Self-awareness assessment during cognitive rehabilitation in children with acquired brain injury: a feasibility study and proposed model of child anosognosia

Abstract

Purpose: To compare three ways of assessing self-awareness in children with traumatic brain injury (TBI) and to propose a model of child anosognosia. Method: Five single cases of children with severe TBI, aged 8–14, undergoing metacognitive training. Awareness was assessed using three different measures: two measures of metacognitive knowledge/intellectual awareness (a questionnaire and illustrated stories where child characters have everyday problems related to their executive dysfunction) and one measure of on-line/emergent awareness (post-task appraisal of task difficulty). Results: All three measures showed good feasibility. Analysis of awareness deficit scores indicated large variability (1–100%). Three children showed dissociated scores. Conclusions: Based on these results, we propose a model of child self-awareness and anosognosia and a framework for awareness assessment for rehabilitation purposes. The model emphasizes (1) the role of on-line error detection in the construction of autobiographical memories that allow a child to build a self-knowledge of his/her strengths and difficulties; (2) the multiple components of awareness that need to be assessed separately; (3) the implications for rehabilitation: errorless versus error-based learning, rehabilitation approaches based on metacognition, rationale for rehabilitation intervention based on child’s age and impaired awareness component, ethical and developmental consideration of confrontational methods.

• Implications for Rehabilitation

• Self-awareness has multiple components that need to be assessed separately, to better adapt cognitive rehabilitation.

• Using questionnaires and discrepancy scores are not sufficient to assess awareness, because it does not include on-line error detection, which can be massively impaired in children, especially those with impaired executive functions.

• On-line error detection is important to promote and error-based learning is useful to allow a child to build a self-knowledge of his/her strengths and difficulties, in the absence of severe episodic memory problems.

• Metacognitive trainings may not be appropriate for younger children who have age appropriate developmentally immature self-awareness, nor for patients with brain injury if they suffer anosognosia because of their brain injury.