The Measurement of Everyday Life Executive Functioning in Adults with FASD: A Pilot Study

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1 The Measurement of Everyday Life Executive Functioning in Adults with FASD: A Pilot Study 11/15/2013 Dr. M. Tracy Morrison, OTD R/L Clinical Scientist and Manager of Clinical Programs and Services, Courage Kenny Rehabilitation Institute Dr. Gordon Giles, PhD Professor, Samuel Merritt University Dr. Raj K. Kalapatapu, MD Assistant Adjunct Professor of Psychiatry, University of California, San Francisco Dr. Dorothy F. Edwards, PhD Professor and Chair, Department of Kinesiology, University of Wisconsin

2 Disclaimers & Disclosures This presentation is NOT intended to be: An evidenced-based review of FASD and/or executive functioning Disseminated into routine clinical practice A clinical case conference The data for all pilot studies are in a preliminary stage We do not benefit financially from the materials discussed in this presentation Dr. Morrison is currently funded by Sister Kenny Foundation Dr. Kalapatapu is currently funded by K23DA (National Institute on Drug Abuse) We are not experts in FASD

3 Executive Functioning and Everyday Life The executive functions comprise those mental capacities necessary for formulating goals, planning how to achieve them, and carrying out the plans effectively. They are at the heart of all socially useful, personally enhancing, constructive, and creative activities. (Lezak, 1982)

4 Clinical Relevance of Detecting Everyday Life Deficits Community-based population Difficult to identify clinically Have insight into personal challenges Experience functional difficulty in novel situations Behavioral challenges during unpredictable social scenarios High level deficits conflict with motivation to engage in: Roles Meaningful activities Social life (Blundon & Smits, 2000; Burgess, 2000; Levine et al., 2000; Lezak, 1982; Burgess et al., 1998; Baddeley et al., 1997; Shallice & Burgess, 1991)

Multiple Errands Test-Revised (MET-R): Background MET-R is an ecological measure of real-world functional deficits Strength-based testing Neurocognitive Poor test performance was associated with

5 Multiple Errands Test-Revised (MET-R): Background MET-R is an ecological measure of real-world functional deficits Strength-based testing Neurocognitive Poor test performance was associated with frontal lobe dysfunction Ventromedial prefrontal cortex Test situated in a real-world context Multiple unstructured tasks while following rules Priorities are determined by the participant Test performance is video recorded to support scoring Scoring focuses on efficiency and effectiveness, not behaviors (Torralva et al., 2008; Tranel et al., 2008; Shallice & Burgess, 1991; Rand, Rukan, Weiss & Katz, 2008; Dawson et al., 2009 Morrison et al., 2005, 2012)

6 In this exercise you should complete the following in any order: You should: Collect something for the examiner from the Information Desk and do what is necessary Buy 4 pieces of candy (This is 1 item) Buy a get well card Buy a Coca-Cola Telephone Bonnie Logsdon at and say where you are, who you are, and what time it is Leave something to be mailed to Dr. Alex Dromerick with your examiner. You should also obtain the following information: What is the closing time of the uniform shop on a Thursday? What is the opening time of the gift shop on a Friday? What is the price of a bag of Pringles chips? Where is the chapel located Meet me at the fountain 10 minutes after you have started the task and tell me the time Tell me when you have completed the exercise. While carrying out this exercise you must obey the following rules: 1.You must carry out all these tasks but may do so in any order 2.You should spend no more than $ You should stay within the limits of the main floor of the hospital (i.e., the 1 st floor) 4.You should not enter any of the hospital treatment areas or staff only areas 5.You should buy no more than 2 items in the gift shop 6.Take as little time to complete this exercise without rushing excessively 7.You should not go back into an area you have already been in (e.g., the gift shop) 8.Do not speak to us unless this is part of the exercise Your examiner is: Tracy Morrison Dr. Alex Dromerick Dept. of Neurology, St. Louis, Mo

7 In this exercise you should complete the following in any order: You should: Collect something for the examiner from the Information Desk and do what is necessary Buy 4 pieces of candy (This is 1 item) Buy a get well card Buy a Coca-Cola Telephone Bonnie Logsdon at and say where you are, who you are, and what time it is Leave something to be mailed to Dr. Alex Dromerick with your examiner. You should also obtain the following information: What is the closing time of the uniform shop on a Thursday? What is the opening time of the gift shop on a Friday? What is the price of a bag of Pringles chips? Where is the chapel located Meet me at the fountain 10 minutes after you have started the task and tell me the time. Tell me when you have completed the exercise. Tell me when you have completed the exercise.

8 While carrying out this exercise you must obey the following rules: 1.You must carry out all these tasks but may do so in any order 2.You should spend no more than $ You should stay within the limits of the main floor of the hospital (i.e., the 1 st floor) 4.You should not enter any of the hospital treatment areas or staff only areas 5.You should buy no more than 2 items in the gift shop 6.Take as little time to complete this exercise without rushing excessively 7.You should not go back into an area you have already been in (e.g., the gift shop) 8.Do not speak to us unless this is part of the exercise Your examiner is: Tracy Morrison Dr. Alex Dromerick Dept. of Neurology, St. Louis, Mo

10 MET-R Scoring Item Total time to complete Number of locations visited Total number of tasks completed Total number of passes Total number of rule breaks Operational Definition Total time elapsed from start to when the participant tells the examiner he or she is finished Total number of locations visited, regardless of whether the locations are related to a task Number of the 17 tasks assigned that were finished Number of times the participant visited any location relevant to the test tasks Number of instructions violated (e.g. if a participant undertook 3 nonrequisite lexical interactions with the examiner, the calculation would include these 3 instances) Money spent Money spent during the test out of $10.00 Performance efficiency ratio 0 1 scale (tasks)/(location) = 3.4 (17)/(5)/3.4 = 1

11 Video I. Control

12 MET-R Study I. Theoretical Assumptions Multitasking = performance of simultaneous competing tasks Task complexity multitasking Multitasking = high demand scenario Processing speed Differences between efficient and effective multitasking How and if does not necessarily mean what (Marois and Ivanoff, 2005; Schumacher et al., 2001;Jonides,2004; Petersen et al., 1998;Erickson et al.,2007;dux et al., 2009)

13 Objectives Improve the clinical utility of the MET-R MET-R Study I. Discriminant validity Mildly impaired stroke population Frontal lobe and basal ganglia lesions/controls Improve test scoring Rater reliability

14 Study I. Participant Characteristics Edwards and Colleagues Mild Stroke Study 25 individuals with mild stroke (NIHSS 5) and 21 age, gender, education, and race matched controls participated Mild stroke participants were 6 months post-stoke Lesion distributions: 76% basal ganglia, 23% frontal, 1% cerebellar (Morrison et al., 2013)

15 Video II: Mild Stroke

16 RESULTS Variable Control Group (n = 21) mcva Group (n = 25) p Effect size Performance Efficiency Total tasks completed Total number of rule breaks 0.50 ± ± ± ± ± ± Total locations 9.00 ± ± Total time ± ± (ICC = 1.00)

17 Study I Result I. Everyday Life Deficits All individuals experienced mild cognitive impairment Individuals lived in the community 100% of participants were not able to maintain work 100% of participants experienced significant disability in the domains of: Psychosocial Engagement in meaningful activities Roles MET-R was sensitive to detecting differences between individuals with mild stroke and normal populations

18 Pilot Study II. Exploration of the MET-R in Other Populations Does the MET identify adults with FASD who experience everyday life deficits? Variable FASD (n = 5) mild TBI (n = 5) Control (n = 5) p Mean ± SD Mean ± SD Mean ± SD Age ± ± ± Years of Education ± ± ± n (%) n (%) n (%) Male 3 (60) 3 (60) 4 (80) 0.74

19 Video III: Adult with FASD

20 Variable Pilot Study II: Preliminary Results FASD (n = 5) Mild TBI (n = 5) Control (n = 5) Mean ± SD Mean ± SD Mean ± SD F p Effect size Rules Broken 3.20 ± ± ± Tasks Completed 13.0 ± ± ± Number of Locations 7.80 ± ± ± Number of Revisits 1.60 ± ± ± Talked to Examiner 1.60 ± ± ± Time (minutes) ± ± ±

21 Discussion of Preliminary Findings Individuals with FASD performed better than individuals with acquired mild TBI Resiliency and persistence Both patient groups experienced more challenges compared to controls All individuals with FASD accurately recalled rules following the MET All individuals with FASD identified feelings of real life stress during the MET All individuals with FASD accurately described what they needed to do pre/post test Individuals with FASD struggled to understand less concrete information Task missed the most by all groups: Prospective memory task Individuals with FASD were more socially confidant than individuals with mild TBI

22 Strengths First known use of MET in FASD 3-group comparison identified quantifiable differences First known use of MET in adults with FASD MET-R successfully simulated real life challenges experienced by adults with FASD Strong effect size even in a small sample All participants were diagnosed with FASD by a University clinic

23 Limitations Comorbid diagnoses Findings do not yet translate to children or adolescents Results are not yet correlated with neurocognitive measures Small sample size

24 Take Home Points The MET-R may be a useful everyday life assessment tool for adults with FASD Future directions: Correlate with neurocognitive measures Investigate younger and older populations Identify the sensitivity of this tool to FASD-specific strengths/deficits Part of a diagnostic workup Potential use in educational/vocational settings to educate teachers/supervisors Training clinical providers for eventual dissemination

25 Thank You Study participants MOFAS, Ruth Richardson Jeff and Nancy Beyer Jodi Kulp Sister Kenny Foundation Dorothy F. Edwards, PhD Gordon Giles, PhD Contact s: Tracy Morrison: Raj Kalapatapu:

Complex Task Performance Assessment. Timothy J. Wolf, OTD, MSCI, OTR/L Assistant Professor Program in Occupational Therapy Department of Neurology

Complex Task Performance Assessment Timothy J. Wolf, OTD, MSCI, OTR/L Assistant Professor Executive Function Definitions Executive function is the ability to integrate various component cognitive abilities