ABSTRACTS

Brain Impairment

4.1
Volume 4 Number 1 2003

Context-sensitive Cognitive Rehabilitation after Brain Injury: Theory and Practice
Mark Ylvisaker
College of Saint Rose, Albany, New York, USA

The goal of this article is to describe and offer a rationale for an approach to cognitive rehabilitation labelled “context sensitive”. This approach stands in contrast to the modern tradition of cognitive rehabilitation that features massed and decontextualized process-specific cognitive exercises. The paper begins with theoretical considerations, emphasises the history of research in transfer of cognitive skill, incorporates the World Health Organization framework, describes context-sensitive apprenticeship procedures, draws on evidence accumulated over several decades with related disability groups, and ends with answers to frequently asked questions.

Cognitive Rehabilitation Revisited
Catherine A. Mateer
University of Victoria, Canada

McKay Moore Sohlberg
University of Oregon, USA

Many controversies remain with respect to how best to work with individuals who are challenged by cognitive impairments. Yet in the last decade, there has been substantial new research and a proliferation of literature, which has served to clarify major principles underlying cognitive interventions, and specified training procedures and teaching techniques that have demonstrated some effectiveness. Increasingly, it is possible to identify what techniques are likely to work for a particular individual, based on a number of variables including their cognitive profile, level of insight, and capacity for self-regulation. Education, the development of compensatory behaviours, the use of specialised instructional techniques and the inclusion of activities to improve self awareness and self-efficacy are but a few of the important components of most efforts at rehabilitation for cognitive impairments. Cognitive rehabilitation must be creative, eclectic, functionally oriented, and based in a partnership between clients, families/caregivers, and professionals.

Goal Planning Rather than Neuropsychological Tests Should Be Used to Structure and Evaluate Cognitive Rehabilitation
Barbara A. Wilson
Medical Research Council Cognition and Brain Sciences Unit, Cambridge and Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely, UK

Many studies of cognitive rehabilitation use neuropsychological tests to plan and evaluate treatment. This paper suggests that this is not a good rehabilitation procedure. The main purposes of rehabilitation are to achieve the maximum physical, psychological, social and vocational wellbeing of each individual and to enable people to return to their own, most appropriate environment. We do not engage in rehabilitation in order to help people achieve better scores on tests. This might be acceptable if there were a direct relationship between test scores and real life problems but there is not such a relationship. Although tests are useful in providing a picture of strengths and weaknesses, they are extremely limited in identifying everyday disabilities and handicaps. People can lead improved lives by compensating for or by-passing some of their cognitive problems yet remain unchanged on test scores. Conversely, they can improve on test scores yet remain severely handicapped in everyday life. One approach that is gaining ground in rehabilitation is goal planning. This allows patients/clients, their relatives and rehabilitation staff to negotiate appropriate and meaningful goals, determine how these should be achieved and measure success, or failure in real life situations. Goal planning both reduces the artificial distinction between rehabilitation practice and outcome measures, and allows the integration of theory and practice. The processes and procedures involved in goal planning are described and followed by an evaluative discussion.

Realising the Potential of Cognitive Rehabilitation for the Brain-Injured: Next Steps
Kenneth M. Adams
Department of Veterans Affairs and The University of Michigan, USA

Contemporary psychological literature as well as the preceding papers (Mateer & Sohlberg, 2003; Wilson, 2003; Ylvisaker, 2003) emphasise the individual patient’s personal ecological context as a crucial factor in the delivery of cognitive rehabilitation services. Testing and assessment procedures in neuropsychology have been enjoined to take increasing notice of the patient’s historical, cultural and social background in providing services (American Psychological Association, 2003). Similarly, the design and delivery of treatment services must take into account how and where patients are living their lives post-injury. This has the benefit of moving cognitive rehabilitation from an emphasis on the more obvious or face-valid concerns about sterile “cognitive” models to individual ways of facilitating learning and information transfer improvement in the real world. In this way of approaching the problem, the patient’s cultural and demographic context as well as their emotional adaptations are not confounding variables but critical design variables. The challenge now in delivering these paradigms of care is to show that they are appropriate and effective in some place in healthcare delivery systems, whether traditional or alternative. Questions of effectiveness of cognitive rehabilitation treatments and cost should be balanced in an equation relating to the probability of objective and demonstrable patient enhancement in living. Goals set and achieved must have consensual value that cannot be captured by traditional cost-benefit analysis in preventive or curative healthcare economic methodology. Cognitive rehabilitation as a family of interventions has little to no chance of being evaluated as efficacious using traditional treatment designs, using traditional neuropsychological measures as dependent variables, and involving research designs with crossover, sham or placebo conditions.

President's Address 2002
Traumatic Brain Injury and Psychosocial Function: Let’s Get Social
Skye McDonald
University of NSW, Australia

Disorders of psychosocial function manifested in a reduction in socially skilled behaviour, are prevalent following traumatic brain injury. It is clear to most clinicians that these can present the major obstacle to successful rehabilitation. Outcome studies also support this view. Despite this, there is relatively little systematic work addressing social skills remediation in Australia or elsewhere. There are even fewer studies that have evaluated the effectiveness of social skills treatment after traumatic brain injury. In this address I will consider social skills from a social skills framework that has been developed in the normal literature. This framework encompasses social behaviour and social perception (i.e., the ability to read cues accurately and social problem-solving). Social behaviour is the most common target for remediation in both the normal and brain-injured populations. There is a range of useful techniques that have proven to be efficacious in treating social skills in non-brain-injured populations and also to have some effectiveness in the treatment of traumatic brain injury. In addition, however, it is clear that both social perception (i.e., the ability to read social cues accurately and social problem-solving are also compromised after TBI). These areas are infrequently targeted for remediation, although again, there are some remediation principles that are relevant and potentially fruitful. Finally, it is important to understand the impact of psychological reactive factors such as depression and poor self-esteem in producing or maintaining poor social skills.

 

---

3.2
Volume 3 Number 2 2002
Special Issue: Child Neuropsychology

---

Neuropsychological Outcomes of Children Treated for Posterior Fossa Tumours: A Review
Robyn Stargatt and Vicki Anderson
Murdoch Children’s Research Institute, Royal Children’s Hospital and University of Melbourne, Australia
Jeffrey V. Rosenfeld
Alfred Hospital, Australia

The posterior fossa region of the brain is a frequent site for tumour development in children, with over half of all childhood tumours occurring at this site. The principal brain structure implicated at this site is the cerebellum. Children treated for posterior fossa tumours can have a wide range of neurological and psychosocial problems. This paper describes the literature to date that addresses the neuropsychological impact of tumour and treatment in children with posterior fossa tumours. This paper reviews the literature on the causes of morbidity in this group. It discusses the recent research on the role of the cerebellum in outcomes and the studies that identify variables that interact with radiation effects.

Adaptive Behaviour and Moral Reasoning in Children with Frontal Lobe Lesions
Emma Couper
University of Melbourne, Australia
Rani Jacobs and Vicki Anderson
University of Melbourne and Murdoch Children’s Research Institute, Melbourne, Australia

Children with frontal lobe damage often appear to demonstrate remarkable recovery with few apparent signs of impairment immediately after injury. Over time, however, many develop increasing deficits in self-regulation, attention, and executive function, as well as in other higher functions. Current literature suggests that, in particular, these children seem to experience worsening socio-behavioural problems. Some case studies (Grattan & Eslinger, 1992; Anderson et al., 1999) describe individuals with childhood frontal lesions who developed severe social problems, deficits in executive functions and who also had lower than expected levels of moral reasoning. In the present study, social-adaptive behaviour and maturity of moral reasoning were measured in 16 children with focal frontal lesions and in 12 age-matched controls. Children with frontal lobe lesions had poorer adaptive behaviour ratings and lower levels of moral maturity than controls. These results support previous research suggesting that children with frontal lobe lesions have reduced social understanding and typically experience ongoing sociobehavioural problems.

Verbal Memory and IQ in Childrenwho Undergo Focal Resection for Intractable Epilepsy: A Clinical Review
Suncica Sunny Lah
Sydney Children’s Hospital and Macquarie University, Australia
Pamela Joy and Kathleen Bakker
The Children’s Hospital at Westmead, Australia
Laurie Miller
Royal Prince Alfred Hospital, Sydney, Australia

Previous studies have indicated an increased likelihood of intellectual and memory impairments in children with epilepsy. It has been argued that early surgical intervention in children with intractable seizures might be advantageous to their development. We conducted a retrospective review of pre- and post-operative IQ and verbal memory scores in 16 paediatric patients who underwent temporal (N = 10) or extra-temporal (N = 6) focal surgery for epilepsy. Patients with an extratemporal seizure focus performed significantly worse than patients with a temporal lobe seizure focus on Full Scale IQ and Verbal IQ before surgery. Postoperatively a statistically significant decline in verbal memory, but not in any of the IQ indices was noticed in the extratemporal group. Individual outcome analyses revealed a significant decline in verbal memory in 22% of temporal lobectomy and 60% of extratemporal cases. Our review suggests that verbal memory but not IQ is vulnerable to postoperative decline in children who undergo focal extratemporal surgery for intractable epilepsy. The findings raise the possibility that extratemporal regions play a role in anterograde memory in children. Given the small number of subjects in this study, further investigations into the cognitive effects of paediatric surgical intervention are recommended.

Memory for Faces and Paired Associates After Temporal Lobectomy in Childhood
Andrew G. Rothwell and Alan Tucker
Victoria University, Australia

Findings are reported from the first examination of the Beardsworth Memory for Children’s Faces Test (BMCFT) (Beardsworth & Zaidel, 1994) tested on a selected sample of 10 left (LATL) and 7 right (RATL) anterior temporal lobectomy patients an average of 7 years post surgery. No differences between LATL and RATL groups were found on immediate or delayed memory trials of the BMCFT. Verbal memory was assessed with a verbal analogue of this test, the Extended Verbal Paired Associates Test (EVPAT) specifically constructed for this study. Differences were obtained on the immediate (F = 5.17; p < .01) and delayed (F = 6.55; p < .01) memory trials of the EVPAT with LATL patients learning and retrieving fewer verbal associations than their right ATL counterparts. No differences were found on the memory decline to delayed recall scores on the EVPAT. The findings suggest that people who have left or right ATL in childhood cannot be distinguished on the basis of their immediate or delayed memory for paired faces an average of 7 years post-surgery. These results are consistent with the immediate memory performance of children 6 months post-surgery as reported by Beardsworth and Zaidel (1994), but are not consonant with the delayed memory performance of their children on this task. This indicates that left–right dissociations found in children on measures of delayed memory for faces 6 months post-surgery may represent a component of memory that is still in a state of recovery. The findings for the immediate memory trials of the EVPAT conformed to expectations and underscore the dependability of simple rote verbal memory tasks in dissociating left from right ATL 7 years post-surgery. The study addresses the issue of the recovery of immediate versus delayed memory and time of assessment post-surgery.

Functional Magnetic Resonance Imaging of Language Function in Children
Dianne P. Anderson
Brain Sciences Institute, Swinburne University of Technology, Australia

Functional magnetic resonance imaging (fMRI) has been recognised as a neuroimaging technique suitable for examination of higher cognitive function in children. It has been used to elucidate cognitive neural networks associated werbal Memory and IQ in Childrenwho Undergo Focal Resection for Intractable Epilepsy: A Clinical Reviewith various aspects of language function in several group and case studies of school-aged children. Language function has been lateralised and localised with fMRI in clinical samples, neurologically normal children and children with developmental language disorders. Issues of plasticity of language function during development and following injury have also been considered. Several paediatric case studies have also raised questions with respect to the interpretation of fMRI language activation. In spite of methodological challenges, fMRI has proved a useful technique for examination of the brain-behaviour relationship in developmental language functions. This paper reviews fMRI studies of language, including reading, in children.

 

3.1
Volume 3 Number 1 2002

---