping of SCD. Problem focused or active focused coping increased from 58% to 72% and emotion or avoidant coping from 50% to 79%. This supports the study by Anie et al. (2007) that Nigerian patients compared with UK patients, used more active coping strategies such as praying and hoping.

Participants in both groups showed improvement on the coping scales. For example, seeking social support for the experimental group increased from 6% to 49%. However, amongst the control group this measure increased from 4% to 32%. Acceptance increased from 12% to 66% for the experimental group; and 12% to 30% for the control group. Acceptance as a coping strategy is very important in an illness like SCD because patients accepting the condition after understanding the etiology and inheritance may focus on how to manage the disease and live a happy life rather than being in denial and blaming others for their condition. Acceptance allows the SCD patient to be free of anger, fear, suicidal ideations and depression. The Ghanaian society and family is largely an extended one, therefore support for clients comes from all directions; siblings, grandparents, aunts, uncles, and cousins (Nukunya, 2003). This social support serves as a protector for most people and help patients to manage with the condition better than those societies with independent nuclear families in restricted societies. The extended style of family in Ghana encourages SCD patients to open up and talk about how they feel. The person the patient chooses to confide in is not necessarily immediate family members (siblings or parents) but anyone they trust and feel comfortable with.

Utilizing the Health Belief Model, the results showed that SCD patients utilized more traditional treatment (i.e., use of herbs, and visiting the shrine for guidance), than the medical treatment (i.e., complying with routine medication and regular visit to the doctor for reviews).

The study also predicted that the use of traditional medicine would lead to a decline in the use of medical treatment. This is consistent with the findings by Danquah (2008) that Ghanaians/Africans behaviors are motivated by their belief systems. Their belief is based on what they experience; their approach to health seeking is based on the mystical beliefs connected to the history and culture of Africa (Danquah, 1982). As observed during this research, some of the patients attributed the cause of their illness to evil spirits and curses that was handed down from generation to generation. Some also had the belief that SCD could not run in their families because they came from the royal clan. Due to these beliefs, there was low compliance to the medical treatment. Patients came to the clinics mainly for injections to reduce the pain; some came because of pressure from a partner or parents. There were others who had not attended the clinic for as long as 2 to 15 years. In the absence of the utilization of medical care they used traditional medicine (herbs) visiting the shrine and the use of religious practices such as praying and hoping.

Danquah (1982) suggested that the choice of the treatment modalities by the patient is not associated with the proximity or with the cost of treatment. Rather, it seems to be related to the patients or the family’s concept of the etiology of the illness, which is usually based on their spiritual beliefs. It has been noted that in Ghana the current trend in the health seeking behaviors of clients are mostly focused on the Charismatic Churches, followed by the shrines, including the traditional herbal treatment where some of the practitioners combine shrine and herbal treatment approaches. The western medical practices including psychiatry and psychology seem to be less patronized by the Ghanaian clients. This may be due to two factors; cost of medical treatment compared to traditional treatment. Second, the African belief system emphasizes religion (i.e., Charismatic Churches) demonic influences, or the combination of the shrine and the demonic approaches by some of the charismatic church leaders. This interesting finding suggests that level of education, wealth or age does not influence the type of treatment an individual receives in Ghana. This may help physicians to understand why some patients prefer traditional approach to the western medical treatment. It can be argued that the Ghanaian SCD patient still possess the intrinsic values in relation to choice of treatment in the African Belief System. Added to that, cost of the traditional treatment is affordable compared to the medical treatment as reported by Danquah (2008).

Since there is no cure for SCD at the moment, if patients get relief from using herbs, it should be investigated and encouraged. However, it will be good to combine both medical and traditional treatment since our belief is intrinsic and it is difficult to work with patients (Africans) based on only one treatment model especially the medical model. Social support in Ghana (Africa) is broad and readily available even although health care delivery is not is considered that expensive by patients. This finding explains some of the issues raised by Gustafson about her study with the African American population who did not believe that sickle cell disease was a genetic disease. The study also predicted that, there would be a significant relationship between socio-economic status and coping of SCD; this was supported and consistent with the findings reported by Thomas et al., (2001).

Limitations The major problem encountered during this research project was crisis. A significant number of the patients were unable to complete the questionnaire because they were in crises pain. Another problem encountered is the lack of literature on the psychological aspects of sickle cell in Ghana. The generalization of this study is also restricted because of research design. Also even though socioeconomic status was investigated as a possible correlation to coping, the scoring made a weak conclusion. Future studies should address these issues adequately.

CONCLUSION The specific aims of the study were to improve knowledge of SCD, understand patient’s ways of coping. To investigate whether SC patients transfer knowledge and health beliefs to coping and to understand the general belief in the population that SCD is due to spiritual factors. As observed in the findings, knowledge does increase after educational session and this leads to improvement in coping comparing pre- and post test results. It was also observed on the Health Belief Model that traditional treatment was used more in Ghana than medical treatment. As the results revealed most SCD patients use the traditional mode of treatment and visit the hospital usually when in severe crisis and need to be hospitalized. This means that SCD patients are compliant but more to the traditional treatment because it is attached to their belief in the choice of treatment. Socioeconomic status correlated significantly but weakly with better coping. This could be due to the scoring.

The main concern of the study was about how much SCD patients know about the disease and whether giving them education as intervention could help them manage better and change certain beliefs they had about SCD. The study was successful in this aspect. It was found that coping was improved after the educational intervention, even though knowledge of SCD and health belief is independent of coping skills. The implication of this to patients is that more can be achieved through education as mentioned in the relevance of the study. The burden on the health personal and frequent hospitalization could be reduced by giving a good foundation for both parent’s families and sufferers of the disease. This means that a multi-disciplinary approach will be more beneficial, where the SCD patient have access to a Physician, Psychologist, Social worker and an Occupational therapist.

RECOMMENDATIONS Primary sources of information could be given in schools, work places, churches (posters & educational handouts) through the media, awareness campaigns for family and friends. The Adult sickle cell clinic at could improve a congenial environment for the patients.

The effect of SCD pervades all aspects of the patients’ lives. It is true that the hallmark of the disease is pain crises, but in the absence of pain crises which differs among individuals there are other psychological and social stressors the patients face daily which could be more profound than episodes of crises. Awareness might seem simple and not sophisticated enough but awareness in addition to social and psychological support could provide a strong foundation and relief on which the patients will build their lives. A holistic approach should be adopted as this then embraces the application of Biopsychosocial model.

ACKNOWLEDGEMENT We are most grateful to Dr. B. Amponsah for his time, contribution and support. We are also indebted to Professor C.C Mate-Kole for his immense contribution, guidance and advice. We are grateful to the following persons who provided help toward the completion of this research work: Dr. Sey – Sickle Cell Adult Clinic, Korle Bu and Dr. I Ekem, Haematology Department, Korle Bu, and Kofi Atim-Nagah – Korle Bu Library.

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Butler, Dennis J., Beltran, Lou R., (1997). Functions of an Adult Sickle Cell Group; Education, Task orientation and support. Health and Social work, 18 (1): 49-56

Champion, V.L. (1984). Instrument Development For Health Belief Model Construct. Advances in Nursing Science, 6 (3), 73-85

Carver, C.S., Scheier, M.F., & Weintraub, J. K.,(1989). Assessing coping strategies: A theoretically based approach, Journal of Personality and Social Psychology, 56, 2,267-83

Claster, S., & Vichinsky, E. P. (2003). Managing sickle cell disease. British Medical Journal, 327(7424), 1151-1155.

Danquah, S.A. (2008). The relevance of African Belief System and the patient’s choice of treatment. From the existing health models in Ghana. The Mind 1; 11-27.

Danquah, S.A. (1982). The Practice of Behaviour therapy in West Africa: The case of Ghana. Journal of Behaviour therapy & Experimental psychiatry. Vol. 13, No. 1, pp. 5-13, 1982.

Gustafson, S. (2006). Knowledge and health beliefs of sickle cell disease and Sickle cell trait: The influence on acceptance of genetic screening for sickle cell trait. University of Pittsburgh.

Janz, N. K., & Becker, M. H. (1984). The Health Belief Model: A Decade Later. Health Education Quarterly, 11(1), 1-47.

Koontz, K., Short, A. D., Kalinyak, K., & Noll, R. B. (2004). A randomized, controlled pilot trial of a school intervention for children with sickle cell anemia. Journal of Pediatric Psychology, 29(1), 7-17

Karnon, J., Zeuner, D., Ades, A. E., Efimba, W., Brown, J., & Yardumian, A. (2000). The effects of neonatal screening for sickle cell disorders on lifetime treatment costs and early deaths avoided: a modelling approach. J Public Health Med, 22(4), 500-511.

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Thomas V.J. & Taylor, L.M. (2002). The Psychosocial experience of people with sickle Cell disease and its impact on quality of life; Qualitative findings from focus group British Journal of Health Psychology 7,345-363.

Thomas, Hambleton & Sejeant. (2001) Psychological distress and coping in Sickle Cell Disease; Comparison of British & Jamaica attitudes. Ethnicity & Health, 6(2): 129-136.

Wethers, D. L. (2000a). Sickle cell disease in childhood: Part I. Laboratory diagnosis, pathophysiology and health maintenance. American Family Physician, 62(5), 1013-1020.

Wethers, D. L. (2000b). Sickle cell disease in childhood: Part II. Diagnosis and treatment of major complications and recent advances in treatment. American Family Physician, 62(6), 1309-1314.

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DOLL CHOICE IN YOUNG CHILDREN: REPRESENTING SELF THROUGH SKIN COLOR

Sheriffa Mahama1, Adam Nyarko Danquah2, Ming Wai Wan3

1Home Science Department, University of Ghana 2Psychology Department, University of Ghana 3Psychiatry Research Group, University of Manchester

ABSTRACT This study is an exploratory study that examines skin color identification in children aged six to nine. Results show that in all, there was no overall preference for either color doll. No significant age differences were found according to theme or reason given for the doll selected. However, child gender was highly predictive of child doll choice with boys more likely to choose pale dolls. Using chi-square tests, significant results were provided for socioeconomic status (SES). Results indicate that boys from lower socioeconomic backgrounds, and who attended public school were more likely to choose the pale doll. Also, there was a significant association between school type and SES. The school and SES differences were mainly attributed to a comparatively better English comprehension on the part of the private schools and children from high SES backgrounds and the seeking of high status symbols from the public school children as a result of low SES. Recommendations are made for further studies to investigate more fully the reasons children give for their choices as well as measure the relationship between doll choice and other socio-demographic variables and indices of psychological functioning

CORRESPONDENCE: Sheriffa Mahama Home Science Department, University of Ghana, Legon P. O. Box 48, Legon Email: [email protected]

INTRODUCTION

Skin color alone does not define one’s race or ethnicity. However, skin color is commonly used as the most salient and distinctive physical feature to mark members as belonging to a particular racial or ethnic group (Montalvo & Codina, 2001). Although genetic variation within racial groups is greater than genetic variation between them (Cavelli-Sforza et al., 1996), racial groups are often referred to by skin color. Thus, one’s ‘color’ represents a crucial dimension in the development of ethnic identity (which – unlike traditional views of ‘race’ – is socially constructed – Chávez & Guido-DiBrito, 1999). Ethnicity is an umbrella term used to describe groups differentiated by color, language, religion, ethnicity, race, nationality – or ‘descent-based attributes’ (Chandra, 2006). Children first become aware of ethnic differences during the preschool years (Clark et al., 1980). The development of ethnic identity, a psychosocial process in which an individual moves toward a conscious identification with their own cultural values, behaviors, beliefs, and traditions – proceeds with cognitive development along similar lines as gender identification (Katz, 1983). The promotion and reinforcement of negative ethnic group messages within society, however, may lead to a disconnection or shame associated with one’s own ethnic identity. Some social commentators have viewed this to be the case among African Americans that there exists a pervasive devaluing of African people and ‘blackness’ in Western culture (Murray & Mandara, 2003), and both a perceived and real disadvantaged status associated particularly with African Americans (Loury, 2000) and people with darker skin tone more generally (Sweet et al., 2007; Wade et al., 2004). Perhaps as a consequence of these, African American children and adolescents display a preference for lighter skin (Porter, 1991; Robinson & Ward, 1995).

One method that has been widely used to study young children’s skin color preference and ethnic identification is the doll choice test. Early studies showed that, when offered a choice of otherwise identical black and white dolls, African American children indicated an overwhelming preference for the white doll and a rejection of the darker doll (e.g. Clark & Clark, 1947). Later studies produced contrasting results in favor of the black doll, which suggested a changing US trend toward racial pride (e.g. Hraba & Grant, 1970). A more detailed 10-question version of the doll choice study showed that most children showed no particular strong preference, but that preference for the Black doll increased between six and nine years, such that there were equal numbers preferring each doll by nine years (Burnett & Sisson, 1995). Recently, however, Craemer’s (2005) implicit dolls test – in which the reaction times of overt responses are used to infer subconscious processes – found a substantial disconnect between explicit and implicit responses among African American participants, suggesting that, despite overt pro-black pronouncements, subconscious feelings towards their own group had not changed much. For those studies in which white preference was demonstrated, it has been argued that these findings relate to a rejection of self and own ethnic group tantamount to psychopathology (Burnett & Sisson, 1995). However, as these US studies have been of Black children as a minority group, the findings may reflect prejudices against minorities rather than their own ethnic group per se.

There have been few studies of children’s attitudes to skin color or ethnic identification in Africa. The relationship between ethnic identity and skin color is complicated by the widespread perception across African nations of lighter skin color as being more desirable (e.g. Ntambwe, 2004). Similar to early US findings, a doll choice study with Bantu children in South Africa found a distinct preference for the White doll (Gregor & McPherson, 1966). In general, nowhere is pale skin tone preference better reflected than

78 in the widespread use of skin bleaching products among women in Ghana (Akosa, 2005) and across Africa (e.g. Frost, 2006; Glenn, 2008). However, lighter skin color preference goes beyond physical attractiveness. In a study of Ghanaian students aged eight to eighteen, lighter skin color was consistently associated also with opportunity, power and acceptance (Mackey, 2005). In Ghana, the general belief that men consider lighter skinned women more attractive than their darker counterparts is evidenced by the expression ‘Me broni’ (i.e. my white lady), a term of endearment in Akan, but one which, according to Akosa, (2005), is “demeaning of our blackness, our ‘Africanness’ and our ‘Ghanaianness’” (para. 20). Thus, here, skin color is viewed as synonymous with racial, ethnic and national identity. How such complex messages regarding skin color and identity are transmitted across generations in Ghanaian society has been little studied. Children’s attitudes may be influenced by society’s preference for lighter skin from a young age, but which may be in conflict with their developing understanding of their own ethnicity as part of their self-concept.

This paper reports on the doll choices – as differentiated by skin color – made by a diverse sample of five- to nine-year-old Ghanaian children, which were selected to represent themselves in a doll play task (based on Green et al. 2000) as part of a larger project. The current study is the first, to our knowledge, to investigate skin color preference among children in Ghana. Although it is considered inclusive (and thus good practice) to offer dolls from a range of ethnic groups in doll play tasks (which are used to gain insight into children’s internal representations in a range of domains; e.g. aggression, attachment), the choice of doll, and specifically its skin color, has not been systematically studied within the doll play (or ‘story stem’) methodology. The current exploratory study differs from the traditional doll choice test in that, rather than simply asking about doll preference, we examined skin color identification implicitly, by asking children to choose a doll to represent them in play.

Method

Participants Seventy-seven children (38 male, 39 female) aged between 5.5 and 9.5 years were recruited following parental consent from two primary schools: a public school in Legon, and a private school in Tema, both in the Greater Accra region capital of Ghana. Participation was part of a larger doll-play study on child- parent relationships, although the focus of this brief report is on doll choice. To be eligible, the children were required to speak sufficient English language to select a doll in the task administered in English (which is the official language in Ghana, including primary level teaching). For those whose date of birth information was available from the school or family (N=66), the mean age was 7.65 years (range: 5.58- 9.42 years). Complete but less precise age (year) data from child/teacher report yielded a similar mean (7.25 years) and range (5-9 years). Based on a combination of parental and child report of parent/caregiver occupations, and parent-reported household income, we found that a range of socioeconomic groups were represented (N=11 (14%) professional/managerial; N=26 (34%) skilled manual or non-manual; N=16 (21%) semi-skilled; N=23 (30%) unskilled; 1 missing). For those parents who provided the information (N=54; 70%), 82% had parents who were married/cohabiting, and 18% had parents who were separated/single. Based on child-report, N=54 (70%) presently lived with both parents, N=14 (18%) lived with the mother, and N=5 (6.5%) lived with the father -with or without other adult family members. Children were in Grade 1 (N=18; 23%), Grade 2 (N=40; 52%) or Grade 3 (N=19; 25%), which provides an estimate of educational level rather than age necessarily.

Measures and Procedure As part of a doll play task procedure (Manchester Child Attachment Story Task –Green et al., 2000), children were asked to select a doll that is understood to represent themselves within the play. To explore skin color identification/preference specifically, the task procedure was modified in the current study in which children were presented with two wooden ‘traditional doll house’ dolls of the child’s sex, one of paler color than the other. The dolls were intended to be identical in all respects except for skin color, although the girl dolls differed slightly also in size and hairstyle, due to the unavailability of otherwise identical dolls by manufacturers. Children were asked: “Which doll do you choose to be - doll?” – The implication in the question is that the doll would represent them. Their choice was followed by the question, “Why do you choose this one and not the other one?” The doll choice and reason given were recorded verbatim. Socio-demographic data was obtained separately through parent and child report.

Results In total, 40 (51.9%) children selected the pale doll and 37 (48.1%) selected the dark doll to represent the ‘child doll’. Forty-seven (61%) of the children provided a reason for their doll choice when prompted. The reasons provided were sorted thematically from which three themes emerged: skin color (N=16), some other aspect of physical appearance (N=17), and general evaluations or nonsense (N=14). No significant age differences were found according to theme or to whether a reason was given for the doll selected. Of the skin color related comments, 12 were by boys and 4 by girls, with 9 in favor of the pale doll and 7 (including all 4 girls) of the dark doll. Remarks for choosing the pale doll seemed to reveal a personal preference (or non-preference for the darker doll) while choosing the dark doll tended to be about providing an accurate depiction of self:

Boy, aged 8, chose dark doll: “Because I am a black man” Girl, aged 7, chose dark doll: “Because she’s dark like me” Boy, aged 8, chose pale doll: “They are both strange but this one is fair” Boy, aged 8, chose pale doll: “This one, his face is fair” Boy, aged 6, chose pale doll: “This one is white”

Because the girl dolls did differ slightly from one another, the reasons given in the ‘other physical appearance’ category by girls were reasonable (mainly relating to slight differences in hairstyle), whereas those given by boys did not equate to reality since the boys were identical aside from skin color; e.g. “This is bigger” (dark doll); “Because this is thinner” (white doll). General evaluative reasons were given more frequently by girls (N=11 v N=6), and of those who made such comments, 8 were in favor of the dark doll and 6 of the pale doll; e.g. “It’s nice” (pale doll); “Because I love it so much” (dark doll).

The association of specific social factors with doll choice was examined (Table 1). Using chi squared tests, significant effects were found for SES (professional/managerial and skilled V other; X2=4.23; p=0.04), school attended (X2=6.01; p=0.01), and child gender (X2=8.16; p=0.004), but not school grade (X2=0.04; p=ns). Although we found a slight shift toward a preference for the pale doll with child- reported age (5-7 years V 8-9 years), this was a trend effect (X2=2.91; p=0.09). Thus, those boys from lower socioeconomic backgrounds, and who attended public school were more likely to choose the pale

80 doll. As expected, there was a significant association between school and SES (X2=5.50; p=0.02). Slightly more girls in the sample were from the private school (N=25; 64.1%) than from the public school (N=14; 35.9%; X2=2.19; p=0.14).

Table 1. Child doll preference by socio-demographic factors Dark doll Pale doll (% within doll group) (% within doll group)

Professional/ 22 (59.5%) 15 (40.5%) managerial or skilled

Semi-skilled or 14 (35.9%) 25 (64.1%) unskilled

Attended public school 11 (32.4%) 23 (67.6%)

Attended private school 26 (60.5%) 17 (39.5%) Aged 5-7 22 (57.9%) 16 (42.1%)

Aged 8-9 15 (38.5%) 24 (61.5%) Boy 12 (31.6%) 26 (68.4%)

Girl 25 (64.1%) 14 (35.9%)

To delineate independent effects, a logistic regression was calculated, with child gender, school attended and SES entered as independent variables. Child gender was highly predictive of child doll choice (Wald=6.91; p=0.009), with school attended contributing a borderline effect (Wald=3.62; p=0.057), in total accounting for 25.8% of the variance. The probability of choosing the pale doll compared with the dark doll is increased by a factor of 3.88 by being male rather than female, after controlling for school and SES.

Discussion The current study represents the first doll choice study to our knowledge of a Ghanaian sample of children, and took the novel approach of asking children to make a doll choice pertaining to self- identification specifically. Given the equivocal nature of doll choice preferences in previous, primarily US, studies, the study reported here was exploratory. As a whole, there was no overall preference for either doll, with the proportions selecting each doll being almost equal. A variety of reasons were given to support the child’s doll choice and most children did not refer to skin color, despite this being the most salient difference between the dolls offered. Of the reasons based on skin color, some gave meaningful comments with reference to their own skin color, suggesting that – at five to nine years – many children have some appreciation of ethnic identity, at least at a perceptual level. However, the findings are

81 inconsistent with doll choice studies that have shown black children’s strong preference for pale dolls (e.g. Clark & Clark, 1947; Craemer, 2005) or dark dolls (e.g. Burnett & Sisson; Farrell & Olson, 1983; Hraba & Grant, 1970). Most previous studies were conducted in the USA, against the backdrop of its own ethno-racial history and politics, whereas the current study is an attempt to investigate skin color preference and identification in a country with a majority black African population. If the dolls are assumed to represent different skin colors, then, what the seeming lack of overall preference means for issues of black identification and wellness requires a more sophisticated understanding of what the choice of one doll as against another means to the children themselves (cf. Burnett & Sisson, 1995).

More detailed examination found that boys in our sample were almost four times more likely than girls to choose the pale doll, particularly those attending public school and from lower SES backgrounds. Differing levels of English language comprehension may explain public/private school differences such that the privately educated group may have tended to interpret the researcher’s questions more accurately. However, this explanation does not account for the strong gender differences we found which almost completely occluded school and SES effects. Recent research suggests that girls show lower initial ethnic identity but which develops faster (Smith et al., 2009), consistent with the validity of the current task as one of self-identification since more girls chose the dark doll than boys, independent of school attended and SES. However, the results are unlikely to reflect only differing levels of cognitive development toward ethnic self-identification, since we report a general trend toward preference for the pale doll with age. From a social perspective, the general preference for paleness in Ghanaian culture (e.g. Kwabla, 2009; Rogers, 2006; Blay, 2007) may also contribute to an earlier awareness of the significance of skin color among girls, including their actual skin color. Another interpretation is that public school/low SES boys are the group most in need of status (and are likely to have a less advanced development of self- concept), so are more likely to choose the white doll, as a ‘fantasy’ preference. Ramsey (1987) found that children who express strong ethnic bias seem to be repeating comments they have heard from adults. For these reasons, it may be that the boys’ choices are a more accurate depiction of Ghanaian children’s skin color preference rather than self-identification.

A number of potential confounds need to be considered. Firstly, although the implicit nature of the doll task instruction was intended to minimize effects such as social desirability, a disadvantage is that children may have made choices based on skin color preference, skin color identification, more accurate visual depiction, or play character preference (e.g. Clark, 1947). The potential for confusion is compounded by English not being the first language of much of the sample, although most of the reasons provided suggest that doll choices were not simply random or creative/fantastical, but represented either preference for or identification with some (real or imagined) appearance-based feature. Secondly, due to slight differences (other than skin color) between the girl dolls, particular caution must be taken in interpreting the results for girls. Thirdly, although symbolic play is universal (e.g. Mathews, 2003; Bornstein et al, 1999), doll play may not be familiar to children who do not have access to doll figures, which is likely to include a large proportion of the current sample. Since the paradigm is predicated on the automaticity with which children will identify with figures, any such unfamiliarity could mean that something other than identification was being measured. Fourthly, it is implicit in the task that the wooden dolls represent individuals from black and white ethnic groups rather than, variants within a single group, although previous work suggests that doll choices do not reflect the child's own relative paleness (Farrell and Olson, 1983). Fifthly, the ethnicity of the administrator (East Asian, considered

‘obroni’ or ‘white’ in Ghana), may have led to a ‘pro-White’ bias (Clark et al., 1980). More generally, doll choice tests have been criticized for being over-simplistic, where paler doll choice is presumed to undermine ethnic identity among Black children (e.g. Burnett & Sisson, 1995). Unrelated to ethnicity or race, children may have an inherent inclination to prefer lightness and light colors over darkness and dark colors (e.g. Williams & Morland, 1976).

Though the distinction between ethnic identification and skin color preference is not clear, what is clear is the fact that for some particular groups of children, there is a preference for paler skin color and this preference might impact on ethnic preference. Given the importance of skin color in the child’s developing understanding of ethnicity and ethnic identity and the pervading preference for lighter skin tone (and possibly other attributes associated with Western people, especially recently) in Ghanaian culture, there are possible implications for psychological wellness, which warrant further investigation. Despite criticism of the doll test as a viable measure of children’s ethnic preferences (Cross, 1991; Hraba & Grant, 1970), it is a convenient and useful tool that presents intriguing possibilities for gaining a better understanding of children’s skin color identification and preferences, and implications thereof. Further studies might investigate more fully the reasons children give for their choices, and measure the relationship between doll choice and other socio-demographic variables and indices of psychological functioning.

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RECOGNITION OF NONWORDS IN TWO PATIENTS WITH DEEP DYSLEXIA: IMPLICATIONS FOR MODELS OF READING

Rebecca M. Wood 1 and C. Charles Mate-Kole2

1Central Connecticut State University, New Britain, CT 2Department of Psychology, University of Ghana, Legon

ABSTRACT Deep dyslexia is an acquired reading disorder characterized by poor oral reading of nonwords, as well as by semantic, derivational, visual, and function word errors. Traditional explanations of the disorder assume that patients’ difficulties in reading aloud nonwords reflect an inability to process phonology. Although recent studies have shown that some deep dyslexics implicitly process phonology, current accounts of the disorder do not allow for explicit phonological processing. Using a forced-choice memory task, we investigated the explicit phonological processing of two deep dyslexic patients to determine if such processing occurs. During familiarization, the patients were presented a series of target nonwords. During recognition, they saw each target paired with a foil nonword, and they were asked to point to the target. Each patient earned a perfect score on this task. In addition, one patient performed well on a similar task presented in the auditory domain. These findings demonstrate explicit phonological processing in at least two deep dyslexics, requiring a re-examination of explanations of the disorder.

Keywords: Deep dyslexia; explicit phonological processing; brain damage; acquired reading disorders

Correspondence: Rebecca M. Wood, Ph.D. Department of Psychology, Central Connecticut State University 1615 Stanley Street, New Britain, CT 06050 Phone: (860) 832-3106; Fax: (860) 832-3123 Email: [email protected]

INTRODUCTION Deep dyslexia has become the most extensively studied acquired reading disorder since Marshall and Newcombe gave the first description of the disorder in 1966. The classic symptoms of deep dyslexia are semantic (e.g., close  “shut”), derivational (e.g., wise  “wisdom”), visual (e.g., stock  “shock”), and function word errors (e.g., for  “and”; Coltheart, 1987a; Marshall, Newcombe, & Marshall, 1970). In addition, Coltheart (1987b) reported that deep dyslexics experience difficulties in reading aloud nonwords, especially those that do not sound like real words (e.g., jisp). Marshall and Newcombe (1987) described their patient as someone who, “…can never read aloud a non-word [the patient’s] typical response upon being presented with a pronounceable nonword is to indicate that he simply cannot perform the task” (pp. 2-3). Two decades later, deep dyslexia is still considered a disorder that includes an inability to read aloud nonwords (Buchanan, Hildebrandt, & MacKinnon, 1994, 1996, 1999; Colangelo & Buchanan, 2006).

Several models have attempted to explain the semantic, derivational, visual, and function word errors associated with deep dyslexia. These include the right-hemisphere hypothesis (Coltheart, 1983, 1987c, 2000), the dual route model (Coltheart, Curtis, Atkins, & Haller, 1993; Morton & Patterson, 1987), the continuum model (Glosser & Friedman, 1990), and connectionist models (Coltheart, Rastle, Perry, Langdon, & Ziegler, 2001; Hinton & Shallice, 1991; Plaut & Shallice, 1993; Seidenberg & McClelland, 1989). These traditional models assume that deep dyslexics cannot process nonlexical phonological stimuli (Buchanan et al., 1994; Buchanan et al., 1996, 1999; Colangelo & Buchanan, 2006; Coltheart, 1987a; Coltheart, 2000). In fact, Coltheart (1987b) suggested that this inability might underlie the derivational and semantic errors made by deep dyslexics, as well as the problems these patients have with low-frequency and abstract words. However, recent studies have shown that at least some deep dyslexics may, in fact, be sensitive to phonology (Buchanan et al., 1994, 1996, 1999; Buchanan et al., 2000), defying the popular conceptualization of deep dyslexia and demanding a closer look at traditional models of the disorder.

Phonological Processing in Deep Dyslexia Deep dyslexics typically are unable to read aloud pronounceable nonwords (Coltheart, 1987a, 1987b). For example, Marshall and Newcombe (1987) described a patient who either read pronounceable nonwords as words (wep  “wet”; zul  “zulu”) or indicated an inability to perform the task (wux  “don’t know”; nol  “no idea”). However, asking patients to read nonwords aloud is not the only way to test for ability to process written phonological stimuli. Studies have reported that a different technique involving implicit processing of nonwords has shown that deep dyslexic patients may be able to process nonwords (Buchanan et al., 1994, 1996, 1999).

Buchanan et al. (1994) described a deep dyslexic patient (JC) who refused to attempt oral reading of nonwords, but who showed evidence of implicit processing of nonwords. Specifically, JC showed the pseudohomophone priming effect; she used semantic information from pseudo homophones (dokter) as primes for target words (“nurse”; i.e., the primes resulted in faster reaction times for judgments regarding whether or not the target words were, in fact, real words). For example, taybul served as an effective prime for the target word “chair”, whereas the orthographically similar nonword tarble and semantically unrelated pseudo homophone brane did not. Further, in contrast to previous work (Hildebrandt & Sokol, 1993; Patterson & Marcel, 1977), JC showed a pseudo homophone effect; she took longer to reject pseudo

87 homophones like taybul as real English words than orthographic control nonwords, such as tarble (the authors argue that their patient showed this effect because of increased power provided by longer stimulus list than lists used in previous studies). These findings support the assertion that JC could implicitly process phonological stimuli.

Buchanan et al. (1996) replicated Buchanan et al.’s (1994) findings with two additional patients. One patient, PB, made reading errors consistent with deep dyslexia, including semantic (e.g., clock  “watch”), nonword (e.g., bave “brief”), derivational (e.g., word “words”), and visual errors (e.g., once “one”). PB produced the pseudo homophone effect, as did another deep dyslexic patient in the study (i.e., GZ). PB and GZ also took less time to accept target words like “chair” as real words when these words were preceded by semantically related pseudo homophones like taybul than when the words were preceded by semantically unrelated pseudo homophones like brane. In other words, like JC, these two patients showed a pseudo homophone priming effect.

The findings described above suggest a nonlexical, phonological pathway to the semantic system in deep dyslexics (Buchanan et al., 1996). Thus, the findings have implications for current models of deep dyslexia that assume an inability to process phonological information (i.e., the right hemisphere hypothesis, the dual route model, etc.). However, Buchanan and her colleagues showed implicit processing of nonwords by deep dyslexics. Evidence for explicit processing would require even more scrutiny of traditional models of deep dyslexia. Following Buchanan et al.’s (1994) example, we review each model in light of the deep dyslexic cases described in the present study, who we believe showed explicit phonological processing of nonwords.

Brief Overview of Models of Deep Dyslexia The Right Hemisphere Hypothesis Coltheart (1983, 1987c, 2000) and Saffran, Bogyo, Schwartz, and Marin (1987) suggested that reading in deep dyslexia involves the right hemisphere, as the left hemisphere is too damaged to perform its usual function; converting orthography into phonology. Thus, the patient with left hemisphere damage will find nonword reading tasks difficult, because phonological tasks are carried out by the left hemisphere. According to Saffran et al. (1987), the right hemisphere reading system bypasses phonology and involves only the matching of written words to “stored orthographic entries” (p. 399). Furthermore, most of these entries are for concrete words, as the right hemisphere appears to lack entries for abstract, low-frequency words (see also Coltheart, 1983). Indeed, “the deep dyslexic makes numerous errors and omissions when attempting to read abstract words aloud” (Coltheart, 1987c, p. 363).

Coltheart (1987c) cited evidence for whole-word processing by the right hemisphere, and superior (or perhaps total) conversion of orthography to phonology by the left, largely from split-field experiments with normal English and Japanese readers. For example, several tachistoscopic experiments with normal Japanese readers have shown that presentation of the kana script (a phonological script with a one-to-one correspondence between a character and a syllable) to the left hemisphere results in more accurate responses than presentation of this script to the right hemisphere. On the other hand, when the kanji script (in which a character represents a whole word) is presented to the right hemisphere, responses are more accurate than when this script is presented to the left hemisphere. These results suggest that while the left

88 hemisphere is good at grapheme-phoneme conversion, the strength of the right hemisphere is the identification of whole words.

More recent research has shown greater regional cerebral blood flow (rCBF) in the right hemisphere than in the left during a word-recognition task in a deep dyslexic patient (Weekes et al., 1997). This finding supports the contention that right hemisphere reading involves matching written words to visual word forms stored in that hemisphere (Saffran et al., 1987). As Weekes et al. acknowledged, increased rCBF in the right hemisphere of one deep dyslexic during word recognition does not lead to the conclusion that this will happen in every case. However, it does show that, at least for this individual, the right hemisphere is involved in the word-recognition task as predicted by the right hemisphere hypothesis.

Even in light of such evidence, controversy surrounds the right hemisphere hypothesis. Price et al., (1998) reported on two deep dyslexics who showed increased right hemisphere rCBF (as indicated on PET scans) during naming and semantic tasks relative to non-dyslexics, although the areas of activation were different for each patient. Interestingly, the two dyslexics also showed left hemisphere activity during these tasks. The authors interpreted this latter finding as evidence against the right hemisphere hypothesis, as the left hemisphere was clearly engaged during phonological and semantic tasks. In contrast, Coltheart (2000) argued that “no one has ever claimed that the reading of deep dyslexics relies exclusively on a right-hemisphere reading system” (p. 300). More recently, Coltheart (2000) has suggested that the left hemisphere may be involved in some reading tasks, and those that it cannot perform will be adopted by the right hemisphere. Roeltgen (1987) provided evidence against this assertion when he described a deep dyslexic patient who lost virtually all his remaining reading abilities after suffering a second stroke in his left hemisphere.

Studies regarding right hemisphere hypothesis are equivocal. However, this model remains an influential account of deep dyslexia and must therefore be considered in light of support for phonological processing by deep dyslexics. Buchanan et al. (1994) indicated that the right hemisphere model of deep dyslexia can accommodate their findings because their tasks were implicit, and the right hemisphere hypothesis simply states that the right hemisphere is incapable of explicit processing of orthographyphonology conversion. If, however, evidence of explicit processing in deep dyslexics were found, the hypothesis would no longer sufficiently explain reading errors made by deep dyslexics. We propose that the two cases described in this paper did show evidence of explicit phonological processing, thus requiring another look at the right hemisphere hypothesis.

The Dual Route Model Morton and Patterson (1987) and Coltheart et al. (1993) described two routes (plus a third) for reading letter strings aloud. One pathway converts orthographic segments of words into phonological segments, which leads to pronunciation. This pathway is involved in reading words and nonwords, as the orthography of the letter string corresponds to the phonology. Because exception words (e.g., yacht) do not contain this correspondence, a second pathway involving specific knowledge of these words (a lexicon) is necessary. This lexical route can also be used when reading regular words, but not when reading nonwords. A third pathway is proposed which bypasses the lexicon and contains strictly phonological codes for whole words. Deep dyslexics’ difficulty in reading aloud nonwords suggests damage to the first and third pathways. Damage to the second pathway is also assumed, but this pathway

89 is also thought to be responsible for any spared reading ability of the deep dyslexic (Buchanan et al., 1994).

The dual route model predicts neither the pseudo-homophone effect nor the pseudo-homophone priming effect found by Buchanan et al. (1994, 1996) in some patients with deep dyslexia. Buchanan et al. (1994) indicated that the model would have to be revised such that the damage to the reading system occurs closer to the output stage, as damage to the first pathway (conversion of orthography to phonology) is inconsistent with these findings. Evidence for explicit phonological processing in deep dyslexics would also require this modification of the dual route model.

The Continuum Model of Deep/Phonological Alexia Glosser and Friedman (1990) proposed that nonwords are read aloud via a process of approximation. Words that a reader has encountered previously are stored in a lexicon, and during reading, these orthographic word forms are activated. The word form has corresponding semantic and phonological entries, which are activated during oral reading. The orthographic, semantic, and phonological lexicons are connected. When a reader encounters a word or nonword, all visually-similar word forms within the orthographic lexicon are activated. For words, exact matches are found and the words are pronounced; for nonwords, pronunciation is an amalgamation of several visually-similar words. In this model, any disruption in the ability to access phonological representations of words greatly impairs nonword reading, as this reading depends on the system’s ability to correctly pronounce several words and merge these pronunciations into a nonword. Glosser and Friedman suggested that such a disruption occurs in deep dyslexia, therefore, evidence of phonological processing in patients with deep dyslexia would argue against the continuum model.

Connectionist models In general, connectionist architecture is a computational model designed to simulate some cognitive process; it is a computerized analog of the human brain. Connectionist models are characterized by interconnected layers of nodes (units) that represent bits of information. Models meant to explain oral reading (e.g., Seidenberg & McClelland, 1989) include such layers as the orthographic, which contains nodes that learn patterns of written letters, and the phonological, which learns patterns of sounds corresponding to the letters (see Buchanan et al., 1999, for a more detailed explanation of connectionist models).

Although several connectionist accounts of deep dyslexia have been offered, none has succeeded in explaining all errors associated with the disorder. Hinton and Shallice (1991), for example, lesioned their connectionist architecture (by altering its configuration, e.g., by disconnecting a randomly chosen portion of units in one layer from units in another) to produce the semantic errors made by deep dyslexics. However, because their model did not include phonological units, they could not simulate the difficulty deep dyslexics have with nonwords. Plaut and Shallice’s (1993) connectionist architecture did include a phonological layer (a set of units that converted orthography to phonology), but its activation depended on activation in the semantic layer which, of course, contained no information about nonwords (Buchanan et al., 1994, 1999). Because Hinton and Shallice’s and Plaut and Shallice’s systems were incapable of reading nonwords in the first place, these systems could not be lesioned to produce the nonword errors made by deep dyslexics. Seidenberg and McClelland’s (1989) model included a phonological layer, but

90 not a semantic one. Thus, this model could not address the deep dyslexic’s semantic errors. Like other connectionist models, Seidenberg and McClelland’s model explained some aspects of deep dyslexia, but not others.

More recently, and based on the dual route model of reading, Coltheart et al. (2001) described the Dual Route Cascaded (DRC) model of normal reading. This connectionist architecture has three layers: lexical nonsemantic (graphemes activate words in the orthographic lexicon, which in turn activate words in the phonological lexicon), GPC (grapheme-phoneme conversion), and lexical semantic (not thoroughly described or implemented as of 2001 or, to our knowledge, since then). The term “cascaded” refers to the fact that even slight activation in one module (a layer) causes activation in later modules. For example, Rosson (1983, as cited in Colheart et al., 2001) found that participants were likely to pronounce louch like “couch” if this nonword was preceded by the word “sofa”, but they pronounced it like “touch” if the word “feel” was presented first. In this case, activation of the lexical orthographic module resulted in simultaneous activation of the phonological module.

According to Coltheart et al. (2001), the DRC model has successfully simulated errors made by surface and phonological dyslexics. However, they proposed that the model is not useful for simulating reading by deep dyslexics. The argument is that reading by deep dyslexics involves an entirely different system than is involved in normal reading (i.e., an abnormal system located in the right hemisphere), whereas surface and phonological dyslexics use the (albeit damaged) normal reading system. Consequently, “...the explanation of any symptom of deep dyslexia is outside the scope of the DRC model…” (p. 246).

Parsimony requires that models of reading at least attempt to account for all difficulties associated with that process. This is especially true for connectionist accounts, as they are powerful tools for gaining insight into cognitive processes. It is possible that causing damage to the DRC model toward the end of the routine, just before phonological output, could simulate the problems that deep dyslexics encounter when reading nonwords. Unfortunately, this has not been attempted, as this model assumes that reading in deep dyslexia cannot be explained by any model of normal reading. Evidence of phonological processing in deep dyslexia would, of course, require abandonment of this assumption and testing of the DRC model’s ability to simulate the deep dyslexic’s inability to produce nonwords.

The Production, Explicit, Implicit, Representation (PEIR) Model In contrast to the models described previously, which assume that phonological processing in deep dyslexia is either damaged or absent, Buchanan et al. (1994, 1999) and Buchanan et al. (2000) have proposed that these nonword reading impairments reflect an output problem; that is, “…deep dyslexics have reduced sensitivity to activation levels in the phonological output lexicon. This insensitivity leads to reading errors because the patient is unable to correctly determine the most highly activated candidate representation for output” (Buchanan et al., 2000, pp. 65-66). Support for this notion comes from the case of a deep dyslexic, SD, whose nonword reading was impaired (though not abolished; her score was 6/54), but whose performance reading pseudo-homophones was much better (36/54; Buchanan et al., 2000). This effect was replicated for a different deep dyslexic by Buchanan, McEwen, Westbury, and Libben (2003). Such differential performance on nonword and pseudo-homophone tasks suggests that the patients used their lexical pathways to strengthen activation of phonological representations during the pseudo- homophone task, thus improving their scores. Activation of this kind is impossible with nonwords (the

91 semantic lexicon does not contain entries for nonwords that do not sound like existing words), thus, deep dyslexics make more errors when reading nonwords than when reading pseudo-homophones.

Buchanan et al. (2000) reported that SD’s scores on picture naming tasks improved from 19/46 to 18/22 when phonemic cues were given. It is possible that the phonemic cues reduced the number of candidates for selection at the output level, thus reducing reading and naming errors. These results, and those summarized in the preceding paragraph, support the idea that deep dyslexics may be sensitive to phonology, even if their oral reading of nonwords is impaired.

In the PEIR model, production during reading depends on explicit access to a word’s phonology, morphology, or meaning, which depends on implicit access to this information. For its part, implicit access depends on an intact representation of the stimulus. Impairment can occur at any of these stages, and Buchanan et al. suggested that in deep dyslexia a failure of inhibition results in impaired explicit access and production. Thus, data showing explicit access to once-learned stimuli would necessitate modification of this model.

The Present Study In contrast to the implicit tasks used by Buchanan et al. (1994, 1996, 1999), which by definition involved unintentional processing of linguistic stimuli, the nonword tasks given to the deep dyslexics described here were explicit in that the patients were asked to decide whether or not they had previously seen a particular nonword. To do this, they had to (1) phonologically process the target nonwords during familiarization, and (2) explicitly identify the target nonwords. This is exactly how Nelson, Schreiber, and McEvoy (1992) define explicit memory: “Explicit memory refers to the intentional recollection of previous experience achieved by direct reference to the experience during testing. Subjects are exposed to information during a study phase and are explicitly asked to recall or recognize that information during a testing phase. They are aware that they are recollecting the experience established during study” (p. 322).

The explicit tasks performed by the deep dyslexics in the present study required the patients to discriminate previously-seen nonwords from foils via pointing, rather than via oral reading. This method of testing phonological processing distinguishes these tasks from those used in previous studies (see Coltheart, 1987a, for a review). This difference in testing is important: We argue that explicit phonological processing by deep dyslexics has not been found thus far not because patients are unable to process phonology, but because the explicit tasks used in previous studies have required verbal output. In other words, previous studies have assumed that because deep dyslexics could not read nonwords aloud, they could not process phonology. We did not make this assumption. The patients reported here were capable of phonological processing, as evidenced by their ability to perform well on nonverbal phonological processing tasks. We argue that the breakdown in oral reading by deep dyslexics may occur at the verbal output stage (see also Colangelo & Buchanan, 2006), which is why Buchanan and colleagues have been able to show implicit processing of phonology in deep dyslexics, and why we purport to show explicit phonological processing in patients with this disorder.

We present two cases of deep dyslexia who show the classic features of the symptom complex, and an atypical feature, namely, explicit processing of phonology. We argue that these cases add to a growing

92 literature supporting phonological processing in deep dyslexia; a state of affairs that requires reexamination of the current explanation of the disorder.

Case Reports

Case 1: TA TA was 21-year-old right-handed man with a history of seizures. He completed grade 12 and studied at a broadcasting institute. Before his incident in 1991, TA worked as a radio disc jockey. His symptoms started suddenly one evening and were characterized by slurred speech and difficulty holding objects. Upon admission to the hospital, he displayed aphasia, weakness on his right side, and right-side facial paralysis. TA’s visual-motor skills were compromised and there was some evidence of problems in incidental memory for visual material. In addition, TA had problems imitating complex gestures, suggesting ideational apraxia. A cerebral angiogram revealed an embolic infarct of the middle cerebral artery, possibly due to an air embolism (the source of the embolic event remains unclear). An initial CT scan showed a large middle cerebral artery infarct in the left hemisphere, but a subsequent CT scan showed a smaller area of hypodensity.

Case 2: AW AW was a 24-year-old left-handed woman who suffered a left cerebrovascular accident which resulted in right hemiplegia, expressive aphasia, moderate receptive aphasia and anomia. There was also evidence of damage to the frontal and parietal lobes. AW demonstrated difficulty concentrating, but this might have been due to her problems in processing auditory semantic information. She appeared to benefit from repeated presentation of tasks during the neuropsychological and language assessments she underwent at the hospital. Like TA, AW showed evidence of ideational apraxia. She also had problems executing commands; she sometimes completed only one of several steps. Before her incident in 1990, AW was a nursing student.

Neuropsychological Assessments TA and AW were each assessed from 1991 to 1993 (AW was also assessed in 1990 and followed until the summer of 1994). The tests used to evaluate the patients’ neuropsychological status were: the Wechsler Adult Intelligent Scale Revised (WAIS-R; Wechsler, 1981), the Wechsler Adult Intelligent Scale Revised as a Neuropsychological Instrument (WAIS-R-NI; Kaplan, Fein, Morris, & Delis, 1991), the Quick Cognitive Screening Test (QCST; Mate-Kole, Major, Lenzer, & Connolly, 1994), the Recognition Memory for Words and Faces Test (RMT for words, RMT for faces; Warrington, 1974), the Visual Paired Associates subtest of the Wechsler Memory Scale Revised (WMS-R; Wechsler, 1987), the Facial Recognition Test (FRT) and the Right/Left Orientation Test (RLO; Benton, Hamsher, Varney, & Spreen, 1983), the Unusual/Usual Views Test (UVR; Warrington & Taylor, 1973), the Weigl Sorting Test (WST; McFie, 1975; McFie & Piercy, 1952), the Visual Search Test (VST; Kimura, 1986), and the Modified Card Sorting Test (MCST; Nelson, 1976). TA’S and AW’s scores on these tests are listed in Table 1.

General Intellectual Function In general, both patients’ scores on the performance subtests of the WAIS-R and the visual/spatial tasks of the QCST exceeded their scores on the verbal portions of the WAIS-R-NI and QCST, with the

93 exception of the Similarities portion of the WAIS-R-NI. It should be noted that the Similarities and Vocabulary subtests of the WAIS R-NI were administered visually in a multiple choice format (the patients had to point to the correct answer out of four choices). This administration method differs from the traditional auditory method of presenting the items on these subtests. The visual mode of presentation resulted in high scores on the Similarities portion for both TA and AW (see Table 1), indicating an ability to form abstractions. On the other hand, both patients’ scores on the Vocabulary portion remained low despite visual presentation. Further, their performance on the Sentence Arrangement subtest of the WAIS- R-NI was below average. On another verbal task, the Digit Span subtest of the WAIS-R, both patients performed poorly. TA scored 1 upon second testing; AW scored 0 on two occasions. On the MCST, which requires attention to explicit instructions, AW completed one category upon first testing and six categories upon second testing. She made 50% perseverative errors on both occasions. TA obtained a perfect score upon first testing with 20% perseverative errors. Thus, the two patients’ performance on the MCST was satisfactory.

Memory Both TA and AW showed adequate performance in tests of recognition memory for faces and words. They each had perfect scores on nonword recognition tests by the second testing session (we will discuss this point in detail below). Their facial recognition was consistently in the high average range, and spatial memory was adequate. TA’s performance on the Visual Paired Associates subtest of the WMS-R was 50% correct. AW’s performance was much better: she scored 16/18. On a forced-choice memory test for words, TA achieved a perfect score upon second testing. AW obtained an almost-perfect score on two occasions. Both patients also obtained high scores on a similar task with faces by the second testing session.

Perceptual/Visuospatial Function TA and AW obtained high scores on the UVR, showing an ability to identify and recognize all (in the case of AW) or almost all (in the case of TA) of the objects presented from an unconventional angle. Both patients scored 5/5 on all testing occasions (except one for AW, see Table 1) on the Object Identification, Geometric Design, and Perceptual Closure portions of the QCST. Such good performance on the Geometric Design portion in particular suggests adequate visual constructional skills.

TA’s performance on the Picture Arrangement subtest of the WAIS-R was above average on two occasions, suggesting a high level of social awareness, whereas AW’s was below average upon the first administration and average upon the second. Their scores on the Picture Completion subtest of the WAIS- R were below average upon first testing. TA’s improved to above average on second testing, whereas even though AW’s score improved, it was still below average. For TA, deficits were noted on the Block Design subtest of the WAIS-R, which assesses constructional skills and spatial relations; AW’s scores on this task were in the average range. Both patients obtained high scores on the Arithmetic and Object Identification portions of the QCST. As was the case for the Similarities and Vocabulary subtests of the WAIS R-NI, the QCST was administered visually, as the patients could not perform the tasks when they were administered via the auditory modality. Results of the Right/Left Orientation Test Praxis test indicated poor performance; however, given high scores on other spatial tasks, this pattern suggests that the patients showed more receptive aphasia than visual/spatial dysfunction. On the Visual Search Test,

94 both patients showed evidence of right visual neglect, though AW showed improvement upon second testing. See Table 1

Table 1 -Neuropsychological Test Scores for TA and AW First Administration Last Administration Test TA AW TA AW

WAIS –R (Age-Scaled Scores) Digit Span 0 0 1 0 Picture Completion 8 7 14 8 Picture Arrangement 17 7 15 10 †Block Design 6 12 9 11 †Object Assembly 9 ------

WAIS-R-NI Raw Scores Similarities (MCQ) 23 21 -- -- Vocabulary (MCQ) 16 8 -- -- Sentence Arrangement 2 0 -- -- Spatial Span (Total) 17/28 15/28 -- -- Forward 10/14 9/14 -- -- Backward 7/14 6/14 -- --

QCST Naming (Multiple Choice) 5/5 3/5 4/5 5/5 Vocabulary 0/7 2/7 4/7 1/7 Similarities 4/4 ¾ 2/4 4/4 Analogies 2/4 ¼ 4/4 2/4 Arithmetic 12/12 9/12 11/12 12/12 Object Identification 5/5 4/5 5/5 5/5 Geometric Design 5/5 5/5 5/5 5/5 Perceptual Closure 5/5 5/5 5/5 5/5 Recognition Memory Test Words 41/50 47/50 50/50 48/50 Faces 45/50 28/50 42/50 48/50 Nonwords 19/25 25/25 25/25 25/25

Table 1 (contd.) Test First Administration Last Administration TA AW TA AW

WMS - Revised

Visual Paired Associates Test Immediate 9/18 16/18 -- -- Delayed 2/6 6/6 -- -- Facial Recognition† 52/54 47/54 -- 50/54

Right/Left Orientation 0/20 3/20 5/20 3/20

Unusual Views Unusual 17/20 20/20 -- -- Usual 20/20 20/20 -- -- Weigl Sorting Test 0/15 0/15 4/15 0/15 Visual Search Preference Score Left 6 9 7 5 Right 5 0 3 4 Time Left 4.9 8.9 8.6 11.0 Right 11.3 25.4 14.0 9.0

Modified Card Sorting Test Categories 6 1 6 6 Perseverative Errors 20% 50% 50% 50% Note. MCQ = multiple choice questions † Corrected scores.

Summary In general, the pattern of test results for both patients was similar. Both patients showed relatively intact memory function but drastically affected language skills, which we discuss in detail below. Both performed well on visual spatial tasks: they correctly identified most of the common objects presented from an unconventional angle, and their facial recognition scores fell in the high-average range. Both displayed evidence of right visual field neglect, although AW’s performance improved by the last administration of the test.

Language Assessments Both TA and AW underwent a screening of their linguistic abilities over a three-year period (Tables 2 and 3). The screening comprised the following tests: a modified version of the Verbal Repetition Test (MVRT, Goodglass & Kaplan, 1983), selected portions of the Johns Hopkins University Dysgraphia

Battery (JHDB; Goodman & Caramazza, 1986), a forced choice recognition memory tasks for words (Warrington, 1984) and nonwords (see Table 1), the Boston Naming Test (BNT; Borod, Goodglass, & Kaplan, 1980; Goodglass & Kaplan, 1983), a test of semantic processing (Baddeley, personal communication), and the Homophone Picture Match and Homophone Nonword subtests of the Battery of Adult Reading Function (BARF; Rothi & Moss, 1985, in Webb, 1997).

Verbal Repetition Both patients did poorly on all subtests of the MVRT upon first administration. They showed the most improvement upon second testing on the Repeating Monosyllables portion of the test (from 6/25 to 22/25 for TA, and from 0/25 to 22/25 for AW). They also improved on the Repeating Phrases portion (e.g., from 0/20 to 10/20 for AW), but they maintained their scores of “0” on the Repeating Sentences portion.

Reading Aloud Each patient read aloud the words on the Writing to Dictation portion of the JHDB, and each performed well on the high-frequency nouns relative to their performance on other words (e.g., high-frequency verbs and adjectives). In general, TA outperformed AW on subtests of the JHDB for which scores from both patients are available.

Naming The BNT is a 60-item test that is useful in identifying anomia. For this test, the patient is presented an item to name. If the patient fails to name the item, a phonemic cue is provided. If the patient fails again, a semantic cue is provided. Both TA and AW had difficulty naming the items on the BNT, even with cues, which indicates significant anomia for each patient.

Semantic Processing AW’s score on a direct test of semantic processing showed impairment in this area, although her score improved upon second testing. TA’s semantic processing improved to a satisfactory level upon second testing.

Recognition Tasks On a forced choice task with words, TA and AW identified the target word on most of the recognition trials. Both patients recognized target nonwords in a similar task (we discuss this task in detail in the “Nonword tasks” section below).

Each patient did relatively well on the Homophone Picture Match subtest of the BARF, showing that they recognized the correct spelling of a homophone (a real word that sounds like another real word, e.g., hare and hair) that matched a particular picture (see Figure 1 for an example of the stimuli used in this test). The patients’ performance on this test indicates both phonological and semantic processing of the words. In addition, TA scored 10/18 on the Homophone Nonword subtest of the BARF during his last testing session. This task involved identifying (by pointing) a picture of an object that matched a pseudo- homophone (e.g., bomm) from an array of pictures whose names began with the same two letters. For example, a picture of a bomb was arranged with pictures of a book and a bowl, and the patient was required to read the pseudo-homophone (bomm) and point to the correct picture (Figure 2). We contend

97 that TA’s better-than-chance score on this test shows his ability to process the phonology of some nonwords, (e.g., coam, prarey, yott, shooz) and to link phonology with semantics. See Table 2

Table 2

Language Test Scores for TA and AW

First Administration Last Administration

Test TA AW TA AW

Modified Verbal Repetition

Repeating Monosyllables 6/25 0/25 22/25 22/25 Repeating Phrases ------10/20 10/20 Repeating Sentences ------0/5 0/5

Johns Hopkins University Dysgraphia Battery: Writing to Dictation (read aloud)

High-Frequency Words Nouns 9/14 6/14 14/14 10/14 Verbs --- 1/14 5/14 1/14 Adjectives --- 5/14 12/14 ---

Low-Frequency Words Nouns --- 4/14 9/14 --- Verbs --- 0/14 8/14 --- Adjectives ------10/14 --- Function Words --- 0/20 3/20 ---

Abstract Nouns High Frequency 1/7 6/7 --- Mid Frequency --- 0/7 4/7 ---

Concrete Nouns High Frequency 4/7 5/7 --- Mid Frequency --- 4/7 6/7 --- Low Frequency --- 1/7 4/7 ---

Table 2 (contd.)

First Administration Last Administration

Test TA AW TA AW

Letter Length Four-Letter; High Frequency --- 5/7 6/7 --- Five-Letter; High Frequency --- 3/7 6/7 --- Six-Letter; High Frequency ------5/7 ---

Probability of Phoneme-Grapheme Conversions High-Probability Words High Frequency --- 6/15 ------Low Frequency --- 1/15 ------Low-Probability Words High Frequency 12/40 ------

Boston Naming Test 11/60 20/60 ------Semantic Processing 33/50 0/20 41/50 11/20

Battery of Adult Reading Function Subtest 5: Homophone Picture Match 14/18 15/18 14/18 ---

Subtest 6: Homophone Nonwords 1/18 0/18 10/18 --- ______

Summary The patients’ performance on language tests revealed limited oral language skills, as evidenced by their difficulty repeating utterances containing more than a single word. Their oral reading of high-frequency nouns was superior to their reading of high-frequency verbs and adjectives. Further, AW’s reading of concrete nouns was somewhat better than her reading of abstract nouns; a pattern that is consistent with previous descriptions of patients with deep dyslexia (Coltheart, 1987a). Additional evidence for deep dyslexia comes from the pattern of errors each patient made while reading aloud. We will now discuss this evidence in detail.

Evidence for Deep Dyslexia Table 3 displays representative errors made by TA and AW on the language tests. Both patients made semantic errors, such as TA’s reading of priest as “preacher; minister” and his reading of digit as “numbers”. AW’s semantic errors included learn  “college; teaching”, and series  “As the World Turns”. Both patients made derivational errors such as learn  “learning” (TA) and lobster  “lobsters”

(AW). Visual errors characterized some responses. For example, in response to the word spend, TA read “spand” and AW read “the end”. TA made visual (those  “hose”), semantic (above  “bottom; up there”, and derivational errors (while  “awhile”) when confronted with function words. AW also made such errors (e.g., the semantic error under  “up”), but more often she was unable to read the function word aloud. Each patient was unable to read nonwords (e.g., lesk, zwib) aloud. This pattern of errors is consistent with Marshall and Newcombe’s (1966), Marshall et al.’s (1970) and Coltheart’s (1987b) descriptions of deep dyslexia.

Nonword tasks TA’s and AW’s ability to process nonwords was assessed with a forced choice, recognition memory task. (Note that this section summarizes both patients’ performance, even though TA and AW were tested independently.) For this task, the patients were presented 25 nonwords (e.g., jisp, vatter; see Appendix A for the complete list of stimuli) from the Battery of Adult Reading Function (Rothi & Moss, 1985, in Webb, 1997). Each nonword was presented one at a time, and was centered on an 8 ½ x 11 sheet of paper. The nonwords were in upper-case, bolded, 18-point Times New Roman font, and were presented in a random order. The patients studied each nonword for five seconds. There was a one-minute pause between the familiarization and recognition tasks.

For the recognition task, the patients were shown the same words in a random order, only this time; each word was paired with a different nonword, one above the other (placement of the target nonwords was counterbalanced in the recognition phase). The patients had to point to the word they had already seen. Each patient ultimately scored 25/25 on this test (AW obtained this score on two testing occasions; see the “Recognition Memory” portion of Table 1).

AW performed an additional recognition task involving three blocks of nonwords (e.g., lesk, sorb). During familiarization, all nonwords were presented one at a time on an 8 ½ x 11 sheet of white paper, in the center of the page. The letters were upper-case and in 22-point Ariel font. The presentation time for each nonword was five seconds, and there was a one-minute pause between the familiarization and recognition tasks.

During recognition, AW was presented the same nonwords in a random order, but each one was paired with a different nonword, randomly chosen (in some cases one above the other, in others, side by side vertically). Also in some cases, the letter case used during recognition was different from that used during familiarization. These measures were taken to control for simple visual recognition of the targets. Each pair of nonwords appeared in the center of an 8 ½ x 11 sheet of white paper in 22-point Ariel font. The position of the target word was counterbalanced. The patient circled the target word, going at her own pace.

AW completed two of the three blocks in this manner. On Blocks 1 and 2, she scored 10/10. The familiarization portion of Block 3 was completed auditorially. In other words, the test administrator read aloud the list of targets during familiarization, instead of presenting them visually. In the recognition phase, the target and distracter nonwords were presented one above the other on a sheet of paper as described above. AW’s score on this task was 8/10. See Table 3.

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Table 3 - Sample Errors on Reading Tests for TA and AW

Test Target Response TA AW J HDB (Read Aloud) High-Frequency Words Nouns length long long member memories memories

Verbs learn learning college; teaching solve solve alpha; omega listen silence teaching Adjectives bright left left; right broad broad road Low Frequency Words Nouns priest preacher; minister priest threat throat needle

Verbs spoil spoiled mud argue confusion angry; angry

Function Words while awhile wait; no under bottom up Abstract Nouns High Frequency beauty beautiful beautiful method idea (couldn’t read) Mid Frequency theory theoror priest; saint advice principal; advised; Low Frequency status statue; abtrack math pursuit courage; suit purple Concrete Nouns High Frequency cabin cabing cottage engine engineer edging; the car

Mid Frequency planet palette; the earth planet

dollar dollar money

Low Frequency bullet bullet gun; bullet

fabric frabdic; clothes (couldn’t read)

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Table 4 – Sample errors on reading tests on word-length

Test Target Response TA AW Letter Length Four-Letter unit Unit (couldn’t read) iron ironing blood; iron Five-Letter solid solid liquid color colors color Other Words letter leather/letter writing series ball game As the World Turns flies flying

Table 5 - Battery of Adult Reading Function (BARF) Subtest 6: Homophone Nonwords Test Target Response TA AW Pales palace target picture: police) (foil picture) (couldn’t do task) Prarey pray (target picture: prairie) Modified Verbal Repetition

Repeating Monosyllables boy I boy (couldn’t repeat) zoo (couldn’t repeat) so Show (couldn’t repeat) Snow Repeating Phrases man and woman with me man and woman light the lamp lamp light light and lamp sing a song single song sing a song Repeating Sentences she wore a black coat and an old felt hat (couldn’t repeat)

Discussion The two patients described here showed the classic symptoms of deep dyslexia, but each was able to identify target nonwords in an explicit, forced-choice memory task (or, in the case of AW, two explicit forced-choice tasks). These results do not appear to be the result of simple visual recognition of the targets. Furthermore, AW was able to visually recognize 8 of 10 nonwords after they had been presented in the auditory modality during familiarization, showing that she processed and transferred phonology from the auditory to the visual domain. TA’s performance on the Homophone Nonword subtest of the BARF showed his ability to process phonology and to link it to semantic information.

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The nonword recognition tasks employed here required the patients to (1) encode the nonwords’ orthography; (2) process the nonwords phonologically in a way that could not have involved a semantic route; (3) distinguish the phonology of the targets from that of the distracters; and (4) explicitly identify the targets by nonverbal means. The additional task performed by AW required her to process the phonology of some nonwords via an auditory pathway. AW’s success at this task, as well as the controls employed against visual recognition (e.g., the difference in font between the familiarization and recognition stimuli), suggest that both patients processed the phonology of the nonwords, rather than recognizing their orthographic configuration. We argue that because the nonword recognition tasks used in the present study did not require oral reading of the stimuli, the patients were able to demonstrate evidence of explicit processing of phonology. Thus, deep dyslexics’ difficulty reading aloud nonwords may not be due to an inability to process phonology. Instead, we agree with Buchanan et al. (1994, 1999, 2000) that this difficulty may reflect a problem on the output side of oral reading.

Buchanan and colleagues (1994, 1999, 2000) described the output problem as one of selection. Specifically, these authors accept the assertion of the dual route model that a phonological output lexicon (a lexicon containing pronunciations of known words) exists, and they suggest that oral reading involves comparing the pronunciation of a written word to words in the output lexicon. If no match exists, as in the case of nonwords, then the system must make a guess about the word’s pronunciation. For normal readers, this process leads to correct pronunciation of nonwords most of the time. Deep dyslexics, however, have difficulty determining that no match exists in the lexicon, and may therefore choose a phonologically similar word. For example, the nonword zin sounds like sin, fin, zip, and chin, so the deep dyslexic may produce one of these words while attempting to read the nonword. On the other hand, the memory demands of the nonword reading task may be so high that the system “times out” (Buchanan et al., 1999, p. 207), thus supplying no response.

Our data are consistent with Buchanan et al.’s (1994, 1999, 2000) account of the output problem associated with oral reading of nonwords by deep dyslexics. Because our nonverbal recognition tasks did not require the reading system to choose the pronunciation of the target nonwords from an output lexicon, pronunciation mistakes involving real words were avoided. In addition, in most cases, the distractors were both orthographically and phonologically unlike the targets (e.g., the target sive is different from the distractor upex), again avoiding confusion around the pronunciation of the target. Furthermore, memory demands were diminished by the multiple choice nature of the task. That is, the patients did not have to search an output lexicon for a match to the nonword; they simply had to compare the target to the distractor and match the nonword in memory to the one on the page. Again, this required phonological processing of the nonwords, as several controls (e.g., differences in fonts between familiarization and recognition stimuli; AW’s task involving auditory presentation of the targets) indicated that the patients’ performance could not be attributed to visual recognition alone.

Buchanan and colleagues (Buchanan et al., 1996, 2003; Colangelo & Buchanan, 2005, 2006) suggest that explicit access to phonological representations is eradicated in deep dyslexia. We disagree. While oral reading of nonwords is problematic for deep dyslexics, including those reported here, explicit processing became evident in the present study when the patients identified nonwords by nonverbal means. TA and AW could not read aloud the nonwords, but they could indicate, by pointing, that they had explicit access to the phonology of each stimulus. Again, the recognition tasks employed in this study required the

103 patients to process the phonology of the targets and distinguish it from the phonology of the distractors. All of this was done consciously; in other words, the task was explicit according to the definition provided by Nelson et al. (1992). Thus, the nonword reading problems that deep dyslexics experience do not appear to be due to an ability to demonstrate implicit versus explicit access to phonology. Instead, the problem is unique to verbal output, at least for some deep dyslexics.

As previously stated, evidence for explicit processing of phonology in deep dyslexics requires modification of the models of the disorder. Below, we revisit each model and discuss how it would have to be altered to accommodate our findings.

The Right Hemisphere Hypothesis The right hemisphere hypothesis assumes that the right hemisphere recognizes whole word forms and is incapable of extracting phonology from orthography. Since this hemisphere is considered the dominant (if not the only, see Coltheart, 1987b) hemisphere involved in deep dyslexic reading, people with this disorder are thought to be unable to read nonwords that do not have lexical entries. While it may be argued that TA and AW recognized the whole forms of the targets during the nonword recognition tasks (they did, after all, encode the visual forms of the nonwords), the visual differences between the stimuli in the familiarization and recognition portions of the second task performed by AW (see Appendix B), and her recognition of stimuli that had been presented auditorally, suggest that this is not the case.

The right hemisphere hypothesis also states that the right hemisphere cannot explicitly convert orthography to phonology (Buchanan et al., 1994). However, the tasks performed by the patients described here were explicit tasks, and the patients showed evidence of phonological processing. Thus, if the right hemisphere is mostly responsible for reading in deep dyslexia, the following modifications must be made to this account of the disorder: (1) the model must allow for explicit phonological processing, however impaired such processing may be; and (2) the model must either allow for some ability of the deep dyslexic’s left hemisphere to convert graphemes to phonemes, or it must give the right hemisphere some ability to make this conversion explicitly. Neuroimaging studies could then be conducted to show exactly where phonological processing occurs in the brains of people with deep dyslexia.

The Dual Route Model Like Buchanan et al. (1994), we argue that the dual route model must be revised to place the damage to the reading system closer to the output stage. Clearly, some deep dyslexics are capable of processing phonology, both implicitly and explicitly. These data refute the contention of the dual route model that the pathways involved in converting orthography to phonology are damaged and, for all practical purposes, uninvolved in deep dyslexic reading (Morton & Patterson, 1987; Coltheart et al., 1993).

The Continuum Model Glosser and Friedman (1990) indicate that the nonword reading impairment associated with deep dyslexia results from difficulty accessing phonological representations of existing words, as oral nonword reading involves composing pronunciation from several similar real words. If one cannot extract phonology from orthography, nonword reading will greatly suffer. Again, this model assumes an inability to process phonology on the input side of reading, and the performance of the patients reported here suggests that some deep dyslexics can process phonology.

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The continuum model could explain the oral output problem demonstrated by the deep dyslexics reported here and by Buchanan et al. (e.g., 1994) if the emphasis were placed on its assertions about the output phase of reading, rather than on the input phase. Specifically, Glosser and Friedman (1990) propose that nonword pronunciation is the result of combining sounds of similar real words. Perhaps this is where the difficulty in oral reading lies for deep dyslexics. It could be that finding the correct combination of pronounceable sounds is difficult, even though a patient can extract phonology from orthography. Perhaps this is why the deep dyslexics reported here could recognize nonwords whose phonology they had already processed, but could not read the words aloud: they simply could not find the correct sounds to produce, even though they had processed the phonology of the nonword. Further research involving nonword recognition by deep dyslexics is needed to evaluate this hypothesis.

Connectionist Models Traditional connectionist models (e.g., Hinton & Shallice, 1991; Plaut & Shallice, 1993; Seidenberg & McClelland, 1989) do not include all the relevant components to simulate the reading difficulties associated with deep dyslexia, so they must be revised to include those components if they are to aid in our understanding of the disorder. As previously stated, Coltheart et al.’s (2001) DRC model has the potential to provide such aid, but the authors assume that the model does not apply to the “abnormal” process of reading (located in the right hemisphere) involved in deep dyslexia. Just as the right hemisphere hypothesis must be altered to accommodate the evidence of explicit phonological processing by the deep dyslexics described here, so must the DRC model. We can no longer assume that reading in deep dyslexia involves little or no conversion of orthography to phonology. Thus, connectionist models like the DRC must allow for such conversion in their simulations and lesion their models closer to the output stage to see if such damage causes reading errors (especially of nonwords) like those seen in deep dyslexic patients.

The Production, Explicit, Implicit, Representation (PEIR) model. Buchanan et al. (2000) proposed that explicit access to a nonword’s phonology is impaired in deep dyslexia, and that is what causes the difficulty in reading aloud. Specifically, there is a failure of inhibition of candidates for output, causing the reading system to either produce the wrong candidate, or to time out and produce no response. As previously stated, our data are consistent with this account only with regard to its claims about verbal output. Deep dyslexics do have difficulty reading nonwords aloud, as did the patients described in the present study. However, TA and AW were clearly able to explicitly recognize the nonwords they had been presented, thus providing evidence against Buchanan et al.’s (2000) assumption that deep dyslexics cannot explicitly access phonology. We agree with the PEIR model’s assertion that oral output is impaired in the nonword reading of deep dyslexics, and the failure of inhibition mechanism proposed by Buchanan et al. is a viable explanation. The recognition tasks employed in the present study did not require oral reading, and therefore avoided this problem. Future research will need to compare verbal and nonverbal responses of deep dyslexics to nonwords to further investigate and explain their differential performance on these tasks.

Conclusion The models of deep dyslexia discussed here assume some difficulty with phonology, either at the input or output phase of oral reading. The studies by Buchanan et al. (1994, 1996), and the data reported here,

105 provide strong evidence that at least some deep dyslexics can extract phonology from orthography. We concur with Buchanan et al. (1994, 1999, 2000) that the deep dyslexic’s problems with oral reading of nonwords occur at the output phase, and we agree that a failure of inhibition may be the explanation for these problems. On the other hand, we do not agree with Buchanan et al. (1996, 2003) and Colangelo and Buchanan (2005, 2006) that deep dyslexics do not have explicit access to phonology. We propose that the problem is unique to verbal output. Perhaps deep dyslexics cannot form the sounds needed to read nonwords aloud, either because they have too many choices for sounds (as Buchanan & colleagues argued), or because they lack the ability to combine the available sounds appropriately (the mechanism offered by Glosser & Friedman, 1990). Whatever the case, future research will need to abandon the assumption that deep dyslexics cannot explicitly process phonology. When this is done, we will come closer to understanding the factors that impair oral reading in individuals afflicted with this disorder.

Acknowledgements We thank TA and AW for their patience in participating in extensive testing. We acknowledge the contribution of Dr. Patricia McMullen of Dalhousie University for her input in the testing, for providing some of the nonwords, and for offering her expertise. We thank John Connolly for his comments and Lorraine Smith and Dr. Richard Braha of the Nova Scotia Rehabilitation Center for their assistance. We also thank Natalee Lubkeman for her assistance with the artwork.

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APPENDIX A

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PSYCHOTROPIC MEDICINE SHORTAGES IN GHANA: A SITUATION ANALYSIS

Truelove Antwi-Bekoe 2 , Dominic N.W Deme-Der1, Gordon M. Donnir3, Shoba Raja4, Badimak2 and Yaro Peter2

1 BasicNeeds Northern Ghana 2 BasicNeeds Ghana – Accra 3 Faculty of Psychiatry, Ghana College of Physicians 4 BasicNeeds International, India

ABSTRACT Psychotropic medicines shortage is a serious problem in developing countries. Out of pocket payments for psychotropic medicines by mentally ill people and their caregivers directly contradict the policy of free treatment in all public health institutions in Ghana. BasicNeeds examined the state of psychotropic drugs supply in Ghana to understand the processes and procedures of its acquisition and distribution in the country. The study employed qualitative methods and involved both primary and secondary data. Secondary data was collected from government documents such as the Ghana Essential Medicines List (2004), Procurement Procedures Manual, Standard Treatment Guidelines (2004) and the Draft Mental Health Bill. The primary data on the other hand was collected through field consultations, discussions and interviews with key stake holders in the mental health sub-sector. A total of 335 mentally ill people and caregivers of mentally ill people participated in the study. However 108 respondents representing 32.2% agreed participated. Over 70% of the 108 participants interviewed reported that psychotropic drugs on the essential medicines list were not unavailable. Irrational use of medicines by prescribers, dispensers and users of psychotropic medicines also accounted for improper forecasting and shortages of psychotropic medicines in the country.

CORRESPONDENCE: Peter Yaro, BasicNeeds Ghana, P. O. Box TL1140, Tamale, N/R, Ghana. Email: [email protected] . Phone: +233 (0)71 23566

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INTRODUCTION Medication plays a very central role in the treatment of mentally ill people. Psychotropic medicines supply is a serious problem in developing countries. The lack of psychotropic medicines results in people with mental illness having to pay higher prices at private pharmacies for these medications. Out of pocket payments for psychotropic medicines by mentally ill people and their caregivers also directly contradict the policy of free treatment for mental health patients in all public health institutions in Ghana. Unsustainable financing and out-of-pocket payment for psychotropic medicines all contribute to making psychotropic medicines inaccessible (World Health Organization; WHO, 2004).

Data gathered and analyzed by BasicNeeds, a nonprofit organization in developing countries in Africa and Asia indicates that medications for mentally ill individuals are not given the kind of attention that they deserve. A recent report by BasicNeeds in Accra, Ghana for instance, states that; “drug shortages and costs have been a major concern which mentally ill people and caregivers complained bitterly about. Modern psychotropic medicines are not available at the government hospitals and as such these medicines have to be purchased when prescribed” (BasicNeeds, 2006). The life stories recounted by some mentally ill people and their caregivers are consistent with these reports.

It is in this regard that BasicNeeds undertook a full scale study into the situation of psychotropic drugs supply in Ghana to understand the processes and procedures of psychotropic drugs acquisition and distribution in the country with a view to recommending ways for improving the situation.

Literature on psychotropic medicine supply especially in Ghana is almost non-existent. Overall, a review indicates that there are several factors which hinder the smooth procurement and supply of psychotropic drugs in developing countries in particular, Africa. These include procurement practices, access, financing, and abuse.

Procurement Practices: Availability, Prices and Access to Psychotropic Drugs Although medicines are very important in the implementation of any health programme, their availability is low in Ghana. Ghana Ministry of Health (2006) reported that medicine availability in Ghana is worse in the public and mission health facilities than in the private retail pharmacies. Of 39 medicines studied, it was found that availability was less than 50% in the public and mission hospitals. A study in Ghana by Shoba et al. (2007) corroborated that the long periods of treatment of mental illness have implications for treatment costs and access. One way of ensuring affordable pricing and quality products of psychotropic drugs is by adopting best procurement practices (WHO, 2004). However, a study conducted by the Ministry of Health/Ghana Health Service (MH/GHS) in collaboration with the World Health Organization (WHO; MH/GHS; 2006) and the Health Action International Africa (HAI) showed that while 45% of Ghanaians live on less than US$1 a day, prices of medicines in the country were high and unaffordable. Duties and tariffs account for about 30%-40% of the final prices of medicines while mark-ups account for about 50%-200% (MH/GHS, 2006).

The cash and carry system creates a financial barrier to health care accessibility to the majority of people in Ghana. It is estimated that about 80% of the people living in Ghana cannot afford to make out-of-

113 pocket payment at the point of service. This has resulted in delays in seeking health care and non- compliance with treatment (Ghana Ministry of Health; GMH, 2005).

Access to Market Information and Bulk Purchases Well prepared procurement systems, access to market information and bulk orders can achieve considerable savings which can then be spent on improving health care systems or availability of medicines (WHO, 2004). Complete, accurate and up-to-date information on prices of medicines can be of great value to policy-makers, health professionals, people in the distribution chain, and consumers or their caregivers. Several other non-profit medicine wholesalers such as the International Dispensary Association (IDA, www.ida.nl), the Supply Division of the United Nations Children’s Fund (UNICEF) in Copenhagen (www.supply.unicef.dk) and other agencies supply medicines of good quality at low prices, and provide price information through catalogues and their websites. A comprehensive list of prices for medicines can be found on: www.who.int/medicines/organization/par/ipc/drugpriceinfo.shtml

Appropriate Procurement Method Good procurement involves accurate “quantification” (determination of quantities needed) at the national, regional or institutional levels. The major procurement methods include open tender, restricted tender, competitive negotiation and direct procurement. These vary with respect to their effect on price, delivery times and workload. In reality however, the commonly used methods are restricted tender and direct procurement from not-for-profit suppliers (WHO, 2004). The technical details of these methods are well explained by Quick et al. (1997). In Ghana, the drugs supply chain is managed by the Store Supplies and Drugs Management (SSDM) directorate of the Ministry of Health (MoH). The SSDM supervises and gives guidelines for the administration of medicines of the MoH including procurement, storage, and distribution and monitoring of use. While procurement is currently undertaken by the Procurement Unit (PU) of the Ghana MoH, the storage and distribution function is performed by the Central Medical Stores (CMS).

The supply chain of the MoH comprises the CMS, the Regional Medical Stores, and the local or institutional stores which then feeds the institutional pharmacies. The CMS usually procures once a year through international competitive bidding (ICB). By law, all public procurement units including the CMS should put in place their procurement plans which will be implemented by a tender committee which in turn will be reviewed by a tender board in order to reduce the incidence of manipulation. The CMS also manages shortfalls within the year by procuring without resorting to tender. Under normal circumstances, the local/institutional stores should procure their supplies from the CMS or its regional depots and procures only from the private sector if there are stock-outs. However, because the CMS is not marketing- oriented, the local/institutional medical stores prefer to procure from private pharmacies due to the convenience that the private wholesalers provide by delivering directly and timely to the institutions (Ghana National Drugs Programme, 2004). The regional and institutional medical stores can then procure from private pharmacies but to a limited extent. These thresholds put pressure on procurement facilities and ensure that the units plan their annual procurement very well. The thresholds of the various levels of the health delivery system are local/institutional stores (US$6,000), regional medical stores (US$50,000) and CMS (US$300,000)

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Ensuring Sustainable Financing Financing the purchase of medicines has become increasingly important in the formulation and implementation of policies on access. The combined effects of economic pressures, continued population growth and the aging of populations, especially in developing countries, have made this a difficult task for many countries. Financing mechanisms are crucial to the development of sustainable mental health systems and the medicines they need. The challenge is to implement those financing strategies that best ensure equity of access and a continuous supply of medicines.

A major objective of a financing strategy should be to reduce out-of-pocket expenditures for psychotropic treatments (WHO 2004). However, according to the WHO Atlas Project, one-third of countries do not have any specific mental health budget although they presumably devote some resources to mental health. Out-of-pocket payments are the primary methods of financing mental health in one-third of countries in the African and South-East Asian Regions. Private insurance and external grants account for a negligible proportion of costs of mental health care in low-income countries. External grants support mental health as a primary method of financing in only 5%-8% of low-income countries (WHO, 2001). This is contrary to the situation in Ghana where in the past two years; financing of drugs has been solely dependent on external donors.

Health insurance is making considerable inroads in many developing countries, and some countries even have special arrangements for rural and low-income populations (WHO, 1998). This is similar to the situation in Ghana such that people are exempted from the payment of insurance premiums in the District Mutual Health Insurance Scheme (DMHIS). However, mental disorders are not always covered in the National Health Insurance Scheme (NHIS). When they are included, they may only cover inpatient costs and exclude outpatient consultations, drug costs or day-care services. Yet, the latter two are the principal forms of health care needed for most mental disorders (Wang et al., 2000). WHO (2004) recommended that governments should help the establishment or expansion of health insurance schemes through supportive legislation and subsidies, and ensure that mental disorders are included especially outpatient treatment and the associated costs of drugs.

The roles of public and private entities involved in arrangements for the distribution of medicines vary greatly. The best systems are probably based on a combination of public and private management (Quick et al., 1997). Alternative strategies for the supply of medicines to the public are attracting interest. These include formation of an autonomous supply agency, direct delivery, the prime vendor system, various privatized models and mixed systems. These alternative supply systems may be evaluated for their applicability in improving the supply of essential psychotropic medicines. Details about these systems are provided in the standard essential medicines literature (Quick et al., 1997).

Abuse Leading to Control of Psychotropic Substances in Africa Psychotropic medicines and their raw materials are under control by the United Nations Commission on Narcotic Drugs. The International Narcotic Control Board (INCB; 1995) reported that there was gross abuse of controlled substances in Africa using falsified import certificates. There is evidence that legally imported psychotropic substances are diverted due to inadequate supervision of the pharmaceutical supply system in the region. The abuse of benzodiazepines, especially Diazepam and Flunitrazepam was reported in several African countries. The INCB mission found that although the Government of Ghana was

115 seriously committed to meeting its obligations under the international drug control treaties, it should pay more attention to the increased transit traffic in abuse of cocaine, heroin and psychotropic substances (INCB, 1995).

One factor contributing to the problem is the fact that psychotropic pharmaceutical preparations can be obtained easily from legitimate distributors without a medical prescription and from "parallel markets". The INCB therefore gathered information about methods used in the assessment of medical needs in African countries. The INCB urged African States importing psychotropic substances to respond in a timely manner to avoid delay of the process of procurement and worsen the psychotropic medicines supply situation in Africa.

Poor procurement Practices Hampers Effective Community Mental Health Care: the case of Ghana According to Asare, former Chief Psychiatrist of Ghana and former Medical Director of Accra Psychiatric Hospital in Ghana, poor procurement practices hamper effective community mental health care. He argued that to achieve a larger coverage of mental health services, Ghana should implement a pilot training program of non-mental-health personnel. With the support of WHO, two remote villages in Ghana were used as a pilot project. New mental health care providers were identified from the communities and trained in the management of mental disorders including the use of selected essential psychotropic medicines. More complicated cases were referred to district hospitals where trained mental health staff was available.

Within three months, the number of known cases of mental disorders had increased by 300% as the volunteers created awareness of mental disorders. Since the volunteers were actually living within the communities they were able to identify cases in their areas, and members of the communities even informed them about cases. The program was remarkably successful for a period of time. However, when the supply of medicines became irregular, attendance rates fell. Poor procurement practices and availability of medicines appeared to jeopardize efforts to improve mental health care delivery.

Studies overall, reveal that medicines have to be available and affordable in order for them to be accessible for the mentally ill. Availability of medicines is low in Ghana. Irregular supply of medicines results in reduced attendance at the health institutions and lack of confidence in the health system. Financing of medicines in a way that best ensures access and a continuous supply of medicines is a challenge especially in Africa and South East Asia where one-third of the countries do not have any specific mental health budget but rely on out of pocket payment for financing mental health.

Purpose This qualitative study explored knowledge on the psychotropic medicine situation in Ghana. Further, it sought to understand and equip BasicNeeds Ghana with adequate information for its policy work/advocacy, and to contribute to BasicNeeds’ overall understanding of issues relating to access and availability of psychotropic medicines in developing countries. An in-depth examination was undertaken of BasicNeeds Ghana operational areas in Greater Accra Region in the south and Upper East Region in the northern part of the country. Further, the study determined availability and accessibility of psychotropic medicines.

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This is an inquiry into the best possible ways of psychotropic drugs acquisition and distribution in the country. It is important for policy makers and practitioners in the mental health sub-sector. It is also relevant for NGOs and other community based organizations (CBOs) interested in advocacy work in mental health services.

Methods The study employed qualitative methods and involved both primary and secondary data. Secondary data was collected through records from government documents such as the Ghana Essential Medicines List (2004), Procurement Procedures Manual, Standard Treatment Guidelines (2004), and the Draft Mental Health Bill.

The primary data on the other hand was collected through field consultations, discussions and interviews with key stake holders in the mental health sub-sector. These included two officials of the Ministry of Health; the Chief Psychiatrist and the Director of Procurement at the Ghana Ministry of Health; Ghana Health Service staff; two Pharmacists including the Deputy Director of Pharmacy in charge of psychotropic medicines, one medical director (of the three psychiatry hospitals in Ghana), one regional coordinator of community psychiatry nursing in Upper East region, both deputy directors of nursing services in-charge of the two psychiatry hospitals in Accra, both administrators of the two psychiatric hospitals in Accra and five community psychiatric nurses in both Accra and Northern Ghana. Focus group discussions were also held with five self help groups of mentally ill people and their caregivers in Accra and Northern Ghana. A total of 335 mentally ill people and their caregivers were consulted.

Data Analysis The data was analyzed qualitatively. Based on the structure of the discussion and interview guides, information was gathered on the following topics: Analysis and report included adequacies of the essential drug list (is the Essential Medicines List really essential), current sources; processes and procedures of psychotropic medicines supply in Ghana (system of procurement and supply of psychotropic medicines in the country), adequacies/sufficiency of the psychotropic medicines purchased and problems if any in the current Essential Medicines List.

RESULTS AND DISCUSSION The following findings emerged from the analysis of data collected: Shortage of Psychotropic Medicines in Ghana 108 respondents representing 32.2% indicated that, they had been to the polyclinic/hospital and they were not given medicines between June and July 2007. The deputy chief pharmacist in charge of psychotropic medicines estimated that there is a short fall of about 40% of the psychotropic medicines requirement in the country. Psychotropic drugs such as Risperidone, Haloperidol, and Diazepam are on the essential medicines list but often unavailable.

Causes of Psychotropic Medicines Shortages in Ghana Some of the causes include incomprehensive protocols in diagnosing and treatment, and the lack of availability of psychotropic medicines. For the past two years, Ghana has been relying solely on donors for its medicines import. Irrational use of medicines by prescribers, dispensers and users of psychotropic

117 medicines also accounts for the shortages of psychotropic medicines in the country. Some patients sell their drugs to other patients. As mental health services receive little attention in general, it is usually considered low priority. Thus, less attention is paid to the purchase of psychotropic medicines. Some community psychiatric nurses do not send in their requisition for psychotropic medicines in time leading to under estimations sometimes of the quantity of drugs needed.

Payment for Treatment of Mental Health Conditions Individuals with mental illness in Ghana pay for their treatment in various ways although the medications are supposed to be free. The medicines are often out of stock at the government health facilities. Over 70% of the 108 mentally ill people interviewed who were given prescriptions in two months, did not have money to buy the medicines nor could they buy the right quantity. For others, even if the money was available they could not get the right drugs. Given the poverty level of people, some families resort to borrowing from friends and relations. Participants and their caregivers described the prices of medications outside the psychiatric hospitals as “very expensive and unaffordable”.

The Essential Medicines List Professionals are of the view that pharmacologically, the 2004 Essential Medicines List is adequate as it was developed by experts in the field to cover and manage all psychopathological conditions. However, they are dissatisfied with the essential medicines list as some of the medicines are old. Some new and efficacious psychotropic medicines are missing from the Essential Medicines List for Ghana.

Conclusions Psychotropic medicines supply is a serious problem in Ghana. The lack of psychotropic medicines results in people with mental illness having to pay higher prices at private pharmacy for these medications. Out of pocket payments for psychotropic medicines by patients and their caregivers directly contradict the policy of free treatment for mental health patients in all public health institutions in Ghana. Medications for mentally ill people are not given the kind of attention that they deserve. Good procurement involves accurate “quantification” (determination of quantities needed) at the national, regional or institutional levels.

There are inadequacies attributable to problem of forecasting, inaccurate reporting of psychotropic drug use, delays in the process of procurement especially the international tender which can delay up to 8 months. In addition, irrational use of medicines by prescribers, dispensers and users of psychotropic medicines also account for improper forecasting and shortages of psychotropic medicines in the country. These problems tend to negate the benefits the Procurement Act and Procedural manual bring about.

Recommendations The procurement procedures for acquiring psychotropic medicines should be streamlined and shortened. Methods such as the Limited International Tender sometimes employed by the Ministry of Health should be emphasized. Attention should also be directed towards suppliers of psychotropic medicines at not-for- profit world market wholesale prices such as the International Dispensary Association (IDA > www.ida.nl), the Supply Division of the United Nations Children Fund (UNICEF > www.supply.unicef.dk etc).

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The NHIS should be extended to cover people with mental illness in order to do away with the effect of the phenomenon of “no money” and the reliance on donor funding for psychotropic medicines.

Efficient and effective new psychotropic medicines which are not on the Essential Medicines List are recommended for possible inclusion into the Essential Medicines List through the chief psychiatrist to the MoH/GHS Executives and the Expert Committee Members who set the Standard Treatment Guidelines and prepare the Essential Medicines List. The Ministry of Health/Ghana Health Service should develop interest in mental health in order to treat it as a priority. There should be a separate budget devoted to the procurement of mental health medications. Qualified personnel/pharmacists should handle the disbursement of psychotropic medicines. The SSDM directorate of the Ministry of Health should intensify its education in monitoring of medicines use in the country to reduce misuse.

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Deme-Der D. (2006). Baseline Study Report - Accra Urban Programme.

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Ghana Demographic and Health Survey (2003). Ghana Statistical Service, Accra, Noguchi Memorial Institute for Medical Research, Legon, and ORC Macro, Calverton, Maryland, USA: Ghana, Accra. Ghana International Narcotics Control Strategy Report, 21/03/2007

Appiah-Kubi, K., Raja, S. & Boyce, W. (2006). Mental Health: Access To Treatment and Macroeconomics In Ghana.

Montia, L. (2005). Six Monthly Review Report; Basicneeds Accra, Ghana; July – December 2006

Mental Health Bill; A Bill Entitled the Mental Health Act, 2005

MSH (2002) International Drug Price Indicator Guide. Washington, DC. Management Sciences for Health. (Annual publication, in collaboration with WHO, Online access at: http://erc.msh.org). Ministry of Health/Ghana Health Service (2006) Medicine Prices in Ghana; A Competitive Study of Public, Private and Mission Sector Medicine Prices, Ghana

Quick JD et al., eds. (1997) Managing Drug Supply. 2nd ed. West Hartford, Connecticut, Kumarian Press. Republic of Ghana, Ministry of Health/GNDP (2005); Improving Access to Medicines: The Case of Local Production and Greater Access to Medicines for Ghana

Republic of Ghana, Ministry of Health/Ghana National Drug Programme (2004sa); Ghana Essential Medicines List, Fifth Edition

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Republic of Ghana, Ministry of Health/Ghana National Drug Programme (2004b); Standard Treatment Guidelines

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Shoba, R., Antwi Bekoe, T., Deme-Der, D., Addo, B., Addo-Ayesu, A. & Bernard, A. (2007), Mental Illness and Economic Well-Being; A Study in Ghana

Wang PS et al. (2000) Initiation of and adherence to treatment for mental disorders: Examination of Patient Advocate Group Members in 11 Countries. Medical Care, 38: 926-936.

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EXPOSURE TO VIOLENCE ON TELEVISION AND VIDEO GAMES AND AGGRESSIVE BEHAVIOR AMONG CHILDREN:

Wiafe-Akenten C.B1.

1Department of Psychology, University of Ghana, Legon

ABSTRACT: There is a growing concern in Ghana over the kind of television (TV) programs (i.e., movies, cartoons, documentaries, soap operas, video games) children and teenagers in particular are exposed to. Of particular concern is violence in some of the video games they play as well as the movies and other TV programs they have access to or watch in their homes, internet cafes and cinema centers. These concerns have arisen as a result of empirical studies which have established relationships between exposure to violence and aggressive behavior. This article discusses the relationship between watching violence in movies, TV programs, video/computer games and aggressive behavior among children and teenagers. It also highlights the dangers associated with an ‘aggressive culture’, its implications for child upbringing, policy formulation, education and the role of law enforcement in the management of aggressive behavior.

Correspondence Wiafe-Akenten C.Brenya Department of Psychology, University of Ghana, Legon Box LG 877 Legon Email: [email protected] Tel: +233-24-463 2756

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INTRODUCTION One of the major objectives of science and technology is to improve quality of life and thus make the day- to-day activities of individuals and groups better than it would otherwise have been without technology. Indeed, inventions such as aircraft, vehicles, telephone, radio, air-conditioners, television, video, the computer and many others, have significantly made life more comfortable and less tiresome and stressful. The increased availability of television and video sets as well as computers over the last decade in many homes, offices and educational institutions, have led to easy accessibility to, and dissemination of information. The computer for instance allows for the storage of a large chunk of documents while the video and television bring to us a variety of educative, entertaining and informative programs. Through the use of the internet, various documents and pieces of information could be accessed easily. Communication across the globe has also been made much easier and faster. Various computer software and programs have contributed significantly to teaching and learning. The above have in turn made the concept of globalization a reality.

In spite of the numerous advantages derived from the by-products of technology, they also have their adverse effects on those who use it - consumers. For the purposes of this article, the focus will be on TV/video programs and computer games. As part of the efforts to ‘enrich’ their programs, appeal to a larger audience or viewers, inform, educate and entertain the public, TV stations have over the years broadened and improved upon the quality of the programs they present. Computer games and other video manufacturers, as well as movie producers, have also stepped up production for almost the same reason as that of TV stations. Around the same time, the number of people who have direct or indirect access to TV sets, video and computer games and movies has also increased. One major concern of parents, teachers, caregivers, educationists and indeed, many others, is the prevalence of violence and aggressive scenes in most TV programs, video and computer games and cartoons.

According to Rideout, Foehr, Roberts and Brodie, (1999), American youth between the ages of 8 and 18 spend more than 40 hours per week watching one kind of TV/video program or the other. In the same study it was revealed that about 10% of children aged 18 and below play more than 1 hour of computer video games per day. It was further revealed that among 8 to 13 year-old boys, the average time spent on TV/video programs was more than 7 hours per week. A similar study by the Cooperative Institutional Research Program (1998 & 1999; cited in Anderson & Bushman, 2001) also found that almost 14% of high school seniors and male college students played at least 6 hours of video games per week and watch almost the same hours of TV programs. A random survey carried out by this writer among primary, Junior High School (JHS), Senior High School (SHS) and tertiary students in Accra as part of this article also showed that the number of hours children and teenagers spend playing computer/video games and/or watching TV programs is in the average of 15 hours per week. The worrying aspect of the above scenario is not the time children and teenagers spend watching TV programs or playing video games per se. After all, there are a lot of valuable lessons, information and knowledge to be gained from TV/video programs and computer games. The issue of concern is the violent content of these programs and video games they watch/play or are exposed to. For instance, a review of 10,000 hours of television programming by the National Television Violence Center in the United States of America (USA), reported in 2004 that: Sixty percent (60%) of the programs it sampled contained violent scenes; One-third of the violent scenes showed villains who were never punished; Seventy percent (70%) of these “bad” characters showed no

122 remorse when committing violence; Forty percent (40%) of the violence in the scenes was carried out by the hero; Only fewer than 5% of these violent programs had anti-violent messages.

In a related study carried out over a period of three consecutive years by a Television Violence Monitoring Project and reported by Smith & Donnerstein (1998), it was found that: Sixty-one percent (61%) of television programs contain some violence, and only 4% of those containing violent content featured “antiviolence” themes; Forty-four percent (44%) of the violent interactions on television involve perpetrators who have some attractive qualities worthy of emulation; forty-three percent (43%) of violent scenes involve humor either directed at the violence or used by characters involved with the violence; nearly 75% of violent scenes on television feature no immediate punishment or condemnation of violence; forty percent (40%) of programs feature “bad” characters who are never or rarely punished for their aggressive actions.

Another review carried out in 2001 covering 70 top-selling video games found that 89% of them contained some kind of violence; 49% contained serious violence, while 40% contained comic violence. In 17% of them, violence was the primary focus of the game itself (Smith & Donnerstein, 1998). The level of violence in video games in particular is not surprising because the first few video games (Mortal Kombat, Street Fighter and Wolfenstein 3D) made available on the market were largely violent in nature. In each of the three games mentioned above, the main task was to maim, wound, or kill opponents. This trend has continued and by the beginning of 2000, more and more graphically violent games have become available to people of all ages (Walsh, 1999). It is of interest to note that although many educational, nonviolent and decent sports games do exist, the most patronized and marketed games are the violent ones (Buchman & Funk, 1996). In the same study, Buchman & Funk revealed that 59% of fourth-grade (class four) girls and 73% boys reported that their favorite games are violent ones.

Although there are no such extensive studies on Ghana in terms of the exact or even approximate content (violence and otherwise) of TV/video programs and video/computers games, a careful observation of TV programs particularly movies and to some extent cartoons shows that the situation is not very different from those discussed above from countries like the United States of America. A careful observation by the author and two research assistants over a period of three months showed that a significant number of the movies and especially cartoons shown on Ghana’s TV screens contain significant amount of violent scenes and in almost all cases, the aggressors were invariably not punished but rather got away with their aggressive behaviors or even in some instances, were rewarded directly or indirectly. In recent times, video games of all kinds are available in shops and on road side and are being sold to whoever can afford, no matter its content and the age of the buyer. The question of interest then is whether watching violence in movies and on television is potentially harmful to children, teenagers and even adults. If yes, what form does the violence take? Does it influence children and teenagers differently? What about males and females? Is there any link/association between the level of violent scenes and the levels of aggression? What about whether the aggressor is punished or not?

One of the early studies on the link between a violent model and aggressive behavior was carried out by Bandera, Ross, & Ross, (1961 & 1963 cited in Myers, 2003). In their study children were shown (on film, in a cartoon form or live) a model attacking a ‘Bobo’ doll or inflated toy by beating the doll/toy on the head with a small mallet, throwing it into the air, yelling at it, kicking it across the room and pummeling it

123 with balls. Subsequently when the children had the opportunity to play with the doll/toy they behaved as the adult model did – kicked the doll, yelled at it and threw it about. After series of such classic studies, Bandura and his associates declared that watching an aggressive model led to aggressive behavior. This evidence has been supported by Smith and Donnerstein (1998) who also pointed out that as early as the 1960s, various studies have reported that watching violent scenes could make children more aggressive.

A number of studies and reviews reported by the American Medical Association, the American Academy of Child and Adolescent Psychiatry, and the National Institute of Mental Health have all established a strong linkage between violent TV and movies scenes with aggressive behavior in children and young people (Smith, & Donnerstein, 1998). In sum, a large volume of research evidence accumulated on the subject since the 1960s have consistently linked aggressive behavior to exposure to violence. A recent study by the New York Times and reported in The Watch Tower (June 2006) indicated that even one year old babies can be influenced by the type of TV programs they are exposed to. In the study under review one year old children were exposed to short television clips in which an actress reacted to a toy in a variety of ways. When the actress reacted to a toy with fear the babies avoided playing with the toy in question and were more likely to appear worried, frown or cry. On the other hand, if the actress was enthusiastic towards the toy, the babies were more apt to play with the toy.

Why does exposure to violent media increase aggression? A General Aggression Model (GAM) by Anderson and Bushman (2002), based on several earlier models of human aggression (Lindsay & Anderson, 2000; Anderson et al., 1995 & 1996; cited in Anderson & Bushman, 2001; Berkowitz, 1993; Geen, 1990); Husesmann, 1986; Bandura, 1973) has offered an explanation to the understanding of the effects of violent media on aggression. According to the model, the enactment of aggression is largely based on learning, activation and application of aggression-related knowledge structures stored in memory (i.e., known in psychology as scripts or schemas). These learned aggressive behaviors are activated in a given situation and together with the influence of a person’s disposition to aggression as well as his/her present internal state, represented by cognitive, affective, and arousal, he/she might engage in aggression. Thus, violent media increases aggression by teaching observers how to aggress, by priming aggression and by increasing arousal or by creating an aggressive affective state.

The model explains further that from infancy, humans learn how to perceive, interpret, judge, and respond to events in the physical and social environment. Various types of knowledge structure for these tasks develop over time on the basis of day-to-day observations of and interactions with other people whether real (as in the family) or imagined (as in the media). As these knowledge structures are rehearsed, they become more complex, differentiated, and difficult to change. According to Huesmann (1994), as a child becomes more habitually aggressive, the quality and types of social interactions he/she experiences also change. In sum, the combination of short-term and long-term processes produces the positive relation between exposure to media violence and aggressive-violent behavior.

Another explanation for the link between video game violence and aggression is provided from the angle of physiology. According to this model, exposure to violent video games increases physiological arousal in the form of systolic blood pressure, diastolic blood pressure, and heart rate. Such arousal and its accompanying physiological state predispose one toward aggression especially when one’s stored

124 knowledge of violence is that of reward or fun (and not punishment) or it is viewed as acceptable and not reprehensible. In such cases there is little or no inhibition for one to restrain oneself, but rather a higher propensity for one to engage in aggression emerges.

It has further been postulated that the way violent programs and games are portrayed is another reason why exposure to violent media increase aggression. It has been argued that in most cases violence in movies and on television is portrayed without consequences. That is, there is nothing wrong with it and that is it right and acceptable. Usually, such violent acts are not condemned let alone punished. The aggressor shows no remorse and the unfortunate message it conveys to children in particular (either directly or indirectly) is that violence is acceptable and even desirable. This point is buttressed by a report by Smith and Donnerstein (1998) which indicated that television programs fail to depict the harmful consequences of violence. Specifically, it finds that of all violent behavioral interactions on television, 58% depicts no pain, 47% depicts no harm, and 40% depict harm unrealistically. A similar study by University of Pittsburg Office of Child Development shows that of all violent scenes on television only 16% of violent programs feature the long-term realistic consequences of violence. The result of this study suggests that viewers, especially children, are given wrong impression about violence and its real and potential consequences.

In spite of the foregoing it must be pointed out that exposure to violent programs does not invariably lead to aggressive behavior. Indeed, it has been found that for some individuals exposure to violence is functional in the sense that it rather reduces their propensity to engage in aggression. According to Galotti (2004), Freud refers to this as catharsis - a model which postulates that the individual would be less violent if there are avenues or opportunities for them to vent their anger and aggression. Watching movies or playing video games with violent scenes is thus, one of the various ways by which aggression could be reduced. Thus, the central idea of catharsis is that as individuals are exposed to violent scenes, they tend to shout, scream, kick about, and engage in behaviors (imaginary, mental or physical) as if they were the actors. In the process they release part of their own aggressive tendencies as they tend to project themselves into those acting violently.

Closely related to the issue of catharsis is the argument that a significant number of people who prefer violent programs are high sensational seekers who just enjoy such violent acts although such acts not necessarily prod them to act aggressively. Galotti (2004) objected to the catharsis theory by saying that at best the theory is a very sloppy approximation of the facts of human hostility. On the basis of available studies it is the position of the author that negative the effects of exposure to violent programs out-weight that of the positive.

What can be done? - The way forward: It is a generally acceptable axiom that knowledge of the causes of a problem is in itself part of the solution. On the basis of this, the challenges posed by exposure to violent video and computer games as well as TV programs and movies could be tackled from the very root of the problem. In this regard, one of the ways forward is for parents in particular, to monitor and supervise the kind of TV programs and video or computer games their children watch and/or have access to. As much as possible, parents and caregivers must ensure that the content of the programs and games are appropriate for the age and cognitive levels of their children. The best way to do this is for parents to oversee the purchases of video

125 games or preview them and where available to depend on the ratings assigned to these programs. Such ratings indicate the age at which it is appropriate for a person (children in particular) to view a program alone, with parental guidance or not to view it at all.

Unfortunately however, a study by Walsh (2000) carried out in the United States reported that 90% of teenagers in grades 8 through 12 (approximately Junior to Senior High School - JHS 2 to SHS1) indicated that their parents never check the ratings of video games they buy and that only 1% of the parents of these teenagers had ever prevented their children from buying a video game on the basis of its content. In the light of this revelation, it is incumbent upon parents and caregivers to keep a close eye on their children and to control the kind of TV programs and video games they watch or play. It is also recommended that parents and caregivers should explain to their children the differences between the real World and the World of fantasy as epitomized by video games, cartoons and other related programs shown on TV screens. This is very important because studies (Anderson, & Bushman, 2001; Heusmann, 1986)) have shown that most children tend to practice most of the things they see on TV and that they do not draw any line between reality and fantasy. For most children what they see on TV (whether positive or negative) is real, good, fun and acceptable as long as it appeals to them.

This situation is mainly due to the fact that cognitively children up to about 10 years or thereabout are not able to distinguish between reality and fantasy as is the case with adults. This is deeply rooted in Piaget’s theory of cognitive development which asserts that until an individual attains formal operation (about twelve years) they are not capable of or at best find it very difficult to appreciate certain cognitive operations and issues (Piaget, 1965; as cited in Galotti, 2004). It is probably for the same reason that legally, children of eight years and below cannot be charged for any offence, criminal or otherwise, in many countries including Ghana. Since children in particular do not differentiate between fantasy and reality, the explanation given by parents and caregivers must be focused on letting the child know what would happen if he/she was to act in violent ways similar to what he/she sees on video games, movies or other television programs. In addition, the consequence of imitating aggressive behavior on other people, the larger society, and more importantly, on the child must be emphasized.

This kind of guidance provides children with information which would help them make informed decisions and choices now and during their teenage years and even during adulthood. This could be very effective if parents use reasoning, negotiations and logic as opposed to the use of brute force. If force is used, children may be compelled to avoid those TV programs and video games their parents disapproved of when the parents are present but in their absence, they are likely to access them. If that happens, the objective of trying to prevent children from watching certain programs will be undermined.

Another important measure parents could adopt is to control the number of hours their wards spend behind the TV screen watching programs or playing video games on the computer or any other medium. This is because the more time children spend behind TV screen or playing video games, the more likely I is for them to be exposed to violent programs and scenes. As indicated earlier, there are a number of very informative, educative and entertaining and non violent TV programs and video games parents could buy for their children. Parents should also develop the habit of periodically checking the stock of movies and video games their children have in their possession with a view of ensuring that only the ones appropriate for the respective ages and cognitive levels of their children are allowed. In schools with facilities where

126 children can play video and computer games, teachers and other staff members must be designated to ensure that no child accesses or brings any such programs to school. Those who are found accessing or watching banned sites and programs must be sanctioned. Ironically a study by Walsh (2000) revealed that 89% of parents of respondents do not limit the time spent playing video games or watching TV programs. This is not surprising because nowadays most parents are not at home during the greater part of the day hence a lot of children after school hours and during holidays are most of the time alone or with a house- help or someone who might not be in a position to prevent the children from watching unapproved TV programs and video games. If this is the situation, parents may disenable their TV while they are away or engage a code which prevents children from accessing channels which have the propensity of showing violent programs. A lot of devices for this purpose are in-built in some TV sets while for those with no such facility, it could be installed.

Another area from where this menace could be checked is the various Internet Cafés scattered all over the cities and towns in Ghana. Because of the profit motive of the owners of these Cafes, most of them do not seem to care about who patronizes their facilities and the kind of sites and programs patrons log on to. It is not uncommon to see children as young as nine years accessing unimaginable sites and watching very violent programs in Cafes in the full glare of the Café attendant(s) and other patrons. In this particular instance, there is the need for a policy on Information Communication Technology (ICT) with particular reference to the kind of information children and teenagers in particular can access in Internet Cafes and other related facilities. Law enforcement is critical in this direction because in the opinion of the writer one of the banes of the country’s development (be it social, economic or otherwise) is the low level of law enforcement and in some cases complete absence of enforcement.

This by implication means that whatever policy is put in place must be enforced to the letter. In the absence of enforcement, such policy, no matter how well is it couched, will be unworkable and useless. A related control measure is the classification of TV programs and video games by content and age. This classification is very important because it gives an indication as to the nature of the content and for that matter who is permitted to watch or stay away from or whether it should be viewed under parental guidance. This needs to be done thoroughly since it could be subjected to manipulations by those who have financial interest in the movie and video game industry. If the players in the industry are able or allowed to manipulate the process, then, the purpose of which it is introduced will be defeated. This fear is borne out of a study by Funk et al. (1999) which showed that cartoons and movies with very high violent scenes are classified by those in the industry as appropriate for general audiences when in actual fact it is not. In this direction, law enforcement and the application of appropriate sanctions are crucial for its successful implementation.

Fortunately, Ghana has a Cinematography Act (Act 76 of 1961) which was amended in 1975 (National Redemption Council Degree – N.R.C.D. 350). The Act among others covers censorship and classification of films. For instance, section 7, paragraph 1 and sub-sections a – c of the Act states that any person desiring to exhibit any film shall submit the film to the Board for examination and the Board may, having viewed and examined the film (a) pass and issue a ‘U’ certificate for film which is suitable for showing to all audience, (b) pass and issue an ‘A’ certificate for a film which is suitable for showing but restricted to adults and children under the age of 18 years if accompanied by adults,

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In effect, for movies shown in public places there are legal restrictions as to what can be shown and at what age one is permitted to watch. However, as stated earlier this law does not seem to be enforced as minors are allowed access to video centers and watch all kinds on films as long as they can pay. Besides, the advent of video games, Video Cassette Recorders (VCR) and recently Digital Video Disc (DVD) and related ones which could be viewed in homes and in private, have to a greater extent made the cinematography Act somehow ineffective. The onus once again is on parents and guardians to check and regulate the kind of video games and movies their children have access to. In the light of this there is the need to amend the existing Cinematography Act to regulate the operation of Internet Cafes.

CONCLUSIONS It is now very clear that TV, computers and videos have become part of life in the twenty-first century. Access to TV and its programs and use of video/computer games have become widespread in recent times. They have become very popular and are patronized by all classes of people and are likely to continue to enjoy high patronage particularly from children and the teenagers until a more exciting substitute is made available. Indeed, these gadgets are very useful source of information, education and entertainment. The computer in particular has now become a household name not only because of its availability but more importantly, as a result of its usefulness in contemporary society, especially in business and education.

The unfortunate aspects of the access to and use of these machines is not in the machines themselves but rather the uses they are put into. Of particular concern is the projection of violence and aggression through these media. For instance, both experimental and non-experimental studies have associated exposure to violence on TV and video games with increases propensity to engage in aggressive behavior particularly among children and teenagers (Bandura, Ross, & Ross, 1961 & 1963; as cited in Myers, 2003; Kuttschreuter & Baarda, 2004, as cited in Asare et. el., 2005). Since aggression in general is unacceptable, there is the need to control or at least manage its adverse effects on the individual and society. It is of utmost importance that conscious efforts are made by TV stations, and the movie and video games industry to reduce to the barest minimum the elements of violence in their programs. It is also important for people and indeed, the general public to send unambiguous signals to viewers that aggression is not good, is unacceptable and must be condemned. In other words, current high patronage of these products must be used to shape society for the better.

References Anderson, A. C. & Bushman B. J. (2001). Effects of violence video on aggressive cognition, aggressive affect, physiological arousal and prosocial behavior: A meta-analytic review of the scientific literature. Psychological Science; 12(5), 167-202.

Bandura, A. (1973). Aggression: A social analysis. Englewood Cliffs, New Jersey: Prentice-Hall.

Berkowitz, L. (1993) Aggression: A social learning analysis. Englewood Cliffs, New Jersey: McGraw Hill

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Bushman, D.D. & Funk, J.B. (1996). Video and computer games in the 1990s: Children’s time commitment and games preference. Children Today, 24, 12–16.

Funk, J.B., Flores, G., Bushman, D.D., & Germann, J.N. (1999). Rating electronic games: Violence in the eye of the beholder. Youth & Society, 30, 283-312.

Galotti, M. K. (2004). Cognitive psychology: In and out of the laboratory (3rd Ed). Australia: Thomson Wadsworth.

Geen, R.G. (1990). Human aggression. Pacific Grove, CA: McGraw Hill.

Heusmann, L. R. (1986). Psychological processes promoting the relation between exposure to media violence and aggressive behavior by the viewer. Journal of Social Issues; 42, 125-139.

Lindsay, J.J. & Anderson, C.A. (2000). From antecedent condition to violent actions: A general affective aggression model. Personality and Social Psychology Bulletin; 26, 533-547.

Mensah, W. (2004). The influence of violent movies on aggressive acts of children. Unpublished Dissertation submitted to the Department of Psychology, University of Ghana.

Myers, D. G. (2003) Social psychology (7th Ed). Boston, McGraw-Hill College.

Rideout, V.G. Foehr, U.G., Roberts, D.F. & Brodie, M. (1999). Kids & media at the new millennium: Executive summary: Menlo Park, CA Kaiser Family Foundation.

Smith, S.L., & Donnerstein, E. (1998). Harmful effects of exposure to media violence: Learning of aggression, emotional desensitization and fear. In R.G. Geen & E. Donnerstein (Eds.) Human aggression: Theories, research, and implications for social policy New York: Academic Press.

Smith, S.L., & Donnerstein, E. (2006) Television: A good babysitter. The watchtower: Announcing Jehovah’s Kingdom. June 15.

Smith, S.L., & Donnerstein, E. (2004) TV and movie violence: Why Watching, it is harmful. A publication by the University of Pittsburg office of Child Development.

Walsh, D. (2000). Interactive violence and children: Testimony submitted to the Committee on Commerce, Science and Transportation, United States Senates

Walsh, D. (1999). 1999 video & computer game report card (On-line) http//www.mediaandthefamily.org1999vgrc2.html

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INSTRUCTIONS TO AUTHORS The Ghana International Journal of Mental Health invites original contributions in the areas of mental health. Submissions may include results of empirical research, case studies, short reports, commentaries, correspondence and literature reviews of significant theoretical interest.

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