patients with executive function deficits after acquired brain injury René ter Horst & Suzanne Kruiper
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1 The efficacy of VTS for patients with executive function deficits after acquired brain injury René ter Horst & Suzanne Kruiper
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6 Executive functions The functions that regulate and control cognitive processes. Especially important when behavior is not automatic and routine, in new and complex situations (Shallice 1988)
7 Executive function deficits: examples impulsive difficulty in grasping the whole picture difficulty generating thoughts / ideas /solutions to problems get caught in a thinking rut, cannot easily shift frames of mind In social communication: not listening jumping to conclusions inappropriate comments
8 Critical Thinking the purposeful and reflective judgment about what to believe or what to do in response to observations, experience, verbal or written expressions, or arguments. It involves determining the meaning and significance of what is observed or expressed. Facione (2007) Dauer, Francis Watanabe executive function deficits trouble with critical thinking
9 Fluid intelligence the capacity to think logically and solve problems in novel situations, independent of acquired knowledge. It is the ability to analyze novel problems, identify patterns and relationships that underlie these problems, and the extrapolation of these using logic Executive function deficits trouble with fluid intelligence
10 Rehabilitation of executive function deficits protocol for disexecutive syndrome, Spikman (2010) Goal Management training Problem Solving training Algemene Plannings Aanpak PCR (Policlinic Cognitive Rehabilitation) INR (Intensive Neuro Rehabilitation)
11 How? The group setting: Different perspectives (shift between points of view) Discuss and compare different points of view Highlight agreement or contrasts Invite explanations Ongoing process of exploration and elaboration
12 Art as a medium to practice critical thinking Accessible: no prior knowledge necessary No fixed meaning (therefore no wrong answers) Many layers of interpretation
13 Inclusion Criteria No current cognitive rehabilitation Executive function deficits (DEX > 27) Acquired brain injury, at least 1 year post onset Age Informed consent
14 Design Group A T1 VTS Twice a week for 4 weeks T2 no intervention T3 Randomisation Group B no intervention VTS Twice a week for 4 weeks
15 Rappid Assessment of Problem Solving
16 WAIS III Picture Arrangement
17 WAIS III Comprehension Explain social conventions, rules or expressions
18 Dysexecutive Questionnaire (DEX) (Burgess et al., 1996) Examples Does or says embarrassing things when in the company of others. Loses his/her temper at the slightest thing. Finds it hard to stop repeating saying or doing things once started.
19 Social Communication Skills Q. Examples Thinks of new topics to discuss and questions to ask Allows others to express themselves without interruptions Reads and responds to clues the other person gives Supports opinions with facts
20 ADI and MOI Aesthetic Development Interview (ADI) (Housen, 1983) 2 paintings (3 parallel versions) No aid of facilitator or groupmembers Material Object Interview (MOI) (Housen, 2002) 2 objects: generalisation to different context No aid of facilitator or groupmembers
21 Analysing the ADI and MOI CADRE = Framework - Context - Association - Divergent thinking - Revision - Explanation
22 Context Examples Context That looks like a Monet! I think it is an Italian painter out of Rembrandts time! A Greek nose from the Hellenistic era
23 Association Example Association Oh I love sunflowers, they are such cheerfull flowers. I always bought them for my grandmother. She died seven years ago, her nose was always so red etc.
24 ADI
25 ADI.It seems like that is the edge of a bath, and on top there is something made of fabric.i do not know whether it is something she had wrapped around herself, or if it s her clothes (divergent thinking) No, I do not think it s her clothes (revision), because if this was the case, she would nt have put them aside so carelessly; youcanseethe fabric almost hanging in the water (explanation).
26 MOI
27 MOI
28 Baseline characteristics Group A (n=7) Group B (n=6) Age (14.29) (14.00) Sex male: 4 female: 3 male: 5 female: 1 Time since onset (years) 6.89 (3.83) 9.53 (7.32) Education 5.57 (0.98) 5.00 (1.27)
29 Baseline (cognitive screening) Group A Group B TMT A (6.48) (17.82) TMT B / A (7.80) (7.39) Stroop I (9.96) (13.57) Stroop II (9.61) (12.77)* Stroop III / II (8.95) (8.31) RBMT immediate (12.42) (4.36)* RBMT delayed (12.56) (6.78)
30 Results group A VTS T1 T2 T3 Picture Arrangement 9.43 (3.8) (4.4) (4.22) Comprehension (2.3) (2.8) (2.34) DEX (18.0) (12.0) (16.4) SCSQ self (9.90) (10.3) (14.38) SCSQ proxy (11.3) (12.4) (10.29) RAPS % constraint q (7.3) (8.4) (9.4) RAPS efficiency q (10.2) (23.8) (13.6) RAPS efficiency q (11.2) (9.5) (13.8)
31 Results group A VTS T1 T2 T3 ADI Divergent th 2.00 (1.61) 4.21 (3.88) 4.42 (3.64) MOI Divergent th 3.57 (2.88) 5.21 (4.11) 4.17 (2.44) ADI Revision 0.79 (1.47) 1.36 (1.89) 0.92 (1.56) MOI Revision 1.43 (2.73) 2.21 (1.63) 2.00 (2.12) ADI Explanation 2.71 (2.63) (8.36) (11.07) MOI Explanation 2.21 (2.06) 6.29 (3.97) 6.58 (5.32)
32 Results group B VTS T1 T2 T3 Picture Arrangement 7.67 (2.25) 9.33 (4.13) (4.27) Comprehension 9.50 (2.88) 9.83 (2.64) (2.48) DEX (8.12) (13.7) (8.29) SCSQ self (7.17) (11.27) (5.44) SCSQ proxy (13.03) (9.71) (11.31) RAPS % constraint q (21.35) (18.01) (12.82) RAPS efficiency q (18.33) (24.21) (30.97) RAPS efficiency q (14.7) (15.9) (18.6)
33 Results group B VTS T1 T2 T3 ADI Divergent th 0.50 (0.63) 0.58 (1.02) 1.42 (1.50) ADI Explanation 2.25 (2.66) 3.17 (3.80) 5.42 (4.41) ADI Revision 0.17 (0.26) 0.42 (0.49) 0.33 (0.41) MOI Divergent th 2.25 (2.56) 2.08 (2.40) 1.17 (1.75) MOI Explanation 0.58 (0.38) 1.58 (1.59) 1.00 (1.76) MOI Revision 0.75 (0.99) 0.42 (0.49) 0.58 (0.80)
34 Evaluation: what have you learned? observe in a different manner (more consciously, from a broader perspective) (n=8) revise opinion more easily making it easier to choose between alternatives (n=5) less inclined to jump to conclusions and respond premature (agressively) (n= 5) More inclined to listen to others (n= 4) more awareness (n= 3)
35 Summary Group A improved after VTS: ADI Explanation, MOI Explanation, WAIS III Comprehension Group B did not improve on the tests after VTS: cognitive deficits? Questionnaires (DEX, SCSQ) did not show improvement: better awareness / not all questions applicable
36 Future research Effect of deficits in attention and memory on efficacy of VTS MOI and ADI as outcome measures Goal Attainment Scaling in stead of questionnaires
37 Conclusions VTS seems to improve critical thinking in patients with deficits in executive functioning. Top down & bottom up Compensation and/or new routines
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