Social communication skills in persons with post-acute traumatic brain ...

Brain Injury, April 2006; 20(4): 425–435

Social communication skills in persons with post-acute traumatic brain injury: Three perspectives

CYNTHIA DAHLBERG, LENORE HAWLEY, CLARE MOREY, JODY NEWMAN, CHRISTOPHER P. CUSICK, & CYNTHIA HARRISON-FELIX Craig Hospital, Englewood, USA (Received 24 May 2005; accepted 11 January 2006)

Abstract Objective: To describe social communication skills problems identified by individuals with traumatic brain injury (TBI) compared to significant other (SO) and clinician ratings; and associations between these skills and participation outcome measures. Design: Cohort study. Methods: Sixty individuals with TBI 1 year post-injury were administered measures of social communication, societal participation, social integration and life satisfaction. Clinicians and SOs rated the social communication skills of the subjects. Results: Subjects were able to identify social communication skills problems, associated with lower ratings of community integration and satisfaction with life. Males reported higher scores in social communication and social integration than females. SOs and clinicians identified more social skills problems than subjects. Conclusions: Persons with TBI experience social communication skills deficits, associated with decreased societal participation and life satisfaction. Further research is needed to determine efficacy of social communication skills treatment and association with improved participation and satisfaction with life. Keywords: Traumatic brain injury, social communication skills, participation

Introduction Functioning in society requires the ability to effectively interact and communicate with others. After a traumatic brain injury (TBI), however, these skills may be compromised [1–5], often resulting in vocational/academic failure, interpersonal conflicts and loneliness [5–8]. Over time, these problems may become even more apparent as the individual attempts to return to pre-injury life. Difficulties in social communication (or pragmatic language skills) may represent the most pervasive problem in the chronic stage after TBI [5, 9]. At least one researcher found that after 10–15 years postsevere-head-injury, loss of social contact was the most disabling handicap in daily life [10]. This social

isolation has been found to be accompanied by a significant decrease in life satisfaction, which is not otherwise correlated with injury severity [11]. Furthermore, Milton et al. [12] noted that ‘inappropriate management of communication exchanges by a head injured individual . . . presents a major barrier to social reintegration’ p. 115, and includes such problems as decreased social perception, difficulty following the rules of social interaction, disorganization of language output, disinhibition and poor self-monitoring in communication situations [12]. Others have found that, as social contacts for work/school and leisure are decreased, areas relating to social competency and adjustment may become further impaired [13–15].

Correspondence: Cynthia Dahlberg, MA, CCC-SLP, Craig Hospital, 3425 South Clarkson Street, Englewood, USA. Tel: (303) 789 8228. Fax: (303) 789 8219. E-mail: [email protected] ISSN 0269–9052 print/ISSN 1362–301X online ß 2006 Taylor & Francis DOI: 10.1080/02699050600664574

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Despite the many consequences of impaired pragmatic communication skills, it is not always apparent to the individual that they are experiencing problems in this domain. After TBI, the family member/significant other (SO) is frequently more likely to recognize problems with socialization and personality or behaviour than is the individual with TBI, even 5 years post-injury [11, 16]. Therefore, it has been recommended that communication be rated by someone who is familiar with the person, in addition to expert listeners, to better identify specific problem areas [17, 18]. Not withstanding, it is helpful that persons with TBI who experience difficulties with social communication skills have some awareness of these problems and can identify specific goals that could be targeted for remediation. From the clinician’s perspective, it is important to understand the types of pragmatic communication problems that persons with post-acute TBI experience and how insightful they are regarding their social communication skills, in order to provide effective treatment interventions. Likewise, it is also important to understand which areas of social communication are most associated with significant outcomes such as life satisfaction, productivity and community reintegration, in order to provide interventions that will ultimately improve outcomes in persons with TBI. Consequently, this study examines the baseline data from a clinical trial on the efficacy of a social communication skills treatment programme to address the following research questions for persons with TBI: (1) Which social communication skills are identified as problematic by persons with TBI, family members/significant others (SOs) and clinicians? (2) Are social communication skills identified as problematic by persons with TBI, their SOs and clinicians associated with reduced community reintegration and life satisfaction?

Patient characteristics Participants in this Institutional Review Board (IRB) approved study included individuals with TBI who enrolled in a clinical trial to evaluate the efficacy of a social communication skills treatment programme within a TBI Model System of Care centre [19], funded by the National Institute on Disability and Rehabilitation Research. Inclusion criteria were that the individual must: (1) have a TBI, defined as injury to brain tissue caused by an external mechanical force, as evidenced by loss of consciousness due to brain trauma, post-traumatic amnesia, skull fracture or objective neurological findings that can be reasonably attributed to TBI on physical or

mental status exam (excludes anoxia, stroke and tumour, etc.) [19]; (2) be at least 16 years of age; (3) be at least 1 year post-injury; (4) have received initial rehabilitation for their TBI; (5) have adequate receptive and expressive communication skills for group participation (5 on the Comprehension and Expression items of the Functional Independence Measure [20]; (6) have sufficient recall of day-to-day events for learning in a group setting; (7) be functioning at level 6 or higher on the Rancho Los Amigos Level of Cognitive Functioning Scale [21]; (8) demonstrate some aspect of problematic social communication skills on the Social Communication Skills Questionnaire-Adapted [22]; (9) be English speaking; (10) not have any significant psychiatric diagnoses or current history of substance abuse; and finally (11) provide informed consent. Eight-hundred and seventy-nine potential participants were initially identified and recruited by mail and by telephone from a list of former patients of eight rehabilitation and community-based brain injury programmes in a large metropolitan area. Of those 879 individuals, 125 (14%) expressed interest in participating. Ultimately, 91 of the willing candidates were deemed eligible to participate and, of those, 60 were eventually enrolled, representing 66% of those eligible and 7% of those initially recruited. Of the 60 study participants, 83% were male and 17% were female, with a mean age of 39 years (SD 11 years, range 20–63 years). Caucasians represented 85% of the study population, 10% were Hispanic and 5% were African-American. The mean time post-injury was 7 years (SD 6 years, range 1–21 years). Initial injury severity, as measured by the Glasgow Coma Scale Score (GCS) [23] was considered severe (score 3–8) for 65% of participants, moderate (score 9–12) for 13%, mild (score 13–15) for 8% and unknown for 13%. The mean duration of post-traumatic amnesia (PTA) was 60 days (SD 70 days, range 3–365 days); data was missing for 13% of cases. The mean length of inpatient rehabilitation was 74 days, with a median of 66 days (SD 49 days, range 15–244 days; four outliers were 174, 191, 200 and 244 days); data was missing for 15% of cases. With regards to education level, 8% had less than a high school diploma, 10% had earned a high school diploma, 52% had attended some college courses, 28% received a bachelor’s degree or higher and 2% were unknown. Upon enrollment, 20% were competitively employed, 2% were students, 3% were homemakers, 22% were volunteers, 43% were unemployed, 8% were retired and the remaining 2% were coded as ‘other’. The family member/significant others included parents (32%), spouses (27%), friends (20%), other (12%: sibling, child, grandparent,

Social communication skills in persons with post-acute traumatic brain injury paid attendant); and 10% of participants did not have an SO. Demographic data was not available for the 31 individuals who were otherwise eligible, but ultimately elected not to participate.

Instruments Data from five instruments collected during baseline evaluations for the clinical trial were utilized for this study. Persons with TBI completed the Social Communication Skills Questionnaire–Adapted (SCSQ-A) [22], Social Integration and Occupational sub-scales of the Craig Handicap Assessment and Reporting Technique–Short Form (CHART-SF) [24], the Social Integration and Productivity sub-scales of the Community Integration Questionnaire (CIQ) [25], as well as the Satisfaction with Life Scale (SWLS) [26]. The SCSQ-A, CHART-SF and CIQ ratings were also collected from the participant’s SO, based on their perception of the person with TBI. Clinical staff evaluated participants utilizing the Profile of Functional Impairment in Communication (PFIC) [27], rating videotaped conversations between study participants and study confederates. The social communication skills questionnaire–adapted (SCSQ-A) [22] This is a subjective assessment which allows participants to evaluate themselves on a variety of social communication skills. The tool was adapted to include a 5-point scale for the purposes of the study (e.g. ‘I am able to begin a conversation’: 5 ¼ always, 4 ¼ often, 3 ¼ sometimes, 2 ¼ rarely or 1 ¼ never) [22]. Higher scores indicate better social communication skills. The original instrument with 26 skill statements grouped into five sections [22], was further adapted by adding 11 additional questions (see Appendix) to capture all the topics presented in the treatment phase of this study. The additional questions were scored in the same format as the original questions and added to the totals for each section of the tool. Analysis showed the SCSQ-A with the additional 11 questions was strongly correlated with the original instrument (0.99 for persons with TBI and 0.97 for SOs). The profile of functional impairment in communication (PFIC) [27] This is a tool designed to measure communication impairments following TBI. This tool is based on principles of social communication and the specific impairments seen in TBI. It includes 84 behaviour items assessing frequency and severity of specific

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communication impairments divided into 10 subscales: (1) Logical Content: use of logical, understandable and coherent language; (2) General Participation: participation in conversation in a manner which is organized and sensitive to the other’s interests; (3) Quantity: information provided is the appropriate amount given the other’s needs or understanding; (4) Quality: subject contributes information that appears honest and factual; (5) Internal Relation: as a speaker, the subject’s ideas are clear, cohesive, relevant and related; (6) External Relation: as a listener, the subject relates their own comments to the other’s preceding contributions; (7) Clarity of Expression: ideas are presented clearly and concisely; (8) Social Style: use of appropriate social style given the context and background of the conversation; (9) Subject Matter: subject adheres to socially, culturally or morally appropriate subject matter in conversation; and (10) Aesthetics: speech characteristics of loudness, rate, affect, articulation, phoneme stress and other aesthetic features of communication are rated. Each of the 10 PFIC sub-scales has an overall summary scale rating; 0–normal; 1–very mildly impaired; 2–mildly impaired; 3–moderately impaired; 4–severely impaired; and 5–very severely impaired. Thus, lower scores on the PFIC indicate better functional communication skills. The PFIC has shown good inter-rater reliability with high concurrent validity [27].

The Craig handicap assessment and reporting technique–short form (CHART-SF) [24] This is a widely-used measure of societal participation and community integration. The CHART-SF is comprised of six sub-scales which quantify the extent to which individuals fulfil various social roles. Two sub-scales, Occupation and Social Integration, were selected for this study. Higher scores for each of the CHART sub-scales reflect higher levels of participation, with a score of 100 indicating no handicap. CHART scores have been normed on a non-disabled population and Rasch analysis was used to verify its scaling and scoring procedures [24]. Test–re-test and participant-proxy reliability have both been shown to be high, with correlation coefficients ranging from 0.80–0.95 [28].

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The community integration questionnaire (CIQ) [25] This measure of community integration examines how the individual performs specific activities within the household or community. The CIQ is comprised of three sub-scales which include 15 items such as frequency of shopping, leisure activities, visiting friends or relatives, travel and one’s work, school or volunteer situation. Two sub-scales were used for this study, Productivity and Social Integration. Higher scores indicate greater levels of community integration. In samples of persons with TBI, reliability has been shown to be good with test–retest coefficients of 0.91 and participant-proxy coefficients of 0.89 for the total score [25]. The satisfaction with life scale (SWLS) [26] This is a measure of global life satisfaction developed by Diener et al. [26]. Life satisfaction is described as a cognitively driven component of subjective well-being. Higher scores are considered to be indicative of greater life satisfaction. This five-item scale has been used for persons with TBI [29–31].

Data collection and analysis Relevant data for this baseline study were collected between December 2002 and April 2004. During the recruitment phase of the project, data were abstracted from inpatient rehabilitation medical records to verify patient eligibility and to collect demographic and injury severity data. Within this same time period, additional demographic and eligibility data were collected via telephone interviews with participants and their SO. After informed consent for enrolment in the study, participants were asked to complete a series of self-administered questionnaires (SCSQ-A, CHART-SF, CIQ and SWLS) and to participate in a 10 minute videotaped conversational session. Corresponding SO questionnaires (SCSQ-A, CHART-SF and CIQ) were administered either in-person or via telephone interview within 14 days of the participants’ completion of the baseline data. To obtain the videotaped conversations, each participant was brought to a comfortable meeting area—similar to a living room setting—where he/she was introduced to an unfamiliar communication partner (one of eight female employees of the rehabilitation hospital’s research department). Both the participant and the communication partner were instructed to ‘talk and get to know one another’. The video recorder was turned on and left unattended for 10 minutes. Two speech language pathologists then independently rated each of the videotaped conversations using the PFIC and scores for both raters

were averaged for the analysis. Both raters were trained and tested for reliability on the PFIC. Intraclass correlation coefficients ranged from 0.33–0.71, with three of the sub-scales moderately correlated and seven sub-scales strongly correlated, indicating moderate-to-strong inter-rater reliability. All study data were entered into an AccessÕ database created in version XP. Test measures were scored using programmed modules within the AccessÕ database according to published protocols for each measure. SPSSÕ version 12.0 was used for all statistical analyses. Analytic techniques for the two research questions are described below. Which social communication skills are identified as problematic by persons with TBI, family members/significant others and clinicians? To address this question for persons with TBI and SOs, SCSQ-A data were primarily analysed using descriptive statistics. First, item means were calculated to identify the lowest rated social communication areas for both groups. Additionally, the Wilcoxon test was used to test for significant differences ( p < 0.05) between the ratings of persons with TBI and their SOs. Non-parametric tests were deemed appropriate as all social skills related data were ordinal in nature. Finally, one-way random intra-class correlation coefficients (ICCs) were computed to assess agreement between the person with TBI and the SO. Following a standard employed by others [32], ICC values below 0.30 were considered to be poor, those between 0.30–0.50 were considered moderate and those greater than 0.50 were considered strong. The ICCs were further supplemented using Spearman’s Rho as well as Bland and Altman plots. For item-level data, weighted Kappa coefficients were also calculated. The statistical analysis examined linearity, bias and variance between raters. To address this question with regard to clinicians, PFIC item and sub-scale data were analysed using descriptive statistics. Are social communication skills identified as problematic by persons with TBI, SOs and clinicians associated with reduced community reintegration and life satisfaction? To address this question, bivariate correlations between social skills and the outcome measures were calculated using Spearman’s Rho. Again, nonparametric tests were deemed appropriate as the social skills data were ordinal in nature. Social skills measures collected from persons with TBI, SOs and clinicians were compared to outcome measures provided by persons with TBI in all analyses at the sub-scale and total scale level.

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Table I. Social communication skills rated lowest by persons with TBI on the SCSQ-A.

Table II. Social communication skills rated lowest by SOs on the SCSQ-A.

Mean

Mean

I can think of two or three new places/avenues for meeting new people I am able to keep the conversation going I know when and how to end a conversation I am able to change the subject smoothly If I interrupt someone, I do it in a way that fits into the conversational flow I can think of new topics to discuss and new questions to ask My thoughts are organized

3.07 3.15 3.18 3.28 3.34 3.46 3.47

Results Social communication skills that were identified as problematic by persons with TBI Mean SCSQ-A item scores for persons with TBI ranged from 3.06–4.11, indicating perceptions of ‘sometimes’ (score 3) to ‘often’ (score 4) able to demonstrate good social communication skills. No item means reflected perceptions of ‘never’ (score 1), ‘rarely’ (score 2) or ‘always’ (score 5) able to perform well at social communication tasks. The average score across all SCSQ-A items for persons with TBI was 3.71. There were seven items (of 37 total) that had mean scores less than 3.49, below the level of ‘often’ able to perform well in areas of social communication. These seven items were the lowest rated social skills for persons with TBI (see Table I). Social communication skills of persons with TBI identified as problematic by their significant other (SO) Mean SCSQ-A item scores for the person with TBI as rated by their SO ranged from 2.85–4.18, indicating perceptions of slightly less than ‘sometimes’ (score 3) to ‘often’ (score 4) able to perform well in areas of social communication. The average score across all of the SCSQ-A items was 3.52. In contrast to persons with TBI, 18 items identified by the SO had mean scores less than 3.49, below the level of ‘often’ able to demonstrate good social communication skills in specific situations. These items were the lowest rated social skills for the person with TBI as rated by their SO (see Table II). Differences in SCSQ-A scores further illustrate the perceived differences in social communication skills as rated by the persons with TBI and their SOs. For 27 of the 37 SCSQ-A items, persons with TBI rated themselves better than their SOs did. Ten of these 27 items were found to be significantly

I can think of two or three new places/avenues for meeting new people I know when and how to end a conversation I am able to change the subject smoothly I allow them to express themselves completely without interruptions I am able to read and respond to clues that the other person is giving me I’m able to reword my comments if the listener doesn’t understand my viewpoint My thoughts are organized I can think of new topics to discuss and new questions to ask I support my opinions with facts I use a tone of voice that is assertive, not aggressive I am able to keep the conversation going I control my emotions If I interrupt someone, I do it in a way that fits into the conversational flow I am able to focus on other person and discuss his/her topics I state my ideas clearly I stay focused on the topic When asking someone to join me for an activity, I know how to give the invite I am able to control my facial and body expressions

2.86 2.96 3.04 3.17 3.19 3.24 3.25 3.25 3.31 3.31 3.31 3.33 3.36 3.39 3.42 3.42 3.47 3.48

different ( p < 0.05) using a Wilcoxon test. For the remaining 10 items where SOs ratings were higher, differences were not statistically significant ( p > 0.05). Furthermore, out of a possible 185 points on the SCSQ-A, the median score for persons with TBI was 136.5 points (25th %ile 123–75th %ile 149), while SOs averaged only 130 points (25th %ile 120–75th %ile 139). This difference was statistically significant ( p < 0.05), indicating that persons with TBI perceived themselves as functioning better than their SOs rated their functioning on social communication skills. Agreement between persons with TBI and SOs on the specific social communication skill problems identified, as measured by Intraclass Correlation Coefficients (ICCs), was generally poor. ICCs were found to be poor for 29 (78%) of the 37 SCSQ-A items and moderate for eight (22%) items. The ICC was also poor for the SCSQ-A total (ICC 0.16), indicating that persons with TBI and SOs did not agree on how well the persons with TBI performed on the various social communication skills rated. Further analysis using Spearman’s Rho, weighted Kappa coefficients and Bland and Altman plots validated the overall lack of agreement between raters.

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C. Dahlberg et al. ‘moderately impaired’ range for the General Participation (mean 2.87, SD 0.85) sub-scale.

Social communication skills impairments in persons with TBI as identified by clinicians At the item level, PFIC mean scores ranged from 0–2.03, with 0 being the best score possible and 3 being the worst score possible. Of the 84 items, seven had mean scores of 1.5 or higher, indicating that participants on average demonstrated good social communication skills in applicable areas only ‘occasionally’. These seven items were the lowest rated social communication skills for persons with TBI based upon the perceptions of the Speech Language Pathologists (see Table III). At the sub-scale level, mean scores ranged from 0.20–2.87. For the 10 PFIC sub-scales 0—normal; 1—very mildly impaired; 2–mildly impaired; 3—moderately impaired; 4–severely impaired; and 5—very severely impaired. Speech language pathologists rated persons with TBI as functioning in the ‘normal’ range for the Quality (mean 0.20, SD 0.52) sub-scale and in the ‘very mildly impaired’ range for the Subject Matter (mean 0.96, SD 1.03), Quantity (mean 1.27, SD 1.01), Logical Content (mean 1.34, SD 0.90) and Clarity of Expression (mean 1.37, SD 1.13) sub-scales. Ratings were in the ‘mildly impaired’ range for the Social Style (mean 1.68, SD 0.83), Aesthetics (mean 1.75, SD 0.83), Internal Relation (mean 2.10, SD 0.82) and External Relation (mean 2.19, SD 1.04) sub-scales. Ratings were in the Table III. Social communication skills rated lowest* by clinicians on the PFIC. Mean Asks questions (General Participation) Perceives misinterpretation of meaning (Quantity) Uses questions well (External Relation) Skilled at taking turns (General Participation) Integrates own ideas with other’s ideas (External Relation) Contributes equally to the conversation (General Participation) Helps direct the conversation (Social Style)

2.03 2.00 1.92 1.87 1.85 1.75 1.53

*Higher scores indicate poorer performance.

Associations between social communication skills and outcome measures of community reintegration and satisfaction with life For the participants with TBI, statistically significant ( p < 0.01 and p < 0.05) correlations were found between the SWLS total (mean 19.82, SD 8.47, range 5–35) and all sections of the SCSQ-A as well as the SCSQ-A total score (coefficients ranged from 0.31–0.39), indicating that poorer perceived social communication skills were associated with less satisfaction with life. For the CHART-SF Social Integration sub-scale, four of the five SCSQ-A sub-scales and the SCSQ-A total score were significantly correlated ( p < 0.01 and p < 0.05), with coefficients ranging from 0.28–0.43, indicating that poorer social communication skills, as perceived by the person with TBI, were associated with less social integration. The CIQ Productivity sub-scale was significantly correlated ( p < 0.01 and p < 0.05) with three of the SCSQ-A sections and the SCSQ-A total score (significant correlation coefficients ranged between 0.26–0.39), indicating that poorer social communication skills were associated with less productivity (e.g. work, school, volunteer). Finally, the CHART-SF Occupational sub-scale was significantly ( p < 0.05) correlated with one of the SCSQ-A sections, with a coefficient of 0.29. Overall, the results indicate that some aspects of poorer social communication skills, as measured by the SCSQ-A, were associated with less occupational participation in society as measured by the CHART-SF and the CIQ. Of the 25 correlation coefficients that were computed, 5% (or 1.25) would be expected to be significant due to chance alone. Thirteen significant correlations were identified of the 25 total, only one of which could be attributed to a Type I error (not formally tested) (see Table IV). Few associations were identified between the outcome measures for persons with TBI and the social communication ratings made by the SOs or

Table IV. Correlation between participants’ social communication skills ratings and outcomes. SCSQ-A sub-sections and total score SCSQ-A: When I express my opinions SCSQ-A: When people give opinions that differ from mine SCSQ-A: In conversations with people I don’t know very well SCSQ-A: In general conversation SCSQ-A: In other situations SCSQ-A: Total

CIQ: SI

CIQ: P

CHART: 0

CHART: SI

SWLS

0.10 (0.445) 0.09 (0.484)

0.31* (0.020) 0.26* (0.049)

0.18 (0.203) 0.11 (0.431)

0.42y (0.002) 0.21 (0.138)

0.39y (0.003) 0.31* (0.018)

0.15 (0.269)

0.25 (0.062)

0.29* (0.045)

0.38** (0.005)

0.37** (0.005)

0.04 (0.787) 0.07 (0.118) 0.16 (0.294)

0.26 (0.073) 0.37y (0.005) 0.39y (0.009)

0.10 (0.496) 0.22 (0.129) 0.13 (0.408)

0.39y (0.007) 0.28* (0.047) 0.43y (0.004)

0.31* (0.029) 0.37y (0.005) 0.38y (0.011)

SI ¼ Social Integration; P ¼ Productivity; O ¼ Occupation; SWLS ¼ Satisfaction with Life Scale. Note: Exact p-values are noted in parentheses; yp < 0.01; *p < 0.05; **p < 0.01.


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Table V. Inter-rater reliability between participants and significant others. Participants

CHART: O CHART: SI CIQ: P CIQ: SI

Significant others

Differences

n

Mean

SD

Mean

SD

Mean

SD

ICC

Spearman

41 35 52 52

72.34 80.51 4.10 7.98

33.16 22.66 1.61 2.26

64.63 83.77 3.77 8.25

34.32 25.74 1.65 2.46

7.71 3.26 0.33 0.27

31.97 23.75 1.35 2.31

0.540* 0.524* 0.645* 0.523*

0.552* 0.525* 0.656* 0.523*

O ¼ Occupational sub-scale; SI ¼ Social Integration sub-scale; P ¼ Productivity sub-scale. *p < 0.001.

clinicians. With regards to SOs, only two significant correlations were identified among the 30 coefficients examined. For clinicians, only three of the 50 coefficients examined were significant. This finding suggests that how the SO or clinician perceived the social communication abilities of the person with TBI was not closely associated with the levels of community integration and satisfaction with life as identified by the person with TBI. Other findings The total SCSQ-A showed a higher rating by males (median 138, 25th%ile 124–75th %ile 153) than females (median 118, 25th %ile 105–75th %ile 140) and the difference was statistically significant using the Mann-Whitney test ( p < 0.05). In addition, males rated themselves higher on the CHART-SF Social Integration sub-scale, with a median of 92 (25th %ile 70–75th %ile 100) compared to 57 (25th %ile 38–75th %ile 82) for females. Using a Mann-Whitney test, the difference was found to be statistically significant ( p < 0.05). Analysis of the other demographic and injury severity data showed no significant differences between the males and females. Finally, in another sub-analysis of the data, participants and SOs showed strong inter-rater reliability on CHART-SF and CIQ measures of participation (ICCs from 0.52–0.65). Both the CHART-SF Occupation sub-scale (mean 72.34) and the Social Integration sub-scale (mean 80.51) showed a decreased level of participation and social integration for this group of individuals with TBI, compared to a norm of 100 [24] (see Table V).

Discussion Which social communication skills are identified as problematic by persons with TBI, family members/ significant others and clinicians? Individuals with TBI, who were an average of 7 years post-injury for this study, rated seven specific pragmatic communication skills as more problematic using the SCSQ-A. The lowest rated area reported

by both the person with TBI and their significant other was ‘thinking of two or three new places for meeting people’, which is more of an executive function involving planning and initiation, rather than a pragmatic communication function. However, the other skills rated lowest were more typical pragmatic language functions involving conversational competence and keeping thoughts organized. The clinical impression is that the ability of the person with TBI to identify areas of reduced social communication may be a function of improved self-awareness that seems to evolve as time post-injury increases, supported in a study by Godfrey et al. [33] reporting increased insight into deficit areas beyond 1 year post-injury. This evolving awareness may assist in treatment, as the individual with TBI recognizes the potential problem areas and may be more motivated in treatment efforts. Compared to the SO perspective, individuals with TBI 1 year or more post-injury rated themselves higher in social communication skills on the SCSQ-A, a finding supported by other published studies [11, 16]. Significant other/family members observed more than twice as many problematic skill areas than the individual with TBI. In addition, the specific skills identified by the SO and the person with TBI were different. Many of the skills rated lower by the SO, but not identified by the person with TBI as problematic, involved the emotional and nonverbal aspects of pragmatic communication (e.g. responding to non-verbal cues, using appropriate tone of voice and controlling emotions, facial and body expressions). These skills rated lower by the SO are more subjective, harder to self-identify by the persons with TBI and require a greater level of selfawareness. The SCSQ [22] was developed as a tool to help identify participant’s level of awareness of their social communication skills in a group therapy setting. The tool was used to help the individual identify their communicative needs and then select treatment goals to improve social communication competence. The SCSQ as adapted was found to be a sensitive measure for this population and it was used in a similar manner as McGann et al. [22] in the treatment phase of this study.

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From the clinician’s perspective, social communication impairments were present in the individuals in this study sample as measured by the PFIC video conversation analysis. As an example, a common conversational scenario involved the partner initiating the conversation with a statement such as ‘How are you’? Then, the participant with TBI responded by going on about him/herself and not asking questions of the partner. Attempts by the partner to contribute to the conversation were often ignored. These behaviours were rated as difficulty integrating ideas, not asking questions of the partner, not contributing equally, seeming disinterested in the partner and appearing unskillful in turn taking and in overall conversational skills. Areas of least impairment rated on the PFIC included logical content or use of language, quality or truthfulness of content and socially appropriate subject matter, except for the tendency to talk too much about one’s self. The areas of impairment as identified by the PFIC are congruent with the persons with TBI reported problems in keeping a conversation going, knowing how to end a conversation, changing the subject or interrupting smoothly, initiating new topics and questions and keeping thoughts organized. The findings from the PFIC in this study are supported by other research. Coelho et al. [34] found five subjects with TBI had more difficulty initiating and sustaining conversations than normal controls. Another study reported 18 subjects with closed head injury appeared disinterested, had difficulty expressing ideas clearly and overall pragmatic language skills were decreased compared to normal controls [35]. Persons with TBI were less interesting, less rewarding, less appropriate and required more effort in conversation compared to normal controls in a large study (n ¼ 62) by Bond and Godfrey [36]. McDonald and Pearce [2] reported on 15 persons with TBI with executive impairments who had difficulty making requests and were insensitive to listener’s needs in conversation. Individuals with severe TBI (n ¼ 26) had difficulty meeting the informational needs of the listener during conversation, compared to normal controls [3]. Of note, none of the studies cited included the perspective of the person with TBI or the family member; the pragmatic communication deficits reported were based solely on clinician ratings. Are social communication skills identified as problematic by persons with TBI, significant others or clinicians associated with reduced community integration and life satisfaction? Poorer social communication skills, as perceived by the individual with TBI, were associated with less social integration and productivity. In addition,

participants with TBI who reported reduced social communication skills on the SCSQ-A also reported less satisfaction with life. Overall ratings on measures of participation and social integration showed good reliability between the person with TBI and their SO; however, there were few associations found between the SO or clinician ratings of social communication skills and the outcome measures of community integration and satisfaction with life as rated by the individual with TBI. In contrast, a study by Galski et al. [5] reported problems in conversational discourse as rated by clinicians were significantly related to social integration and quality of life in 30 subjects with TBI compared to normal controls. Both clinician and SO ratings are important to identify specific areas to be targeted in treatment and may identify problem areas of which the person with TBI is not yet aware. In addition, the findings that males reported better social skills and higher levels of social integration than females supports reports that females have a tendency to report more symptoms than males [37] or, conversely, males may tend to minimize symptoms. Either interpretation may be important in developing increased awareness and treatment strategies for improved social communication skills. A strength of this study includes the large sample size of 60 individuals which was considerably larger than most previous studies, as well as the inclusion of the perspective of the person with TBI, not found in the literature. Another strength is the analysis of social communication skills related to participation and quality of life measures, which was found in only one other study [5]. This study, however, is not without limitations. First, due to the stringent inclusion/exclusion criteria, applicability to all persons with TBI (e.g. those with psychiatric or drug/alcohol history or persons not aware of their social communication skill deficits) is unknown. Also, the study sample had a relatively higher level of education with less diversity and possibly performed better on measures of social communication skills than a more representative group of persons with TBI. Any conclusions for the general TBI population must be drawn with caution. Another limitation is the lack of availability of widely used measures that could be used by the clinician, SO and person with TBI, with well established validity and reliability. However, the measures selected did show sensitivity for identifying and measuring social communication skills in persons with TBI and are promising as clinical tools for evaluation of these skills. Subjective observations were made on the SCSQ-A and PFIC, with moderate-to-strong inter-rater reliability on the PFIC, but these measures were not checked for test–re-test reliability.

Social communication skills in persons with post-acute traumatic brain injury In addition, the study authors were interested in the initial level of self-awareness of the participants with TBI and postulated that the level of selfawareness may contribute to the level of motivation and progress in a treatment programme. A measure of self-awareness, however, was not added until halfway through the study, thus not enough data was collected to analyse in this paper. Analysis of self awareness would be an important consideration for future studies. The person with TBI, their SO and clinicians all have valid perspectives and provided empirical data to further define the issues of social communication skills in this population and highlight social skills that could be targeted for improvement. Findings from this study support a recent study reporting that higher social integration was associated with higher life and family satisfaction in 34 subjects with TBI and recommended development of treatment techniques to enhance social interactions and, thus, increase social integration and satisfaction with life [38]. A clinical trial to evaluate the efficacy of a specific treatment programme to improve pragmatic communication skills and outcomes of social integration, participation and satisfaction of life in persons with TBI is in progress. Conclusion Pragmatic communication skills deficits are common many years post-TBI. Persons with TBI are able to identify some areas of problematic social communication function, which were found to be associated with decreased societal participation, social integration and satisfaction with life. Clinicians and SOs report more social communication skill impairments than the person with TBI, as well as different areas of reduced social communication skill. Hopefully, this information can be used to develop treatment strategies for social communication problems in the individual with TBI, with the ultimate goal of improving outcomes of participation in society and satisfaction with life. The next phase of this study is to analyse the efficacy of a social communication skills treatment programme. Acknowledgements This research was supported by the Rocky Mountain Regional Brain Injury System (H133A020510-03) which is funded by an award from the US Department of Education, Office of Special Education and Rehabilitation Services, National Institute on Disability and Rehabilitation Research. The opinions expressed in this manuscript are those of the authors and do not necessarily reflect the views of the Department of Education.

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Additionally, the authors wish to acknowledge and thank the Scientific Advisor on this project, Gail Ramsberger, ScD and Associate Professor in the Department of Speech, Language and Hearing Sciences at the University of Colorado in Boulder, CO, and the Consumer Advisor, Carol Loewecke, BSN, MA, nurse case manager and the mother of a TBI survivor.

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Appendix: Additions to the social communication skills questionnaire 3. In general conversation: (eight skills in this section, 10 added as follows) I am able to initiate conversations about topics other than myself or my injury I can think of new topics to discuss and new questions to ask I am able to focus on the other person and discuss his/her topics I am able to read and respond to clues that the other person is giving me (turning away, yawning, looking bored or frightened, etc.) I can let others know when I don’t understand, by asking questions to clarify I feel confident in a conversation I can use humour appropriately (laughing only when something funny is said, not repeating jokes over and over, telling jokes only at appropriate times, etc.) I refrain from odd or offensive behaviours (standing too close to someone, twirling my hair, cracking knuckles, etc.) I can think of two or three new places/avenues for meeting new people I control my emotion (anger, giddiness, frustration, etc.) 5. Other situations: (three skills in this section, one added as follows) I can follow and participate in an hour-long group discussion Adapted from McGann et al. [22].

Always (5)

Often (4)

Sometimes (3)

Rarely (2)

Never (1)

Always (5)

Often (4)

Sometimes (3)

Rarely (2)

Never (1)