Social Skills Treatment for People With Severe, Chronic Acquired Brain Injuries: A Multicenter Trial


      McDonald S, Tate R, Togher L, Bornhofen C, Long E, Gertler P, Bowen R. Social skills treatment for people with severe, chronic acquired brain injuries: a multicenter trial.


      To determine whether social skills deficits including unskilled, inappropriate behavior, problems reading social cues (social perception), and mood disturbances (such as depression and anxiety) could be remediated after severe traumatic brain injuries.


      Randomized controlled trial comparing a social skills program with social activity alone or with waitlist control. Several participants were reassigned after randomization.


      Hospital outpatient and community facilities.


      Fifty-one outpatients from 3 brain injury units in Sydney, Australia, with severe, chronic acquired brain injuries were recruited. A total of 39 people (13 in skills training, 13 in social activity, 13 in waitlist) completed all phases of the study.


      Twelve-week social skills treatment program encompassing weekly 3-hour group sessions focused on shaping social behavior and remediating social perception and 1-hour individual sessions to address psychologic issues with mood, self-esteem, etc.

      Main Outcome Measures

      Primary outcomes were: (1) social behavior during encounters with a confederate as rated on the Behaviorally Referenced Rating System of Intermediary Social Skills−Revised (BRISS-R), (2) social perception as measured by The Awareness of Social Inference Test, and (3) depression and anxiety as measured by the Depression, Anxiety and Stress Scale. Secondary outcomes were: relative report on social behavior and participation using: the Katz Adjustment Scale−R1; the Social Performance Survey Schedule; the La Trobe Communication Questionnaire; and the Sydney Psychosocial Reintegration Scale (both relative and self-report).


      Repeated-measures analysis of variance indicated that social activity alone did not lead to improved performance relative to waitlist (placebo effect) on any outcome variable. On the other hand, the skills training group improved differentially on the Partner Directed Behavior Scale of the BRISS-R, specifically the self-centered behavior and partner involvement behavior subscales. No treatment effects were found for the remaining primary outcomes (social perception, emotional adjustment) or for secondary outcome variables (relative and self-report measures of social function).


      This study suggested that treatment effects after social skills training in people with severe, chronic brain injuries are modest and are limited to direct measures of social behavior.

      Key Words

      List of Abbreviations:

      ANOVA (analysis of variance), BRISS-R (Behaviorally Referenced Rating System of Intermediary Social Skills−Revised), DASS (Depression Anxiety and Stress Scale), ICC (intraclass correlation coefficient), KAS-R1 (Katz Adjustment Scale−R1), LCQ (La Trobe Communication Questionnaire), PCSS (Personal Conversational Style Scale), PDBS (Partner Directed Behavior Scale), RCT (randomized controlled trial), SPRS (Sydney Psychosocial Reintegration Scale), SPSS (Social Performance Survey Schedule), TASIT (The Awareness of Social Inference Test), TBI (traumatic brain injury), WAIS-III (Wechsler Adult Intelligence Scale, 3rd Edition)
      To read this article in full you will need to make a payment


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Togher L.
        • McDonald S.
        • Code C.
        Communication disorders following traumatic brain injury.
        in: McDonald S. Togher L. Code C. Communication disorders after traumatic brain injury. Psychology Pr, Hove1999: 1-18
        • Hartley L.L.
        • Jensen P.J.
        Three discourse profiles of closed-head-injury speakers: theoretical and clinical implications.
        Brain Inj. 1992; 6: 271-281
        • Dahlberg C.
        • Hawley L.
        • Morey C.
        • Newman J.
        • Cusick C.P.
        • Harrison-Felix C.
        Social communication skills in persons with post-acute traumatic brain injury: three perspectives.
        Brain Inj. 2006; 20: 425-435
        • Doctor J.N.
        • Castro J.
        • Temkin N.R.
        • Fraser R.T.
        • Machamer J.E.
        • Dikmen S.S.
        Workers' risk of unemployment after traumatic brain injury: a normed comparison.
        J Int Neuropsychol Soc. 2005; 11: 747-752
        • Ponsford J.L.
        • Olver J.H.
        • Curran C.
        • Ng K.
        Prediction of employment status two years after traumatic brain injury.
        Brain Inj. 1995; 9: 11-20
        • Demakis G.J.
        • Hammond F.
        • Knotts A.
        • et al.
        The Personality Assessment Inventory in individuals with traumatic brain injury.
        Arch Clin Neuropsychol. 2007; 22: 123-130
        • Gomez-Hernandez R.
        • Max J.E.
        • Kosier T.
        • Paradiso S.
        • Robinson R.G.
        Social impairment and depression after traumatic brain injury.
        Arch Phys Med Rehabil. 1997; 78: 1321-1326
        • Bellack A.S.
        • Mueser K.T.
        • Gingerich S.
        • Agresta J.
        Social skills training for schizophrenia: a step-by-step guide.
        2nd ed. Guilford Pr, New York2004
        • Ozonoff S.
        • Miller J.N.
        Teaching theory of mind: a new approach to social skills training for individuals with autism.
        J Autism Dev Disord. 1995; 25: 415-437
        • Kavale K.A.
        • Forness S.R.
        Social skill deficits and learning disabilities: a meta-analysis.
        J Learn Disabil. 1996; 29: 226-237
        • Bramston P.
        • Spence S.H.
        Behavioural versus cognitive social skills training with intellectually handicapped adults.
        Behav Res Ther. 1985; 23: 239-246
        • Benton M.K.
        • Schroeder H.E.
        Social skills training in schizophrenics: a meta-analytic evaluation.
        J Consult Clin Psychol. 1990; 55: 741-747
        • Tate R.
        Issues in the management of behaviour disturbance as a consequence of severe head injury.
        Scand J Rehabil Med. 1987; 19: 13-18
        • McDonald S.
        Psychosocial deficits after traumatic brain injury.
        Brain Impair. 2003; 4: 36-47
        • Flanagan S.
        • McDonald S.
        • Togher L.
        Evaluation of the BRISS as a measure of social skills in the traumatically brain injured.
        Brain Inj. 1995; 9: 321-338
        • Meghji C.
        An innovative self-monitoring treatment approach for use with the brain injured population.
        J Cogn Rehabil. 2002; 20: 12-18
        • Helffenstein D.A.
        • Wechsler F.S.
        The use of interpersonal process recall (IPR) in the remediation of interpersonal and communication skill deficits in the newly brain-injured.
        Clin Neuropsychol. 1982; 4: 139-142
        • Dahlberg C.
        • Cusick C.P.
        • Hawley L.
        • et al.
        Treatment efficacy of social communication skills training after traumatic brain injury: a randomized treatment and deferred treatment controlled trial.
        Arch Phys Med Rehabil. 2007; 88: 1561-1573
        • McFall R.M.
        A review and reformulation of the concept of social skills.
        Behav Assess. 1982; 4: 1-33
        • McDonald S.
        • Saunders J.C.
        Differential impairment in recognition of emotion across different media in people with severe traumatic brain injury.
        J Int Neuropsychol Soc. 2005; 11: 392-399
        • Milders M.
        • Fuchs S.
        • Crawford J.R.
        Neuropsychological impairments and changes in emotional and social behaviour following severe traumatic brain injury.
        J Clin Exp Neuropsychol. 2003; 25: 157-172
        • Combs D.R.
        • Tosheva A.
        • Wanner J.
        • Basso M.R.
        Remediation of emotion perception deficits in schizophrenia: the use of attentional prompts.
        Schizophr Res. 2006; 87: 340-341
        • Bolte S.
        • Hubl D.
        • Feineis-Matthews S.
        • Prvulovic D.
        • Dierks T.
        • Poustka F.
        Facial affect recognition training in autism: can we animate the fusiform gyrus?.
        Behav Neurosci. 2006; 120: 211-216
        • McKenzie K.
        • Matheson E.
        • McKaskie K.
        • Hamilton L.
        • Murray G.C.
        Impact of group training on emotion recognition in individuals with a learning disability.
        Br J Learn Disabil. 2000; 28: 143-147
        • Bornhofen C.
        • McDonald S.
        Treating emotion perception deficits following traumatic brain injury.
        Neuropsychol Rehabil. 2008; 18: 22-24
        • Shoumitro D.
        • Lyons I.
        • Koutzakis C.
        • Ali I.
        Rate of psychiatric illness 1 year after traumatic brain injury.
        Am J Psychiatry. 1999; 156: 374-378
        • Hibbard M.R.
        • Uysal S.
        • Kepler K.
        • Bogdany J.
        • Silver J.
        Axis I psychopathology in individuals with traumatic brain injury.
        J Head Trauma Rehabil. 1998; 13: 24-39
        • Van Reekum R.
        • Bologa I.
        • Finlayson M.A.
        • Garner S.
        • Links P.S.
        Psychiatric disorders after traumatic brain injury.
        Brain Inj. 1996; 10: 319-327
        • Ponsford J.
        • Sloan S.
        • Snow P.
        Traumatic brain injury: rehabilitation for everyday adaptive living.
        Psychology Pr, Cornwall1995
        • Sohlberg M.M.
        • Mateer C.A.
        Cognitive rehabilitation: an integrative neuropsychological approach.
        Guilford Pr, New York2001
        • Libet J.
        • Lewinsohn P.M.
        Concept of social skills with special reference to the behavior of depressed persons.
        J Consul Clin Psychol. 1973; 40: 304-313
        • Gotlib I.H.
        • Whiffen V.E.
        Depression and marital functioning: an examination of specificity and gender differences.
        J Abnorm Psychol. 1989; 98: 23-30
        • Giannini A.J.
        • Folts D.
        • Melemis S.M.
        • Giannini M.C.
        • Loiselle R.H.
        Depressed men's lower ability to interpret non-verbal cues: a preliminary study.
        Percept Mot Skills. 1995; 81: 556-560
        • Hale W.W.
        • Janson J.H.
        • Bouhuys A.L.
        • van der Hoofdakker R.H.
        The judgement of facial expressions by depressed patients, their partners and controls.
        J Affect Disord. 1998; 47: 63-70
        • Furukawa T.A.
        • Watanabe N.
        • Churchill R.
        Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: systematic review.
        Br J Psychiatry. 2006; 188: 305-312
        • Butler A.C.
        • Chapman J.E.
        • Forman E.M.
        • Beck A.T.
        The empirical status of cognitive-behavioral therapy: a review of meta-analyses.
        Clin Psychol Rev. 2006; 26: 17-31
        • Hale W.W.
        • Janson J.H.
        • Bouhuys R.
        • Gertler P.
        A randomised controlled trial of a cognitive-behavioural therapy program for managing social anxiety after acquired brain injury.
        Brain Impair. 2005; 6: 169-180
        • Medd J.
        • Tate R.L.
        Evaluation of an anger management therapy programme following acquired brain injury: a preliminary study.
        Neuropsychol Rehabil. 2000; 10: 185-201
        • Anson K.
        • Ponsford J.
        Evaluation of a coping skills group following traumatic brain injury.
        Brain Inj. 2006; 20: 167-178
        • Wechsler D.
        The Wechsler Test of Adult Reading.
        Psychological Corp, New York2001
        • Wechsler D.
        Wechsler Adult Intelligence Scale−Third Edition (WAIS-III).
        Psychological Corp, San Antonio1997
        • Wechsler D.
        Wechsler Memory Scale.
        3rd ed. Psychological Corp, San Antonio1997
        • Heaton R.K.
        • Chelune G.J.
        • Talley J.L.
        • Kay G.G.
        • Curtiss G.
        Wisconsin Card Sorting Test.
        Psychological Assessment Resources, Philadelphia1993
        • Benton A.L.
        • Hamsher K.
        • Sivan A.B.
        Multilingual Aphasia Examination.
        AJA Associates, Iowa City1994
        • Delis D.C.
        • Kaplan E.
        • Kramer J.H.
        Delis-Kaplan Executive Function System (D-KEFS).
        Harcourt Assessment, Psychological Corp, New York2001
        • Trower P.
        Situational analysis of the components and processes of behavior of socially skilled and unskilled patients.
        J Consult Clin Psychol. 1980; 3: 327-339
        • Wallander J.L.
        • Conger A.J.
        • Conger J.C.
        Development and evaluation of a behaviorally referenced rating system for heterosocial skills.
        Behav Assess. 1985; 7: 137-153
        • Farrell A.D.
        • Rabinowitz J.A.
        • Wallander J.L.
        • Curran J.P.
        An evaluation of two formats for the intermediary level assessment of social skills.
        Behav Assess. 1985; 7: 155-171
        • Marsh N.V.
        • Knight R.G.
        Behavioral assessment of social competence following severe head injury.
        J Clin Exp Neuropsychol. 1991; 13: 729-740
        • McDonald S.
        • Flanagan S.
        • Martin I.
        • Saunders C.
        The ecological validity of TASIT: a test of social perception.
        Neuropsychol Rehabil. 2004; 14: 285-302
        • McDonald S.
        • Flanagan S.
        • Rollins J.
        • Kinch J.
        TASIT: a new clinical tool for assessing social perception after traumatic brain injury.
        J Head Trauma Rehabil. 2003; 18: 219-238
        • McDonald S.
        • Bornhofen C.
        • Shum D.
        • Long E.
        • Saunders C.
        • Neulinger K.
        Reliability and validity of ‘The Awareness of Social Inference Test’ (TASIT): a clinical test of social perception.
        Disabil Rehabil. 2006; 28: 1529-1542
        • Lovibond P.
        • Lovibond S.
        The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories.
        Behav Res Ther. 1995; 33: 335-343
        • Katz M.M.
        • Lyerly S.B.
        Methods for measuring adjustment and social behavior in the community: I. Rationale, description, discriminative validity and scale development.
        Psychol Rep. 1963; 13: 503-535
        • Johnson D.A.
        • Newton A.
        Social adjustment and interaction after severe head injury: II. Rationale and bases for intervention.
        Br J Clin Psychol. 1987; 26: 289-298
        • Hanks R.A.
        • Temkin N.
        • Machamer J.
        • Dikmen S.S.
        Emotional and behavioral adjustment after traumatic brain injury.
        Arch Phys Med Rehabil. 1999; 80: 991-997
        • Lanham R.A.
        • Wiessenburger J.E.
        • Schwab K.A.
        • Rosner M.M.
        A longitudinal investigation of the concordance between individuals with traumatic brain injury and family or friend ratings on the Katz Adjustment Scale.
        J Head Trauma Rehabil. 2000; 15: 1123-1138
        • Fabiano R.J.
        • Goran D.A.
        A principal component analysis of the Katz Adjustment Scale in a traumatic brain injury rehabilitation sample.
        Rehabil Psychol. 1992; 37: 75-85
        • Goran D.A.
        • Fabiano R.J.
        The scaling of the Katz Adjustment Scale in a traumatic brain injury rehabilitation sample.
        Brain Inj. 1993; 7: 219-229
        • Jackson H.F.
        • Hopewell C.
        • Glass C.A.
        • Warburg R.
        • Dewey M.
        • Ghadiali E.
        The Katz Adjustment Scale: modification for use with victims of traumatic brain and spinal injury.
        Brain Inj. 1992; 6: 109-127
        • Lowe M.R.
        • Cautela J.R.
        A self-report measure of social skill.
        Behav Ther. 1978; 9: 535-544
        • Lowe M.R.
        • D'Ilio V.
        Factor analysis of the Social Performance Survey Schedule.
        J Psychopathol Behav Assess. 1985; 7: 13-22
        • Lowe M.R.
        Validity of the Positive Behavior Subscale of the Social Performance Survey Schedule in a psychiatric population.
        Psychol Rep. 1982; 50: 83-87
        • Miller L.S.
        • Funabiki D.
        Predictive validity of the Social Performance Survey Schedule for component interpersonal behaviors.
        Behav Assess. 1984; 6: 33-44
        • Douglas J.A.
        • O'Flaherty C.A.
        • Snow P.
        Measuring the perception of communicative ability: the development and evaluation of the La Trobe communication questionnaire.
        Aphasiology. 2000; 14: 251-268
        • Tate R.
        • Hodgkinson A.
        • Veerabangsa A.
        • Maggiotto S.
        Measuring psychosocial recovery after traumatic brain injury: psychometric properties of a new scale.
        J Head Trauma Rehabil. 1999; 14: 543-557
        • Ekman P.
        Emotions revealed: recognizing faces and feelings to improve communication and emotional life.
        Times Books/Henry Holt, New York2003
        • Spence S.H.
        Social skills training: enhancing social competence with children and adolescents.
        NFER-NELSON, Windsor1995
        • Khan-Bourne N.
        • Brown R.G.
        Cognitive behaviour therapy for the treatment of depression in individuals with brain injury.
        Neuropsychol Rehabil. 2003; 13: 89-107
        • Shrout P.E.
        • Fleiss J.L.
        Intraclass correlations: uses in assessing rater reliability.
        Psychol Bull. 1979; 86: 420-428
        • Cicchetti D.V.
        Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology.
        Psychol Assess. 1994; 6: 284-290
        • Bird K.
        • Hadzi-Pavlovic D.
        • Isaac A.
        PSY: a program for contrast analysis.
        School of Psychology, Univ New South Wales, Sydney2001
        • Bornhofen C.
        • McDonald S.
        Comparing strategies for treating emotion perception deficits in traumatic brain injury.
        J Head Trauma Rehabil. 2008; 23: 103-115
        • Johnson K.
        • Davis P.K.
        A supported relationships intervention to increase the social integration of persons with traumatic brain injuries.
        Behav Modif. 1998; 22: 502-528
        • Glang A.
        • Todis B.
        • Cooley E.
        • Wells J.
        • Voss J.
        Building social networks for children and adolescents with traumatic brain injury: a school-based intervention.
        J Head Trauma Rehabil. 1997; 12: 32-47