James P. Donnelly

Reliability, sensitivity, and specificity of the VA traumatic brain injury screening tool.

Objective:To provide item analyses, estimates of temporal reliability and internal consistency, and examination of the sensitivity and specificity of a traumatic brain injury-screening tool. Participants:Five hundred veterans of the wars in Iraq and Afghanistan enrolled in the study, approximately half of whom (248) volunteered. The remaining 252 participants were referred to Veteran Affairs (VA) neuropsychology or polytrauma clinics. Design:This psychometric study constitutes part of a larger 4-year, multisite prospective cohort study of veterans returning from Iraq and Afghanistan. Setting:Five VA medical centers and one VA outpatient clinic. Main Measures:Veteran traumatic brain injury screening tool (VATBIST), a structured diagnostic interview for traumatic brain injury; a military-oriented posttraumatic stress disorder checklist. Results:The VATBIST appeared to have high-internal consistency (0.77) and test-retest reliability (0.80), high sensitivity (0.94) and moderate specificity (0.59). Diagnostic odds ratios for the screening tool ranged from 12.6 for the total sample to 24, when veterans with probable posttraumatic stress disorder were excluded from analysis. Conclusions:The VATBIST appears to be a reliable and valid instrument. The presence of significant posttraumatic stress disorder symptoms, however, reduces the accuracy of the measure and highlights the need for careful clinical follow-up of persons who screen positive.

Psychometric study of the Neurobehavioral Symptom Inventory.

The Department of Veterans Affairs (VA) uses the Neurobehavioral Symptom Inventory (NSI) to measure postconcussive symptoms in its comprehensive traumatic brain injury (TBI) evaluation. This study examined the NSIs item properties, internal consistency, and external validity. Data were obtained from a federally funded study of the experiences of combat veterans. Participants included 500 Operations Iraqi and Enduring Freedom veterans, 219 of whom sustained at least one TBI. Data were collected at five VA medical centers and one VA outpatient clinic across upstate New York. Measures included neuropsychological interview, NSI, Beck Anxiety Inventory, Beck Depression Inventory-II, and Posttraumatic Stress Disorder Checklist-Military Version. The NSI demonstrated high internal consistency (total alpha = 0.95; subscale alpha = 0.88 to 0.92). Subscale totals based on Caplan et al.s factor analysis correlated highly with the NSI total score (r = 0.88 to 0.93). NSI scores differentiated veterans with TBI history from those without but were strongly influenced by variance associated with probable posttraumatic stress disorder, depression, and generalized anxiety. Results suggest that the NSI is a reliable and valid measure of postconcussive symptoms. Scale validity is evident in the differentiation of TBI and non-TBI classifications. The scale domain is not limited to TBI, however, and extends to detection of probable effects of additional affective disorders prevalent in the veteran population.

Effects of Methylphenidate on Fatigue and Depression: A Randomized, Double-Blind, Placebo-Controlled Trial

CONTEXT Fatigue is highly prevalent in populations with advanced illness and is often associated with depressed mood. The role of psychostimulant therapy in the treatment of these conditions remains ill defined. OBJECTIVES To evaluate the response of fatigue and depression in patients with advanced illness to titrated doses of methylphenidate (MP) as compared with placebo. METHODS In a randomized, double-blind, placebo-controlled trial, 30 hospice patients, both inpatients and outpatients, who had fatigue scores of at least four on a scale of zero to 10 (0=no fatigue and 10=worst fatigue), were randomly assigned to receive either 5mg of MP at 8 am and 1 pm or placebo. Doses of MP were titrated every three days according to response and adverse effects. Home care patients were monitored daily by telephone and visited by a research nurse on Study Days 0 (baseline), 3, 7, and 14. Fatigue was assessed using the Piper Fatigue Scale as the primary outcome measure and validated by the Visual Analogue Scale for Fatigue and the Edmonton Symptom Assessment Scale (ESAS) fatigue score. Subjects in inpatient facilities were interviewed or assessed by staff on an identical schedule. Depressive symptoms were assessed by the Beck Depression Inventory-II, Center for Epidemiologic Studies Depression Scale, and the ESAS depression score. Primary statistical analysis was conducted using repeated-measures multivariate analysis of the variance. RESULTS Both MP- and placebo-treated groups had similar measures of fatigue at baseline. Patients taking MP were found to have significantly lower fatigue scores (Piper Fatigue Scale, Visual Analogue Scale for Fatigue, and ESAS) at Day 14 compared with baseline. The improvement in fatigue with MP treatment was dose-dependent; the mean average effective dose was 10mg on Day 3 and 20mg on Day 14 (dose range of 10-40 mg). Placebo-treated individuals showed no significant improvement in fatigue. For patients with clinically significant depression on Day 0, treatment with MP was associated with a significant reduction in all test indices for depressed mood. For the placebo group, the changes in measures of depression were less than observed in the treatment group but were inconsistent between assessment tools. No significant toxicities were observed. CONCLUSION MP reduced symptoms of fatigue and depression when compared with placebo. The effect of MP on fatigue was dose-dependent and sustained over the duration of the study.

Progression of Delirium in Advanced Illness: A Multivariate Model of Caregiver and Clinician Perspectives

BACKGROUND Delirium is one of the most distressing and difficult to manage problems in advanced illness. Family caregivers have a unique view of the progression of delirium. OBJECTIVE This study examined precursors to delirium from the perspective of family caregivers. DESIGN This study utilized a two-stage concept mapping design that began with semistructured interviews with caregivers of patients suffering with delirium. The interview data was sorted and rated by clinicians prior to quantitative data analysis via multidimensional scaling (MDS) and cluster analysis. SUBJECTS/SETTINGS The subjects were 20 family caregivers of patients with a diagnosis of delirium in a hospice inpatient unit. RESULTS The main outcome of the study was a multidimensional model of precursors of delirium that included 99 specific items. The model included ten clusters within three general domains: Cognition, Distress, and Rest/Sleep. An exploratory analysis suggested that Rest and Sleep issues were evident to caregivers much earlier than other kinds of problems (mean=17.56 weeks prior to hospice admission, 95% CI=9.2-25.0 weeks). CONCLUSIONS This study provides detailed insights from family caregivers about the progression of delirium. The caregiver observations were clustered by multivariate analysis to provide a map of symptom domains. The principal finding of this study is that sleep disturbance was identified by almost all family caregivers much earlier than other more commonly recognized symptoms associated with delirium. The study highlights the importance of sleep fragmentation in the temporal progression of delirium and points toward opportunities for improved measurement, prevention, and treatment.

A systematic review of concept mapping dissertations

The purpose of this study was to identify, summarize, and synthesize all doctoral dissertations completed using Trochims concept mapping methodology between 1985 and 2014. A comprehensive search produced a set of 108 eligible dissertations; of which 104 were available as full-text or hard copy. The studies were coded on 77 variables, which were summarized in descriptive analyses. The dissertations were conducted in a wide variety of topic areas and completed at 35 different universities in the US and Canada. On comparable variables, the results were similar to two prior syntheses (Trochim, 1993; Rosas & Kane, 2012). The mean multidimensional scaling analysis stress value for 96 concept maps was 0.26 with a standard deviation of 0.05. Cumulative rates of dissertation completion and resulting citations of the dissertations and any resulting articles were plotted over the study period. Reliability and validity were considered in most studies but formally assessed in a minority of cases. The review concludes with a summary of findings and thoughts about future studies.

The relationships among premilitary vocational aptitude assessment, traumatic brain injury, and postdeployment cognitive functioning in combat veterans.

Traumatic brain injury (TBI) in Iraq and Afghanistan war veterans is frequently associated with a variety of complaints, including cognitive problems and posttraumatic stress disorder. In this study, the authors explored the predictive impact of premilitary cognitive abilities on postdeployment cognitive functioning, as mitigated by posttraumatic stress symptoms in a sample of veterans with and without history of TBI. Measures included clinical interview, neuropsychological tests, the PTSD Checklist-Military Version, and the Armed Services Vocational Aptitude Battery. In contrast to history of TBI, premilitary abilities and posttraumatic stress symptoms emerged as significant predictors of postdeployment cognitive deficits.

Community Effectiveness RCT of a Comprehensive Psychosocial Treatment for High-Functioning Children With ASD

This community effectiveness randomized clinical trial examined the feasibility and effectiveness of a comprehensive psychosocial treatment, summerMAX, when implemented by a community agency. Fifty-seven high-functioning children (48 male, 9 female), ages 7–12 years with autism spectrum disorder participated in this study. The 5-week summerMAX treatment included instruction and therapeutic activities targeting social/social-communication skills, interpretation of nonliteral language skills, face-emotion recognition skills, and interest expansion. A behavioral program was also used to increase skills acquisition and decrease autism spectrum disorder symptoms and problem behaviors. Feasibility was supported via high levels of fidelity and parent, child, and staff clinician satisfaction. Significant treatment effects favoring the treatment group over waitlist controls were found on all 5 of the primary outcome measures (i.e., child test of nonliteral language skills and parent ratings of the children’s autism spectrum disorder symptoms, targeted social/social-communication skills, broader social performance, and withdrawal). Staff clinician ratings substantiated the improvements reported by parents. Results of this randomized clinical trial are consistent with those of prior studies of summerMAX and suggest that the program was feasible and effective when implemented by a community agency under real-world conditions.

Longitudinal study of objective and subjective cognitive performance and psychological distress in OEF/OIF Veterans with and without traumatic brain injury

Abstract Objective: To describe changes in post-deployment objective and subjective cognitive performance in combat Veterans over 18 months, relative to traumatic brain injury (TBI) status and psychological distress. Method: This prospective cohort study examined 500 Veterans from Upstate New York at four time points, six months apart. TBI status was determined by a structured clinical interview. Neuropsychological instruments focused on attention, memory, and executive functions. Subjective cognitive complaints were assessed with the Neurobehavioral Symptom Inventory (NSI). A psychological distress composite included measures of post-traumatic stress disorder (PTSD), depression, and generalized anxiety. Results: Forty-four percent of the sample was found to have sustained military-related TBI, 97% of which were classified as mild (mTBI), with a mean time since injury of 41 months. Veterans with TBI endorsed moderate cognitive symptoms on the NSI. In contrast to these subjective complaints, mean cognitive test performance was within normal limits at each time point in all domains, regardless of TBI status. Multilevel models examined effects of TBI status, time, and psychological distress. Psychological distress was a strong predictor of all cognitive domains, especially the subjective domain. Substantial proportions of both TBI+ and TBI− groups remained in the clinically significant range at the initial and final assessment for all three distress measures, but the TBI+ group had higher proportions of clinically significant cases. Conclusions: Objective cognitive performance was generally within normal limits for Veterans with mTBI across all assessments. Psychological distress was elevated and significantly related to both objective and subjective cognitive performance.

Open-trial pilot study of a comprehensive outpatient psychosocial treatment for children with high-functioning autism spectrum disorder.

This study examined the feasibility and initial outcomes of a comprehensive outpatient psychosocial treatment (MAXout) for children aged 7–12 years with high-functioning autism spectrum disorder. The 18-week treatment, two 90-minute sessions per week, included instruction and therapeutic activities targeting social/social communication skills, facial emotion recognition, non-literal language skills, and interest expansion. A behavioral system was implemented to reduce autism spectrum disorder symptoms and problem behaviors and increase skills acquisition and maintenance. Feasibility was supported via high levels of treatment fidelity and parent, child, and staff satisfaction. Significant post-treatment improvements were found for the children’s non-literal language skills and facial emotion recognition skills, and parent and staff clinician ratings of targeted social/social communication skills, broad social skills, autism spectrum disorder symptoms, and problem behaviors. Results suggested that MAXout was feasible and may yield positive outcomes for children with high-functioning autism spectrum disorder.

A Concept Map of Campers’ Perceptions of Camp Experience: Implications for the Practice of Family Counseling

Camp programs are a popular medium for providing children and adolescents with opportunities for growth and development. Specialized camps may provide powerful contextual support for campers with disabilities and families with limited resources, but knowledge of what constitutes an effective camp experience is limited. Further, family counseling practice principles seem relevant to camp programming, but research is absent in this area. Present study applied concept mapping to capture the quantitative and qualitative dimensions of 173 campers’ experiences to examine its implications for the practice of family counseling. Seven thematic concepts emerged consistent with previous research confirming the positive and transformative nature of camp. The current study advances the knowledge base of camp programming for family counselors and helps improve future family counseling practice and research.