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Objective: There are very few evidence-based treatments for individuals with mild to moderate traumatic brain injuries. We developed and tested a 12-week, manualized, compensatory cognitive training intervention, Cognitive Symptom Management and Rehabilitation Therapy (CogSMART), which targeted postconcussive symptom management, prospective memory, attention, learning/memory, and executive functioning. The intervention focused on psychoeducation and compensatory strategies such as calendar use, self-talk, note taking, and a 6-step problem-solving method. Setting: VA Healthcare System. Participants: A total of 50 Veterans with mild to moderate traumatic brain injuries receiving supported employment. Design: Twelve-month randomized controlled trial with participants assigned to receive CogSMART or additional supported employment sessions for the first 12 weeks. Outcome assessments were administered at baseline and 3, 6, and 12 months. Main Measures: Assessments measured postconcussive symptoms, neuropsychological performance, functional capacity, psychiatric symptom severity, quality of life, and weeks worked during the 12-month trial. Results: Hierarchical linear modeling analyses using all 4 time points demonstrated significant CogSMART-associated reductions in postconcussive symptoms (r = -0.28, P = .026, d = 0.64) and improvements in prospective memory (r = 0.35, P = .031, d = 0.55) and quality of life (r = 0.34, P = .009, d = 1.0). The groups did not differ on weeks worked during the trial. Conclusion: CogSMART has the potential to improve postconcussive symptoms, cognitive performance, and self-rated quality of life in individuals with mild to moderate traumatic brain injuries.

Neuropsychological, neuroanatomical, and electrophysiological data are presented on two subjects with fetal alcohol syndrome (FAS). Both boys had intelligence quotients in the mentally deficient range and were found to have several other severe, specific deficits. Magnetic resonance imaging showed abnormalities of the corpus callosum, and reductions in the size of the basal ganglia and thalamic structures. No focal abnormalities were noted in the electroencephalogram records, although the electroencephalograms of both boys were moderately abnormal for their age group. A multidisciplinary approach to the study of FAS, hopefully will lead to a more unified concept of the disorder and perhaps indicate specific areas of vulnerability.

Traumatic brain injury (TBI) can result in cognitive impairments and persistent postconcussive symptoms that limit functional recovery, including return to work. We evaluated a 12 wk compensatory cognitive training intervention (Cognitive Symptom Management and Rehabilitation Therapy [CogSMART]) in the context of supported employment for Veterans with mild to moderate TBI. Participants were randomly assigned to receive 12 wk of supported employment plus CogSMART or enhanced supported employment that controlled for therapist attention (control). CogSMART sessions were delivered by the employment specialist and included psychoeducation regarding TBI; strategies to improve sleep, fatigue, headaches, and tension; and compensatory cognitive strategies in the domains of prospective memory, attention, learning and memory, and executive functioning. Compared with controls, those assigned to supported employment plus CogSMART demonstrated significant reductions in postconcussive symptoms (Cohen d = 0.97) and improvements in prospective memory functioning (Cohen d = 0.72). Effect sizes favoring CogSMART for posttraumatic stress disorder symptom severity, depressive symptom severity, and attainment of competitive work within 14 wk were in the small to medium range (Cohen d = 0.35-0.49). Those who received CogSMART rated the intervention highly. Results suggest that adding CogSMART to supported employment may improve postconcussive symptoms and prospective memory. These effects, as well as smaller effects on psychiatric symptoms and ability to return to work, warrant replication in a larger trial.

Context: The nature of executive dysfunction in schizophrenia is nebulous, due to inconsistencies in conceptualizing and operationalizing the construct, and the broader question of whether schizophrenia is best characterized in terms of specific vs generalized cognitive deficits. The current study aimed to determine whether executive functions represent unitary vs diverse constructs in schizophrenia., Methods: Participants included 145 community-dwelling individuals with schizophrenia. Executive functions were measured with the Delis-Kaplan Executive Functioning System (D-KEFS). We conducted an exploratory factor analysis (EFA) with principal axis factoring, as well as parallel analyses to examine the latent constructs underlying the D-KEFS tasks, a second EFA on weighted residuals of the D-KEFS tasks (after accounting for processing speed measured with the Digit Symbol task), and bivariate correlations to examine relationships between the D-KEFS components and relevant demographic and clinical variables, crystallized verbal knowledge, and functional capacity., Results: EFA of the D-KEFS tasks yielded 2 factors (cognitive flexibility/timed tests and abstraction). EFA of the processing speed-weighted D-KEFS residuals also yielded 2 factors (cognitive flexibility and abstraction). Cognitive flexibility was negatively correlated with psychopathology. Better abstraction was associated with higher education, shorter illness duration, and better functional capacity. Both factors were positively correlated with crystallized verbal knowledge., Conclusions: Executive functions in schizophrenia could be parsed into 2 partially related but separable subconstructs. Future efforts to elucidate functional outcomes as well as neurobiological underpinnings of schizophrenia may be facilitated by attending to the distinction between cognitive flexibility and abstraction.

In neuropsychological practice, individuals often present with evidence of excessive cognitive complaints or invalid test performances indicative of symptom exaggeration; however, clinicians often struggle with how to diagnose these cases once they have been identified. Difficulties in subsuming these individuals within existing DSM-IV diagnoses such as Malingering, Factitious Disorder, and Conversion Disorder are discussed, including: (a) lack of a diagnostic category that adequately targets the specific features of this relatively common condition and (b) the use of criteria that require the clinician to make judgments about internal states that are difficult to evaluate in an objective manner (e.g., intentional versus unintentional production of exaggerated symptoms). Two diagnostic categories--Cogniform Disorder and Cogniform Condition--are proposed as new subtypes of the Somatoform Disorders to encompass cases of excessive cognitive complaints and inadequate test-taking effort in the absence of sufficient evidence to diagnose Malingering. Of the two new categories, Cogniform Disorder is defined as a more pervasive form in which the individual tends to exhibit the excessive cognitive symptoms in widespread areas of his or her life, thereby suggesting a conversion-like adoption of the sick role manifested primarily as cognitive dysfunction. Guidelines for improving the evidence-based diagnosis of these cases, particularly with regards to criteria related to intentionality, secondary gain, and sick role factors, are also discussed.

The California Verbal Learning Test - second edition (CVLT-II) is one of the most widely used neuropsychological tests in North America. The present study evaluated the 1-month test-retest reliability and practice effects associated with the standard and alternate forms of the CVLT-II in a sample of 195 healthy adults. Eighty participants underwent repeat assessment using the standard form of the CVLT-II on both occasions, whereas the remaining 115 individuals received the standard form at baseline and the alternate form at follow-up. Consistent with prior research, results revealed generally large test-retest correlation coefficients for the primary CVLT-II measures in both the standard/standard (range=0.80-0.84) and standard/alternate (range=0.61-0.73) cohorts. Despite exhibiting slightly lower test-retest reliability coefficients, participants in the alternate form group displayed notably smaller practice effects (Cohen's d range=-0.01 to 0.18) on the primary indices relative to individuals who received the standard form on both occasions (Cohen's d range=0.27-0.61). Reliable change indices were also generated and applied to primary CVLT-II variables to determine the base rates of significant improvements (range=2-10%), declines (range=0-7%), and stability (range=85-97%) in performance over time. Overall, findings from this study support the test-retest reliability of the standard and alternate forms of the CVLT-II in healthy adults and may enhance the usefulness of this test in longitudinal neuropsychological evaluations.

Executive deficits of problem solving and concept formation have been associated with frontal lobe dysfunction. Here we describe a new clinical test of concept formation based on the parlor game, Twenty Questions. The Twenty Questions Test requires examinees to ask the fewest number of yes/no questions possible in order to identify a target item from an array of 30 line drawings. The items belong to a number of categories and subcategories that exist in a hierarchical, semantic structure. Patients with focal prefrontal lesions asked significantly more questions than controls in their attempt to guess the target items and sometimes exhausted the 20-question limit. Qualitative analyses revealed that patients tended to use ineffective categorization strategies, for example, relying exclusively on questions that referred to single items. Taken together with previous findings, we conclude that prefrontal cortex supports the on-line organization and conceptualization of category exemplars in concept-formation tasks.

Although verbal memory deficits are frequently reported in reading disabled children, the specific mechanisms underlying these impairments have yet to be clearly defined. The present study used the California Verbal Learning Test-Children's Version (CVLT-C) to assess verbal learning in 57 dyslexic children and 114 controls matched for gender, age, and WISC-R Vocabulary score. Three areas of verbal memory were investigated: Recall and recognition, use of learning strategies, and interference effects. The dyslexic group learned the list items more slowly, recalled fewer words on the last learning trial and the delayed trials, and performed less well on the recognition condition. Dyslexics and controls displayed similar vulnerability to interference, but group differences were evident in serial position effects. Taken together, our data suggest that dyslexics have less efficient rehearsal and encoding mechanisms, resulting in deficient encoding of new information, but normal retention and retrieval.

The tendency of young children to attend to global and/or local levels of hierarchically structured patterns was examined using an orientation judgment task. 3- and 4-year-old children and adults were asked to judge which way an equilateral triangle was pointing under different contextual conditions. In Experiment 1, contextual variations included overall pattern orientation, configuration alignment type, presence or absence of an immediate frame of reference, and type of local element context. The results showed that, contrary to previous reports in the literature, young children, like adults, attend to both global and local levels of a pattern. Both pattern orientation and the introduction of contextual cues affected children's judgments, and the magnitude of that effect varied with the particular contextual cue present in the stimulus array. In Experiment 2, contextual variations included overall pattern orientation and presence or absence of an internal local level element. Consistent with the results of Experiment 1, young children's orientation judgements were influenced by the addition of local level factors.

Patients with unilateral right-hemisphere lesions performed significantly worse than normal controls in arranging the mixed-up sentences of stories. This impairment was not restricted to paragraphs conveying primarily spatial information, but occurred on other types of paragraphs as well. Nonspecific deficits of brain injury were ruled out as possible alternative explanations for the patients' difficulty on the task. The organization of language at the paragraph level may depend on right-hemisphere functioning.