The relative importance of metacognitive skills, emotional status, and executive function in psychosocial adjustment following acquired brain injury

Identifying conflict monitoring as a specific executive component that contributes to impaired self-awareness in patients with acquired brain injury

OBJECTIVE

Impaired self-awareness (SA) after acquired brain injury (ABI) has traditionally been linked to deficits in executive functions. However, conflicting findings about this relationship have been reported in the literature. This inconsistency is probably due to the multicomponent nature of both constructs, as not all aspects of executive functions may be equally relevant to all components of self-awareness. This study explored whether offline SA (i.e. metacognitive knowledge) and online SA (i.e. error detection) relate to a less studied executive component, conflict monitoring/resolution.

METHOD

Twenty-six patients with ABI performed the Three-Conflict Cognitive Control Task (3CCT), an experimental task that allowed to measure the ability to monitor and solve three different types of conflicts (Distractors-filtering, Spatial Stroop and Simon). Measures of SA were collected: offline SA was based on self-informant discrepancy about patient's everyday functional difficulties, and online SA was based on error detection abilities during a performance-based naturalistic task (The Breakfast Conflict Task).

RESULTS

After controlling for global cognition, the conflict monitoring measure of 3CCT demonstarted incremental validity in predicting offline and online SA measured in naturalistic tasks.

CONCLUSIONS

Conflict monitoring/resolution seems to be an important component of SA. This finding contributes to further understand the relationship between executive functions and SA. In addition, conflict monitoring/resolution is an executive component that should be considered when designing assessment and intervention strategies to deal with ISA.

"We can all relate": patient experience of an emotion-oriented group intervention after Acquired Brain Injury

Introduction

Group interventions are carried out routinely across neuropsychological rehabilitation services, to improve understanding of brain injury and aspects of impairment. Treatment provided in a group modality can bring additional perceived benefits, such as co-operative learning. However, there are very few studies which explore patient perceptions and experiences of such interventions. In the present study we investigated the experience of attending a group-based educational intervention for the consequences of acquired brain injury (ABI), which had a strong focus on emotion and emotion regulation.

Methods

Using qualitative semi-structured interviews (approximately 20 minutes), the study explores the lived experience of participating in the seven-session programme, the better to identify the perceived efficacy, salience and value of individual elements. Twenty participants with ABI took part in individual interviews, after completion of the group programme (the Brain Injury Solutions and Emotions Programme, BISEP). The study adopted a descriptive phenomenological philosophy, which focuses on lived experience to explore a phenomenon (i.e. the experience of BISEP). As regards methods, the study employed thematic analysis to cluster experiences into themes of meaning.

Results

Five themes were identified: (1) 'Long term consequences and psychological needs', which related to the persistent nature of direct consequences of injury and adjustment, and how these result in a need for interventions such as BISEP. (2) 'Positive experiences of participating in the programme', referred to participants' overall experience of the programme and valued elements within it. The remaining themes referred to the programme as (3) a social milieu; (4) a place to learn; and (5) a place to promote positive emotional experiences.

Discussion

Similar to previous studies, many people reported high acceptability and perceived value of the group programme, and its role in facilitating adjustment and understanding of injury. Of particular importance was the opportunity to socialise with people who "can all relate", in line with a growing emphasis on social rehabilitation. The findings especially highlight the relevance of emotion-focused group programmes for ABI, promoting emotion regulation, and practical tools that are delivered optimistically. Further implications for practice and future research include to focus on long term rehabilitation, a social milieu, and strategies to support adjustment.

The contribution of executive functions to the process of return to work after brain injury: A systematic review

Acquired brain injury (ABI) is a worldwide public health issue for its high prevalence rate and the disability it produces. The consequences of ABI, including cognitive deficits, may impact return to work. This review focuses on the association between executive functions (EFs) and return to work after ABI. A systematic review of the literature between 1998 and 2023 was conducted following PRISMA guidelines. The articles were retrieved from the Pubmed, Medline and Web of Science databases. A total of 49 studies were finally selected. Impairments of EF were consistently shown to have a negative impact on return to work after an ABI. There is evidence that specific executive functions and neurobehavioral variables may affect return to work Studies showed a significant theoretical and methodological heterogeneity, representing an important limitation to understand the relation between EFs and work. There is a robust association between EFs and return to work after brain injury. Findings in this systematic review raise the need for further research on the role of specific EF profiles in the process of returning to work after brain damage.

When stroke survivors' self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Background Stroke survivors' self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as 'impaired self-awareness' (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling). Methods Forty-five subacute stroke survivors participated (Age M (s.d.) =  71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures. Results Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R 2  = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R 2  = 0.66). Conclusions Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships.

Use of person-centered goals to direct interdisciplinary care for military service members and Veterans with chronic mTBI and co-occurring psychological conditions

OBJECTIVE

To explore the use of person-centered goals (PCGs) to direct interdisciplinary care to support PCG attainment in military service members and Veterans (SM/Vs) with chronic mild traumatic brain injury (mTBI) and co-occurring psychological conditions.

METHODS

A retrospective chart review was completed for 146 United States military SM/Vs reporting chronic symptoms following mTBI and co-occurring psychological conditions who received care in the SHARE Military Initiative intensive outpatient program, a donor-funded program administered by a not-for-profit hospital, between April 1, 2015 and March 31, 2019. PCGs were used to direct care consisting of individual and group-based interventions and therapies delivered by an interdisciplinary, co-located team including behavioral health, case management, neurology or physiatry, nursing, occupational therapy, physical therapy, recreation therapy, speech-language pathology, and transition support. The primary outcome measure was PCG attainment measured via goal attainment scaling.

RESULTS

Increased PCG attainment was demonstrated at program discharge and throughout the first year following program discharge. Predictors of goal attainment at discharge included longer participation in treatment, greater reduction in depressive symptoms and greater improvement in adjustment at discharge, male gender, and higher cognitive and physical abilities on admission.

CONCLUSIONS

This sample of military SM/Vs with mTBI and co-occurring psychological conditions who received intensive, interdisciplinary, PCG directed care demonstrated increased PCG attainment at program discharge which further increased with transition support over the year post-discharge. Results suggest PGC goal directed care is a feasible, promising methodology of individualizing treatment in this population. This exploratory study lays a foundation for future prospective, controlled, comparative effectiveness research that will further understanding of the effectiveness of intensive, interdisciplinary, PCG directed care.

MetaCogs: Mitigating Executive Dysfunction via Agent-Based Modeling for Metacognitive Strategy Development

Executive functions (EF) are a collection of cognitive domains governing task initiation, motor planning, attention, and goal-oriented action. Difficulties with EF have marked impacts on adaptive living skills, learning outcomes, and quality of life for people with cognitive and psychosocial disabilities, as well as the broader population. While there is considerable research interest in EF training intervention for disabled populations, very few studies explore metacognitive intervention for people with cognitive disabilities. Metacognition comprises conscious beliefs and strategies around task management and goal setting. Metacognitive awareness has been shown to mediate the effects of executive function on self-regulated learning. Metacognitive interventions have also shown promise in general education, military training, and medical practice. We present a virtual reality experience deploying agent-based modeling to support explicit metacognitive strategy instruction for undergraduate students of all neurotypes. Our results support that explicit instructional material explaining executive function and metacognition in relation to problem-solving experiences influenced participant self-concept and awareness of personal traits and cognitive processes.

Online awareness of performance on a functional cognitive assessment in individuals with stroke: A case-control study

Unawareness is a significant barrier to cognitive rehabilitation following acquired brain injury. Little is known about online awareness of cognitively-based instrumental activities of daily living (C-IADL) after stroke, particularly C-IADLs that emphasize executive functions. Our goal was to evaluate in stroke patients (1) online awareness during and immediately after a C-IADL task that emphasizes executive functions and (2) the association between awareness and performance on the C-IADL task. Seventy-seven stroke patients on an acute inpatient rehabilitation unit and 77 control participants completed the 10-item Weekly Calendar Planning Activity (WCPA-10), a standardized C-IADL task that requires working memory, planning, shifting, and inhibition. Trained examiners observed the use of a self-checking strategy and self-recognition of errors during the task. Immediately after the task, participants estimated their accuracy, and rated their own performance, which was compared with objective accuracy. Relative to the control group, stroke patients overestimated their accuracy, less often recognized errors, and less frequently used a self-checking strategy. Overestimation was associated with worse overall performance on the WCPA-10. Findings suggest that poor online awareness of C-IADL performance is common in stroke patients undergoing acute inpatient rehabilitation. Increasing awareness through metacognitive interventions should be a core focus of early post-stroke cognitive rehabilitation.

Assessing prospective and retrospective metacognitive accuracy following traumatic brain injury remotely across cognitive domains

The ability to monitor one's behaviour is frequently impaired following TBI, impacting on patients' rehabilitation. Inaccuracies in judgement or self-reflection of one's performance provides a useful marker of metacognition. However, metacognition is rarely measured during routine neuropsychology assessments and how it varies across cognitive domains is unclear. A cohort of participants consisting of 111 TBI patients [mean age = 45.32(14.15), female = 29] and 84 controls [mean age = 31.51(12.27), female = 43] was studied. Participants completed cognitive assessments via a bespoke digital platform on their smartphones. Included in the assessment were a prospective evaluation of memory and attention, and retrospective confidence judgements of task performance. Metacognitive accuracy was calculated from the difference between confidence judgement of task performance and actual performance. Prospective judgment of attention and memory was correlated with task performance in these domains for controls but not patients. TBI patients had lower task performance in processing speed, executive functioning and working memory compared to controls, maintaining high confidence, resulting in overestimation of cognitive performance compared to controls. Additional judgments of task performance complement neuropsychological assessments with little additional time-cost. These results have important theoretical and practical implications for evaluation of metacognitive impairment in TBI patients and neurorehabilitation.

Online Awareness among Adolescents with Acquired Brain Injury: Preliminary Findings following Performance of Motor, Cognitive and Functional Tasks

Aims: Online awareness is an ongoing ability to monitor performance within the stream of action. It involves the ability to detect errors emerging during actual performance, as well as to anticipate potential problems. This preliminary within-subject study aimed to evaluate emergent and anticipatory online awareness among adolescents with Acquired Brain Injury (ABI) during performance of motor, cognitive and functional tasks.Methods: 14 adolescents (11-18 years) following ABI were recruited. Before and after completion of the tasks, participants fulfilled task-related awareness questionnaires.Results: In the motor task, no significant correlations were found between heart rate and the subjective perceived exertion scale (emergent awareness). In the cognitive task, no significant correlations were found between the estimated difficulty before the task (anticipatory awareness) and actual performance, however a significant correlation was found between performance and the self-evaluation of performance (emergent awareness), in the easiest item of the task. In the functional task, two main patterns of online awareness were recognized: accurate and overestimation of performance.Conclusions: Online awareness deficits in adolescents after ABI, vary as a function of task characteristics. Clinicians who aim to improve online awareness should direct interventions to mainly include functional tasks, as compared to cognitive and motor tasks.

Impaired self-awareness after traumatic brain injury: A systematic review. Part 2. Consequences and predictors of poor self-awareness

BACKGROUND

Impaired self-awareness (ISA) has frequently been found both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

This is the second of a two-part systematic review on ISA after TBI, focusing on the consequences and predictors of ISA after TBI.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included; 46 were specifically related to this second part of the review.

RESULTS

Among 16 studies that investigated the effect of ISA on outcome, most (n=13) found poor self-awareness associated with poor rehabilitation, functional, social and vocational outcome and with increased burden on relatives. Multiple factors have been found associated with increased frequency of ISA. ISA was found significantly related to injury severity in 8 of 10 studies, impaired executive functions in 12 of 15 studies, and poor social cognition in 3 studies, but paradoxically inverse associations were repeatedly found between self-awareness and emotional status (11 of 12 studies). Finally, although research in the field is still scarce, ISA seems associated with a dysfunction within brain networks involving the anterior cingulate cortex, anterior insula and fronto-parietal control network.

CONCLUSIONS

ISA is a complex and multifaceted disorder associated with poor rehabilitation outcome, severe injuries, and deficits of executive functions and social cognition but has an inverse association with mood impairments.

Social Cognition in Paediatric Traumatic Brain Injury: A Systematic Review and Meta-analysis

Recent evidence suggests social cognitive deficits may be among the most profound and disabling consequences of childhood traumatic brain injury (TBI); however, it is only over the last decade that this area has received increasing research attention. This study aims to systematically review all studies reporting on the effects of childhood TBI on social cognition. Meta-analytic techniques were employed to determine the magnitude of social cognitive deficits in childhood TBI. Literature searches were conducted in electronic databases (Medline/PubMed, Scopus, Cochrane, EMBASE, PsycINFO and CINAHL) to retrieve relevant articles on social cognitive outcomes of paediatric TBI published from 2007-2019. The systematic review identified fourteen eligible studies, which examined the effect of paediatric TBI on five dimensions of social cognition, including emotion recognition or perception, theory of Mind (ToM), pragmatic language, moral reasoning, and social problem solving. Of these studies, eleven articles were included in subsequent meta-analyses, which included 482 children with TBI. Meta-analysis using a random-effects model revealed non-significant differences between TBI and typically developing (TD) control groups on measures of emotion perception or recognition. In contrast, children and adolescents with TBI performed significantly worse than control groups on ToM and pragmatic language tasks, with small and medium effect sizes, respectively (Hedge's g = -0.46; -0.73). Meta-regression indicated that post-injury social cognitive deficits were not moderated by child age. While the effect of time since injury was not statistically significant, poorer social cognitive outcomes are documented soon after injury. Despite relatively intact basic social cognitive skills (i.e. emotion perception or recognition) children and adolescents with TBI are vulnerable to deficits in higher-order aspects of social cognition, including ToM and pragmatic language. These findings underscore the importance of further research, using well-validated, standardised outcome instruments, in larger paediatric TBI samples. Furthermore, longitudinal prospective studies are needed to evaluate the respective contribution of injury and non-injury factors to individual variation in outcome and recovery of social cognition after paediatric TBI.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Building the bond: Predictors of the alliance in neurorehabilitation

BACKGROUND

Neurorehabilitation services are often delivered through group psycho-education programmes. However, little is known about the therapeutic process at work during such sessions. The present study is the first to gain insight into the therapeutic alliance, during a seven-session group programme. In addition, cognitive, emotional, and demographic predictors of the alliance, and participants' feelings towards their group members, were investigated, together with predictors of patient engagement.

METHODS

Forty-five participants with an acquired brain injury completed a series of questionnaires, and neuropsychological assessment, following group psycho-education. The group facilitator completed a parallel therapeutic alliance questionnaire, and rated participants' engagement.

RESULTS

Results demonstrated that a strong alliance can be formed in seven group sessions. Notably, no demographic or cognitive factors appear to pose a barrier to developing a therapeutic alliance, nor to group attraction.

CONCLUSION

High levels of depression, however, may be a challenge, and clinicians may need to tailor their clinical skills to ensure a good therapeutic relationship with such patients. To promote engagement, clinicians may also need to provide additional support to patients with lower levels of education, working memory, and episodic memory impairment.

Executive Dysfunction and Reduced Self-Awareness in Patients With Neurological Disorders. A Mini-Review

Awareness of deficits in patients with neurological disorders may be described as a theoretical unitary phenomenon, which has been analysed reaching interesting results in the last decades. Awareness of deficits manifests itself in a continuum ranging from full awareness to total absence. In line with a neurocognitive approach, a reduction in self-awareness could be explained considering executive dysfunction associated with prefrontal cortex anatomo-functional changes. Our mini-review will focus on reduced self-awareness in neurological disorders, such as Alzheimer’s disease, behavioural Frontotemporal Dementia and Acquired Brain Injuries. Results achieved thanks to an explanatory investigative approach combined with a theoretical reference model will be presented. Data suggest the key role of executive functions in supporting adequate self-awareness towards patients’ cognitive-behavioural profile and instrumental activity autonomy. The Cognitive Awareness Model seems to be one of the best theoretical model to better approach this phenomenon.

Exploring Traumatic Brain Injuries and Aggressive Antisocial Behaviors in Young Male Violent Offenders

Background: Traumatic brain injury (TBI) is a major cause of disabilities and mortality worldwide, with higher prevalence in offender populations than in the general population. Previous research has strongly advocated increased awareness of TBI in offender populations. The aim of this study was to explore the prevalence and characteristics of TBI, and to investigate associations and interactions between TBI, aggressive antisocial behaviors, general intellectual functioning, and substance use disorders (SUD) in a well-characterized group of young violent offenders. Methods: The study investigated a cohort (n = 269) of 18 to 25-year-old male violent offenders in Sweden. Data on TBI (files + self-report), aggressive antisocial behaviors (Life History of Aggression), SUD (clinical interviews), and general intellectual functioning (General Ability Index, Wechsler Adult Intelligence Scales Third Edition) were collected between 2010 and 2012. Parametric (Student's t-test) and non-parametric (Mann-Whitney U-test, Spearman's rho, χ², Kruskal Wallis test) inferential statistics were applied and effect sizes reported. Results: TBI, both with and without loss of consciousness, was common, with 77.5% of the offenders reporting having suffered at least one TBI during their lifetime. TBI was associated with an increased occurrence of aggressive antisocial behaviors and SUD, and offenders with both TBI and SUD evidenced the largest amount of aggressive antisocial behaviors. No clinically meaningful associations were found between TBI and general intelligence. Effect sizes were in the small to medium range. Conclusions: Our study confirms an increased prevalence of TBI among young violent offenders compared to the general population, as well as associations between TBI, aggressive antisocial behaviors, and SUD. However, it provides no information on the severity of the TBI, nor on the causality of the demonstrated associations. Nevertheless, TBI, and possible related deficits, need to be considered in the assessment and treatment of young violent offenders.

Metacognitive knowledge and functional outcomes in adults with acquired brain injury: A meta-analysis

Pronounced difficulties in functional outcomes often follow acquired brain injury (ABI), and may be due, in part, to deficits in metacognitive knowledge (being unaware of one's cognitive strengths and limitations). A meta-analytic review of the literature investigating the relationship between metacognitive knowledge and functional outcomes in ABI is timely, particularly given the presence of apparently inconsistent findings. Twenty-two articles revealed two distinct methods of measuring metacognitive knowledge: (1) absolute (the degree of inaccurate self-appraisal regardless of whether the error tends towards under- or over-confident estimations) and (2) relative (the degree and the direction of the inaccuracy) discrepancy. Separate meta-analyses were conducted for absolute and relative discrepancy studies to assess the relationship between metacognitive knowledge and functional outcomes (affect-related quality of life, family and community integration, and work outcomes). The pattern of results found suggested that better metacognitive knowledge is related to better overall functional outcomes, but the relationship may differ depending on the outcome domain. These findings generally support the importance of focusing on metacognitive knowledge to improve outcomes following ABI. Nonetheless, the relatively small effect sizes observed suggest that other predictors of functional outcome should be investigated, including other subdomains of metacognition.

Prefrontal gray matter volume predicts metacognitive accuracy following traumatic brain injury

OBJECTIVE

To examine metacognitive ability (MC) following moderate to severe traumatic brain injury (TBI) using an empirical assessment approach and to determine the relationship between alterations in gray matter volume (GMV) and MC.

METHOD

A sample of 62 individuals (TBI n = 34; healthy control [HC] n = 28) were included in the study. Neuroimaging and neuropsychological data were collected for all participants during the same visit. MC was quantified using an approach borrowed from signal detection theory (Type II area under the receiver operating characteristic curve calculation) to evaluate judgments during a modified version of the 3rd edition of the Wechsler Adult Intelligence Scale's Matrix Reasoning subtest where half of the items were presented randomly and half were presented in the order of increasing difficulty. Retrospective confidence judgments were collected on an item-by-item basis. Brain volumetric analyses were conducted using FreeSurfer software.

RESULTS

Analyses of the modified Matrix Reasoning task data demonstrated that HCs significantly outperformed TBIs (ordered: d = .63; random: d = .58). There was a significant difference between groups for MC for the randomly presented stimuli (d = .54) but not the ordered stimuli. There was an association between GMV and MC in the TBI group between the right orbital region and MC (R2 = .11). In the HC group, there were associations between the left posterior (R2 = .17), left orbital (R2 = .29), and left dorsolateral (R2 = .21) regions and MC.

CONCLUSIONS

These results are consistent with those of previous research on MC in the cognitive neurosciences, but this study demonstrates that injury may moderate the regional contributions to MC. (PsycINFO Database Record

Enhanced default mode connectivity predicts metacognitive accuracy in traumatic brain injury

OBJECTIVE

To examine the role that intrinsic functional networks, specifically the default mode network, have on metacognitive accuracy for individuals with moderate to severe traumatic brain injury (TBI).

METHOD

A sample of 44 individuals (TBI, n = 21; healthy controls [HCs], n = 23) were included in the study. All participants underwent an MRI scan and completed neuropsychological testing. Metacognitive accuracy was defined as participants' ability to correctly judge their item-by-item performance on an abstract reasoning task. Metacognitive values were calculated using the signal detection theory approach of area under the receiver operating characteristic curve. Large-scale subnetworks were created using Power's 264 Functional Atlas. The graph theory metric of network strength was calculated for six subsystem networks to measure functional connectivity.

RESULTS

There were significant interactions between head injury status (TBI or HC) and internetwork connectivity between the anterior default mode network (DMN) and salience network on metacognitive accuracy (R2 = 0.13, p = .047) and between the posterior DMN and salience network on metacognitive accuracy (R2 = 0.15, p = .038). There was an interpretable interaction between head injury status and internetwork connectivity between the attention network and salience network on metacognitive accuracy (R2 = 0.13, p = .067). In all interactions, higher connectivity predicted better metacognitive accuracy in the TBI group, but this relationship was reversed for the HC group.

CONCLUSION

Enhanced connectivity to both anterior and posterior regions within the DMN facilitates metacognitive accuracy postinjury. These findings are integrated into a larger literature examining network plasticity in TBI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Role of Emotional Intelligence in Community Integration and Return to Work After Acquired Brain Injury

OBJECTIVE

To investigate whether emotional intelligence (EI) skills measured via the Perceiving, Understanding, and Managing Emotions branches of the Mayer-Salovey-Caruso Emotional Intelligence Test V2.0 are associated with community integration (CI) and return to work (RTW) after moderate-to-severe acquired brain injury (ABI), after accounting for other established predictors.

DESIGN

Retrospective cohort study.

SETTING

Outpatient follow-up services within 2 specialist ABI rehabilitation centers in Melbourne, Australia.

PARTICIPANTS

Individuals (N=82) with moderate-to-severe ABI discharged from inpatient rehabilitation and living in the community (2mo to 7y postinjury).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Community Integration Questionnaire scores for the total sample (N=82; age range 18-80) and RTW status (employed vs not employed) for the subset of participants employed prior to ABI (n=71; age range 19-66).

RESULTS

Hierarchical logistic and multiple regression analyses were used to examine the unique contribution of Perceiving, Understanding, and Managing Emotions scores to RTW and CI, after controlling for demographic, injury-related, psychological, and cognitive predictors. As a set, the 3 EI variables did not explain incremental variance in outcomes. However, individually, Understanding Emotions predicted RTW (adjusted odds ratio=3.10, P=.03), χ² (12)=35.52, P<.001, and Managing Emotions predicted CI (β=0.23, P=.036), F_12,69=5.14, P<.001.

CONCLUSION

Although the EI constructs in combination did not improve prediction beyond the effects of established variables, individual components of strategic EI may be important for specific participation outcomes after ABI.

Do People With Severe Traumatic Brain Injury Benefit From Making Errors? A Randomized Controlled Trial of Error-Based and Errorless Learning

Background. Errorless learning (ELL) and error-based learning (EBL) are commonly used approaches to rehabilitation for people with traumatic brain injury (TBI). However, it is unknown whether making errors is beneficial in the learning process to promote skills generalization after severe TBI. Objective. To compare the efficacy of ELL and EBL for improving skills generalization, self-awareness, behavioral competency, and psychosocial functioning after severe TBI. Method. A total of 54 adults (79% male; mean age = 38.0 years, SD = 13.4) with severe TBI were randomly allocated to ELL or EBL and received 8 × 1.5-hour therapy sessions that involved meal preparation and other goal-directed activities. The primary outcome was total errors on the Cooking Task (near-transfer). Secondary outcome measures included the Zoo Map Test (far-transfer), Awareness Questionnaire, Patient Competency Rating Scale, Sydney Psychosocial Reintegration Scale, and Care and Needs Scale. Results. Controlling for baseline performance and years of education, participants in the EBL group made significantly fewer errors at postintervention (mean = 36.25; 95% CI = 32.5-40.0) than ELL participants (mean = 42.57; 95% CI = 38.8-46.3). EBL participants also demonstrated greater self-awareness and behavioral competency at postintervention than ELL participants ( P < .05). There were no significant differences on other secondary outcomes ( P > .05), or at the 6-month follow-up assessment. Conclusion. EBL was found to be more effective than ELL for enhancing skills generalization on a task related to training and improving self-awareness and behavioral competency.

Psychometric properties of the awareness questionnaire, patient competency rating scale and Dysexecutive Questionnaire in patients with acquired brain injury

OBJECTIVE

Lack of self-awareness of impairments is common after acquired brain injury (ABI). We evaluated the psychometric properties of three commonly used instruments for measuring self-awareness: Awareness Questionnaire (AQ), Patient Competency Rating Scale (PCRS) and Dysexecutive questionnaire (DEX).

METHOD

We recruited 105 patients with ABI and their relatives. We determined feasibility, responsiveness, test- retest reliability, internal consistency, and construct validity of AQ, PCRS and DEX.

RESULTS

No floor or ceiling effects were present. Total scale scores showed sufficient responsiveness: effect sizes were moderate to large (.57-.85); test-retest reliability was sufficient for patient forms (.75- .88) but mixed for relative forms (.60-.66). Internal consistency was good (.80-.89). Construct validity results confirmed a three-factor structured AQ and a four-factor structured PCRS. A two-facture structure was found for DEX patient forms; a three-factor structure was found for relative forms.

CONCLUSION

Overall, the total scale scores of patient forms of all questionnaires demonstrated sufficient psychometric properties. Psychometric properties of subscales are questionable. We could not replicate the factor structures of AQ, PCRS and DEX: the items within subscales differed with previous findings. Additional research into the test-retest, inter-rater reliability and responsiveness of relative and clinician forms is required.

Associations between executive functions and mental health outcomes for adults with autism spectrum disorder

Associations between executive functions (EF) and mental-health in adults with autism spectrum disorder (ASD) were examined. Forty-two adults with ASD completed measures of EF, mood and self-concept. Better concept formation and social inference skills were significantly associated with fewer anxiety symptoms. Conversely, participants with better non-verbal reasoning, cognitive flexibility and social cognition reported more negative self-concept and lower self-esteem. Overall, individuals with impaired EF are more prone to anxiety, whereas those with stronger EF are more likely to experience negative self-concept. Screening for and monitoring mental-health concerns in people with ASD regardless of their level of EF is recommended.

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.

Clinical assessment of decision-making capacity in acquired brain injury with personality change

Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the "frontal lobe syndrome"). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be present. However, the awareness of deficit may not be "online" and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI , and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined.

The feasibility and impact of a yoga pilot programme on the quality-of-life of adults with acquired brain injury

OBJECTIVE

This pilot study measured the feasibility and impact of an 8-week yoga programme on the quality-of-life of adults with acquired brain injury (ABI).

METHODS

Thirty-one adults with ABI were allocated to yoga (n = 16) or control (n = 15) groups. Participants completed the Quality of Life After Brain Injury (QOLIBRI) measure pre- and post-intervention; individuals in the yoga group also rated programme satisfaction. Mann-Whitney/Wilcoxon and the Wilcoxon Signed Rank tests were used to evaluate between- and within-group differences for the total and sub-scale QOLIBRI scores, respectively.

RESULTS

No significant differences emerged between groups on the QOLIBRI pre- or post-intervention. However, there were significant improvements on overall quality-of-life and on Emotions and Feeling sub-scales for the intervention group only. The overall QOLIBRI score improved from 1.93 (SD = 0.27) to 2.15 (SD = 0.34, p = 0.01). The mean Emotions sub-scale increased from 1.69 (SD = 0.40) to 2.01 (SD = 0.52, p = 0.01), and the mean Feeling sub-scale from 2.1 (SD = 0.34) to 2.42 (SD = 0.39, p = 0.01).

CONCLUSION

Adults with ABI experienced improvements in overall quality-of-life following an 8-week yoga programme. Specific improvements in self-perception and negative emotions also emerged. High attendance and satisfaction ratings support the feasibility of this type of intervention for people with brain injury.

Scoping Review of Self-Regulation: What Are Occupational Therapists Talking About?

Although the term self-regulation is appearing more frequently in the occupational therapy literature, the extent to which it is consistently conceptualized is not clear. The aim of this scoping review was to examine how the term self-regulation is used by occupational therapists in research and practice literature. A total of 58 publications that included occupational therapy and self-regulation in the title, key words, or abstract were identified. Self-regulation was not explicitly defined by more than half of the authors. Four theoretical orientations seem to guide conceptualization: synactive development, sensory integration, cognitive-behavioral theory, and self-regulation theory. Conceptualization differed according to the population, levels of strategy use, source of strategy implementation, and desired outcomes. A lack of definitional clarity and conceptual consistency of the term self-regulation was noted. Use of an explicit definition in relation to an identified theoretical framework is recommended to promote intra- and interprofessional communication, education, and research.

Metacognitive function poststroke: a review of definition and assessment

Metacognition is the conscious knowledge individuals have about their own cognitive capacities and the regulation of these activities through self-monitoring. The aim of this review was to identify the definitions and assessment tools used to examine metacognition in relation to stroke studies. A computer database search was conducted using MEDLINE, CINAHL, PsycINFO, Cochrane Reviews, Scopus and Web of Science. A total of 1412 publications were retrieved from the initial database search. Following the removal of unrelated articles, 34 articles remained eligible. 5 studies examined metacognition in relation to cognitive and/or emotional functioning, 4 examined the concept in relation to memory, while others investigated its relationship to driving, employment or restrictions in daily living. 12 studies examined metacognitive function exclusively in stroke. Only 1 study examined metacognition in the acute phase of stroke. 7 studies adhered to the standard definition of metacognition in line with the neuropsychological literature. The main assessment tools utilised included the Self-Regulation and Skills Interview (SRSI), the Self-Awareness of Deficits Interview (SADI), the Awareness Questionnaire (AQ) and the Patient Competency Rating Scale (PCRS). Assessment of metacognition has tended to focus on traumatic and other acquired brain injury in comparison to stroke. The majority of the studies that examined metacognition in stroke did not assess patients in the acute phase. The heterogeneity of assessment tools was in keeping with the variation in the definition of metacognition. The emergence of a standard metacognitive assessment tool may have important implications for future rehabilitative programmes.

Pilot feasibility of an mHealth system for conducting ecological momentary assessment of mood-related symptoms following traumatic brain injury

OBJECTIVE

This study assessed pilot feasibility and validity of a mobile health (mHealth) system for tracking mood-related symptoms after traumatic brain injury (TBI).

DESIGN

A prospective, repeated measures design was used to assess compliance with daily ecological momentary assessments (EMA) conducted via a smartphone application over an 8-week period.

METHODS

An mHealth system was developed specifically for individuals with TBI and utilized previously validated tools for depressive and anxiety symptoms (Patient Health Questionnaire-9, Generalized Anxiety Disorder-7). Feasibility was assessed in 20 community-dwelling adults with TBI via an assessment of compliance, satisfaction and usability of the smartphone applications. The authors also developed and implemented a clinical patient safety management mechanism for those endorsing suicidality.

RESULTS

Participants correctly completed 73.4% of all scheduled assessments, demonstrating good compliance. Daily assessments took <2 minutes to complete. Participants reported high satisfaction with smartphone applications (6.3 of 7) and found them easy to use (6.2 of 7). Comparison of assessments obtained via telephone-based interview and EMA demonstrated high correlations (r = 0.81-0.97), supporting the validity of conducting these assessments via smartphone application in this population.

CONCLUSIONS

EMA conducted via smartphone demonstrates initial feasibility among adults with TBI and presents numerous opportunities for long-term monitoring of mood-related symptoms in real-world settings.

Affective state and community integration after traumatic brain injury

Previous studies investigating the relationship between affective state and community integration have focused primarily on the influence of depression and anxiety. In addition, they have focused on frequency of participation in various activities, failing to address an individual's subjective satisfaction with participation. The purpose of this study was to examine how affective state contributes to frequency of participation and satisfaction with participation after traumatic brain injury among participants with and without a current major depressive episode. Sixty-four community-dwelling participants with a history of complicated mild-to-severe traumatic brain injury participated in this cross-sectional cohort study. High positive affect contributed significantly to frequency of participation (β = 0.401, P = 0.001), and both high positive affect and low negative affect significantly contributed to better satisfaction with participation (F2,61 = 13.63, P < 0.001). Further investigation to assess the direction of these relationships may better inform effective targets for intervention. These findings highlight the importance of assessing affective state after traumatic brain injury and incorporating a subjective measure of participation when considering community integration outcomes.

Connecting clinical and experimental investigations of awareness in traumatic brain injury

Questionnaire-based demonstrations of impaired self-awareness (SA) after traumatic brain injury (TBI) are not always supported by experimental studies of in-the-moment or online awareness. This chapter begins by describing the clinical phenomenon of impaired SA, how it is measured, and why its interdependency with mechanisms of online awareness may provide the scaffolding from which appraisals of cognitive functioning can be accurately revised following a brain injury. We review research that has measured unawareness of errors in routine action in TBI patients and propose more rigorous methodological approaches to studying the emergent properties of awareness with greater clarity in the laboratory. We discuss how neuropsychological and electrophysiologic studies are beginning to inform our understanding of impaired error processing in TBI patients and we highlight recent theory proposing that online metacognitive processes accumulate evidence of erroneous responses in a graded fashion. Neural signals with amplitudes that scale with the strength of accruing evidence and peak latencies that mark the threshold at which awareness emerges represent important neural mechanisms to examine the breakdown of error awareness after brain injury. We also discuss how errors can be investigated in relation to different sources of evidence that contribute to aware experiences after brain injury. Finally, we explore conditions beyond error signaling, and how different "objects of insight" that require retrospective and prospective judgments of confidence need to be examined in relation to the clinical phenomenon of impaired SA.

Unawareness of bipolar disorder: the role of the cingulate cortex

Reduced awareness of illness is a well-known phenomenon that has been understudied in remitted patients with bipolar disorder. In particular, the relationship between reduced awareness and executive dysfunction is an intriguing question that has yet to be resolved. The aim of the current study is to analyze the link between reduced awareness, brain dysfunction, and concomitant cognitive-behavioral disturbances from a neurocognitive perspective. In previous studies, we demonstrated the role of the anterior cingulate cortex (ACC) in the unawareness of distinct pathologies that exhibit overlapping symptoms in the context of overlapping circuit-specific dysfunction. Given the clinical importance of the results obtained, the present study considers six aware and four unaware remitted bipolar disorder patients. Cingulate functionality was assessed with functional magnetic resonance imaging while patients performed a go/no-go task. Patients were also studied on an overall cognitive task battery and with behavioral assessment of mood changes in terms of apathy and disinhibited behavior. Unaware patients showed frontoparietal hypo-perfusion, with a significant reduction of task-sensitive activity in the bilateral superior and middle frontal gyrus, putamen, insular, and ACCs.

Gender differences in awareness and outcomes during acute traumatic brain injury recovery

BACKGROUND

Recent literature on traumatic brain injury (TBI), though mixed when reporting outcomes, seems collectively to suggest possible gender advantage for women in postinjury recovery, especially in executive functions. Hormonal neuroprotection, through female reproductive hormones, is often proposed as an underlying factor in these results. We explored potential gender differences in an aspect of executive functions, self-awareness (SA), which is often impaired after TBI, limits patient effort in critical rehabilitation, and increases caregiver burden.

METHODS

Within a prospective survey, repeated-measures design, 121 patients with moderate or severe TBI undergoing acute rehabilitation in a Level 1 trauma center, a family member or caregiver informant, and a treating clinician were asked to complete the Patient Competency Rating Scale (PCRS) and the Frontal Systems Behavior Scale (FrSBe) at admission and discharge.

RESULTS

Although overall, women and men with TBI showed generally similar levels of SA, women had significantly better awareness of their injury-related deficits at acute rehabilitation discharge, even when controlling for age, education, and injury severity.

CONCLUSIONS

Mixed findings in this study mirror the pattern of results that dominate the published literature on gender and TBI. Gender differences in executive dysfunction may not be as large or robust as some researchers argue. In addition, complex interplays of socialization, gender-role expectations, naturally occurring male and female ability differences, and differences in access to postinjury rehabilitation are understudied potential moderators.

Brief report of affective state and depression status after traumatic brain injury

OBJECTIVE

To examine the relationship between affective state (positive and negative affect) and depression status among adults with chronic traumatic brain injury (TBI).

RESEARCH METHOD

This is a cross-sectional cohort study of community-dwelling adults with chronic TBI (n = 64) that assesses the relationship between affective state (positive and negative affect), using the Positive and Negative Affect Schedule (PANAS), and depression status, categorized as no depression, history of depressive episode, and current depressive episode, using the Primary Care Evaluation of Mental Disorders (PRIME-MD).

RESULTS

Affective state differed significantly across depression status groups for both positive affect (F (2, 61) = 5.10, p = .009) and negative affect (F ( 2, 61) = 8.19, p = .001). Participants with no depression reported higher positive affect (M = 35.67, SD = 9.08) than those with a current depressive episode (M = 27.64, SD = 8.59, p = .007) and lower negative affect (M = 14.52, SD = 5.08) than those with a history of a depressive episode (M = 20.21, SD = 5.08, p = .006) and those with a current depressive episode (M = 22.29, SD = 6.21, p = .001).

CONCLUSIONS

Poor affective state, including both low positive affect and high negative affect, is associated with depression diagnosis. High negative affect is present, even in the absence of a current depressive episode, after TBI. These data highlight the need to assess affective state in addition to screening for mood disorders among adults with chronic TBI.