Abstract
Objective: To develop a clinically sensitive test of social perception for people with traumatic brain injury (TBI).
Design: An assessment tool comprising videotaped vignettes and response probes was developed in successive stages and tested on both normal participants and those with TBI.
Subjects: A total of 169 normal adults and 7 adults with severe TBI (pilot studies), 283 normal adults, and 12 people with severe TBI (main studies).
Main outcome measures: "The Awareness of Social Inference Test" (TASIT) comprises videotaped vignettes of everyday social interactions and has three parts, each with alternate forms. The Emotion Evaluation Test (EET) assesses recognition of spontaneous emotional expression (happy, surprised, sad, anxious, angry, disgusted, and neutral). The Social Inference-Minimal (SI-M) test assesses comprehension of sincere versus sarcastic exchanges, whereas the Social Inference-Enriched test (SI-E) assesses lies versus sarcasm. In both SI-M and SI-E speaker demeanor (voice, facial expression) indicate the intended meaning of the exchange. In addition, the SI-E vignettes have other contextual clues that reveal the speakers' intentions. Performance on SI-E and SI-E is assessed via four standard questions per item probing for understanding of the emotions, intentions, beliefs, and meanings of the speakers and their exchanges.
Results: Groups taken from the pool of 283 normal adults achieved a high level of performance on all aspects of the test with some influence from both education and intelligence. The 12 people with TBI were poorer at judging emotions than were matched controls, with particular difficulties recognizing neutral items, fear, and disgust. They were as capable as matched controls when understanding sincere exchanges and lies but had difficulty with sarcasm.
Conclusions: TASIT is straightforward for people with a normal range of social skills while being sensitive to social perception deficits after traumatic brain injury.
POOR social behavior is a common and disabling consequence of severe traumatic brain injury (TBI). This may be characterized by self-focused conversation without interest in other people, immature or inappropriate humor, frequent interruptions and sudden topic shifts, blunt manner, overly familiar and disinhibited remarks or advances, inappropriate levels of self-disclosure, difficulty shifting from a topic, and slowness of comprehension.1-9 Without effective treatment, poor social skills present a major stumbling block to successful social integration and have been found to be associated with limited relationships, low social participation, and poor self-esteem.10-16 Poor social skills reflect acquired cognitive and personality change as a result of the brain injury and are an important target for rehabilitation.20-23 This is given momentum by treatment outcome studies that indicate intervention can be effective in improving aspects of social behavior and quality of life for people with TBI.21,23-24
Critical to social skills training is the assessment of strengths and weaknesses upon which the program is to be based. To this end a number of major components have been identified.25-28 Typically, these include a group of expressive or behavioral components and a group of receptive or cognitive components. The latter, frequently termed "social perception," encompasses attention, decoding, and higher-level components known as "social intelligence" (i.e., knowledge of social customs and expectations, and problem solving). These perceptive abilities need to be applied to a range of social phenomena, including verbal messages, paralinguistic information (e.g., intonation), nonverbal behaviors, (e.g., facial expression, eye gaze, gesture) and social context.29-33 Normal individuals with low sensitivity to these contextual cues have been found to have poor social skills.30,32,34-36
Reflecting its behavioral origins, social skills training has traditionally focused upon improving social responses. However, there is growing awareness that social perception must also be addressed,37 because training of particular skills will be ineffective or even counterproductive if they are used indiscriminately.36 Furthermore, improvement in social perception can occur with adequate training, signifying social awareness as both a valuable and feasible target for remediation.38,39
This issue is particularly pertinent when dealing with adults with TBI who are known to experience a variety of social perception deficits. Difficulties interpreting basic cues such as the emotion reflected in facial expression and tone of voice have been reported.40-42 Individuals with TBI have also been found to have deficits in higher-level facets of social perception, such as the ability to consider social situations from another person's point of view43-47 and the ability to interpret pragmatic inference.48-50 Clearly, social skills programs need to be developed with an awareness of the presence and nature of such difficulties. To this end, accurate and comprehensive assessment tools for social perception skills are needed. But few have been available and even fewer assess social cues as they occur in everyday social settings.