Goal Management Training Combined With External Cuing as a Means to Improve Emotional Regulation, Psychological Functioning, and Quality of Life in Patients With Acquired Brain Injury: A Randomized Controlled Trial

Assessing adherence and clinical utility of modified goal management training for adolescents with ADHD: A pilot study

Many adolescents with attention-deficit hyperactivity disorder (ADHD) have executive functioning (EF) difficulties that contribute to academic and social-emotional challenges. This pilot explored adherence to and effectiveness of modified Goal Management Training (GMT), an EF intervention, with ADHD youth. Six adolescents with ADHD (14-17 years, 2 female) participated in a 6-session online group. Adherence was tracked via attendance and homework. Reliable change scores gaged pre-post differences on measures before and after training (primary: everyday EF and goal attainment; secondary: EF task performance, functional impairment, emotional adjustment, and self-concept). All youth attended at least 4 sessions, though homework completion was mixed. Four youth achieved their goal, some demonstrated reliable change on outcome measures, and all evidenced a reduction in impairment. Results support the feasibility of modified GMT in adolescents with ADHD and suggest that youth may benefit from this more personalized and holistic approach to EF intervention.

A Naturalistic Intervention to Promote Executive Functions in Primary School Children: A Pilot Study

Executive functions are related to the control of cognition, emotion, and behavior. They are essential to lifelong outcomes, including school performance. Naturalistic interventions embedded in children's daily activities and environments have greater effects. Therefore, this pilot study aimed to develop a naturalistic program suitable for schools, based on Goal Management Training (GMT), and to analyze its effects on executive functions and behavior. The participants consisted of 35 students from 2nd to 5th grade with executive dysfunction complaints. They underwent neuropsychological assessments of working memory, inhibition, cognitive flexibility, and intellectual capacity. Teachers and parents answered questionnaires on executive functions and behavior. Students were randomly assigned to an active control group, who participated in sessions on citizenship, and an experimental group (EG), stimulated through the executive function program, both with 16 sessions conducted by psychologists. After the intervention, all participants were reevaluated. The two-way Wald-type statistic (WTS) revealed greater improvement in executive functions for the EG, including working memory and inhibition. Additionally, parents and teachers, blind to the experimental conditions, reported improvements in some measures of executive functions and behavior. The results are encouraging, but further studies should test the intervention when implemented with larger samples and by teachers.

Stroke rehabilitation adaptive approaches: A theory-focused scoping review

BACKGROUND

Stroke rehabilitation consists of restorative and adaptive approaches. Multiple adaptive approaches exist.

AIMS/OBJECTIVES

The objective of this study was to develop a framework for categorising adaptive stroke rehabilitation interventions, based on underlying theory.

MATERIAL AND METHODS

We searched multiple databases to April 2020 to identify studies of interventions designed to improve participation in valued activities. We extracted the name of the intervention, underlying explicit or implicit theory, intervention elements, and anticipated outcomes. Using this information, we proposed distinct groups of interventions based on theoretical drivers.

RESULTS

Twenty-nine adaptive interventions were examined in at least one of 77 studies. Underlying theories included Cognitive Learning Theory, Self-determination Theory, Social Cognitive Theory, adult learning theories, and Psychological Stress and Coping Theory. Three overarching theoretical drivers were identified: learning, motivation, and coping.

CONCLUSIONS

At least 29 adaptive approaches exist, but each appear to be based on one of three underlying theoretical drivers. Consideration of effectiveness of these approaches by theoretical driver could help indicate underlying mechanisms and essential elements of effective adaptive approaches.

SIGNIFICANCE

Our framework is an important advance in understanding and evaluating adaptive approaches to stroke rehabilitation.

Improvement of anxiety in ADHD following goal-focused cognitive remediation: a randomized controlled trial

Introduction

Despite the high prevalence and detrimental consequences of cognitive and executive dysfunction in ADHD, the evidence base of cognitive remediation in the adult ADHD population is sparse. Executive problems can increase both anxiety and depression in ADHD. Thcus, it is important to develop treatment options for adults with ADHD, aiming to improve goal-directed behavior and mood. Goal Management Training (GMT) is an intervention that has received empirical support in improving executive functions and mood in normal aging and for various neurological and psychiatric conditions. The present randomized controlled trial investigated the effects of a goal-focused intervention combining 1) group-based GMT incorporating psychoeducation about ADHD and 2) guidance in implementing individual goals for coping with executive problems in everyday life, compared to treatment as usual (TAU). The primary outcome was perceived executive functioning in everyday life. Secondary outcomes included psychological well-being (anxiety, depression, and coping with ADHD symptoms).

Methods

We recruited 81 adult participants with a verified ADHD diagnosis (Mage   = 31 years). Inclusion was based upon the presence of executive functioning complaints. The participants were randomly assigned to either the intervention or TAU. The intervention group (n = 41) received 16 hours of GMT and psychoeducation, in addition to 4 individual sessions focusing on formulating goals. The goals were assessed in 6 bi-weekly phone calls in the first three months following the group sessions. Participants in the TAU group (n = 40) received standard, individually-adapted follow-up in an outpatient psychiatric health care setting. All participants were assessed at baseline, post-intervention, and at 8-month follow-up (main measurement time point).

Results

Significant improvements in everyday executive functioning, psychological wellbeing, and symptoms of ADHD from baseline to 8-month follow-up were reported in both groups. The intervention group reported a significantly higher reduction in symptoms of anxiety compared to TAU. Conclusions. Our findings provide support for considering cognitive remediation as a treatment option for patients with ADHD.Clinical Trial Registration: https://clinicaltrials.gov/study/NCT04638283?term=NCT04638283&rank=1, identifier: NCT04638283.

Combined Cognitive and Psychological Interventions Improve Meaningful Outcomes after Acquired Brain Injury: A Systematic Review and Meta-Analysis

Interventions addressing cognitive and emotional difficulties after acquired brain injury (ABI) often focus on specific impairments in cognition or mood. These interventions can be effective at addressing their specific target, but do not routinely translate to improved activity and participation outcomes. Approaches that combine cognitive and psychological rehabilitation are increasingly popular; however, to date, there have been no systematic evaluations of their efficacy. We conducted a systematic review of five databases, searching for randomised controlled trials of adults with diagnoses of non-progressive ABI at least 1-month post injury, in receipt of interventions that combined cognitive and psychological components compared to any control. Screening and data extraction were evaluated by two independent reviewers using a standardised protocol. Effect sizes were calculated using Hedge's g and estimated using a random-effects model. Risk of bias was assessed using the PEDro-P rating system, and quality of evidence evaluated using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Thirteen studies were included in the meta-analysis (n = 684). There was an overall small-to-medium effect (g = 0.42) for combined interventions compared with controls, with gains maintained at 6-month follow-up. Improvements were observed at the level of impairment, activity, participation and quality of life. GRADE ratings and analyses investigating sensitivity, heterogeneity and publication bias indicated that these effects were robust. No a priori variables moderated these effects. Overall, this review provides strong evidence that combined cognitive and psychological interventions create meaningful change in the lives of people with ABI.

Occupational Therapy Practice Guidelines for Adults With Traumatic Brain Injury

IMPORTANCE

Occupational therapy practitioners are uniquely qualified to address the occupational needs of people with traumatic brain injury (TBI) and their caregivers to maximize participation, health, and well-being.

OBJECTIVE

These Practice Guidelines are informed by systematic reviews of the effectiveness of interventions that address impairments and skills to improve the occupational performance of people with TBI, as well as interventions for caregivers of people with TBI. The purpose of these guidelines is to summarize the current evidence available to assist clinicians' clinical decision-making in providing interventions for people with TBI and their caregivers.

METHOD

We reviewed six systematic reviews and synthesized the results into clinical recommendations to be used in occupational therapy clinical practice.

RESULTS

Sixty-two articles served as the basis for the clinical recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports multimodal sensory stimulation, unimodal auditory stimulation, physical activity, virtual reality, cognitive interventions, vision therapy, goal-focused interventions, individual and group training and education, and caregiver supports. Occupational therapy practitioners should incorporate these interventions into individual and group sessions to maximize recovery and promote occupational participation. Additional interventions are also available, based on emerging evidence and expert opinion, including prevention approaches, complexity of injury, and the use of occupation-based performance assessments. What This Article Adds: These Practice Guidelines provide a summary of evidence in clinical recommendations tables supporting occupational therapy interventions that address impairments resulting from and skills to improve occupational performance after TBI. The guidelines also include case study examples and evidence graphics for practitioners to use to support clinical reasoning when selecting interventions that address the goals of the person with TBI and their caregiver's needs.

Increased top-down control of emotions during symptom provocation working memory tasks following a RCT of alpha-down neurofeedback in PTSD

BACKGROUND

Posttraumatic stress disorder (PTSD) has been found to be associated with emotion under-modulation from the prefrontal cortex and a breakdown of the top-down control of cognition and emotion. Novel adjunct therapies such as neurofeedback (NFB) have been shown to normalize aberrant neural circuits that underlie PTSD psychopathology at rest. However, little evidence exists for NFB-linked neural improvements under emotionally relevant cognitive load. The current study sought to address this gap by examining the effects of alpha-down NFB in the context of an emotional n-back task.

METHODS

We conducted a 20-week double-blind randomized, sham-controlled trial of alpha-down NFB and collected neuroimaging data before and after the NFB protocol. Participants performed an emotional 1-back and 2-back working memory task, with interleaved trauma-neutral and trauma-relevant cues in the fMRI scanner. Data from 35 participants with a primary diagnosis of PTSD were analyzed in this study (n = 18 in the experimental group undergoing alpha-down NFB, n = 17 in the sham-control group).

RESULTS

Firstly, within-group analyses showed clinically significant reductions in PTSD symptom severity scores at the post-intervention timepoint and 3-month follow-up for the experimental group, and not for the sham-control group. The neuroimaging analyses revealed that alpha-down NFB enhanced engagement of top-down cognitive and emotional control centers, such as the dorsolateral prefrontal cortex (dlPFC), and improved integration of the anterior and posterior parts of the default mode network (DMN). Finally, our results also indicate that increased alpha-down NFB performance correlated with increased activity in brain regions involved in top-down control and bodily consciousness/embodied processing of self (TPJ and posterior insula).

CONCLUSION

This is the first study to provide mechanistic insights into how NFB may normalize dysfunctional brain activity and connectivity in PTSD under cognitive load with simultaneous symptom provocation, adding to a growing body of evidence supporting the therapeutic neuromodulatory effects of NFB. This preliminary study highlights the benefits of alpha-down NFB training as an adjunctive therapy for PTSD and warrants further investigation into its therapeutic effects on cognitive and emotion control in those with PTSD.

Dynamic cognitive inhibition in the context of frustration: Increasing racial representation of adolescent athletes using mobile community-engaged EEG methods

Introduction

Concussive events and other brain injuries are known to reduce cognitive inhibition, a key aspect of cognition that supports ones' behaviors and impacts regulation of mood or affect. Our primary objective is to investigate how induction of negative affect (such as frustration) impacts cognitive inhibition and the dynamic process by which youth athletes modulate responses. Secondary objective is to address the lack of Black representation in the scientific literature that promotes brain health and investigates pediatric sports-related brain injury. In particular, neuroscience studies predominantly include White participants despite broad racial representation in sport, in part due to technological hurdles and other obstacles that challenge research access for Black participants.

Methods

Using electroencephalography (EEG), we evaluate the dynamic brain processes associated with cognitive inhibition in the context of frustration induction in adolescent athletes during pre-season conditioning (i.e., prior to contact; N = 23) and a subset during post-season (n = 17).

Results

The N2 component was sensitive to frustration induction (decreased N2 amplitude, slower N2 latency), although effects were less robust at postseason. Trial-by-trial changes indicated a steady decrease of the N2 amplitude during the frustration block during the preseason visit, suggesting that affective interference had a dynamic effect on cognitive inhibition. Lastly, exploratory analyses provide preliminary evidence that frustration induction was less effective for athletes with a previous history of concussion or migraines (trending result) yet more effective for athletes endorsing a history with mental health disorders.

Discussion

We emphasize the urgent need to improve representation in cognitive neuroscience, particularly as it pertains to brain health. Importantly, we provide detailed guides to our methodological framework and practical suggestions to improve representative participation in studies utilizing high-density mobile EEG.

Cognitive rehabilitation in post-COVID-19 condition: A study protocol for a randomized controlled trial

BACKGROUND

Post-COVID-19 condition is frequently comprised of persistent cognitive sequela, including deficits in attention and executive functions (EFs), which can act as a barrier for regaining pre-illness functional levels. Goal Management Training (GMT) is a cognitive rehabilitation (CR) intervention for improving attention and EFs that has received empirical support in studies of other patient groups. The present study aims to determine the efficacy of GMT for improving everyday attention and EFs in adults who experience persistent cognitive deficits after COVID-19.

METHODS

This study protocol describes an open-label randomized controlled trial comparing the efficacy of GMT to a wait list control condition (WL), for improving persistent (> 2 months) cognitive sequela in post-COVID-19 condition. The study aims to recruit 240 participants aged 18 to 65 years with a history of SARS-CoV-2 infection and perceived attentional and EF difficulties in daily life. Participants will be block randomized (computer-algorithm) to either group-based GMT (n = 120) or WL (n = 120). GMT will be internet-delivered to groups of six participants in six two-hour sessions delivered once a week. The primary outcome will be the Metacognition Index of the Behavior Rating Inventory of Executive Function - Adult Version, a self-report measure assessing everyday EF difficulties, specifically metacognition, at six months post-treatment. Secondary outcomes include performance-based neurocognitive measures, and tertiary outcomes include rating scales of cognition, emotional health, quality of life, and fatigue.

CONCLUSION

Study findings could contribute to providing an evidence-based treatment option for symptoms that are frequent and debilitating following a prevalent condition.

TRIAL REGISTRATION NUMBER

NCT05494424.

Goal- and Client-Directed Interventions for Adults With Traumatic Brain Injury (2013-2020)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on goal- and client-directed interventions to improve psychosocial outcomes for people with traumatic brain injury.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

Regional brain volume prior to treatment is linked to outcome after cognitive rehabilitation in traumatic brain injury

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Advanced neuroimaging has potential to inform new practices in cognitive rehabilitation.

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Regional brain volume was linked to effect of cognitive rehabilitation in traumatic brain injury.

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The most robust effects were observed in midline fronto-parietal brain regions.

Cognitive rehabilitation is useful for many after traumatic brain injury (TBI), but we lack critical knowledge about which patients benefit the most from different approaches. Advanced neuroimaging techniques have provided important insight into brain pathology and systems plasticity after TBI, and have potential to inform new practices in cognitive rehabilitation. In this study, we aimed to identify candidate structural brain measures with relevance for rehabilitation of cognitive control (executive) function after TBI. Twenty-eight patients (9 female, mean age 40.5 (SD = 13.04) years) with TBI (>21 months since injury) that participated in a randomized controlled cognitive rehabilitation trial (NCT02692352) were included in the analyses. Regional brain volume was extracted from T1-weighted MRI scans before treatment using tensor-based morphometry. Both positive and negative associations between treatment outcome (everyday cognitive control function) and regional brain volume were observed. The most robust associations between regional brain volume and improvement in function were observed in midline fronto-parietal regions, including the anterior and posterior cingulate cortices. The study provides proof of concept and valuable insight for planning future studies focusing on neuroimaging in cognitive rehabilitation after TBI.

Rehabilitation of executive function in chronic paediatric brain injury: a randomized controlled trial

BACKGROUND

Impaired executive functions (EFs, i.e., purposeful, goal-directed behaviour) cause significant disability after paediatric acquired brain injury (pABI) warranting efficient interventions. Goal Management Training (GMT) is a metacognitive protocol proven effective for executive dysfunction in adults. This pre-registered, blinded, parallel-randomized controlled trial evaluated efficacy of a paediatric adaptation (pGMT) compared to a psychoeducative control (paediatric Brain Health Workshop, pBHW) to improve EF.

METHODS

Children aged 10 to 17 years with pABI (e.g., traumatic brain injury, brain tumour), ≥ 1 year post-onset or ended treatment, with parent-reported EF complaints were eligible. Participants were randomized (computer-algorithm) to either group-based pGMT (n = 38) or pBHW (n = 38). The active control was tailored to keep non-specific factors constant. Thus, both treatments comprised of 7 sessions at hospitals over 3 consecutive weeks, followed by 4 weeks of telephone counselling of participants, parents, and teachers. Parent-reported daily life EF, assessed by the questionnaire Behavior Rating Inventory of Executive Function (BRIEF; Behavioral Regulation Index (BRI) and Metacognition Index (MI)), were co-primary outcomes 6 months post-intervention. Secondary outcomes included neuropsychological tests and a complex naturalistic task (Children's Cooking Task).

RESULTS

Seventy-three participants (96%) completed allocated interventions and 71 (93%) attended the 6-month follow-up. The results demonstrated no significant difference in effectiveness for the two interventions on parent-reported EF: For BRIEFBRI, mean (SD) raw score for pGMT was 42.7 (8.8) and 38.3 (9.3) for pBHW. Estimated difference was - 2.3 (95% CI - 5.1 to 0.6). For BRIEFMI, the corresponding results were 80.9 (20.4) for GMT and 75.5 (19.3) for pBHW. Estimated difference was - 1.4 (95% CI -8.5 to 5.8). In performance-based tests, pGMT was associated with improved inhibition and executive attention, while pBHW was associated with fewer errors in the naturalistic task.

CONCLUSIONS

In pABI, metacognitive training (pGMT) did not demonstrate additional effectiveness on parent-reported daily life EF at 6-month follow-up, when compared to a psychoeducative control. Both interventions were well-tolerated and demonstrated distinct improvements at different EF assessment levels. To conclude on pGMT efficacy, larger studies are needed, including further investigation of appropriate assessment levels and possible differences in effect related to treatment duration, developmental factors, and injury characteristics.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT0321534211, 11 July 2017.

Improved emotion regulation in depression following cognitive remediation: A randomized controlled trial

OBJECTIVE

Executive functions (EFs) play a key role in emotion regulation and, related to this, depression. Cognitive remediation (CR) targeting EFs, such as Goal Management Training (GMT) and computerized cognitive training (CCT), may reduce maladaptive emotion regulation. However, the clinical potential of GMT in the context of depression and emotion regulation remains to be tested. Hence, the primary aim of the present study was to compare effects of GMT with CCT on symptoms of emotion dysregulation.

METHOD

The paper reports the effects of a preregistered randomized controlled trial. Sixty-three participants (18-60yrs) with active or remitted depression and EF complaints were randomized to nine sessions of GMT (n = 35) or CCT (n = 28). All were assessed at baseline, post-intervention, and at 6-month follow-up. The Ruminative Response Scale and the Difficulties in Emotion Regulation Scale were employed to assess emotion regulation.

RESULTS

Both groups improved following the intervention on emotion regulation domains after controlling for intention-to-treat, including brooding rumination and on items reflecting non-accepting reactions to distress. Relative to CCT, the GMT-group demonstrated increased clarity of emotional responses in the per protocol analysis.

CONCLUSIONS

Our findings demonstrate the potential of GMT and CCT in reducing maladaptive emotion regulation in depression.

The effectiveness of an integrated counseling program on emotional regulation among undergraduate students with depression

Purpose

This study investigated the effectiveness of a new counseling program integrating cognitive behavioral therapy and acceptance and commitment therapy to promote emotional regulation (ER) among undergraduate students with depression.

Design/methodology/approach

An interventional mixed method design was employed with the development of a qualitative method-based program using experimental and qualitative research. The sample consisted of 792 third-year undergraduate students at a public university in Bangkok. A total of 34 students with depression voluntarily enrolled and were divided into 2 groups. The 17 students in the experimental group received integrated counseling, while those in the control group received brochures. The effectiveness was evaluated using the self-assessment section on the ER scale and the Beck Depression Inventory form before and after counseling. When the program ended, qualitative research was conducted using in-depth interviews. In terms of quantitative research, the data were analyzed using one-way MANOVA and the qualitative research data used content analysis.

Findings

The mean scores for ER and depression in the experimental group before and after counseling were significantly different (p-value <0.05). Results were also significantly different from the control group (p-value <0.05). Students with depression showed improvements in ER in all six components after joining the program, including awareness, clarity, acceptance, impulse, goals and strategies.

Originality/value

Integrated counseling is an effective program that can increase ER and reduce depression among adolescents and can be an alternative program for depressive patients or other mood-regulating problems to promote ER.

Qualitative study of loneliness in a senior housing community: the importance of wisdom and other coping strategies

OBJECTIVE

Older adults are at a high risk for loneliness, which impacts their health, well-being, and longevity. While related to social isolation, loneliness is a distinct, internally experienced, distressing feeling. The present qualitative study sought to identify characteristics of loneliness in older adults living independently within a senior housing community, which is typically designed to reduce social isolation.

METHOD

Semi-structured qualitative interviews regarding the experience of loneliness, risk factors, and ways to combat it were conducted with 30 older adults, ages 65-92 years. The interviews were audiotaped, transcribed, and coded using a grounded theory analytic approach based on coding, consensus, co-occurrence, and comparison.

RESULTS

Three main themes with multiple subthemes are described: (A) Risk and Protective factors for loneliness: age-associated losses, lack of social skills or abilities, and protective personality traits; (B) Experience of loneliness: Sadness and lack of meaning as well as Lack of motivation; and (C) Coping strategies to prevent or overcome loneliness: acceptance of aging, compassion, seeking companionship, and environment enables socialization.

DISCUSSION

Despite living within a communal setting designed to reduce social isolation, many older adults described feeling lonely in stark negative terms, attributing it to aging-associated losses or lack of social skills and abilities. However, interviewees also reported positive personal qualities and actions to prevent or cope with loneliness, several of which mirrored specific components of wisdom. The results support the reported inverse relationship between loneliness and wisdom and suggest a potential role for wisdom-enhancing interventions to reduce and prevent loneliness in older populations.

The Influence of Metacognitive Strategies on the Improvement of Reaction Inhibition Processes in Children with ADHD

Background: Low response inhibition underlies attention disorders and hyperactivity. The aim of this study is to check whether these processes will be strengthened by three months of training with metacognitive strategies. Methodology: Forty-five schoolchildren took part in an experimental study (M = 10.41; SD = 1.42). Each child had been diagnosed with attention deficit hyperactivity disorder (ADHD). The participants were randomly assigned into three groups: the first group was tested for the effect of Mind Maps; the second group, for the effect of Sketchnoting, while the third group was assigned the role of a Control group. All of the groups were examined with the Loud Subtraction 7 test (LS7T) with a distractor before and after the training. Results: Analysis with the Wilcoxon test showed that children with ADHD made significantly fewer errors in the LS7 Test in the second measurement in the Mind Maps group (M1 = 7.45; SD1 = 4.07; M2 = 5.76; SD2 = 4.68; p = 0.02). In the remaining groups, there were no statistically significant differences in the average number of errors made. Conclusions: Mind Maps are an effective metacognitive strategy. Regular use of this method strengthens the inhibition of children with ADHD in this study. It can complement the existing forms of support for the child.

Goal Management Training and Computerized Cognitive Training in Depression-a 2-Year Follow-Up of a Randomized Controlled Trial

Objective: Information on the long-term effects of cognitive remediation (CR) in major depressive disorder (MDD) is lacking. The present study reports 2-year follow-up data from a previously published randomized controlled trial (RCT) from our research group, comparing Goal Management Training (GMT), a strategy-based CR intervention, to drill-and-practice computerized cognitive training (CCT). In previous work, we found comparable improvements in executive function (EF), in addition to reductions in depressive symptoms, following both GMT and CCT at 6-month follow-up. Methods: Forty-two participants of the RCT, all diagnosed with MDD, were invited to complete rating-scales pertaining daily-life EF, rumination, and depressive symptoms. Explorative analyses compared the 2-year follow-up with previously published baseline and 6-month follow-up data, using non-parametric statistics. Similarly, GMT and CCT were compared at the 2-year follow-up, and completers were compared with non-completers. Results: Twenty participants completed the study. Overall, completers (n = 20) and non-completers (n = 22) were similar. There were no significant differences between GMT (n = 11) and CCT (n = 9) for any outcome 2 years post-treatment. Reduction compared to baseline in depressive symptoms and rumination, but not in daily-life EFs, emerged for GMT only. Conclusions: Findings suggest long-term improvements in mental health following GMT, while improvements in everyday EFs might require additional treatment or maintenance to sustain. Caution is warranted in the interpretation due to the small sample size and high attrition rates.

Emotional Regulation Following Acquired Brain Injury: Associations With Executive Functioning in Daily Life and Symptoms of Anxiety and Depression

Objective: To examine whether a questionnaire measuring emotional regulation after acquired brain injury adds clinical information beyond what can be obtained with a comprehensive executive function questionnaire and an anxiety and depression measure.

Method: Seventy adult persons (age 19–66 years, M_age = 43, SD_age = 13) with acquired brain injury in the chronic phase and executive function complaints. All were recruited to participate in a randomized controlled trial (NCT02692352) evaluating the effects of cognitive rehabilitation. Traumatic brain injury was the dominant cause of injury (64%), and mean time since injury was 8 years. Emotional regulation was assessed with the Brain Injury Trust Regulation of Emotions Questionnaire (BREQ). Executive function was assessed with the Behavior Rating Inventory of Executive Function Adult Version (BRIEF-A). The Hopkins Symptom Checklist 25 (HCSL-25) was employed to measure anxiety and depression symptoms.

Results: Overall, significant correlations were found between reports of emotional regulation (BREQ) and executive function in daily life (BRIEF-A). Furthermore, our analyses revealed a significant relationship between self-reported scores of emotional regulation (BREQ) and symptoms of anxiety and depression (HSCL-25).

Conclusion: The significant associations between the BREQ and most of the other clinical measures indicate that, for patients with acquired brain injury, the BREQ does not add substantial information beyond what can be assessed with the BRIEF-A and the HSCL-25.

Outcomes of Randomized Clinical Trials of Interventions to Enhance Social, Emotional, and Spiritual Components of Wisdom: A Systematic Review and Meta-analysis

Importance

Wisdom is a neurobiological personality trait made up of specific components, including prosocial behaviors, emotional regulation, and spirituality. It is associated with greater well-being and happiness.

Objective

To evaluate the effectiveness of interventions to enhance individual components of wisdom.

Data Sources

MEDLINE and PsycINFO databases were searched for articles published through December 31, 2018.

Study Eligibility Criteria

Randomized clinical trials that sought to enhance a component of wisdom, used published measures to assess that component, were published in English, had a minimum sample size of 40 participants, and presented data that enabled computation of effect sizes were included in this meta-analysis.

Data Extraction and Synthesis

Random-effect models were used to calculate pooled standardized mean differences (SMDs) for each wisdom component and random-effects meta-regression to assess heterogeneity of studies.

Main Outcomes and Measures

Improvement in wisdom component using published measures.

Results

Fifty-seven studies (N = 7096 participants) met review criteria: 29 for prosocial behaviors, 13 for emotional regulation, and 15 for spirituality. Study samples included people with psychiatric or physical illnesses and from the community. Of the studies, 27 (47%) reported significant improvement with medium to large effect sizes. Meta-analysis revealed significant pooled SMDs for prosocial behaviors (23 studies; pooled SMD, 0.43 [95% CI, 0.22-0.3]; P = .02), emotional regulation (12 studies; pooled SMD, 0.67 [95% CI, 0.21-1.12]; P = .004), and spirituality (12 studies; pooled SMD, 1.00 [95% CI, 0.41-1.60]; P = .001). Heterogeneity of studies was considerable for all wisdom components. Publication bias was present for prosocial behavior and emotional regulation studies; after adjusting for it, the pooled SMD for prosocial behavior remained significant (SMD, 0.4 [95% CI, 0.16-0.78]; P = .003). Meta-regression analysis found that effect sizes did not vary by wisdom component, although for trials on prosocial behaviors, large effect sizes were associated with older mean participant age (β, 0.08 [SE, 0.04]), and the reverse was true for spirituality trials (β, -0.13 [SE, 0.04]). For spirituality interventions, higher-quality trials had larger effect sizes (β, 4.17 [SE, 1.07]), although the reverse was true for prosocial behavior trials (β, -0.91 [SE 0.44]).

Conclusions and Relevance

Interventions to enhance spirituality, emotional regulation, and prosocial behaviors are effective in a proportion of people with mental or physical illnesses and from the community. The modern behavioral epidemics of loneliness, suicide, and opioid abuse point to a growing need for wisdom-enhancing interventions to promote individual and societal well-being.

The feasibility and acceptability of goal management training of executive functions in children with spina bifida and acquired brain injury

Executive dysfunction causes significant real-life disability for children with spina bifida (SB) and acquired brain injury (ABI), and efficient interventions are needed. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with SB and ABI. The purpose of this study was to determine the feasibility and acceptability of a newly developed pediatric GMT protocol (pGMT). Thirteen children (7 boys, 10-16 years) with SB (n = 4), traumatic brain injury (n = 8), and encephalitis (n = 1) were included, based upon the presence of EF problems as described by parents. The participants received 21 h of pGMT, using inpatient intervention periods, followed by 4 h of pGMT outpatient guidance over 8 weeks. Notably, pGMT was found to be both feasible and acceptable, with satisfactory compliance for the children, parents and teachers, in addition to being considered acceptable by all participants. Furthermore, a reliable change in daily life EF was reported by the parents for 2 children. And, some children obtained scores below clinical cut-off on a measure of parent reported real-life EF after intervention. Hence, findings suggest that a randomized controlled trial of pGMT, with a larger sample size, should be conducted.

Use It or Lose It? A 5-Year Follow-up Study of Goal Management Training in Patients with Acquired Brain Injury

OBJECTIVES

To determine the perceived 5-year outcome of Goal Management Training (GMT) for individuals with chronic acquired brain injury and executive dysfunction, when compared to a nonspecific psychoeducational intervention (Brain Health Workshop, BHW).

METHODS

Of the 67 subjects in the initial randomized controlled trial [Tornås et al. (2016). Journal of the International Neuropsychological Society, 1-17], 50 (GMT, n = 21; BHW, n = 29) subjects returned written consent and questionnaires (54% male, age 45.8 ± 10.9 years). The 5-year follow-up consisted of two questionnaires, including the Behavior Rating Inventory of Executive Function for daily life executive function (EF) and Quality of Life after Brain Injury to assess health-related quality of life (HRQoL). Changes related to daily life EF and HRQoL were assessed pre-treatment, post-treatment, 6-month follow-up, and 5-year follow-up. Data were analyzed using a 2 × 4 mixed-design ANOVA.

RESULTS

The findings indicate that GMT is efficacious in improving EF and HRQoL 6-month post-treatment. However, these changes failed to remain significant at 5-year follow-up.

CONCLUSIONS

Data from 50 participants receiving either GMT or BHW suggested that the significant GMT-related improvements on perceived EF and HRQoL observed at 6-month follow-up were no longer present at 5-year follow-up. These findings indicate a need to promote maintenance of interventions post-treatment.

High prevalence and adverse health effects of loneliness in community-dwelling adults across the lifespan: role of wisdom as a protective factor

OBJECTIVES

This study of loneliness across adult lifespan examined its associations with sociodemographics, mental health (positive and negative psychological states and traits), subjective cognitive complaints, and physical functioning.

DESIGN

Analysis of cross-sectional data.

PARTICIPANTS

340 community-dwelling adults in San Diego, California, mean age 62 (SD = 18) years, range 27-101 years, who participated in three community-based studies.

MEASUREMENTS

Loneliness measures included UCLA Loneliness Scale Version 3 (UCLA-3), 4-item Patient-Reported Outcomes Measurement Information System (PROMIS) Social Isolation Scale, and a single-item measure from the Center for Epidemiologic Studies Depression (CESD) scale. Other measures included the San Diego Wisdom Scale (SD-WISE) and Medical Outcomes Survey- Short form 36.

RESULTS

Seventy-six percent of subjects had moderate-high levels of loneliness on UCLA-3, using standardized cut-points. Loneliness was correlated with worse mental health and inversely with positive psychological states/traits. Even moderate severity of loneliness was associated with worse mental and physical functioning. Loneliness severity and age had a complex relationship, with increased loneliness in the late-20s, mid-50s, and late-80s. There were no sex differences in loneliness prevalence, severity, and age relationships. The best-fit multiple regression model accounted for 45% of the variance in UCLA-3 scores, and three factors emerged with small-medium effect sizes: wisdom, living alone and mental well-being.

CONCLUSIONS

The alarmingly high prevalence of loneliness and its association with worse health-related measures underscore major challenges for society. The non-linear age-loneliness severity relationship deserves further study. The strong negative association of wisdom with loneliness highlights the potentially critical role of wisdom as a target for psychosocial/behavioral interventions to reduce loneliness. Building a wiser society may help us develop a more connected, less lonely, and happier society.

Paediatric goal management training in patients with acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Compromised integrity of the brain due to paediatric acquired brain injury (pABI) has been associated with cognitive impairment, particularly executive dysfunction, in addition to somatic and emotional symptoms and reduced everyday function. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with ABI. The purpose of the present study is to determine the efficacy of a recently developed paediatric version of GMT (pGMT) for children and adolescents with ABI and reported executive dysfunction.

METHODS AND ANALYSIS

This study protocol describes a parallel randomised controlled trial including allocation concealment and assessor blinding. Eighty survivors after pABI, aged 10-17 years at the time of intervention, will be recruited. Participants will be randomly allocated to either pGMT (n=40) or a psychoeducative control intervention (n=40; paediatric Brain Health Workshop). Both interventions consist of seven group sessions for participants and parents, followed by external cueing and telephone counselling. The study also includes involvement of teachers. Assessments will be performed at baseline, immediately postintervention and at 6 months' follow-up. Primary outcome measure will be changes in daily life EF as reported by parents (The Behavior Rating Inventory of Executive Function). Secondary outcomes include other assessments of EF (neuropsychological tests and questionnaires). Furthermore, we aim to assess generalisation effects of pGMT on other cognitive functions, as well as emotional, behavioural, adaptive and family function, academic performance, fatigue and quality of life.

ETHICS AND DISSEMINATION

Results from this study will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals, in addition to presentations at scientific conferences. The study will be conducted in accordance with the Helsinki declaration and the Ethical Research Involving Children (ChildWatch International and Unicef). In accordance to Good Clinical Practice our study includes safety and quality monitoring guarantees in compliance with research ethics and safety. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items for Reporting in Trials recommendations, in addition to being registered at ClinicalTrials.gov. The study has been approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/772).

TRIAL REGISTRATION NUMBER

NCT03215342.

Associations between self-generated strategy use and MET-Home performance in adults with stroke

Self-generated strategy use has substantial potential for improving community living outcomes in adults with impaired executive function after stroke. However, little is known about how self-generated strategies support task performance in people with post-stroke executive function impairments living in the community. We explored strategy use among home-dwelling persons with stroke and neurologically-healthy control participants during the Multiple Errands Test-Home Version (MET-Home), a context-specific assessment with evidence of ecological validity designed to examine how post-stroke executive dysfunction manifests during task performance in the home environment. For persons with stroke, significant associations were identified between planning and tasks accurately completed on the MET-Home. Significant associations were also identified among the control participants for self-monitoring, multitasking, and "using the environment" strategies. These associations are related to enhanced MET-Home performance on sub-scores for levels of accuracy, passes, and total time. Rehabilitation interventions that focus on reinforcing self-generated strategy use may support community living outcomes in persons with post-stroke executive function impairments, but this area needs additional investigation.

Effectiveness of goal management training® in improving executive functions: A meta-analysis

Our objective was to review the literature and quantitatively summarise the effectiveness of Goal Management Training® (GMT) (alone or in combination with other training approaches) in improving executive functions in adult populations. Ovid, Scopus, Web of Science, and ProQuest Dissertations & Theses Global were searched for articles citing "goal management training". Any group trials (n > 3) in adults that used multiple-session GMT programmes were included in the analyses. Outcome variables were extracted and classified into one of nine cognitive measures domains: executive functioning tasks, everyday executive functioning tasks, subjective executive tasks rated by the patient, subjective executive tasks rated by proxy, working memory, speed of processing, long-term memory, instrumental activities of daily living and general mental health status questionnaires. A total of 21 publications, containing 19 separate treatment group samples were included in the final analyses. Significantly positive small to moderate effect sizes were observed in all cognitive measure domains (except speed of processing) with effects maintained at follow-up assessments for all followed-up outcome measures, except for subjective ratings by patients and proxy. The analysis suggests that GMT is an effective intervention, leading to moderate improvements in executive functions that are usually maintained at follow-up.

Moderators, mediators and nonspecific predictors of outcome after cognitive rehabilitation of executive functions in a randomised controlled trial

Moderators, mediators and nonspecific predictors of treatment after cognitive rehabilitation of executive functions in a randomised controlled trial Objective: To explore moderators, mediators and nonspecific predictors of executive functioning after cognitive rehabilitation in a randomised controlled trial, comparing Goal Management Training (GMT) with an active psycho-educative control-intervention, in patients with chronic acquired brain injury.

METHODS

Seventy patients with executive dysfunction were randomly allocated to GMT (n = 33) or control (n = 37). Outcome measures were established by factor-analysis and included cognitive executive complaints, emotional dysregulation and psychological distress.

RESULTS

Higher age and IQ emerged as nonspecific predictors. Verbal memory and planning ability at baseline moderated cognitive executive complaints, while planning ability at six-month follow-up mediated all three outcome measures. Inhibitory cognitive control emerged as a unique GMT specific mediator. A general pattern regardless of intervention was identified; higher levels of self-reported cognitive-and executive-symptoms of emotional dysregulation and psychological distress at six-month follow-up mediated less improvement across outcome factors.

CONCLUSIONS

The majority of treatment effects were nonspecific to intervention, probably underscoring the variables' general contribution to outcome of cognitive rehabilitation interventions. Interventions targeting specific cognitive domains, such as attention or working memory, need to take into account the patients' overall cognitive and emotional self-perceived functioning. Future studies should investigate the identified predictors further, and also consider other predictor candidates.