8

Executive Function

OVERVIEW

Executive function is generally described as a set of integrated cognitive processes necessary to perform or accomplish everyday life activities. These cognitive processes allow individuals to plan or develop goals, initiate behavior, solve problems, anticipate consequences of actions, monitor progress toward goals, reason, strategize, direct attention to goal-relevant information, and manage time and space (Cicerone et al. 2000; Kennedy et al. 2008). Deficits in executive functions may include an inability to perform these cognitive processes or a lack of awareness that these or other cognitive and physical deficits exist and impede everyday life (Kennedy et al. 2008; Stuss 1991). Therefore, this chapter reviews the evidence for treatment of executive function in two main sections: awareness (i.e., deficits in self-awareness) and non-awareness (e.g., deficits in problem solving, planning, initiating behavior). Because executive function incorporates a number of subprocesses, and there is no consensus on precisely how to subdivide this complex domain, treatment development has typically focused on addressing individual subcomponents rather than the entire domain of executive function. Multiple approaches to the larger executive domain are sometimes included in comprehensive treatment programs. The committee’s conclusions are provided at the end of each section, in awareness and non-awareness.

AWARENESS

The committee could not find any randomized controlled trials (RCTs) of mild traumatic brain injury (TBI) and awareness, perhaps reflecting the



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8 Executive Function OVERVIEW Executive function is generally described as a set of integrated cogni- tive processes necessary to perform or accomplish everyday life activities. These cognitive processes allow individuals to plan or develop goals, initi- ate behavior, solve problems, anticipate consequences of actions, monitor progress toward goals, reason, strategize, direct attention to goal-relevant information, and manage time and space (Cicerone et al. 2000; Kennedy et al. 2008). Deficits in executive functions may include an inability to perform these cognitive processes or a lack of awareness that these or other cognitive and physical deficits exist and impede everyday life (Kennedy et al. 2008; Stuss 1991). Therefore, this chapter reviews the evidence for treatment of executive function in two main sections: awareness (i.e., deficits in self- awareness) and non-awareness (e.g., deficits in problem solving, planning, initiating behavior). Because executive function incorporates a number of subprocesses, and there is no consensus on precisely how to subdivide this complex domain, treatment development has typically focused on addressing individual subcomponents rather than the entire domain of executive func- tion. Multiple approaches to the larger executive domain are sometimes in- cluded in comprehensive treatment programs. The committee’s conclusions are provided at the end of each section, in awareness and non-awareness. AWARENESS The committee could not find any randomized controlled trials (RCTs) of mild traumatic brain injury (TBI) and awareness, perhaps reflecting the 137

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138 COGNITIVE REHABILITATION THERAPY FOR TBI fact that awareness deficits are more typically associated with more severe injuries. The committee reviewed four studies of participants with moderate- severe injuries who were in the chronic stage of recovery—two RCTs (Cheng and Man 2006; Goverover et al. 2007) and two single-subject, multiple baseline experiments of treatments intended to improve awareness of deficits (Sohlberg et al. 1998; Toglia et al. 2010). The committee did not find any nonrandomized, parallel group studies or pre-post designs on awareness. Table 8-1 presents a summary of all included studies in this review. Chronic Phase of Recovery, Moderate-Severe TBI Randomized Controlled Trials Goverover et al. (2007) examined the effects of an awareness training protocol embedded within the practice of instrumental activities of daily living (IADLs) as compared to IADL training without any self-awareness training. The 20 participants had moderate-severe injuries that occurred an average of about 10 months prior to trial entry; participants’ phase of recovery ranged between the subacute and chronic stages. Participants were randomly assigned to either group, and treatments were provided in six, 45-minute sessions, two or three times per week, across 3 weeks. Tasks were identical in the treatment and control groups; however, the treat- ment group participants were asked to predict their own performance on the IADL tasks and to self-evaluate performance immediately after tasks. They received immediate feedback from therapists, as well as instruction to write about their experiences in a journal. Improvement in task-specific self- awareness (AAD scores) was not significantly different between the groups. Improvement in a self-regulation skill inventory was significantly greater in the treatment group, after adjusting for baseline scores. Functional per- formance as reflected by Assessment of Motor and Process Skills (AMPS) scores also improved significantly more for the treated group than for the control group. Distal outcomes (e.g., secondary measures) were not signifi- cantly different between the groups, including an Awareness Questionnaire. Cheng and Man (2006) investigated a newly developed Awareness Intervention Program (AIP) compared to a conventional rehabilitation pro- gram. The AIP focused on improving awareness of the patient’s disease and related deficits such as physical or cognitive function. The AIP included educational sessions based on the types of deficits manifested by the pa- tients and functional training sessions, in which patients practiced setting performance goals and then evaluating their own performance against those goals. The conventional rehabilitation program included physical, functional, and cognitive aspects of occupational therapy. The 21 subjects participating in the study were in the subacute phase of recovery from

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TABLE 8-1 Evidence Table: Executive Function TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings AWARENESS RCT Cheng and 21 Moderate- Comparison of a Y • Self-Awareness of Deficits Analysis showed the Man 2006 Severe systematic intervention, Interview (SADI) AIP training group Awareness Intervention Other CRT Content: • FIM improved significantly Program (AIP), versus Conventional • Lawton Instrumental Activities over conventional conventional rehabilitation, rehabilitation of Daily Living (IADL) scale rehabilitation group. to improve self-awareness. Goverover 10 Moderate- Examined a self-awareness Y • Awareness Questionnaire Improvements in self- et al. 2007 Severe retraining program using • Assessment of Awareness of regulation skill and practice of IADLs to Other CRT Content: Disability functional performance improve task-specific IADL training • Self-Regulation Skills Inventory were significant in self-awareness and (SRSI) intervention group. self-regulation. • Assessment of Motor and Process Skills (AMPS) Single Subject, Multiple Baseline Experiment Sohlberg et al. 3 Moderate- Examined three categories N • Caregiver rating of subject Qualitative analysis 1998 Severe of awareness to determine awareness suggested improved optimal outcome measures • Self/Other Rating Form awareness after in awareness interventions ▪ Caregiver rating treatment via for future research (a pilot ▪ Subject rating behavioral measure; no study). • Photograph (portion of the change in awareness via “Picture This!”) rating Self/Other measures. • Behavioral measure 139 continued

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TABLE 8-1 Continued 140 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Toglia et al. 4 Not Identified multifaceted task N • Proximal outcomes: Participants improved 2010 reported training approach to assess ▪ Executive Function in self-regulatory use of and skill in cognitive Performance Test subtask skills and strategy use strategies to accomplish ▪ Multiple Errands Test across tasks; general tasks and assess changes in ▪ SRSI awareness deficits were general awareness (a pilot • Distal outcomes: unchanged. study). ▪ Awareness Questionnaire ▪ Behavior Rating Inventory of Executive Function NON-AWARENESS RCT Constantinidou 35 Moderate- Evaluating the Y • California Verbal Learning Both groups improved at al. 2008 Severe Categorization Program Test II on a number of (CP) to determine if it Other CRT • Community Integration neuropsychological improves cognitive abilities. Content: Typical Questionnaire (CIQ) measures, and • Part A included object treatment • Control Oral Word Association functional improvement categorization, teaching regimen of the • Mayo-Portland Adaptability was comparable perceptual features to rehabilitation Inventory III between groups; the describe objects or living site • Rey Complex Figure Test experimental group things, and higher levels • Scales of Cognitive Ability for showed significant of cognitive function TBI improvement on more including analyses, • Symbol Digits Modalities Test measures, with better synthesis, linguistic • The Booklet Category Test maintenance. A group flexibility, and abstract • Trail Making Tests comparison for change reasoning; • Wechsler Abbreviated Scale of in neuropsychological Intelligence measures was not performed.

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• Part B included new • Wechsler Memory Scale III category learning, • Wisconsin Card Sorting Test focusing on learning rules • Woodcock-Johnson III for categorization, with use of errorless learning principles and cueing hierarchies. Couillet 12 Severe Research on a rehabilitation Y • Divided Attention Tests: Significant treatment et al. 2010 program for divided ▪ Test for Attention effect shown for attention, i.e., the ability Other CRT Performance (TAP), subtest for dual task on the TAP to complete dual tasks Content: divided attention (divided attention simultaneously (e.g., Nonspecific ▪ Go–no go, and digit span subtest), go–no go, and walking and talking). cognitive • Executive and working digit span. Subjects randomized in a training memory tests: crossover design. ▪ Brown-Peterson Paradigm ▪ Stroop ▪ TAP, subtest for flexibility ▪ Trail Making Test • Rating Scale of Attentional Behaviour 141 continued

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TABLE 8-1 Continued 142 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Evans et al. 19 NR Evaluated the efficacy of a Y • Spot the Word Test or National Improved performance 2009 cognitive–motor dual- Adult Reading Test among treatment group tasking training program to No Content: • Divided Attention and Dual- shown for sentences improve performance with Placebo (no Tasking Battery: and walking dual- dual-tasking difficulties. training) control ▪ Walking task. Treatment group ▪ Clicking showed a reduction ▪ Speed of Comprehension in self-reported Task, adapted difficulties (authors ▪ Tone counting suggest caution in interpretation). Fasotti 22 Severe Evaluates attention deficit Y • Auditory Concentration Test No significant et al. 2000 rehabilitation program, • Dutch version, Rey’s 15 Words difference between Time Pressure Management Other CRT Test groups on use of (TPM). In brief, videotaped Content: • PASAT anticipatory strategies stories, a compensatory Concentration • Rivermead Behavioural or actual task cognitive strategy is training from an Memory Test (RBMT) performance. Treatment outlined with four existing • Visual Choice Reaction Time group showed some objectives: memory training • Visual Simple Reaction Time improvement on • Recognize time pressure program neuropsychological in the task at hand; measures; authors • Prevent as much time do not identify how pressure as possible; strategies could • Deal with time pressure be evaluated by as quickly and effectively standardized tests. as possible; and • Urge the patient to monitor himself while using TPM.

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Hewitt et al. 30 Severe Examines a method to Y • Brixton Test Group by time 2006 aid individuals with • Hayling Test interaction significantly “dysexuctive syndrome,” No Content: • RBMT screening score improved for the or problems with planning Control received • Speed and Capacity of treatment group, but and problem solving, no treatment Language Processing Test no effect for group or with overcoming related • The Modified Six Elements Test time separately. challenges. Levine et al. 30 Moderate- Assessed the effects of Goal Y • Paper-and-pencil tasks Treatment group 2000 Severe Management Training to • Proofreading improved significantly improve disorganized, or Non-CRT • Grouping from pre- to post- maintenance of goal- Content: Motor • Room layout test compared to directed, behavior. skills training • Neuropsychological tests: control. Treatment ▪ Stoop group reported to ▪ Trail Making Test take more time to ▪ WAIS-R, digit symbol complete tasks— subtest authors determined as evidence of care and double-checking. 143 continued

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TABLE 8-1 Continued 144 TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Rath et al. 60 Mild, Group treatment focusing Y • Problem solving tests: Nearly 25 percent of 2003 Moderate- on emotional self- ▪ Perseverative Response score participants overall Severe regulation strategies for Other CRT ▪ Problem Solving Inventory (both groups) dropped problem orientation as Content: (PSI) out prior to post-test well as problem-solving Conventional ▪ Wisconsin Card Sorting Test measures. Both groups skills; including weekly treatment (WCST) improved on a wide “consolidation sessions” to • Psychosocial functioning tests: range of measures review materials and notes ▪ Brief Symptom Inventory generally subject from each group. ▪ Community Integration to practice effects Questionnaire or expectation of ▪ Problem Checklist improvement. ▪ Recreation + Social Interaction composite score ▪ Rosenberg Self-Esteem Scale ▪ Sickness Impact Profile • Cognitive Skills tests: ▪ FAS-COWAT ▪ Stroop Color-Word Task ▪ WAIS-III ▪ Watson-Glaser Critical Thinking Appraisal ▪ Wechsler Memory Scale-III ▪ Weinberg Visual Cancellation Test ▪ Will-Temperament Scale

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Webb and 16 NR Goal setting training Y Goal Attainment Scaling (GAS) Both groups improved Glueckauf involving orientation, goal to comparable degree. 1994 setting, goal monitoring Other CRT Treatment group with use of worksheet and Content: Less maintained effect at follow-up form. intensive goal- 1-month follow-up. setting activities Nonrandomized, Parallel Controlled Group Cicerone 2002 8 Mild Evaluating the efficacy Y • 2 and 7 Test Difference between of a treatment, based on • Attention Rating and groups was significant, conceptualization of deficits No Content: Monitoring Scale (ARMS) self- with treatment related to working memory, Control group report scale group demonstrating to address deficits of did not receive • Continuous Performance Test clinically meaningful attention. treatment of Attention improvement on • PASAT majority of initially • Trail Making Test impaired measures. ▪ Automatic Detection Speed Treatment group ▪ Controlled Processing Speed demonstrated significantly greater reduction in the experience of attentional difficulties. Fong et al. 33 Moderate Examined the effectiveness Y • Key Search test Significant 2009 of a problem-solving • Means-Ends Problem-Solving improvement was skills training program, Other CRT Measure (MEPSM) reported in the delivered to the treatment Content: • Metacomponential Interview treatment group by group, when provided with Conventional (MI) the MI. No significant conventional cognitive cognitive • Modified Six Elements test difference in change training, which all training • Raven’s Progressive Matrices scores between groups participants received. (RPM) for most outcomes. • Social Problem-Solving Video Measure (SPSVM) 145 continued

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146 TABLE 8-1 Continued TBI Severity Study N Level Brief Narrative Comparator Outcome Measures Findings Man et al. 50 NR Evaluated the efficacy Y • Halstead Reitan Test Battery Treatment group 2006 of a pictorial-based (HRTB), Category Test demonstrated some analogical problem-solving No Content: • Lawton IADL scale, Hong improvement in skills training program Placebo (no Kong-Chinese version functional and overall to help patients better treatment) problem-solving learn problem-solving skills, immediately skills through systematic, posttreatment and theoretically driven maintained at 4 weeks. strategies. Manly et al. 10 Mild, Examines treatment for Y • Hotel Task Treatment group 2002 Moderate, dysexecutive syndrome, ▪ Compiling individual bills did not perform Severe or challenges in planning Other CRT ▪ Sorting the charity collection significantly different and problem solving for Content: ▪ Looking up telephone than control. everyday life activities, Controls were numbers using a brief auditory tested on task ▪ Sorting conference labels stimuli to interrupt activity without use of ▪ Proofreading and cue patients to consider auditory cues ▪ Opening and closing garage the overall goal. door • Version B same tests, different timing

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Pre-Post Single Group Constantinidou 23 Moderate- Explores the effects of the N • Categorization tests All participants showed et al. 2005 Severe Categorization Program ▪ Object categorization improvement following (CP), a systematic treatment ▪ New category learning tasks CP training at and program, to improve • Community Integration second posttests. Probe categorization performance. Questionnaire (CIQ) Tasks elicited much • Mayo-Portland Adaptability lower responses from Inventory-3 (MPAI-3) TBI participants than • Probe Tasks at the first probe, and their performance improved systematically in a linear fashion as they received more training on the CP. The overall multivariate probe effect was also significant, reflecting the improvement on the three probes demonstrated by participants with TBI. Fish et al. 20 Severe Examined use of an alerting N • Cambridge Prospective Significant difference 2007 strategy with a content-free Memory Test reported after cued cue to determine utility for • Cattell Culture Fair Test calls versus non-cued a prospective memory task, • Hotel test days. comparing cued and non- • National Adult Reading Test cued days for completion of (NART) telephone calls. • RBMT, story recall • Rey Auditory Verbal Learning Test • Sustained Attention to Response Test (SART) 147 continued • Trail Making Test

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152 COGNITIVE REHABILITATION THERAPY FOR TBI what was likely moderate-severe TBI. The AIP treatment program con- sisted of two individual sessions a day, 5 days per week, for 4 weeks. The AIP group demonstrated significantly improved awareness as compared to the conventional rehabilitation group. Functional outcomes did not differ between the groups. Single-Subject, Multiple Baseline Experiments Sohlberg et al. (1998) conducted a pilot study to assess three categories of awareness measures administered to three individuals with moderate- severe brain injury and their caregivers. Individuals were 7 to 21 years postinjury. This pilot study intended to determine which set of outcome measures would be more useful for further research in awareness interven- tions. Two groups of outcome measures were used to determine improved awareness in participants: behavioral indicators (e.g., increased indepen- dence, decreased interruptive behavior) and perceptions (self and others’ [e.g., caregivers’]) regarding awareness abilities (e.g., caregiver ratings and self-ratings of competency, self-judgments about likely cognitive break- downs depicted photographically, or global ratings by a significant other). The treatment consisted of showing patients pictures of activities they were likely or unlikely to experience as cognitive failures (e.g., forgetting peoples’ names, forgetting to move the wet laundry from the washing machine to the dryer). To judge self-awareness, the examiner asked each subject whether the photographs represent problems they were likely or unlikely to experience. Qualitative analysis suggested dissociation between behavioral and perceptual indicators of awareness. Behavioral measures showed im- proved awareness after treatment; others’/self-perception measures showed no change in awareness. Toglia et al. (2010) conducted a single-subject design trial with four subjects, using a multi-context approach to promote strategy use across situ- ations and increase self-regulation, awareness, and functional performance. Treatment included nine 75-minute treatment sessions, provided twice a week for approximately 5 weeks. Sessions were divided into three phases: error- discovery, strategy training and mediation, and reinforcement of strategy. Each session included different multi-step (i.e., 10–15 steps) tasks, approached in various settings such as a kitchen or office. In qualitative analysis, partici- pants demonstrated improvement in self-regulatory skills and strategy use. General awareness of deficits remained unchanged in these subjects. CONCLUSIONS: AWARENESS The committee found no evidence from two RCTs (Cheng and Man 2006; Goverover et al. 2007) that self-awareness training produced

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153 EXECUTIVE FUNCTION an overall increase in self-awareness beyond the types of tasks and activities that were the subject of self-appraisal (i.e., patient-centered outcomes). The committee found no evidence from two RCTs (Cheng and Man 2006; Goverover et al. 2007) that measured posttreatment follow-up to show whether awareness treatment effects were maintained. The committee found limited evidence from two RCTs (Cheng and Man 2006; Goverover et al. 2007) that showed an immediate increase in accuracy of self-assessment and self-regulation from treatments that involved practice in prediction and evaluation of task performance, for individuals with chronic stage, moderate-severe TBI. The committee found no studies of cognitive rehabilitation therapy (CRT) for awareness deficits in mild TBI or subacute, moderate-severe TBI. The committee reviewed two RCTs and two single-subject, multiple base- line studies to address awareness deficits in patients with moderate-severe TBI in the chronic phase of recovery. The evidence provides no support for long-term treatment effect. Treatment effects show benefit for immediate/ short-term outcomes, such as improvement in self-regulatory skills. NON-AWARENESS The committee reviewed eight RCTs of treatments intended to im- prove cognitive aspects of executive function (i.e., aspects other than self- awareness). These studies speak primarily to treatments for individuals in the chronic phase with at least moderate injuries. Seven of them were conducted in the chronic phase, with one (Couillet et al. 2010) enrolling patients in both subacute and chronic phases. Seven of the studies enrolled only participants with traumatic injuries, while one (Evans et al. 2009) included a mixture of individuals with TBI and stroke, although a major- ity had TBI. Most studies included only patients with moderate or severe injuries, while two RCTs (Levine et al. 2000; Rath et al. 2003) included individuals with mild injuries; however, the results in these two studies were not separated by subgroup for analysis. One study (Evans et al. 2009) defined severity with respect to the executive impairment of interest, rather than injury severity. The ages of those treated ranged from the late 20s to early 40s. The studies enrolled a total of 218 participants, with sample sizes in each treatment arm ranging from 5 to 30. Two of these studies com- pared the experimental intervention to no treatment (Hewitt et al. 2006, used an unfilled waiting interval; Evans et al. [2009], used “usual care”), one to a physical skill training intervention (Levine et al. 2000), and five

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154 COGNITIVE REHABILITATION THERAPY FOR TBI to other forms of cognitive treatment. Five of the treatments studied were compensatory in nature, two (Couillet et al. 2010; Evans et al. 2009) were restorative, and one (Constantinidou et al. 2008) was less clearly classifiable between restorative and compensatory. The committee also identified four nonrandomized, parallel group designs, four pre-post single group designs, and six single-subject, multiple baseline experiments. Chronic Phase of Recovery, Moderate-Severe TBI Comparator Group: No or Minimal Content Evans et al. (2009) evaluated the effectiveness of a 5-week cognitive– motor dual-tasking training program developed to improve the performance of a group of people with divided attention difficulties arising from brain injury and thought to place demands on executive function. A treatment group of 10 people was compared with a control group of 9; the control group received no training. The intervention involved twice-daily exercises involving walking in combination with tasks of increasing cognitive de- mand over the course of the intervention. The primary outcome measure was a task requiring participants to walk and carry out a spoken sentence verification task simultaneously. Secondary outcome measures were mea- sures of dual-tasking involving either two motor tasks or two cognitive tasks. A questionnaire measure relating to daily activities requiring divided attention was also completed. Compliance with the training program was good. Results showed evidence of improvement in performance on the pri- mary outcome measure, but little evidence of generalization to other mea- sures. Some evidence showed that participants believed their dual-tasking performance in everyday life improved after the intervention. The study was limited in terms of sample size, was not blinded, and did not control fully for therapist contact time, but it has produced valuable data relating to effect sizes associated with this form of intervention. Hewitt et al. (2006) assessed participants’ ability to develop a plan to accomplish a minimally familiar task such as planning a trip. Participants were asked to list the steps required to accomplish a simulated task prior to treatment. They were randomized to then have a 30-minute break or 30 minutes of instruction in an approach to task planning that asked them to recall an example of a similar activity that they had planned in the past and consider that task in planning a new one. The outcome measures were number of steps listed and effectiveness of the new plan, and they were assessed immediately after the break/strategy training by raters blinded to the group assignment. Both groups improved on these measures, with the strategy training group improving more from pre- to posttest. This study suggests that such a strategy is useful in improving the planning of complex

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155 EXECUTIVE FUNCTION activities, but does not answer the question of whether the strategy can be trained in such a way that it is retained and used in daily life. Comparator Group: Non-CRT Content Levine et al. (2000) assessed a strategy entitled Goal Management Training (GMT), in which an overt sequence of steps leading from a goal, to a set of actions to accomplish the goal, to a checking process that as- sesses progress toward that goal, is taught as a way to enhance the comple- tion of goal-directed activities. Participants attempted to perform a set of laboratory-based simulations of real-world tasks, which were scored for time and errors. The participants were then randomized to receive either a motor skills training group or a GMT group for a single, 4- to 6-hour training session. In the GMT group, the training session involved didactic teaching of the GMT concept and practice applying it to a set of simulated activities similar to those used at baseline. Subsequently, both groups were reassessed on a similar set of simulated activities. The degree of improve- ment in errors from pre- to posttesting was significantly larger for the GMT group than the motor skills group, and GMT group members performed some activities more slowly, interpreted as evidence of care and “checking.” Although two of the trained activities were used in the assessment, another task that was not part of the GMT also showed differential improvement suggestive of short-term generalization of the strategy. This study suggests that GMT can be helpful when used, but does not answer the question of how to achieve regular spontaneous use of the strategy in daily life. Comparator Group: Other CRT Content Constantinidou et al. (2008) examined whether intensive training in categorization results in improvement in two untrained categorization tasks, a battery of neuropsychological tests, and a functional assessment scale. The comparison group received “usual care” including a range of cognitive rehabilitation activities, but without an intense focus on catego- rization training. Both groups received approximately 60 hours of training over about 13 weeks. The experimental group performed significantly bet- ter on both categorization tasks after treatment than the comparison group, whereas the two groups did not differ significantly prior to treatment. Also, the ability to categorize appeared better maintained across follow-up probes in the experimental group. Both groups improved on a number of the neuropsychological measures, and the experimental group improved significantly on more of them. However, a comparison of change in neuro- psychological measures was not conducted. Functional improvement was comparable between the two groups. These conclusions are tempered by the

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156 COGNITIVE REHABILITATION THERAPY FOR TBI small group size, the fact that direct tests that group by time comparison were not statistically significant, and the lack of direct comparison of the neuropsychological outcomes. Couillet et al. (2010) conducted a randomized crossover design ad- dressing divided attention difficulties. The study included 12 patients at a subacute or chronic stage of recovery after severe TBI. Treatment consisted of training to perform two concurrent tasks using a hierarchical order of difficulty that progressively increased task difficulty following each patient’s individual improvement. A variety of task combinations were used during training. The control group practiced a range of computerized and paper and pencil tasks that did not require divided attention. Training lasted 6 weeks, with four, 1-hour sessions per week. Outcome measures included specific divided attention measures, other executive and working memory tasks, nontarget cognitive tasks to assess the specificity of treatment, and the Rating Scale of Attentional Behaviour addressing attentional problems in everyday life. The authors reported a significant treatment effect for divided attention measures and on the divided attention item of the Rating Scale of Attentional Behaviour. Less consistent effects were seen on other executive and working memory measures, and no significant effect was seen on nontarget measures. Fasotti et al. (2000) studied a strategy training intervention entitled Time Pressure Management (TPM), which is based on the premise that slowed information processing leads to task failures and that strategies such as avoiding interruptions, taking the necessary time, taking pauses, etc., may lead to improved task performance. The experimental group was taught this strategy and practiced it for about 7 hours over 2 to 3 weeks. The comparison group was given didactic instruction in “how to concen- trate.” Both were then assessed on two simulated tasks in which they had to recall directions provided via videotape or perform a computer task when given recorded directions. Performance on these tasks was coded with re- spect to specific TPM strategies that were performed in anticipation of task problems and in response to task problems, as well as quality of actual task performance. Both groups were also assessed on a range of neuropsycho- logical and psycho-social measures. After treatment, the two groups did not differ on the use of anticipatory strategies; the TPM group using TPM strat- egies in response to task problems. Actual task performance did not differ between the groups. Interestingly, performance on the neuro-psychological test battery, but not the psychosocial measures, improved more in the TPM group, despite the fact that it is not obvious how the strategies taught can be applied during standardized testing. Rath et al. (2003) compared two multi-component group treatment programs for problem solving deficits. Both groups received 2 to 3 hours of treatment per week over 24 weeks, although the experimental group

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157 EXECUTIVE FUNCTION received treatment in a single, longer weekly block while the comparison group had shorter sessions across the week. The experimental group fol- lowed a structured lesson plan that started with problem orientation (i.e., identification of problems, attitudes toward problem solving, attribution of problem sources) and then focused on applying specific problem solv- ing strategies to real-world problems. The comparison group’s treatment focused on several different cognitive domains as well as psychosocial ad- justment, but without the specific focus on a problem solving framework. Multiple outcome measures focusing on attention, memory, problem solv- ing, emotional adjustment, and physical symptoms, as well as caregiver reports, were assessed. Unfortunately, 5 of 32 participants assigned to the experimental group and 9 of 28 participants assigned to the comparison group dropped out prior to outcome assessment (nearly 25 percent overall). Moreover, the degree of improvement seen in the two groups was not di- rectly compared statistically. Relative improvement between the two groups was impossible to assess because the outcome measures that improved sig- nificantly within each group (10 measures in the experimental group, 8 in the comparison group) were reported with effect sizes. However, no effect sizes were reported for those measures that did not improve significantly, nor were confidence intervals around the effect sizes reported. Both groups appeared to show significant improvement in a wide range of measures, but some of the measures are subject to practice effects and/or expectation of improvement. Webb and Glueckauf (1994) assessed whether participant involvement in setting and reviewing treatment goals affected progress toward those goals or retention of improvement. Two groups participated in the identi- fication of a priority behavioral goal, as well as a goal attainment scaling (GAS) exercise to anchor potential outcomes with respect to that goal into a five-point scale. One group was involved in more intensive discussion of the goal and more intensive review and reflection on the goal and progress toward it at weekly follow-up sessions. Both groups made progress on the GAS scale from pre- to posttreatment. The intensive goal group maintained this improvement at 2-month follow-up, whereas the other group regressed by the follow-up assessment. Each group lost participants; two dropped from the intensive training, and three dropped out from the other. More- over, the degree of GAS improvement or maintenance was not statistically assessed head to head. Nonrandomized, Parallel Group Designs Fong and Howie (2009) studied a program of explicit problem solv- ing training. Experimental and control groups were formed from pairs of participants matched on demographic and injury severity measures. All

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158 COGNITIVE REHABILITATION THERAPY FOR TBI participants received conventional cognitive training composed of func- tional skills training. The experimental intervention consisted of additional explicit training in problem solving skills with an emphasis on metacom- ponential strategies, delivered in 22 75-minute sessions over 15 weeks. The treatment was oriented toward the primary metacomponents of problem solving: defining the problem, representing the problem, planning problem solving strategies, monitoring selected strategies, and evaluating outcomes. Patients from the treatment group improved significantly on tests that as- sessed metacognitive ability. The significance level of this result would not have survived corrections for multiple comparison, and it was not clear which of the 22 outcome measures would have been considered sufficiently relevant to require correction. This and the other nonrandomized, parallel group studies (Cicerone 2002; Man et al. 2006; Manly et al. 2002), single group pre-post studies (Constantinidou et al. 2005; Fish et al. 2007; Marshall et al. 2004; Serino et al. 2007), and single-subject, experimental designs (Dawson et al. 2009; Delazer et al. 1998; Ehlhardt et al. 2005; Nott et al. 2008; Vallat-Azouvi et al. 2009; Zencius et al. 1998) provided modest support for the conclusions of the RCTs. In general, the methodology of these studies was weaker, not only due to the nonrandomized nature of treatment assignment or single group design, but also due to very small sample sizes and inappropriate use of statistics in some cases. Like several of the RCTs, many were pilot studies or proof-of-principle trials that aimed to test the potential for a new intervention to be utilized in larger studies with more substantial statistical power. In addition, the generalizability of some of the studies was limited due to extensive methodological overlap between the intervention and the pri- mary outcome measures (e.g., Constantinidou et al. 2005; Ehlhardt et al. 2005; Marshall et al. 2004). However, supportive evidence was provided for interventions that demonstrated early promise, some of them with im- plications for the functional consquences of the interventions. Externally originated alertness enhancement (random beeps during a reasoning task) facilitated attention and reasoning performance during a time-allocation task (Manly et al. 2002). The notion that metacognitive interventions such as context-free reminders could be successfully applied to facilitate memory for real-world tasks was also supported (Fish et al. 2007). CONCLUSIONS: NON-AWARENESS Not Informative • T he committee found studies of goal management training, inten- sive goal setting, familiar tasks as a planning template, and TPM

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159 EXECUTIVE FUNCTION (Constantinidou et al. 2008; Fasotti et al. 2000; Hewitt et al. 2006; Levine et al. 2000) not informative for conclusions about the impact on patient-centered outcomes (quality of life, functional status). • T he committee found studies of goal management training, inten- sive goal setting, familiar tasks as a planning template, TPM, or training in divided attention (Constantinidou et al. 2008; Couillet et al. 2010; Evans et al. 2009; Fasotti et al. 2000; Hewitt et al. 2006; Levine et al. 2000) not informative regarding measures of posttreatment follow-up to show whether goal management train- ing treatment effects were maintained. • T he committee found studies of goal management training, inten- sive goal setting, familiar tasks as a planning template, and TPM (Constantinidou et al. 2008; Fasotti et al. 2000; Hewitt et al. 2006; Levine et al. 2000) not informative to show benefit from goal man- agement training beyond the training session for individuals with chronic, moderate-severe TBI. Limited Evidence • T he committee found limited evidence for conclusions about the impact (efficacy) of training in divided attention on patient-centered outcomes (Couillet et al. 2010; Evans et al. 2009). • T he committee found limited evidence that training in divided attention led to immediate enhancement of divided attention per- formance beyond the combination of tasks trained (Couillet et al. 2010; Evans et al. 2009). In summary, the committee evaluated a wide range of strategies, pri- marily compensatory, in patients with executive deficits related to moderate- severe TBI. There is evidence that GMT, using prior planned tasks as guides to planning new tasks, intensive involvement in goal setting, and delivery of content-free alerting stimuli during performance of complex tasks, may enhance task accomplishment. However, these studies did not establish the spontaneous use of these strategies after longer-term treatment or the breadth of tasks for which such strategies might be beneficial. The evidence for TPM is weaker since the use of the trained strategies did not result in clear improvements in performance, and, again, longer-term treatment with intent to generalize to daily life was not studied. The benefits of categoriza- tion training are less clear from research to date. Two of the trials (Hewitt et al. 2006; Levine et al. 2000) were essentially proof of principle studies, which assessed the immediate benefit of a single session of strategy training, as opposed to the longer-term benefit of a course of treatment.

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160 COGNITIVE REHABILITATION THERAPY FOR TBI Studies of divided attention training provided somewhat conflicting re- sults. Both studies suggest improvement in performance of combinations of tasks that were performed together in training (Couillet et al. 2010; Evans et al. 2009), but only one (Couillet et al. 2010) suggested generalization to other task combinations. Because many combinations of tasks were used in training and their similarity to the outcome tasks is unclear, the degree of generalization implied by the outcome task performance improvement is unclear. Other intensive executive treatments, such as those studied by Rath et al. (2003), are difficult to assess because of the lack of direct compari- son to an alternative treatment (i.e., comparator included other CRT-like components). Because of the preliminary nature of most of the executive treatments studied, patient-centered outcomes were rarely included in the outcome measures. Thus, although several compensatory strategy training approaches show enhanced executive management of complex tasks on a short-term basis, there is limited evidence from two RCTs to document longer-term change to demonstrate the impact of such treatments on real- world performance (Couillet et al. 2010; Evans et al. 2009). REFERENCES Cheng, S. K., and D. W. Man. 2006. Management of impaired self-awareness in persons with traumatic brain injury. Brain Injury 20(6):621–628. Cicerone, K. D. 2002. Remediation of “working attention” in mild traumatic brain injury. Brain Injury 16(3):185–195. Cicerone, K. D., C. Dahlberg, K. Kalmar, D. M. Langenbahn, J. F. Malce, T. F. Bergquist, T. Felicetti, J. T. Giacino, J. P. Harley, D. E. Harrington, J. Herzog, S. Kneipp, L. Laatsch, and P. A. Morse. 2000. Evidence-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine and Rehabilitation 81:1596–1615. Constantinidou, F., R. D. Thomas, V. L. Scharp, K. M. Laske, M. D. Hammerly, and S. Guitonde. 2005. Effects of categorization training in patients with TBI during post- acute rehabilitation: Preliminary findings. Journal of Head Trauma Rehabilitation 20(2):143–157. Constantinidou, F., R. D. Thomas, and L. Robinson. 2008. Benefits of categorization train- ing in patients with traumatic brain injury during post-acute rehabilitation: Additional evidence from a randomized controlled trial. Journal of Head Trauma Rehabilitation 23(5):312–328. Couillet, J., S. Soury, G. Lebornec, S. Asloun, P. A. Joseph, J. M. Mazaux, and P. Azouvi. 2010. Rehabilitation of divided attention after severe traumatic brain injury: A randomised trial. Neuropsychological Rehabilitation 20(3):321–339. Dawson, D. R., A. Gaya, A. Hunt, B. Levine, C. Lemsky, and H. J. Polatajko. 2009. Using the Cognitive Orientation to Occupational Performance (CO-OP) with adults with ex- ecutive dysfunction following traumatic brain injury. Canadian Journal of Occupational Therapy/Revue Canadienne D’Ergotherapie 76(2):115–127. Delazer, M., T. Bodner, and T. Benke. 1998. Rehabilitation of arithmetical text problem solv- ing. Neuropsychological Rehabilitation 8(4):401–412.

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