Study Notes on Social Competence Treatment After TBI Research

Original Research on Social Competence Treatment After Traumatic Brain Injury

Authors and Affiliations

  • Cynthia Harrison-Felix, PhD

    • Craig Hospital, Englewood, CO

    • Traumatic Brain Injury Model Systems National Data and Statistical Center, Englewood, CO

  • Jody K. Newman, MA, CCC-SLP

    • Craig Hospital, Englewood, CO

  • Lenore Hawley, MSSW, LCSW, CBIST

    • Craig Hospital, Englewood, CO

  • Clare Morey, MA, CCC-SLP

    • Craig Hospital, Englewood, CO

  • Jessica M. Ketchum, PhD

    • Craig Hospital, Englewood, CO

  • William C. Walker, MD

    • Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA

    • Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA

  • Kathleen R. Bell, MD

    • Department of Rehabilitation Medicine, University of Washington, Seattle, WA

  • Scott R. Millis, PhD, ABPP-CN

    • Rehabilitation Institute of Michigan, Detroit, MI

    • Wayne State University School of Medicine, Detroit, MI

  • Cynthia Braden, MA, CCC-SLP

    • Craig Hospital, Englewood, CO

  • James Malec, PhD, ABPP-CN

    • Rehabilitation Hospital of Indiana, Indianapolis, IN

    • Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN

  • Flora M. Hammond, MD

    • Rehabilitation Hospital of Indiana, Indianapolis, IN

  • C.B. Eagye, MS

    • Craig Hospital, Englewood, CO

  • Laura Howe, JD, PhD

    • Craig Hospital, Englewood, CO

  • Current affiliation for Bell

    • University of Texas Southwestern Medical Center, Dallas, TX.

Abstract

Objective

  • Goal: Evaluate the effectiveness of a replicable group treatment program for improving social competence after TBI.

Design

  • Type: Multicenter randomized controlled trial.

  • Methods Compared:

    1. Group Interactive Treatment (GIST): 13 weekly group sessions of 1.5 hours each with structured, facilitated interactions.

    2. Alternative Treatment (AT): 13 traditional classroom lectures with supplemental individual sessions.

Setting

  • Conducted in community and veteran rehabilitation centers.

Participants

  • Eligibility: 179 civilian, military, and veteran adults with TBI, at least 6 months post-injury.

Interventions

  • GIST: Focus on social competence through interaction.

  • AT: Same curriculum without facilitated group dynamics.

Main Outcome Measures

  • Primary: Profile of Pragmatic Impairment in Communication (PPIC).

  • Secondary: LaTrobe Communication Questionnaire (LCQ), Goal Attainment Scale (GAS), Satisfaction with Life Scale (SWLS), Posttraumatic Stress Disorder Checklist-C (PCL-C), Brief Symptom Inventory (BSI), Scale of Perceived Social Self-Efficacy (PSSE).

Results

  • Goals were achieved and maintained across both treatment methods. Significant improvements noted in:

    • PPIC (primary outcome) and LCQ, BSI (secondary outcomes) were immediate but did not differ significantly between groups.

    • Improvements in PSSE and PCL-C were comparable.

Conclusions

  • Both treatments improved social competence skills for individuals with TBI, with no superior effectiveness of the GIST method demonstrated.

Introduction

Definition of Social Competence

  • Social Competence: Cognitive, emotional, and communication skills for successful interaction in various situations.

Importance

  • Impairments in social competence are prevalent post-TBI, serving as barriers to reintegration into society.

Factors Affecting Social Competence Post-TBI

  • Factors include extent of neurological injury, preinjury functioning, psychological reaction, social context, coexisting pain, and fatigue.

Consequences

  • Major aspects influencing interpersonal relationships and employment, leading to isolation, difficulty adapting to social situations, and misunderstanding social cues.

    • Impairments noted in conversation initiation, focus during interactions, conflict resolution, etc.

Background

Historical Treatment Approaches

  • Historically, social skills have been promoted in group settings emphasizing feedback and interaction.

  • Issues specifically within military TBI population highlighted as they face unique reintegration challenges.

Treatment Challenges

  • A lack of consensus on treatment methodology for social competence post-TBI and few evidence-based programs exist.

  • GIST was developed as structured cognitive behavioral group intervention emphasizing interactive feedback.

Methods

Design Overview

  • Trial Structure: 2-arm multicenter randomized controlled trial, with randomized participants across multiple sites.

Participant Criteria

  • Inclusion Criteria: History of TBI, >=6 months post-injury, >18 years old, English-speaking, and demonstrating social competence difficulties.

  • Exclusion Criteria: Inability to communicate verbally, concurrent participation in other interventions, etc.

Measurement Instruments

  • Primary Outcome Measure: PPIC (objective behavioral rating of communication).

  • Self-Report Instruments: LCQ, PSSE, and functional outcome measures via GAS.

  • Emotional Well-being: Measured by SWLS, PCL-C, and BSI.

Intervention Structure

GIST Program

  • Duration: 13 weeks of interactive format.

  • Topics Covered: Self-assessment, goal setting, conversation strategies, social problem solving, and positive self-talk.

  • Implementation: Two therapists per group, incorporation of group feedback, and practice in real-life situations.

Alternative Treatment Approach

  • Similar content delivered in a non-interactive classroom setup; focus on individual tasks rather than group dynamics.

Statistical Analysis

Sample Size Calculation

  • A power analysis suggested a required sample size of 192 participants for robust findings.

Analysis Techniques

  • Mixed-effects models employed to evaluate changes in outcomes over time, accounting for treatment arm, time, and covariates.

Results

Statistical Findings

  • Improvements were noted in several outcome measures, including measurable changes in PPIC, LCQ, BSI, and PCL-C.

Goal Attainment

  • High rates of goal attainment reported across both groups, suggesting treatment efficacy.

Discussion

Summary of Findings

  • While both GIST and AT improved social competence skills, GIST did not demonstrate greater effectiveness than AT.

Implications for Treatment

  • Findings indicate a potential need for booster sessions post-intervention.

Limitations of the Study

  • The reliance on self-reported measures, the heterogeneity of TBI severity, and the overlap in curriculum between GIST and AT may impose challenges in accurately assessing treatment effectiveness.

Recommendations for Future Research

  • Future studies should explore responses to treatment in relation to individual characteristics and investigate therapist training methods for group interventions.

Conclusion

  • The study underscores that while group interactive format did not confer superiority in treatment delivery, significant improvements can still be realized from both interactive and non-interactive approaches to social competence training.

Keywords: Brain injuries; Rehabilitation; Social skills; Treatment

Acknowledgments: Special thanks to study assistants.

Correspondence: For further inquiries contact Lenore Hawley at lhawley@craighospital.org.