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Rehabilitation of executive dysfunction: A controlled trial of an attentionand problem solving treatment groupEliane C. Miotto a; Jonathan J. Evans bc; Mara C. Souza de Lucia a;Milberto Scaff a

a Hospital das Clinicas, University of Sao Paulo, Brasil b Section of Psychological Medicine, Universityof Glasgow, UK c Oliver Zangwill Centre for Neuropsychological Rehabilitation, Ely, UK

To cite this Article Miotto, Eliane C. , Evans, Jonathan J. , Souza de Lucia, Mara C. andScaff, Milberto(2009) 'Rehabilitationof executive dysfunction: A controlled trial of an attention and problem solving treatment group', NeuropsychologicalRehabilitation, 19: 4, 517 — 540To link to this Article: DOI: 10.1080/09602010802332108URL: http://dx.doi.org/10.1080/09602010802332108

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Rehabilitation of executive dysfunction: A controlled

trial of an attention and problem solving

treatment group

Eliane C. Miotto1, Jonathan J Evans2, Mara C. Souza de Lucia1,and Milberto Scaff1

1Hospital das Clinicas, University of Sao Paulo, Brasil; 2Section of

Psychological Medicine, University of Glasgow, UK and Oliver Zangwill Centre

for Neuropsychological Rehabilitation, Ely, UK

In this study, the effectiveness of a group-based attention and problem solving(APS) treatment approach to executive impairments in patients with frontallobe lesions was investigated. Thirty participants with lesions in the frontallobes, 16 with left frontal (LF) and 14 with right frontal (RF) lesions, were allo-cated into three groups, each with 10 participants. The APS treatment was initiallycompared to two other control conditions, an information/education (IE)approach and treatment-as-usual or traditional rehabilitation (TR), with each ofthe control groups subsequently receiving the APS intervention in a crossoverdesign. This design allowed for an evaluation of the treatment through assessmentbefore and after treatment and on follow up, six months later. There was animprovement on some executive and functional measures after the implemen-tation of the APS programme in the three groups. Size, and to a lesser extent later-ality, of lesion affected baseline performance on measures of executive function,but there was no apparent relationship between size, laterality or site of lesion andlevel of benefit from the treatment intervention. The results were discussed interms of models of executive functioning and the effectiveness of domain specificinterventions in the rehabilitation of executive dysfunction.

Keywords: Executive function; Problem solving; Rehabilitation; Frontal lobes;Brain injury.

Correspondence should be sent to Eliane C. Miotto, Division of Psychology and Department of

Neurology,Hospital dasClinicas – InstitutoCentral,RuaDrEneas deCarvalhoAguiar155, PAMB,

Terreo, CEP 05403-000 Cerqueira Cesar, Sao Paulo – Sao Paulo, Brasil. E-mail: [email protected]

NEUROPSYCHOLOGICAL REHABILITATION

2009, 19 (4), 517–540

# 2008 Psychology Press, an imprint of the Taylor & Francis Group, an Informa business

http://www.psypress.com/neurorehab DOI:10.1080/09602010802332108

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INTRODUCTION

Evidence for the effectiveness of treatments for impairments in executivefunctioning remains scarce. In part, this may be because the development ofrehabilitation interventions for this area of cognitive functioning has beenlimited by a lack of conceptual clarity and consensus on the precise definitionof executive function and dysfunction. The term executive function hasprimarily been linked with an anatomically based description of a variety offunctions attributed to the frontal lobes (Fuster, 1997; Stuss & Benson,1986). Baddeley (1986) coined the term “dysexecutive syndrome” to charac-terise the range of impairments that commonly arise with frontal lobe lesions.In the last two decades numerous studies have indicated the presence ofdissociations in the cognitive functions served by the frontal lobes and thishas led to more circumscribed descriptions of the component processeswithin the broader construct of executive functions. The general concept ofexecutive functions has thus been associated with more specific concepts ofproblem-solving, planning and organisation, initiation, monitoring, and beha-viour regulation (Baddeley & Wilson, 1988; Duncan, 1986; Miotto, 1994;Miotto et al., 2006; Shallice, 1988; Stuss, 2007). Cicerone, Levin, Malec,Stuss, and Whyte (2006) break down the broader concept of executivefunctioning into four domains: (1) executive cognitive functions – involvedin the control and direction of action; (2) behavioural self-regulatory func-tions – involved in emotional reward processing; (3) activations regulatingfunctions – providing initiative and energising behaviour; and (4) metacogni-tive processes. Focusing on the first of these domains, there are a number oftheoretical models of control of everyday action and its fractionation(Duncan, 1986; Grafman, 1989; Kimberg & Farah, 1993; Norman & Shallice,1986), but perhaps the most influential model is that of Norman and Shallice(1986), which characterises a key function of the frontal lobes in terms of asupervisory attentional system.

The supervisory attentional system

Norman and Shallice (1986) argued that two systems control action, thecontention scheduling system (CSS) and the supervisory attentional system(SAS). The former is conceived as a hierarchically structured network ofaction schemas or well-learned action sequences. The SAS is invoked incircumstances where the CSS does not contain a schema for the desired beha-viour or where it is necessary to avoid strong habitual responses by exciting orinhibiting particular schemas within the CSS to achieve an intended aim orgoal. Subsequently, Shallice and Burgess (1996) suggested an internal struc-ture for the SAS, describing the function of the SAS in terms of problemsolving and fractionating it into a set of sub-processes. In novel situations

518 MIOTTO ET AL.


the interaction between the SAS and CSS is effected through: (1) a planningprocess leading to the construction (by the SAS) of temporary new schemas,(2) a special purpose working memory system holding relevant informationon-line for the implementation of the temporary new schema, and (3) asystem responsible for monitoring and evaluation which allows or rejectsactions according to the problem solution.

Shallice and Burgess’s model thus provides a structured problem-solvingframework, divided into stages consisting of more basic dissociable cognitiveprocesses, which can potentially be examined independently. This has specialrelevance to rehabilitation in that, as suggested by Crepeau, Scherzer,Belleville, and Desmarais (1997), it allows for the possibility of more preciseidentification of impaired and preserved components of executive functions.For each stage of the problem solving process, a number of co-ordinated evenmore basic cognitive processes are required, including, for example, attentionalskills in order to notice that a problem exists, episodic and semantic memory fora referential reserve of potential actions, working memory to hold in mind andevaluate alternative solutions, in addition to mood and motivation factors(Dritschel, Kogan, Burton, Burton, & Goddard, 1998; Evans, 2001; Evans,Williams, O’Loughlin, & Howells, 1992). In this context, breakdown cantake place in one or more stages and processes. For instance, patients may beimpulsive if they are impaired in the ability to plan, but are intact in theirability to translate intention into action. By contrast, another patient may beable to create a plan and solution to a problem but not be capable of translatingan intention into action, leading to initiation difficulties (and descriptions such asinertia or adynamia).

In summary, according to this model, problem-solving depends upon threebroad processes: (1) “on-line monitoring” or awareness of problem existence,and monitoring/evaluation of plan implementation; (2) development of aplan of action; and (3) initiation and implementation of action or translationof intention into action. Relevant to the present study, the use of a problem-solving framework can potentially provide an effective way to structure andevaluate rehabilitation treatment for people with a dysexecutive syndrome.

Intervention approaches to the dysexecutive syndrome

The main treatment approaches to the dysexecutive syndrome described inthe literature can be classified as interventions with the aim of: (1) restoringor re-training executive functions; (2) compensating for executive impair-ments through the use of internal or external strategies; (3) promoting modi-fication of the environment or behaviour by working with carers, family andfriends and behaviour modification techniques; and (4) pharmacologicaltreatments. At the present time, evidence for the effectiveness of interventionsin each of these areas is rather limited. Perhaps the most substantial body of

NEUROPSYCHOLOGICAL REHABILITATION OF EXECUTIVE FUNCTION 519


evidence relates to evaluations of group-based interventions involving train-ing in problem solving (Rath, Simon, Langenbahn, Sherr, & Diller, 2003; vonCramon, Matthes von Cramon, & Mai, 1991).

Von Cramon et al. (1991) developed a problem solving therapy (PST)group programme, with the aim of enabling patients to be more effective inbreaking down problems, adopting a slowed down, controlled and stepwiseprocessing approach in contrast to the more usual impulsive approach.Drawing on the work of d’Zurilla and Goldfried (1971) the aim of thegroup programme was to enhance skills in each of the separate stages ofproblem solving through the use of tasks and exercises that require ormake demands on skills involved in each of the stages. Von Cramon et al.(1991) compared a group of patients who received PST with a controlgroup who received memory therapy, finding that the PST group improvedto a greater extent on tests of problem solving, although no evidence was pre-sented in relation to generalisation to everyday functioning. Similarly Rathet al. (2003) compared outcome for 27 patients who undertook a similarform of problem solving training with a control group of 19 patients whoreceived “conventional” therapy. They found greater improvement for theproblem solving training group on measures of problem-solving and a role-play of a practical problem solving scenario that was rated by independentraters.

Another treatment approach that has shown some promise is goal manage-ment training (GMT; Robertson, 1996). This technique was derived fromDuncan’s (1986) concept of goal neglect and involves training patients todevelop a mental checking routine (using the metaphor of checking amental blackboard), combined with a strategy of very clearly defining agoal to be achieved, learning the steps required to achieve the goal andthen regularly checking progress as part of the mental checking routine.Levine et al. (2000) described some preliminary evaluation of this approachwith positive results and the training has recently been shown to be effectivein healthy older adults (Levine et al., 2007).

The attention and problem solving group approach

Recently, Evans (2001, 2005) described an attention and problem solving(APS) group programme, which was loosely adapted from a combination ofVon Cramon et al.’s (1991) problem solving therapy and Robertson’s(1996) goal management training. The APS group was developed as one com-ponent of a holistic rehabilitation programme (Wilson et al., 2000) and runsover a period of 8 to 10 weeks, twice weekly for about an hour eachsession. The aim of the initial sessions is to address attentional difficultiesand the latter ones to introduce and practise the use of a problem solvingframework (PSF). The PSF has a format of a paper-based checklist with

520 MIOTTO ET AL.


an associated exercise template (see Figures 1 and 2). The main aim of thegroup is to encourage participants to adopt a systematic approach to identify-ing ways of solving problems (preventing a more impulsive approach) andmanaging/monitoring goal achievement through development of a mentalchecking, goal management routine. Within the group programme, specificcomponents of executive functioning are targeted as follows:

Problem awareness (meta-cognitive processes), monitoring andevaluation. One aim of the treatment is to increase insight and awarenessof how difficulties impact on everyday tasks. For this, clients and staffwork on self-monitoring sheets (for recording problems as they occur inday-to-day life), receive education about the nature of the brain injury andconsequences on behaviour and carry out a series of exercises simulating

Figure 1. Attention and problem solving framework template.



the different types of attentional demands (sustained, selective, and dividedattention). Tasks that also make demands on planning and goal management(e.g., practical forms of multiple elements tasks) are also used. In part the aimof these programme components is to develop meta-cognitive skills.Subsequently, clients are trained on specific internal and external strategiesfor managing attention difficulties, including using the GMT concept ofchecking the mental blackboard, time management strategies, environmentmodification, cue cards, and watch alarms.

Developing a plan. A major focus within the group programme is onteaching clients to replace impulsive or inappropriate responses with more

Figure 2. Problem solving framework template.

522 MIOTTO ET AL.


effective planning skills, based on the steps illustrated in the PSF (see Figure 1).Amajor focus of thiswork is on teaching a “STOP: THINK!” strategy, a formofself-instruction that is aimed at encouraging clients to interrupt impulsive actionwhen faced with a problem or goal to achieve. Practice at using the PSF is givenwith both hypothetical and real life problems, incorporating goal managementtraining with application of the PSF. When using the PSF, patients are encour-aged to generate a range of possible solutions to problems presented, usingdivergent thinking, and to create strategies for managing the implementationof plans using attention strategies, memory aids, etc. In the final stage of theprogramme, clients are asked to plan and perform a day activity away fromthe centre using the PSF.

Initiating and implementing a plan. Some patients have difficulty intranslating intention into action or initiation problems. Within the group pro-gramme patients learn to compensate for such difficulties using electronicreminder systems (e.g., watch alarms, pagers), often in conjunction withexternal memory aids such as diaries, checklists, etc. and are encouraged toadopt daily routines in order to cope with difficulties related to unstructuredand unpredictable situations.

There has been no formal evaluation of the APS group approach, as yet.There are considerable difficulties, related to the issue of experimentalcontrol, in investigating individual components of a holistic rehabilitationprogramme. The aim of the current study was therefore to investigate,outside of a holistic rehabilitation environment, the effectiveness of the APStreatment approach in a group of patients with executive impairments usingtwo experimental control groups, in a cross-over design. Cicerone et al.(2006) highlighted the pressing need to address the question of whether reha-bilitation that targets impairments in specific executive function domains iseffective in changing both the specified impairments and associated activitiesand participation. This study aimed to do this by examining the impact of atargeted intervention approach, using traditional measures of executive func-tioning and measures aimed at reflecting participation in everyday activities,with a group of people with clearly documented frontal lobe damage.

METHOD

Participants

In the current study, 30 participants with lesions in the frontal lobes took part,all of them recruited from the outpatient service of the Neurology Department,Hospital das Clinicas, University of Sao Paulo, Brazil. There were 16 partici-pants with left frontal lesions (LF) and 14 with right frontal lesions (RF).



Among them, 23 had undergone neurosurgery for the removal of a tumour(9 cases of meningioma and 14 cases of low grade astrocytoma) and 7 hadsuffered a mild TBI from a road traffic accident resulting in a mainly frontallobe lesion. The site of the lesions included the orbitofrontal cortex (OFC,n ¼ 9), dorsolateral prefrontal cortex (DLPFC, n ¼ 8) and orbitofrontal com-bined with dorsolateral prefrontal cortical lesions (OFC/DLPFC, n ¼ 13).Seven patients were on anti-convulsive medication. The average time sinceinjury or surgical procedure was 2.4 years (SD ¼ 1.04). The 15 male and 15female participants were aged between 25 and 60 years (mean 41.7;SD ¼ 9.72). The number of years of education ranged between 5 and 16years (mean 9.17; SD ¼ 2.88). Employment status was categorised asfollows: Full-time employment/study (n ¼ 3); part-time employment/study/volunteer work (n ¼ 8); unemployed (n ¼ 19). All participants reportedno prior involvement with a neuropsychological rehabilitation programme.A number of neuropsychological measures were administered before andafter the interventions in order to characterise the patients and to measure theimpact of the group programme. Inclusion criteria included having a deficitin at least one measure of executive functioning and evidence that everydayfunctioning was significantly affected by the cerebral lesion (e.g., inability toreturn to previous work/study activity, impulsivity, apathy, etc.) determinedby an independent professional (neurologist, neurosurgeon or other healthcare professional). None of the patients had a prior history of psychiatric dis-orders or neurodegenerative conditions. The study had ethical committeeapproval by the Hospital das Clinicas, University of Sao Paulo, Brazil andall participants and their carers signed an informed consent.

Procedure

Design

A counterbalanced, cross-over experimental design was used. The 30participants were allocated into three groups (G1, G2 and G3), each with10 subjects. Allocation to group was pseudo-random in that initial allocationto groups of half of the participants was random, with the second half allo-cated in order to ensure that groups were matched for age, education, timesince injury and performance on the main baseline neuropsychological tests(see Table 1).

Following baseline assessment (Assessment 1) by three examiners, Group1 received the attention and problem solving (APS) intervention. The APSgroup received 10 weekly sessions of attention and problem solving trainingprovided by two neuropsychologists. The group ran once a week for an hourand a half each session. Following baseline assessment (Assessment 1),Group 2 received an information and education (IE) intervention. The IE

524 MIOTTO ET AL.


control group received an educational material in a booklet format with infor-mation about brain injury, cognitive, behavioural and social consequencesand suggestions for cognitive exercises using the mental blackboard andproblem-solving framework with the only instruction to read the booklet ascarefully as possible and try to apply the exercises suggested, at home.Following baseline assessment (Assessment 1), Group 3 received any usualtreatment, such as physiotherapy, when needed, but did not receive anyspecific cognitive rehabilitation intervention (as this was not part of usualtreatment). Following the first intervention period, all patients were reas-sessed (Assessment 2). Then, Groups 2 and 3 received the APS intervention.After this, all patients were again reassessed (Assessment 3). Six months afterthe end of the APS intervention, patients were reassessed for a final time(Follow Up).

Assessment procedures

A number of neuropsychological tests and a questionnaire examiningdysexecutive syndrome (DEX) were administered to all participants at thethree baseline assessments and at follow up (see Table 1). In addition, partici-pants carried out a functional task (Modified Multiple Errands Task),described below, developed and piloted for this study, in order to investigategeneralisation of strategies to real-life situations. For each assessment the fol-lowing neuropsychological measures were administered:

Assessment 1 (Baseline). FSIQ (WASI),Digit Span (WMS-III),WarringtonRecognition Memory for Words and Faces (Camden Memory Tests), LogicalMemory I and II and Visual Reproduction I and II (WMS-III), WisconsinCard Sorting Test (WCST), Verbal Fluency (FAS), Virtual Planning Test(VIP; Miotto and Morris, 1998, which assesses planning, sequencing andorganisation of daily life activities in the laboratory), Digit Symbol(WAIS-III), the DEX Questionnaire from the Behavioural Assessment of

TABLE 1Experimental design

A 1 I 1 A 2 I 2 A 3 FU

G1 � APS � — � �

G2 � IE � APS � �

G3 � TR � APS � �

G ¼ group, A ¼ Assessment�, I ¼ Intervention received: Attention and Problem-Solving Group

(APS); Information and Education (IE); Traditional rehabilitation (TR); FU ¼ follow up at 6 months.



the Dysexecutive Syndrome (BADS), and the Modified Multiple ErrandsTask (see below for a description of this task).

Assessment 2. Digit Span (WMS-III), Warrington Recognition Memoryfor Words and Faces, Logical Memory I and II and Visual Reproduction Iand II (WMS-III), WCST, FAS, VIP, Digit Symbol, DEX and Modified Mul-tiple Errands Task.

Assessment 3. WCST, FAS, VIP, DEX and Modified Multiple ErrandsTask.

Follow up (6 months later). WCST, FAS, VIP, DEX and ModifiedMultiple Errands Task

Modified Multiple Errands Task (MMET)

This task was adapted from the Multiple Errands Task of Shallice andBurgess (1991). Participants were taken to a local shopping precinct andasked to carry out a series of activities requiring planning, strategy, sequencingand monitoring of behaviour and spend a limited amount of money given inadvance. The activities were written on an instruction card given to them,which they could consult throughout the activity. For baseline 2 and 3 theywere taken to a novel nearby area and asked to carry out similar activities. Atfollow up they carried out the same tasks in the same environment as in baseline1. The instructions for the functional taskwere as follows: “Wewould like you toperforma number of activities in the next 15minutes. Theywill bewritten in thiscard given to you so you can consult themat any time.Youwill receive a piece ofpaper, a pencil and 1.50 (local money), which you will have to use according tothe instructions and return allmaterials to the examiner at the end.Make sure youunderstand all tasks before starting and once you begin you are allowed to speakto the examiner only when designated in the instructions.”

In order to carry out all activities, the participants had to plan in advancehow they would go about and select the specific shops among the various onesin the street to perform the tasks. If they just followed the order of the taskswritten in the instruction card they would not have enough time to completeall tasks. This is because the shops to be entered according to the sequence inthe instruction card were located at a distance from each other of approxi-mately 30 metres. In addition, the first shop of the instruction card was atthe end of the street next to the final position where the subject should beat the end of the task. The second shop according to the instruction cardwas at the beginning of the street where the subject started the task. Thismeans that if participants followed exactly the order of the instruction cardthey would end up walking long distances and not be able to complete all

526 MIOTTO ET AL.


TABLE 2Neuropsychological test results for each group at Assessment 1, 2, 3 and follow up, six months after the intervention

Assessment 1 Assessment 2 Assessment 3 Follow up

Test G1 G2 G3 G1 G2 G3 G1 G2 G3 G1 G2 G3

Intellectual Functions (WASI)1

FSIQ 97.2

(5.73)

96.5

(6.43)

98.5

(7.34)

__ __ __ __ __ __ __

Memory Functions

Digit Span (%) 29.0

(14.49)

24.5

(9.3)

29.8

(15.8)

30.0

(14.77)

22.0

(2.58)

30.7

(17.7)

Word Recognition2 (%) 30.0

(10.54)

28.8

(16.4)

40.0

(22.1)

30.0

(10.53)

29.0

(16.29)

38.3

(21.5)

Face Recognition2 (%) 35.0

(17.48)

29.5

(16.06)

41.5

(23.2)

35.0

(17.07)

30.0

(15.8)

42.5

(25.5)

Logical Memory I3 (%) 32.5

(12.53)

31.5

(10.55)

38.1

(19.6)

31.5

(11.31)

30.5

(10.92)

40.4

(18.6)

Logical Memory II3 (%) 29.0

(11.25)

30.5

(8.64)

35.5

(18.0)

28.0

(7.88)

30.0

(11.3)

38.5

(17.5)

Visual Reproduction I3(%) 30.8

(9.23)

30.7

(16.1)

36.8

(18.9)

33.5

(10.81)

31.5

(15.46)

33.7

(14.1)

Visual Reproduction II3(%) 30.0

(10.80)

30.4

(16.12)

36.3

(18.2)

32.0

(12.52)

30.5

(15.89)

32.0

(13.2)

Executive Functions

WCST4 Categories 3.0

(0.79)

3.0

(0.74)

3.0

(0.95)

4.0

(0.47)

4.0

(0.82)

4.0

(1.3)

4.0

(0.47)

4.0

(0.79)

5.0

(0.93)

4.0

(0.71)

4.0

(0.79)

5.0

(0.95)

(Table continued )

NEUROPSYCHOLOGICALREHABILITATIO

NOFEXECUTIVEFUNCTIO

N527


TABLE 2 Continued

Assessment 1 Assessment 2 Assessment 3 Follow up

Test G1 G2 G3 G1 G2 G3 G1 G2 G3 G1 G2 G3

FAS 25.0

(4.85)

23.0

(4.6)

25.0

(5.9)

26.00

(3.30)

23.0

(4.6)

27.0

(5.7)

27.00

(3.10)

24.0

(3.6)

28.0

(4.72)

26.00

(3.67)

26.0

(3.6)

28.0

(5.4)

VIP5 (Max. Total ¼ 16) 11.0

(1.89)

9.0

(1.22)

9.0

(1.5)

14.0

(2.67)

10.0

(1.8)

11.0

(2.72)

14.0

(1.87)

12.0

(1.7)

14.0

(1.8)

15.0

(1.19)

13.0

(1.8)

14.0

(1.1)

Information Processing

Digit Symbol (%) 25.1

(9.04)

22.9

(3.44)

29.1

(13.5)

24.5

(5.98)

22.7

(3.89)

26.0

(11.7)

DEX Questionnaire6

Patient (Total) 51.9

(5.13)

49.3

(5.23)

51.9

(6.5)

51.30

(5.10)

51.1

(6.26)

51.2

(8.2)

42.4

(9.72)

50.22

(6.14)

51.0

(9.9)

41.4

(11.3)

49.0

(7.2)

47.6

(9.2)

Independent

(Total)

52.5

(4.95)

49.3

(4.9)

52.9

(9.6)

41.3

(10.1)

48.7

(5.01)

52.4

(9.6)

42.1

(10.5)

45.7

(4.85)

47.2

(7.6)

40.6

(12.0)

45.1

(4.9)

45.6

(7.4)

MMET

(Max. Total ¼ 10) 8.0

(0.92)

8.0

(0.85)

7.0

(1.5)

9.0

(0.63)

8.0

(0.92)

7.0

(1.8)

9.0

(0.69)

9.0

(0.88)

9.0

(1.2)

9.0

(0.35)

9.0

(0.67)

9.0

(0.64)

Results are expressed by means and standard deviation for each group.1WASI: Wechsler Abbreviated Scale of Intelligence

(Full Scale IQ based on Vocabulary and Matrix subtests scores)2 The Camden Memory Tests3 WMS-III: Wechsler Memory Scale –III4 Wisconsin Card Sorting Test5 Virtual Planning Test6 BADS: Behavioural Assessment of the Dysexecutive Syndrome

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tasks in the time available. For successful performance of the task, subjectshad to plan ahead the sequence of tasks and create the strategy of starting atask with the shop nearest to the start position. To achieve this, they wouldhave to quickly explore the area before deciding which task should becarried out first and then plan subsequent steps.

Scoring the MMET. One point was given for each activity undertakencorrectly (up to a total of 10 points). An error could occur for the followingreasons: (1) non-completion of an activity, either because of lack of time orperforming a different task; (2) execution in a wrong order (e.g., returning thematerials before using them); (3) rule break (e.g., talking to the examinerabout irrelevant information, inappropriate conversation with people in theprecinct, spending money over the budget or buying other items).

Attention and Problem Solving (APS) Rehabilitation Group

This group approach was based on that developed for the Oliver ZangwillCentre for Neuropsychological Rehabilitation (see Evans, 2001) which wasitself adapted from von Cramon’s PST (von Cramon et al., 1991) and fromthe GMT (Levine et al., 2000). The group ran over a period of 10 weeks,meeting once a week for 90 minutes. The first four weeks of the programmefocused on attention. Each session had a similar format and included presen-tation of educational information on attention (forms of attention, anatomy)and problems with attention that may arise after brain injury. Tasks wereused to illustrate different forms of attention (selective, sustained, dividedattention). Internal and external strategies for managing attention were intro-duced to the participants. One key concept emphasised was the mental black-board as a metaphor for thinking about attention/working memory. Inrelation to this idea, participants were also instructed in the use of goal man-agement techniques derived from GMT. The following weeks had a similarformat, but with a focus on problem solving. Participants were introducedto the problem solving framework (Figure 1) which presents the stages inthe problem solving (and goal management) process. Tasks were used toillustrate stage in the problem solving process. Participants were also pro-vided with a problem solving template (Figure 2). They were instructed inthe use of this template and practised the use of this framework usinghypothetical problems at first and then practical real-life examples fromtheir own current experiences. The aim of the practice was to encourage par-ticipants to internalise the steps in the process. During each session, two pro-fessionals were present, one to deliver the information and teach participantshow to use the various strategies and the other to monitor each person’s beha-viour. Further details of the programme content of each session are availablefrom the corresponding author.



RESULTS

The data for the three groups for many of the measures used did not conformto a normal distribution and therefore a non-parametric approach was takenfor the analyses. Chi-square and Kruskal Wallis tests were used for thecomparison of all three groups together across the various measures andthe baseline assessments. Subsequently, each separate group was analysedindependently comparing the performance of the subjects across the threeassessments and follow up. The follow-up assessment, carried out sixmonths later, included only 25 participants. Four participants were notlocated due to change of address and one participant died due to a systemicinfection.

Pre-intervention

At Assessment 1, before any treatment, the results showed no significantdifference between the participants in terms of Full Scale IQ (WASI),Short-Term Memory (Digit Span), Recognition Memory (Warrington), FreeRecall (Logical Memory and Visual Reproduction, WMS-III), ExecutiveFunctions (WCST, FAS, MMET), Information Processing (Digit SymbolWAIS-III) and the Dysexecutive Questionnaire (DEX). In addition, therewas no difference in age, time since injury and education. There washowever a difference in baseline performance on the Virtual Planning Test(VPT; H ¼ 7.07, df ¼ 2, p ¼ .029), with Group 1 having significantlyhigher scores than the other two groups.

Post-intervention

To examine changes over time and the impact of the intervention, change-scores were calculated for each of the measures. We examined whetherthere were changes on the background neuropsychological measures ofmemory and information processing, the tests of executive functioning andon the ratings of patients and carers of everyday problems with executivefunctioning (DEX questionnaire).

Background cognitive functions

There was no significant change in performance on any of the measures ofrecognition and recall memory and information processing between Assess-ment 1 and Assessment 2.

Measures of executive functioning

There were no significant differences between the three groups in changesbetween Assessment 1 and Assessment 2 for WCST (H ¼ 0.344, df ¼ 2,

530 MIOTTO ET AL.


p ¼ .842) or FAS (H ¼ 2.04, df ¼ 2, p ¼ .361). In fact all three groupsshowed an improvement between Assessments 1 and 2 on the WCST,although G3’s change did not quite reach significance (G1, T ¼ 0,Z ¼ 20.27, p ¼ .023; G2, T ¼ 0, Z ¼ 22.449, p ¼ .014; G3, T ¼ 0,Z ¼ 21.890, p ¼ .059). On FAS, G1 and G2 did not show any differencebetween Assessments 1 and 2, but scores for G3 improved (G1, T ¼ 20,Z ¼ 20.77, p ¼ 0.441; G2, T ¼ 20, Z ¼ 20.832, p ¼ .405; G3, T ¼ 0,Z ¼ 22.754, p ¼ .006).

On the VIP test, there was a trend towards a significant difference betweenthe groups (H ¼ 5.59, df ¼ 2, p ¼ .061), with G1 showing a greater changethan G2 (U ¼ 17.0, Z ¼ 22.562, p ¼ .01), but no difference from G3(U ¼ 41.5, Z ¼ 20.655, p ¼ .512), with G2 and G3 also showing no signifi-cant difference from each other (U ¼ 34.5, Z ¼ 21.218, p ¼ .223). All threegroups showed a significant increase in performance on the VIP from Assess-ment 1 to Assessment 2 (G1, T ¼ 0, Z ¼ 22.814, p ¼ .005; G2, T ¼ 0,Z ¼ 22.588, p ¼ .010; G3, T ¼ 0.0, Z ¼ 22.549, p ¼ .011). On theMMET there was a significant effect of the intervention with an overall sig-nificant difference between the groups in terms of improvement in perform-ance from Assessment 1 to Assessment 2 (H ¼ 8.466, df ¼ 2, p ¼ .015).Post-hoc analysis showed that G1 improved more than G2 (U ¼ 17.5,Z ¼ 22.63, p ¼ .009) and G3 (U ¼ 20.5, Z ¼ 22.33, p ¼ .02). There wasno difference in change scores for G2 and G3 (U ¼ 47, Z ¼ 20.252,p ¼ .853).

Examining changes from Assessment 2 to Assessment 3 (after the inter-vention for groups 2 and 3), there were significant differences in changescores for the WCST (H ¼ 6.301, df ¼ 2, p ¼ .043), VIP (H ¼ 13.258,df ¼ 2, p ¼ .001) and MMET (H ¼ 8.209, df ¼ 2, p ¼ .017), but not forFAS (H ¼ 0.072, df ¼ 2, p ¼ .965). Looking at each group separately,there were no further changes from Assessment 2 to 3 for G1. For G2 therewas no change in performance on FAS, but there was an improvement in per-formance on the WCST (T ¼ 0.0, Z ¼ 22.24, p ¼ .025), the VIP (T ¼ 0.0,Z ¼ 22.694, p ¼ .007) and the MMET (T ¼ 0.0, Z ¼ 22.121, p ¼ .034).For G3 there was no change in performance on FAS or WCST, but therewas an improvement in performance on the VIP (T ¼ 0.0, Z ¼ 22.684,p ¼ .007) and the MMET (T ¼ 0.0, Z ¼ 22.392, p ¼ .017).

There were no changes on any of the executive functioning measuresbetween Assessment 3 and the Follow Up assessment.

Dysexecutive Questionnaire (DEX)

The DEX was used as a means to assess changes in the participants’ beha-viour related to executive dysfunction. This scale has an independent



(carer) version and self-rating version. Both versions were administered atassessments 1, 2, 3 and follow up.

For the independent rater version, there was no difference between thegroups at Assessment 1 (H ¼ 3.142, df ¼ 2, p ¼ .208), but there was a differ-ence between the groups at Assessment 2 (H ¼ 6.715, df ¼ 2, p ¼ .035).Analysing change scores, there was a significant difference between thegroups in terms of changes from Assessment 1 to 2 (H ¼ 18.257, df ¼ 2,p ¼ ,.001). Examining each group separately, the results showed that G1demonstrated a significant reduction in the number of symptoms attributedby the carer at assessment 2 (Z ¼ 22.80, p ¼ .005) while G2 and G3showed no reduction in symptoms. Analysing change scores from Assess-ment 2 to 3, there was a significant difference between the groups(H ¼ 10.263, df ¼ 2, p ¼ .006). For G1 there was no change (T ¼ 9,Z ¼ 21.634, p ¼ .102). However, both G2 and G3 demonstrated a reductionof symptoms following the intervention (G2, Z ¼ 22.09, p ¼ .036; G3,Z ¼ 22.25, p ¼ .025). Although there was evidence of symptom reductionpost-intervention, the total DEX scores remained elevated compared to thecontrol levels reported by Wilson, Alderman, Burgess, Emslie, and Evans(1996), presumably reflecting a continuing significant level of functional dis-ability despite some apparent improvement as a result of the intervention.

For the self-rated DEX questionnaire, there were no differences in totalscores between the groups at any of the assessment points. Critically, therewas no evidence of difference in change scores between the groups fromAssessment 1 to 2 (H ¼ 4.533, df ¼ 2, p ¼ .104), although looking at eachgroup separately revealed that there was no change from Assessment 1 toAssessment 2 for G1 and G3, but there was an increase in scores for G2(T ¼ 7, Z ¼ 22.106, p ¼ .035).

There was a difference between the groups in change scores from Assess-ment 2 to 3 (H ¼ 12.231, df ¼ 2, p ¼ .002) and looking at the groups separ-ately, for G1 there was a significant reduction of symptoms betweenAssessment 2 and Assessment 3 (T ¼ 0.0, Z ¼ 22.812, p ¼ .005). For G2and G3 there was no change post-intervention or subsequently.

Lesion effects

The patient groups were divided according to the side of the lesion (RF ¼ 14and LF ¼ 16), size (,4.5 cm2, n ¼ 13; .4.5 cm2, n ¼ 17) and site(OFC ¼ 9, DLPFC ¼ 8 and OFC/DLPFC ¼ 13) and their performance com-pared on the main measures at Assessment 1, using Kruskal-Wallis for theanalyses. There were significant differences between the groups on the fol-lowing measures: side of lesion for FAS (CS ¼ 4.22, p ¼ .040) with LFbeing more impaired; size of lesion for the DEX patient (CS ¼ 4.58,p ¼ .032), DEX independent (CS ¼ 4.03, p ¼ .025), VIP (CS ¼ 4.54,

532 MIOTTO ET AL.


p ¼ .033) and MMET (CF ¼ 4.22, p ¼ .040), with patients having lesionsmore than 4.5 cm2 showing the greater impairment. There was no significantdifference when comparing side, site or size of lesion and improvement inperformance as a result of participation in the group (i.e., comparingchanges in scores from pre- to post-intervention).

Return to occupational activities

Employment status before treatment was as follows: full-time employment/study (n ¼ 3); part-time employment/study/volunteer work (n ¼ 8); unem-ployed (n ¼ 19). At follow up assessment, 6 months after G2 and G3 receivedthe APS intervention, employment status was: full-time employment/study(n ¼ 6); part-time employment/study/volunteer work (n ¼ 14), unemployed(n ¼ 5). As mentioned earlier the remaining five patients were not included inthe follow up assessment (four patients changed their addresses and onepatient died).

DISCUSSION

The current study investigated the effectiveness of the APS treatmentapproach to executive impairments in patients with frontal lobe lesionsusing a cross-over design with two control groups. The design of the studyallowed for an evaluation of the treatment through three baseline assessmentsand a follow up six months later. The 30 participants were divided into threegroups, each with 10 patients (G1, G2 and G3) and the APS treatment wascompared to two intervention procedures, an information/education (IE)approach and traditional rehabilitation (TR).

Firstly, the participants’ performance was analysed in terms of whetherthere was an improvement in cognitive performance after the interventionon measures of executive functions, memory and information processing.There was no difference between the groups pre- or post-first interventionon measures of memory or information processing. Overall, there was littleevidence of improvement on the more traditional measures of executive func-tioning as a result of the intervention. On the WCST there was evidence ofimprovement in all three groups. The most likely explanation for thiswould seem to be a practice effect arising from task familiarity – althoughwe cannot be sure that all three “interventions” did not have some effect, itseems unlikely that any increase in performance in G3 was a result of inter-vention as they received at that time only physical therapy. For the VIP therewas a trend towards a significant difference between the groups in terms ofchanges in scores between Assessment 1 and 2, although this did not reachsignificance. Here again there was evidence of an increase in performancein all three groups. Although the intervention group showed the greatest



improvement in functioning, the level of improvement was only significantlygreater than one of the control groups (information and education), but not theother (treatment as usual). One piece of evidence that the intervention mayhave had an effect on the VIP performance is that between Assessment 2and 3 (when the two control groups underwent the group intervention). G2and G3 improved further their performance on the VIP, but G1 showed nochange. One interpretation of this result is that there was a practice effectoperating between Assessment 1 and 2, with G1 gaining additional benefitfrom the intervention. Then between Assessment 2 and 3, there is noadditional practice effect evident (because G1 did not change further) andthe improved performances of G2 and G3 are thus attributable to the interven-tion. The strongest evidence for an effect of the intervention came from themore functional multiple elements task (MMET) and from the ratings ofcarers on the Dysexecutive Questionnaire. For both of these measures therewas improvement after the implementation of the APS programme in allthree groups. However, despite this improvement, the results showed thatthere was still evidence for the presence of a significant degree of executiveimpairment, with scores on the DEX still in the elevated range.

The improvement on the MMET suggests that the three groups were ableto improve their ability to carry out novel real-life situation tasks particularlyafter the APS programme was implemented. Our interpretation of how par-ticipants improved their performance was through adopting a simple strategyof exploring the precinct first before deciding on the best task to start withdepending on which shop was located near the start position. This strategyreflects a more planned and efficient approach to the task and contrastswith a more impulsive or unplanned one (e.g., starting the test entering thefirst shop described in the instruction card) that characterised pre-interventionperformance. A strong emphasis was placed in the group training on theSTOP: THINK element of the problem-solving framework. Von Cramonet al. (1991) similarly emphasised that a key focus of their problem solvingtraining was on the management of impulsivity.

An issue that is relevant to all cognitive rehabilitation studies is therelationship between training tasks, outcome measures and functioning ineveryday “real-life”. Some interventions are focused on teaching a task-specific skill or strategy where the aim is to improve performance on aspecific functional task. In this case the patient is trained on the specifictask, hopefully improves performance on that task in everyday life and nogeneralisation to other situations is expected. The study by von Cramonand Matthes-von Cramon (1995) in which a physician who had executivedysfunction after a head injury was trained to use a checklist to improvehis performance in undertaking and reporting on pathology examinationswas a good example of this approach. His performance in the work situationimproved, but there was no evidence of improvement on other measures of

534 MIOTTO ET AL.


planning. However, if an intervention is aimed at improving cognitivefunctioning with the aim that performance will be improved in a variety ofeveryday situations (that all make demands on the trained cognitive function),then it is important in evaluating the efficacy of the treatment that at leastsome of the outcome measures are not tasks that have been specificallytrained as part of the intervention. In the present study there was evidenceof improvement as a result of participation in the group on the VIP and theMMET. These tasks were not specifically trained as part of the group inter-vention. There was, as would be expected, overlap in the demands made bythese tasks and some of the practical tasks used in the group to teach planningand goal management skills. For example in the group, participants had toplan an outing for the group where they were encouraged to stop and thinkabout what was required, consider options for the outing, choose an option,plan the details and implement that planned outing. Furthermore, participantswere supported in applying these strategies to difficulties arising for them intheir daily lives. In this way the aim was explicitly to train participants to gen-eralise strategy use to new situations. As already discussed, perhaps the clear-est example of this was prompting use of a STOP: THINK strategy, whichparticipants were encouraged to apply in everyday life. Therefore, althoughthe VIP and MMET were not specifically practised as part of the training pro-gramme, it seemed that participants were able spontaneously to transfer use ofstrategies to these situations. Nevertheless one should still be cautious aboutthe extent to which participants transfer skills to actual everyday life giventhat tasks such as the VIP and MMET are at least broadly similar in formto the sort of tasks used in the group. It was important therefore to have atleast some other measure of transfer of training to everyday life and thiswas provided by the DEX questionnaire.

The DEX questionnaire examines behavioural, cognitive, personality andmotivational changes associated with the dysexecutive syndrome and resultsshowed that there was a significant change over time in the way the carers orrelatives rated the participants’ performance. There was a reduction in thenumber of items rated as happening “very frequently”. Of relevance ofcourse is the fact that relatives were not blind to intervention condition andthe possibility that ratings are influenced by expectations of change orindeed by a desire to please the researchers cannot be ruled out. By contrastto the ratings from relatives, no significant changes were observed in terms ofthe participants’ self-rating scores. One interpretation of these findings is thatas a result of participation in the group, insight did improve, and at the sametime, and possibly in part as a result of improved insight, participants werebetter at applying planning and problem solving strategies. In this case,although one might expect self-rating DEX scores to increase, as a result ofgreater insight, because functioning is better as a result of strategy appli-cation, so scores might not increase or might even decrease. In other



words, pre-treatment, participants may have an unrealistically low rating ofeveryday problems, after the intervention that same rating level is in fact amore realistic evaluation of functioning. Von-Cramon and colleagues(1991) also noted that a proportion of patients deteriorated on tests after treat-ment possibly due to an increased awareness of the complexity of theirproblems.

Current neuropsychological assessment tools are not specifically designedto identify which stage of the problem-solving process might be impaired.The view of the clinicians running the intervention groups, based on thestandardised and functioning test performance, questionnaire scores andobservation of the patients in the group setting was that the most commonarea of deficit was in the planning phase, or, using Shallice and Burgess(1996) terminology, the phase in which a temporary new schema is devel-oped. Although there were patients with poor initiation and with poor moni-toring, the most striking difficulties were in the ability to generate alternativesolutions to problems. This phase of the process might be said to be the mostcomplex, making demands upon a range of underlying cognitive processesand hence most vulnerable to disruption. For instance, most patients haddifficulties with divergent thinking when creating alternative solutions to pro-blems such as providing an important document to a medico-legal interviewin order to obtain another period of sickness leave from work despite theproper knowledge of it or how to make sure all the lights in the housewould be turned off before going out. Nevertheless, after a number of sessionsworking on alternative solutions to various problems with the APS frame-work, the majority were able to generate appropriate solutions to otherproblems as demonstrated by what they wrote on their template sheets (seeFigure 1).

There was an association between size of lesion and performance on some,although not all, measures of executive functioning. Patients with lesionslarger than 4.5 cm2 showed the greatest deficits on the VIP, MMET andDEX. This finding is consistent with a few studies showing that largelesions in the frontal lobes, especially more than 5 cm2 can produce greaterimpairment (Goldstein, Bernard, Fenwick, Burgess, & McNeil, 1993; Gotoet al., 2003; Leimkuhler & Mesulam,1985). Tests such as the VIP andMMET are relatively complex and hence it makes sense that as lesion sizeincreases, the range and severity of impairments are likely to increase,which will be reflected by poorer performance on complex multi-componenttests. Similarly, the DEX questionnaire was designed to reflect the very widerange of potential symptoms of frontal lobe dysfunction and as lesion sizeincreases one would expect an increase in the range and severity of symptomsendorsed. Laterality of lesion showed an effect only on the FAS verbalfluency task. However, site of lesion did not produce any significant differ-ences in performance on tests used. It seems likely that this latter finding

536 MIOTTO ET AL.


may also be the result of the fact that most of the measures used are complexand rely on multiple aspects of executive functioning for successful perform-ance. Hence a range of different impairments may impact on performance onsuch measures. From the perspective of ecological assessment of everydayexecutive functioning this is perhaps not critical. However it does raise thequestion as to whether it is possible to design assessment procedures thatare able not only to predict performance on complex everyday tasks, butalso identify component processes that may be selectively impaired, andhence could be specifically targeted by rehabilitation interventions. In thepresent study, there was no relationship apparent between side, site or sizeof lesion and relative benefit from the intervention. It might be arguedhowever that such a relationship might not be expected as the treatmentgroup programme addresses a wide range of aspects of attention and execu-tive functioning in a “catch all” manner. Hence it could be said that whateverthe problem, some aspect of the treatment programme will help and so onewould not expect a specific relationship with particular impairments orindeed the side/site/size of the lesion. The ideal would be of course to beable to identify specific impairments and apply targeted rehabilitation inter-ventions that have effects that generalise to everyday functioning. Sturmet al. (2002) presented preliminary evidence that attention training aimed atspecific attention systems selectively improved the targeted domain of atten-tion functioning, although evidence of generalisation to everyday life was notpresented. Similar evidence does not exist for the broader concept of execu-tive functioning. Many of the patients who present in rehabilitation settings,particularly those with head injury, do not of course have very circumscribedlesions nor highly selective cognitive impairments. For most therefore, atreatment intervention that covers a broad range of cognitive functions andfocuses on improving functioning on complex everyday tasks seems entirelyappropriate. Nevertheless, it also seems reasonable to assume that pro-grammes that include individually evaluated component interventions thatare derived from clear theoretical models of executive functioning arelikely to be the most effective, as long as there is also a focus on everydayfunctioning.

In summary, the main results showed some evidence for the effectivenessof a treatment approach to the dysexecutive syndrome, namely the APS treat-ment. There was also an indication of a degree of generalisation to real-lifeactivities. However, these findings should be interpreted as preliminaryresults, from which we should be cautious in drawing conclusions. Thereare several methodological limitations associated with this study, some ofwhich should be addressed in future studies. Firstly, the sample might besaid to consist of participants with only mild to moderate levels of executiveimpairment and future studies might usefully examine a broader range ofpatients in order to clarify for which patients the intervention might be



helpful. Although the person who carried out the assessments was notinvolved in the treatment interventions, she was not blind to group member-ship, which is a significant weakness of this design. It is impossible to runstrict double blind studies, but future studies should adopt a single blindevaluation where possible. In the present study we compared the experimen-tal condition with a treatment as usual condition and an information and edu-cation condition. The latter was chosen to investigate the possibility thatsimply providing structured information about improving problem solvingmight be effective. If it had proved to be as effective as the interventiongroup then it would have provided a much more cost-effective approach torehabilitating executive difficulties. The limitation of this approach is thatthe possibility that some more general effect of contact with therapists isresponsible for the improvement in performance cannot be ruled out. Theuse of wait-list controls has been common in this type of research (Fox,Martella, & Marchand-Martella, 1989; Medd & Tate, 2000; Tiersky et al.,2005) and does avoid the ethical issue of giving participants a “treatment”which is considered unlikely to have a significant effect on the problemswith which they are presenting. Despite these limitations, the study goessome way to bridge the gap between the identification of executive deficitsspecifically related to problem solving, planning, initiation, monitoring andbehaviour regulation and the implementation of a targeted intervention atthese deficits having functional outcome as the main goal of treatment.

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