A Systematic Review and Meta-Analysis on the Association Between Driving Ability and Neuropsychological Test Performances after Moderate to Severe Traumatic Brain Injury.

OBJECTIVES: Guidelines on return-to-driving after traumatic brain injury (TBI) are scarce. Since driving requires the coordination of multiple cognitive, perceptual, and psychomotor functions, neuropsychological testing may offer an estimate of driving ability. To examine this, a meta-analysis of the relationship between neuropsychological testing and driving ability after TBI was performed. METHODS: Hedge's g and 95% confidence intervals were calculated using a random effects model. Analyses were performed on cognitive domains and individual tests. Meta-regressions examined the influence of study design, demographic, and clinical factors on effect sizes. RESULTS: Eleven studies were included in the meta-analysis. Executive functions had the largest effect size (g = 0.60 [0.39-0.80]), followed by verbal memory (g = 0.49 [0.27-0.71]), processing speed/attention (g = 0.48 [0.29-0.67]), and visual memory (g = 0.43 [0.14-0.71]). Of the individual tests, Useful Field of Vision (UFOV) divided attention (g = 1.12 [0.52-1.72]), Trail Making Test B (g = 0.75 [0.42-1.08]), and UFOV selective attention (g = 0.67 [0.22-1.12]) had the largest effects. The effect sizes for Choice Reaction Time test and Trail Making Test A were g = 0.63 (0.09-1.16) and g = 0.58 (0.10-1.06), respectively. Years post injury (ß = 0.11 [0.02-0.21] and age (ß = 0.05 [0.009-0.09]) emerged as significant predictors of effect sizes (both p < .05). CONCLUSIONS: These results provide preliminary evidence of associations between neuropsychological test performance and driving ability after moderate to severe TBI and highlight moderating effects of demographic and clinical factors.

The association between cognitive fluctuations and activities of daily living and quality of life among institutionalized patients with dementia.

OBJECTIVE: Cognitive fluctuations (CFs) occur commonly in dementia of all types. While it is generally accepted that CFs can affect the clinical rating of dementia severity and neuropsychological performance, little is known about their impact on patients' activities of daily living (ADLs) and quality of life (QOL). Our study aims to explore the impact of CFs on ADLs and QOL among institutionalized patients with dementia. METHODS: The present study examined the nature and frequency of CFs in 55 institutionalized dementia patients. We used the Dementia Cognitive Fluctuation Scale (DCFS) to assess the presence and severity of CFs. The Alzheimer's Disease Functional Assessment of Change Scale (ADFACS) was used to assess patients' ADLs, and the Quality of Life in Late Stage Dementia scale (QUALID) was used to assess QOL. Linear regression models were used to assess the relationships between CFs, ADLs, and QOL. RESULTS: The mean age of the patients was 90.41 years (SD = 2.84). Their mean Aggressive Behavior Scale score was 1.13 (SD = 1.59), mean Severe Impairment Battery total score was 86.65 (SD = 13.77), and mean DCFS score was 10.07 (SD = 3.04). The mean ADFACS-ADL score was 10.88 (SD = 6.37), mean ADFACS-IADL score was 16.61 (SD = 9.54), and mean QUALID total score was 18.25 (SD = 5.70). DCFS significantly predicted ADFACS-ADL score (R2  = 0.39, ß = 0.30, P = .011) although the relationship between ADFACS-IADL score and DCFS score was not significant (R2  = 0.16, P = .111). DCFS significantly predicted QUALID score (R2  = 0.08, ß = 0.29, P = .033). CONCLUSION: More severe CFs in patients with dementia were significantly associated with impaired ability to engage in ADLs and poorer QOL.

Correlates of nursing care burden among institutionalized patients with dementia.

ABSTRACTBackground:The stress associated with care of patients with dementia has led to high nursing staff turnover. This study aims to explore patient factors that are related to nursing burden. METHODS: The present study examined nursing care burden related to 55 institutionalized dementia patients using the Modified Nursing Care Assessment Scale (M-NCAS). Cognition was assessed with the Severe Impairment Battery (SIB), activities of daily living (ADLs) were measured with the Alzheimer's Disease Functional Assessment of Change Scale (ADFACS), aggression was measured with the Aggressive Behavior Scale (ABS), and the Charlson Comorbidity Index (CCI) was used to assess medical comorbidity. Finally, the Dementia Cognitive Fluctuation Scale (DCFS) was used to assess the presence and severity of cognitive fluctuations (CFs). Linear regression models were used to assess their relationships with nursing care burden. RESULTS: The mean age of the patients was 90.41 years (SD=2.84) and 89.10% were males. ADFACS total score (B = 0.36, ß = 0.42, p = 0.002) and ABS score (B = 2.933, ß = 0.37, p = 0.002) significantly predicted the M-NCAS Attitude score. ABS score was the only significant predictor of M-NCAS Strain score (B = 2.57, ß = 0.35, p = 0.009). CONCLUSIONS: In the long-term care setting, aggressive behavior plays an important role in both subjective and objective nursing burden, while impaired ADLs increase the objective burden for nursing staff.

Neuropsychological performance of youth with secondary attention-deficit/hyperactivity disorder 6- and 12-months after traumatic brain injury.

The present study compared executive dysfunction among children with attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (S-ADHD), pre-injury ADHD and children with TBI only (i.e., no ADHD). Youth aged 6-16 years admitted for TBI to five trauma centers were enrolled (n=177) and evaluated with a semi-structured psychiatric interview scheduled on three occasions (within 2 weeks of TBI, i.e., baseline assessment for pre-injury status; 6-months and 12-months post-TBI). This permitted the determination of 6- and 12-month post-injury classifications of membership in three mutually exclusive groups (S-ADHD; pre-injury ADHD; TBI-only). Several executive control measures were administered. Unremitted S-ADHD was present in 17/141 (12%) children at the 6-month assessment, and in 14/125 (11%) children at 12-months post-injury. The study found that children with S-ADHD exhibited deficient working memory, attention, and psychomotor speed as compared to children with pre-injury ADHD. Furthermore, the children with S-ADHD and the children with TBI-only were impaired compared to the children with pre-injury ADHD with regard to planning. No group differences related to response inhibition emerged. Age, but not injury severity, gender, or adaptive functioning was related to executive function outcome. Neuropsychological sequelae distinguish among children who develop S-ADHD following TBI and those with TBI only. Moreover, there appears to be a different pattern of executive control performance in those who develop S-ADHD than in children with pre-injury ADHD suggesting that differences exist in the underlying neural mechanisms that define each disorder, underscoring the need to identify targeted treatment interventions.

Fear avoidance, fear of falling, and pain disability in hypermobile Ehlers-Danlos syndrome and hypermobility spectrum disorders.

PURPOSE: Hypermobile Ehlers-Danlos Syndrome (hEDS) and Hypermobility Spectrum Disorders (HSD) are understudied conditions characterized by hallmark hypermobility and chronic pain. Disease manifestations lead to significant disability. Understanding predictors of disability, over and above the univariate construct of pain severity, is necessary to tailor treatment. Thus, the current study examined the impact of the Fear-Avoidance Model [FAM] on disability in hEDS/HSD. Fear of falling was included as a novel fear-avoidance factor impacting disability. METHODS: A total of 168 individuals with hEDS/HSD answered a cross-sectional online survey regarding FAM constructs, fear of falling, disability, and clinical-demographic factors. A hierarchical regression analysis was used to assess whether FAM constructs and fear of falling significantly predicted disability, over and above pain severity and age. RESULTS: Pain catastrophizing, anxiety, and fear of falling contributed significant unique predictive relations, above age and average pain severity. Pain severity and fear of falling were the strongest unique predictors of disability. CONCLUSIONS: This is the first study to assess the relations among FAM constructs, pain severity, and disability in hEDS/HSD, and introduces fear of falling as a novel fear-avoidance factor specific to this population. Future research should apply these findings towards individualized interventions to improve disability in hEDS/HSD.

Disability is significant in hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders, and may be predicted by psychosocial factors of anxiety, pain catastrophizing, and fear of falling.Our findings suggest that improving disability in hypermobile Ehlers-Danlos Syndrome and Hypermobility Spectrum Disorders involves the consideration of physical factors, such as pain severity, along with psychosocial factors, the latter of which are amenable to change through individualized intervention plans.Fear of falling is a novel fear-avoidance construct that should be considered in future research and clinical settings to increase functionality in this frequently falling population.

The effect of emotion-focused orientation at retrieval on emotional memory in young and older adults.

This study examines how emotion-focused orientation at retrieval affects memory for emotional versus neutral images in young and older adults. A total of 44 older adults (ages 61-84 years, M=70.00, SD=5.54) and 43 young adults (ages 17-33 years, M=20.58, SD=3.72) were tested on their free recall and forced-choice recognition of images. At retrieval the emotion-focused orientation was manipulated by instructing participants to focus on emotion-related information (i.e., emotional content of images and the emotional reactions evoked by the images). In the control conditions participants were either instructed to focus on visual information or not provided any specific orientation instruction. In free recall but not forced-choice recognition, the emotion-focused orientation increased young adults' positivity bias and thus wiped out their superior negativity bias. However, the emotion-focused orientation did not affect older adults' emotional memory. The data suggest that young adults activate and prioritise emotional goals in response to external demand during intentional information processing whereas older adults seem to spontaneously tune themselves to emotional goals.

Neuropsychological performance in childhood OCD: a preliminary study.

BACKGROUND: Neuropsychological deficits have often been found in studies of adults with obsessive compulsive disorder (OCD). However, few studies have examined such impairment in children with OCD and of those studies published, the results are mixed. METHODS: In the present study, 14 OCD children were compared to 24 healthy developing children of similar age and intellectual ability on a series of neuropsychological tests that assess response inhibition, abstract reasoning and problem solving, planning ability, verbal and nonverbal fluency, working memory, attention and information processing speed, and visual and verbal memory and learning. RESULTS: No significant differences emerged between the children with OCD and healthy controls for working memory, verbal fluency, attention, information processing speed, concept formation/abstraction, and response inhibition. We observed some deficits and a trend toward performance differences between the groups for psychomotor speed and attention, cognitive flexibility, nonverbal fluency, planning ability, and verbal memory and learning. Results are partially consistent with those found in adults with OCD. Findings were not related to depressive symptoms or self-report feeling of anxiety. CONCLUSIONS: This preliminary survey indicates that OCD children may have deficits for cognitive flexibility and planning ability and differ from adults with OCD in not presenting with poor response inhibition or memory deficits. Larger, multi-site studies are warranted to help delineate the neurocognitive deficits associated with childhood OCD.

Performance monitoring in children following traumatic brain injury.

BACKGROUND: Executive control deficits are common sequelae of childhood traumatic brain injury (TBI). The goal of the current study was to assess a specific executive control function, performance monitoring, in children following TBI. METHODS: Thirty-one children with mild-moderate TBI, 18 with severe TBI, and 37 control children without TBI, of comparable age and sex, performed the stop signal task, a speeded choice reaction time task. On occasion, they were presented with a signal to stop their responses. Performance monitoring was defined as the extent of slowing in go-task reaction time following failure to stop responses. RESULTS: The TBI group as a whole demonstrated less post-error slowing than did controls. This finding suggested impaired error monitoring performance. In addition, time since injury and socioeconomic status predicted less slowing after stopped responses. CONCLUSIONS: We suggest that alterations in performance monitoring expressed as the inability to notice, regulate and adjust behavior to changing situations are an effect of TBI in children.

Neuropsychological function after endovascular and neurosurgical treatment of subarachnoid hemorrhage: a systematic review and meta-analysis.

OBJECTIVE Subarachnoid hemorrhage (SAH) is treated with either surgical clipping or endovascular coiling, though the latter is the preferred treatment method given its more favorable functional outcomes. However, neuropsychological functioning after treatment is rarely taken into account. In this meta-analysis, the authors synthesized relevant data from the literature and compared neuropsychological functioning in patients after coiling and clipping of SAH. They hypothesized that the coiled patients would outperform the clipped patients; that group differences would be greater with higher posterior circulation rupture rates, in older patients, and in more recent publications; that group differences would be smaller with greater rates of middle cerebral artery (MCA) rupture; and that anterior communicating artery (ACoA) rupture rates would not influence effect sizes. METHODS The MEDLINE, Embase, and PsycINFO databases were searched for clinical studies that compared neuropsychological functioning after either endovascular coiling or surgical clipping for SAH. Hedge's g and 95% confidence intervals were calculated using random effects models. Patients who had undergone coiling or clipping were compared on test performance in 8 neuropsychological domains: executive functions, language, attention/processing speed, verbal memory, visual memory, spatial memory, visuospatial functions, and intelligence. Patients were also compared with healthy controls, and meta-regressions were used to explore the relation between effect sizes and publication year, delay between treatment and neuropsychological testing, mean patient age, and rates of posterior circulation, ACoA, and MCA ruptures. RESULTS Thirteen studies with 396 clipped cases, 314 coiled cases, and 169 healthy controls were included in the study. The coil-treated patients outperformed the clip-treated patients on executive function (g = 0.17, 95% CI 0.08-0.25) and language tests (g = 0.23, 95% CI 0.07-0.39), and all patients were impaired relative to healthy controls (g ranged from -0.93 to -0.29). Coiled patients outperformed clipped patients to a greater degree in more recent publications, over longer posttreatment testing delays, and among older patients. Higher rates of posterior circulation and MCA aneurysms were associated with smaller group differences, while ACoA rupture rates did not influence effect sizes. CONCLUSIONS Coiling of SAH may promote superior neuropsychological functioning under certain circumstances and could have applications for the specialized care of SAH patients.

Cognitive Fluctuations and Cognitive Test Performance Among Institutionalized Persons With Dementia.

OBJECTIVE: To examine the nature and frequency of cognitive fluctuations (CFs) among institutionalized persons with dementia. METHOD: A clinical interview and a medical chart review were conducted, and 55 patients were assigned a specific dementia diagnosis. The Severe Impairment Battery (SIB) was administered to assess cognitive function, and the Dementia Cognitive Fluctuation Scale (DCFS) was administered to each patient's primary nurse to determine the presence and severity of CFs. RESULTS: A simple linear regression model was conducted with DCFS as the predictor variable and SIB total score as the dependent variable. The overall model was significant, suggesting that score on the DCFS significantly predicted SIB total score. Additionally, greater severity of CFs predicted poorer performance in the areas of orientation, language, and praxis. CONCLUSIONS: Results suggest that CFs exert a clinically significant influence over patients' cognitive abilities and should be considered as a source of excess disability.

Assessing accident phobia in mild traumatic brain injury: The Accident Fear Questionnaire.

PURPOSE: Despite a documented prevalence of accident phobia in almost 40% of motor vehicle accident (MVA) survivors, the onset of accident phobia after traumatic brain injury (TBI) remains poorly understood. There is currently a body of knowledge about posttraumatic stress disorder (PTSD) in patients with TBI, but less is known about accident phobia following TBI, particularly in cases of mild TBI (mTBI). Accident phobia can impede safe return to driving or motor vehicle travel, inhibiting return to daily functioning. In addition, pain complaints have been found to correlate positively with postinjury anxiety disorders. METHOD: The present study sought to determine the reliability and validity of the Accident Fear Questionnaire (AFQ), a measure used to assess accident phobia, in 72 patients with mTBI using secondary data analysis and the subsequent development of accident phobia postinjury. Furthermore, we sought to examine the impact of pain, anxiety, and depression complaints on the AFQ. RESULTS: Results reveal convergent validity and reliability in mTBI populations. Additionally, pain, anxiety, and depression measures were significantly correlated with scores on the AFQ. CONCLUSIONS: Psychometrically, the phobia avoidance subscale of the AFQ is a reliable measure for use with mTBI populations, although some limitations were found. In particular, the accident profile (AP) subscale was not found to be reliable or valid and could be eliminated from the AFQ. Collectively, the present study contributes to the small body of published literature evaluating accident phobia in patients with mTBI and the impact of pain on the development of postinjury anxiety disorders. (PsycINFO Database Record

Inhibition of motor responses in siblings concordant and discordant for attention deficit hyperactivity disorder.

OBJECTIVE: The authors sought to determine whether nonaffected siblings of ADHD probands have a motor response inhibition deficit and to assess concordance for this inhibition deficit in ADHD-concordant and ADHD-discordant sibling pairs. METHOD: ADHD-concordant pairs (21 probands and their affected siblings), ADHD-discordant pairs (18 probands and their nonaffected siblings), and a group of unrelated, demographically balanced, healthy individuals (N=24) were compared on measures of response inhibition, ADHD behavior, impairment, and environmental risk. RESULTS: Concordant-pair probands, their affected siblings, and discordant-pair probands exhibited inhibitory control impairment relative to healthy comparison subjects. The performance of nonaffected siblings was intermediate between that of ADHD children and the healthy comparison subjects. Group differences persisted after age was controlled, and performance was not correlated with the number of ADHD symptoms. In ADHD-concordant sibling pairs, there was a significant relationship between proband and sibling inhibition deficit. In ADHD-discordant sibling pairs, inhibition deficit was evident in half of the nonaffected siblings of probands with an inhibition deficit. Groups did not differ in exposure to environmental risks. CONCLUSIONS: Impaired inhibitory control aggregates in the family members of individuals with ADHD and may serve as an indicator of genetic vulnerability to the disorder.

The manifestation of anxiety disorders after traumatic brain injury: a review.

The development of anxiety disorders after a traumatic brain injury (TBI) is a strong predictor of social, personal, and work dysfunction; nevertheless, the emergence of anxiety has been largely unexplored and poorly understood in the context of TBI. This article provides an overview of the limited published research to date on anxiety disorders that are known to develop after TBI, including post-traumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, specific phobia, and social anxiety disorder. This review also examines diagnostic criteria, the epidemiology of each disorder, and the factors that influence the expression of these conditions, including injury-related and psychosocial variables. Putative neural correlates will be reviewed where known. A discussion of current treatment options and avenues for further research are explored.

Evidence for an error monitoring deficit in attention deficit hyperactivity disorder.

We studied error monitoring in ADHD and control children in a task requiring inhibition of a motor response. The extent of slowing following successful (stopped) and failed (nonstopped) inhibition was compared across groups. We also measured the time required to inhibit a response (stop signal reaction time, SSRT). Compared to controls, ADHD participants slowed less following nonstopped responses. Slowing did not vary with comorbid reading, oppositional, conduct or anxiety disorder, sex or ADHD subtype. Slowing after nonstopped responses was marginally, although significantly correlated with total ADHD symptoms and with age. ADHD participants had significantly longer SSRT than controls, but SSRT was not significantly correlated with slowing. The apparent deficit in error monitoring in ADHD and its independence from the inhibition deficit observed in ADHD has implications for executive control models of ADHD, performance problems associated with the disorder and for component theories of executive control.

Response inhibition in children with and without ADHD after traumatic brain injury.

Children with attention-deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) show deficient response inhibition. ADHD itself is a common consequence of TBI, known as secondary ADHD (S-ADHD). Similarity in inhibitory control in children with TBI, S-ADHD, and ADHD would implicate impaired frontal-striatal systems; however, it is first necessary to delineate similarities and differences in inhibitory control in these conditions. We compared performance of children with ADHD and those with TBI without pre-injury ADHD on a stop signal, response inhibition task. Participants were 274 children aged 6-14 years. There were 92 children with ADHD, 103 children with TBI, and 79 typically developing children who served as controls. Among the TBI participants, injury severity ranged from mild to severe. Children with ADHD and TBI showed deficient inhibition. The deficit in children with ADHD was as great as or greater than that in children with TBI, regardless of degree of TBI severity or the presence of S-ADHD. The finding indicates that TBI results in deficient inhibition regardless of the development of S-ADHD.

Predictive validity of DSM-IV and ICD-10 criteria for ADHD and hyperkinetic disorder.

BACKGROUND: The goal of this study was to compare the predictive validity of the two main diagnostic schemata for childhood hyperactivity - attention-deficit hyperactivity disorder (ADHD; Diagnostic and Statistical Manual- IV) and hyperkinetic disorder (HKD; International Classification of Diseases- 10th Edition). METHODS: Diagnostic criteria for ADHD and HKD were used to classify 419 children ages 6 to 16 years referred to a clinic for behavioral problems into one of four groups: HKD, ADHD combined subtype (ADHD-C), ADHD hyperactive-impulsive subtype (ADHD-HI), ADHD inattentive subtype (ADHD-IA). These groups were compared on clinical characteristics including total symptom severity, overall impairment, exposure to psychosocial and neuro-developmental risks, family history of ADHD in first-degree family members, rate and type of comorbidity, intelligence, academic achievement, and on laboratory tests of motor response inhibition and working memory with each other and with normal controls (47). RESULTS: Of the 419 cases, there were 46 HKD (11.0%), 200 ADHD-C (47.7%), 60 ADHD-HI (14.3%) and 113 ADHD-IA (27.0%) cases. The HKD group had more symptoms and was more impaired on teachers' ratings than were the other groups. The ADHD-C and HKD groups had poorer inhibitory control than the ADHD-IA, ADHD-HI and control groups, and all four clinic groups showed inhibition deficit compared to controls. Groups did not differ in working memory. Compared to controls, the HKD, ADHD-C, ADHD-HI and ADHD-IA groups had higher familial risk of ADHD, greater psychosocial risk exposure, lower intellectual level and poorer academic attainment. However, we observed no differences among the clinic groups in these characteristics. CONCLUSIONS: Like earlier versions, ICD-10 and DSM-IV continue to delineate diagnostic entities with substantially different prevalence in clinic samples. However, HKD, ADHD-C, ADHD-IA and ADHD-HI groups overlap substantially in terms of important clinical characteristics, although HKD and ADHD-C may be somewhat more severe variants of the condition than ADHD-IA and ADHD-HI.