Ashlee R. Loughan

Executive functioning and adaptive living skills after acquired brain injury.

Executive dysfunction is common following brain injury, with impairments involving attention, social pragmatics, higher-order thinking, judgment, and reasoning. Executive function impairments may have a direct impact on an individuals ability to return to instrumental activities of daily living (IADL), including employment, money management, driving, and maintaining a residence. Research has shown that neuropsychological executive function measures may be able to predict daily-living skills. There is limited research evaluating the relationship between executive functions and IADLs in adults with acquired brain injuries (ABI), with none investigating levels of proficiency as related to specific test scores. We hypothesize that neuropsychological executive function measures will have significant and moderate-to-strong correlations with participant-rated proficiency on functional tasks as measured by the Mayo-Portland Adaptability Inventory. Results support that IQ and some of the executive function measures (Processing Speed, Working Memory, and Trail-Making Test-Part B) correlated significantly and strongly and explained unique variance in all IADLs in this study. Data suggest that individuals with ABI who performed in the higher end of the low-average range or higher on measures of executive functioning tend to require little or no assistance to be independent with transportation, money management, living without support, and employment. Results also suggest that individuals with less executive dysfunction are likely to have greater overall community participation.

The value of the wechsler intelligence scale for children-fourth edition digit span as an embedded measure of effort: an investigation into children with dual diagnoses.

The Test of Memory Malingering (TOMM) is a measure of test-taking effort which has traditionally been utilized with adults, but which more recently has demonstrated utility with children. The purpose of this study was to investigate whether the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) Digit Span, commonly used in neuropsychological evaluations, can also be functional as an embedded measure by detecting effort in children with dual diagnoses; a population yet to be investigated. Participants (n = 51) who completed neuropsychological evaluations including the TOMM, WISC-IV, Wisconsin Card Sorting Test, Childrens Memory Scale, and Delis-Kaplan Executive Function System were divided into two groups: Optimal Effort and Suboptimal Effort, based on their TOMM Trial 2 scores. Digit Span findings suggest a useful scaled score of ≤4 resulted in optimal cutoff scores, yielding specificity of 91% and sensitivity of 43%. This study supports previous research that the WISC-IV Digit Span has good utility in determining optimal effort, even in children with dual diagnosis or comorbidities.

The Value of Embedded Measures in Detecting Suboptimal Effort in Children: An Investigation Into the WISC-IV Digit Span and CMS Verbal Memory Subtests

The Test of Memory Malingering (TOMM) is a measure of test-taking effort that has traditionally been utilized with adults but more recently has demonstrated utility with children. The purpose of this study was to investigate whether commonly used neuropsychological measures can be used as embedded measures in detecting effort during testing. Participants (N = 75) who completed neuropsychological evaluations including the TOMM, Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) Digit Span, Childrens Memory Scale (CMS) Verbal Memory, and other neuropsychological measures were divided into two groups: Optimal Effort and Suboptimal Effort, based on their TOMM Trial 2 scores. Digit Span findings suggest a useful standard score of ≤ 70 resulted in optimal cutoff scores, yielding specificity of 94% and sensitivity of 44%. The CMS Verbal Memory Recall > Recognition scores did not appear as valuable indicating a discrepancy of 20+ points were required for specificity to attain optimal scores of 90% and sensitivity of 11%. This study illustrates the WISC-IV may have good utility in determining optimal effort; however, the CMS may not be as functional.

Performance and Specificity Rates in the Test of Memory Malingering: An Investigation Into Pediatric Clinical Populations

Symptom validity tests are becoming standard as an effort measure during pediatric neuropsychological assessment. An important component of symptom validity test use is understanding limitations of these measures and how select clinical groups may have difficulty with them. Research has begun to clarify the limits of the Test of Memory Malingering (TOMM) with diverse childhood diagnoses. This study compared TOMM scores of children (N = 86) classified with common childhood disorders. Findings suggest that a substantial proportion of children performed below the recommended cutoff score of 45 on Trial 2 and attained varied specificity rates. This included children with conduct disorders (85%), affective disorders (92%), traumatic brain injury (83%), attention-deficit hyperactivity disorder (93%), learning disabilities (100%), and pervasive developmental disorder (88%). The group with the most children scoring below the cutoff was children with intellectual disabilities (76%). This finding is consistent with some of the adult research suggesting that very limited cognitive ability may compromise TOMM performance. Caution may be necessary when drawing conclusions about test-taking effort based on the recommended TOMM cutoff scores when evaluating children with disabilities.

Children and the Test of Memory Malingering: Is one trial enough?

There is a growing body of research suggesting that the first trial of the TOMM may provide an accurate screener of effort in children. During neuropsychological assessments, some circumstances result in only one completed trial of the TOMM. Research on adults reflects that passing scores on Trial 1 (based on Trial 2 cutoff) are highly predictive of passing scores on Trial 2 and the TOMM overall. Pediatric research found that 100% of children and adolescents who passed Trial 1 of the TOMM also passed Trial 2. Our research hypothesis is that children who pass Trial 1 will also pass Trial 2. Data from 75 clinically diagnosed children (ages 6–18 years) found that 64% performed above the published adult TOMM cutoff on Trial 1. All children who passed Trial 1 also passed Trial 2 suggesting support for the research hypothesis. Sensitivity was 1.0, specificity was 0.72, positive predictive value was .33, and negative predictive value was 1.0. These findings suggest that in this sample, the children who performed above the Trial 2 cutoff on Trial 1 also all passed Trial 2 (so there were no false negatives, thus a perfect sensitivity and negative predictive value). Of the 36% of children who did not pass the Trial 1 cutoff, 67% passed on Trial 2. Data clearly support that children passing Trial 1 have a high likelihood of passing Trial 2, thus drawing conclusions about performance validity after passing Trial 1. Conclusions after failing Trial 1 require further investigation.

The Influence of Effort on Neuropsychological Performance in Children: Is Performance on the TOMM Indicative of Neuropsychological Ability?

The Test of Memory Malingering (TOMM) is a measure of effort that has traditionally been utilized with adults but is being increasingly used with children, though it is not yet entirely clear what suboptimal TOMM performance means in terms of neuropsychological test scores. The purpose of this study was to investigate whether performance on the TOMM can be used as a predictive marker for neuropsychological performance in children. Participants (N = 75) completed the TOMM, Wechsler Intelligence Scale for Children-Fourth Edition, Wisconsin Card-Sorting Test (WCST), Childrens Memory Test, and Delis-Kaplan Executive Function System Trails. Results revealed significant correlations between age, education level, IQ, and many of the neuropsychological measures administered, indicating that as childrens TOMM scores increase, so do their cognitive performances. Children were subsequently divided into two groups: optimal effort and suboptimal effort, based on their TOMM Trial 2 scores. Results suggest significant differences in IQ performance and WCST Failure to Maintain Set; however, there were no differences in regard to any other neuropsychological measures administered. It was also found that a larger proportion of the younger children (aged 6 to 10 years old) scored below the TOMM cutoff compared with older children. This study illustrates that although correlations exist, suboptimal effort on the TOMM may not predict poorer performance on a neuropsychological evaluation in children as has been reported in other studies.

Test of memory malingering with children: The utility of Trial 1 and TOMMe10 as screeners of test validity

There is a growing body of research suggesting that the shorter versions of the Test of Memory Malingering (TOMM) may provide an accurate assessment of effort in children. During neuropsychological evaluations, some circumstances result in only one completed trial of the TOMM or partial completion of a trial. Research suggests that a cut-score of 40 or 41 on Trial1 is highly predictive of passing the TOMM overall. In the current study, 194 school-age children with academic and/or behavioral problems were used to compare the accuracy of TOMM1 and TOMMe10 (errors on the first 10 items of TOMM1) in predicting passing/failing of TOMM2. For the children in this sample, a score of < 40 items correct (≥ 10 errors) on TOMM1 was highly accurate in predicting a passing performance on the TOMM2 (sensitivity = .80, specificity = .91) with a Negative Predictive Value = .98 at the malingering base rate of 7% (TOMM2 failure in our sample). A score of 2 errors (8 items correct) on the TOMMe10 was slightly less sensitive than that of the TOMM1 (specificity = .96, sensitivity = .53) but with a similar Negative Predictive Value (.96). Consistent with the research from adult populations, TOMM1 and TOMMe10 appear to be quite accurate in predicting performance on the standard administration of the TOMM and may be useful screeners. However, compared to that found in adult samples, slight differences in suggested cutoffs for TOMM1 and TOMMe10 may be warranted for children.

Gestational Diabetes: Long-Term Central Nervous System Developmental and Cognitive Sequelae

Gestational diabetes is a common complication of pregnancy and occurs in approximately 7% of all pregnancies. It has been associated with an increased rate of congenital anomalies including disturbances of intrauterine growth, delayed brain maturity, and neurobehavioral abnormalities in the offspring. The resulting maternal and fetal metabolic dysfunction leads to diminished iron stores (which can affect red blood cell [RBC] production and subsequent organogenesis), a metabolism–placental perfusion mismatch, increased FFA, increased lactic acidosis, and potential hypoxia. Though most newborns born in the context of gestational diabetes are not significantly affected by it, empirical research suggests gestational diabetes has been associated with lower general intelligence, language impairments, attention weaknesses, impulsivity, and behavioral problems. In extreme cases, it may essentially function as a gestational brain insult. Children who are exposed to poorly controlled gestational diabetes may benefit from some form of tracking or follow-up assessments. Additionally, clinicians evaluating children with developmental learning or cognitive dysfunction may want to seek appropriate gestational diabetes-related information from the parents. A greater understanding of this significant gestational risk may help foster improved prenatal diabetes management and may help reduce the neurodevelopmental effects of gestational diabetes.

Anti-N-Methyl-D-Aspartate Receptor Encephalitis: A Review and Neuropsychological Case Study

Objective: Anti-N-Methyl-d-Aspartate Receptor (NMDAR) Encephalitis is an autoimmune-mediated encephalitis, which may be associated with a tumor, which occurs when antibodies bind central NMDA receptors. Although typically diagnosed in women, approximately 20% of cases have been males. Due to the challenges with identification, imaging, and diverse symptom presentation, this syndrome is often misdiagnosed. Accurate diagnosis may provide an opportunity for introduction of disease-modifying therapies, which may alter disease trajectory. Moreover, neuropsychology has yet to fully clarify the pattern of impairments expected with this disorder. Methods: This manuscript reviews a single case study of a 42-year-old male diagnosed with NMDAR encephalitis. Neuropsychological evaluation was completed subsequent to diagnosis, treatment, and rehabilitation. Ongoing patient complaints, approximately six months post diagnosis, included reduced sustained attention, poor word retrieval, and daily forgetfulness. Adaptive skills were improved following rehabilitation. Results: Direct testing revealed mildly impaired sustained attention, processing speed, oral word fluency, and executive functioning. All other cognitive domains were within estimated premorbid range, low average to average. Conclusions: Neuropsychological deficits were consistent with mild frontal brain dysfunction and continued recovery. This case illustrates the need for medical and psychological practitioners to understand NMDAR encephalitis, its symptom presentation, and related neuropsychological impact; particularly with the potential for misdiagnosis.

Terbutaline and Associated Risks for Neurodevelopmental Disorders

Preterm labor often leads to a preterm birth and has been shown to be the most important determinant of risk for perinatal morbidity and mortality. While medication management has been utilized by physicians to delay preterm labor, the results these medications achieve remain inconsistent, in addition to increasing the risk to the developing fetus. Terbutaline has been among the most commonly used -adrenoreceptor (AR) agonists in the management of preterm labor. The research suggests that tocolytic terbutaline therapy carries a significant risk for the mother and the child, which can be magnified by extended exposure, sex of the fetus, and administration during critical fetal developmental periods. This paper highlights the research on terbutaline in treatment of preterm labor, along with the possible associated cognitive deficits in adolescents who were treated with terbutaline in utero. Two case summaries are presented to illustrate the potential deficits in clinical presentations of adolescents with history of intrauterine exposure to terbutaline. Publicizing the association between terbutaline and these deficits can not only assist obstetricians and expectant mothers in making a more informed choice in the treatment of preterm labor but also provide neuropsychologists and pediatricians with information helpful in understanding the etiology of these impairments.