Can Facial Affect Recognition Skills in TBI be Restored?
Cognitive rehabilitation has been shown to be effective in improving cognitive functioning for patients with TBI (Cicerone et al., 2005; Cicerone et al., 2011). Two systematic meta-analytic studies provide compelling evidence supporting the use of cognitive remediation strategies to overcome a host of cognitive deficits after TBI (Cicerone et al., 2011; Rohling, Faust, Beverly, & Demakis, 2009). Techniques such as vanishing cues, feedback, and use of specific computer-based programmes have been listed as some of the effective cognitive remediation strategies used in the field of brain injury rehabilitation. Despite this, research is only now beginning to explore the remediation of facial affect recognition deficits in the TBI population. Given that people with TBI can benefit from cognitive rehabilitation interventions, they may also be helped by the proposed affect recognition training.
Research investigating the trainability of facial affect recognition has been carried out essentially on people with autism. As with people with TBI, these people have impoverished emotion recognition skills including deficiencies in identifying facial affect and inferring emotion in social contexts (see review by Harms, Martin, & Wallace, 2010). A growing number of successful training programmes have been developed to enhance facial affect recognition in adults and children with autism (Baron-Cohen, Golan, & Ashwin, 2009; Bölte et al., 2006; Lacava, Golan, Baron- Cohen, & Myles, 2007; Ryan & Charragáin, 2010; Silver & Oakes, 2001). Hadwin, Baron-Cohen, Howlin and Hill (1996), for instance, taught 10 children with autism to recognize the photographed facial expressions of happiness, sadness, anger and fear using a question–answer format with corrective feedback. These children were also taught about different situations, desires and beliefs that could cause different emotions. The accuracy of the children’s facial affect recognition improved significantly after eight days of training.
Golan and Baron-Cohen (2006) also included a task of facial affect recognition in their computerized multi-programmes geared to teach emotions and mental states to adults with Asperger’s disorder. The facial affect was presented in video clips along with definitions of each emotional expression. Participants were asked to associate the video
clips of facial expressions with affective words. After 10-15 weeks (with about two hours weekly) of computer intervention, participants improved significantly in their ability to associate specific facial affects with appropriate affective words.
A more recent study by Ryan and Charrágain (2010) investigated the effectiveness of four one-hour sessions of emotion recognition training, with a waiting list control group, in 33 children with autism (30 boys, 3 girls). These children were required to learn the constitutive parts of specific facial expressions (instead of the whole face). Results indicated that those who received the emotion recognition training showed significant gains in the emotion recognition task even at a follow-up session three months later.
Facial affect recognition impairments in other clinical populations have also been shown to respond to targeted emotion recognition training. The patients have included individuals with schizophrenia (see review by Horan, Kern, Penn, Green, & Penn, 2008), learning disabilities (P. M. Wood & Kroese, 2007) and eating disorders (Money, Davies, & Tchanturia, 2011). In the schizophrenia context, for example, Mazza, Lucci and Pacitti (2010) developed a group treatment that required participants to observe photos, paintings, figures, strips and imitations of facial emotional expressions. Sixteen patients with schizophrenia who received this training improved significantly on measures of emotion recognition, social functioning and theory of mind, compared to a control group that received problem solving training. In short, the success these studies have enjoyed suggests that facial affect recognition is an impairment that can be rehabilitated.
Despite this, only five studies have investigated methods for training facial affect recognition in persons with TBI. In the first, Guercio and colleagues (2004) found that deficits in facial affect recognition in three adults who had suffered brain injury could be reduced by stimulus equivalence techniques—directly training a person through reinforcement to associate pictures of facial affect with their corresponding verbal or written descriptors. Similar positive effects were reported by two subsequent randomized controlled studies using other cognitive remediation strategies such as errorless learning, reinforcement and self-monitoring (Bornhofen & McDonald, 2008b, 2008c). Bornhofen et al. (2008c), for example, compared two training approaches (errorless learning and self-instruction training) for treating emotion perception deficits in 18 individuals with TBI (17 male, 1 female). The training was administered in 10 2.5-hour sessions over 10 weeks. Participants exhibited improved ability to recognize
emotion from static using either strategy, while social inferences were improved only through self-instruction training.
A US pilot study by Radice-Neumann, Zupan, Tomita and Willer (2009) investigated the efficacy of two computer-based training programmes for two aspects of emotion recognition processing in adults with TBI. One programme focused on retraining people to identify emotions in others through analysis of facial expressions (Faces), the other on retraining identification of emotions through social context (Stories). Nineteen adults with moderate to severe TBI were randomly assigned to either Faces or Stories training. Both types of training consisted of six to nine sessions over a two-week period, with each session lasting one hour. Results showed that the Faces group not only improved in emotion recognition from faces but also extended this skill to social contexts and social-emotional behaviours. Stories training, on the other hand, led only to improved ability to infer how members of the group would feel in a given context.
In contrast to the experiments outlined above, another intervention study incorporating facial mimicry and focused attention remediation strategies for development of facial affect recognition skills in adults with TBI, proved inconclusive (McDonald et al., 2009b). Significantly, this study provided only a brief intervention—a single session consisting of two different treatments for 20 minutes each. In this case, the lack of success of the two strategies might well have been attributable to the short duration of the training.
While evidence from the aforementioned training studies suggests that people with TBI can at least be taught to accomplish facial emotion recognition tasks successfully, several drawbacks should also be noted. Many had only small sample sizes, some had no control groups, and few measured the durability of the treatment gains. Moreover, in Guercio et al’s study (2004), the emotional stimuli used for assessment and treatment were the same. The treatment effects may then have been due to practice rather than to the benefits of the treatment per se. In McDonald et al.’s study (2009b), on the other hand, the training programme was very short-term (the participants were trained on one day and tested the same day). More broadly, although facial affect recognition can be improved by training to a certain degree, the precise extent to which these training- related benefits can be generalized to real life is unclear. Such limitations
notwithstanding, the five training studies provide initial support for the hypothesis that people with TBI can be trained to recognize emotions in others.
In essence, these findings underscore the need for development of treatment strategies to enhance facial affect recognition for people with TBI. Better controlled trials with larger TBI samples are required to strengthen the effectiveness of the early interventions and determine whether they are clinically practicable. It would be valuable to address the question of whether improvement in facial affect recognition is durable, and whether it can be generalized to social functioning. It is also important to investigate whether cognitive functioning influences treatment outcomes. An interesting and highly relevant question is whether cognitive abilities need to be remedied before training in facial affect recognition can be effective. All of this increased awareness would perhaps shed light on the nature of the relationship between facial affect recognition and cognition, and assist clinicians in predicting those patients most likely to benefit from interventions.
Summary
The studies reviewed indicate that while difficulties in facial affect recognition pose a challenge to a significant number of people with moderate to severe TBI, little is known about appropriate treatment for this condition. Evidence from facial affect recognition intervention strategies designed for patients with autism has provided impetus for the development and evaluation of intervention strategies for people with TBI. Improving facial affect recognition skills may be a potential rehabilitation tool to improve social functioning for this clinical group and that would be a highly valuable outcome. For enhanced insight into the nature of social cognition, it is essential that there be a sounder understanding of ways in which various cognitive factors may relate to the processing of facial affect recognition. A grasp of the theoretical models underpinning facial affect recognition could result in an important contribution to the development of effective intervention strategies. Ultimately, these might improve the quality of life of people with TBI and their families.