Validity of the brief executive-function assessment tool in an outpatient substance use disorder setting.

The Brief Executive-function Assessment Tool (BEAT) was developed and validated for use in residential substance use disorder treatment settings, where participants are mostly abstinent. It is therefore unclear whether the BEAT is valid for use in outpatient settings, where participants may be actively using substances. The effects of acute intoxication and withdrawal have the potential to alter the results of the BEAT. The current study sought to establish construct and criterion validity of the BEAT in an outpatient substance use disorder sample and to detect its sensitivity to substance use over the previous 24 hours and also over the past month. A total of 74 clients of a New South Wales-based outpatient substance use disorder service participated in the current study. Construct validity was demonstrated by significant correlations between the BEAT and three performance-based tests of executive functioning. Criterion validity was established in that the BEAT discriminated between those deemed impaired or not on a criterion composite measure of executive functioning. Test operating characteristics (88% sensitivity, 69% specificity, 44% PPV, and 95% NPV) were also established relative to this composite measure as a reference standard. The BEAT was insensitive to use/abstinence over the previous 24 hours and the past month.

Brief executive-function assessment tool: A new cognitive impairment screening tool for alcohol and other drug services.

Accurate screening for cognitive impairment in alcohol and other drug (AOD) services would help to identify individuals who may need supports to obtain the greatest benefit from substance use disorder (SUD) treatment. At present there is no screening measure that has been developed specifically to detect cognitive impairment in a SUD population. This study examines the psychometric properties of the Brief Executive-function Assessment Tool (BEAT), which was specifically designed for this purpose. This study involving 501 individuals with SUD and 145 normal control participants established internal consistency (n = 646; 0.734), interrater (n = 60; 0.994), and test-retest reliability (n = 177; 0.845), and construct (all correlations p ≤ 0.05), and criterion (n = 467; ANCOVA p < 0.001) validity. Test operating characteristics (n = 500; 87% sensitivity, 71% specificity, 21% PPP, and 99% NPP) were also established relative to an independent criterion variable made up of three established performance-based neuropsychological tests. Findings support the reliability and validity of the BEAT as a screening measure of executive function impairment with high sensitivity and a low rate of false negatives.

The diagnostic accuracy of the Revised Westmead PTA Scale as an adjunct to the Glasgow Coma Scale in the early identification of cognitive impairment in patients with mild traumatic brain injury.

BACKGROUND: Assessment of patients with mild traumatic brain injury (mTBI) is predominantly done using the Glasgow Coma Scale (GCS). While the GCS is universally accepted for assessment of severity of traumatic brain injury, it may not be appropriate to rely on the GCS alone when assessing patients with mTBI in prehospital settings and emergency departments. OBJECTIVE: To determine whether administering the Revised Westmead Post-traumatic Amnesia (PTA) Scale (R-WPTAS) in addition to the GCS would increase diagnostic accuracy in the early identification of cognitive impairment in patients with mTBI. METHODS: Data were collected from 82 consecutive participants with mTBI who presented to the emergency department of a level 1 trauma centre in Australia. A matched sample of 88 control participants who attended the emergency department for reasons other than head trauma was also assessed. All patients were assessed using the GCS, R-WPTAS and a battery of neuropsychological tests. RESULTS: Patients with mTBI scored poorly compared with control patients on all measures. The R-WPTAS showed greater concurrent validity with the neuropsychological measures than the GCS and significantly increased prediction of group membership of patients with mTBI with cognitive impairment. CONCLUSIONS: The R-WPTAS significantly improves diagnostic accuracy in identifying patients with mTBI who may be in PTA. Administration takes less than 1 min, and since early identification of a patient's cognitive status facilitates management decisions, it is recommended for routine use whenever the GCS is used.

Mild traumatic brain injury does not predict acute postconcussion syndrome.

BACKGROUND: The aetiology of postconcussion syndrome (PCS) following mild traumatic brain injury (mTBI) remains controversial. Identifying acute PCS (within the first 14 days after injury) may optimise initial recovery and rehabilitation, identify those at risk and increase understanding of PCS. OBJECTIVE: To examine predictors of acute outcome by investigating the relationship between preinjury psychiatric disorder, demographic factors, injury related characteristics, neuropsychological and psychological variables and acute PCS. METHODS: Prospective study of consecutive trauma admissions to a level 1 trauma hospital. The final sample comprised 90 patients with mTBI and 85 non-brain injured trauma controls. Individuals were administered a PCS checklist, and neuropsychological and psychological measures. Multiple imputation of missing data in multivariable logistic regression and bivariate logistic regressions were used to predict acute PCS at a mean of 4.90 days after injury. RESULTS: Diagnosis of acute PCS was not specific to mTBI (mTBI 43.3%; controls 43.5%). Pain was associated with acute PCS in mTBI. The strongest effect for acute PCS was a previous affective or anxiety disorder (OR 5.76, 95% CI 2.19 to 15.0). Females were 3.33 times more likely than males to have acute PCS (95% CI 1.20 to 9.21). The effect of acute post-traumatic stress and neuropsychological function on acute PCS was relatively small. Higher IQ was associated with acute PCS. CONCLUSIONS: There is a high rate of acute PCS in both mTBI and non-brain injured trauma patients. PCS was not found to be specific to mTBI. The use of the term PCS may be misleading as it incorrectly suggests that the basis of PCS is a brain injury.

Natural history of cognitive deficits and their relationship to MRI T2-hyperintensities in NF1.

BACKGROUND: Cognitive impairment is the most common complication of neurofibromatosis type 1 (NF1) in childhood. Current research suggests a strong relationship between cognitive deficits and brain T2-hyperintensities. The majority of these lesions disappear as the child ages. Cross-sectional data suggest that there also are improvements in intellect. OBJECTIVE: To determine the natural history of cognitive functioning and MRI T2-hyperintensities from childhood into adulthood, and whether changes in MRI T2-hyperintensities over time are predictive of changes in cognitive functioning. METHODS: The authors conducted a prospective longitudinal study of a cohort of 32 patients with NF1 and 11 unaffected sibling controls. All patients underwent neuropsychological assessments and 27 children underwent MRI examinations. The patients were then reassessed after an 8-year period. RESULTS: and CONCLUSIONS: There was no improvement in cognitive ability as the children with NF1 developed into adulthood compared with controls. Despite significant decreases in the number, size, and intensity of the T2-hyperintensities over the 8-year period, these changes were not associated with changes in cognitive ability. T2-hyperintensities in the cortex or subcortical or deep white matter are more frequent with age and these lesions are likely to have a different pathology than basal ganglia lesions. The best predictor of cognitive dysfunction in adulthood was the presence of T2-hyperintensities in childhood, rather than current lesion status. There is a limited time window (<18 years) in which the presence of T2-hyperintensities can be used as biologic markers of cognitive dysfunction.

Simulated pain on the Symptom Checklist 90-Revised.

This study investigated whether a pain clinical sample and pain simulators could be distinguished by their responses on the Symptom Checklist 90-Revised (SCL-90-R). Fifty patients with a pain condition completed the SCL-90-R under normal instructions while 20 students responded under instructions to feign a pain disorder to obtain compensation but to attempt to avoid detection. Pain patients obtained generalized elevations, with the highest scores on Depression, Obsessive-Compulsive, and Somatization. The simulators exceeded the pain group on all clinical scales of the SCL-90-R, tending to greatly overestimate the degree of psychological distress in pain patients. Simulators had extreme elevations and were more likely to obtain a T score greater than 70 on each of the clinical scales. Sensitivity, specificity, positive and negative predictive power values, and optimal diagnostic cutoff scores for the clinical scales are reported. The recommended Positive Symptom Total (PST) cutoff score for "faking bad" in the SCL manual had poor specificity. The SCL-90-R warrants further study as an aid to identifying pain simulation.

Simulated malingering in pain patients: a study with the Pain Patient Profile.

OBJECTIVE: To investigate the utility of the Pain Patient Profile (P3) in detecting those who are faking or exaggerating complaints of pain while attempting to avoid detection. METHOD: A control group of pain patients ('Pain Controls'; PC; N = 62) was compared with a general clinical group who did not report pain but were instructed to simulate malingered pain ('General Rehabilitation Simulators', GR, N = 34); and a group whose primary problem was chronic pain who were instructed to exaggerate the extent of their pain and related problems ('Pain Simulators' PS; N = 26). RESULTS: Both groups of simulating participants reported significantly higher scores on all clinical scales (anxiety, depression, somatization) compared with non-simulating control participants and were more likely to obtain an abnormal T-score on the clinical scales. The validity scale was able to differentiate the PS group from the PC group, but the GR group was not differentiated from the PC group by the validity scale. CONCLUSIONS: The results indicate that with further study, the P3 may be a useful adjunct to the clinical assessment of symptom magnification in pain claimants.

Pain patient profile and the assessment of malingered pain.

This study investigated whether a pain sample and pain simulators could be distinguished on the Pain Patient Profile (P3). Forty patients with a pain condition completed the P3 under normal instructions, while 20 students responded under instructions to feign a pain disorder but to attempt to avoid detection. The simulators did not differ on the P3 Validity Scale compared with the pain group, but scored significantly higher than the pain group on the P3 clinical scales (Depression, Anxiety, Somatization). The simulators were more likely to obtain an abnormal score (T score > 55) on all of the clinical scales. The Depression scale had highest positive and negative predictive power and correctly classified 80% of the participants. The P3 may be a useful screening tool for assessing those feigning pain but requires further research.

Factorial invariance for combined Wechsler Adult Intelligence Scale-Revised and Wechsler Memory Scale-Revised scores in a sample of clients with alcohol dependency.

This study examined the joint factor structure of the WAIS-R and WMS-R in a sample of 289 participants (mostly males) with alcohol dependency. In a confirmatory phase we contrasted a range of factor models derived from previous analyses of the Wechsler scales. The best fitting model incorporated five factors representing Verbal Comprehension, Perceptual Organization, Attention-Concentration, Verbal Memory, and Visual Memory, with reassignment of factor loadings for two subtests. The invariance of the measurement model was then examined comparing data from a large sample of healthy participants (J. R. Carstairs & E. A. Shores, 1999). The results indicated that the number of factors was invariant across samples, and four of the factors satisfied the criterion of partial measurement invariance.

Traumatic brain injury as a risk factor for Alzheimer's disease: a review.

Accumulating epidemiological evidence implicates traumatic brain injury as a pathogenic agent in the development of Alzheimer's disease (AD). Considering the increase in the prevalence of both traumatic brain injury and AD in recent times, the possibility that brain trauma may provoke the early development of AD has important implications for health service planning, preventative efforts, and medico-legal compensation settlements. This paper evaluates the plausibility of the proposed link between traumatic brain injury and AD, largely by way of exploring a theoretical perspective advanced by Satz (1993) and considering recent contributions from the epidemiological, neuropathological, and biochemical literature that are pertinent to this issue. The literature reviewed provides sufficient support and empirical vindication to give credence to the proposed association between these two neuropsychological entities at the statistical, theoretical, and biological level.

Neuropsychological functioning of adults with attention deficit hyperactivity disorder.

The neuropsychological functioning of adults with Attention Deficit Hyperactivity Disorder (ADHD) was compared to that of healthy controls and individuals with mild psychiatric disorders including attentional complaints. Thirty adults in each group were examined on the Conners' Continuous Performance Test (CPT) and measures of attention, executive function, psychomotor speed, and arithmetic skills. The ADHD group performed lower than healthy controls on most measures. However when compared to the psychiatric group, the performances of the ADHD group were not significantly lower on any of the measures. The predictive power of the tests was poor in discriminating ADHD from psychiatric disorder. Implications for the clinical diagnosis of ADHD are discussed.

Effects of reducing attentional resources on implicit and explicit memory after severe traumatic brain injury.

Implicit and explicit memory were examined in individuals with severe traumatic brain injury (TBI) under conditions of full and divided attention. Participants included 12 individuals with severe TBI and 12 matched controls. In Experiment 1, participants carried out an implicit test of word-stem completion and an explicit test of cued recall. Results demonstrated that TBI participants exhibited impaired explicit memory but preserved implicit memory. In Experiment 2, a significant reduction in the explicit memory performance of both TBI and control participants, as well as a significant decrease in the implicit memory performance of TBI participants, was achieved by reducing attentional resources at encoding. These results indicated that performance on an implicit task of word-stem completion may require the availability of additional attentional resources that are not preserved after severe TBI.

Malingering of memory impairment on the Colorado Priming Test.

OBJECTIVES: We hypothesized that simulated malingerers would show a weaker priming effect and a longer response latency than control patients and patients with a brain injury on a priming test. DESIGN: Participants were compared on their performance on the Colorado Priming Test to replicate and extend the original validation study. METHODS: Of 33 participants, 16 were people with a brain injury and 17 were non-head injured control patients who were also instructed to feign cognitive impairment (simulators N = 17). RESULTS: Up to 88 per cent of simulating malingerers and 75 per cent of head-injured participants were correctly classified. CONCLUSIONS: The Colorado Priming Test may be useful in identifying patients feigning memory impairment.

Sensitivity of the WAIS-R Verbal-Performance IQ difference and intersubtest scatter to traumatic brain injury. Wechsler Adult Intelligence Scale-Revised.

The Wechsler Adult Intelligence Scale-Revised (WAIS-R) Verbal IQ-Performance IQ (VIQ-PIQ) discrepancy and a number of indices of intersubtest scatter were examined in 25 subjects with a history of traumatic brain injury (TBI) and magnetic resonance imaging (MRI) evidence of structural brain abnormality. Abnormal VIQ-PIQ differences and scatter index values were identified by referring to published normal base rates. Only 16% of the subjects were identified as abnormal on any one of these WAIS-R measures, which suggests these measures are largely insensitive to the presence of structural brain abnormality in TBI.

Further concurrent validity data on the Westmead PTA Scale.

Further data supporting the concurrent validity of the Westmead PTA scale is presented. The initial concurrent validation data on the Westmead PTA Scale study was based on two separate groups of traumatic brain injury patients. In order to ensure that the results of that study were not due to sampling differences between the groups related to different degrees of recovery as a consequence of varying times since trauma, further investigation of the concurrent validity was undertaken using a group of patients as their own controls, tested once while in post-traumatic amnesia (PTA) and again shortly after emerging from PTA. Thirty patients with severe traumatic brain injuries, who were still experiencing PTA as defined by their Westmead PTA Scale performance, were assessed on an independent test of verbal learning ability. Once out of PTA, as defined by their performance on the Westmead PTA Scale they were retested on a parallel form of the test of verbal learning. Their performance on the two occasions differed significantly providing further concurrent validation of the Westmead PTA Scale.

Neuropsychological abnormalities in patients with pituitary tumours.

Neuropsychological assessment of 65 patients with pituitary tumours revealed impairment of memory and executive function. This did not appear to be related to the size or type of tumour or the effects of radiotherapy or surgery. It is possible that the problems arose from multiple unconnected factors but this observation lends support to the suggestion that pituitary or hypothalamic hormones have a role in the modulation of memory and behavioural pathways. Whatever the cause, neuropsychological impairment is common in patients with pituitary tumours and is an aspect of their disability which has received insufficient attention in the past.

Preliminary validation of a clinical scale for measuring the duration of post-traumatic amnesia.

An operational definition of post-traumatic amnesia is presented and a standardized procedure for the measurement of post-traumatic amnesia, which has been clinically tested in over 100 patients with severe, closed head injury is described. Twenty patients with severe head injuries who were still experiencing post-traumatic amnesia (as defined in this study), were assessed on an independent test of learning ability, as were 20 other patients with severe head injury who were no longer suffering post-traumatic amnesia. The performance of the two groups differed significantly; those in a state of post-traumatic amnesia performed more poorly. Both these groups showed significant impairment when compared with a control group of 20 patients who were in hospital because of orthopaedic injuries that were suffered during a motor vehicle accident. These preliminary results are sufficiently encouraging to recommend this simple procedure for routine use in hospitals, to enhance the accuracy of measuring the severity of head injury. The medicolegal use of this measure is also discussed.