Ecological Validity of Neurocognition and Community Functioning

1. Ecological Validity of Neurocognition and Community Functioning Debbie Gioia, Ph.D. University of Maryland, Baltimore School of Social Work Research Lunch-Time Seminar Series October 23, 2008 dgioia@ssw.umaryland.edu

2. Interest in neuropsychology • Clinical social worker on NIMH longitudinal study at UCLA (18 years) • Funded R03 (2002-2004) • The neuropsych puzzle of schizophrenia • Reduced cognitive capacity is one of the core features of schizophrenia and independent of clinical symptoms • Unraveling the brain conditions that account for cognitive decline

3. Core social work constructs • Biopsychosocial(spiritual) • Person-in-environment • Services for change These constructs of our profession provide legitimacy for me to enter an area of science that has not traditionally been populated by social workers

4. Schizophrenia research • Heterogeneity of the disorder • Tremendous individual variation in response to evidence-based interventions (e.g., social skills training, ACT, supported employment) • Persons with schizophrenia perform typically 2 standard deviations below the norm on neurocognitive tests • People with schizophrenia have the poorest functional outcomes (e.g. work, social, independent living) of all the serious mental disorders • There is no effective treatment for cognitive deficits • Neurocognition and social cognition scores as predictors of psychosocial functioning (Brekke et al., 2005)

5. Social work involvement with other populations with cognitive risk factors • Aging populations (all of us ) • Alzheimer’s and mild cognitive impairment • Substance users • Chronic physical conditions – e.g. cardiac, diabetes, pulmonary, stroke • Persons with ADHD (children and adults) • Poverty • Poor nutrition • Traumatic brain injury • Depression • Living with stress (all of us )

6. Components of Memory Encoding (getting the information in) Consolidation (transferring information into long-term store) Retrieval (getting the information out) Intact cognitive functioning defines who we are

7. Cognition • From the Latin ‘cognoscere’: to come to know • Cognition is the process of being aware, knowing, thinking, learning, reasoning, remembering, planning and judging. • It can be closely associated with emotion

8. Measuring cognition Verbal Learning: Ability to acquire, store, and retrieve verbal information for more than a few minutes Example: California Verbal Learning Test drill chives plums tangerines vest chisel parsley jacket grapes nutmeg paprika apricots sweater pliers wrench slacks

9. Why is verbal learning important? • Helps to assess what an individual can remember in a rehabilitation environment, in a doctor’s office, or other learning environment (following instructions) • Helps individuals navigate their homes and communities safely • Enables individuals to incorporate advice

10. Immediate/Working memory • Definition: Ability to hold information “online” in a temporary store or to manipulate the information Example: Letter Number Sequencing Test K3B4 _ _ _ _ R8C3G5 _ _ _ _ _ _

11. Why is working memory important? • Remembering a phone number/address • Social conversation (storing information about another person and maintaining your side of the conversation) • Switching between different tasks

12. Sustained attention • Definition: Ability to respond to targets, not respond to non-targets over a period of time • Also called vigilance • Involves cognitive and ocular motor processes • Usually a computerized test – individual asked to press whenever s/he sees a zero and ‘hold’ when another number appears • Visual attention is critical for assessing and processing motion information – moving cars, etc • Example: Continuous performance test (CPT) Startle Blink test

13. The amplitude of the eye blink is a measure of how much you startleIndividuals with schizophrenia also startle to a non-startling quiet tone – failure of gating

14. Why is sustained attention important? • In any social interaction there is a need to maintain what is relevant and what is not • With ADHD and schizophrenia information floods the individual and they have less discretion in sorting out what is most important for their attention

15. Executive functioning Definition: The cognitive system that is the manager of all cognitive processes and heavily involved in our ability to handle new information and situations (prefrontal cortex) Has been measured since 1950’s mostly with the Wisconsin Card Sorting Test- persons with schizophrenia have significant difficulty (large effect size) in these measures compared to other psychiatric patients (-1.45 compared to -0.40)

16. Why is executive functioning important? • Helps us to correct errors • Helps us to plan and structure our time • Helps us understand dangerous situations and make plans to avoid or reduce the danger • Helps us to moderate our impulses and resist temptations

17. Why do we need to go to the next step? • The relationship between neuropsychological (NP) test scores and community functioning is strong but do we really know what is being measured? • Low scores on NP tests predict poor outcome in schizophrenia more strongly than psychotic symptoms • Developing functionally meaningful methods to accurately capture and focus on community functioning outcomes that are correlated with NP testing is just beginning

18. Ecological Validity • is defined as “the functional and predictive relationship between an individual’s performance on a chosen set of neuropsychological tests and the individual’s behavior in a variety of real world settings”. • is related to external validity but different • is related to the inferences drawn from the test The test can be valid but not ecologically valid • Walking speed after TBI study (example)

19. Ecological validity review article (Chaytor & Schmitter-Edgecombe, 2003) • Studies reviewed – populations – closed head injury, chronic medical conditions, schizophrenia • Concern: NP tests developed to provide information about diagnosis are being used to answer questions about everyday functioning with very little empirical evidence to support this practice

20. Two properties of ecological validity • Versimilitude The degree to which the cognitive demands of a test resemble the cognitive demands of everyday life • Verdicality The degree to which existing tests are empirically related to measures of everyday functioning such as clinician ratings, employment status etc Ecological questions are focused on what the client actually does in the real world (messier) and usually not the best performance state that is achieved in a lab (ideal)

21. Trends from the review • Most frequently used outcomes in studies – (1) return to work and (2) IADLs obtained through clinician ratings and self-report – this review looked at everyday cognitive skills • Studies varied in choice of NP tests & outcomes • Tests of memory related to everyday memory ability • Significant relationships between executive function tests and ratings by clinicians and others (not self-report) • The magnitude of the relationships between individual tests and measures of outcome was weakly related

22. Sbordone & Long (1996)Ecological Validity of Neuropsych Tests Vector approach – If all sources of information point in the same direction, the assessment is likely to be ecologically valid 

23. Findings from my R03 • Gioia (in press); Gioia & Brekke (in press); Gioia (2006) • We found support for theecological validity of NP test scores in that they were strongly associated with the character of community behavior in predictable and consistent ways for this sample of individuals with schizophrenia. • There was some tendency for those with low NP functioning to have higher positive symptoms. • Self-esteem scores were lowest in those with low NP functioning, but satisfaction with life showed no difference between the two groups. • The high NP group also showed deficits • This method of observation and coding yielded useful and rich data on the range and predominant style of community functioning. This method showed sensitivity to functional variation not found in the quantitative measurement. • Even though there was a predominant behavioral style or strategy evident for each individual, there was notable heterogeneity in the behavior of each individual. • Despite a range of functioning levels across the individuals, all were ‘making it’ in complex real world situations.

24. My R01 study proposal • Project rationale (a psychosocial rehabilitation/recovery philosophy) There is a real need to measure and treat neurocognitive deficits in schizophrenia in order to enable more individuals with the disorder to achieve their personal recovery goals and function as a full participant in the life of their community. This proposal’s novel use of mixed methods to assess ecological validity of NP tests with direct behavioral observation and use of co-primary measures will provide valuable insights for the field in understanding the real world performance of individuals with schizophrenia; developing targeted interventions for cognitive deficits; documenting the resilience of individuals who negotiate life’s tasks despite cognitive deficits; and reducing the public health risk.

25. Definitions • Direct behavioral observations • Co-primary or (proxy) measures of cognitive functioning • TABS (Test of Adaptive Behavior in Schizophrenia – Dawn Velligan) • UPSA (The University of California Performance Skills Assessment – Tom Patterson et al)

26. Proposed Study Method • Sample (N=80) (age 18-50) • Two sites (Harbor City & Mosaic) • Measures – symptom, QOL, self-efficacy • Eight step ethnographic procedure (handout) • Main goal – to add critical information through community observation of daily tasks to improve measurement of community functioning and eventually to develop community performance- based interventions.

27. Critiques from the reviewers • Consistent with national initiatives MATRICS (Measurement and Treatment Research to Improve Cognition) and TURNS (Treatment Units for Research on Neurocognition) • Distinguishing specific NP tests related to community functioning in schizophrenia (learning potential and verbal learning) • Non-cognitive confounding factors • Extent to which the observers change the nature of the interaction

28. Medications Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NIH) • Comparing the effectiveness of older neuroleptics and novel neuroleptics (over 1400 clients) • Some cognitive improvement with clozapine, riperidone, quetiapine reported in some but not all studies • Nicotine agonists • Glutamate blockers (normalize abnormalities in prefrontal contex)

29. Effect of Nicotine • Studies have suggested improvement in some areas of attention and memory with the use of nicotine (nicotinic neurotransmitters) (Dr. Gunvant Thaker) • Sensory gating improves • Swedish study of military recruits looked at early smoking (18-20 years) and lower rate of schizophrenia onset (protective factor)

30. Cognitive Remediation • Cognitive remediation is an array of behavioral interventions which use computer programs and other targeted learning tools to enable individuals to retrieve some of their lost skills by teaching a variety of compensatory strategies

31. Future • Re-submit R01 in March to NIMH & NARSAD with additional consult from Dr. Jim Gold at MPRC and others • Continue learning in this area – reading, lectures, courses • Possible text for social work students