Diagnostic Utility of Attention Measures in Postconcussion Syndrome

Neuropsychological evaluation may be of particular relevance in the detection of subtle cognitive impairments after mild traumatic brain injury (MTBI), including the subgroup of MTBI patients with a persistent postconcussion syndrome (PCS). Attention measures may be the most sensitive indicators of dysfunction associated with MTBI; however, previous studies have typically relied on the analysis of overall group differences, which may not reflect the diagnostic accuracy of attention measures when applied to individuals with MTBI. In the present study, subjects with persistent symptoms at least 3 months following a mild traumatic brain injury were compared with a sample of community living, normal control subjects in order to evaluate the sensitivity, specificity, and diagnostic accuracy of attention measures. Patients with PCS, screened with conservative inclusion and exclusion criteria, and a matched normal control group were administered six clinical tests of attention: Digit Span, Trail Making Test, Part A and Part B, Stroop Color-Word Test, Continuous Performance Test of Attention (CPTA), Paced Auditory Serial Addition Test (PASAT), and Ruff 2 & 7 Selective Attention Test. Consistent with prior research, these measures exhibited a wide range of sensitivity and specificity to possible cognitive impairment among patients. Attention measures may be the most sensitive indicators of dysfunction associated with PCS. Measures with high specificity (e.g., Stroop Color, and 2 & 7 Processing Speed) were shown to have strong positive predictive value, while measures with high sensitivity (e.g., CPTA) demonstrated strong negative predictive value for diagnosing PCS. Examination of the Odds Ratios indicated that measures assessing processing speed had a reliable, positive association with PCS, while measures without a processing speed component did not. Implications for making informed clinical decisions are discussed.     

脑外伤患者恢复期的注意障碍

目的探索脑外伤恢复期患者注意的改变及其特征.方法对42例大型医院神经外科住院治疗的脑外伤恢复期患者和42名正常人进行"2,7"划消测验和Strop测验.结果脑外伤患者在标准情况、不相关分心情况和相关分心情况下的划消速度明显低于正常对照组,而精确率无明显差异.进一步比较相关分心情况下划消速度的下降率显示脑外伤患者显著大于正常对照组.Stroop测验显示脑外伤患者读单色字时间、读色块时间和读彩色字颜色时间较正常对照组显著延长,但两组之间错误数无显著性差异.比较两组读彩色字颜色时间的延长率和读彩色字文字时间的延长率,脑外伤患者均显著大于对照组.结论脑外伤后患者的注意力下降.注意的分配受损,抗干扰能力下降,而选择注意相对完整.     

Comparing the performance of people who stutter and people who do not stutter on the Test of Everyday Attention

Introduction: Compelling findings into the relationship between stuttering and attentional ability have started to emerge, with some child and adult studies indicating poorer attentional ability among people who stutter (PWS). The purpose of the present research was to provide a more complete picture of the attentional abilities of PWS, as well as to gather insights into their individual attentional performance.

Method: We compared the attentional ability of PWS to that of people who do not stutter (PWNS) by using the Test of Everyday Attention (TEA). TEA is a clinical assessment battery with a very good validity and reliability comprising 8 subtests that pose differential demands on sustained attention, selective attention, attentional switching, and divided attention. Fifty age- and gender-matched PWS and PWNS (aged 19–77 years) took part in the study. Importantly, we also examined stuttering severity in the PWS group.

Results: PWS performed significantly worse on tasks tapping into visual selective and divided attentional resources. Furthermore despite failing to reach statistical significance, the results also revealed an interesting trend for stuttering to be associated with poorer performance on two subtests measuring attentional switching and one tapping into auditory selective attention. Moreover, as hypothesized, there was also a negative association between stuttering severity and performance on two TEA subtests measuring visual selective attention. Finally, the type of TEA test variant produced no significant effect on performance.

Conclusions: We interpret these results as indicative of stuttering being associated with poorer performance on tasks measuring certain attentional abilities. These tie in well with theoretical models identifying speech production as particularly attention-demanding in stuttering or approaches placing attentional dysfunction at the heart of the condition. The present research also has practical implications for the use of attentional training to improve fluency.     

Criterion validity of the D-KEFS color–word and verbal fluency switching paradigms following traumatic brain injury

The present study was composed of two parts examining the clinical utility of the Delis–Kaplan Executive Function System (D-KEFS) Verbal Fluency and Color–Word subtests in traumatic brain injury (TBI). In the first part, the performance of 128 outpatients with mild to severe TBI on the Verbal Fluency and Color–Word subtests was examined in relation to two primary indicators of TBI severity: length of coma and the presence of intracranial lesions on neuroimaging through regression analysis. After controlling for education, ethnicity, and complicating premorbid and comorbid factors, length of coma predicted performance on the Color–Word Inhibition/Switching subtest, whereas the presence of diffuse lesions was related to Verbal Fluency Category Switching performance. In the second part of this study, performance on the Category Switching and Inhibition/Switching subtests was compared between a group of 28 participants with moderate-to-severe TBI and demographically matched groups with mild-uncomplicated TBI (n = 28) and neurologically healthy control participants (n = 56). The moderate-to-severe TBI group performed significantly worse on both subtests than the mild-uncomplicated TBI and control groups, and the latter groups did not differ from each other on these subtests. Logistic regression analysis showed that the combined group classification accuracy of these subtests was 66.07%, with an area under the curve (AUC) of .70 and a likelihood ratio of 1.93. The findings provide modest support for the clinical utility of the Color–Word Inhibition/Switching subtest in the cognitive assessment of TBI, while also replicating prior research suggesting clinical utility of the Category Switching subtest in this population.     

The Covert Orienting of Visual Attention Following Severe Traumatic Brain Injury

Attentional problems have frequently been identified following traumatic brain injuries (TBIs) using both clinical assessments and self-report measures. Unfortunately, most measures of attention do not enable us to determine the underlying basis of these attentional deficits. One exception is Posner's Covert Orienting of Attention Task (COAT), which is designed to identify some of the fundamental mental operations underlying attention. This study sought to determine whether the COAT task could identify discrete attentional deficits following TBI beyond those caused by reduced speed of information processing. Thirty five patients who had sustained a severe TBI were compared to 35 age-matched controls. Results revealed that, although the reaction times of the patients with TBI were significantly slower than the controls, there were no differences between the two groups in terms of their ability to disengage, move, and engage their attention. The introduction of a secondary (language) task produced no significant difference between the two groups on the COAT task. However, there was a significant difference between the two groups on the language-based task, suggesting a deficit in auditory-verbal attention under dual task conditions.     

New scores for the Category Test: measures of interference for subtests 5 and 6

The Category Test is a well-known neuropsychological instrument used to assess concept formation and higher executive abilities. The present study investigated the utility of additional scores for the Category Test. We used principles developed in cognitive psychology to create several new measures for subtests 5 and 6 of this test. These scores were primarily designed to be sensitive to interference effects of learning decision rules from subtest 2, subtest 3, and subtest 4. The new scores as well as the total error scores from subtests 5 and 6 were used to discriminate subjects with documented brain injury from subjects who were neurologically normal based on neuroimaging and neurologic evaluation. The Category Test was given following Reitan's (1979) instructions, with the exception that no additional prompting was given to participants who struggled early with the test in order to reduce the "executive" guidance of the examiner. Because any "interference" from earlier subtests on performance of subtest 5 and subtest 6 should be related to mastery of these earlier subtests, the normal group was matched to the brain-impaired group on which subtest(s) they learned. This resulted in four learning groups: (a) learned subtests 3 and 4; (b) learned subtest 4 but not 3; (c) learned subtest 3 but not 4; and (d) failed to learn either subtest. ANOVA analyses revealed that the three measures of interference were significantly greater in the brain-damaged group than in the normal controls. Also, specific interference measures were related to specific prior subtest mastery, thus providing support for a proactive interference effect. In addition, we have evidence that our new measures may be selectively sensitive to frontal system dysfunction.     

An Examination of the Wechsler Adult Intelligence Scales,Fourth Edition (WAIS-IV) in Individuals with Complicated Mild,Moderate and Severe Traumatic Brain Injury (TBI)

This study examined the clinical utility of the Wechsler Adult Intelligence Scales-Fourth Edition (WAIS-IV) in individuals with complicated mild, moderate or severe TBI. One hundred individuals with TBI (n = 35 complicated mild or moderate TBI; n = 65 severe TBI) and 100 control participants matched on key demographic variables from the WAIS-IV normative dataset completed the WAIS-IV. Univariate analyses indicated that participants with severe TBI had poorer performance than matched controls on all index scores and subtests (except Matrix Reasoning). Individuals with complicated mild/moderate TBI performed more poorly than controls on the Working Memory Index (WMI), Processing Speed Index (PSI), and Full Scale IQ (FSIQ), and on four subtests: the two processing speed subtests (SS, CD), two working memory subtests (AR, LN), and a perceptual reasoning subtest (BD). Participants with severe TBI had significantly lower scores than the complicated mild/moderate TBI on PSI, and on three subtests: the two processing speed subtests (SS and CD), and the new visual puzzles test. Effect sizes for index and subtest scores were generally small-to-moderate for the group with complicated mild/moderate and moderate-to-large for the group with severe TBI. PSI also showed good sensitivity and specificity for classifying individuals with severe TBI versus controls. Findings provide support for the clinical utility of the WAIS-IV in individuals with complicated mild, moderate, and severe TBI.     

A Preliminary Validity Study of the Cambridge Neuropsychological Test Automated Battery for the Assessment of Executive Function in Schizophrenia and Bipolar Disorder

Objective

Although the executive function subtests of the Cambridge Neuropsychological Test Automated Battery (CANTAB) have been used to assess cognitive function in diverse psychiatric illnesses, few studies have verified the validity of this battery for Korean psychiatric patients. Therefore, this preliminary study evaluated the construct and concurrent validity of the executive function subtests of the CANTAB for Korean psychiatric patients by comparing it with subtests of the Computerized Neuropsychological Test (CNT).

Methods

Three subtests of the CANTAB and three subtests of the CNT were administered to 36 patients diagnosed with either schizophrenia or bipolar disorder. Subtests of the CANTAB included the Intra/Extra-Dimensional Set Shift (IED), Stockings of Cambridge (SOC), and Spatial Working Memory (SWM). Differences between groups on each subtest as well as correlations between the subtests of the CANTAB and the CNT were assessed.

Results

The schizophrenia group performed significantly more poorly on the IED and the Wisconsin Card Sorting Test (WCST) compared with the bipolar disorder group. Additionally, correlation analyses revealed a significant correlation between the IED and the WCST; a positive correlation between the SOC and the Trail Making Test, Part B and the Stroop test; and a significant correlation between the SWM and the Stroop test.

Conclusion

This study verified the construct and concurrent validity of the executive function subtests of the CANTAB for Korean psychiatric patients and suggests that the subtests of this battery would be useful and appropriate for assessing deficits in executive function in Korean clinical settings.     

Attention following traumatic brain injury: Neuropsychological and driving simulator data,and association with sleep,sleepiness, and fatigue

The objectives of this study were to compare individuals with traumatic brain injury (TBI) and healthy controls on neuropsychological tests of attention and driving simulation performance, and explore their relationships with participants’ characteristics, sleep, sleepiness, and fatigue. Participants were 22 adults with moderate or severe TBI (time since injury ≥ one year) and 22 matched controls. They completed three neuropsychological tests of attention, a driving simulator task, night-time polysomnographic recordings, and subjective ratings of sleepiness and fatigue. Results showed that participants with TBI exhibited poorer performance compared to controls on measures tapping speed of information processing and sustained attention, but not on selective attention measures. On the driving simulator task, a greater variability of the vehicle lateral position was observed in the TBI group. Poorer performance on specific subsets of neuropsychological variables was associated with poorer sleep continuity in the TBI group, and with a greater increase in subjective sleepiness in both groups. No significant relationship was found between cognitive performance and fatigue. These findings add to the existing evidence that speed of information processing is still impaired several years after moderate to severe TBI. Sustained attention could also be compromised. Attention seems to be associated with sleep continuity and daytime sleepiness; this interaction needs to be explored further.     

Wechsler Adult Intelligence Scale-Third Edition findings in relation to severity of brain injury in litigants

WAIS-III findings were reported for 150 litigants, classified into three groups according to severity of traumatic brain injury (TBI), and a general population control group. There was a significant "dose response" relationship between TBI severity and all Index/IQ scores. Effect size was greatest for the Processing Speed Index (PSI). Between group differences were significant on all subtests except Information and Digit Span. Effect sizes were greatest for Digit Symbol, Symbol Search, Similarities, and Picture Arrangement. Relative to the control group, there was a significant difference for the Severe and Extremely Severe TBI groups on all IQ/Index scores and most subtests. The Moderate TBI group differed significantly on one Index (the PSI) and none of the subtests. Clinical implications of the findings are discussed in relation to the utility of the WAIS-III in assessing the cognitive sequelae of TBI, the use of current WAIS-III IQ scores to assess intelligence-memory discrepancies, WAIS-III short forms, and estimation of premorbid intelligence.     

Wechsler Adult Intelligence Scale – Third Edition Findings in Relation to Severity of Brain Injury in Litigants

WAIS-III findings were reported for 150 litigants, classified into three groups according to severity of traumatic brain injury (TBI), and a general population control group. There was a significant “dose response” relationship between TBI severity and all Index/IQ scores. Effect size was greatest for the Processing Speed Index (PSI). Between group differences were significant on all subtests except Information and Digit Span. Effect sizes were greatest for Digit Symbol, Symbol Search, Similarities, and Picture Arrangement. Relative to the control group, there was a significant difference for the Severe and Extremely Severe TBI groups on all IQ/Index scores and most subtests. The Moderate TBI group differed significantly on one Index (the PSI) and none of the subtests. Clinical implications of the findings are discussed in relation to the utility of the WAIS-III in assessing the cognitive sequelae of TBI, the use of current WAIS-III IQ scores to assess intelligence – memory discrepancies, WAIS-III short forms, and estimation of premorbid intelligence.     

Attentional deficits following closed-head injury.

Aimed to assess, in the light of current attentional theories, the nature of the attentional deficit in a group of severely traumatically head-injured subjects, relative to a group of orthopaedic rehabilitation patients, and to establish which neuropsychological measures best reflected the deficit. Three separate studies were conducted in order to meet these aims. The first study focused on selective attention; the second, on vigilance or sustained attention; the third, on the Supervisory Attentional System. Results provided no evidence for the presence of deficits of focused attention, sustained attention, or supervisory attentional control, but ample evidence for the presence of a deficit in speed of information processing. Those neuropsychological measures shown to be the best measures of this deficit included the Symbol Digit Modalities Test, simple and choice reaction-time tasks, colour naming and word reading scores on the Stroop, and the Paced Auditory Serial Addition Test.     

Intelligence,Attention, and Behavioral Outcomes in Internationally Adopted Girls with a History of Institutionalization

Objective: The aim of this study was to investigate the association of neurocognitive functioning with internalizing and externalizing problems and school and social competence in children adopted internationally. Method: Participants included girls between the ages of 6–12 years who were internationally adopted from China (n = 32) or Eastern Europe (n = 25) and a control group of never-adopted girls (n = 25). Children completed the Vocabulary and Matrix Reasoning subtests from the Wechsler Abbreviated Scale of Intelligence and the Score! and Sky Search subtests from the Test of Everyday Attention for Children. Parents completed the Child Behavior Checklist and the Home and Community Social Behavior Scales. Results: Compared to the controls, the Eastern European group evidenced significantly more problems with externalizing behaviors and school and social competence and poorer performance on measures of verbal intelligence, perceptual reasoning, and auditory attention. More internalizing problems were reported in the Chinese group compared to the controls. Using generalized linear regression, interaction terms were examined to determine whether the associations of neurocognitive functioning with behavior varied across groups. Eastern European group status was associated with more externalizing problems and poorer school and social competence, irrespective of neurocognitive test performance. In the Chinese group, poorer auditory attention was associated with more problems with social competence. Conclusions: Neurocognitive functioning may be related to behavior in children adopted internationally. Knowledge about neurocognitive functioning may further our understanding of the impact of early institutionalization on post-adoption behavior.     

Attention dysfunction and psychopathology in college men

Four hundred college men were screened on a measure of vigilance, the Continuous Performance Test (CPT). The individuals with good and poor attention (the upper and lower 5% of the CPT score distribution) were compared on multiple measures of psychiatric disturbance, cognition, and psycho-physiologic function. The attention dysfunction group (lower 5%) had a higher incidence of symptoms of hyperactivity both in childhood and as adults, but had no higher incidence of other psychopathology as assessed with either the Research Diagnostic Criteria or the Minnesota Multiphasic Personality Inventory. Cognitive differences between the lower and upper CPT groups, including differences on Wechsler Adult Intelligence Scale subtests, the Stroop test, reaction time, and evoked potentials, substantiated an attention dysfunction syndrome. Thus, attentional dysfunction in young adults seems more closely linked to hyperactivity than to current psychopathology.     

Attentional deficits following closed-head injury

Abstract

Aimed to assess, in the light of current attentional theories, the nature of the attentional deficit in a group of severely traumatically head-injured subjects, relative to a group of orthopaedic rehabilitation patients, and to establish which neuropsychological measures best reflected the deficit. Three separate studies were conducted in order to meet these aims. The first study focused on selective attention; the second, on vigilance or sustained attention; the third, on the Supervisory Attentional System. Results provided no evidence for the presence of deficits of focused attention, sustained attention, or supervisory attentional control, but ample evidence for the presence of a deficit in speed of information processing. Those neuropsychological measures shown to be the best measures of this deficit included the Symbol Digit Modalities Test, simple and choice reaction-time tasks, colour naming and word reading scores on the Stroop, and the Paced Auditory Serial Addition Test.     

The written language performance of children with Attention Deficit Hyperactivity Disorder in Taiwan

Poor writing is common in children with Attention Deficit Hyperactivity Disorder (ADHD). However, the writing performance of children with ADHD has been rarely formally explored in Taiwan, so the purpose of this study was to investigate writing features of children with ADHD in Taiwan. There were 25 children with ADHD and 25 normal children involved in a standardization writing assessment – Written Language Test for Children, to assess their performance at the dictation, sentence combination, adding/deducting redical, cloze and sentence making subtests. The results showed that except for the score of the sentence combining subtest, the score of children with ADHD was lower than the normal student in the rest of the subtests. Almost 60% of ADHD children's scores were below the 25th percentile numbers, but only 20% for normal children. Thus, writing problems were common for children with ADHD in Taiwan, too. First, children with ADHD performed worse than normal children on the dictation and cloze subtests, showing the weaker abilities of retrieving correct characters from their mental lexicon. Second, children with ADHD performed worse on the adding/deducting redical subtest than normal children did. Finally, at the language level, the score of children with ADHD on the sentence combination subtest was not lower than normal children, implicating their normal grammatic competence. It is worth mentioning that Taiwanese children with ADHD ignore the details of characters when they are writing, a finding that is common across languages.     

Attention Deficits in Patients with Persisting Postconcussive Complaints: A General Deficit or Specific Component Deficit?

This study aimed to examine attentional performance in patients with persisting postconcussive complaints, using a multi-componential perspective. Comparisons of attentional performances of 92 patients with postconcussive complaints and 86 normal controls were conducted using tests of sustained attention (Sustained Attention to Response Task; Digit Backward Span), selective attention (Stroop Word-Color Test; Color Trails Test), divided attention (Paced Auditory Serial Addition Test; Symbol Digit Modalities Test), and attentional control processing (Six Elements Test; Tower of Hanoi). Questionnaires on daily life inattentive behaviour were also administered to all participants and their significant others. A MANOVA indicated that patients with persisting postconcussive complaints demonstrated a general deficit in attentional performance as compared with their normal controls, F (18, 145) = 7.939, p = .005. These patterns still persisted when measures of emotional disturbance were controlled, F (18, 143) = 5.159, p = .005. Moreover, for sustained attention and selective attention, we were able to statistically control for speed and the differences remained. Future research should be conducted to better control the potential confound of speed for all the attentional components in order to differentiate any specific component deficits in these patients.     

Impaired sustained attention and error awareness in traumatic brain injury: Implications for insight

The processes of error awareness and sustained attention were investigated in 18 traumatic brain injury (TBI) individuals and 16 matched control participants. In Experiment 1, we found that: (1) in comparison to controls, TBI participants displayed reduced sustained attention and awareness of error during the Sustained Attention to Response Task; (2) degree of error awareness was strongly correlated with sustained attention capacity, even with severity of injury partialed out; and (3) that error feedback significantly reduced errors. We replicated the finding of a correlation between error awareness and sustained attention capacity in Experiment 2 with a separate sample of 19 TBI participants and 20 controls. We conclude that TBI leads to impaired sustained attention and error awareness. The finding of a significant relationship between these two deficits in TBI suggests there may be a link between these two processes. Feedback on error improves sustained attention performance of control and TBI participants.     

Impaired sustained attention and error awareness in traumatic brain injury: implications for insight

The processes of error awareness and sustained attention were investigated in 18 traumatic brain injury (TBI) individuals and 16 matched control participants. In Experiment 1, we found that: (1) in comparison to controls, TBI participants displayed reduced sustained attention and awareness of error during the Sustained Attention to Response Task; (2) degree of error awareness was strongly correlated with sustained attention capacity, even with severity of injury partialed out; and (3) that error feedback significantly reduced errors. We replicated the finding of a correlation between error awareness and sustained attention capacity in Experiment 2 with a separate sample of 19 TBI participants and 20 controls. We conclude that TBI leads to impaired sustained attention and error awareness. The finding of a significant relationship between these two deficits in TBI suggests there may be a link between these two processes. Feedback on error improves sustained attention performance of control and TBI participants.     

Test-retest practice effects and test score changes of the WAIS-R in recovering traumatically brain-injured survivors

A group of adult TBI subjects who were tested at approximately 2, 4, 8, and 12 months postinjury with the WAIS-R were compared with a matched control group of similar adult TBI survivors who were tested twice with the WAIS-R at approximately 2 and 12 months postinjury. No significant differences were noted between the two groups on numerous preinjury, injury, or postinjury variables. Both groups demonstrated significant gains in both IQ and subtest scaled scores at 1 year postinjury. Significantly greater change scores were demonstrated in the experimental group than in the control group, suggesting possible test-retest practice effects in Performance IQ and several subtests. Trend analyses detected both linear and quadratic recovery curves, with recovery slowing by the third evaluation. Implications of results for clinical practice are discussed.