ORIGINAL RESEARCH| Volume 103, ISSUE 5, P937-943, May 2022

Examination of Social Inferencing Skills in Men and Women After Traumatic Brain Injury

Published:November 30, 2021DOI:



      To examine sex differences in social inferencing deficits after traumatic brain injury (TBI) and to examine the odds of men and women being impaired while controlling for potential confounders.


      Cross-sectional survey.


      Two TBI rehabilitation hospitals.


      One hundred five participants with TBI (60 men, 45 women) and 105 controls without TBI (57 men, 48 women) (N=210).


      Not applicable.

      Main Outcome Measures

      The Awareness of Social Inference Test (TASIT), which includes (1) Emotion Evaluation Test (EET), (2) Social Inference-Minimal (SI-M) test, and (3) Social Inference-Enriched (SI-E) test.


      Within the control sample, men and women performed similarly on all 3 TASIT subtests. Within the group with TBI, men had significantly lower scores than women on EET (P=.03), SI-M (P=.01), and SI-E (P=.04). Using impairment cutoffs derived from the sample without TBI, we found significantly more men with TBI (30%) were impaired on the EET than women (16.7%); impairment was similar between men and women on SI-M and SI-E. When adjusting for executive functioning and education, the odds of being impaired on the EET did not significantly differ for men and women (odds ratio, 0.47; 95% CI, 0.16-1.40; P=.18).


      Although more men with TBI have emotion perception deficits than women, the difference appears to be driven by education and executive functioning. Research is needed in larger samples with more definitive norms to better understand social inferencing impairments in men and women with TBI as well as translation to interpersonal behaviors.


      List of abbreviations:

      EET (Emotion Evaluation Test), PTA (posttraumatic amnesia), SI-E (Social Inference-Enriched), SI-M (Social Inference-Minimal), STAI (State Trait Anxiety Inventory), TASIT (The Awareness of Social Inferencing Test), TBI (traumatic brain injury)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      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


        • 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
        • Sullivan KW
        • Winner E
        • Hopfield N.
        How children tell a lie from a joke: the role of second order mental state attributions.
        B J Dev Psychol. 1995; 13: 191-204
        • Babbage DR
        • Yim J
        • Zupan B
        • Neumann D
        • Tomita MR
        • Willer B.
        Meta-analysis of facial affect recognition difficulties after traumatic brain injury.
        Neuropsychology. 2011; 25: 277-285
        • McDonald S.
        Impairments in social cognition following severe traumatic brain injury.
        J Int Neuropsychol Soc. 2013; 19: 231-246
        • McDonald S
        • Flanagan S.
        Social perception deficits after traumatic brain injury: Interaction between emotion recognition, mentalizing ability, and social communication.
        Neuropsychology. 2004; 18: 572-579
        • Rosenberg H
        • Dethier M
        • Kessels RP
        • Westbrook RF
        • McDonald S.
        Emotion perception after moderate-severe traumatic brain injury: the valence effect and the role of working memory, processing speed, and nonverbal reasoning.
        Neuropsychology. 2015; 29: 509-521
        • Williams C
        • Wood RL.
        Impairment in the recognition of emotion across different media following traumatic brain injury.
        J Clin Exp Neuropsychol. 2010; 32: 113-122
        • Milders M.
        Relationship between social cognition and social behaviour following traumatic brain injury.
        Brain Inj. 2019; 33: 62-68
        • Zupan B
        • Babbage D
        • Neumann D
        • Willer B.
        Sex differences in emotion recognition and emotional inferencing following severe traumatic brain injury.
        Brain Impair. 2017; 18: 36-48
        • Zupan B
        • Neumann D
        • Babbage D
        • Willer B.
        Sex-based differences in affective and cognitive empathy following severe traumatic brain injury.
        Neuropsychology. 2018; 32: 554-563
        • Turkstra LS.
        Conversation-based assessment of social cognition in adults with traumatic brain injury.
        Brain Inj. 2008; 22: 397-409
        • Rigon A
        • Turkstra L
        • Mutlu B
        • Duff M.
        The female advantage: sex as a possible protective factor against emotion recognition impairment following traumatic brain injury.
        Cogn Affect Behav Neurosci. 2016; 16: 866-875
        • Turkstra L
        • Norman R
        • Mutlu B
        • Duff M.
        Impaired theory of mind in adults with traumatic brain injury: a replication and extension of findings.
        Neuropsychologia. 2018; 111: 117-122
        • Hall JA
        • Matsumoto D.
        Gender differences in judgments of multiple emotions from facial expressions.
        Emotion. 2004; 4: 201-206
        • Kessels RP
        • Montagne B
        • Hendriks AW
        • Perrett DI
        • de Haan EH.
        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
        • Weisenbach SL
        • Rapport LJ
        • Briceno EM
        • et al.
        Reduced emotion processing efficiency in healthy males relative to females.
        Soc Cogn Affect Neurosci. 2014; 9: 316-325
        • Turkstra LS
        • Mutlu B
        • Ryan CW
        • et al.
        Sex and gender differences in emotion recognition and theory of mind after TBI: a narrative review and directions for future research.
        Front Neurol. 2020; 11: 59
        • Stafslien EHD
        • Turkstra LS.
        Sex-based differences in expectations for social communication after TBI.
        Brain Inj. 2020; 34: 1756-1762
        • Neumann D
        • Sander AM
        • Perkins SM
        • Bhamidipalli SS
        • Hammond FM.
        Negative attribution bias and related risk factors after brain injury.
        J Head Trauma Rehabil. 2021; 36: E61-E70
        • Brookshire R
        • Nicholas L.
        Discourse comprehension test.
        Communication Skill Builders, Tucson, AZ1993: 105-108
        • Malec JF
        • Brown AW
        • Leibson CL
        • et al.
        The Mayo Classification System for Traumatic Brain Injury Severity.
        J Neurotrauma. 2007; 24: 1417-1424
        • Bibby H
        • McDonald S.
        Theory of mind after traumatic brain injury.
        Neuropsychologia. 2005; 43: 99-114
        • 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
        • Saunders J.
        Differential impairment in recognition of emotion across different media in people with severe traumatic brain injury.
        J Int Neuropsychol Soc. 2005; 11: 392-399
        • 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
        • Stroop JR.
        Studies of interference in serial verbal reactions.
        J Exp Psychol. 1935; 18: 643
      1. Golden CJ. Stroop color and word test: a manual for clinical and experimental uses. Chicago: Stoelting; 1978.

        • Spreen O
        • Strauss E.
        Controlled oral word association (word fluency).
        in: Spreen O Strauss E A compendium of neuropsychological tests. Oxford University Press, Oxford1991: 219-227
        • Spielberger CD
        • Gorsuch RL
        • Lushene RE.
        Manual for the State-Trait Anxiety Inventory.
        Consulting Psychologists Press, Palo Alto, CA1970
      2. Spielberger CD, Reheiser EC, Ritterband LM, Sydeman SJ, Unger KK. Assessment of emotional states and personality traits: measuring psychological vital signs. In: Butcher JN, ed. Clinical personality assessment: practical approaches. New York: Oxford University Press; 1995. p 42--58.

        • Kroenke K
        • Spitzer RL
        • Williams JBW.
        The PHQ-9.
        J Gen Int Med. 2001; 16: 606-613
        • Niemeier JP
        • Marwitz JH
        • Lesher K
        • Walker WC
        • Bushnik T.
        Gender differences in executive functions following traumatic brain injury.
        Neuropsychol Rehabil. 2007; 17: 293-313
        • Spikman JM
        • Timmerman ME
        • Milders MV
        • Veenstra WS
        • van der Naalt J.
        Social cognition impairments in relation to general cognitive deficits, injury severity, and prefrontal lesions in traumatic brain injury patients.
        J Neurotrauma. 2012; 29: 101-111
        • Yim J
        • Babbage DR
        • Zupan B
        • Neumann D
        • Willer B.
        The relationship between facial affect recognition and cognitive functioning after traumatic brain injury.
        Brain Inj. 2013; 27: 1155-1161
        • Honan CA
        • McDonald S
        • Sufani C
        • Hine DW
        • Kumfor F.
        The awareness of social inference test: development of a shortened version for use in adults with acquired brain injury.
        Clini Neuropsychol. 2016; 30: 243-264