A Single Error Is One Too Many: The Forced Choice Recognition Trial of the CVLT-II as a Measure of Performance Validity in Adults with TBI.

OBJECTIVE: The Forced Choice Recognition (FCR) trial of the California Verbal Learning Test-Second Edition (CVLT-II) was designed to serve as a performance validity test (PVT). The present study was designed to compare the classification accuracy of a more liberal alternative (≤15) to the de facto FCR cutoff (≤14). METHOD: The classification accuracy of the two cutoffs was computed in reference to psychometrically defined invalid performance, across various criterion measures, in a sample of 104 adults with TBI clinically referred for neuropsychological assessment. RESULTS: The FCR was highly predictive (AUC: .71-.83) of Pass/Fail status on reference PVTs, but unrelated to performance on measures known to be sensitive to TBI. On average, FCR ≤15 correctly identified an additional 6% of invalid response sets compared to FCR ≤14, while maintaining .92 specificity. Patients who failed the FCR reported higher levels of emotional distress. CONCLUSIONS: Results suggest that even a single error on the FCR is a reliable indicator of invalid responding. Further research is needed to investigate the clinical significance of the relationship between failing the FCR and level of self-reported psychiatric symptoms.

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.

Aggregating validity indicators embedded in Conners' CPT-II outperforms individual cutoffs at separating valid from invalid performance in adults with traumatic brain injury.

Continuous performance tests (CPT) provide a useful paradigm to assess vigilance and sustained attention. However, few established methods exist to assess the validity of a given response set. The present study examined embedded validity indicators (EVIs) previously found effective at dissociating valid from invalid performance in relation to well-established performance validity tests in 104 adults with TBI referred for neuropsychological testing. Findings suggest that aggregating EVIs increases their signal detection performance. While individual EVIs performed well at their optimal cutoffs, two specific combinations of these five indicators generally produced the best classification accuracy. A CVI-5A ≥3 had a specificity of .92-.95 and a sensitivity of .45-.54. At ≥4 the CVI-5B had a specificity of .94-.97 and sensitivity of .40-.50. The CVI-5s provide a single numerical summary of the cumulative evidence of invalid performance within the CPT-II. Results support the use of a flexible, multivariate approach to performance validity assessment.

Characteristics of a mild head injury subgroup with extreme, persisting distress on the Rivermead Postconcussion Symptoms questionnaire.

UNLABELLED: Kirsch NL, de Leon MB, Maio RF, Millis SR, Tan-Schriner CU, Frederiksen S. Characteristics of a mild head injury subgroup with extreme, persisting distress on the Rivermead Postconcussion Symptoms Questionnaire. OBJECTIVE: To examine baseline variables and identify characteristics of participants with extremely high reports of symptoms (ie, outliers) 12 months after mild head injury (MHI). DESIGN: A prospective cohort study of MHI with and without loss of consciousness (LOC) and/or posttraumatic amnesia (PTA) recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months. SETTING: Level II community hospital ED. PARTICIPANTS: Participants (n=58) with MHI and LOC less than or equal to 30 minutes and/or PTA less than 24 hours and participants (n=173) with MHI but no PTA/LOC. INCLUSION CRITERIA: age greater than or equal to 18 years, less than or equal to 24 hours after injury, Glasgow Coma Scale score greater than or equal to 13, and discharge from the ED. Fourteen (6%) participants had extremely high scores on the Rivermead Postconcussion Symptoms Questionnaire (RPQ). MAIN OUTCOME MEASURES: RPQ and questions on health services use and litigation. RESULTS: Characterizing the outlier cases are prior head injury, preinjury disability, history of substance use, unemployment, and elevated somatic symptoms at the ED. At 12 months, outliers had higher use of health services and litigation. CONCLUSIONS: The existence of a subgroup with a distinctive pattern of baseline characteristics in combination with elevated somatic symptoms at the time of presentation to the ED suggests that further taxonomic distinctions may be warranted for the MHI population, each requiring appropriately targeted interventions for addressing symptomatic complaints.

Evaluating a clinical measure of reaction time: an observational study.

The present study was an initial evaluation into the reliability and validity of a novel clinical measure of reaction time that consists of a vertical cylinder that is released and caught as quickly as possible. 65 healthy adults performed clinical and computerized reaction time tasks (RT(clin) and RT(comp)) under simple and dual-task conditions. RT(clin) demonstrated excellent test-retest and interrater reliabilities and was significantly correlated with the criterion standard RT(comp). RT(clin) increased with increasing age and when tested under dual-task conditions. These preliminary results suggest that RT(clin) is a reliable and valid measure of reaction time.

Baseline predictors of fatigue 1 year after mild head injury.

OBJECTIVE: To compare reports of fatigue 12 months after minor trauma by participants with mild head injury (MHI) with those with other injury, and identify injury and baseline predictors of fatigue. DESIGN: An inception cohort study of participants with MHI and other nonhead injuries recruited from and interviewed at the emergency department (ED), with a follow-up telephone interview at 12 months. SETTING: Level II community hospital ED. PARTICIPANTS: Participants (n=58) with MHI and loss of consciousness (LOC) of 30 minutes or less and/or posttraumatic amnesia (PTA) less than 24 hours, 173 with MHI but no PTA/LOC, and 128 with other mild nonhead injuries. INCLUSION CRITERIA: age 18 years or older, within 24 hours of injury, Glasgow Coma Scale score of 13 or higher, and discharge from the ED. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Medical Outcomes Study 36-Item Short-Form Health Survey Vitality subscale. RESULTS: Significant predictors of fatigue severity at 12 months were baseline fatigue, having seen a counselor for a mental health issue, medical disability, marital status, and in some stage of litigation. Injury type was not a significant predictor. CONCLUSIONS: Fatigue severity 12 months after injury is associated with baseline characteristics and not MHI. Clinicians should be cautious about attributing persisting fatigue to MHI without comprehensive consideration of other possible etiologic factors.

Health status, not head injury, predicts concussion symptoms after minor injury.

OBJECTIVE: Postconcussion (PC) syndrome etiology remains poorly understood. We sought to examine predictors of persistent PC symptoms after minor injury. METHODS: Health status, symptom, and injury information were obtained on a sample of patients presenting to the emergency department after minor injury. Postconcussion and cognitive symptoms were assessed at 1, 3, and 12 months. RESULTS: Among 507 patients enrolled, 339 had head injury. Repeated-measures logistic regression modeling of PC and cognitive symptom presence across time indicated that baseline mental health status and physical health status were most predictive of persistent symptoms. In contrast, head injury presence did not predict persistent PC syndrome. DISCUSSION: Baseline mental health status and physical health status were associated with persistent PC syndrome after minor injury, but head injury status was not. Further studies of PC syndrome pathogenesis are needed.

Distributed cognitive aid with scheduling and interactive task guidance.

A cognitive assistive technology system has been designed for use by people with memory and organizational impairments. This system will provide a distributed architecture for both scheduling assistance and task guidance, as well as intelligent, automatic replanning on the levels of both the schedule and individual tasks. A prototype of this architecture has been developed that focuses on interactive task guidance capabilities. Scheduling software has been developed but not fully integrated with the task guidance features. The system has been preliminarily tested through simulated trials, monitored use of the prototype in a clinical setting, and usability trials of the task-design interface with rehabilitation professionals. Participants were able to respond appropriately to cues provided by the system and complete prescribed tasks.

Chronic stress, salivary cortisol response, interpersonal relatedness, and depression among community-dwelling survivors of traumatic brain injury.

Depression is a common mood disorder after traumatic brain injury (TBI). Largely, study of this phenomenon is theoretical and without biological measures. This explanatory study, guided by McEwen's allostasis model of stress, examined relationships among chronic stress, salivary cortisol profiles, post-injury depression, and interpersonal relatedness. Seventy-five participants, who were or had participated in outpatient brain injury rehabilitation therapies and experienced mild-to-moderate levels of brain injury, were recruited for this cross-sectional study. Salivary cortisol levels showed the usual patterns of circadian rhythmicity, and those with milder injuries had higher 8 am cortisol levels. Salivary cortisol values were not related to measures of chronic stress, interpersonal relatedness, or depression with two exceptions. The 8 am and noon mean values were significantly greater for those who reported more pre-injury childhood adversity, while the 8 pm cortisol mean level was associated with the frequency of pre-injury stressful life events. For this outpatient sample, salivary cortisol levels do not appear to be elevated after TBI or to lack circadian rhythmicity as previously reported. There may be some value in using this measure as a correlate with persons treated in specialized TBI clinics who report pre-injury chronic stress, but future studies are needed with TBI persons who were not treated in specialized clinics or were not taking medications known to influence the hypothalamic-pituitary-adrenal axis.

An assistive-technology intervention for verbose speech after traumatic brain injury: a single case study.

OBJECTIVE: To assess an assistive-technology intervention for neurobehavioral change, coordinated with a Web-based data recording system. PARTICIPANT: Male, mid-thirties, with a complex history, having verbose speech subsequent to traumatic brain injury. DESIGN: BAB' single-case. INTERVENTION AND MEASURES: The intervention (B and B' trials) was a digital recording of the participant's voice, stating "be brief," delivered at fixed intervals by a personal digital assistant. Utterance start and stop times were monitored with a wireless, Web-enabled device and were recorded in a server-side database. RESULTS: Utterance frequency did not change. However, the total utterance time was reduced during B trials, attributable to the reduced frequency of lengthier utterances. CONCLUSIONS: The target behavior was modified successfully. The participant adopted a specific cue-appropriate strategy. Since a variety of alternative response strategies may be required of a person, given a range of context-specific social practices and community settings, the importance of context-sensitive assistive technology cue repertoires is discussed.

Chronic stress conditions do explain posttraumatic brain injury depression.

Psychosocial and biologic mechanisms are implicated in depression after traumatic brain injury (TBI). Using McEwen's stress theory of allostasis as a guidepost, this study examined whether pre- and postinjury chronic stress conditions could explain post-TBI depressive symptoms. Seventy-five community-dwelling persons who sustained a mild-to-moderate TBI and were within 2 years of the injury participated in this cross-sectional study. The participants completed measures of chronic stress and depression, measured with the Neurobehavioral Functioning Inventory. Data were collected also on brain injury severity. Using multiple regression analysis, the frequency of childhood adversities and postinjury stress explained post-TBI depression. When time-since-injury was in the regression model, the frequency of preinjury stressors and postinjury stress significantly explained post-TBI depressive symptoms while the combined effect of childhood adversity with postinjury stress was not significant in explaining depressive symptoms. Pre- and postinjury chronic stress explained post-TBI depressive symptoms. These findings support stress-diathesis theory within the psychiatric literature and a linkage between chronic stress, an indicator of allostatic load, and post-TBI depression. These findings are important for nurse specialists working with persons who sustained brain injury, for chronic stress can be buffered by efficient and effective support systems.

A generic, 'in-house', alphanumeric paging system for prospective activity impairments after traumatic brain injury.

OBJECTIVE: For settings having suitable infrastructure, generic, 'in-house' alphanumeric paging systems can be constructed that are fully under clinician control. Development of such a system for therapeutic application is described and a single-case study presented that assessed whether the system could improve repetitive, prospective use of a daily planner. DESIGN: ABA' single case. METHODS: The participant was male, in his mid-30s, having cognitive impairments subsequent to recent TBI superimposed on remote neurological changes. The pager reminded him to record therapeutic information in a daily planner, for discussion with a family member each evening. RESULTS: During intervention (B) trials, reliable memory log usage was noted. By trial five of return-to-baseline (A') trials, there was decreased memory log use. CONCLUSIONS: Alphanumeric paging facilitated reliable use of a memory log compensation technique. The 'in-house' paging system proved particularly suitable for intervention development. Limits of the study are discussed and other therapeutically useful wireless technologies are noted.

Chronic stress, sense of belonging, and depression among survivors of traumatic brain injury.

PURPOSE: To test whether chronic stress, interpersonal relatedness, and cognitive burden could explain depression after traumatic brain injury (TBI). DESIGN: A nonprobability sample of 75 mild-to-moderately injured TBI survivors and their significant others, were recruited from five TBI day-rehabilitation programs. All participants were within 2 years of the date of injury and were living in the community. METHODS: During face-to-face interviews, demographic information, and estimates of brain injury severity were obtained and participants completed a cognitive battery of tests of directed attention and short-term memory, responses to the Perceived Stress Scale, Interpersonal Relatedness Inventory, Sense of Belonging Instrument, Neurobehavioral Functioning Inventory, and Center for Epidemiological Studies Depression Scale;. FINDINGS: Chronic stress was significantly and positively related to post-TBI depression. Depression and postinjury sense of belonging were negatively related. Social support and results from the cognitive battery did not explain depression. CONCLUSIONS: Postinjury chronic stress and sense of belonging were strong predictors of postinjury depression and are variables amenable to interventions by nurses in community health, neurological centers, or rehabilitation clinics. Future studies are needed to examine how these variables change over time during the recovery process.