EXPLORING THE USE OF QUESTION METHODS: PICTURES DO NOT ALWAYS HELP PEOPLE WITH LEARNING DISABILITIES

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1 The British Journal of Developmental Disabilities Vol. 45, Part 2, JULY 1999, No. 89 EXPLORING THE USE OF QUESTION METHODS: PICTURES DO NOT ALWAYS HELP PEOPLE WITH LEARNING DISABILITIES Denise Cardone Introduction Since the early 1980 s there has been a growing body of literature looking at how best to obtain meaningful information from people with learning disabilities. Several types of response bias have been identified which contaminate reliability. These include acquiescence (a person answering yes, regardless of the question) (Sigelman et al., 1981), consistently choosing the last alternative in a multiple guess (Sigelman et al., 1983) and giving false information in response to a leading closed question (Cardone and Dent, 1996). Although the results of different studies are sometimes contradictory (Cardone, 1995) two premises are generally accepted. First, it is both necessary and desirable to seek the opinions of people with learning disabilities about issues that affect them. Second, responses should be checked for their reliability. To do this, for example, the same question could be asked using several formats and consistency compared, or interviews could be supplemented by observational data or information from third party informants (Lowe and de Pavia, 1988; March, 1992; Edgerton, 1984). Recently, two potentially useful methods for asking questions have been piloted (Dagnan et al., 1994; Dagnan et al., 1995). Both methods allow reliability to be checked and provide quantitative information. The first method, the personal questionnaire, involves participants choosing the answers from three printed words, each on a separate card. The second method, the pictorial analogue, consists of 2 pictures representing extremes. Participants then indicate their feelings by marking a line between them. The results have shown that many people with learning disabilities were able to use these methods reliably. However, each of the methods had their own strengths and drawbacks. Although the personal questionnaire had an in-built reliability check and was easy to score, participants with higher receptive language tended to be able to use it better than those of lower ability. This tendency was not apparent with the pictorial analogue scale: its strength is its accessibility to people with varying degrees of learning disability. However, the pictorial analogue *Denise Cardone Chartered Clinical Psychologist, Community Learning Disabilities Team, Tewkesbury Hospital, Barton Street, Tewkesbury, Glos. GL20 5QN UK. Tel: 0044 (0) * For Correspondence 93

2 scale also has its problems. First, there may have been a test-retest bias; since it is given more than once during an interview participants may simply score reliably because they remember their earlier response. Second, to calculate reliability one has to use statistical methods making this an impractical method for use by clinical professionals in everyday settings. Aims of the Present Study As part of a service evaluation project, the aim of the present study was to find a reliable, easy to score method for asking people with various degrees of learning disability. Dagnan s work (Dagnan et al., 1994; Dagnan et al., 1995) was replicated and extended by using both the personal questionnaire format, and by creating a pictorial version of the personal questionnaire format. It was hypothesised that, unlike the personal questionnaire, the pictorial version of the personal questionnaire would be independent of receptive language ability. Method Materials i) The British Picture Vocabulary Scale (BPVS) (Dunn et al., 1982). This instrument measures receptive language ability. ii) Personal questionnaire (Shapiro, 1961; Dagnan et al., 1994; Dagnan et al., 1995). This response format is individualised according to the question asked. For each question, three cards with words printed on them are created, representing two extremes and a choice in the middle (e.g., Always, Sometimes, Never ). These three responses are presented to the interviewee in the three possible paired combinations (Always/ Sometimes, Always/Never, Sometimes/ Never). A four point scale results, or unreliable responding is detected. For example, if someone chooses Always; Always; Never, this is not consistent and therefore not reliable (see Dagnan et al., 1994, for a full explanation of scoring). iii) Pictorial personal questionnaire. This was devised for this study, replacing the words as above with pictures taken from Makaton Symbols (Walker, 1985). Participants Twenty-eight people with learning disabilities were interviewed. All were receiving a service from the Community Learning Disabilities teams of the East Gloucestershire NHS Trust and were being seen on an ongoing basis for at least the past year. The group consisted of 13 men and 15 women, and had a mean age of years (SD = 13.40, range years). The Interview All interviews took place at the participants convenience, either in their homes, colleges or Adult Opportunity Centres. The confidential nature of the interviews was explained with the proviso that the interviewer would share any information at the participant s request. All interviews were tape recorded. Interviews lasted approximately one hour. Following the protocol of Dagnan et al. (1994), the interview was semi-structured, covering four broad areas which were explored in an open-ended manner. The first two of these broad areas were replicated from the above study, the second two were not. In each broad area, a structured question was asked, using the pictorial questionnaire and the personal questionnaire response format as follows: 94

3 1. Broad area - How the client felt when they saw the service provider. Structured question: How do you feel when you see (the service provider s name)? Response format: Happy, OK, Sad. 2. Broad area - What the clients felt the sessions were for. Structured question: Does the (service provider s name) listen to you? Response format: A lot, Sometimes, Never. 3. Broad area - Whether the client felt the sessions were beneficial. Structured question: Does (service provider s name) help you? Response format: A lot, A little, Not at all. 4. Broad area - How the client felt about the amount of help they were receiving. Structured question: Thinking about the number of times you have seen (service provider s name), is it... Response format: Too much, Just right, Too little? Question and response format were randomised. Midway through the interview, the BPVS was administered. Results TABLES I and II present the number of people who were unable to respond (did not give an answer), refused to respond (would not choose one of the two cards when presented with a forced-choice), responded reliably, and responded unreliably to each question, using the personal questionnaire and the pictorial personal questionnaire respectively. To see if language ability affected reliable responding, the BPVS scores of people who TABLE I Responses to the Personal Questionnaire Question No. Unable Refused Reliable Unreliable Number of people responsing in each way using the personal question TABLE II Responses to the Pictorial Personal Questionnaire Question No. Unable Refused Reliable Unreliable Number of people responsing in each way using the pictorial personal question 95

4 were reliable were compared with the scores of people who were not, for both the personal questionnaire and the pictorial personal questionnaire. Of the people who agreed to complete the BPVS, TABLE III shows the results for the personal questionnaire and TABLE IV the results of the pictorial personal questionnaire. These tables show the number of people who were reliable and unreliable, also their median BPVS scores, and whether there was a statistically significant difference between the BPVS scores of people who were reliable, compared with those who were unreliable, as calculated using a Wilcoxon-Mann- Whitney test WX. TABLE III Results from the Personal Questionnaire Question Reliable Unreliable Statistical Differences No. Group Group between Groups 1 N = 12 N = 12 Yes = 65.5 = N = 10 N = 2 Yes Median BPVS score Median BPVS score W = 3.0, p<0.05 = 80.5 = N = 9 N = 3 Yes = 91 = 30 4 N = 9 N = 3 No Median BPVS score Median BPVS score W = 9.0 = 91 = 30 TABLE IV Results from the Pictorial Personal Questionnaire Question Reliable Unreliable Statistical Differences No. Group Group between Groups 1 N = 13 N = 3 Yes = 61 = 29 2 N = 11 N = 2 Yes Median BPVS score Median BPVS score W = 3.0, p<0.05 = 70 = N = 9 N = 3 Yes = 91 = 30 4 N = 11 N = 2 Yes Median BPVS score Median BPVS score W = 3.0, p<0.05 = 70 =

5 Discussion As expected, people with better receptive language ability were more reliable using the personal questionnaire than people of lower ability. However, the same trend was apparent using the pictorial version, a finding that was not predicted based on previous research (Dagnan et al., 1994; Dagnan et al., 1995). The present study suggests that the use of pictures is not always helpful to people with lower language ability. This may be due to the way in which the pictures were presented; the combination of forced choices inherent in the personal questionnaire format may make responding difficult for this client group. This was reflected in the number of people who refused to answer questions presented in this format, whether pictorial or written. Generally, people who refused to answer were only happy to make 2 of the 3 forced choices which presented their chosen response. For example, they chose Happy twice when presented with the choices Happy/Sad and Happy/OK. However, when presented with the forced choice that did not include their chosen response, e.g. Sad/OK, they refused to choose, instead verbally saying Happy. Thus, the demand characteristics inherent in the personal questionnaire may mask reliable responding. There were also a number of people who were unable to use the personal questionnaire format: they simply did not answer. However, they could answer Yes/No questions reliably and were able to give nonelaborate information in response to open questions. Yes/No questions were asked using a reversal design (Sigelman et al., 1983). For example, participants were asked Do you like seeing (service provider s name)? and then later in the interview were asked, Do you dislike seeing (Service provider s name?). Using this format, participants were generally able to answer reliably both factual questions and questions which required a preference or opinion. Further, they could generally provide factual information to open questions (e.g., What do you do with (service provider s name)? ), but had some difficulty expressing preferences (e.g., What else would you like to do with (service provider s name)? ). It is likely that this group of people had low receptive language ability, but this cannot be determined, since they chose not to complete the BPVS. Finally, the majority of participants in this and other studies (Cardone, 1995; Cardone and Dent, 1996) became annoyed by the repetitive asking of the same questions in different formats. Participants often commented, saying things such as I ve already answered that! Although reliability checks are important, future research should take a more qualitative approach, asking questions in ways that make sense to the participants. Summary This study evaluated the usefulness of various question formats for assessing consumer satisfaction with a community learning disabilities service. Twenty eight people with learning disabilities were interviewed using various question formats, including the forced-choice personal questionnaire method, along with a pictorial version of this method. Contrary to expectation, it was found that many participants had difficulty using the personal questionnaire method, and that supplementing it with pictures did not help. It was suggested that the combination of forced choices inherent in the personal questionnaire made responding difficult for this client group and future research should take a more qualitative approach. 97

6 References Cardone, D. (1995). Interviewing people with a learning disability: A case study. Unpublished doctoral thesis. Birmingham University Psychology Training Course. Cardone, D. and Dent, H. (1996). Memory and Interrogative Suggestibility: The effects of modality of information presentation and retrieval conditions upon the suggestibility scores of people with learning disabilities. Legal and Criminal Psychology, 1, Dagnan, D., Dennis, S. and Wood, H. (1994). A pilot study of the satisfaction of people with learning disabilities with the services they receive from Community Psychology services. The British Journal of Developmental Disabilities, 40, Dagnan, D. J. and Ruddick, L. (1995). The use of analogue scales and personal questionnaires for interviewing people with learning disabilities. Clinical Psychology Forum, 69, Dunn, L. M., Whetton, E. and Pintilie, D. (1982). British Picture Vocabulary Scale. Windsor, Berkshire: NFER-Nelson. Edgerton, R. (1984). The Participant-Observer approach to research in Mental Retardation. American Journal of Mental Deficiency, 88, Lowe, K. and de Pavia, S. (1988). Canvassing the views of people with a mental handicap. The Irish Journal of Psychology, 9, March, P. (1992). Do photographs help adults with severe mental handicap make choices? The British Journal of Mental Subnormality,38, Shapiro, M. B. (1961). A method of measuring psychological changes specific to the individual psychiatric patient. British Journal of Medical Psychology, 34, Sigelman, C. K., Budd, E. C., Spantel, C. L. and Schoenrock, D. J. (1981). When in doubt, say yes : Acquiescence in interviews with mentally retarded persons. Mental Retardation, 19, Sigelman, C. K., Schoenrock, C. J., Budd, E. C., Winer, J. L., Spantel, C. L., Martin, P. W., Homas, S. and Bensberg, G. J. (1983). Communicating with Mentally Retarded Persons: Asking questions and getting answers. Lubbock: Texas Technical University. Walker, M. (1985). Symbols for Makaton. Camberley: MVDP/EARO. 98