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Sex-Based Differences in Perceived Pragmatic Communication Ability of Adults With Traumatic Brain Injury

Published:February 05, 2015DOI:https://doi.org/10.1016/j.apmr.2014.06.023

      Abstract

      Objective

      To identify sex-based differences in self-reported and close other–reported perceptions of communication behaviors in adults with traumatic brain injury (TBI).

      Design

      Between-groups comparison of questionnaire data from men and women with TBI and their close others.

      Setting

      University academic department.

      Participants

      Adults with medically documented TBI (n=160) and adults without TBI (n=81; control group) (N=241).

      Interventions

      Not applicable.

      Main Outcome Measure

      La Trobe Communication Questionnaire, a standardized measure of communication problems in everyday life.

      Results

      Participants with TBI endorsed more communication problems than controls (P<.001). There were no significant differences in self-ratings (P=.20) or in the ratings of close others (P=.09) in communication behaviors of men with TBI compared with women with TBI. There was no difference between the self-ratings of women with TBI and their close others (P=.59). However, men with TBI significantly underreported communication problems compared with reports of close others (P<.001).

      Conclusions

      Women with TBI might be more accurate than men with TBI in recognizing their own pragmatic communication problems.

      Keywords

      List of abbreviations:

      GCS (Glasgow Coma Scale), LCQ (La Trobe Communication Questionnaire), PTA (posttraumatic amnesia)
      Pragmatic communication problems, which can be defined as difficulty using language and nonverbal communication in social contexts,
      • Hartley L.L.
      • Levin H.S.
      Linguistic deficits after closed head injury: a current appraisal.
      have been well described in the TBI literature. Problems reported in adults with TBI include a higher proportion of inadequate responses in conversation,
      • Coelho C.A.
      • Liles B.Z.
      • Duffy R.J.
      Analysis of conversational discourse in head injured adults.
      • Coelho C.A.
      • Youse K.M.
      • Le K.N.
      Conversational discourse in closed-head-injured and non-brain-injured adults.
      impoverished content,
      • Coelho C.A.
      • Liles B.Z.
      • Duffy R.J.
      Analysis of conversational discourse in head injured adults.
      • Snow P.
      • Douglas J.
      • Ponsford J.
      Conversational discourse abilities following severe traumatic brain injury: a follow-up study.
      • Mentis M.
      • Prutting C.A.
      Cohesion in the discourse of normal and head-injured adults.
      and errors in accurate transfer of information.
      • Snow P.
      • Douglas J.
      • Ponsford J.
      Conversational discourse abilities following severe traumatic brain injury: a follow-up study.
      • Snow P.
      • Douglas J.
      • Ponsford J.
      Conversational assessment following traumatic brain injury: a world comparison across two control groups.
      In addition, individuals with TBI may have impairments in initiating and maintaining conversations,
      • Coelho C.A.
      • Liles B.Z.
      • Duffy R.J.
      Analysis of conversational discourse in head injured adults.
      • Mentis M.
      • Prutting C.A.
      Cohesion in the discourse of normal and head-injured adults.
      producing and comprehending implied meaning,
      • Martin I.
      • McDonald S.
      Evaluating the causes of impaired irony comprehension following traumatic brain injury.
      • Muller F.
      • Simion A.
      • Reviriego E.
      • et al.
      Exploring theory of mind after severe traumatic brain injury.
      • Johnson J.E.
      • Turkstra L.S.
      Inference in conversation of adults with traumatic brain injury.
      and structuring discourse to meet the needs of the listener and context.
      • O'Flaherty C.
      • Douglas J.M.
      Living with cognitive-communicative difficulties following traumatic brain injury: using a model of interpersonal communication to characterize the subjective experience.
      Conversational discourse of adults with TBI has been described as tangential
      • Coelho C.A.
      • Liles B.Z.
      • Duffy R.J.
      Analysis of conversational discourse in head injured adults.
      • Mentis M.
      • Prutting C.A.
      Cohesion in the discourse of normal and head-injured adults.
      • Bracy C.
      • Douglas J.
      Marital dyad perceptions of injured partners’ communication following traumatic brain injury.
      and egocentric,
      • Friedland D.
      • Miller N.
      Conversation analysis of communication breakdown after closed head injury.
      with inappropriate word choice
      • Snow P.
      • Douglas J.
      • Ponsford J.
      Conversational assessment following traumatic brain injury: a world comparison across two control groups.
      • Togher L.
      • Hands L.
      • Code C.
      Analysing discourse in the traumatic brain injury population: telephone interactions with different communication partners.
      and interaction style.
      • O'Flaherty C.
      • Douglas J.M.
      Living with cognitive-communicative difficulties following traumatic brain injury: using a model of interpersonal communication to characterize the subjective experience.
      Pragmatic communication impairments place a burden on the communication partner to maintain the flow of the conversation
      • Coelho C.A.
      • Youse K.M.
      • Le K.N.
      Conversational discourse in closed-head-injured and non-brain-injured adults.
      • Bracy C.
      • Douglas J.
      Marital dyad perceptions of injured partners’ communication following traumatic brain injury.
      • Togher L.
      • Hands L.
      • Code C.
      Analysing discourse in the traumatic brain injury population: telephone interactions with different communication partners.
      • Turkstra L.S.
      Should my shirt be tucked in or left out? The communication context of adolescence.
      and may contribute to loss of friends by individuals with TBI in the chronic stage postinjury
      • Jones C.A.
      • Turkstra L.S.
      Selling the story: narratives and charisma in adults with TBI.
      ; they may also contribute to reduced social integration, family burden, and poor vocational outcomes.
      • Snow P.
      • Douglas J.
      • Ponsford J.
      Conversational discourse abilities following severe traumatic brain injury: a follow-up study.
      • Godfrey H.
      • Partridge F.
      • Knight R.
      • Bishara S.
      Course of insight disorder and emotional dysfucnction following closed head injury: a controlled cross-sectional follow-up study.
      • Struchen M.A.
      • Pappadis M.R.
      • Mazzei D.K.
      • Clark A.N.
      • Davis L.C.
      • Sander A.M.
      Perceptions of communication abilities for persons with traumatic brain injury: validity of the La Trobe Communication Questionnaire.
      • Struchen M.A.
      • Pappadis M.R.
      • Sander A.M.
      • Burrows C.S.
      • Myszka K.A.
      Examining the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for adults with traumatic brain injury.
      Although there is consistent evidence that pragmatic communication is impaired after TBI in general, to our knowledge no studies have considered potential differences between men and women with TBI.
      • Farace E.
      • Alves W.M.
      Do women fare worse: a metaanalysis of gender differences in traumatic brain injury outcome.
      The lack of research on sex-based differences in communication likely reflects the fact that the incidence of TBI is about twice as high in men as in women.

      Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: Fact Sheet. Available at: http://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed May 10, 2014.

      Unfortunately, the incidence of TBI among women has increased over the last 2 decades,

      Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: Fact Sheet. Available at: http://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed May 10, 2014.

      and it is not only possible but necessary to ask questions about sex-based differences.
      One reason to expect sex-based pragmatic communication differences in adults with TBI is that typical men and women differ in cognitive functions underlying social behaviors (eg, emotion recognition and theory of mind,
      • Kessels R.P.
      • Montagne B.
      • Hendriks A.W.
      • Perrett D.I.
      • de Haan E.H.
      Assessment of perception of morphed facial expressions using the Emotion Recognition Task: normative data from healthy participants aged 8-75.
      • Krach S.
      • Blumel I.
      • Marjoram D.
      • et al.
      Are women better mindreaders? Sex differences in neural correlates of mentalizing detected with functional MRI.
      which is the ability to appreciate that others have thoughts different from one's own). An advantage for women in emotion recognition begins in infancy
      • McClure E.B.
      A meta-analytic review of sex differences in facial expression processing and their development in infants, children, and adolescents.
      and is present through childhood
      • Bosacki S.
      • Astington J.W.
      Theory of mind in preadolescence: relations between social understanding and social competence.
      • Baron-Cohen S.
      • Jolliffe T.
      Another advanced test of theory of mind: evidence from very high functioning adults with autism or Asperger syndrome.
      • Baron-Cohen S.
      • O'Riordan M.
      • Stone V.
      • Jones R.
      • Plaisted K.
      Recognition of faux pas by normally developing children and children with Asperger syndrome or high-functioning autism.
      into adulthood.
      • Krach S.
      • Blumel I.
      • Marjoram D.
      • et al.
      Are women better mindreaders? Sex differences in neural correlates of mentalizing detected with functional MRI.
      • Yamasue H.
      • Kuwabara H.
      • Kawakubo Y.
      • Kasai K.
      Oxytocin, sexually dimorphic features of the social brain, and autism.
      • Clark M.S.
      • Reis H.T.
      Interpersonal processes in close relationships.
      • Hall J.A.
      Gender effects in decoding nonverbal cues.
      Likewise, there is evidence of an advantage for women on theory of mind tasks
      • Krach S.
      • Blumel I.
      • Marjoram D.
      • et al.
      Are women better mindreaders? Sex differences in neural correlates of mentalizing detected with functional MRI.
      • Turkstra L.S.
      Conversation-based assessment of social cognition in adults with traumatic brain injury.
      ; however, this difference might be task dependent.
      • Russell T.A.
      • Tchanturia K.
      • Rahman Q.
      • Schmidt U.
      Sex differences in theory of mind: a male advantage on Happé's cartoon task.
      In the same way premorbid intelligence is positively correlated with outcomes after TBI,
      • Powell J.M.
      • Machamer J.E.
      • Temkin N.R.
      • Dikmen S.S.
      Self-report of extent of recovery and barriers to recovery after traumatic brain injury: a longitudinal study.
      an advantage in social cognition might predict better pragmatic communication recovery after TBI.
      Research on social cognition in individuals with brain injury is in the early stages, but findings to date suggest sex-based effects on outcome. For example, girls with brain tumors had lower emotion recognition test scores when they received cranial radiation than when they did not, but boys with brain tumors had low scores regardless of treatment.
      • Willard V.W.
      • Hardy K.K.
      • Bonner M.J.
      Gender differences in facial expression recognition in survivors of pediatric brain tumors.
      Also, girls with childhood TBI recovered emotion recognition ability faster and better than boys over the first 2 years postinjury.
      • Schmidt A.T.
      • Hanten G.R.
      • Li X.
      • Orsten K.D.
      • Levin H.S.
      Emotion recognition following pediatric traumatic brain injury: longitudinal analysis of emotional prosody and facial emotion recognition.
      Findings in adults with TBI were similar to those for children, with higher theory of mind test scores in women with TBI than men with TBI.
      • Turkstra L.S.
      Conversation-based assessment of social cognition in adults with traumatic brain injury.
      One method for evaluating pragmatic communication is to elicit opinions from communication partners—the individuals who interact socially with the person with TBI. Comparison of self-ratings and close other ratings of communication behaviors provides useful information not only about pragmatic communication impairments, but also about self-awareness of the person who is being rated, which is useful given the prevalence of impaired awareness among individuals with TBI.
      • Bach L.J.
      • Happe F.
      • Fleminger S.
      • David A.S.
      Intact theory of mind in TBI with behavioural disturbance.
      Information from communication partners can provide a clearer understanding of communication impairments after TBI, which may be beneficial for planning intervention goals. To our knowledge, only 1 study to date has reported sex-based differences in perceived communication ability for individuals with TBI. Dahlberg et al
      • 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.
      used the Social Communications Skills Questionnaire-Adapted
      • McGann W.
      • Werven G.
      • Douglas M.M.
      Social competence and head injury: a practical approach.
      to evaluate 50 men and 10 women in the chronic stage after TBI and found that men with TBI reported significantly better pragmatic communication skills than women with TBI.
      Communication outcomes may differ for men and women with TBI because of sex-based differences in expectations for social behavior. Society's concepts of masculinity and femininity create stereotypes of sex roles for men and women against which one perceives, categorizes, and evaluates his or her own behavior and personality and the behavior and personality of others.
      • Bem S.L.
      Gender schema theory. A cognitive account of sex typing.
      • Bem S.L.
      Androgyny and gender schema theory: a conceptual and empirical integration.
      For example, Tannen et al
      • Tannen D.
      Gender and discourse.
      observed that men communicate as a means to establish place in hierarchy or to acquire information. Conversely, women use pragmatic interactions to build consensus or to share thoughts and feelings, show more listening behavior and less interrupting, and use more self-disclosure, openness, support, and collaboration in discourse. Therefore, a man with TBI who discloses personal information might be more socially penalized than a woman who shows the same behavior, whereas a woman who monopolizes a conversation might be judged more harshly than a man who does the same thing. Many of these stereotypes have not changed over the last 40 years,
      • Auster C.J.
      • Ohm S.C.
      Masculinity and femininity in contemporary American society: a reevaluation using the Bem Sex-Role Inventory.
      and the social desirability for congruence of sex roles and behaviors is likely to influence how pragmatic communication impairments of individuals with TBI are perceived.
      Auster and Ohm
      • Auster C.J.
      • Ohm S.C.
      Masculinity and femininity in contemporary American society: a reevaluation using the Bem Sex-Role Inventory.
      reported sex-based differences in the perceived social desirability of masculine and feminine traits. Men and women mostly agreed on desirable traits for a man with the exception of affectionate, which women rated as more important for men than men themselves.
      • Auster C.J.
      • Ohm S.C.
      Masculinity and femininity in contemporary American society: a reevaluation using the Bem Sex-Role Inventory.
      Men and women differed, however, in perceived social desirability of traits for a woman because men were more likely than women to rate the masculine traits of competitive, defends own beliefs, and willing to take a stand as being socially desirable for women, whereas women were more likely than men to rate feminine traits (eg, eager to soothe hurt feelings, feminine, flatterable, gullible, shy, soft-spoken) as socially desirable for women. These results suggest that men and women differ in their expectations for women's social behavior, but they have similar expectations for men.
      • Auster C.J.
      • Ohm S.C.
      Masculinity and femininity in contemporary American society: a reevaluation using the Bem Sex-Role Inventory.
      Sex-based differences in sex-role expectations may play a critical role in TBI, given the relative preponderance of caregivers and service providers who are women evaluating men with TBI.
      These studies show that sex-role stereotypes continue to be pervasive in today's society and raise questions about how sex-role stereotypes influence expectations of and for men and women in pragmatic communication interactions. The prevalence of sex-based differences in social expectations supports the importance of examining sex-based differences in pragmatic communication ability after TBI because these differences are likely to affect clinicians' identification of problem behaviors and also what we choose to treat in rehabilitation.
      Research evidence suggests that there might be differences between men and women in perceived pragmatic communication performance after TBI, including evidence that women have better social cognition
      • Turkstra L.S.
      Conversation-based assessment of social cognition in adults with traumatic brain injury.
      • Ratcliff J.J.
      • Greenspan A.I.
      • Goldstein F.C.
      • et al.
      Gender and traumatic brain injury: do the sexes fare differently?.
      and evidence that society has different expectations for pragmatic communication in men and women.
      • Tannen D.
      Gender and discourse.
      The advantage of women in social cognition might predict higher ratings of women's pragmatic communication skills, but if societal expectations for women are higher, women might rate themselves more critically, and others might be more critical as well. It is important to identify sex-based influences on pragmatic communication because these influences will play a role in our evaluation of people with TBI, selection of treatment goals, and expectations for long-term communication outcomes.
      The aim of the current study was to determine if there were sex-based differences in self-reported and close other–reported perceptions of communication skills in adults with TBI. Specific questions were as follows: Do self-ratings of communication ability differ between men and women with TBI? Do communication ratings by close others differ for men versus women with TBI?
      There were 2 competing hypotheses about sex-based differences in self-reported and close other–reported pragmatic communication skills for participants with TBI. Higher societal expectations for women would predict that self-ratings and others' ratings would identify more problems in women than men. Alternatively, evidence of an advantage of women in social cognition would predict better ratings for women than men.

      Methods

      Participants

      Participants included 160 adults with medically documented TBI (106 men, 54 women) and 81 adults without TBI who served as a control group (35 women, 46 men). One family member or friend (40 men, 120 women) was nominated by each participant with TBI as a close other who could rate that participant's communication ability. Demographic characteristics for all groups are shown in table 1. Table 2 lists close others' relations and frequency of contact with persons with TBI, and table 3 summarizes injury chronicity and severity data for participants with TBI. Injury severity was classified according to Glasgow Coma Scale (GCS) score
      • Jennett B.
      Medical aspects of head injury.
      in the emergency department or, if not available, the best GCS score for day 1 postinjury or duration of posttraumatic amnesia (PTA), according to published guidelines.
      • Sherer M.
      • Struchen M.A.
      • Yablon S.A.
      • Wang Y.
      • Nick T.G.
      Comparison of indices of traumatic brain injury severity: Glasgow Coma Scale, length of coma and post-traumatic amnesia.
      GCS scores of 3 to 8 were classified as severe, scores of 9 to 12 were classified as moderate, and scores of 13 to 15 were classified as mild. Duration of PTA was the only injury severity variable available for 11 participants, all of whom had documented PTA of >14 days and were classified as severe.
      Table 1Participant demographic characteristics
      DemographicsControl GroupTBI GroupClose Others
      Females (n=35)Males (n=46)Females (n=54)Males (n=106)FemalesMales
      Age, y38.43±12.9236.22±12.7437.37±12.5838.01±13.5236.56±12.9141.37±13.31
      Age range, y18–6518–6318–6318–7219–8517–78
      Years of education13.29±2.3212.96±2.1013.27±2.2513.08±2.2513.78±2.3513.61±2.54
      Race/ethnicity
       White20 (57)27 (59)35 (65)67 (63)75 (63)27 (66)
       Black8 (23)7 (15)9 (16)19 (18)23 (19)5 (12)
       Hispanic5 (14)5 (11)8 (15)14 (13)17 (14)5 (12)
       Asian/Pacific Islander2 (6)5 (11)1 (2)4 (4)3 (3)2 (5)
       Native American0 (0)1 (2)0 (0)2 (2)1 (1)1 (92)
       Other0 (0)1 (2)1 (2)0 (0)0 (0)1 (2)
       Did not provide000000
      NOTE. Values are mean ± SD, n (%), or as otherwise indicated.
      Table 2Close other relations and frequency of contact with persons with TBI
      Relation vs Frequency of ContactNo. of Close Others (n=160)
      Relation
       Parent68
       Spouse47
       Sibling17
       Boyfriend/girlfriend8
       Adult child6
       Friend5
       Other/unknown9
      Frequency of contact
       Daily132
       Several times weekly14
       Once per week4
       Several times per month3
       Once per month1
       Several times per year3
       Unknown or cannot estimate3
      Table 3Injury chronicity and severity data for participants with TBI
      Injury CharacteristicsFemales (n=54)Males (n=106)
      Time postinjury (mo)77.38±8.9171.62±4.91
      Severity
       Mild9 (17)14 (13)
       Moderate4 (7)5 (5)
       Severe35 (65)77 (73)
       Could not be determined6 (11)10 (9)
      NOTE. Values are mean ± SD or n (%).
      Inclusion criteria for participants with TBI were a medically documented TBI; age ≥18 years; English as a primary spoken language; and informed consent by the person with TBI. Exclusion criteria were severe communication deficits (eg, severe aphasia) or other inability to communicate, and premorbid central nervous system dysfunction, severe psychiatric disorder, or severe behavioral disorder. Persons with mild communication deficits, such as word-finding difficulties or mild-to-moderate behavioral problems (eg, inappropriate comments, difficulty respecting interpersonal space), were not excluded because these behaviors were the subject of study. As in all prior studies using the La Trobe Communication Questionnaire (LCQ), there were no inclusion or exclusion criteria for close others, with the exception that they were nominated by the participant with TBI as a person who could rate that participant's communication ability
      • Douglas J.
      • O'Flaherty C.
      • Snow P.
      Measuring perception of communication ability: the development and evaluation of the La Trobe communication questionnaire.
      and provided informed consent for participation in the study.
      Control group participants were recruited from among friends and family members of participants with TBI and from the general community. Control group participants were matched to persons with TBI by age (within 10% of age in years), sex, and education (≤2y for grades K–7, and ≤3y for grades ≥8). Exclusion criteria for potential control participants were history of central nervous system dysfunction and severe psychiatric disorder.

      Materials

      The LCQ
      • Douglas J.
      • O'Flaherty C.
      • Snow P.
      Measuring perception of communication ability: the development and evaluation of the La Trobe communication questionnaire.
      was completed by participants and their close others. The LCQ was created to capture performance individuals with TBI in everyday conversations.
      • Douglas J.
      • O'Flaherty C.
      • Snow P.
      Measuring perception of communication ability: the development and evaluation of the La Trobe communication questionnaire.
      Items reflect both characteristics of normative communication and typical cognitive communication impairments seen as a result of TBI. The LCQ has established validity and reliability for evaluation of perceived pragmatic communication problems
      • Bracy C.
      • Douglas J.
      Marital dyad perceptions of injured partners’ communication following traumatic brain injury.
      • Struchen M.A.
      • Pappadis M.R.
      • Mazzei D.K.
      • Clark A.N.
      • Davis L.C.
      • Sander A.M.
      Perceptions of communication abilities for persons with traumatic brain injury: validity of the La Trobe Communication Questionnaire.
      • Douglas J.
      • O'Flaherty C.
      • Snow P.
      Measuring perception of communication ability: the development and evaluation of the La Trobe communication questionnaire.
      • Douglas J.M.
      • Bracy C.A.
      • Snow P.C.
      Exploring the factor structure of the La Trobe Communication Questionnaire: insights into the nature of communication deficits following traumatic brain injury.
      • Douglas J.
      Using the La Trobe Communication Questionnaire to measure perceived social communication ability in adolescents with traumatic brain injury.
      • Watts A.J.
      • Douglas J.M.
      Interpreting facial expression and communication competence following severe traumatic brain injury.
      and includes both a self-report form and a caregiver-report form that ask about type and frequency of communication behaviors.
      The LCQ is composed of 30 items that are answered using a Likert-type scale (1=never/rarely, 2=sometimes, 3=often, 4=usually/always), rating the frequency of occurrence of the behavior described in each item. Item ratings are summed, and total scores range from 30 to 120, with higher scores indicative of greater communication problems. In the current study we analyzed total scores for the self-rated and close other–rated LCQ.
      Participants with TBI, their close others, and adults in the control group completed the LCQ as part of a larger project by the third and fourth authors: project 1 focused on assessment of social communication skills in persons with TBI, and project 2 investigated an intervention to improve social communication skills post-TBI. The relevant institutional review boards approved these studies, including the sharing of coded, deidentified data for the present analyses.

      Data analysis

      Analyses of variance and t tests were used to compare TBI versus control group self-ratings and to compare self-ratings and close others' ratings of men versus women with TBI. An alpha level of .05 was used for all comparisons, with a Bonferroni correction for multiple comparisons as needed. All analyses were conducted using Stata statistical software.a

      Results

      There were no sex-based differences in time postinjury (t158=.61, P=.54) or injury severity (χ2=1.07, P=.58).
      Data for study hypotheses are shown in table 4. There was a significant main effect of group on self-ratings (TBI group mean ± SD, 63.86±16.41; control group mean ± SD, 59.48±15.76; F1,237=5.69; P<.001). For participants with TBI, close others' ratings were significantly higher than self-ratings (mean ± SD, 63.86±16.41 vs 59.48±15.76; F1,317=5.93; P<.05). There was no significant interaction of group × sex (F1,237=.71, P=.40). There was no significant difference in self-ratings between men and women with TBI (t158=.84, P=.20, effect size=.14) or in close others' ratings of men versus women with TBI (t158=1.36, P=.09, effect size=.22). Small mean differences and large variances in total scores resulted in low power for these analyses (α values, .07 and .16, respectively), and sample sizes required to obtain a significant difference were very large (1600 and 700, respectively).
      Table 4Average LCQ total scores for self-ratings and others' ratings of adults with TBI and controls
      RaterWomen With TBI (n=54)Men With TBI (n=106)Female Controls (n=35)Male Controls (n=46)
      Self-ratings60.94±14.0158.72±16.60
      P<.001.
      51.31±9.7852.37±7.94
      Close others' ratings61.41±16.5965.08±16.18
      P<.001.
      NANA
      NOTE. Values are mean ± SD.
      Abbreviation: NA, not applicable.
      P<.001.
      Because women's self-ratings appeared to be more congruent with ratings by their close others, we compared self-ratings by men and women with ratings by their close others (table 5). Women's self-ratings were not significantly different from ratings by close others (t53=.22, P=.59), whereas men's self-ratings were significantly lower than ratings by close others (t104=4.39, P<.001). The distribution of raters who were men and women differed between men and women with TBI because in most cases caregivers who were men were rating men with TBI. There was, however, no significant difference between men's and women's ratings of men with TBI (t103=.22, P=.59).
      Table 5LCQ close other's scores by sex of the participant and sex of the rater
      RaterMen With TBIWomen With TBI
      Male close others65.85±13.51 (n=20)61.41±16.59 (n=54)
      Female close others64.91±16.81 (n=86)61.97±16.98 (n=33)
      NOTE. Values are mean ± SD.

      Discussion

      In the present study, there were no significant differences in self-ratings or close others' ratings between men and women with TBI. The effect size in this large sample was very small; therefore, even if a difference could be found in a larger group, the clinical significance is unclear. The lack of a significant difference can be interpreted as either evidence that there is no sex-based difference or perhaps evidence that the 2 competing factors (better skills, higher expectations) exert opposite effects, resulting in no net difference in others' perceptions. The latter interpretation is supported by the finding that women and their close others agreed on LCQ ratings, whereas men with TBI rated themselves as having significantly fewer problems than did their close others. Congruence between women with TBI and their close others suggests that women have better insight into their abilities (ie, consistent with better social cognition). Alternatively, men with TBI may be overestimating their communication abilities. To our knowledge, women and men have not been considered separately in studies of awareness of deficits after TBI, which may be an important area for future study given the relation of awareness to many valued life outcomes.
      • Ownsworth T.
      • Fleming J.
      The relative importance of metacognitive skills, emotional status, and executive function in psychosocial adjustment following acquired brain injury.
      Overall, results of this study were consistent with previous research using the LCQ. Individuals with TBI reported more problems than a comparison group of uninjured adults who were similar in age, sex, and years of education. The finding of impaired pragmatic communication in adults with TBI is consistent with the large body of evidence that TBI disrupts communication in everyday social interactions with others.
      • Struchen M.A.
      • Pappadis M.R.
      • Mazzei D.K.
      • Clark A.N.
      • Davis L.C.
      • Sander A.M.
      Perceptions of communication abilities for persons with traumatic brain injury: validity of the La Trobe Communication Questionnaire.
      • 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.
      • Douglas J.
      • O'Flaherty C.
      • Snow P.
      Measuring perception of communication ability: the development and evaluation of the La Trobe communication questionnaire.
      The finding that close others reported significantly more problems than were perceived by individuals with TBI may reflect the well-documented phenomenon of impaired self-awareness in individuals with TBI,
      • Sherer M.
      • Boake C.
      • Levin E.
      • Silver B.
      • Rinhgholz G.
      • High W.
      Characteristics of impaired awareness after traumatic brain injury.
      which can persist even in the chronic stage postinjury.
      • Schrijnemaekers A.C.
      • Smeets S.M.
      • Ponds R.W.
      • van Heugten C.M.
      • Rasquin S.
      Treatment of unawareness of deficits in patients with acquired brain injury: a systematic review.
      However, further analyses of our data revealed that a significant discrepancy in communication ratings was present only in men with TBI. Previous studies comparing self-ratings and others' ratings of communication behaviors using the LCQ have been somewhat equivocal, with findings of greater discrepancies among persons <1 year postinjury
      • McNeill-Brown D.
      • Douglas J.
      Perceptions of communication skills in severely brain-injured adults.
      and greater concordance among persons >1 year postinjury.
      • Struchen M.A.
      • Pappadis M.R.
      • Mazzei D.K.
      • Clark A.N.
      • Davis L.C.
      • Sander A.M.
      Perceptions of communication abilities for persons with traumatic brain injury: validity of the La Trobe Communication Questionnaire.
      • Snow P.
      • Douglas J.
      • Ponsford J.
      Self/close other report and communication skills following severe traumatic brain injury.
      Sex differences in LCQ ratings were not investigated in these prior studies.

      Study limitations

      The present study had several limitations that should be addressed in future research. First, therapy data were not available for participants with TBI, and it is possible that participants who had received therapy had better self-awareness and overall communication skills. Second, we included all individuals with TBI, rather than focusing on just those with high LCQ scores, and results might differ if only those with severe communication problems were included. The challenge is determining the appropriate LCQ cutoff score. Douglas (personal communication, March 2012) suggested a LCQ criterion score of 62 out of 120 on close others' ratings as indicative of clinically problematic communication behaviors. The assumption of this approach, however, is that infrequent problems are not socially penalizing, which might not be the case. Rare occurrences of behaviors (eg, leaving out important information, saying or doing things others might consider rude or embarrassing, answering without taking time to think about what the other person has said) can prohibit an individual from returning to their preinjury employment and community life. The LCQ now includes follow-up questions about the importance of specific behaviors for that individual, and consideration of those responses in future studies will be revealing. It likewise would be interesting to examine how communication behaviors related to overall quality of life. Women and men might value and be affected by impairments in different communication behaviors, and this should be considered in treatment planning. Cultural differences also are worth examining in future studies, which was not possible with the present sample size and range of possible cultures represented.
      A third potential limitation was that there were more raters who were women rating men with TBI than any other combination of men and women (ie, ratings again reflected a female bias). There were no significant differences between raters who were men and women, however, one also could argue that women evaluating men is the typical scenario for adults with TBI, given that most are men with close others who are women. Most close others were parents or spouses and interacted daily with the person with TBI; therefore, their perspectives are critical. Because nonsignificant effect sizes were small, results are likely to reflect the everyday reality of persons with TBI.
      A fourth potential limitation was that close others' ratings might not be the most accurate account of the individual's communication ability after TBI because grief, depression, and other psychosocial factors may influence caregivers' perceptions. Ratings by clinicians or others with more objectivity might have been revealing. Close others ultimately will be the primary communication partners for individuals with TBI however; and in the bigger picture of community reintegration, close others' judgments may be the most important barometers of pragmatic communication success.
      Imaging data were not available for participants with TBI, which limits our ability to investigate the impact of focal lesions on social communication. However, all participants sustained injuries typically associated with both focal and diffuse damage to the brain.
      • Bigler E.D.
      Traumatic brain injury, neuroimaging, and neurodegeneration.
      • Bigler E.D.
      • Maxwell W.L.
      Neuroimaging and neuropathology of TBI.
      Therefore, isolating the effects of individual focal lesions is problematic, particularly with respect to complex interpersonal and context-dependent skills (eg, social communication).
      A final potential limitation is reliance on self-reports of communication skills and reports of close others. Inclusion of additional measures of social communication (eg, behavioral measures, ratings of third-party observers) would enhance our ability to interpret findings and would be a direction of future study. It may be argued, however, that where social communication is concerned, what matters most is the opinions of the participants.

      Conclusions

      Previous studies of pragmatic communication in adults with TBI have represented mostly perspectives of men. Given the increasing incidence of TBI in women and sex-based differences in social cognition and social expectations, it is important to ask if there are sex-based differences in pragmatic communication outcomes after TBI. Results of this study revealed one difference with potential implications for rehabilitation: compared with their close others, men underreported their communication problems, whereas women did not. This finding has implications for rehabilitation, particularly interventions aimed at improving awareness of pragmatic communication problems, which may be of particular importance for men. Future studies should consider other perspectives on pragmatic communication (eg, clinician and broader social perspectives) and also should address gender—the social construct—in addition to biologic sex.

      Supplier

      • a.
        Stata (version 10.1); StataCorp.

      Acknowledgment

      We thank Sarah Riedeman for her assistance with data aggregation.

      References

        • Hartley L.L.
        • Levin H.S.
        Linguistic deficits after closed head injury: a current appraisal.
        Aphasiology. 1990; 4: 353-370
        • Coelho C.A.
        • Liles B.Z.
        • Duffy R.J.
        Analysis of conversational discourse in head injured adults.
        J Head Trauma Rehabil. 1991; 6: 92-99
        • Coelho C.A.
        • Youse K.M.
        • Le K.N.
        Conversational discourse in closed-head-injured and non-brain-injured adults.
        Aphasiology. 2002; 16: 659-672
        • Snow P.
        • Douglas J.
        • Ponsford J.
        Conversational discourse abilities following severe traumatic brain injury: a follow-up study.
        Brain Inj. 1998; 12: 911-935
        • Mentis M.
        • Prutting C.A.
        Cohesion in the discourse of normal and head-injured adults.
        J Speech Hear Res. 1987; 30: 88-98
        • Snow P.
        • Douglas J.
        • Ponsford J.
        Conversational assessment following traumatic brain injury: a world comparison across two control groups.
        Brain Inj. 1997; 11: 409-429
        • Martin I.
        • McDonald S.
        Evaluating the causes of impaired irony comprehension following traumatic brain injury.
        Aphasiology. 2005; 19: 712-730
        • Muller F.
        • Simion A.
        • Reviriego E.
        • et al.
        Exploring theory of mind after severe traumatic brain injury.
        Cortex. 2009; 46: 1088-1099
        • Johnson J.E.
        • Turkstra L.S.
        Inference in conversation of adults with traumatic brain injury.
        Brain Inj. 2012; 26: 1118-1126
        • O'Flaherty C.
        • Douglas J.M.
        Living with cognitive-communicative difficulties following traumatic brain injury: using a model of interpersonal communication to characterize the subjective experience.
        Aphasiology. 1997; 11: 889-911
        • Bracy C.
        • Douglas J.
        Marital dyad perceptions of injured partners’ communication following traumatic brain injury.
        Brain Impair. 2005; 6: 1-12
        • Friedland D.
        • Miller N.
        Conversation analysis of communication breakdown after closed head injury.
        Brain Inj. 1998; 12: 1-14
        • Togher L.
        • Hands L.
        • Code C.
        Analysing discourse in the traumatic brain injury population: telephone interactions with different communication partners.
        Brain Inj. 1997; 11: 169-189
        • Turkstra L.S.
        Should my shirt be tucked in or left out? The communication context of adolescence.
        Aphasiology. 2000; 14: 349-364
        • Jones C.A.
        • Turkstra L.S.
        Selling the story: narratives and charisma in adults with TBI.
        Brain Inj. 2011; 25: 844-857
        • Godfrey H.
        • Partridge F.
        • Knight R.
        • Bishara S.
        Course of insight disorder and emotional dysfucnction following closed head injury: a controlled cross-sectional follow-up study.
        J Clin Exp Neuropsychol. 1993; 15: 503-515
        • Struchen M.A.
        • Pappadis M.R.
        • Mazzei D.K.
        • Clark A.N.
        • Davis L.C.
        • Sander A.M.
        Perceptions of communication abilities for persons with traumatic brain injury: validity of the La Trobe Communication Questionnaire.
        Brain Inj. 2008; 22: 940-951
        • Struchen M.A.
        • Pappadis M.R.
        • Sander A.M.
        • Burrows C.S.
        • Myszka K.A.
        Examining the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for adults with traumatic brain injury.
        J Head Trauma Rehabil. 2011; 26: 30-42
        • Farace E.
        • Alves W.M.
        Do women fare worse: a metaanalysis of gender differences in traumatic brain injury outcome.
        J Neurosurg. 2000; 93: 539-545
      1. Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: Fact Sheet. Available at: http://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Accessed May 10, 2014.

        • Kessels R.P.
        • Montagne B.
        • Hendriks A.W.
        • Perrett D.I.
        • de Haan E.H.
        Assessment of perception of morphed facial expressions using the Emotion Recognition Task: normative data from healthy participants aged 8-75.
        J Neuropsychol. 2014; 8: 75-93
        • Krach S.
        • Blumel I.
        • Marjoram D.
        • et al.
        Are women better mindreaders? Sex differences in neural correlates of mentalizing detected with functional MRI.
        BMC Neurosci. 2009; 10: 9
        • McClure E.B.
        A meta-analytic review of sex differences in facial expression processing and their development in infants, children, and adolescents.
        Psychol Bull. 2000; 126: 424-453
        • Bosacki S.
        • Astington J.W.
        Theory of mind in preadolescence: relations between social understanding and social competence.
        Social Devel. 1999; 8: 237-255
        • Baron-Cohen S.
        • Jolliffe T.
        Another advanced test of theory of mind: evidence from very high functioning adults with autism or Asperger syndrome.
        J Child Psychol Psychiatr. 1997; 38: 813-822
        • Baron-Cohen S.
        • O'Riordan M.
        • Stone V.
        • Jones R.
        • Plaisted K.
        Recognition of faux pas by normally developing children and children with Asperger syndrome or high-functioning autism.
        J Autism Devel Dis. 1999; 29: 407-418
        • Yamasue H.
        • Kuwabara H.
        • Kawakubo Y.
        • Kasai K.
        Oxytocin, sexually dimorphic features of the social brain, and autism.
        Psychiatry Clin Neurosci. 2009; 63: 129-140
        • Clark M.S.
        • Reis H.T.
        Interpersonal processes in close relationships.
        Annu Rev Psychol. 1988; 39: 609-672
        • Hall J.A.
        Gender effects in decoding nonverbal cues.
        Psychol Bull. 1978; 85: 845-857
        • Turkstra L.S.
        Conversation-based assessment of social cognition in adults with traumatic brain injury.
        Brain Inj. 2008; 22: 397-409
        • Russell T.A.
        • Tchanturia K.
        • Rahman Q.
        • Schmidt U.
        Sex differences in theory of mind: a male advantage on Happé's cartoon task.
        Cog Emot. 2012; 21: 1554-1564
        • Powell J.M.
        • Machamer J.E.
        • Temkin N.R.
        • Dikmen S.S.
        Self-report of extent of recovery and barriers to recovery after traumatic brain injury: a longitudinal study.
        Arch Phys Med Rehabil. 2001; 82: 1025-1030
        • Willard V.W.
        • Hardy K.K.
        • Bonner M.J.
        Gender differences in facial expression recognition in survivors of pediatric brain tumors.
        Psychooncol. 2009; 18: 893-897
        • Schmidt A.T.
        • Hanten G.R.
        • Li X.
        • Orsten K.D.
        • Levin H.S.
        Emotion recognition following pediatric traumatic brain injury: longitudinal analysis of emotional prosody and facial emotion recognition.
        Neuropsychologia. 2010; 48: 2869-2877
        • Bach L.J.
        • Happe F.
        • Fleminger S.
        • David A.S.
        Intact theory of mind in TBI with behavioural disturbance.
        Brain Cogn. 2006; 60: 196-198
        • 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
        • McGann W.
        • Werven G.
        • Douglas M.M.
        Social competence and head injury: a practical approach.
        Brain Inj. 1997; 11: 621-628
        • Bem S.L.
        Gender schema theory. A cognitive account of sex typing.
        Psychol Rev. 1981; 88: 354-364
        • Bem S.L.
        Androgyny and gender schema theory: a conceptual and empirical integration.
        in: Sonderegger B. Nebraska symposium on motivation: psychology and gender. Univ of Nebraska Pr, Lincoln1985: 179-226
        • Tannen D.
        Gender and discourse.
        Oxford Univ Pr, New York1994
        • Auster C.J.
        • Ohm S.C.
        Masculinity and femininity in contemporary American society: a reevaluation using the Bem Sex-Role Inventory.
        Sex Roles. 2000; 43: 499-528
        • Ratcliff J.J.
        • Greenspan A.I.
        • Goldstein F.C.
        • et al.
        Gender and traumatic brain injury: do the sexes fare differently?.
        Brain Inj. 2007; 21: 1023-1030
        • Jennett B.
        Medical aspects of head injury.
        Medicine in North America. 1986; 36: 5210-5238
        • Sherer M.
        • Struchen M.A.
        • Yablon S.A.
        • Wang Y.
        • Nick T.G.
        Comparison of indices of traumatic brain injury severity: Glasgow Coma Scale, length of coma and post-traumatic amnesia.
        J Neurol Neurosurg Psychiatr. 2008; 79: 678-685
        • Douglas J.
        • O'Flaherty C.
        • Snow P.
        Measuring perception of communication ability: the development and evaluation of the La Trobe communication questionnaire.
        Aphasiology. 2000; 14: 251-268
        • Douglas J.M.
        • Bracy C.A.
        • Snow P.C.
        Exploring the factor structure of the La Trobe Communication Questionnaire: insights into the nature of communication deficits following traumatic brain injury.
        Aphasiology. 2007; 21: 1181-1194
        • Douglas J.
        Using the La Trobe Communication Questionnaire to measure perceived social communication ability in adolescents with traumatic brain injury.
        Brain Impair. 2011; 11: 171-182
        • Watts A.J.
        • Douglas J.M.
        Interpreting facial expression and communication competence following severe traumatic brain injury.
        Aphasiology. 2006; 20: 707-722
        • Ownsworth T.
        • Fleming J.
        The relative importance of metacognitive skills, emotional status, and executive function in psychosocial adjustment following acquired brain injury.
        J Head Trauma Rehabil. 2005; 20: 315-332
        • Sherer M.
        • Boake C.
        • Levin E.
        • Silver B.
        • Rinhgholz G.
        • High W.
        Characteristics of impaired awareness after traumatic brain injury.
        J Int Neuropsychol Soc. 1998; 4: 380-387
        • Schrijnemaekers A.C.
        • Smeets S.M.
        • Ponds R.W.
        • van Heugten C.M.
        • Rasquin S.
        Treatment of unawareness of deficits in patients with acquired brain injury: a systematic review.
        J Head Trauma Rehabil. 2014; 29: E9-30
        • McNeill-Brown D.
        • Douglas J.
        Perceptions of communication skills in severely brain-injured adults.
        in: Ponsford J. Anderson V. Snow P. In: International Perspectives on Traumatic Brain Injury Proceedings of the Fifth International Association for the Study of Traumatic Brain Injury Conference; Melbourne (Australia). Australian Academic Pr, Brisbane1997: 247-250
        • Snow P.
        • Douglas J.
        • Ponsford J.
        Self/close other report and communication skills following severe traumatic brain injury.
        Brain Impair. 2000; 1: 57
        • Bigler E.D.
        Traumatic brain injury, neuroimaging, and neurodegeneration.
        Front Hum Neurosci. 2013; 7: 395
        • Bigler E.D.
        • Maxwell W.L.
        Neuroimaging and neuropathology of TBI.
        NeuroRehabilitation. 2011; 28: 63-74