Behavior problems in children at time of first recognized seizure and changes over the following 3 years.

OBJECTIVES: The purposes of this 36-month study of children with first recognized seizures were: (1) to describe baseline differences in behavior problems between children with and without prior unrecognized seizures; (2) to identify differences over time in behavior problems between children with seizures and their healthy siblings; (3) to identify the proportions of children with seizures and healthy siblings who were consistently at risk for behavior problems for 36 months; and (4) to identify risk factors for behavior problems 36 months following the first recognized seizure. Risk factors explored included demographic (child age and gender, caregiver education), neuropsychological (IQ, processing speed), seizure (epileptic syndrome, use of antiepileptic drug, seizure recurrence), and family (family mastery, satisfaction with family relationships, parent response) variables. METHODS: Participants were 300 children aged 6 through 14 years with a first recognized seizure and 196 healthy siblings. Data were collected from medical records, structured interviews, self-report questionnaires, and neuropsychological testing. Behavior problems were measured using the Child Behavior Checklist and the Teacher's Report Form. Data analyses included descriptive statistics and linear mixed models. RESULTS: Children with prior unrecognized seizures were at higher risk for behavior problems at baseline. As a group, children with seizures showed a steady reduction in behavior problems over time. Children with seizures were found to have significantly more behavior problems than their siblings over time, and significantly more children with seizures (11.3%) than siblings (4.6%) had consistent behavior problems over time. Key risk factors for child behavior problems based on both caregivers and teachers were: less caregiver education, slower initial processing speed, slowing of processing speed over the first 36 months, and a number of family variables including lower levels of family mastery or child satisfaction with family relationships, lower parent support of the child's autonomy, and lower parent confidence in their ability to discipline their child. CONCLUSIONS: Children with new-onset seizures who are otherwise developing normally have higher rates of behavior problems than their healthy siblings; however, behavior problems are not consistently in the at-risk range in most children during the first 3 years after seizure onset. When children show behavior problems, family variables that might be targeted include family mastery, parent support of child autonomy, and parents' confidence in their ability to handle their children's behavior.

Academic problems in children with seizures: relationships with neuropsychological functioning and family variables during the 3 years after onset.

OBJECTIVES: Children with long-standing epilepsy have a significantly increased risk of academic underachievement compared with healthy controls. We prospectively followed children from seizure onset to assess the relationship between change in neuropsychological functioning and change in academic achievement and to explore the risk and protective moderating effects of demographic, seizure, and family variables. METHODS: As part of a larger study, neuropsychological and academic data were collected at both baseline and 36 months for 219 children 6-14 years of age with seizures. Prior factor analysis of results from a battery of well-standardized neuropsychological tests yielded four factors: language, processing speed, attention/executive/construction, and verbal memory/learning. Academic achievement was measured with the Woodcock-Johnson Revised Achievement Test Battery. Correlation coefficients and linear mixed models were used for analysis. RESULTS: The reading and math scores of children with seizures and siblings did not differ at baseline, but children with seizures had lower scores than siblings at 36 months. Writing scores were significantly lower for affected children than siblings at both times. Among children with seizures, there were positive correlations between neuropsychological functioning and academic achievement at baseline and 36 months. Changes in language and in verbal memory/learning were positively correlated with change in reading achievement (r = 0.25 and r = 0.17, respectively). Age at onset moderated the association between change in neuropsychological functioning and change in reading and writing achievement (P ≤ 0.006), with stronger relationships among younger children (ß = 0.25-0.44). The association between change in language and change in writing achievement was moderated by caregiver anxiety (P = 0.04; stronger for more anxious parents, ß = 0.40), and the association between change in processing speed and change in math achievement was moderated by etiology (P = 0.02; stronger for symptomatic/cryptogenic vs idiopathic, ß = 0.29). Gender and other family variables did not have significant moderating effects. CONCLUSIONS: Changes in neuropsychological function were associated with changes in academic achievement following onset of seizures, with risk factors being younger age at onset, lower caregiver education, high parental anxiety, and symptomatic/cryptogenic etiology. Academic performance should be closely monitored in children with early-onset seizures.

Neuropsychological status at seizure onset in children: risk factors for early cognitive deficits.

OBJECTIVE: This large, prospective, community-based study characterized neuropsychological functioning and academic achievement at the time of the first recognized seizure and identified risk factors for cognitive deficits. METHODS: We compared 282 children (ages 6-14 years, IQ > or =70) with a first recognized seizure to 147 healthy siblings on a battery of well-standardized and widely used neuropsychological and academic achievement tests and examined relationships with demographic and clinical variables. RESULTS: In this intellectually normal cohort, 27% with just one seizure and up to 40% of those with risk factors exhibited neuropsychological deficits at or near onset. Risk factors associated with neuropsychological deficits included multiple seizures (i.e., second unprovoked seizure; odds ratio [OR] = 1.96), use of antiepileptic drugs (OR = 2.27), symptomatic/cryptogenic etiology (OR = 2.15), and epileptiform activity on the initial EEG (OR = 1.90); a child with all 4 risks is 3.00 times more likely than healthy siblings to experience neuropsychological deficits by the first clinic visit. Absence epilepsy carried increased odds for neuropsychological impairment (OR = 2.00). CONCLUSIONS: A subgroup of intellectually normal children with seizures showed neuropsychological deficits at onset. Academic achievement was unaffected, suggesting that there is a window early in the disorder for intervention to ameliorate the impact on school performance. Therefore, the risk factors identified here (especially if multiple risks are present) warrant swift referral for neuropsychological evaluation early in the course of the condition.

A study of persistent post-concussion symptoms in mild head trauma using positron emission tomography.

BACKGROUND: Complaints of persistent cognitive deficits following mild head trauma are often uncorroborated by structural brain imaging and neuropsychological examination. OBJECTIVE: To investigate, using positron emission tomography (PET), the in vivo changes in regional cerebral uptake of 2-[(18)F]fluoro-2-deoxy-D-glucose (FDG) and regional cerebral blood flow (rCBF) in patients with persistent symptoms following mild head trauma. METHODS: Five patients with mild head trauma and five age and education matched healthy controls were imaged using FDG-PET to measure differences in resting regional cerebral glucose metabolism. Oxygen-15 labelled water (H(2)(15)O)-PET was also used to measure group differences in rCBF changes during a spatial working memory task. In addition, neuropsychological testing and self report of dysexecutive function and post-concussion symptoms were acquired to characterise the sample. RESULTS: There was no difference between patients and controls in normalised regional cerebral FDG uptake in the resting state in frontal and temporal regions selected a priori. However, during the spatial working memory task, patients had a smaller increase in rCBF than controls in the right prefrontal cortex. CONCLUSIONS: Persistent post-concussive symptoms may not be associated with resting state hypometabolism. A cognitive challenge may be necessary to detect cerebral changes associated with mild head trauma.

Self-Appraisal of Illness Questionnaire (SAIQ): relationship to researcher-rated insight and neuropsychological function in schizophrenia.

The Self-Appraisal of Illness Questionnaire (SAIQ) is a self-report instrument designed to assess attitudes toward mental illness among persons receiving psychiatric treatment. This instrument was developed for use in community settings, adapted closely from the Patient's Experience of Hospitalization questionnaire. In order to examine the validity of the SAIQ, a factor analysis was first conducted on the items of this instrument in a sample of 59 outpatients with schizophrenia or schizoaffective illness. Three factors emerged: Need for Treatment, Worry, and Presence/Outcome of Illness. Next, to examine the concurrent validity of these three SAIQ subscales, they were correlated with researcher rated insight scales and neuropsychological tests. Results indicated that the Need for Treatment and Presence/Outcome subscales were significantly correlated with both researcher-rated insight scales and with neuropsychological tests of executive functioning. The Worry subscale was not associated with either researcher-rated insight scales or neuropsychological tests. It was concluded that the Need for Treatment and Presence/Outcome subscales may be used in combination as a brief screening instrument for clients with schizophrenia receiving outpatient psychiatric treatment who may be at risk for treatment non-compliance due to a lack of insight into illness.

Obsessive and compulsive symptoms in schizophrenia: clinical and neurocognitive correlates.

Although research suggests that the presence of obsessive and compulsive symptoms in schizophrenia is associated with graver levels of psychosocial dysfunction, it is unclear whether it is also related to clinical features of illness. Accordingly, the present study compared the symptom levels and neurocognitive function of participants with schizophrenia who had and did not have significant obsessive or compulsive symptoms. Analyses of variance revealed that participants with significant levels of either obsessive or compulsive symptoms (N = 21) had higher levels of positive and emotional discomfort symptoms on the Positive and Negative Syndrome Scale (PANSS) and performed more poorly on the Wisconsin Card Sorting Test, a measure of executive function, than participants without obsessions or compulsions (N = 25). ANCOVAs controlling for level of obsessions also revealed that participants with significant levels of compulsions (N = 12) in particular had higher levels of negative and positive symptoms on the PANSS than participants without compulsions (N = 34). The impact of obsessive-compulsive phenomena on the course and outcome of schizophrenia is discussed.

Modality specificity of memory span tasks among Zaïrian children: A developmental perspective.

Digit span (DS) and visual memory span (VMS) tasks have been shown to be distinct in young children but fail to show modality specificity in older American children and adults (Fastenau, Conant, & Lauer, 1997, 1998). The present study examines the possibility that processing of VMS becomes automatized with written language training. In a sample of 139 Zaïrian children, separate factor analyses on K-ABC data for younger children (6.1-8.5 years) and older children (8.6-12.8 years) yielded two-factor solutions in both cases, which appear to represent verbal and visual-spatial abilities. Modality specificity of the visual span task is supported in both age groups. Findings of modality specificity in both Zaïrian age groups provides support for the theoretical distinction between verbal and visual memory span. Continued modality specificity of visual memory span tasks in older Zaïrian children suggests that the increased verbal loadings of these tasks seen for older American children may reflect differences in written language development.

Adult norms for the Rey-Osterrieth Complex Figure Test and for supplemental recognition and matching trials from the Extended Complex Figure Test.

The Rey-Osterrieth Complex Figure Test ("the Rey"; Osterrieth, 1944; Rey, 1941) has accumulated a considerable literature as a test of visual-spatial perception/construction and memory. The Extended Complex Figure Test (ECFT; Fastenau, 1996a, in press-a; Fastenau & Manning, 1992) supplements the Rey with Recognition and Matching trials that follow Copy, Immediate Recall, and Delayed Recall. The Rey and ECFT were administered to 211 healthy adults. Age ranged from 30 years to 85 years (M = 62.9, SD = 14.2), education ranged from 12 years to 25 years (M = 14.9, SD = 2.6), 55% were women, and over 95% were Caucasian. Age and education effects were evident on all trials (Multiple R ranged .23 to .50, p < .05), but education explained minimal variance (usually 2-3%) on copy and memory trials. Gender effects were negligible, if present. Age-appropriate norms are presented using Osterrieth's 36-point scoring, overlapping cells, and convenient tables for converting raw scores to scaled scores.

Working memory in young children: evidence for modality-specificity and implications for cerebral reorganization in early childhood.

Digit span (DS) and visual-spatial memory span (VMS) tasks have been considered indices of auditory and visual spatial processing, respectively, often classified as "primary memory" or "attention". There has been limited evidence for their modality specificity, however. We present two children who showed visual spatial processing deficiencies (including VMS) and non-dominant manual inefficiency with normal visual-spatial perception, auditory-verbal processing and dominant fine manual skills. These children support a distinction between auditory and visual-spatial memory span. These findings are discussed with regard to a hypothesis that the unique expression of VMS is time-limited, that visual-spatial processing becomes more verbalized as children learn to read and that these behavioral changes produce a lateral shift in cortical processing of visual spatial information.

Parallel short forms for the Boston Naming Test: psychometric properties and norms for older adults.

Four 15-item and two 30-item short forms for the Boston Naming Test were validated using 108 non-neurological community-dwelling adults, ages 57-85. All forms were administered to all participants (counterbalanced), with no effect of administration sequence on any score. An age effect emerged (Multiple R = .28, p< or =.01). No effects for education or gender were found, nor were there any interactions (p> or = .10). Descriptive data are stratified by age group. Reliability and validity for each form were demonstrated in several ways. These short forms should be very useful as screening instruments and/or as alternate forms for the BNT in test-retest clinical protocols, pre-post experimental designs, and longitudinal research.

Validity of regression-based norms: an empirical test of the comprehensive norms with older adults.

This study empirically tested Fastenau and Adams' (1996) concerns about using regression-based norms (RBN) to statistically correct for demographic influences. A widely used RBN system (Heaton, Grant, & Matthews, 1991) was applied to scores from 63 healthy older adults for the Trail Making Test, Boston Naming Test, and Wisconsin Card Sorting Test (WCST). Age influences on all tests were virtually eliminated by the RBNs, whereas education influences were created by the RBN (better educated older adults penalized by the norms). Using RBNs from the Revised WCST Manual also created distortions, far overcorrecting for age. These findings cast considerable suspicion on norms that are generated by statistical regression when there are not adequate numbers of people supporting each demographic cell. Clinically, these norms can lead to higher rates of false negatives (or missed diagnoses) in older adults, especially those with less education and especially women in their 60s.

Use of the odds ratio to translate neuropsychological test scores into real-world outcomes: from statistical significance to clinical significance.

Standard parametric tests generate p values and effect sizes, but often these are difficult to translate into real-world outcomes. In this study, the odds ratio was applied to neuropsychological testing and was compared to parametric approaches. Participants were 26 community-dwelling adults with possible or probable Alzheimer's disease and 25 matched healthy community-dwelling volunteers. Odds ratios were computed to estimate the probability of concurrent diagnosis given neuropsychological performance level. Odds ratios discriminated the groups at magnitudes that could not be discerned from t-test significance tables. These values were compared to sensitivity, specificity, and overall accuracy. Clinical and research applications and implications were addressed.

Application of psychometric standards to scoring system evaluation: is "new" necessarily "improved"?

Psychometric guidelines are suggested that expand the evaluation of scoring systems beyond the most frequently (and often singly) considered criterion, that of interrater reliability. Principles of reliability and validity are elaborated and discussed with regard to scoring systems. Also addressed are assays for efficiency in applying a new system, the effects of rater proficiency on outcome scores, the comparison of costs and benefits of new scoring systems, and the comparison of a new scoring system to an existing system to demonstrate its advantage. As a timely example to illustrate these principles, a new scoring system is introduced for the Rey-Osterrieth Complex Figure Test and is compared to the most popular scoring system for this test (Lezak, 1983, p. 400). The proposed principles would be relevant to any scoring system that codes subjective behavioral data into objective values.

Age differences in retrieval: further support for the resource-reduction hypothesis.

Age differences in processing resources seem salient to age-related declines in secondary (or "recent") memory. Community-dwelling adults (N = 90, ages 30-80) completed 4 memory tests: Wechsler Memory Scale-Revised (WMS-R) Logical Memory (LM), Cowboy Story (CS), WMS-R Visual Reproductions (VR), and Extended Complex Figure Test (ECFT; Fastenau, in press). Two space-capacity measures (WMS-R Digit Span and Visual Memory Span) and 4 processing speed measures (cancellation and mental-tracking tasks) assessed processing resources. A statistical control procedure was used to isolate retrieval efficiency and measures contributions of age and processing resources to retrieval. A negative relationship between age and retrieval efficiency emerged on all measures (p < .05). The age effect was reduced 60% on LM and CS when processing resources were controlled, eliminated for VR, and unchanged on ECFT. It is possible that visual-spatial retrieval requires fewer processing resources than does verbal retrieval.

Development and preliminary standardization of the "extended complex figure test" (ECFT).

Recognition and matching trials were designed for the Rey-Osterrieth Complex Figure Test (ROCFT). Following pilot testing and expert review, they were standardized using 90 community-dwelling adults (58% female, ages 30 to 88). Recognition has 30 multiple-choice items for different figural elements; scores distributed normally with strong item-total correlations and with normally distributed item difficulties. Cronbach alphas were .84,.61, and .81 for the Total, Global, and Detail Scales. Recognition correlated .81 with ROCFT recall and .65 with Visual Reproductions. Matching has 10 multiple-choice items; scores were negatively skewed with a substantial ceiling effect. Alpha for Matching was .58, limited in part by few items. Matching correlated .68 with Judgment of Line Orientation and .74 to .90 with copy trials. Both Recognition and Matching discriminated 34 patients with intractable epilepsy from 34 matched controls. Overall, Recognition appeared to be reliable and showed evidence of validity. By comparison, Matching reliability and validity were less impressive and warrant further examination.

Development and validation of an instrument to measure occupational stress in speech-language pathologists.

The Speech-Language Pathologist Stress Inventory (SLPSI) is a 48-item questionnaire adapted from the Teacher Stress Inventory (Fimian, 1988). Factor analyses of the responses of 626 speech-language pathologists revealed four stress source factors (Bureaucratic Restrictions, Time and Workload Management, Lack of Professional Supports, and Instructional Limitations) and two stress manifestation factors (Emotional-Fatigue Manifestations and Biobehavioral Manifestations). The internal consistency reliability of scales based on these factors ranged from .71 to .87, with .93 for the entire scale. Evidence for construct validity was found in moderate positive correlations between the scales of the SLPSI and the scales of the Maslach Burnout Inventory (MBI) (Maslach & Jackson, 1986). Stress and burnout subscale intercorrelations ranged from .10 to .82 (p less than .01), and the correlation between stress strength and burnout frequency was .66 (p less than .001).