“Cognitive Mediation”

University of Chicago Medical Center

Maureen Lacy, Ph.D.

Assessment of intelligence and academic

functioning

Patients 41 individuals Ages 6 to 16 Etiology was posthemorrhagic hydrocephalus shunted nonsiphoning valves within first year of life Free of revision or infection for one year

Controls 23 individuals: Family & friends - Ages 6 to 15 - Medical History-Unremarkable

WISC-III: Standard Intelligence Full Scale IQ; Verbal IQ and Performance IQ

Woodcock-Johnson-III Broad Achievement Index

Scholastic attainment

Intellect and Academic Outcome

Shunted Patients

N=41

Controls

N=23

P-value

Full Scale IQ 82.5 (17.1) 106.1 (19.0) .000

Verbal Scale 86.1 (16.3) 108.5 (16.8) .000

Performance 81.3 (17.6) 102.5 (20.6) .000

Scholastic Achievement

99.6 (18.6) 107.0 (15.7) .115

Cognitive Domains

Intellect

Memory

Executive

Functional

CVLT-C

Let pretend you are going shopping on Monday. I’m going to read a list of things for you to buy. Listen carefully, because when I am through I want you to tell as many of

the things as you can. You can say them in any order, just say as many as you can Are you ready?

Bananas Sweater Puzzle Jacket Grapes Blocks Watermelon Shorts Crayons Peaches Balloons Hat Strawberries Belt Marbles

California Verbal Learning Test

Child Version Delis, Kramer, Kaplan, and Ober

Copy this figure

Memory Measures ****** Shunted N=41 Controls N=23 P-value

RCFT

Immediate

6.80 (6.5) 14.72 (9.1) .000

RCFT Delay 6.09 (5.6) 14.52 (9.0) .000

RCFT

Recognition

17.73 (2.9) 19.70 (2.3) .01

CVLT Total 35.27 (11.2) 49.22 (10.0) .000

CVLT LDFR 6.20 (3.3) 10.39 (2.4) .000

CVLT

Recognition

12.49 (2.8) 14.18 (1.1) .01

Attention Battery

Freedom from Distractibility (WISC-3)

Planned Connections*

Expressive Attention*

Receptive Attention* (*Cognitive Assessment system)

Gordon Vigilance and Distractibility

CAS

Receptive

Attention

Results Shunted N=41 Controls N=23 P-value

FDI 91.2 (19.0) 104.0 (14.0) 0.01

CAS_PC 208.66 (142.7) 146.39 (62.7) 0.05

CAS_RA 34.18 (16.1) 41.00 (15.3) 0.11

CAS_EA 34.6 (14.3) 49.0 (17.3) 0.00

GDS_VT 32.9 (10.6) 37.0 (10.8) 0.15

GDS_VC 20.2 (24.8) 13.2 (24.4) 0.30

GDS_DT 18.0 (13.5) 27.6 (15.8) 0.02

GDS_DC 44.4 (55.5) 14.3 (24.7) 0.02 •O’Brien’s procedure maintains the type I error rate, and it is best used when differences are expected for all of the endpoints.

•Hydrocephalic patients displayed inefficiencies on selective tasks of attention and working memory as compared to age and education matched peers •Specifically, the shunted group showed a reduced ability to concentrate as well as an inability to modify attention focus fluidly

Executive Functioning and Adaptive Behavior

Parents were asked to complete a questionnaire examining executive skills

How is your child functioning at home?

BRIEF

Behavioral Rating Inventory of Executive Functioning

BRIEF Results

Shunted Patients

(n=39)

Controls (n=20) p-value

Global Executive

Composite

55.31 (11.0) 48.50 (10.4) 0.03

Metacognition Index 55.87 (10.3) 50.00 (11.6) 0.05

Initiate 53.38 (10.2) 51.95 (10.8) 0.62

Working Memory 56.87 (11.2) 48.95 (11.2) 0.01

Plan/Organize 53.18 (10.8) 48.25 (9.5) 0.09

Org. of Materials 53.85 (13.4) 49.85 (9.1) 0.24

Monitor 54.49 (10.6) 48.15 (7.9) 0.02

Behavioral

Regulation Index

53.82 (10.8) 47.50 (9.8) 0.03

Inhibit 53.62 (10.1) 48.85 (10.3) 0.09

Shift 52.74 (9.8) 46.15 (11.9) 0.03

Emotional Control 53.28 (11.3) 48.80 (9.7) 0.14

Shift Items

Resists or has trouble accepting a different way to solve a problem with schoolwork, friends, chores, etc.

Becomes upset with new situations Tries the same approach to a problem over and over even

when it does not work. Acts upset by a change in plans. Is disturbed by change of teacher or class. Resists change of routine, foods, places, etc. Has trouble getting used to new situations (classes,

groups, friends). Thinks too much about the same topic.

Working Memory

When given three things to do, remembers only the first or last Has a short attention span Is easily distracted by noises, activity, sights, etc. Has trouble with chores or tasks that have more than one step Needs help from an adult to stay on task Forgets what he/she is doing When sent to get something, forgets what he/she is supposed to

get Has trouble concentrating on chores, homework,etc. Has trouble finishing tasks (chores, homework) Has trouble remembering things, even for a few minutes

Correlations to Cognitive Domains

Working Memory correlated with children’s lower performances on

Immediate Verbal Memory (p<0.01)

Self Monitoring correlated with children’s actual

problems on

Attentional Composite (p<.05)

Age Related Differences

• Patients were separated into groups of younger patients (less than or equal to 9 years of age and older patients (greater than 9 years of age)

•Results indicated that older children demonstrated greater executive problems, suggesting more functional impairment as shunted children age

Younger Patients

(n=24) Older Patients (N=15) P-value

Global Executive

Composite 51.75 (9.5) 61.00 (11.0) .01

Metacognition Index 52.75 (10.1) 60.87 (8.9) .02

Initiate 50.13 (9.5) 58.60 (9.2) .01

Working Memory 53.38 (9.1) 62.47 (12.2) .01

Plan/Organize 50.63 (10.4) 57.27 (10.3) .06

Organization of Materials 50.96 (10.6) 58.47 (16.2) .08

Monitor 53.00 (11.4) 56.87 (9.1) .28

Behavioral Regulation

Index 51.75 (10.1) 57.13 (11.4) .13

Inhibit 53.00 (10.0) 54.60 (10.7) .64

Shift 49.88 (8.8) 57.33 (9.9) .02

Emotional Control 51.54 (11.3) 56.07 (11.1) .23

Initiative

Is not a self-starter Needs to be told to begin a task even when willing Has trouble coming up with ideas for what to do in

play or free time Has trouble getting started on homework or chores Has trouble organizing activities with friends Does not take initiative Complains there is nothing to do Sits around the house a lot ("couch potato”)

Intellectual

Memory-Encoding

Attention, Working Memory, Shifting attention

Executive Functioning

22

Summary

List of Cognitive Remediation Programs

Braintrain

Luminosity

CogMed

MindFit

CogState

MindWeavers

NeuroCogX

MindSparkle

SharpBrains

CogniPlus

BrainAge

HAPPYneuron

23

Working Memory Training for children with attentional problems of Hyperactivity: A School Based Pilot Study, 2010

Working Memory Deficits can be Overcome: Impacts of Training and medication on working Memory in Children with ADHD, 2009

Adaptive training leads to sustained enhancement of poor working memory in children, 2009

Changes in Cortical Dopamine D1 Receptor Binding Associated with Cognitive Training, 2009

Training and transfer effects of executive function in preschool children, 2009

Computerized Training of Working memory in Children with ADHD-A randomized, Controlled Trial, 2005

Increased prefrontal and parietal activity after training of working memory, 2003

Training of Working Memory In Children with ADHD, 2002

24

Performance on a specific task can be improved with practice

There are neural correlates of this change

Often reduced activation as you become more efficient

Questionable if it translates to real life skills-abilities-reading, math, etc

Summary of Studies

25

Focused training program with children with hydrocephalus

Control groups

Generalizes Post Training Tasks

Maintenance==6-1 years

Future

26