1.
RANCHO I: (no response)
GENERAL BEHAVIORS: Patient appears to be in a deep sleep and is completely unresponsive to any stimuli.
LANGUAGE BEHAVIORS: Receptive and Expressive: No evidence of processing or verbal or gestural expression.
2.
RANCHO II: generalized response
GENERAL BEHAVIORS: Patient reacts inconsistently and non-purposefully to stimuli in a nonspecific manner. Responses are limited and often the same, regardless of stimulus presented. Responses may be physiologic changes, gross body movements, or vocalization.
LANGUAGE BEHAVIORS: Receptive and Expressive: No evidence of processing or verbal or gestural expression.
3.
RANCHO III: localized response
GENERAL BEHAVIORS: Patient reacts specifically, but inconsistently, to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as "close your eyes" or "squeeze my hand" in an inconsistent, delayed manner.
LANGUAGE BEHAVIORS: Language begins to emerge.
RECEPTIVELY: Patient progresses from localizing to processing and following simple commands that elicit automatic responses in a delayed and inconsistent manner. Limited reading emerges.
EXPRESSIVELY: Automatic verbal and gestural responses emerge in response to direct elicitation. Negative head nods emerge before positive head nods. Utterances are single words serving as "holophrastic" responses.
4.
RANCHO IV: Confused-agitated
GENERAL BEHAVIORS: Behavior is bizarre and non-purposeful relative to immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts; verbalizations are frequently incoherent or inappropriate to the environment; confabulation may be present. Gross attention to the environment is very short, and selective attention is often nonexistent. Patient lacks short-term recall.
LANGUAGE BEHAVIORS: Severe disruption of frontal-temporal lobes, with the resultant confusion apparent.
RECEPTIVELY: Marked disruption in auditory and visual processing, including inability to order phonemic events, monitor rate, and attend to, retain, categorize, and associate stimuli. Disinhibition interferes with comprehension and ability to inhibit responses to self-generated mental activity.
EXPRESSIVELY: Marked disruption of phonologic, semantic, syntactic, and suprasegmental features. Output is bizarre, unrelated to environment, and incoherent. Literal, verbal, and neologisitic paraphasias appear with disturbance of logico-sequential features and incompleteness of thought. Monitoring of pitch, rate, intensity, and suprasegmentals is severely impaired.
5.
RANCHO V: confused, inappropriate, nonagitated
GENERAL BEHAVIORS: Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or fragmented. Has gross attention to the environment but is highly distractible and lacks ability to focus attention on a specific task; with structure, may be able to converse on a social-automatic level for short periods; verbalization is often inappropriate and confabulatory; memory is severely impaired; often shows inappropriate use of subjects; individual may perform previously learned tasks with structure but is unable to learn new information.
LANGUAGE BEHAVIORS: Linguistic fluctuations are in accordance with the degree of external structure and familiarity-predictability of linguistic events.
RECEPTIVELY: Processing has improved, with increased ability to retain temporal order of phonemic events, but semantic and syntactic confusions persist. Only phrases or short sentences are retained. Rate, accuracy, and quality remain significantly reduced.
EXPRESSIVELY: Persistence of phonologic, semantic, syntactic, and prosodic processes. Disturbances in logicosequential features result in irrelevances, incompleteness, tangent, circumlocutions, and confabulations. Literal paraphasias subside, while neologisms and verbal paraphasias continue. Utterances may be expansive or telegraphic, depending on inhibition-disinhibition factors. Responses are stimulus bound. Word retrieval deficits are characterized by delays, generalizations, descriptions, semantic associations, or circumlocutions. Disruptions in syntactic features are present beyond concrete levels of expression or with increased length of output. Written output is severely limited. Gestures are incomplete.
6.
Rancho VI: Confused, appropriate
GENERAL BEHAVIORS: Patient shows goal-directed behavior but depends on external input for direction; follows simple directions consistently and shows carryover for relearned tasks with little or no carryover for new tasks; responses may be incorrect due to memory problems but appropriate to the situation; past memories show more depth and detail than recent memory.
LANGUAGE BEHAVIORS:
RECEPTIVELY: Processing remains delayed, with difficulty in retaining, analyzing, and synthesizing. Auditory processing is present for compound sentences, while reading comprehension is present for simple sentences. Self-monitoring capacity emerges.
EXPRESSIVELY: Internal confusion-disorganization is reflected in expression, but appropriateness is maintained. Language is confused relative to impaired new learning and displaced temporal and situational contexts, but confabulation is no longer present. Social-automatic conversation is intact but remains stimulus bound. Tangential and irrelevant responses are present only in open-ended situations requiring referential language. Neologisms are extinguished, with literal paraphasias present only in conjunction with an apraxia. Word retrieval errors occur in conversation but seldom in confrontation naming. Length of utterance reflects inhibitory-initiation mechanisms. Written and gestural expression increases. Prosodic features reflect the "voice of confusion: characterized by monopitch, monostress, and monoloudness.
7.
RANCHO VII: automatic-appropriate
GENERAL BEHAVIORS: Patient appears appropriate and oriented within hospital and home setting, goes through daily routine automatically, but is frequently robot-like with minimal-to-absent confusion; has shallow recall of activities; shows carryover for new learning but at a decreased rate; with structure, is able to initiate social or recreational activities; judgment remains impaired.
LANGUAGE BEHAVIORS: Linguistic behaviors appear "normal" within familiar, predictable, structured settings, but deficits emerge in open-ended communication and less structured settings.
RECEPTIVELY: Reductions persist in auditory processing and reading comprehension relative to length, complexity and presence of completing stimuli. Retention has improved to short paragraphs but without the abilities to identify salient features, organize, integrate input, order, and retain detail.
EXPRESSIVELY: Automatic level of language is apparent in referential communication. Reasoning is concrete and self-oriented. Expression becomes tangential and irrelevant when abstract linguistic concepts are attempted. Word retrieval errors are minimal. Length of utterance and gestures approximate normal. Writing is disorganized and simple at a paragraph level. Prosodic features may remain aberrant (abnormal). Pragmatic features of ritualizing and referencing are present, while other components remain disrupted.
8.
RANCHO VIII: purposeful and appropriate
GENERAL BEHAVIORS: Patient is able to recall and integrate past and recent events and is aware of and responsive to the environment, shows carryover for new learning and needs no supervision once activities are learned; may continue to show a decreased ability relative to premorbid abilities in language, abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances.
LANGUAGE ABILITIES: Language capacities may fall within normal limits. Otherwise, problems persist in competitive situations and in response to fatigue, stress, and emotionality, characterized in reduced effectiveness, efficiency, and quality of performance.
RECEPTIVELY: Rate of processing remains reduced but unremarkable on testing. Retention span remains limited at paragraph level but improved with use of retrieval-organization strategies. Analysis, organization, and integration are reduced in rate and quality.
EXPRESSIVELY: Syntactic and semantic features fall within normal limits, while verbal reasoning and abstraction remains reduced. Written expression may fall below premorbid level. Prosodic features are essentially normal. Pragmatic features of referencing, presuppositions, topic maintenance, turn taking, and use of paralinguistic features in context remain impaired.
