Frequently Asked Questions about research reported at the Society for Neuroscience Meeting 2009 on traumatic brain injury

"Demonstrating disability following traumatic brain injury should include objective measures of social abilities: Towards a social IQ test"; presented by Valerie E. Stone, Ph.D. & Catherine A. Hynes, Ph.D.

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Why did you do this study and what are your basic findings?

No one would want to see someone who is genuinely disabled being denied benefits he or she needs. Yet exactly this happens to some people with traumatic brain injuries (TBI). The way neuropsychological assessments are currently done may not capture all symptoms, particularly social/emotional deficits. Most widely-used neuropsychological tests focus on cognition, e.g., memory and attention, but long-term changes in social judgment and emotional processing are common following TBI.

To help fill a gap in objective tests, we developed 4 new measures to assess social/emotional competencies quantitatively. On all four, people with moderate to severe TBI from closed head injuries scored lower than a comparison group without brain damage who were matched on age, education, and substance use history.

Our most surprising result was that a composite of 3 social/emotional measures could predict who had a brain injury and who did not, whereas a composite of 3 commonly-used cognitive measures could not make that prediction. These results leads to an unexpected conclusion: for moderate to severe TBI, social/emotional measures can be more sensitive measures of TBI symptoms than some commonly-used cognitive tests.
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What were your tests like?

  • One was a questionnaire we gave to the participants' family or friends to fill out about them, one that was specifically targeted at social skill. Because people with traumatic brain injury (TBI) do not always have self-insight, they might not be aware that they had social skill deficits, so we had to have someone else rate them. We had showed in a previous study that the questionnaire was a good predictor of a lot of other social things: how much someone liked a given person, how socially anxious that person was, how empathic that person was. There was a big difference between how family and friends of people with TBI rated their social skills (ratings were pretty low), and how family and friends of our comparison group without TBI rated them - much higher.
  • One was a video-based test, in which participants watched 10 second clips of two actors having a social interaction and after each clip, answered questions about the characters’ intentions, emotions, and attitudes towards one another. We liked the idea of having a video test, instead of having them read a story or press buttons on a computer, because it’s more like watching social behavior in real life. The people with TBI in our study had real difficulty with this test. Their scores on this test correlated with their social skill from the questionnaire measure, so if they had poorer social skills, they had more trouble knowing what others intended or felt on this test.
  • Another was a test that asks participants to watch short animated cartoons of social interactions between geometric shapes and answer a question about what was going on in the cartoon. Even though it's just a circle and triangle moving around, people easily see this as two people ineracting. This test has been used in social neuroscience research before, and a few years ago, it was found that people with autism didn't see anything social. It's also been reported here at this conference several years ago that patients with bilateral amygdala damage did not see anything social in the cartoons. People with autism or with amygdala damage are quite different from people with traumatic brain injury (TBI), but all of those groups have some social difficulties, so we wanted to see what would happen with people with TBI. They had some trouble with it, but the differences between them and the control group didn't quite reach statistical significance, so we can only say there was a trend in the predicted direction. Their scores on this test did correlate with their social skill from the questionnaire measure, so if they had poorer social skills, they had more trouble with this test.
  • Another was a test of being aware of your own physiological state, which is a key element to being aware of your own emotional state. It was a heartbeat detection task. We just clipped a heart rate monitor onto participants’ fingers, and they listened either to their own heartbeat in real time, or to their heartbeat with a delay introduced, by computer. The two types of trials they might listen to were randomly intermixed, and they just had to say for each trial whether it was their heartbeat or not. The people with TBI in our study had real trouble doing this. We hope that a measure like this might give a good indication of someone's awareness of their own emotions, which could be really useful clinically.
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What are the implications of your research?

  • We recommend a change of practice in how patients with moderate to severe TBI are assessed, and we believe that objective, quantitative measures of social competency must be added to neuropsychological assessment protocols.
  • New rehabilitation methods could become available if the person’s primary problems are assessed in the right kind of detail. One person with TBI might have problems with interrupting others, but have a good sense of when not to trust someone. A different person with TBI might not interrupt much, but might not have a good sense of when others have bad intentions. These differences are important to assess, because the two people would need very different kinds of rehabilitation.
  • Also, if their social deficits are assessed objectively, people with TBI who have these kinds of problems might get benefits, when previously they were denied. For example, when social judgment problems mean that someone with TBI has difficulty holding down a job, but that person’s cognition is relatively intact, right now he or she is often denied benefits from an insurer, or disability benefits, because the right assessment tools for these symptoms (social deficits) have not been used. Valerie Stone (co-author) is trying to educate trial lawyers about this with her business, Answers About Competency, through offering continuing education workshops, so that plaintiff’s attorneys have a better chance of winning benefits for those who truly need them, and so that they don’t waste energy on cases in which the person is not really disabled.
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What is the next step in this research?

We need to do a larger validation study with more people with TBI, and start to collect norms for different age groups and ethnic groups. Once we’ve done that, we hope to make these tests available to clinicians to use in their practices with people with TBI. In the long run, we also hope to investigate whether these tests are useful for people with other disorders that affect social behavior.
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How common are social problems after traumatic brain injury (TBI)?

Problems with social judgment (who to trust, being sensitive to others’ feelings) and inappropriate social behaviour are very common in cases of moderate to severe traumatic brain injury (TBI). Social deficits can also occur in what are called "complicated mild TBI" cases. The severity of social problems varies widely, ranging from having trouble keeping track of what’s going on in a conversation, to disclosing information that’s too personal in a certain social context, to making very inappropriate sexual suggestions, as an extreme.
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Could there be someone with traumatic brain injury (TBI) whose memory and cognition was fine, but who had severe social deficits?

Yes, absolutely. There are many documented cases in medical journals. Sometimes a person has both cognitive and social deficits, but some people with moderate to severe TBI have just the social deficits, so people don’t really believe that they’re disabled. But they are, and they need support and rehabilitation.

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Are there treatments available for people with traumatic brain injury (TBI) who have problems with social judgment and appropriate social behaviour?

Yes, there are many good rehabilitation programs available, and with proper support and rehabilitation, social problems do improve for people with TBI. But, it’s very important for patients and families to realize that someone with TBI needs support and rehabilitation to work on these issues. The person with TBI needs to seek help, and those around them need to help them get treatment.
Treatments available:
     There’s a method of rehabilitation called "Cognitive Rehabilitation" used here in the U.S. that usually includes some focus on interpersonal communication problems, which are often social problems. The person’s social problems are assessed qualitatively, but they are treated in rehabilitation. We would encourage clinicians to assess social problems both qualitatively and objectively, to guide rehabilitation more precisely.
     In Brisbane, Australia, Catherine Hynes (co-author) is working as a neuropsychologist at a hospital, so the patients she works with are certainly getting rehabilitation targeted to their social difficulties.
     In Colorado, rehab specialists Lenny Hawley and Jody Newman have developed a program called the Group Interactive Structured Treatment that focuses specifically on improving social skills. Group Interactive Structured Treatment is a cognitive-behavioral group therapy intervention addressing the cognitive, emotional, and communicative aspects of social competence for people with TBI. They published a study in 2007 done with Cynthia Dahlberg and other colleagues at Craig Hospital in Denver, showing that the program was effective, and did improve interpersonal communication problems. (See Useful Articles for the citation.)
     Skye McDonald in Australia published a study in 2008 with colleagues from U of New South Wales, Sydney University, and the Liverpool Brain Injury Unit in Sydney showing that a specific social skills intervention did have positive effects on some social skills. (See Useful Articles for the citation.)

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How are clinicians assessing social deficits now?

Some clinicians don’t assess them. Most psychologists do assess social deficits now, it’s just that they’re doing it qualitatively, and somewhat subjectively. The problem for clinicians is that there are fewer tests and assessment tools available to assess social deficits objectively than to assess cognitive deficits. Furthermore, many clinicians are not aware of the few new tools that exist on the market now: Skye McDonald’s "The Awareness of Social Inference Test (TASIT)" is one of the very few currently available commercially that’s specifically targeted to social skills. Some of the social subscales on scales developed to measure other things can be helpful too, like the Neuropsychology Behavior and Affect Profile. Clinicians need to know about these, and that’s what Valerie Stone (co-author) is trying to do with her business, Answers About Competency, by offering continuing education workshops to psychologists to let them know what’s available now. Catherine Hynes is beginning a brilliant research career on these issues (says her former advisor, Valerie Stone), and also works in a rehab hospital in Brisbane, so the patients in that hospital will benefit from her expertise.
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What are some of the real-world consequences of problems with social judgment and appropriate social behaviour?

  • Being rejected by other people after behaving inappropriately.  Our society would never blame someone with a stroke for talking differently after the stroke, but generally, our society doesn’t recognize that social behaviour problems can be brain-based. Parts of the brain are specialized for processing social and emotional information. When those areas are damaged, as they can be in TBI, socially inappropriate behavior is a neurological consequence of the damage. The person may have trouble reading social cues, inhibiting impulses, or being aware that their behavior is inappropriate. This doesn’t mean the person can’t learn to control the behavior, but they need very specific rehabilitation to address this. In the early stages, often people with TBI really can’t help it. It’s not just a matter of will power. It’s a matter of needing the right kind of rehabilitation and support.
  • Marital disruption.  In Oct. 2009, at a Brain Injury Association conference in Denver, Tina Trudel from the U of Virginia talked about some of the problems she’s seen in older people with brain injuries that they got when they were young. When she compared them to people their same age without TBI, fewer people with TBI ever married, and of those who did marry, more were divorced.
  • Difficulty with employment. Most jobs involve social interaction, and so social deficits can lead to problems with co-workers on the job. Bosses and co-workers may need to be educated about these issues.
  • Being exploited in some way by social predators, whether the predator is a sub-prime mortgage broker, a scam artist, or a rapist. Some people with social deficits fall for money-related scams, and can be ruined financially that way. Sexual exploitation can range from date rape to being conned into an inauthentic marriage so the con artist can get some resource (money, a green card, etc.)
Social judgment problems are real, and people with TBI who have these problems need support and rehabilitation to avoid the negative consequences.
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What are some examples of the social deficits people suffer after TBI?

  • Someone who has trouble tracking a multi-person conversation might miss something important that happened, and say something off-topic, or make a poorly-timed joke.
  • Someone who has trouble inhibiting impulses might blurt out something insulting when it first comes into his or her head.
  • Someone who doesn’t track social context well might reveal something too personal to someone who doesn’t know them well, and inadvertently put that person off.
  • Someone who doesn’t judge others’ intentions well might trust someone who shouldn’t be trusted. I (V. Stone) knew one patient who got married to a woman who just began transferring money from his bank account to her own private bank account, and his family had to intervene.
  • Someone who has trouble regulating emotions might fly into a full-blown rage over a minor incident, instead of just being annoyed.
  • Someone who is impulsive might interrupt others in conversation, causing others to be frustrated or to reject him or her.
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Can I get a copy of the press release or your poster?

For the lay summary for the press, click here.
For a pdf of the poster presented at the Society for Neuroscience, click here.
Copies of other papers by Dr. Valerie Stone are available under Useful Articles on this web site. Email Catherine Hynes (cahynes@gamil.com) for copies of her other papers.

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Which other scientists could I ask to comment about this research?

Dr. Robert T. Knight, M.D. , UC Berkeley's Helen Wills Center for Neuroscience, expert on frontal lobe injuries
Dr. Jean Decety, Editor of the journal Social Neuroscience, Professor of Psychology and Psychiatry, U of Chicago, expert on brain basis of social behaviour
Dr. Maarten Milders, Professor of Psychology, University of Aberdeen, UK, expert on social consequences of TBI
Dr. Jose Lafosse, Former Director of Neuroscience Program, Regis University, Denver, CO, expert on TBI, both as a researcher and a private clinical neuropsychologist

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Would your results apply to returning veterans with blast-related traumatic brain injuries (TBIs)?

     Recent studies of blast-related TBI’s show little difference in psychological and cognitive symptoms between blast-related TBI’s and TBI’s from a physical blow to the head, so the current scientific understanding would lead us to believe that our results would apply, that the same kinds of social symptoms would be expected in these veterans, although obviously specific research on that question would be needed for us to be certain. From talking to rehab specialists in the VA system, I (V. Stone) have heard that veterans can have a kind of double-whammy, of suffering the social/emotional symptoms typical in TBI, combined with post-traumatic stress disorder. Veterans really need support and understanding in dealing with these consequences.
     Note, however, that our results apply only to people with non-penetrating TBI’s, also called "closed head injuries"; our results might not apply to someone with a brain injury from, say, a bullet entering the brain. With a brain injury caused by an object that penetrates the brain, the person's deficits would depend on the brain areas damaged by the object.
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You’re saying that people’s personalities can change because of damage to their brain? That we shouldn’t blame people with TBI for behaving inappropriately?

Yes, that is exactly what we are saying. Lay people really struggle with believing that inappropriate social behavior can be caused by brain damage. Social inappropriateness and emotional outbursts are not necessarily a moral failing or personal failing. Sadly, people with TBI are often blamed for their inappropriate behavior or emotional outbursts. But we need more public understanding that brain tissue does allow you to monitor your behavior and there are certain circuits in the brain that process social information specifically.

Because people don’t recognize that problems with social judgment and appropriate social behaviour can stem from brain damage, people with TBI aren’t always getting the compassion, the care, or the compensation that they need and deserve.

A stroke victim who doesn’t speak isn’t choosing not to speak; he or she can’t help it. It’s the same with moderate to severe TBI and social deficits. Now, the fact that social problems can be caused by brain damage doesn’t mean the person can’t learn to control the behavior, but they need very specific rehabilitation to address this. In the early stages, often people with TBI really can’t help it. It’s not just a matter of will power. It’s a matter of needing the right kind of rehabilitation and support.

Saying that brain damage causes the problem isn’t an excuse for poor behavior, it’s an explanation of the behavior and a call for action on the part of clinicians and families. If someone has a cough, you don’t blame them for the cough, but you expect them or their family to get them treatment for the cough. Same with TBI and social problems; people with TBI or their family should get them rehabilitation to address the social deficits.
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What do you think about researchers’ referring to such personality changes as "acquired sociopathy"?

It’s very unfortunate that this terminology has been used in scientific literature about people with frontal lobe damage, which can be caused by TBI. It’s not a description that fits the personality changes that follow TBI, or frontal damage. A sociopath is someone who deliberately harms others to benefit him- or herself, who shows a pervasive pattern of disregard for, and violation of, the rights of others. People with frontal lobe damage, whether from TBI or not, are far more likely to be the victims of sociopaths than to act like sociopaths. Our research shows that people with TBI don’t track others’ intentions well, so they are more vulnerable to victimization.

I think this unfortunate term was chosen by researchers who noted that people with damage to the frontal lobes could lose empathy for others, and that some of them were prone to fits of what is called "reactive aggression" - losing their tempers in reaction to frustration of some goal. These two things can happen after frontal lobe damage, whether from TBI or not, but those two characteristics do not make someone a sociopath. Just to clarify some anatomy, researchers using the term "acquired sociopathy" have studied people with damage to certain parts of the frontal lobes: orbitofrontal cortex (the lower surface of the frontal lobes) or ventromedial frontal cortex (the lower part of the middle of the frontal lobes).
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What do you mean by "Towards a social IQ test?"

Psychology has very good methods for testing people's cognitive competencies with an IQ test: IQ is broken down into several components, measured by different objective subtests, and we know how people of many ages and cultures perform on an IQ test, so we have good population norms to compare individuals’ IQ scores to. We want to get to that point with testing social competency. No one would accept it as a measure of cognitive competency if a clinician just talked to a person, talked to their family, and wrote some qualitative conclusions about how smart the person seems to be. It would be considered too subjective. But that’s exactly what people do with assessing social competency right now.

We want social neuroscientists to keep working on what the components of social competency are, develop objective subtests to measure different aspects of social competency, and gather data on how people of different ages and cultures perform on those tests. Courts, for example, would take such an objective "social IQ" test more seriously. Achieving that goal is years off right now, but we're trying to take a step in that direction. We hope other researchers will also.
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Are there people with other kinds of brain-based disorders who might be affected by problems with social judgment and appropriate social behaviour?

Yes, there are many conditions where deficits in social judgment and appropriate social behaviour are problems:
  • Dementia, especially a rare type called frontotemporal dementia, which affects some of the same brain regions that are commonly damaged in more severe TBI’s.
  • Brain tumors could affect social functioning, depending on the location of the tumor, or areas affected when the tumor is removed.
  • Schizophrenia In fact, there was an article published in the Journal of the International Neuropsychological Society this year (2009) showing that objective measures of social competency did a better job of predicting community functioning for people with schizophrenia than did cognitive measures.
  • Attention Deficit Disorder (A.D.D.) Even people with A.D.D. might have some social skill issues, if they’re not paying attention to what other people are doing or saying, or if they act impulsively.
  • Autism and Asperger syndrome. Obviously, deficits in the social realm are one of the defining features of autism spectrum disorders.
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How many people are affected by traumatic brain injury (TBI) every year?

"Of the 1.4 million who sustain a TBI each year in the United States, 50,000 die; 235,000 are hospitalized; and 1.1 million are treated and released from an emergency department. The number of people with TBI who are not seen in an emergency department or who receive no care is unknown." Quote from the Brain Injury Association of the US’ web page, http://www.biausa.org.
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What causes TBI?

The leading causes of TBI are:
  • Falls (28%);
  • Motor vehicle-traffic crashes (20%); (note: alcohol & drug abuse are disproportionately high in people with TBI)
  • Struck by/against (19%);
  • Assaults (11%)
  • Blasts are a leading cause of TBI for active duty military personnel in war zones.
  • Information from the Brain Injury Association of the US’ web page, http://www.biausa.org
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What are risk factors for TBI?

  • Males are about 1.5 times as likely as females to sustain a TBI.
  • The two age groups at highest risk for TBI are 0 to 4 year olds and 15 to 19 year olds.
  • Certain military duties (e.g., paratrooper) increase the risk of sustaining a TBI.
  • African Americans have the highest death rate from TBI.
  • Information from the Brain Injury Association of the US’ web page, http://www.biausa.org
  • Note: Alcohol and drug misuse are disproportionately high in people with TBI, so driving while intoxicated is a risk factor.
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What areas of the brain are damaged in traumatic brain injury (TBI)?

Truly, any part of the brain can be damaged in TBI. That being said, there are areas that are more likely to get damaged than others. Most of the people in our study had damage that included the frontal lobes, but we did not have more specific information about where their damage was. It is not unusual for damage from TBI to include the frontal lobes. Here, I (V. Stone) am just going to quote from the Wikipedia article on TBI, because I’ve contribted to that. "Damage from TBI can be focal (confined to specific areas) or diffuse (distributed in a more general manner). However, it is common for both focal and diffuse injury to exist in moderate to severe cases of TBI. Types of injuries considered diffuse include edema (swelling) and "diffuse axonal injury", which is widespread damage to axons, the connective fibers that allow brain cells to communicate with each other. Focal injuries often produce symptoms related to the functions of the damaged area. Research shows that the most common areas to have focal damage in non-penetrating TBI are the orbitofrontal cortex (the lower surface of the frontal lobes; abbrev. OFC), and the anterior temporal lobes (the frontmost part of the temporal lobes; abbrev. ATL), areas that are involved in social behaviour and emotion regulation." See diagram here; news outlets are hereby granted copyright permission to reproduce this figure, if they state that it is used by permission of Answers About Competency LLC.
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What is the difference between mild, moderate, & severe traumatic brain injuries (TBIs)?

These terms are defined (somewhat differently, depending on which professional organization you consult) according to specific information about 1) the person’s state of awareness after the traumatic brain injury (TBI), measured by something called the "Glasgow Coma Scale", 2) the length of time they are unconscious following the injury, called "loss of consciousness", and 3) the period of amnesia following the injury, called "post-traumatic amnesia".

People whose TBIs are defined as severe generally have a loss of consciousness of more than 36 hours, post-traumatic amnesia lasting more than a week, and after the accident may show only minimal responses to external stimuli, giving them low scores on the Glasgow Coma Scale.

People whose TBIs are defined as moderate generally have a loss of consciousness lasting from about half an hour up to 36 hours, post-traumatic amnesia lasting from a day to a week, and after the accident do show some level of awareness, even if disoriented, giving them mid-range scores on the Glasgow Coma Scale.

People with mild TBI are usually alert and aware after several minutes (30 minutes is the cutoff used by the American College of Rehabilitation Medicine) able to respond to the world around them (high scores on the Glasgow Coma Scale), have only a few minutes’ loss of consciousness (less than 20-30 minutes), and less than 24 hours’ post-traumatic amnesia. Generally, the kinds of social problems we’re describing here don’t occur in cases of mild TBI. Most cases of mild TBI recover within a few months, and the symptoms tend to be in sustained attention or processing speed. Those things can affect social interactions, but the effects are often subtle.
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Dr. Valerie E. Stone

Credentials: Email Dr. Valerie Stone (vestone@assesscompetency.com)
Phone: +1.303.669.8528
Postdoctoral fellowships:
  • University of California, Davis, Center for Neuroscience, 1993-97
  • Cambridge University, England, 1997-98
Faculty appointments at:
  • University of Denver, 1998-2003
  • University of Queensland, Australia, 2003-2008

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