Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): results from a randomised controlled pilot feasibility trial for low mood in acquired brain injury.

BACKGROUND: Acquired brain injury (ABI) is linked to increased depression risk. Existing therapies for depression in ABI (e.g., cognitive behavioural therapy) have mixed efficacy. Behavioural activation (BA), an intervention that encourages engaging in positively reinforcing activities, shows promise. The primary aims were to assess feasibility, acceptability, and potential efficacy of two 8-week BA groups. METHODS: Adults (≥ 18 years) recruited from local ABI services, charities, and self-referral via social media were randomised to condition. The Activity Planning group (AP; "traditional" BA) trained participants to plan reinforcing activities over 8 weeks. The Activity Engagement group (AE; "experiential" BA) encouraged engagement in positive activities within session only. Both BA groups were compared to an 8-week Waitlist group (WL). The primary outcomes, feasibility and acceptability, were assessed via recruitment, retention, attendance, and qualitative feedback on groups. The secondary outcome, potential efficacy, was assessed via blinded assessments of self-reported activity levels, depression, and anxiety (at pre- and post-intervention and 1 month follow-up) and were compared across trial arms. Data were collected in-person and remotely due to COVID-19. RESULTS: N = 60 participants were randomised to AP (randomised n = 22; total n = 29), AE (randomised n = 22; total n = 28), or re-randomised following WL (total n = 16). Whether in-person or remote, AP and AE were rated as similarly enjoyable and helpful. In exploring efficacy, 58.33% of AP members had clinically meaningful activity level improvements, relative to 50% AE and 38.5% WL. Both AP and AE groups had depression reductions relative to WL, but only AP participants demonstrated anxiety reductions relative to AE and WL. AP participants noted benefits of learning strategies to increase activities and learning from other group members. AE participants valued social discussion and choice in selecting in-session activities. CONCLUSIONS: Both in-person and remote group BA were feasible and acceptable in ABI. Though both traditional and experiential BA may be effective, these may have different mechanisms. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03874650. Protocol version 2.3, May 26 2020.

Developing behavioural activation for people with acquired brain injury: a qualitative interpretive description study of barriers and facilitators to activity engagement.

BACKGROUND: Acquired brain injuries (ABI) from stroke, head injury, or resected brain tumours are associated with poor emotional wellbeing and heightened risk of mood disorder. Common sequalae of ABI, such as poor attention and memory, can create barriers to the efficacy of cognitively demanding mood interventions, such as Cognitive Behavioural Therapy (CBT). Behavioural Activation (BA), where individuals plan and engage in reinforcing activities, is a promising alternative due to lower cognitive demands. However, BA was initially developed in clinical populations without ABI where the primary barriers to activity engagement were low mood and anxious avoidance. Additionally, BA can incorporate a range of techniques (e.g., mood monitoring, activity scheduling, targeting avoidance, contingency management) and psychoeducational topics (e.g., mindfulness, managing uncertainty; social/communication skills). Exploring barriers and facilitators to adopting specific BA components in ABI is an important aim. METHODS: Semi-structured interviews were conducted with purposively selected ABI survivors (N = 16) with both low and high depressive symptoms, and family members (N = 7). Questions focused on routine and enjoyable activities, and feedback on 10 different BA techniques and associated psychoeducational topics. Transcripts were analysed using an interpretive description framework. Analysis was informed by field notes, reflexivity diaries, and peer debriefing. RESULTS: The final constructed framework, Creating Sustainable Engagement, comprises a two-tier hierarchy. Higher-level themes concerned core perspectives of BA, regardless of BA component discussed. This included identifying optimal time windows for different BA components (Right Tool at the Right Time), that BA components should, at least initially, not be burdensome or fatiguing (Perceived Effort), that emotional readiness to confront activity-mood relationships should be addressed (Emotional Impact), and that planned BA activities be consistent with individual values (Relation to Values). Lower-level themes concerned specific BA components: Of these, activity scheduling, procedures targeting avoidance, managing uncertainty and social/communication skills were generally well-received, while mood monitoring, contingency management, and mindfulness had mixed feedback. CONCLUSIONS: BA is a widely scalable intervention that can be adapted for ABI. This study provides a novel framework on implementing a range of BA components in ABI and adds to the limited evidence on which components may be particularly suitable.

Measuring Intolerance of Uncertainty After Acquired Brain Injury: Factor Structure, Reliability, and Validity of the Intolerance of Uncertainty Scale-12.

Intolerance of uncertainty (IU) is a risk factor for poor mental health. Acquired brain injury (ABI; for example, stroke, traumatic brain injury) often brings considerable uncertainty and increased mood disorder vulnerability. The Intolerance of Uncertainty Scale-Short Form (IUS-12) is a brief, well-validated IU measure in non-ABI samples, comprising two subscales, namely, Prospective Anxiety and Inhibitory Anxiety. Here, for the first time, we investigated its reliability and validity (N = 118), and factor structure (N = 176), in ABI. Both subscales had high test-retest reliability (intraclass correlation coefficients [ICCs] of .75 and .86) and were significantly associated with mood disorder symptoms. The two-factor model was superior to a one-factor IU model fit. Some fit statistics were less than optimal (standardized root mean square residual [SRMR] = 0.06, root mean square error of approximation [RMSEA] = 0.09); hence, exploration of other factor structures in other ABI samples may be warranted. Nonetheless, the IUS-12 appears suitable in ABI.

Chunking of Control: An Unrecognized Aspect of Cognitive Resource Limits.

Why do we divide ('chunk') long tasks into a series of shorter subtasks? A popular view is that limits in working memory (WM) prevent us from simultaneously maintaining all task relevant information in mind. We therefore chunk the task into smaller units so that we only maintain information in WM that is relevant to the current unit. In contrast to this view, we show that long tasks that are not constrained by WM limits are nonetheless chunked into smaller units. Participants executed long sequences of standalone but demanding trials that were not linked to any WM representation and whose execution was not constrained by how much information could be simultaneously held in WM. Using signs well-known to reflect beginning of new task units, we show that such trial sequences were not executed as a single task unit but were spontaneously chunked and executed as series smaller units. We also found that sequences made of easier trials were executed as longer task units and vice-versa, further suggesting that the length of task executed as one unit may be constrained by cognitive limits other than WM. Cognitive limits are typically seen to constrain how many things can be done simultaneously e.g., how many events can be maintained in WM or attended at the same time. We show a new aspect of these limits that constrains the length of behaviour that can be executed sequentially as a single task-unit.

A Prospective Study of Longitudinal Risks of Cognitive Deficit for People Undergoing Glioblastoma Surgery Using a Tablet Computer Cognition Testing Battery: Towards Personalized Understanding of Risks to Cognitive Function.

Glioblastoma and the surgery to remove it pose high risks to the cognitive function of patients. Little reliable data exist about these risks, especially postoperatively before radiotherapy. We hypothesized that cognitive deficit risks detected before surgery will be exacerbated by surgery in patients with glioblastoma undergoing maximal treatment regimens. We used longitudinal electronic cognitive testing perioperatively to perform a prospective, longitudinal, observational study of 49 participants with glioblastoma undergoing surgery. Before surgery (A1), the participant risk of deficit in 5/6 cognitive domains was increased compared to normative data. Of these, the risks to Attention (OR = 31.19), Memory (OR = 97.38), and Perception (OR = 213.75) were markedly increased. These risks significantly increased in the early period after surgery (A2) when patients were discharged home or seen in the clinic to discuss histology results. For participants tested at 4-6 weeks after surgery (A3) before starting radiotherapy, there was evidence of risk reduction towards A1. The observed risks of cognitive deficit were independent of patient-specific, tumour-specific, and surgery-specific co-variates. These results reveal a timeframe of natural recovery in the first 4-6 weeks after surgery based on personalized deficit profiles for each participant. Future research in this period could investigate personalized rehabilitation tools to aid the recovery process found.

Assessment of neuropsychological function in brain tumor treatment: a comparison of traditional neuropsychological assessment with app-based cognitive screening.

BACKGROUND: Gliomas are typically considered to cause relatively few neurological impairments. However, cognitive difficulties can arise, for example during treatment, with potential detrimental effects on quality of life. Accurate, reproducible, and accessible cognitive assessment is therefore vital in understanding the effects of both tumor and treatments. Our aim is to compare traditional neuropsychological assessment with an app-based cognitive screening tool in patients with glioma before and after surgical resection. Our hypotheses were that cognitive impairments would be apparent, even in a young and high functioning cohort, and that app-based cognitive screening would complement traditional neuropsychological assessment. METHODS: Seventeen patients with diffuse gliomas completed a traditional neuropsychological assessment and an app-based touchscreen tablet assessment pre- and post-operatively. The app assessment was also conducted at 3- and 12-month follow-up. Impairment rates, mean performance, and pre- and post-operative changes were compared using standardized Z-scores. RESULTS: Approximately 2-3 h of traditional assessment indicated an average of 2.88 cognitive impairments per patient, while the 30-min screen indicated 1.18. As might be expected, traditional assessment using multiple items across the difficulty range proved more sensitive than brief screening measures in areas such as memory and attention. However, the capacity of the screening app to capture reaction times enhanced its sensitivity, relative to traditional assessment, in the area of non-verbal function. Where there was overlap between the two assessments, for example digit span tasks, the results were broadly equivalent. CONCLUSIONS: Cognitive impairments were common in this sample and app-based screening complemented traditional neuropsychological assessment. Implications for clinical assessment and follow-up are discussed.

A randomized control trial of the effects of home-based online attention training and working memory training on cognition and everyday function in a community stroke sample.

Cognitive difficulties are common following stroke and can have widespread impacts on everyday functioning. Technological advances offer the possibility of individualized cognitive training for patients at home, potentially providing a low-cost, low-intensity adjunct to rehabilitation services. Using this approach, we have previously demonstrated post-training improvements in attention and everyday functioning in fronto-parietal stroke patients. Here we examine whether these benefits are observed more broadly in a community stroke sample. Eighty patients were randomized to either 4 weeks of online adaptive attention training (SAT), working memory training (WMT) or waitlist (WL). Cognitive and everyday function measures were collected before and after the intervention, and after 3 months. During training, weekly measures of patients' subjective functioning were collected. The training was well received and compliance good. No differences in our primary end-point, spatial bias, or other cognitive functions were observed. However, on patient-reported outcomes, SAT participants showed greater levels of improvement in everyday functioning than WMT or WL participants. In line with our previous work, everyday functioning improvements were greatest for patients with spatial impairments and those who received SAT training. Whether attention training can be recommended for stroke survivors depends on whether cognitive test performance or everyday functioning is considered more relevant.

Brain imaging of executive function with the computerised multiple elements test.

The Computerised Multiple Elements Test (CMET) is a novel executive task to assess goal management and maintenance suitable for use within the fMRI environment. Unlike classical executive paradigms, it resembles neuropsychological multi-elements tests that capture goal management in a more ecological way, by requiring the participant to switch between four simple games within a specified time period. The present study aims to evaluate an fMRI version of the CMET and examine its brain correlates. Thirty-one healthy participants performed the task during fMRI scanning. During each block, they were required to play four simple games, with the transition between games being made either voluntarily (executive condition) or automatically (control condition). The executive condition was associated with increased activity in fronto-parietal and cingulo-opercular regions, with anterior insula activity linked to better task performance. In an additional analysis, the activated regions showed to form functional networks during resting-state and to overlap the executive fronto-parietal and cingulo-opercular networks identified in resting-state with independently defined seeds. These results show the ability of the CMET to elicit activity in well-known executive networks, becoming a potential tool for the study of executive impairment in neurological and neuropsychiatric populations in a more ecological way than classical paradigms.

Mood, Activity Participation, and Leisure Engagement Satisfaction (MAPLES): a randomised controlled pilot feasibility trial for low mood in acquired brain injury.

BACKGROUND: Acquired brain injury (ABI) affects approximately 79.3 million individuals annually and is linked with elevated rates of depression and low mood. Existing methods for treating depression in ABI have shown mixed efficacy. Behavioural activation (BA) is a potentially promising intervention. Its premise is that individuals with low mood avoid planning and engaging in activities due to low expectations of a positive outcome. Consequently, their exposure to positive reinforcement is reduced, exacerbating low mood. BA aims to break this cycle by encouraging activity planning and engagement. It is unknown whether cognitive demands of traditional BA may undermine efficacy in ABI. Here, we assess the feasibility and acceptability of two groups designed to increase activity engagement. In the activity planning group (traditional BA), the importance of meaningful and positive activity will be discussed and participants encouraged to plan/engage in activities in everyday life. The activity engagement group (experiential BA) instead focuses on engagement in positive experiences (crafts, games, discussion) within the group. The primary aims are to evaluate the feasibility and acceptability of the two groups in ABI. A secondary aim is to explore relative efficacy of the groups compared to an equivalent period of waitlist controls. METHOD: This study outlines a parallel-arm pilot feasibility trial for individuals with low mood and ABI that compares a traditional vs experiential BA group vs waitlist controls. Adults (≥ 18 years) will be recruited from local ABI services and randomised to condition. Feasibility and acceptability will be assessed via recruitment, retention, attendance and participant feedback. Groups will be compared (pre- and post-intervention and 1 month follow-up) by assessing self-reported activity engagement. Secondary outcomes include self-report measures of depression, anxiety, post-traumatic distress related to the ABI, motivation, participation and sense of control over one's life. ETHICS AND DISSEMINATION: The trial has been approved by the Health Research Authority of the NHS in the UK (East of England-Cambridge Central, REF 18/EE/0305). Results will inform future research on interventions for mood in ABI and be disseminated broadly via peer-reviewed journals, conference presentations and social media. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03874650 pre-results. Protocol version 2.1, March 5, 2019.

Glioblastoma surgery related emotion recognition deficits are associated with right cerebral hemisphere tract changes.

Patients with glioblastoma face abysmal overall survival, cognitive deficits, poor quality of life and limitations to social participation; partly attributable to surgery. Emotion recognition deficits mediated by pathophysiological mechanisms in the right inferior fronto-occipital fasciculus and right inferior longitudinal fasciculus have been demonstrated in traumatic brain injury and dementia, with negative associations for social participation. We hypothesize similar mechanisms occur in patients undergoing resection surgery for glioblastoma. Here, we apply tract-based spatial statistics using a combination of automated image registration methods alongside cognitive testing before and after surgery. In this prospective, longitudinal, observational study of 15 patients, surgery is associated with an increase in emotion recognition deficits (P = 0.009) and this is correlated with decreases in fractional anisotropy in the inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, anterior thalamic radiation and uncinate fasciculus; all in the right hemisphere (P = 0.014). Methodologically, the combination of registration steps used demonstrate that tract-based spatial statistics can be applied in the context of large, scan distorting lesions such as glioblastoma. These results can inform clinical consultations with patients undergoing surgery, support consideration for social cognition rehabilitation and are consistent with theoretical mechanisms that implicate these tracts in emotion recognition deficits across different diseases.

Dissociable effects of attention vs working memory training on cognitive performance and everyday functioning following fronto-parietal strokes.

Difficulties with attention are common following stroke, particularly in patients with frontal and parietal damage, and are associated with poor outcome. Home-based online cognitive training may have the potential to provide an efficient and effective way to improve attentional functions in such patients. Little work has been carried out to assess the efficacy of this approach in stroke patients, and the lack of studies with active control conditions and rigorous evaluations of cognitive functioning pre and post-training means understanding is limited as to whether and how such interventions may be effective. Here, in a feasibility pilot study, we compare the effects of 20 days of cognitive training using either novel Selective Attention Training (SAT) or commercial Working Memory Training (WMT) programme, versus a waitlist control on a range of attentional and working memory tasks. We demonstrate separable effects of each training condition, with SAT leading to improvements in spatial and non-spatial aspects of attention and WMT leading to improvements on closely related working memory tasks. In addition, both training groups reported improvements in everyday functioning, which were associated with improvements in attention, suggesting that improving attention may be of particular importance in maximising functional improvements in this patient group.

Personally salient, emotionally negative task contexts provoke goal neglect in depression.

BACKGROUND: Goal neglect refers to a dissociation between intended and actual action. Although commonly associated with frontal brain damage, this phenomenon is also characteristic of clinical depression. To date, tests of goal neglect typically require individuals to switch between subtasks populated with neutral stimuli. This study examined the impact of affective and personally salient stimulus contexts on goal neglect in clinical depression. METHODS: Participants were randomly allocated to either positively or negatively-valenced versions of the Affective Six Elements Test (A-SET). We hypothesised that depressed individuals (n = 30) would exhibit an overall impairment in A-SET performance by neglecting entire subtasks and allocating suboptimal time to each task, relative to never-depressed peers (n = 30), with effects being strongest for the negatively-valenced version. RESULTS: Findings showed that depressed individuals exhibited specific deficits, relative to controls on these measures in the negative A-SET only, with a magnitude comparable to that found in brain injured patients. CONCLUSIONS: Individuals with depression are impaired in their ability to monitor performance and implement strategies that are optimal for the purpose of pursuing an overarching goal when the task context is negatively-valenced. Potential mechanisms are discussed.

Mental imagery as a "motivational amplifier" to promote activities.

Facilitating engagement in rewarding activities is a key treatment target in depression. Mental imagery can increase engagement in planned behaviours, potentially due to its special role in representing emotionally salient experiences. The present study tested the hypothesis that mental imagery promotes motivation and engagement when planning pleasant and rewarding activities. Participants were recruited from a community volunteer panel (N = 72). They self-nominated six activities to complete over the following week, and were randomized to either: a) a single-session Motivational Imagery condition (N = 24); b) an Activity Reminder control condition (N = 24); or c) a No-Reminder control condition (N = 24). As predicted, relative to control groups, the Motivational Imagery group reported higher levels of motivation, anticipated pleasure, and anticipated reward for the planned activities. The Motivational Imagery group also completed significantly more activities than the Activity Reminder group, but not more than the No-Reminder group. Relevance of results to behavioural activation approaches for depression are discussed.

Cognitive Rehabilitation With Mobile Technology and Social Support for Veterans With TBI and PTSD: A Randomized Clinical Trial.

OBJECTIVE: To investigate effects of cognitive rehabilitation with mobile technology and social support on veterans with traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). PARTICIPANTS: There were 112 dyads, comprised by a veteran and a family member or friend (224 participants in total). DESIGN: Dyads were randomized to the following: (1) a novel intervention, Cognitive Applications for Life Management (CALM), involving goal management training plus mobile devices for cueing and training attentional control; or (2) Brain Health Training, involving psychoeducation plus mobile devices to train visual memory. MAIN MEASURES: Executive dysfunction (disinhibition, impulsivity) and emotional dysregulation (anger, maladaptive interpersonal behaviors) collected prior to randomization and following intervention completion at 6 months. RESULTS: The clinical trial yielded negative findings regarding executive dysfunction but positive findings on measures of emotion dysregulation. Veterans randomized to CALM reported a 25% decrease in anger over 6 months compared with 8% reduction in the control (B = -5.27, P = .008). Family/friends reported that veterans randomized to CALM engaged in 26% fewer maladaptive interpersonal behaviors (eg, aggression) over 6 months compared with 6% reduction in the control (B = -2.08, P = .016). An unanticipated result was clinically meaningful change in reduced PTSD symptoms among veterans randomized to CALM (P < .001). CONCLUSION: This preliminary study demonstrated effectiveness of CALM for reducing emotional dysregulation in veterans with TBI and PTSD.

Anticipated and imagined futures: prospective cognition and depressed mood following brain injury.

OBJECTIVES: Depression, which is common following acquired brain injury (ABI), has been shown to predict cognitive impairment, rehabilitation outcome, and quality of life. Whilst many studies have examined links between depression and cognitive-affective processing in the non-ABI population, their applicability to this important clinical group, where cognitive difficulties can be marked, remains unknown. Here, we investigated biases in prospective cognition, which is known to be disrupted in (non-ABI) depression yet important for well-being. DESIGN: Cross-sectional design with three groups (depressed ABI, non-depressed ABI, and non-ABI control participants). Continuous data were additionally analysed in correlation analyses. METHODS: Individuals with ABI varying in extent of self-reported depression and matched non-ABI control participants completed assessments of mood and prospective cognition (anticipating and imagining future events), alongside background tests of executive function and fluid intelligence. RESULTS: Relative to non-depressed ABI and control participants, depressed ABI individuals demonstrated a reduced positive bias in prospective cognition: whereas non-depressed ABI and control participants generated more examples of likely or possible positive versus negative future events, there was no evidence for such a positive bias in depressed ABI participants. Non-depressed ABI and control participants also reported more vivid mental imagery for positive versus negative future scenarios, whereas such a pattern was not evident in depressed ABI participants. This pattern emerged despite background impairments in fluid intelligence and executive function associated with ABI. CONCLUSIONS: These findings (1) elucidate depression-linked cognitive-affective processes following ABI, where cognitive difficulties are common, and (2) highlight psychological processes associated with depression that are common to ABI and non-ABI populations. PRACTITIONER POINTS: Clinical implications A relative negative bias in future-directed cognition is associated with depressed mood in individuals with chronic ABI. Such processes may contribute to the onset and maintenance of depression following ABI. These findings suggest it may be important to consider a role for prospective cognition in psychological interventions for depression following ABI. Limitations of the study The extent to which depressed mood following ABI is associated with biases in other cognitive domains remains unclear. Whether similar patterns would be observed in acute patients with more profound cognitive difficulties requires further investigation. Despite large effect sizes, our sample size is modest; these effects thus require replication in larger groups.

We do as we construe: extended behavior construed as one task is executed as one cognitive entity.

We select and execute extended task episodes ('make tea') as one entity and not individually execute their very many components (find kettle, boil water, etc.). Such hierarchical execution is thought to occur in familiar task situations with pre-existing task episode-related scripts that once selected, control the identity and sequence of component steps. Here, in contrast, we show hierarchical execution of extended behavior in situations, where the identity and sequence of component steps were unknown and a predetermined script could not have existed. Participants performed a rule-switching task in which the rule to be applied on each trial could not be predicted. Crucially, they were biased into construing a recurring instance of three or five trials as a single task episode. Behavioral signs of hierarchical execution, identical to those seen during memorized task-sequence executions, were present. These included longer reaction time on the first trial of each episode that was proportionate to the length of that episode, and absence of rule switch costs only between those consecutive trials that crossed episode boundaries. Hierarchical execution thus occurs every time the to-be-executed behavior is construed as one task episode, and is not limited to predictable sequences. We suggest that hierarchical execution occurs because task episodes are controlled and executed through goal-related entities assembled at the beginning of execution that subsume the execution and instantiate purposive control across time until the goal is complete.

Beatboxers and Guitarists Engage Sensorimotor Regions Selectively When Listening to the Instruments They can Play.

Studies of classical musicians have demonstrated that expertise modulates neural responses during auditory perception. However, it remains unclear whether such expertise-dependent plasticity is modulated by the instrument that a musician plays. To examine whether the recruitment of sensorimotor regions during music perception is modulated by instrument-specific experience, we studied nonclassical musicians-beatboxers, who predominantly use their vocal apparatus to produce sound, and guitarists, who use their hands. We contrast fMRI activity in 20 beatboxers, 20 guitarists, and 20 nonmusicians as they listen to novel beatboxing and guitar pieces. All musicians show enhanced activity in sensorimotor regions (IFG, IPC, and SMA), but only when listening to the musical instrument they can play. Using independent component analysis, we find expertise-selective enhancement in sensorimotor networks, which are distinct from changes in attentional networks. These findings suggest that long-term sensorimotor experience facilitates access to the posterodorsal "how" pathway during auditory processing.

Hierarchical Cognition Causes Task-Related Deactivations but Not Just in Default Mode Regions.

The well-known deactivation of the default mode network (DMN) during external tasks is usually thought to reflect the suppression of internally directed mental activity during external attention. In three experiments with human participants we organized sequences of task events identical in their attentional and control demands into larger task episodes. We found that DMN deactivation across such sequential events was never constant, but was maximum at the beginning of the episode, then decreased gradually across the episode, reaching baseline towards episode completion, with the final event of the episode eliciting an activation. Crucially, this pattern of activity was not limited to a fixed set of DMN regions but, across experiments, was shown by a variable set of regions expected to be uninvolved in processing the ongoing task. This change in deactivation across sequential but identical events showed that the deactivation cannot be related to attentional/control demands which were constant across the episode, instead, it has to be related to some episode related load that was maximal at the beginning and then decreased gradually as parts of the episode got executed. We argue that this load resulted from cognitive programs through which the entire episode was hierarchically executed as one unit. At the beginning of task episodes, programs related to their entire duration is assembled, causing maximal deactivation. As execution proceeds, elements within the program related to the completed parts of the episode dismantle, thereby decreasing the program load and causing a decrease in deactivation.

When attended and conscious perception deactivates fronto-parietal regions.

The finding of increased fronto-parietal activity during conscious and attended perception forms a key basis for theories of consciousness and attention. However, this finding comes largely from studies that required explicit detection of events in a way that made detection the goal of the ongoing task. This is an important confound because goal completion itself elicits fronto-parietal activity. In everyday life attended and conscious perception is instrumental in achieving our goals but rarely a goal in itself. Here we examined whether conscious perception that was instrumental to participants' current goals, but not a goal in itself, elicited increased fronto-parietal activity. In Experiments 1 and 2 participants attended to a stream of letters (1 per second) to detect occasional targets in their midst. We found that consciousness of, and attention to, these highly visible non-targets events deactivated fronto-parietal regions. In Experiment 3 participants heard a loud auditory cue that had to be retained in memory for up to 9 sec before being used to select the correct rule for completing the goal. No increased fronto-parietal activity was observed even for such salient, attended and remembered event. In contrast, robust fronto-parietal activation was observed across all the experiments for goal completion events. The results indicate that increased fronto-parietal activity is not a necessary correlate of conscious and attended perception. We speculate that fronto-parietal deactivation during non-target events may be related to the suppression of potential interference from salient, conscious, but non-goal stimuli.

A Randomized Controlled Trial of Assisted Intention Monitoring for the Rehabilitation of Executive Impairments Following Acquired Brain Injury.

BACKGROUND: Acquired brain injury (ABI) can impair executive function, impeding planning and attainment of intentions. Research shows promise for some goal-management rehabilitation interventions. However, evidence that alerts assist monitoring and completion of day-to-day intentions is limited. OBJECTIVE: To examine the efficacy of brief goal-directed rehabilitation paired with periodic SMS text messages designed to enhance executive monitoring of intentions (assisted intention monitoring [AIM]). METHODS: A randomized, double-blind, controlled trial was conducted. Following a baseline phase, 74 people with ABI and executive problems were randomized to receive AIM or control (information and games) for 3 weeks (phase 1) before crossing over to either AIM or no intervention (phase 2). The primary outcome was change in composite score of proportion of daily intentions achieved. A total of 59 people (71% male; 46% traumatic brain injury) completed all study phases. RESULTS: Per protocol crossover analysis found a significant benefit of AIM for all intentions [ F(1, 56) = 4.28; P = .04; f = 0.28; 3.7% mean difference; 95% CI = 0.1%-7.4%] and all intentions excluding a proxy prospective memory task [ F(1, 55) = 4.79; P = .033; f = 0.28, medium effect size; 3% mean difference; 95% CI = 0.3%-5.6%] in the absence of significant changes on tests of executive functioning. Intention-to-treat analyses, comparing AIM against control at the end of phase 1 revealed no statistically significant differences in the attainment of intentions. CONCLUSION: Combining brief executive rehabilitation with alerts may be effective for some in improving achievement of daily intentions, but further evaluation of clinical effectiveness and mechanisms is required.