Dimensions of the Dysexecutive Questionnaire (DEX) examined using Rasch analysis

The 20-item dysexecutive questionnaire after severe traumatic brain injury: Distribution of the total score and its significance

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01437683..

Implementing neuropsychological rehabilitation following severe traumatic brain injury in a low-to-middle income country: a case report

Introduction

TBI incidence and distribution are largely overrepresented in low- to middle-income countries (LMICs), such as South Africa (SA), with substantial associated human and financial costs. However, access to rehabilitation for the public is severely limited and not standard practice in SA. Given this background, studies demonstrating the successful implementation of neuropsychological rehabilitation in a LMIC setting are important. Published studies of this nature are generally lacking in this context. Further, there is a need to evaluate interventions that can be implemented at a low cost. To this end, we report on a neuropsychological rehabilitation program for an individual with severe TBI in a LMIC context, aimed at improving his capacity for activities of daily living.

Method

A 33-year-old, South African male who sustained a severe traumatic brain injury (TBI) partook in a neuropsychological intervention aimed at remediating functional deficits and enhancing independent functioning. The intervention utilised principles of Goal Management Training and external memory aids, with reliance on procedural memory and errorless learning, to target the participant's impairments in executive functioning and memory through the use of assistive technology-namely smart device applications.

Results

Data collected pre- and post-intervention on formal neuropsychological measures demonstrated no significant change in cognition. However, observational data and qualitative feedback from the participant's family indicated notable improvement in performance on everyday tasks with reduced number of errors and reduced need for external prompting whilst completing intervention tasks across sessions.

Discussion

In the context of severe TBI, neuropsychological rehabilitation can facilitate gains in independent functioning. This study provides support for the value of neurorehabilitation especially for interventions that can be rolled out at low cost and should serve as impetus for further such research in South Africa, where neuropsychological rehabilitation infrastructure and services are lacking.

Impaired facial emotion recognition in relation to social behaviours in de novo Parkinson's disease

Facial emotion recognition (FER) is a crucial component of social cognition and is essential in social-interpersonal behaviour regulation. Although FER impairment is well-established in advanced PD, data about FER at the time of diagnosis and its relationship with social behavioural problems in daily life are lacking. The aim was to examine FER at the time of PD diagnosis compared to a matched healthy control (HC) group and to associate FER with indices of social behavioural problems. In total, 142 de novo, treatment-naïve PD patients and 142 HC were included. FER was assessed by the Ekman 60 faces test (EFT). Behavioural problems in PD patients were assessed using the Dysexecutive Questionnaire (DEX-self and DEX-proxy) and the Apathy Evaluation Scale (AES-self). PD patients had significantly lower EFT-total scores (p = .001) compared to HC, with worse recognition of Disgust (p = .001) and Sadness (p = .016). Correlational analyses yielded significant correlations between AES-self and both EFT-total (rs = .28) and Fear (rs = .22). Significant negative correlations were found between DEX-proxy and both EFT-total (rs = -.28) and Anger (rs = -.26). Analyses of DEX-subscales showed that proxy ratings were significantly higher than patient-ratings for the Social Conventions subscale (p = .047). This DEX-proxy subscale had the strongest correlation with EFT-total (rs = -.29). Results show that de novo PD patients already show impaired FER compared to HC. In addition, lower FER is linked to self-reported apathy and proxy-reported social-behavioural problems, especially concerning social conventions. These findings validate the importance of the inclusion of social cognition measures in the neuropsychological assessment even in early PD.

Introducing a Neuroscience-Based Assessment Instrument: Development and Psychometric Study of the Neural Networks Symptomatology Inventory

Background: Neuroscience research methods contribute to the understanding of the underlying neural impairments associated with psychopathology. Previous research suggested that impairments in Default Mode Network, Fronto-Parietal Executive Network, Amygdaloid-Hippocampal Memory Network, and Attentional Salience Network are present in different psychopathological symptoms. However, a self-report measure based on this evidence is lacking. Aims: Therefore, the present study describes the development and preliminary psychometric study of the Neural Network Symptomatology Inventory (NNSI). Method: Two different samples were recruited (sample 1: N = 214, Mage = 21.0, SD = 7.10; sample 2: N = 194, Mage = 21.5, SD = 8.41) and responded to self-report instruments in a cross-sectional design. Standard methodologies to scale development and psychometric study were applied: Item development, Exploratory (EFA), Confirmatory Factor Analysis (CFA), and Pearson correlations. Results: EFA and CFA suggested a 4-factor model with adequate goodness-of-fit indices (χ2(449) = 808,9841, TLI = .89, CFI = .92, RMSEA = .048 (.042-.053). All NNSI subscales correlated positively with psychopathological domains and correlated negatively with psychological well-being. Conclusions: This preliminary study suggests that NNSI may be a valid instrument to assess symptomatology associated with complex neural network impairments. Nevertheless, further research is required to deepen and improve NNSI psychometric characteristics.

The Relations Between an Inventory-Based Measure of Executive Function and Impulsivity Factors in Alcohol- and Cannabis-Relevant Outcomes

OBJECTIVE

While the lack of relation between performance- and inventory-based executive function (EF) measures is well documented, there remains ambiguity between self-report EFs and closely related constructs (e.g., impulsivity) assessed via the same method. The degree of convergence between purported EF measures with similar yet distinct constructs contain important theoretical implications for available EF assessment strategies and their construct validity. A newer measure of EF, the Behavior Regulation Inventory of Executive Functions-Adult (BRIEF-A), allows for more direct comparisons to self-reported measures of impulsivity, such as the commonly used Urgency, Planning, Perseverance, Sensation Seeking-Positive Urgency (UPPS-P) assessment.

METHOD

The present study used factor analysis and hierarchical regression to explore the associations between the BRIEF-A and UPPS-P, using alcohol and cannabis consumption across various outcomes (i.e., quantity-frequency and consequences) as an external criterion. Participants were 339 undergraduate students (Mage = 19.35; Female = 63%) from a large southwestern university.

RESULTS

The BRIEF-A and UPPS-P demonstrated strong correlations at both higher- and lower order facets. While the BRIEF-A was a significant correlate to many substance use outcomes, these relations were generally weaker than those seen with the UPPS-P. Hierarchical regression suggested limited contributions of the BRIEF-A over and above the UPPS-P.

CONCLUSIONS

Overall, this study suggested substantial overlap between impulsigenic factors and EFs when measured by self-report, and limited utility of EF measures to account for unique variance with substance use outcomes in this sample.

Differences in daily life executive functioning between people with autism and people with schizophrenia

This is a comparative analysis of everyday executive functioning between individuals with Autism Spectrum Disorder (ASD), Schizophrenia Spectrum Disorders (SSD) and controls using Dysexecutive Questionnaire-Spanish (DEX-Sp), to identify patterns of difficulties. Also we assessed the relationship between EF and adaptive behavior as measured by the Vineland Adaptive Behavioral Scale-II. Common areas of everyday executive functions were established as problematic in individuals with ASD and SSD related to Disinhibition and Apathy, while Disorganization and Impulsivity was gravely affected in ASD group only. The degree of Dysexecutive Syndrome was predictive of adaptive behavior in ASD group only. These suggest that DEX-Sp could be a useful tool in differentiating areas of strength and weaknesses in clinical groups such as ASD and SDD.

Psychometric Properties of the Revised Dysexecutive Questionnaire in a Non-clinical Population

Aims

The aim of this study was to assess the psychometric properties of the revised self-rated version of the Dysexecutive Questionnaire (DEX-R) within a non-clinical sample.

Methods

The study was hosted online, with 140 participants completing the DEX-R, GAD-2 and PHQ-2. Sixty participants also completed the FrSBe, with 99 additionally completing the DEX-R again 3 weeks later. Correlations with demographic factors and symptoms of anxiety and depression were conducted. Rasch and factor analysis were also used to explore underlying subconstructs.

Results

The DEX-R correlated highly with the FrSBe, indicating sound concurrent validity. Internal consistency, split-half reliability and test-retest reliability were excellent. Age and symptoms of depression and anxiety correlated with DEX-R scores, with older age associated with less dysexecutive problems. The Rasch analysis confirmed the multidimensionality of the rating scale, and a three-factor structure was found relating to activation-self-regulatory, cognitive and social-emotional processes. Frequencies of responses on DEX-R items varied, many were not fully endorsed indicating specific relevance of most but not all items to patients.

Conclusion

Interpretations of DEX-R ratings of dysexecutive problems should consider mood and individual variation. Systematic comparison of DEX-R responses between healthy and clinical groups could help identify a suitable cut off for dysexecutive symptoms.

A Short Version of the EFECO Online Questionnaire for the Assessment of Executive Functions in School-Age Children

Executive function (EF) is a group of processes that allow individuals to be goal-oriented and to have adaptive functioning, so that adequate performance is essential for success in activities of daily living, at school and in other activities. The present study aims to create a short version of the Executive Functioning Questionnaire (EFECO) since there is a gap in the Spanish literature due to the lack of behavioural observation questionnaires at school age. A total of 3926 participants completed the online questionnaire. Subsequently, the validity and reliability of the data are analysed. The results show that the short version of the questionnaire, the EFECO-S, has a structure with five dimensions (emotional self-control, initiation, working memory, inhibition, and spatial organisation), as well as a second-order factor (global executive skill) and high reliability (ordinal Alpha = 0.68-0.88). The EFECO is composed of 67 items, while the EFECO-S has 20 items, four per factor, which turns it into a quick and easy to apply test. Therefore, it becomes an interesting alternative to be applied in screening processes with children who may be experiencing executive difficulties.

The impact of multimodal cognitive rehabilitation on executive functions in older adults with traumatic brain injury

OBJECTIVES

This study evaluated the impact of a 12-week, 24-session multimodal group cognitive rehabilitation intervention, the Cognitive Enrichment Program (CEP), on executive functioning and resumption of daily activities after traumatic brain injury (TBI) in older individuals as compared with an active control group that received individual holistic rehabilitation as usual care.

METHODS

In total, 37 patients with a TBI and aged 57 to 90 years were assigned to experimental (n = 23) and control (n = 14) groups in a semi-randomized, controlled, before-after intervention trial with follow-up at 6 months, with blinded outcome measurement. The CEP's executive function module included planning, problem solving, and goal management training as well as strategies focusing on self-awareness. Efficacy was evaluated by neuropsychological tests (Six Elements Task-Adapted [SET-A], D-KEFS Sorting test and Stroop four-color version); generalization was measured by self-reporting questionnaires about daily functioning (Dysexecutive Functioning Questionnaire, forsaken daily activities).

RESULTS

ANCOVA results showed significant group-by-time interactions; the experimental group showed a statistically significant improvement on Tackling the 6 subtasks and Avoiding rule-breaking measures of the SET-A, with medium effect sizes. The generalization measure, the Dysexecutive Functioning Questionnaire, showed a significant reduction in experimental patient-significant other difference on the Executive cognition subscale. The number of forsaken daily activities was reduced in the experimental versus control group, which was not significant immediately after the CEP but was significant 6 months later.

CONCLUSIONS

Our study shows that older adults with TBI can improve their executive functioning, with a positive impact on everyday activities, after receiving multimodal cognitive training with the CEP. ClinicalTrials.gov Identifier: NCT04590911.

Psychometric properties of the Dysexecutive Questionnaire (DEX): a study with Brazilian older adults

Abstract This study aimed to verify the psychometric properties of the Dysexecutive Questionnaire (DEX) through exploratory factor analysis (EFA), evidence of reliability, and convergent validity, in a sample of neurologically preserved older adults. Participants were 345 older adults who answered, in addition to DEX, a sociodemographic and clinical questionnaire, the Mini-Mental State Examination (MMSE), and two verbal fluency tasks. The EFA was conducted through Parallel Analysis based on the generation of a polychoric correlation matrix, as well as Pearson’s correlation between the DEX scores, age, education, MMSE, and verbal fluency tasks. According to the EFA, the extraction of two factors (“Inhibition” and “Social Regulation and Planning”) was suggested and DEX was negatively associated with age and MMSE. In conclusion, DEX presented a satisfactory factorial structure for older adults, which can be considered a reliable self-report measure for complaints of executive functions.

Anosognosia in amyotrophic lateral sclerosis: A cross-sectional study of 85 individuals and their relatives

BACKGROUND

Amyotrophic lateral sclerosis (ALS) has long been considered a pure motor neurodegenerative disease. However, now, extra-motor manifestations such as cognitive-behavioral disorders are considered not rare and are even a severity factor of the disease. Experiencing anosognosia (i.e., the inability to recognize neurological symptoms) might affect care and treatment compliance in ALS. Regardless, this pivotal feature has been little investigated.

OBJECTIVES

By comparing patients' and caregivers' reports, we analysed whether patients with ALS would experience a lack of awareness about their executive disorders and their apathy symptoms.

METHODS

From the ALS reference center in Paris, we included 85 patients (47 men, mean [SD] age 60.5 [12] years and ALS-Functional Rating Scale-revised score 8 to 46) and their primary family caregivers who all completed the Dysexecutive Questionnaire (DEX) and the Apathy Evaluation Scale (AES). Overall scores and answers were compared by agreement/disagreement statistical methods.

RESULTS

Caregivers reported higher levels of cognitive-behavioral disorders than did patients, but reports matched when cognitive-behavioral disorders were absent or mild. With published DEX and AES cutoffs, 32% and 51% of patients had executive disorders and apathy, respectively. In these patients with significant impairment, Bland-Altman plots (i.e., visual display agreement that represents the difference between the patient's and caregiver's scores as a function of their average) showed a strong discrepancy between joint reports: patients underestimated their symptoms by a mean bias of -6.81 DEX points (95% confidence interval -11.88, -1.75) and -8.85 AES points (95% confidence interval -11.72, -5.98). We found no clear relationship between bulbar or spinal ALS subtypes and anosognosia.

CONCLUSIONS

ALS patients with a cognitive-behavioral phenotype show anosognosia by a mismatch between self and proxy reports, which warrants further investigation in neuroimaging. Systematic longitudinal screening of anosognosia is needed to propose targeted psychoeducation in patient-caregiver dyads showing disagreement.

Return to work after subarachnoid hemorrhage: The influence of cognitive deficits

INTRODUCTION

Cognitive deficits are frequently found after subarachnoid hemorrhage (SAH), but their influence on return to work is largely unknown. To improve identification of those patients at-risk for long-term return to work problems, we aimed to examine the value of cognitive deficits in the prediction of long-term return to work after subarachnoid hemorrhage.

METHODS

SAH patients (N = 71) who were employed before SAH and were able to undergo neuropsychological assessment, were included. Demographic characteristics and acute SAH-related variables (SAH-type and external cerebrospinal fluid drainage) were taken into account. Neuropsychological tests for memory, speed, attention, executive function, and emotion recognition and a questionnaire for executive functions were used. Return to work was assessed using the Role Resumption List.

RESULTS

Results showed that patients with incomplete return to work had significantly lower scores on neuropsychological measures for complex attention and executive functions (p < 0.05) compared to patients with complete return to work. Return to work could not be significantly predicted using only demographic characteristics and acute SAH-related variables, but adding measures of complex attention and executive functions resulted in a prognostic model that could reliably distinguish between complete and incomplete return to work. Statistically significant predictors in the final model were cerebrospinal fluid drainage and scores on a questionnaire for executive functions: patients with cerebrospinal fluid drainage and higher scores on the a questionnaire for executive functions were less likely to return to work.

DISCUSSION

Together, these findings show that neuropsychological measures, especially for complex attention and executive functions, have added value to acute SAH-related and demographic variables in the prediction of long-term return to work after SAH.

Study of the theory of mind in normal aging: focus on the deception detection and its links with other cognitive functions

Detection of deception is crucial to avoid negative circumstances (financial frauds, social tricks) in daily living. Considering that this cognitive function is especially supported by the prefrontal cortex of the human brain and that these cerebral regions change with advanced age, deception detection may also change with aging. Our purpose is to study this complex ability and its potential links with other cognitive functions, such as the executive control, in normal aging. Thirty-five young adults (YA) aged from 20 to 40, thirty-five old adults (OA) aged from 65 to 79 and thirty very old adults (VOA) aged from 80 to 95 were involved in this study. We propose a novel neuropsychological test (inspired by Theory of Mind Picture Story task) assessing the ability to understand deceptive and cooperative interactions, and tasks involving executive processes (monitoring, task setting, flexibility) to all participants. Between-group analyses show that older participants performed worse than YA on deceptive, cooperative and mixed situations (involving deception and reciprocity) of our task. Significant correlations exist between the deception-cooperation detection and the executive functions. Our results show that these frontal abilities decline after 65 years, even more after 80 years, and they are involved on the deceptive-cooperative situations. The verbal IQ is also linked with the deception-cooperation detection. This suggests that mixed cognitive trainings would allow older adults to detect more easily bad intentions of others, to adjust their behavior to context and to achieve their goals with less risk.

Long-term cognitive disability after traumatic brain injury: Contribution of the DEX relative questionnaires

Executive functions are high-level cognitive processes commonly impaired after severe traumatic brain injury (sTBI), which may be associated with persistent anosognosia. The dysexecutive questionnaire (DEX) was designed to assess different domains of executive functioning in daily life. Two versions of the DEX exist (DEX-S completed by the patient, DEX-O completed by a relative) to compare cognitive complaints and patient's awareness. This work was aimed at studying the relevance of DEX-O for assessing daily-life limitations, the persistence of anosognosia and its association with global disability (GOSE) and magnetic resonance imaging (MRI) markers of brain alterations. Sixty-three patients (and relatives) were included within 63.4 months (±20.7) after sTBI. DEX-S and DEX-O scores were significantly positively correlated. We obtained significant correlations between DEX-S and episodic memory and phasic alert but not with executive assessment, GOSE and diffusion MRI markers. DEX-O was significantly correlated with executive function, episodic memory, attention (phasic alert sustained and divided attention), with the GOSE and the volume of the body of the corpus callosum (MRI marker). Anosognosia score (DEX-O minus DEX-S) correlated with mean diffusivity measure. These results highlight the clinical interest of DEX-O in assessing long-term disability.

Social cognition impairments are associated with behavioural changes in the long term after stroke

BACKGROUND AND PURPOSE

Behavioural changes after stroke might be explained by social cognition impairments. The aim of the present study was to investigate whether performances on social cognition tests (including emotion recognition, Theory of Mind (ToM), empathy and behaviour regulation) were associated with behavioural deficits (as measured by proxy ratings) in a group of patients with relatively mild stroke.

METHODS

Prospective cohort study in which 119 patients underwent neuropsychological assessment with tests for social cognition (emotion recognition, ToM, empathy, and behaviour regulation) 3-4 years post stroke. Test scores were compared with scores of 50 healthy controls. Behavioural problems were assessed with the Dysexecutive Questionnaire (DEX) self rating and proxy rating scales. Pearson correlations were used to determine the relationship between the social cognition measures and DEX scores.

RESULTS

Patients performed significantly worse on emotion recognition, ToM and behaviour regulation tests than controls. Mean DEX-self score did not differ significantly from the mean DEX-proxy score. DEX-proxy ratings correlated with tests for emotion recognition, empathy, and behavioural regulation (lower scores on these items were associated with more problems on the DEX-proxy scale).

CONCLUSIONS

Social cognition impairments are present in the long term after stroke, even in a group of mildly affected stroke patients. Most of these impairments also turned out to be associated with a broad range of behavioural problems as rated by proxies of the patients. This strengthens the proposal that social cognition impairments are part of the underlying mechanism of behavioural change. Since tests for social cognition can be administered in an early stage, this would allow for timely identification of patients at risk for behavioural problems in the long term.

Frontal Lobe Functions in Normal Aging: Metacognition, Autonomy, and Quality of Life

BACKGROUND

Starting from the "frontal lobe hypothesis of cognitive aging", we aim to study the metacognitive functions (deception, reciprocity, cognitive and affective theory of mind), autonomy and quality of life in normal aging.

METHODS

Eighty healthy subjects (30 young adults [YA] aged 20-40, 30 old adults [OA] aged 65-79 and 20 very old adults [VOA] aged 80 and over) participated in our study. Standard and novel neuropsychological tasks have been used, assessing abilities to understand others' mental and affective states, deceptive and cooperative situations.

RESULTS

OA and VOA's performances are significantly poorer than those of YA on first-/second-order false beliefs, deception, reciprocity and emotion recognition tasks. VOA have made more errors than other participants on control false beliefs, general cognition, and memory tasks. Normal aging seems also to be characterized by a reduction in processing speed. The level of instrumental activities of daily living decreases with aging. Theory of mind is associated with individual general cognitive state and executive functions, but not with OA and VOA's levels of autonomy and quality of life.

CONCLUSION

In this study, we have shown an age-related deterioration of metacognitive functions, which does not seem to be associated with old adults' autonomy and satisfaction of life. A good level of mental activity could be necessary to maintain satisfactory interpersonal relationships.

Measurement of everyday dysexecutive symptoms in normal aging with the Greek version of the dysexecutive questionnaire-revised

The Dysexecutive Questionnaire is a sensitive and ecologically valid measure of everyday dysexecutive symptoms. Recently, a revised version of the tool has been proposed (DEX-R). The current study aimed to examine the factorial validity of the Greek DEX-R, the level of agreement between the self and informant rating versions and the effect of age on each dysexecutive symptoms component. The questionnaire was administered to a sample of older adults (n = 235) and to a sample of informants (n = 187) in the context of the Neurocognitive Study for the Aging in Cyprus. Confirmatory Factor Analysis results showed that dysexecutive symptoms can be grouped into three underlying components or factors: (a) Motivation and Attention, (b) Flexibility, Fluency and Working Memory, and (c) Social Self-Regulation. Overall, the elderly reported more symptoms than their relatives, however the difference was significant only for the Flexibility, Fluency and Working memory factor. In a structural equation model, a weak positive effect of age was observed on the Flexibility, Fluency and Working Memory factor, based on the informant ratings. This study provides empirical evidence about the use of the DEX-R questionnaire in the Greek-speaking elderly population as a valid and reliable measure of everyday dysexecutive symptoms.

Towards a taxonomy of sexuality following traumatic brain injury: A pilot exploratory study using cluster analysis

INTRODUCTION

Clinicians need to understand the heterogeneity of sexual problems following traumatic brain injury (TBI) for their adequate identification and treatment.

OBJECTIVE

To systematically identify groups of individuals with TBI showing similar patterns of sexual functioning.

METHODS

Forty-two individuals with TBI with a mean age of 37.9 years (SD = 9.7) and an average of 3.3 years post-injury (SD = 4.3). We included four primary measures in the cluster analysis (sexual quality of life questionnaire, sexual desire inventory, generalized anxiety disorder scale, and the patient health questionnaire for depression) and two secondary measures for cluster validation (post-concussion symptom scale and dysexecutive questionnaire).

RESULTS

A hierarchical cluster analysis using the Ward method revealed the existence of two groups of individuals with TBI: a) with sexual problems who were older, showed lower levels of sexual quality of life and sexual desire, with significant symptoms of anxiety and depression, and b) without sexual problems who were younger, showed high levels of sexual quality of life and sexual desire, as well as low complaints of anxiety and depression.

CONCLUSIONS

Clinicians must be more proactive in assessing sexual concerns, mostly when emotional and cognitive difficulties are present in older individuals with TBI, regardless of gender, chronicity and injury severity.

Using Virtual Reality to investigate multitasking ability in individuals with frontal lobe lesions

Individuals with lesions in the prefrontal cortex often show impairments with the organisation of their behaviour in everyday life. These difficulties can be hard to detect using structured formal tests. The objective of this study was to use Virtual Reality (VR) to explore the multitasking performance of individuals with focal frontal lobe lesions, specifically using the Jansari assessment of Executive Functions (JEF^©). Nineteen individuals with frontal lobe lesions were compared with 19 matched controls on the test and a group of commonly used clinical measures of neuropsychological functioning, as well as questionnaire measures of everyday activity, anxiety and depression. There was a significant difference between groups on the overall JEF^© score and on five of the eight individual constructs, namely the planning, creative thinking, adaptive thinking, event-based Prospective Memory (PM) and time-based PM constructs. There were no differences between groups on the non-VR EF individual measures apart from on one EF control measure, Trail Making A. These results demonstrate the potential clinical utility of the JEF^© and highlight the value of ecologically valid VR measures in detecting impairments in EF in individuals with frontal lobe lesions.

The relationship between emotion regulation capacity, heart rate variability, and quality of life in individuals with alcohol-related brain damage

The reliable measurement of quality of life (QoL) presents a challenge in individuals with alcohol-related brain damage. This study investigated vagally mediated heart rate variability (vmHRV) as a physiological predictor of QoL. Self- and proxy ratings of QoL and dysexecutive symptoms were collected once, while vmHRV was repeatedly assessed over a 3-week period at weekly intervals in a sample of nine alcohol-related brain damaged patients. We provide robustness checks, bootstrapped correlations with confidence intervals, and standard errors for mean scores. We observed low to very low heart rate variability scores in our patients in comparison to norm values found in healthy populations. Proxy ratings of the QoL scale "subjective physical and mental performance" and everyday executive dysfunctions were strongly related to vmHRV. Better proxy-rated QoL and fewer dysexecutive symptoms were observed in those patients with higher vmHRV. Overall, patients showed low parasympathetic activation favoring the occurrence of dysfunctional emotion regulation strategies.

Exploration of correlates of self-reported personality change after moderate-severe traumatic brain injury

OBJECTIVE

Individuals with traumatic brain injury (TBI) often express concern that their personality has changed. Factors generating that conclusion are rarely explored quantitatively. Accordingly, this study examines neurobehavioural correlates of self-reported personality change.

METHODS

Seventy-one participants and informants were interviewed M = 57.9 (SD = 46.9) months after a moderate-severe TBI. The degree of self-reported personality change was correlated with scores on measures of general cognitive functioning, executive functioning, olfaction, social-emotional behaviour, emotional distress and the Expressed Emotion close informants directed towards them.

RESULTS

As expected, self-reported personality change correlated with dysexecutive symptoms and depression. Although anosmia (a putative index of ventral frontal damage) correlated with reduced self-reported emotional recognition and empathy, against prediction, the latter measures did not correlate with self-reported personality change. Neither were the predicted positive correlations found between high Expressed Emotion (criticism and emotional over-involvement) and self-reported personality change.

DISCUSSION

These findings are discussed in the context of previous work. A need to replicate and extend the present findings is suggested. A strategy to further clarify the relationships perceived personality change have with (a) self-reported change in specific behaviours and (b) identity change is advocated. Implications for intervention are suggested.

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

OBJECTIVE

To investigate whether goal management training (GMT) expanded to include external cuing and an emotional regulation module is associated with improved emotional regulation, psychological functioning, and quality of life (QOL) after chronic acquired brain injury (ABI).

DESIGN

Randomized controlled trial with blinded outcome assessment at baseline, posttraining, and 6-month follow-up.

SETTING

Outpatient.

PARTICIPANTS

Persons with ABI and executive dysfunction (N=70; 64% traumatic brain injury; 52% men; mean age ± SD, 43±13y; mean time since injury ± SD, 8.1±9.4y).

INTERVENTION

Eight sessions of GMT in groups, including a new module addressing emotional regulation, and external cuing. A psychoeducative control condition (Brain Health Workshop) was matched on amount of training, therapist contact, and homework.

MAIN OUTCOME MEASURES

Emotional regulation was assessed with the Brain Injury Rehabilitation Trust Regulation of Emotions Questionnaire, the Emotional Control subscale and the Emotion Regulation factor (Behavior Rating Inventory of Executive Function-Adult Version), and the Positive and Negative Affect subscales from the Dysexecutive Questionnaire. Secondary outcome measures included psychological distress (Hopkins Symptom Checklist-25) and QOL (Quality of Life After Brain Injury Scale).

RESULTS

Findings indicated beneficial effects of GMT on emotional regulation skills in everyday life and in QOL 6 months posttreatment. No intervention effects on measures of psychological distress were registered.

CONCLUSIONS

GMT is a promising intervention for improving emotional regulation after ABI, even in the chronic phase. More research using objective measures of emotional regulation is needed to investigate the efficacy of this type of training.

Investigating metacognition, cognition, and behavioral deficits of college students with acute traumatic brain injuries

OBJECTIVE

Executive dysfunction in college students who have had an acute traumatic brain injury (TBI) was investigated. The cognitive, behavioral, and metacognitive effects on college students who endorsed experiencing a brain injury were specifically explored.

PARTICIPANTS

Participants were 121 college students who endorsed a mild TBI, and 121 college students with no history of a TBI were matched on sex and ethnicity to examine potential differences between groups.

METHODS

Participants completed the Dysexecutive Questionnaire (DEX).

RESULTS

A Rasch analysis indicated that the TBI group had significantly higher total scores on the DEX than the control group. Moreover, when compared with the control group, the students with a TBI had higher scores on all 3 subcomponents of the DEX.

CONCLUSION

These findings suggest that students who endorse brain injuries may experience more difficulty with specific facets of college. Thus, the importance of academic and personal resources available for students with a TBI is discussed.

Selection and visualisation of outcome measures for complex post-acute acquired brain injury rehabilitation interventions

BACKGROUND

Outcome measurement challenges rehabilitation services to select tools that promote stakeholder engagement in measuring complex interventions.

OBJECTIVES

To examine the suitability of outcome measures for complex post-acute acquired brain injury (ABI) rehabilitation interventions, report outcomes of a holistic, neuropsychological ABI rehabilitation program and propose a simple way of visualizing complex outcomes.

METHODS

Patient/carer reported outcome measures (PROMS), experience measures (PREMS) and staff-rated measures were collected for consecutive admissions over 1 year to an 18-week holistic, neuropsychological rehabilitation programme at baseline, 18 weeks and 3- and 6-month follow-up.

RESULTS

Engagement with outcome measurement was poorest for carers and at follow-up for all stakeholders. Dependence, abilities, adjustment, unmet needs, symptomatology including executive dysfunction, and self-reassurance showed improvements at 18 weeks. Adjustment, social participation, perceived health, symptomatology including dysexecutive difficulties, and anxiety were worse at baseline for those who did not complete rehabilitation, than those who did. A radar plot facilitated outcome visualization.

CONCLUSIONS

Engagement with outcome measurement was best when time and support were provided. Supplementing patient- with staff-rated and attendance measures may explain missing data and help quantify healthcare needs. The MPAI4, EBIQ and DEX-R appeared suitable measures to evaluate outcomes and distinguish those completing and not completing neuropsychological rehabilitation.

Psychometric properties of the Barkley Deficits in Executive Functioning Scale: A Spanish-Language Version in a community sample of puerto rican adults

Performance-based measures have shown some limitation in the assessment of executive functioning (EF) and rating scales have been proposed as an alternative. Our aim was to conduct a comprehensive psychometric evaluation of the Barkley Deficits in Executive Functioning Scale (BDEFS), as administered in 452 Latino community adults (65.5% female). The BDEFS was back-translated into Spanish. We performed exploratory factor analysis (EFA) to assess the structure of the translated BDEFS and to compare it with the original five-factor structure based on the English-language version. Confirmatory factor analysis (CFA) was performed to test the original language structure of the instrument, and also a modified version with items that loaded equally in both versions. The Adult Self-Report Scale was used to screen for ADHD symptoms. We assessed invariance on the latent factor's mean by age and gender, and to estimate associations with ADHD symptom dimensions. The five-factor structure of the BDEFS was partially supported by EFA/CFA, in which 78 out of 89 items loaded similar to the original English-language structure. Factor scores were significantly associated with ADHD symptom dimensions. Model-based contrasts revealed that inattention was primarily associated with disorganization, time-management and motivational aspects of EF; hyperactivity was predominantly related to self-restraint and self-regulation factors. The BDEFS seemingly assesses similar dimensions of the EF construct in English and in the present Spanish-language versions. Factor scores were differentially associated with ADHD subtypes. Replication and confirmation of the Spanish-language BDEFS in a larger sample is advised. (PsycINFO Database Record

Executive performance and dysexecutive symptoms in binge drinking adolescents

Alcohol is probably the most common legal drug of abuse in Western countries. The prevalence of binge drinking (BD) pattern of alcohol consumption among adolescents is a worrisome phenomenon. Adolescents and university students who practice a BD pattern have difficulty performing tasks involving prefrontal cortex functions, such as working memory, planning, attention, and decision making. The aim of the present study was to investigate the association between BD and executive functioning in adolescents. Two hundred twenty-three high-school students between 12 and 18 years old (15.19 ± 2.13) participated in our study. They were assigned to one of three groups according to their pattern of alcohol consumption: BD (subjects who consumed alcohol intensively, n = 48), MAC (subjects who consumed alcohol moderately, n = 53), and CTR (non-drinking subjects, n = 122). The students were evaluated with two groups of testing tools: a set of performance neuropsychological tests and two questionnaires of executive functioning. The results showed that the students who drank alcohol exhibited a more pronounced dysexecutive symptomatology (disinhibition, executive dysfunction, intentionality, executive memory), but they obtained better results than controls on some of the neuropsychological tests such as Spatial Location, Five Digit Tests, or Stroop Test. According to the results, we can deduce that heavy alcohol drinking in adolescents brings a certain dysfunction of prefrontal circuits. This prefrontal dysfunction is not so clearly demonstrated in the neuropsychological tests used, but it was observed in the performance of daily activities. In the Discussion section we raise issues about sociodemographic features of the sample and ecological validity of the traditional neuropsychological tests. The neurotoxic effects of BD on prefrontal cortex can be less evident throughout adolescence, but if alcohol consumption persists, the executive dysfunction would be exacerbated.

Relationships between risky sexual behaviour, dysexecutive problems, and mental health in the years following interdisciplinary TBI rehabilitation

Little is known about the long-term consequences of traumatic brain injury (TBI) regarding risky sexual behaviour. The objectives of the study were (1) to compare risky sexual behaviour in a sample of individuals with TBI having received interdisciplinary rehabilitation with that of healthy controls, and (2) to explore the relationships between risky sexual behaviour, executive functions, and mental health in individuals with TBI. The study group consisted of 42 individuals with TBI with a mean age of 37.9 years (SD = 9.7), 12.8 years of education (SD = 3.3), and 3.3 years post-injury (SD = 4.3). Healthy controls consisted of 47 participants, with a mean age of 37.6 years (SD = 10.7), and 13 years of education (SD = 3). Risky sexual behaviour was measured with the Sexual Risk Survey and executive function with the Dysexecutive Questionnaire. Mental health measures included the Generalised Anxiety Disorder Scale, and the Patient Health Questionnaire for depression. Compared to healthy controls, individuals with TBI reported more dysexecutive and mental health problems, without differences in risky sexual behaviour. In individuals with TBI, risky sexual behaviour was associated with behavioural, cognitive and emotional dysexecutive problems, but not with anxiety or depression. It was concluded that special attention should be given to individuals with TBI showing difficulties in executive functions given their association with risky sexual behaviour.

Dysexecutive Questionnaire (DEX): Unrestricted structural analysis in large clinical and non-clinical samples

The factorial structure of the Dysexecutive Questionnaire (DEX) is an unresolved issue in scientific literature. One-to-five-factor solutions have been found in several studies by applying different research methods. Only a few of these studies used appropriate analysis procedures to suit a Likert scale-type of answer or investigated large enough samples to ensure the stability of factorial solutions. The present study examines a sample of 2151 subjects, 1482 from the general population and 669 from a clinical population. An unrestricted factorial analysis was carried out on both samples. The results unequivocally point to a single-factor solution in both samples. This means that only one latent variable is displayed in the DEX, which accounts for symptoms of oversight malfunction in activities of daily living. It is concluded that the diversity of results previously obtained in other studies may be due to using research methods that depict Likert-type scales on a continuum when they are actually ordinal categorical measures. In conclusion, the DEX should be considered a screening test that reports symptoms of prefrontal malfunction, although it is unable to specify what areas or functions have been affected, as previous studies have claimed.

Conceptualization and Rehabilitation of Executive Functions

Publications on executive functions have increased in the last few years, reflecting the importance of this area of study. The scientific output on executive functions is now extremely diverse, comprising variations around terminology, assessment, and rehabilitation practices, and ranging in topics from neuroanatomical correlates of executive functions to effects of executive dysfunction. This review seeks to explore this diversity around executive functions in order to provide an integrative overview of the topic that systematizes the current knowledge in this area, and to point to trends and future directions for research and practice. The literature review was conducted in the ISI Web of Knowledge databases. The analysis was conducted in NVivo9. Two independent coders applied an inductive analysis to all relevant papers, building a hierarchical model with categories and subcategories of themes emerging from the literature. A confirmatory analysis followed, with the same independent coders applying the model to the papers. The process was validated by a third expert researcher. Out of 187 titles and abstracts, 91 were analyzed. The outcomes were structured in six main categories: central nervous system, diagnosis, population, assessment, intervention, and theoretical models. Key findings included promising trends in executive function assessment and rehabilitation as well as potential implications for current health approaches and future research.

Goal Management Training improves everyday executive functioning for persons with spina bifida: self-and informant reports six months post-training

Executive dysfunction accounts for significant disability for many patients with spina bifida (SB), thus indicating the need for effective interventions aimed at improving executive functioning in this population. Goal Management Training™ (GMT) is a cognitive rehabilitation approach that targets disorganised behaviour resulting from executive dysfunction, and has received empirical support in studies of other patient groups. The purpose of this study was to determine if GMT would lead to perceived improved executive functioning in the daily lives of patients with SB, as evidenced by reduced report of dysexecutive problems in daily life on self- and informant questionnaires. Thirty-eight adults with SB were included in this randomised controlled trial (RCT). Inclusion was based upon the presence of executive functioning complaints. Experimental subjects (n = 24) received 21 hours of GMT, with efficacy of GMT being compared to results of subjects in a wait-list condition (n = 14). All subjects were assessed at baseline, post-intervention, and at six-month follow-up. Self-report measures indicated that the GMT group's everyday executive functioning improved significantly after training, lasting at least 6 months post-treatment. There were no significant effects on informant-report questionnaires. Overall, these findings indicate that executive difficulties in everyday life can be ameliorated for individuals with congenital brain dysfunction.

Relationship between frontostriatal morphology and executive function deficits in bipolar I disorder following a first manic episode: data from the Systematic Treatment Optimization Program for Early Mania (STOP-EM)

OBJECTIVES

Executive function impairments are a core feature of bipolar I disorder (BD-I), not only present during acute episodes but also persisting following remission of mood symptoms. Despite advances in knowledge regarding the neural basis of executive functions in healthy subjects, research into morphological abnormalities underlying the deficits in BD-I is lacking.

METHODS

Patients with BD-I within three months of sustained remission from their first manic episode (n = 41) underwent neuropsychological testing and a 3T magnetic resonance imaging scan and were compared to healthy subjects matched for age, sex, and premorbid IQ (n = 30). Group dorsolateral prefrontal cortex (DLPFC; Brodmann areas 9 and 46) and caudate volumes were examined and analyzed for relationships with the average score from three computerized tests of executive function: Spatial Working Memory, Stockings of Cambridge, and Intradimensional/Extradimensional Shift.

RESULTS

Right caudate volumes were enlarged in patients (z = 3.57, p < 0.05 corrected). No differences in DLPFC volumes were found. Patients showed large deficits in executive function relative to healthy subjects (d = -0.92, p < 0.001). While in healthy subjects, a larger right (r = +0.39, p < 0.05) and left (r = +0.44, p < 0.05) caudate was associated with better executive function score, in patients, larger right (r = -0.36, p < 0.05) and left (r = -0.34, p < 0.05) volumes correlated with poorer performance.

CONCLUSIONS

Although the etiology of gray matter changes is unknown, volume increases in the right caudate may be an important factor underlying executive function impairments during remission in patients with BD-I.

Deficits in facial emotion recognition indicate behavioral changes and impaired self-awareness after moderate to severe traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of disability, specifically among younger adults. Behavioral changes are common after moderate to severe TBI and have adverse consequences for social and vocational functioning. It is hypothesized that deficits in social cognition, including facial affect recognition, might underlie these behavioral changes. Measurement of behavioral deficits is complicated, because the rating scales used rely on subjective judgement, often lack specificity and many patients provide unrealistically positive reports of their functioning due to impaired self-awareness. Accordingly, it is important to find performance based tests that allow objective and early identification of these problems. In the present study 51 moderate to severe TBI patients in the sub-acute and chronic stage were assessed with a test for emotion recognition (FEEST) and a questionnaire for behavioral problems (DEX) with a self and proxy rated version. Patients performed worse on the total score and on the negative emotion subscores of the FEEST than a matched group of 31 healthy controls. Patients also exhibited significantly more behavioral problems on both the DEX self and proxy rated version, but proxy ratings revealed more severe problems. No significant correlation was found between FEEST scores and DEX self ratings. However, impaired emotion recognition in the patients, and in particular of Sadness and Anger, was significantly correlated with behavioral problems as rated by proxies and with impaired self-awareness. This is the first study to find these associations, strengthening the proposed recognition of social signals as a condition for adequate social functioning. Hence, deficits in emotion recognition can be conceived as markers for behavioral problems and lack of insight in TBI patients. This finding is also of clinical importance since, unlike behavioral problems, emotion recognition can be objectively measured early after injury, allowing for early detection and treatment of these problems.

Maternal hypertensive disorders in pregnancy and self-reported cognitive impairment of the offspring 70 years later: the Helsinki Birth Cohort Study

OBJECTIVE

We tested whether maternal hypertensive disorders during pregnancy predict self-reported cognitive impairment, which is one of the earliest behavioral markers of dementia, of the offspring 70 years later.

STUDY DESIGN

We included 876 participants of the Helsinki Birth Cohort Study 1934-44 who were born after normotensive, preeclamptic, or hypertensive pregnancies that were defined by the use of the mother's blood pressure and urinary protein measurements at maternity clinics and birth hospitals. The participants completed a psychological questionnaire that included questions on cognitive failures and dysexecutive functioning at an average age of 69.3 ± 3.1 (SD) years.

RESULTS

In comparison with the offspring who were born after normotensive pregnancies, the offspring who were born after preeclamptic pregnancies reported more frequent complaints of cognitive failures, distractibility, and false triggering. Further, among women we found maternal hypertension without proteinuria that was associated with more frequent complaints of cognitive failures, forgetfulness, and false triggering.

CONCLUSION

Hypertensive disorders during pregnancy are associated with more frequent subjective complaints of cognitive failures of the offspring in old age.