Journal of the International Neuropsychological Society (2013), 19, 508–517.
Copyright E INS. Published by Cambridge University Press, 2013.
Effects of Moderate to Severe Traumatic Brain Injury on
Anticipating Consequences of Actions in Adolescents:
A Preliminary Study
Lori G. Cook,1,2Gerri Hanten,3,4Kimberley D. Orsten,4Sandra B. Chapman,1,2Xiaoqi Li,3
Elisabeth A. Wilde,3,5,6,7Kathleen P. Schnelle,3AND Harvey S. Levin3,5,7
1Center for BrainHealth, The University of Texas at Dallas, Dallas, Texas
2School of Behavioral and Brain Sciences, The University of Texas at Dallas, Dallas, Texas
3Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
4Department of Psychology, Rice University, Houston, Texas
5Department of Neurology, Baylor College of Medicine, Houston, Texas
6Department of Radiology, Baylor College of Medicine, Houston, Texas
7Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
(RECEIVED May 2, 2012; FINAL REVISION October 2, 2012; ACCEPTED October 2, 2012; FIRST PUBLISHED ONLINE January 14, 2013)
For this pilot study, we compared performance of 15 adolescents with moderate–severe traumatic brain injury (TBI) to
that of 13 typically developing (TD) adolescents in predicting social actions and consequences for avatars in a virtual
microworld environment faced with dilemmas involving legal or moral infractions. Performance was analyzed in relation
to cortical thickness in brain regions implicated in social cognition. Groups did not differ in number of actions predicted
nor in reasons cited for predictions when presented only the conflict situation. After viewing the entire scenario, including
the choice made by the avatar, TD and TBI adolescents provided similar numbers of short-term consequences. However,
TD adolescents provided significantly more long-term consequences (p5.010). Additionally, for the Overall qualitative
score, TD adolescents’ responses were more likely to reflect the long-term impact of the decision made (p5.053).
Groups differed in relation of the Overall measure to thickness of right medial prefrontal cortex/frontal pole and
precuneus, with stronger relations for the TD group (p,.01). For long-term consequences, the relations to the
posterior cingulate, superior medial frontal, and precentral regions, and to a lesser extent, the middle temporal region,
were stronger for the TBI group (p,.01). (JINS, 2013, 19, 508–517)
Keywords: TBI, Adolescence, Virtual reality, Social, Decision making, Brain structure
Adolescence is a period of great change in physical, emotional,
psychosocial, and cognitive domains. Research in neurodeve-
lopment indicates that an adolescent’s brain undergoes dramatic
maturation, including extensive reorganization and synaptic
Giedd et al., 2006; Gogtay et al., 2004). Due to the fact that an
adolescent brain is still in active development, any injury to the
brain incurred either during adolescence or before this time (i.e.,
later-emerging skills. Research in pediatric traumatic brain
injury (TBI) has demonstrated that long-term recovery is often
characterized by a persistent gap or ‘‘neurocognitive stall’’
between children with TBI and their typically developing peers
in terms of both cognitive and everyday life functioning
(e.g., Anderson, 1999; Chapman, 2006; Cook, DePompei, &
Chapman, 2011; Sohlberg, Todis, & Glang, 1998).
EXECUTIVE FUNCTION AND SOCIAL
ASPECTS IN ADOLESCENT TBI
Especially vulnerable to pediatric TBI are the complex neural
pathways associated with the frontal lobes, which can be
prematurely disconnected as a result of injury, having a
Correspondence and reprint requests to: Lori G. Cook, Center for
BrainHealth, The University of Texas at Dallas, 2200 W. Mockingbird Lane,
Dallas, TX 75235. E-mail: email@example.com
negative impact on long-term cognitive outcome (Chapman
& McKinnon, 2000). Corresponding with ongoing neural
changes, predominantly in regard to frontal lobe maturation,
is the protracted development of executive functions, which
begin in infancy but are not fully mature until early adulthood
(Anderson, Anderson, Northam, Jacobs, & Catroppa, 2001;
Kelly, 2000; Klenberg, Korkman, & Lahti-Nuutila, 2001;
Levin, Culhane, Hartman, Evankovich, & Mattson, 1991;
Stuss, 1992). As a result, youth with brain injury typically
demonstrate deficits in executive functioning, affecting key
cognitive domains which allow an individual to regulate
Hanten, 2005). In particular, weaknesses in emotional regula-
the likelihood that an adolescent with TBI would engage in
reckless behaviors or activities which would present a risk to
self or others (e.g., Ylvisaker & Feeney, 2002). Recent study of
adolescents and young adults with TBI suggests that an
increased level of executive dysfunction is associated with
immature social problem-solving skills and poorer social out-
come overall (Muscara, Catroppa, & Anderson, 2008).
In general, adolescents have been shown to engage in signi-
ficantly more risky behavior than adults, with risk-taking being
particularly increased in the presence of peers (e.g., Gardner &
this increase in risk-taking may be attributable to elevated
sensitivity to the potential reward value of risky decisions
(Chein, Albert, O’Brien, Uckert, & Steinberg, 2011). Particu-
larly implicated reward-based brain areas include the ventral
guide decision-making based on the assessment and prediction
of potential rewards and punishments (e.g., Bechara, 2005; Van
be compromised by TBI. Therefore, an adolescent with TBI,
relative to his or her peers, may be even more prone to act
without evaluating the effectiveness and safety of possible
action choices. Namely, he or she may have difficulty seeing
the ‘‘big picture’’ or considering the outcome or full range of
consequences for an action (Hanten et al., 2011), opting instead
for more impulsive decision-making based largely on what is
immediately apparent or gratifying. Moreover, considering the
frequency with which youth with brain injury report being
lonely, dissatisfied with their social situations, or having few
close friendships (Yeates et al., 2007), the underlying desire to
‘‘fit in’’ could exacerbate inappropriate decisions stemming
from susceptibility to peer pressure, such as recreational drug
use, legal infractions, or injury to self or others.
Social dysfunction has been well-documented in youth with
TBI (e.g., Hanten et al., 2008; Muscara et al., 2008; Turkstra,
McDonald, & DePompei, 2001; Yeates et al., 2007), with
several underlying cognitive skills being implicated, including
et al., 2004; Hanten et al., 2008, 2011; Muscara et al., 2008).
Yeates and colleagues (2004) demonstrated that children with
moderate to severe TBI used socially immature strategies for
conflict resolution relative to uninjured peers and orthopedic
controls through performance on the Interpersonal Negotiations
Strategy Test (INS; Yeates, Schultz, & Selman, 1991). These
findings were replicated by Hanten and colleagues (2008), who
also reported impaired social problem-solving performance in
youth with TBI on the INS as well as significant relations to
memory and language functioning.
More recently, Hanten and colleagues (2011) sought to
enhance the ecological validity of the INS by modifying it for
use in a computer-generated virtual reality (VR) environment,
where the social conflicts were presented through spoken
dialogue of virtual adolescent characters, or simulated avatars,
rather than through narrative presentation of conflict scenarios
(i.e., being read aloud by the examiner). Additionally, the
cognitive processing load was manipulated by varying the
number of speakers and amount of irrelevant or tangential
information presented. Results indicated overall impairment in
social problem solving for adolescents with TBI, with their
difficulties being most apparent with increased levels of cogni-
narrative version of the INS, TBI participants who completed
the VR version of the task demonstrated impairment not only in
the most complex stages of problem solving (e.g., generating
solutions, evaluating outcomes), but also at most basic stage
of defining the problem, suggesting that the VR version was
perhaps more sensitive to deficits in identifying the social
problem. Namely, to even identify the conflict for the VR
scenarios, or abstract the ‘‘gist’’ of the conversational exchange,
participants were required to select, interpret, and integrate
relevant information, all aspects of social processing that would
likely be necessitated by corresponding real-life situations.
Virtual Reality Applications
In social cognitive research, accurate simulation of social
environments has become an important goal, secondary to the
need to balance experimental control with ecological validity.
Measures that demonstrate mundane realism, that is, in which
the experimental demands match the relevant real-world situa-
tion, increase the subject’s experience of the authenticity of
more controlled experimental manipulation and, therefore, may
be experimentally more rigorous. However, these types of
measures also create a situation in which the measurement
reliability of social cognitive processes takes precedence over
the validityof those processes.With emerging technologies, the
trade-off between realism and experimental control can be
lessened, as virtual technology can be modified and controlled
without compromising measurement (Blascovich et al., 2002;
Loomis, Blascovich, & Beall, 1999). In general, the use of VR
technology facilitates the dynamic, graphical simulation of the
social environment more likely to be encountered during real-
life application of social problem solving or decision-making
while also increasing the chance for the participant to feel as
though he or she is a part of the interactions being portrayed
(Biocca, Harms, & Burgoon, 2003; Blascovich et al., 2002;
Previous studies have demonstrated the efficacy of using
virtual environments to assess social cognition, including
Anticipating consequences in adolescent TBI
For example, Schilbach and colleagues (2006) found activation
virtual characters’ social communication through facial expres-
sions. Additionally, VR environments have been shown to be
effective in eliciting specific emotional responses in participants
similar to those experienced in real-world circumstances (e.g.,
Freeman et al., 2008; Moore, Wiederhold, Wiederhold, & Riva,
2002; Riva et al., 2007).
Clinically, VR technology has been used to explore and
remediate social functioning primarily in autism, with a large
focus on adolescents (Mitchell, Parsons, & Leonard, 2007;
Parsons, Leonard, & Mitchell, 2006; Parsons & Mitchell,
2002; Parsons, Mitchell, & Leonard, 2004). However, before
the study by Hanten et al. (2011), few studies had used VR
technology with acquired brain injury populations, and none
of them addressed social outcome in children or adolescents
with TBI. Overall, virtual reality tools are continuing to grow
in popularity for use in both research and clinical domains
due to their increasing accessibility and utility for improved
real-life simulation and patient engagement.
Neural Correlates of Social Impairments in TBI
The majority of youth with moderate to severe TBI present
with a combination of diffuse and focal injury, particularly in
frontal, temporal, and parietal regions (Wilde et al., 2005).
Moreover, cortical thinning has been observed in these
regionsin children withTBI (McCauleyet al.,2010; Merkley
et al., 2008) over and above the typical pattern of cortical
thinning associated with maturation in the normally devel-
oping brain (e.g., Giedd et al., 2006). In general, deficits in
social cognition, corresponding with disruption to normal
development caused by TBI, have been associated with
damage to each of these brain regions, especially medial
ventral areas (Yeates et al., 2007). In the study by Hanten
et al. (2011), performance on the VR social problem-solving
task was found to be associated with cortical thickness in
specific brain areas such as orbitofrontal regions, the frontal
pole, the cuneus, and the temporal pole. Other studies of
children with TBI have demonstrated relationships between
reasoning and cortical thickness in specific prefrontal regions
(Krawczyk et al., 2010) as well links between lesion location
and decision-making (Hanten et al., 2006). However, the
relation of cortical thinning to anticipating social consequences
in adolescents with TBI has not yet been examined.
This exploratory study evaluated the ability to predict social
actions and the long- and short-term consequences of social
actions in adolescents with TBI as compared to typically
developing (TD) peers using a novel virtual reality task. It
was hypothesized that theTBI group would,in comparisonto
the TD group, produce fewer predictions of actions with
corresponding reasons as well as anticipate fewer long-term
consequences. Also explored was whether group responses
differed based on presentation of a moral or legal issue.
Lastly, performance on the VR-AC task was analyzed in
relation to cortical thickness in brain regions associated with
social cognition. Different patterns of relation between per-
formance and neural structure were predicted between the
adolescents with TBI and the TD adolescents.
The current study’s TBI group included a total of 15 ado-
lescents (ages 12–19 years) who had sustained a moderate to
severe closed head TBI at least 1 year prior. The following
mechanisms of injury were represented: fall (6), motor
vehicle collision (4), recreational/off-road vehicle accident
(2), bicycle accident(1),struckby amotorvehicle(1),sports-
related injury (1). Adolescents with TBI were recruited from
our larger ongoing longitudinal study of recovery from
pediatric TBI (NINDS Grant R01NS021889) based on eligible
age and date of injury as well as willingness to be contacted for
participation in future studies. Of the 25 eligible, 2 were exclu-
ded due to brain imaging safety concerns (orthodontia and/or
pregnancy) and 3 were lost to contact. Of the eligible families
who were approached, five declined because of scheduling
difficulties. That left the final 15 adolescents with TBI included
in this pilot study, yielding a participation rate of 75%. Families
who declined did differ from study participants on distance
required for travel totesting site (i.e., more likelyto live nearer).
However, they did not differ on indices of brain injury, educa-
tion, ethnicity, or socioeconomic status.
Participants were originally recruited at the time of injury
upon admission to Dallas and Houston medical centers.
Severe TBI was defined by lowest post-resuscitation Glasgow
Coma Scale (GCS; Teasdale & Jennett, 1974) score of 8 or
below. Moderate TBI was defined by either GCS of 9–12 or by
GCS of 13–15 coupled with acute brain lesion(s) evident on
computed tomographic (CT) or magnetic resonance (MRI)
scans. Exclusionary criteria were based on medical records
and parental (or guardian) interviews before enrollment and
included: previous hospitalization for head injury; pre-existing
neurological disorder associated with cerebral dysfunction
and/or cognitive deficit (e.g., epilepsy, mental retardation);
previously diagnosed learning disability; pre-existing severe
psychiatric disorder (e.g., schizophrenia, autism); history of
child abuse; penetrating gunshot wound to the brain; history of
hypoxia/anoxia; history of hypotension, meningitis or ence-
phalitis, chronic, serious physical disorder such as cancer,
uncontrolled diabetes, etc.; not an English language learner.
Given its high prevalence in the TBI population, hyperactive
attention deficit disorder was not an exclusion.
for age, gender, and parental education served as a comparison
group. Controls were recruited from the Dallas and Houston
communities and via advertising on an institutional website and
on public bulletin boards. The same exclusion criteria applied.
See Table 1 for group demographic and injury characteristics.
L.G. Cook et al.
A Wilcoxon test indicated no significant differences
between the TBI and TD groups on demographic variables of
age at test (median TD516.64; median TBI516.83;
p5.891) or mother’s education level (median TD515;
median TBI514; p5.188). Additionally, a w2test for
independence indicated no significant association between
group and gender [w2(1, n528)50.1437; p5.705]. Addi-
tionally, as an index of the representativeness of the sample,
in the previous overall project of 76 children with TBI, the
mean mother’s education was 13.0 years, and the mean GCS
was 6.9. Age could not be compared with the overall project
sample due to differing age ranges (the larger grant included
children as young as 7 years old).
To provide estimates of the relative intellectual, expressive
language, and reading functioning of the groups, Table 1 also
includes scores for both groups on the Wechsler Abbreviated
Scale of Intelligence (WASI; Wechsler, 1999), the Clinical
Evaluation of Language Fundamentals—3rd edition (CELF;
Semel, Wiig, & Secord, 1995), and the Gray Oral Reading
Test—4th edition (GORT; Weiderholt & Bryant, 2001).
Informed consent was obtained for all participants from a
parent or legal guardian in addition to assent from each study
participant, as approved by and according to the guidelines
of the Institutional Review Boards of the Baylor College
of Medicine, the University of Texas at Dallas, and the
University of Texas Southwestern Medical Center.
Virtual Anticipating Consequences (VR-AC) Task
The VR-AC task used the same virtual microworld environ-
ment described in Hanten and colleagues (2011) but shifted
the primary focus from conflict resolution to that of anticipating
consequences of actions. In this task, participants viewed four
brief (1–2min each) videos of previously-recorded interactions.
The videos portrayed the choice made by a character (i.e.,
avatar) when faced with a social dilemma that involved either
a legal infraction or a moral infraction. Male participants
viewed videos in which the primary avatar was male, and
female participants viewed videos in which the primary
avatar was female. Of the six possible scenarios, the three
vignettes pertaining to legal infractions included: (1) using a
fake I.D. to get into a club, (2) being involved in hit-and-run
‘‘fender-bender,’’ (3) participating in underage drinking at a
party. The three vignettes pertaining to moral infractions
included: (1) using a friend’s answers to cheat on a test,
(2) sneaking out of the house to hang out with a friend,
(3) blaming an innocent classmate for something the indi-
vidual did. In Part A (Set-Up Only) conditions, participants
were shown only the set-up of a potential moral or legal
dilemma, before a decision was made (e.g., an underage girl
is offered a fake I.D. to get into a club). After each set-up
scenario was viewed, participants were asked what they
thought would happen next. Responses were audio-recorded
and transcribed verbatim. For Part A, all participants viewed
one legal set-up scenario and one moral set-up scenario.
Immediately thereafter, in Part B (Set-Up1Outcome) con-
ditions, participants were shown two complete scenarios,
including both the set-up of a moral or legal dilemma as well as
the outcome, or the choice decided upon by the VR avatar (e.g.,
an underage girl is offered a fake I.D. to get into a club, and the
girl decides to accept the fake I.D. and go to the club). After
viewing the avatar’s resolution of the dilemma, participants
were asked what they thought the consequences would be for
transcribed verbatim. For Part B, all participants viewed one
entire legal scenario and one entire moral scenario (with each
scenario presented in Part B differing from those presented in
Part A), for a total of 4 distinct, randomly assigned scenarios
Table 1. Demographic and injury characteristics of TBI and TD participants
TBI (n515) TD (n513)
Age at test (years)
Mother’s education (years)
Age at injury (years)
Time post-injury (months)
Initial GCS score
8 male ; 7 female
7 Caucasian ; 5 Hispanic
1 African American ;
1 Asian ; 1 Biracial
6 male ; 7 female
6 Caucasian ; 5 Hispanic
2 African American
Note. GCS5Glasgow Coma Scale; WASI–FSIQ-25Wechsler Abbreviated Scale of Intelligence, Full Scale; Intelligence Quotient-2 Subtest;
GORT-4–SSS5Gray Oral Reading Test-4, Sum of Standard Scores; CELF-35Clinical Evaluation of Language Fundamentals-3, Formulated Sentences
subtest raw score; TBI5traumatic brain injury; TD5typically developing.
Anticipating consequences in adolescent TBI
presented to each participant. See Figure 1 for a graphical
example of the task progression for a single participant.
Examples of both Part A and Part B conditions of a script
for a single scenario (Sneaking Out) for a male participant are
Part A (Set-Up Only) Condition:
Scenario: Sneaking Out (two males converse through an
open window/patio of a street-level apartment)
Mike: Hey, David. What’s up?
David: Not much. I’m just trying to find something to
watch on TV. There’s nothing on.
Mike: Why don’t you come over and hang out?
David: My parents are already asleep.
Mike: Wake them up and ask if it’s okay. You’re right
down the street, so you could just walk over.
David: No, they get really mad if I wake them up.
Mike: Just sneak out. It’s not a big deal. They’d let you
come if they were awake, and you can go back in an hour
David: I don’t knowy.they’d be furious if they knew I
Mike: They’d never know.
,Examiner asks.: What do you think will happen?
Part B (Set-Up1Outcome) Condition:
,Dialogue from Part A continuing on to the following.
David: I’ve got to get out of this house! I’m so bored!
It still kind of makes me nervous, though.
Mike: It’s just this one time, and you said yourself, they’re
David: You’re right. They’ll never know. They’re sound
Mike: Yeah, man. We’re just hanging out at the house.
David: Okay, I’ll be over in 10minutes.
Mike: Great! I’ll see you in a little bit. And don’t worry,
it’ll be finey
,Examiner asks.: What are the consequences for the
decision that was made?
The scoring for the VR-AC task focused on predictions of
actions with corresponding reasons (Part A) or anticipation
of short-term consequences and long-term consequences
(Part B). Both quantitative and qualitative data were collected.
Part A scenarios were scored according to two variables, num-
wake up his parents and ask if he can go’’) and number of
reasons given for those actions (e.g., ‘‘ybecause he doesn’t
if he doesn’t ask first’’). These two measures were included to
index factors unrelated to the specific question at hand (i.e.,
ability to anticipate social consequences), but that might none-
theless affect the scores—namely, that being more verbally
forthcoming may increase the likelihood of the youth hitting on
a ‘‘good’’ response. Part B scenarios were scored according to
Scenario #1—Part A (Set-Up Only):
Sneaking Out (Moral Infraction)
Scenario #2—Part A (Set-Up Only):
Hit & Run Fender-Bender (Legal Infraction)
Scenario #3—Part B (Set-Up + Outcome):
Blaming Innocent (Moral Infraction)
Scenario #4—Part B (Set-Up + Outcome):
Underage Drinking (Legal Infraction)
What do you think will happen?What do you think will happen?
What are the consequences for the
decision that was made?
What are the consequences for the
decision that was made?
Fig. 1. Graphical example of the VR-AC task progression for a single participant (male).
L.G. Cook et al.
three variables. The first two reflect quantitative aspects of the
response: the number of short-term consequences given (e.g.,
‘‘his parents will be mad’’), and the number of long-term con-
sequences given (e.g., ‘‘he might lose his parents’ trust’’). The
third variable, the Overall measure, reflected a qualitative
judgment (on a scale of 1–4) of the participant’s overall
response. A score of 1–2 indicated that the participant’s
response did not reflect consideration of the long-term con-
sequences of their/other’s actions, whereas a score of 3–4 indi-
cated that the participant’s response suggested awareness of the
full range of consequences of their/other’s decisions and/or
reasoning regarding the impacts of a poor decision. This mea-
sure allowed for a judgment of the quality over and above the
quantity of short- vs. long-term outcomes given in the response.
Two blinded, trained raters independently scored the
transcribed responses of the participants for both Part A and
Part B scenarios, including both quantitative and qualitative
ratings. Inter-rater reliability was 89%, reflecting good over-
all agreement between raters. Any disagreement between
raters was resolved through discussion and consensus.
Due to the small sample size in this pilot study, coupled with
a skewed data distribution, a nonparametric method, namely,
the Wilcoxon test, was used for analysis of group differences
in performance for each separate condition. Additionally,
since corrections for multiple comparisons were not feasible
with this small sample, effect sizes were calculated using
Cohen’s d (Cohen, 1988) and are reported to inform the
strength of the observed effects according to the following
guidelines: small (d of .2 or lower), medium (d of around .5),
and large (d of .8 or higher). The sample size did not allow
inclusion in the model of other relevant variables, such as age
and GCS, although, as noted above, the groups were closely
equated for demographic variables.
Brain Imaging Measure: Volumetrics Using MRI
Forthemajority ofparticipants, brain imaging wasconducted
on the same day as behavioral testing. T1-weighted 3D
sagittal images were collected on Philips Intera 3T whole
body scanners. Parameters included 1.0-mm-thick slices,
0-mm slice gaps, echo time (TE)54.6ms/repetition time
(TR)515ms, field of view (FOV)5256mm, and a recon-
structed voxel size M/P/S(mm)51.0/1.0/1.0.
Cortical reconstruction and segmentation was accomplished
with Freesurfer with procedures previously described (e.g.,
Dale, Fischl, & Sereno, 1999;Han et al.,2006; Jovicich etal.,
2006; Segonne et al., 2004). This method uses intensity and
continuity information from the whole three-dimensional
MR volume in segmentation and deformation procedures to
generate representations of cortical thickness. QDEC (Query,
Design Estimate, Contrast) is a FreeSurfer application for
performing inter-subject/group averaging and inference on
morphometry data (cortical surface and volume). It was used
to examine group differences in cortical thickness and to
investigate the relation of cortical thickness to behavioral
measures. Analyses were performed using general linear
models with age controlled at each surface vertex. Statistical
parametric maps of the cortical mantle were generated to show
the relation of cortical thickness to behavioral variables and
were overlaid on a pediatric template based on typically-
developing adolescents (Figure 2). A statistical threshold of
p,.01 was used, and values displayed are either positive
relations (in blue) or negative relations (in red). The p-value
shown is a –log(10) p-value, rather than a conventional p-value.
VR-AC Task (see Table 2 for Wilcoxon
On the number of actions predicted in response to the
set-up of a social dilemma scenario, TD adolescents did not
between groups on the number of reasons provided for
those predicted actions did not reach significance, although
there was a trend for the adolescents with TBI to have
For the outcome condition, TD adolescents and adolescents
Fig. 2. QDEC analysis demonstrating group differences (signifi-
(long-term consequences measure) to cortical thinning. The displayed
p-value is a -log(10) value, rather than a conventional p-value.
Anticipating consequences in adolescent TBI
However, TD adolescents provided significantly more long-
term consequences than did adolescents with TBI. Moreover,
for the Overall qualitative score, TD adolescents were more
likely to provide answers that reflected well-thought-out,
long-term impacts of the decision made in the scenario than
were adolescents with TBI.
Legal versus moral
We found no differences on moral versus legal scenarios for
the prediction scores or the scores for short-term or long-term
consequences. However, in the Overall score, we found that
adolescents with TBI had marginally lower scores than TD
adolescents for the moral conflicts [mean for TD53.18;
median for TBI52.57 (Z51.6158; p5.053; d50.71)] but
not for the legal conflicts.
Brain Imaging Volumetrics
Groups differed most notably in the relation of the Overall
measure to the right medial prefrontal cortex (PFC)/frontal
pole and the precuneus, with much stronger relations apparent
for the TD group. On the number of long-term consequences
provided, there was a group difference in the relation of per-
formance to the posterior cingulate, the superior medial frontal
region, and the precentral region, and to a lesser extent, the
middle temporal region (see Figure 2), with stronger relations
shown for the TBI group than the TD group.
Virtual Social Cognition Task
Preliminary results from the Virtual Reality-Anticipating
Consequences task are consistent with the broad pattern of
differences demonstrated by adolescents with TBI as com-
pared to typically developing adolescents in showing few
differences on concrete, short-range tasks, and larger differ-
ences on tasks that require more executive-level processing.
First, on the quantitative measures of number of actions
predicted and reasoned by adolescents with TBI and TD
adolescents, there were no significant differences, suggesting
that group differences observed in other measures were not
the result of the TD group being more verbally forthcoming.
Second, when asked to give the possible consequences of a
potentially risky decision for a social dilemma made by a
character (i.e., avatar) in a virtual vignette, children with
TBI offered as many short-term outcomes and reasons for
those outcomes as did typically developing adolescents.
Of interest, however, adolescents with TBI were less likely
to think beyond the immediate consequences of the actions
or provide reasoning that took into account the full range
of consequences, especially long-term, for a given resolu-
tion to a social problem than were their TD counterparts,
but primarily for social dilemmas of a moral nature. On
social dilemmas concerning legal infractions, task perfor-
mance of children with TBI was similar to TD children.
As a possible explanation to these findings, we suggest that
children with TBI may not have surpassing difficulty in
remembering concrete rules (and laws), but may be less
able to flexibly apply moral reasoning to novel situations
(e.g., Walsh, 1978). An expanded sample and analysis of
age-at-test and age-at injury effects would inform whether
older adolescents or those injured at an older age are more
familiar with the legal infractions portrayed and/or have more
experience with moral dilemmas, influencing the responses.
In the VR-AC task, brain-behavior relationships differed
between groups in the relation of the Overall (qualitative)
measure to the medial PFC/frontal pole and the precuneus
(bilaterally), with stronger relations apparent for the TD
group than the TBI group. The VR-AC task assesses the
ability to understand the future consequences of particular
social actions, which is measured both in quantitative
dimensions (number of short-term or long-term con-
sequences that come to mind) and qualitative dimensions (the
comprehensiveness of the evaluation of consequences) of
anticipating consequences of one’s actions. The prefrontal
system is highly relevant to assessment of reward or penalty
for future consequences (Bechara, 2005), with an immature
or impaired prefrontal system being more likely to corre-
spond with decisions favoring immediate rewards (Chein
et al., 2011; Van Leijenhorst et al., 2010).
Consistent with our findings of the mediation of social
cognition by memory(Hantenet al.,2008), theprecuneus has
been shown to support episodic memory retrieval for con-
crete and abstract stimuli (Krause et al., 1999) and is central
to recognition memory (Do ¨rfel, Werner, Schaefer, Von
Kummer, & Karl, 2009). In addition, and relevant to the
Table 2. Results of Wilcoxon analyses for VR-AC task
VariableMedian for TBIMedian for TD
Zpd (effect size)
Part A: Actions
Part A: Reasons
Part B: Short-term
Part B: Long-term
Part B: Overall
L.G. Cook et al.
current study, a recent report has shown the precuneus to be
involved in the ability to view and evaluate social/emotional
stimulus from the perspective of detachment or distance
(Koenigsberg et al., 2010).
There were few group differences in the relation of
cortical thickness to the number of actions predicted or in the
number of short-term consequences predicted. However, on
the number of long-term consequences, there was a group
difference in the relation of performance to the posterior
cingulate, the superior parietal region, and the precuneus
region, with stronger relations shown for the TBI group than
the TD group. Of interest, the posterior cingulate is a part of
the ‘‘default network’’ and is reported to be abnormal in
children with Autism Spectrum Disorder, with poorer-than-
normal default network connectivity associated with poor
social function and increased restrictive and repetitive beha-
viors, but greater-than-normal connectivity in the network
associated with poorer verbal and non-verbal communication
skills (Weng et al., 2010). Furthermore, studies of micro-
stimulation of the posterior cingulate in non-human primates
(Hayden, Nair, McCoy, & Platt, 2008) reveal its involvement
in the evaluation of actions in situations of dynamic change.
Especially interesting is that stimulation of the posterior
cingulate is associated with a preference for a safer choice
option as compared to a risky choice (Hayden et al., 2008).
Finally, in concert with the above findings, the medial
superior frontal gyrus has been reported to be involved
in selection of action sets and, when integrated with the
cingulate’s role in relating actions to consequences,
guides decision-making (Rushworth, Walton, Kennerley, &
We acknowledge that due to the small sample size and
relative heterogeneity(e.g., wide range oftime post-injury)in
this preliminary study, firm conclusions cannot be drawn.
However, several of the reported effect sizes are reasonably
large, and it is likely that the inclusion of more data may
result in additional significant differences for the conditions
that currently suggested a trend, such as in the fewer number
of reasons provided by the TBI group for the predicted
responses to a social dilemma. Nonetheless, due to the lack
of Type 1 error correction, the current results warrant
cautious interpretation. It is possible that even with an
increased sample size, correction for alpha slippage may
reduce the significance. Moreover, the distribution in the
current sample is skewed, which is typical for studies of TBI.
That, coupled with the small sample size, precluded valid
injury or time since injury, as well as contributions of other
cognitive factors, such as language processing or memory,
which could be addressed within a larger study. Nonetheless,
we find the strength and specificity of the current findings
to be encouraging. Taken together, the preliminary data
motivate further study using an integrated approach of
advanced behavioral and neuroimaging methodologies to
inform the specific processes involved in social decision-
after pediatric TBI.
The behavioral and imaging results from this pilot study
provide possible characterization of social decision-making
deficits in adolescents with moderate to severe TBI. Clinically,
social functioning in everyday life, it is critical to assess key
social decision-making skills, including the ability to consider
the long-term impacts of a decision. Targeted assessment using
virtual reality environments may serve a valuable role in cap-
turing the complex, environmentally sensitive nature of social
patterns in more ecologically valid assessment has the potential
to elucidate how to provide meaningful, effective remediation
for youth with brain injury at each developmental stage.
This work was supported by the National Institute of Neurological
Disorders and Stroke (NINDS) Grant 2R01 NS 21889-16. The
authors report no conflicts of interest.
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