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9
Language and Social Communication
OVERVIEW
Traumatic brain injury (TBI) may cause deficits in language and so-
cial communication, sometimes experienced by delayed word recall or a
diminished ability to detect emotion while communicating with others.
Such impairments may lead to frustrating or embarrassing experiences and
affect an individual’s family dynamic, social life, and employment status.
Cognitive rehabilitation therapy (CRT) interventions for language and so-
cial communication impairments may target social or emotion perception,
social skills, or communication skills. Aphasia is another possible language
impairment following acquired brain injury, although more common af-
ter stroke than TBI. The committee did not identify literature describing
CRT interventions for aphasia after TBI. The following chapter describes
controlled studies in language and social communication, followed by the
committee’s conclusions.
The committee identified and reviewed four randomized controlled tri-
als (RCTs) of language and social communication cognitive rehabilitation
(Bornhofen and McDonald 2008a, 2008b; Dahlberg et al. 2007; McDonald
et al. 2008). The committee found no studies of CRT for the domain of
language and social communication for mild TBI, or for moderate-severe
TBI in the subacute phase. All four trials were in the outpatient setting
and enrolled moderate-severe TBI patients in the chronic phase of recov-
ery. Two of the four RCTs focused solely on CRT for emotion perception
deficits, one RCT focused on social communication skills training, and one
RCT incorporated a combination of both social skills training and social/
163
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164 COGNITIVE REHABILITATION THERAPY FOR TBI
emotion perception training. To be included, participants generally had to
have sufficient language and cognitive capability to participate in a group,
and have impairment in social communication skills either based on a
questionnaire or a referring clinician’s assessment. One of the four RCTs
had some form of CRT in both trial arms but also included comparison to
a waitlist arm. The committee also identified one nonrandomized, parallel
group controlled design (Hashimoto et al. 2006). This study was in the
chronic phase of recovery for patients with moderate-severe TBI. Subjects
were instructed on social skills training; no treatment was provided to the
comparator arm (Hashimoto et al. 2006). Table 9-1 presents a summary of
all included studies in this review.
CHRONIC, MODERATE-SEVERE TBI
Randomized Controlled Trials
Two trials focusing on treatment of emotion perception deficits were
reported by Bornhofen and McDonald (2008a, 2008b). Emotion percep-
tion was defined as “accurate decoding and interpretation of visual and
aural stimuli that signal 1 of 6 emotional states.” The CRT program
reported by Bornhofen and McDonald (2008a) included group activities,
and a notebook and home practice to teach increasingly complex skills on
emotion perception. Sessions were held twice weekly, for 1.5 hours each
over 8 weeks; 25 hours total. One therapist (background not described)
was assigned to every two or three participants. The 12 participants were
receiving outpatient services for TBI and were recruited and allocated at
random to treatment or to a waitlist group; there was one dropout. Study
outcomes were measures of facial expression (naming and matching), The
Awareness of Social Inference Test (TASIT), and psychosocial reintegration.
Immediately posttreatment, the intervention yielded significantly better
TASIT scores relative to the waitlist group. While the intervention group
scored better posttreatment on one form of the facial expression measure
(matching), the groups scored the same on the alternate form of the facial
expression measure (naming), and psychosocial reintegration. One month
follow-up scores in the treatment arm were significantly higher than scores
prior to treatment on all measures.
The other trial reported by Bornhofen and McDonald (2008b) had the
goal of teasing apart the effective components of the intervention in the trial
described above, by separating and comparing an errorless learning strategy
with self-instruction training (which were combined in the 2008a study in-
tervention), with a waitlist control group; both interventions also aimed to
remediate emotion perception deficits. The interventions comprised a total
of 25 hours of treatment across 10 weeks, divided into weekly, 2.5-hour
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TABLE 9-1 Evidence Table: Language and Social Communication
TBI
Severity
Study N Level Brief Narrative Comparator Outcome Measures Findings
RCT
Bornhofen 12 Severe This study investigated Y • Facial Expression Matching At immediate post-
and whether social perception Task treatment, the
McDonald deficits could be No Content: • Facial Expression Naming Task intervention yielded
2008a remediated through Waitlist control • The Awareness of Social significantly better
cognitive rehabilitation, group Inference Test (TASIT), Parts 1, social inference (TASIT)
using a treatment program 2, and 3 scores relative to
that incorporated • The Sydney Psychosocial the waitlist group.
techniques previously Reintegration Scale (SPRS), While the intervention
known to be effective with Current Status – Self Ratings group performed
the TBI population. better posttreatment
on scores of one
form of the matching
measure, there was
no difference between
groups on the alternate
form of the matching
measure, naming
facial expression,
or psychosocial
reintegration. One
month follow-up
scores in the treatment
arm were significantly
higher than prior
to treatment on all
measures.
165
continued
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166
TABLE 9-1 Continued
TBI
Severity
Study N Level Brief Narrative Comparator Outcome Measures Findings
Bornhofen 18 Severe The objective of this Y • Primary outcome measures: Both treatment groups
and study was to compare the ▪ Audiovisual emotional improved modestly in
McDonald efficacy of two strategies, No Content: displays: TASIT, Part 1 emotion perception;
2008b errorless learning (EL) and Waitlist control (Forms A and B) and there is limited evidence
self-instruction training group social inferences based on to suggest that SIT
(SIT), for improving emotional demeanor may be a favorable
deficits in emotion ▪ Higher order social inference approach for this type
perception. making: TASIT, Parts 2 and of remediation.
3 (Forms A and B)
▪ Identification of static
emotion: Facial Expression
Same/Different, Naming,
and Matching Tasks
• Generalization measures:
▪ Current Status–Relative
Ratings (SPRS–Relative)
▪ Depression Anxiety Stress
Scales (DASS)
▪ Katz Adjustment Scale–
Relative Report Form
(KAS–R)
▪ Relative Ratings (SPSS-
Positive and SPSS-Negative)
▪ Social Performance Survey
Schedule
▪ SPRS and SPRS-Self
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Dahlberg 52 Moderate- The study evaluates Y • Community Integration PFIC subscales showed
et al. 2007 Severe the efficacy of a group Questionnaire social more improvement
treatment program that No Content: integration and productivity for treatment versus
targets the broader Waitlist control subscales (CIQ) control; SCSQ–A self-
definition of social skills, group • Craig Handicap Assessment report ratings showed
uses a group process and Reporting Technique more improvement
approach, emphasizes Short Form social integration for treatment versus
self-assessment and and occupation subscales control. Scales
individual goal setting, and (CHART-SF) showed immediate
encourages generalization • Goal Attainment Scaling (GAS) improvement, with
through homework • Profile of Functional some preserved
and family or friend Impairment in Communication improvement at 3- and
involvement. (PFIC) 6-month follow-up.
• Satisfaction with Life Scale
(SWLS)
• Social Communication Skills
Questionnaire–Adapted
(SCSQ–A)
McDonald 39 Severe The aim of this study Y • Primary outcomes: Relative to the waitlist
et al. 2008 was to determine whether ▪ Emotional adjustment: DASS control, social activity
remediation would be No Content and ▪ Social behavior: BRISS-R, alone did not lead to
effective in improving Non-CRT Content: PDBS, and PCSS improved performance
social skills deficits, such Waitlist control ▪ Social perception: TASIT on any outcome
as unskilled, inappropriate group; Social • Secondary outcomes: variable. The skills
behavior; social perception; activity group ▪ Katz Adjustment Scale–RI training group did
and mood disturbances ▪ La Trobe Communication improve differentially
(e.g., depression and Questionnaire on the PDBS of the
anxiety). ▪ Social Performance Survey BRISS-R, while no
Schedule treatment effects were
▪ Sydney Psychosocial found for the other
Reintegration Scale primary outcomes or
any of the secondary
outcomes.
167
continued
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TABLE 9-1 Continued
168
TBI
Severity
Study N Level Brief Narrative Comparator Outcome Measures Findings
Nonrandomized, Parallel Controlled Group
Hashimoto 37 Moderate- This study assessed the Y • Activities of daily living: The enrolled subjects
et al. 2006 Severe efficacy of a comprehensive ▪ FIM version 3.0 displayed significant
day treatment program. No Content: ▪ FAM improvements in speech
Patients who did • Societal participation: intelligibility, problem
not join the day ▪ Community Integration solving, memory,
treatment program Questionnaire (CIQ) attention, and social
integration scores in the
FIM/FAM and scores in
social integration and
productive activity in
the CIQ.
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LANGUAGE AND SOCIAL COMMUNICATION
sessions; in each session, a therapist worked with a group of two or three
patients. The 18 participants were randomized to one of the three study
arms; of these, there were five dropouts. Outcome measures included facial
expression recognition, facial expression naming and matching, psycho-
social reintegration, and depression and anxiety, as well as relative ratings
of adjustment, social performance, and psychosocial reintegration. There
were few statistically significant differences across these very small (four or
five patients per arm) arms on study outcome measures.
Dahlberg et al. (2007) used a randomized trial to evaluate an outpatient
group treatment program aimed at improving social communication skills
after TBI. They employed a treatment workbook (Social Skills and TBI:
A Workbook for Group Treatment) and limited each group’s size to eight
participants. Each group met weekly for 1.5 hours for 12 weeks (18 hours)
and was co-led by professionals from social work and speech pathology.
Early sessions focused on self-assessment and goal setting, middle sessions
focused on learning strategies for those goals, and later sessions focused on
generalization; homework was assigned between sessions. Family members
were involved outside the group setting. The 60 adults with TBI were ran-
domized to either immediate participation in the social communication pro-
gram or delayed treatment 3 months later; 52 people completed the study.
The early treatment arm was followed for 36 weeks following completion
of the program, and the delayed treatment arm was followed for 24 weeks.
Primary outcomes were an objective measure of social communication skills
(based on blinded raters’ assessments of videotaped interactions of the par-
ticipant with research assistants, who were blinded to group assignment);
a subjective assessment of social communication; and a Goal Attainment
Scaling measure. Secondary outcomes were two assessments of community
integration and one measure of life satisfaction. The researchers found that
12 weeks after the treatment sessions had ended, the intervention versus the
control group had better scores on 7 of 10 scales of the primary outcome
measure, which was the objective measure of social communication skills,
as well as on the subjective assessment of social communication. There were
no differences on the secondary outcome measures. Score improvements
were maintained in both groups through 6-month follow-up.
McDonald et al. (2008) conducted a randomized trial of social behav-
ior and social/emotional perception training compared to one control group
receiving the same amount of time in grouped social activities; a second
control group was waitlisted. The CRT intervention was 12 weeks at 4
hours per week, or 48 hours total, at an outpatient or community facility.
It included group sessions each week focusing on social behavior train-
ing (2 hours) and social perception training to help decode expressions of
emotion and social inferences (1 hour). The fourth hour each week was an
individual session with a clinical psychologist who employed cognitive be-
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170 COGNITIVE REHABILITATION THERAPY FOR TBI
havioral therapy (CBT) techniques to address emotional adjustment. Across
the three trial arms, 51 subjects were enrolled and randomized. Due to
scheduling conflicts, nine subjects were reassigned to other arms after ran-
domization and to balance numbers across arms. Outcomes measured in-
cluded social behavior (based on blinded raters’ assessments of videotaped
encounters of participants with an actor), measured by the Partner Directed
Behavior Scale and the Personal Conversational Style Scale; both scales are
part of the Behaviorally Referenced Rating System of Intermediary Social
Skills (Revised). Other primary outcomes were the TASIT to assess social
perception, and self-reported depression and anxiety. Secondary outcomes
included a relative’s rating of social behavior on the Katz Adjustment Scale,
a social performance survey, a communication questionnaire, and both self-
and relative ratings on a psychosocial reintegration scale. Findings showed
that the social skills treatment arm performed significantly better on the
Partner Directed Behavior Scale compared to the social activity or waitlist
trial arms (p = 0.004; effect size 0.70). There were no other differences
across arms on any other primary or secondary outcome measures. Study
limitations included insufficient power due to both attrition and to smaller
effect sizes than anticipated, as well as the reassignment of participants
from their initial randomization arms.
Nonrandomized, Parallel Group Studies
Hashimoto et al. (2006) evaluated an outpatient, day treatment pro-
gram in Japan targeting social skills training. The treatment ranged from of
a minimum of therapy for 2 hours per day, twice each week over 3 months
(52 hours), to 4 hours per day, twice per week for 6 months (208 hours).
The rationale for the variation in volume of day treatment program sessions
was not provided. CRT content included social skills training by a clinical
psychologist/speech therapist based on an approach of teaching improved
behaviors by “redesigning the subjects’ environment.” CRT interventions
also included occupational therapy, family conferences, sports, vocational
rehab, and cooking. Services were delivered by a rehabilitation team, in-
cluding the following: doctor/nurse, social worker, clinical psychologist/
speech therapist, vocational rehabilitation counselor, physical therapist,
rehabilitation gymnastic trainer, occupational therapist, and others. The
sample was 25 adults (22 with TBI) ages 19 to 56. A control group con-
sisted of 12 outpatients with TBI from the same medical center who met
eligibility criteria but did not participate in the program. The study does
not explain how participants were selected or why some selected partici-
pants did not participate in the program. Functional Independence Measure
(FIM) and Functional Assessment Measure (FAM) scores and the Com-
munity Integration Questionnaire (CIQ) were collected before and after
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171
LANGUAGE AND SOCIAL COMMUNICATION
participants completed the program (although it is not clear when the data
were obtained for controls). CRT recipients were compared with controls
on mean improvement in scores on these measures. While the groups did
not differ on total social cognition, communication, or FIM motor score
improvement, the participants improved more than controls on 5 of 12
FIM/FAM scales including social integration, attention, memory, prob-
lem solving, and speech intelligibility. On the CIQ, program participants
improved significantly more on the total score and on subscale scores of
social integration and productive activity than did controls; there was no
difference in improvement on home integration.
CONCLUSIONS: LANGUAGE AND SOCIAL COMMUNICATION
The committee found the evidence of language and social communica-
tion CRT not informative about impact (efficacy) on patient-centered
outcomes (quality of life, functional status). The evidence does not
rule out a potentially meaningful effect of social communication skills
or emotional perception skills training on psychosocial outcomes of
community reintegration in adults with chronic, moderate-severe TBI
(Hashimoto et al. 2006).
The committee found limited evidence for sustained effect of language
and social communication CRT among chronic, moderate-severe TBI
patients from the two RCTs that assessed sustained treatment effects.
These studies found that beneficial effects on social communication skills
or emotion perception were maintained through 1 month (Dahlberg et
al. 2007) and 6 months (Bornhofen and McDonald 2008a).
The committee found modest evidence from a synthesis of findings
across four RCTs and one nonrandomized trial for benefit of CRT on
social communication skills among chronic, moderate-severe TBI pa-
tients. Efficacious interventions were small group, outpatient programs,
meeting once to twice weekly for approximately 3 months. These inter-
ventions also employ a standardized protocol for social communication
skills training, with or without emotion/social perception deficit train-
ing or CBT. In general, appropriate candidates for these programs were
individuals with demonstrated language and social communication
deficits, and who had sufficient language and cognitive capacity to par-
ticipate in a group program (Bornhofen and McDonald 2008a, 2008b;
Dahlberg et al. 2007; Hashimoto et al. 2006; McDonald et al. 2008).
In summary, the committee identified and reviewed four RCTs of lan-
guage and social communication cognitive rehabilitation (Bornhofen and
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172 COGNITIVE REHABILITATION THERAPY FOR TBI
McDonald 2008a, 2008b; Dahlberg et al. 2007; McDonald et al. 2008),
all with chronic phase, moderate-severe TBI patients. Two studies focused
solely on CRT for emotion perception deficits, one focused on social com-
munication skills training, and one incorporated a combination of both
social skills training and social/emotion perception training. Participant
eligibility included having sufficient language and cognitive capability to
participate in a group, and impairment in social communication skills
either based on a questionnaire or a referring clinician’s assessment. The
committee also identified a nonrandomized, parallel group controlled de-
sign study of social skills training versus a “no treatment” comparator arm
(Hashimoto et al. 2006), for a total of five studies reviewed. There were
no studies on CRT for language and social communication deficits among
patients in the subacute phase of TBI or patients with chronic, mild TBI.
One noteworthy aspect of these five CRT interventions was their relative
feasibility in terms of service delivery. These CRT interventions ranged in
time from 18 to 52 hours of services over 3 months; they all included de-
livery with small groups of patients; one employed an available workbook/
manual; and most involved no more than two therapists (either social
work, clinical psychology, or speech pathology, where specified). The types
of intervention in these trials were either social communication skills train-
ing, emotion perception deficit training, or both; one trial also included 12
sessions with a clinical psychologist to deliver CBT.
Despite the fact that none of the five trials had more than 30 subjects
in a given treatment arm, four of the trials yielded positive findings of
the CRT intervention relative to controls on primary study outcomes of
either improved social inference, where emotion perception deficits was a
target (Bornhofen and McDonald 2008a), or social communication skills
(Dahlberg et al. 2007; Hashimoto et al. 2006; McDonald et al. 2008);
the exception to these findings was one very small trial (Bornhofen and
McDonald 2008b). Only two studies examined outcomes after the im-
mediate follow-up after the CRT program ended. One RCT (Dahlberg
et al. 2007) found persistence of improvements in social communication
skills through 6 months after the program ended, and another (Bornhofen
and McDonald 2008a) found persistence of improvements in awareness
of social inference through 1 month after the program ended. Only the
nonrandomized, parallel group study (Hashimoto et al. 2006) showed im-
provements on more “distal” outcomes of social integration and productive
activity. While not powered to detect smaller but potentially meaningful ef-
fects, Dahlberg et al. (2007) and McDonald et al. (2008) found that scores
across treatment and waitlist groups on psychosocial outcome measures did
not trend toward a difference in magnitude.
There is evidence to support benefit of small group outpatient pro-
grams, meeting once to twice weekly for approximately 3 months, and
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LANGUAGE AND SOCIAL COMMUNICATION
employing a standardized protocol for social communication skills training.
Applied in the community setting, such a program may or may not include
concurrent emotion/social perception deficit training and CBT. Evidence
shows these programs have beneficial impact on social communication
skills among adults with moderate-severe TBI in the chronic phase of recov-
ery. Patients with demonstrated language and social communication deficits
should have sufficient language and cognitive capacity to participate in a
group program. Evidence does not show if any subgroups are more likely
to benefit than others.
REFERENCES
Bornhofen, C., and S. McDonald. 2008a. Treating deficits in emotion perception following
traumatic brain injury. Neuropsychological Rehabilitation 18(1):22–44.
———. 2008b. Comparing strategies for treating emotion perception deficits in traumatic
brain injury. Journal of Head Trauma Rehabilitation 23(2):103–115.
Dahlberg, C. A., C. P. Cusick, L. A. Hawley, J. K. Newman, C. E. Morey, C. L. Harrison-Felix,
and G. G. Whiteneck. 2007. Treatment efficacy of social communication skills training
after traumatic brain injury: A randomized treatment and deferred treatment controlled
trial. Archives of Physical Medicine and Rehabilitation 88(12):1561–1573.
Hashimoto, K., T. Okamoto, S. Watanabe, and M. Ohashi. 2006. Effectiveness of a compre-
hensive day treatment program for rehabilitation of patients with acquired brain injury
in Japan. Journal of Rehabilitation Medicine 38(1):20–25.
McDonald, S., R. Tate, L. Togher, C. Bornhofen, E. Long, P. Gertler, and R. Bowen. 2008. So-
cial skills treatment for people with severe, chronic acquired brain injuries. A multicenter
trial. Archives of Physical Medicine 89(9):1648–1659.
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