Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002.

The heterogeneity of traumatic brain injury (TBI) is considered one of the most significant barriers to finding effective therapeutic interventions. In October, 2007, the National Institute of Neurological Disorders and Stroke, with support from the Brain Injury Association of America, the Defense and Veterans Brain Injury Center, and the National Institute of Disability and Rehabilitation Research, convened a workshop to outline the steps needed to develop a reliable, efficient and valid classification system for TBI that could be used to link specific patterns of brain and neurovascular injury with appropriate therapeutic interventions. Currently, the Glasgow Coma Scale (GCS) is the primary selection criterion for inclusion in most TBI clinical trials. While the GCS is extremely useful in the clinical management and prognosis of TBI, it does not provide specific information about the pathophysiologic mechanisms which are responsible for neurological deficits and targeted by interventions. On th...

https://digitalcommons.wustl.edu/cgi/viewcontent.cgi?article=5735&context=open_access_pubs

Classification of Traumatic Brain Injury for Targeted Therapies

Qualitative methods in psychology: A research guide

This article considers the scientific process whereby new and better clinical tests of executive function might be developed, and what form they might take. We argue that many of the traditional tests of executive function most commonly in use (e.g., the Wisconsin Card Sorting Test; Stroop) are adaptations of procedures that emerged almost coincidentally from conceptual and experimental frameworks far removed from those currently in favour, and that the prolongation of their use has been encouraged by a sustained period of concentration on “construct-driven” experimentation in neuropsychology. This resulted from the special theoretical demands made by the field of executive function, but was not a necessary consequence, and may not even have been a useful one. Whilst useful, these tests may not therefore be optimal for their purpose. We consider as an alternative approach a function-led development programme which in principle could yield tasks better suited to the concerns of the clinician because of the transparency afforded by increased “representativeness” and “generalisability.” We further argue that the requirement of such a programme to represent the interaction between the individual and situational context might also provide useful constraints for purely experimental investigations. We provide an example of such a programme with reference to the Multiple Errands and Six Element tests. (JINS, 2006, 12, 194–209.)

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The case for the development and use of “ecologically valid” measures of executive function in experimental and clinical neuropsychology

In this paper, we review the most recent and often conflicting findings on conventional measures of executive control in autism spectrum disorders. We discuss the obstacles to accurate measurement of executive control, such as: its prolonged developmental trajectory; lack of consensus on its definition and whether it is a unitary construct; the inherent complexity of executive control; and the difficulty measuring executive-control functions in laboratory or clinical settings. We review the potential of an ecological-validity framework to address some of these problems, and describe new tests claiming verisimilitude, or close resemblance to “real life” demands. We also review the concept of veridicality, which allows for the measurement of the ecological validity of any task, and discuss the few studies addressing ecological validity in individuals with autism. Our review suggests that a multi-source approach emphasizing veridicality may provide the most comprehensive assessment of executive control in autism.

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Understanding Executive Control in Autism Spectrum Disorders in the Lab and in the Real World

Shallice and Burgess (1991) reported the utility of the Multiple Errands Test (MET) in discriminating executive deficits in three frontal lobe patients with preserved high IQ, who were otherwise unimpaired on tests of executive function. The aim of this study was to ascertain the value of a simplified version of the MET (MET‐SV) for use with the range of people more routinely encountered in clinical practice. Main findings were as follows: 1) The test discriminated well between neurological patients and controls, and the group effects remained when the difference in current general cognitive functions (WAIS‐R FSIQ) was taken into account. 2) The best predictors of performance in the healthy control group (n 5 46) were age and the number of times participants asked for help (with more requests associated with poorer performance). 3) In the neurological group, two clear patterns of failure emerged, with performance either characterized by rule breaking or failure to achieve tasks. These two patterns were associated with different dysexecutive symptoms in everyday life. 4) The patients not only made more errors than controls, but also different ones. A scoring method that took this into account markedly increased test sensitivity. 5) Many patients passed traditional tests of executive frontal lobe function but still failed the MET‐SV. This pattern was strongly associated with observed dysexecutive symptoms in everyday life. The results demonstrate the clinical utility of the test, and suggest that there are two common and independent sources of failure on multitasking tests in a general neurological population: memory dysfunction, and initiation problems. (JINS, 2003, 9, 31‐44.)

/pdf/ecological-validity-of-a-simplified-version-of-the-multiple-2sibeu3bvs.pdf

Ecological validity of a simplified version of the multiple errands shopping test

Problems with executive functioning may have catastrophic consequences following brain injury. Valid neuropsychological assessment procedures are required if the nature and extent of these are to be understood. However, some existing measures do not adequately reflect how executive impairments are manifested in the context of everyday functioning. Shallice and Burgess (1991) described one procedure, the Multiple Errands Test (MET), which did attain this goal. While successful, it was designed for people who performed within or above the normal range when tested using existing psychometric measures: however, it is acknowledged that many patients seen in routine clinical practice perform below normal limits. Furthermore, while the procedure was carried out in a public place a range of constraints may prevent this with some patients. In this paper the utility of a simplified MET designed for use within a hospital environment is explored. Twenty neurologically healthy participants and 20 people with acquired brain injury took part. People with acquired brain injury were clearly discriminated from healthy controls through the number of errors made. Furthermore, one category of error proved highly predictive of difficulties attributable to executive dysfunction observed in the context of everyday living. While one other test correlated almost as well with these difficulties, it was argued that MET methodology is more advantageous to clinicians regarding assessment and rehabilitation.

Development of a simplified version of the multiple errands test for use in hospital settings

Aggressive behaviour creates a significant challenge in neurorehabilitation. Despite the success in using behaviour modification principles in the treatment of post-acute behavioural problems, psychopharmacological approaches to the management of aggression are more frequently reported. However, inconsistencies apparent in the literature hinder inter-study comparisons of treatment methods. These include severity of brain injury, neuropsychological status and rigour of experimental methodology used. Data about aggression is also inconsistently reported, especially with regard to classification and severity. Descriptions of how aggressive behaviour responded to pre-treatment is also generally absent. In this paper an observational rating scale is described in an attempt to address these inconsistencies. The Overt Aggression Scale has been modified by increasing the range of interventions to reflect current practice in neurorehabilitation, and by changing the language to make it suitable for UK users. A range of antecedents has also been added to make the scale useful in behavioural analysis. Preliminary results indicate inter-rater reliability is good, and it is a valid indicator of type and severity of aggression. Antecedents and interventions used in the management of aggressive behaviours in neurorehabilitation are also illustrated. Clinical use of the scale is also discussed.

Use of a modified version of the Overt Aggression Scale in the measurement and assessment of aggressive behaviours following brain injury

The subject of Inappropriate Sexual Behaviour (ISB) amongst clients with neurological impairment, specifically Acquired Brain Injury (ABI) and dementia, has received limited coverage to date within the literature. This paper discusses some of the problems encountered in the definition and quantification of ISB, in particular the absence of standardized measurement tools to record ISB within an inpatient setting. Whilst ISB is reported to be less prevalent than other behavioural sequelae of brain injury or dementia, it is suggested that its impact on patients and carers can be significant. Ill-defined terminology and the absence of relevant assessment tools add to the specific challenges of understanding and managing ISB within a care or rehabilitation setting. As a result, it is argued that the subjective attitudes of staff and the culture of an institution can dominate the approach taken to dealing with ISB for these client groups.

Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment.

This study explored the effects of severe acquired brain injury (ABI) on self-esteem. A within-subjects design investigated 22 severe ABI survivors' self-reported responses on measures of self-esteem, mood and awareness of deficit. Data on cognitive ability and awareness of degree of executive impairment were included in the analysis. Self-esteem was measured using Rosenberg's Self-Esteem Scale (Rosenberg) and psychological distress by the Hospital Anxiety and Depression Scale (HADS). Self-esteem was found to be consistent over a two-week interval. Participants reported that their self-esteem had suffered following ABI when contrasting their current self-esteem with their retrospective perceptions. Self-esteem was highly correlated with psychological distress. More intact cognitive functioning and awareness of deficit were associated with lower self-esteem. The paradoxical finding that survivors who were more impaired cognitively and/or less aware of their deficits reported higher self-esteem poses an ethical dilemma for clinicians. It is hoped that this finding, along with the consistency of self-esteem ratings sparks further debate about how best to address issues of self-esteem among severe ABI survivors, particularly in the context of psychological distress, during rehabilitation.

Caroline Knight

Papers

Ecological validity of a simplified version of the multiple errands shopping test

Development of a simplified version of the multiple errands test for use in hospital settings

Use of a modified version of the Overt Aggression Scale in the measurement and assessment of aggressive behaviours following brain injury

Challenges associated with the definition and assessment of inappropriate sexual behaviour amongst individuals with an acquired neurological impairment.

Self-esteem as a predictor of psychological distress after severe acquired brain injury: An exploratory study