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21 Patterns of Neural Activation Associated with Judgments of Learning and Retrospective Confidence Judgments in Individuals with TBI
- Michael J Walsh, Ekaterina Dobryakova, Erica Weber, Kathy S Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 130-131
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Objective:
Metacognition is defined as the ability to observe, monitor, and make judgments about one’s own cognitive status. Judgments of learning (JOLs) and retrospective confidence judgments (RCJs) are two elements of metacognition related to memory, or metamemory. JOLs refer to one’s assumptions of their memory performance prior to completing a memory task, while RCJs describe one’s subjective assessment of their memory performance after they have completed the task. Traumatic brain injury (TBI) is known to negatively impact general metacognitive functioning. However, the nuanced effects of TBI on constituent metacognitive subprocesses like JOLs and RCJs remain unclear. This study aimed to characterize patterns of brain activity that occur when individuals with TBI render JOLs and RCJs during a meta-memory task. Differences between JOL- and RCJ-related patterns of activation were also explored.
Participants and Methods:20 participants with moderate-to-severe TBI completed a metacognition task while undergoing functional magnetic resonance imaging (fMRI). Participants were first exposed to target slides with a set of polygons placed in specific locations, then asked to identify the target slides within a set of distractors. Before identifying the target slides, participants rated how well they believed they would remember the polygons’ shape and location (JOL). After answering, they rated how confident they were that the answer they provided was correct (RCJ). First-level time series analyses of fMRI data were conducted for each participant using FSL FEAT. Higher-level random effects modeling was then performed to assess average activation across all participants. Finally, contrasts were applied to examine and compare JOL- and RCJ-specific patterns of activation.
Results:JOLs were associated with activation of the left frontal gyri, bilateral anterior cingulate, left insula, and right putamen (p < 0.01). RCJs were associated with activation of the bilateral frontal gyri, bilateral posterior and anterior cingulate, left insula, right putamen, and left thalamus (p < 0.01). Compared to RCJs, JOLs demonstrated greater left insula activation (p < 0.01). Compared to JOLs, RCJs demonstrated greater activation of the left superior frontal gyrus, bilateral middle frontal gyrus, and bilateral anterior cingulate (p < 0.01).
Conclusions:The areas of activation found in this study were consistent with structures previously identified in the broader metacognition literature. Overall, RCJs produced activity in a greater number of regions that was more bilaterally distributed compared to JOLs. Moreover, several regions that were active during both metacognitive subprocesses tended to be even more active during RCJs. A hypothesis for this observation suggests that, unlike JOLs, the additional involvement of reflecting on one’s immediate memory of completing the task during RCJs may require greater recruitment of resources compared to JOLs. Importantly, these findings suggest that, while different metacognitive subprocesses may recruit similar brain circuitry, some subprocesses may require more potent and widespread activation of this circuitry than others. As such, subprocesses with greater activational needs and complexity, such as RCJs, may be more susceptible to damage caused by TBI. Future research should aim to compare patterns of activation associated with certain metacognitive subprocesses between survivors of TBI and healthy controls.
77 Performance on Tests of Attention and Mental Flexibility Predicts Metacognitive Accuracy
- Christopher S. Waller, Michael J. Walsh, Trevor Scarlett, Kathy S. Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 279-280
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Objective:
The process of metacognitive monitoring refers to one’s ability to incorporate rapid in-the-moment self-assessments of their cognitive performance. An area of interest within this literature concerns metacognitive accuracy (MA), or the extent to which an individual can discern when their own judgments are incorrect/correct. Much of the work in this area has either focused on school-aged samples or clinical samples, with findings of impairment in metacognitive processes associated with traumatic brain injury, Schizophrenia, cerebrovascular accidents, and Alzheimer’s disease. Notably, decreased working memory and executive functioning are frequently reported in samples with low MA, suggesting a possible reliance on basic cognitive resources in the facilitation of metacognitive processes. Thus, the goal of this investigation was to elucidate potential relationships between individual domains of cognition and higher-order MA. We hypothesized that performance on measures of working memory and executive function would be positively associated with measures of MA.
Participants and Methods:Data from 87 undergraduate students who volunteered in research for class credit were used. All participants completed a computerized metamemory task where six lists of 12 words each paired with varying point values were first presented to the participants. After each list, participants were instructed to score as many points as possible by recalling words they could remember. After a brief delay, participants completed a recognition task using the words presented earlier and provided a retrospective confidence judgement (RCJ) following each item. A metric for MA, meta d', was calculated using signal-detection theory analysis from the reported RCJs and recognition task performance. Participants also completed neuropsychological tests of attention (Trails A), working memory (WM; Backward Digits), executive function (EF; Trails B), mental flexibility (MF; Trails B/A Ratio), and processing speed (Symbol Digit Modalities). A sequential multiple regression was performed with meta d’ serving as the criterion, with education, age, and performance on neuropsychological measures entered as predictors.
Results:The model indicated that a moderate percentage of the variability (R2 = .201) in metacognitive accuracy could be attributed to the combination of predictors in the model (F (7,79) = 2.843, p = .011). Examination of the regression coefficients indicated that only measures of attention (ß = .638, p = .01), MF (ß = .473, p = .041), and WM ß = .244, p = .024) were significantly related to MA after controlling for all other variables in the model.
Conclusions:The model suggests that working memory, attention, and mental flexibility increased in a linear fashion as MA increased. Our hypotheses were partially supported, while working memory predicted MA, its contribution to the overall model was the smallest among the significant predictors. While executive function was not a significant contributor to the model, MF (a component of EF) was. The largest contributor to the model was attention, which supports prior findings in the literature. This outcome would suggest that while separate from EF, metacognitive processes in neurotypical students may rely on other, more basic cognitive processes. These results may prove beneficial in guiding the development of rehabilitative interventions for MA in clinical samples.
56 Cognitive Intra-Individual Variability Profiles of a Spanish Speaking Population Living with HIV and Injection Drug Use
- Jeremy A Feiger, Rachael L. Snyder, Alec J Miller, Carmen A Davila, Kim G Carrasco, Kirk Dombrowski, Roberto Abadie, Anibal Valentin, Samodha Fernando, John T West, Charles Wood, Sydney J Bennett, Kathy S Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 52-53
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Objective:
Individuals living with HIV may experience cognitive difficulties or marked declines known as HIV-Associated Neurocognitive Disorder (HAND). Cognitive difficulties have been associated with worse outcomes for people living with HIV, therefore, accurate cognitive screening and identification is critical. One potentially sensitive marker of cognitive impairment which has been underutilized, is intra-individual variability (IIV). Cognitive IIV is the dispersion of scores across tasks in neuropsychological assessment. In individuals living with HIV, greater cognitive IIV has been associated with cortical atrophy, poorer cognitive functioning, with more rapid declines, and greater difficulties in daily functioning. Studies examining the use of IIV in clinical neuropsychological testing are limited, and few have examined IIV in the context of a single neuropsychological battery designed for culturally diverse or at-risk populations. To address these gaps, this study aimed to examine IIV profiles of individuals living with HIV and who inject drugs, utilizing the Neuropsi, a standardized neuropsychological instrument for Spanish speaking populations.
Participants and Methods:Spanish speaking adults residing in Puerto Rico (n=90) who are HIV positive and who inject drugs (HIV+I), HIV negative and who inject drugs (HIV-I), HIV positive who do not inject drugs (HIV+), or healthy controls (HC) completed the Neuropsi battery as part of a larger research protocol. The Neuropsi produces 3 index scores representing cognitive domains of memory, attention/memory, and attention/executive functioning. Total battery and within index IIV were calculated by dividing the standard deviation of T-scores by mean performance, resulting in a coefficient of variance (CoV). Group differences on overall test battery mean CoV (OTBMCoV) were investigated. To examine unique profiles of index specific IIV, a cluster analysis was performed for each group.
Results:Results of a one-way ANOVA indicated significant between group differences on OTBMCoV (F[3,86]=6.54, p<.001). Post-hoc analyses revealed that HIV+I (M=.55, SE=.07, p=.003), HIV-I (M=.50, SE=.03, p=.001), and HIV+ (M=.48, SE=.02, p=.002) had greater OTBMCoV than the HC group (M=.30, SE=.02). To better understand sources of IIV within each group, cluster analysis of index specific IIV was conducted. For the HIV+ group, 3 distinct clusters were extracted: 1. High IIV in attention/memory and attention/executive functioning (n=3, 8%); 2. Elevated memory IIV (n=21, 52%); 3. Low IIV across all indices (n=16, 40%). For the HIV-I group, 2 distinct clusters were extracted: 1. High IIV across all 3 indices (n=7, 24%) and 2. Low IIV across all 3 indices (n=22, 76%). For the HC group, 3 distinct clusters were extracted: 1. Very low IIV across all 3 indices (n=5, 36%); 2. Elevated memory IIV (n=6, 43%); 3. Elevated attention/executive functioning IIV with very low attention/memory and memory IIV (n=3, 21%). Sample size of the HIV+I group was insufficient to extract clusters.
Conclusions:Current findings support IIV in the Neuropsi test battery as clinically sensitive marker for cognitive impairment in Spanish speaking individuals living with HIV or who inject drugs. Furthermore, the distinct IIV cluster types identified between groups can help to better understand specific sources of variability. Implications for clinical assessment in prognosis and etiological considerations are discussed.
14 FMRI Investigation of Metacognitive Processing in Moderate to Severe Traumatic Brain Injury
- Kathy S. Chiou, Michael J Walsh, Jeremy A Feiger, Erica Weber, Ekaterina Dobryakova
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 124-125
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Objective:
Metacognition refers to one’s ability to make online, in-the-moment judgments regarding their own cognitive performance, and has significant implications for one’s abilities to function in daily life. It has been documented that individuals with TBI often present with metacognitive deficits, and are slower than neurotypical peers in making such judgments. Preliminary attempts have been made to determine how neural contributions to metacognitive functioning differ after injury. Studies thus far have found unique roles of prefrontal gray matter volume and inter-network connectivity in metacognitive functioning after injury, but functional activation directly associated with metacognitive processing has yet to be investigated. This event-related functional magnetic resonance imaging (fMRI) study aimed to document differences in functional activation between adults with TBI and neurotypical peers when completing metacognitive confidence judgments.
Participants and Methods:16 adults with moderate to severe TBI and 10 healthy adults (HCs) completed a metacognitive task while in the fMRI scanner. All participants were exposed to target slides with polygons arranged in various positions, then asked to identify the target slide from a group including 3 other distractor slides. Following each response, participants provided a metacognitive retrospective confidence judgment (RCJ) by rating their confidence that the answer they provided was correct. Meta d', a signal-detection based metric of metacognitive accuracy, was calculated. FSL FEAT was used for processing and analysis of the imaging data. Contrasts were created to model activation that was greater when RCJs were made compared to target recognition, mixed effects modeling was then used to investigate group differences. Cluster based thresholding set to z>2.3, p<0.01 was used for multiple comparisons correction.
Results:Healthy controls performed significantly better on the target identification task (p<0.01), and were faster at making RCJs (p=0.03). Individuals with TBI had greater meta d’ scores (p=0.03). Significant activation beyond what was present during target recognition (RCJ>recognition) was found in left supramarginal gyrus, left posterior cingulate, and left cerebellum when individuals with TBI made RCJs, while HCs showed significant activation in the left precuneus, and bilateral superior temporal gyri. Individuals with TBI demonstrated more activation in the lateral occipital cortex bilaterally and the left cerebellum than HCs when completing RCJs. HCs presented with more activation in the left supramarginal gyrus than the TBI group when making RCJs.
Conclusions:The areas of activation present in both the TBI and HC groups are consistent with previous imaging findings from studies of healthy samples. Interestingly, two structures previously implicated in self-directed cognition and consciousness, the posterior cingulate and precuneus, were differentially activated by the groups. The lack of a common network between the two groups suggests that survivors may rely on separate neural substrates to facilitate metacognition after injury. The TBI group was found to recruit more functional areas when completing the RCJs. These findings, paired with the behavioral data indicating metacognitive performance differences, suggests that neural recruitment may occur after injury to allow for survivors to engage in making metacognitive judgments. Future qualitative investigations of the metacognitive judgments are needed to determine the compensatory nature of this postinjury recruitment.
11 The Moderating Effect of Depression on Workload Perception in Traumatic Brain Injury
- Jessica L Stump, Jeremy A Feiger, Alec J Miller, Kathy S Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 122-123
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Objective:
Individuals who have experienced traumatic brain injury (TBI) are at an elevated risk for worsened physical and psychological outcomes. Increased rates of anxiety and depression, along with cognitive issues, are common post-TBI. While there is some evidence that anxiety and depression may affect objective cognitive performance, less is known about their effect on other factors that are associated with the individual’s capacity to complete the task, such as perceived workload of the cognitive task. Workload represents an individual’s perception of task difficulty and serves as a proxy for the magnitude of mental demands a given task places on an individual. Preliminary findings in the literature suggest that individuals with TBI commonly report greater workload when completing cognitive tasks compared to neurotypical peers, but the influence of anxiety and depression on survivors’ workload remains unclear. Considering the elevated rates of psychological and cognitive problems in individuals with TBI, the present study examined the moderating role of anxiety and depression on TBI survivor workload perception of a stress-inducing working memory task.
Participants and Methods:Ten participants with moderate to severe TBI and eight neurologically healthy controls performed the Paced Auditory Serial Addition Task (PASAT). After completing the PASAT, participants reported their subjective workload using the NASA task load index (NASA-TLX). Participants also completed measures of psychological functioning, including the Chicago Multiscale Depression Inventory (CMDI) and the State-Trait Anxiety Inventory (STAI). Relationships between workload and depression and trait anxiety were examined using linear regression.
Results:Linear regression was employed for both the TBI and the healthy control groups to assess the influence of trait anxiety and depression on perceived workload. There was no significant difference between the TBI and HC NASA perceived workload scores. Within the TBI group, there was a significant anxiety by depression interaction (b = -.015, p < .001). Simple slopes analyses revealed that for TBI participants reporting low depression, perceived workload increased with increased anxiety (b = .093, p < .001). For TBI participants reporting high depression, perceived workload decreased as anxiety increased (b = -.38, p = .03). While there was also significant anxiety by depression interaction in the healthy control group (b = .033, p = .04), simple slopes analyses revealed that there were no significant associations for healthy controls.
Conclusions:These results demonstrate that in TBI, level of depression moderates the relationship between anxiety and workload perception. The pattern observed in the TBI group was unique from controls. The present findings suggest that post-TBI, higher depression may temper the influence of anxiety on stressful cognitive task performance and workload rating. The tempering effect of high depression in TBI may represent a biased reporting style or impaired assessment of task difficulty, which may ultimately affect the individual’s capacity to accomplish a task well.
29 Predictors of Verbal Memory Performance Following Brain Injury Among Survivors of Intimate Partner Violence
- Seima I Al-Momani, Christopher S Waller, Matthew Garlinghouse, Peggy Reisher, Kathy S Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 137-138
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Objective:
Numerous survivors of Intimate Partner Violence (IPV) experience physical violence to the head and neck areas, placing them at high risk of sustaining a brain injury (BI). Studies report that the prevalence of traumatic BI among IPV survivors ranges from 35% to as much as 80%. IPV-related BIs can have debilitating long-term consequences on survivors’ quality of life and overall functioning. One important factor impacting quality of life following TBI is verbal memory abilities. Given the link between verbal memory abilities and functional status, identifying predictors of verbal memory performance has important implications for directing support and rehabilitative efforts for survivors of IPV-related BIs. The current aim of the study was to investigate predictors of verbal memory performance following TBI among survivors of IPV.
Participants and Methods:A modified HELPS Brain Injury (BI) screener was administered to women receiving services for IPV through community organizations and shelters in two urban, Midwestern cities. Women who screened positive for IPV-related BI (n=32) were invited to complete a comprehensive neuropsychological evaluation including the Rey Auditory Verbal Learning Test. The delayed recall score of the RAVLT was used as a measure of verbal memory performance. BI history and characteristics were based on survivors’ responses to the modified HELPS screener. Multiple regression was used to determine significant predictors of verbal performance with RAVLT-Delayed Recall scores serving as the criterion, and education, age, number of reported injuries, number of injuries that left participants feeling dazed/confused, following provider recommendations, and childhood history of injury all entered as predictors.
Results:The model indicated that a large percentage of the variability (R2 = .378) in delayed recall performance could be attributed to the combination of predictors in the model (F (6, 25) = 2.828, p = .047). Examination of the regression coefficients indicated that only following provider recommendations (ß = .420, p = .019), and number of injuries that induced disorientation/confusion (ß = -.592, p = .004) were significantly related to delayed recall after controlling for all other variables in the model.
Conclusions:The results of this study suggest that injury severity and adhering to medical recommendations after IPV-related TBI play a significant role in predicting cognitive functioning. Consistent with existing literature, our findings show that injury characteristics of severity and repetition are closely associated with memory functioning. These findings have implications for guiding screening procedures that may be more sensitive to functional outcome in survivors of IPV who are at risk for BI. Furthermore, our findings highlight a need to increase awareness of IPV-related BI in medical professionals, and to support these front-line staff in providing medical care and psychoeducation about BI to IPV survivors.
29 Human Immunodeficiency Virus (HIV) Status, Injection Drug Use, and Cognitive Effects in a Spanish-Speaking Population
- Rachael L. Snyder, Alec J. Miller, Jeremy A. Feiger, Carmen A. Davila, Kim G. Carrasco, Kirk Dombrowski, Roberto Abadie, Anibal Valentin, Samodha Fernando, John T. West, Charles Wood, Sydney J. Bennett, Kathy S. Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 442-443
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Objective:
Injection drug use is a significant public health crisis with adverse health outcomes, including increased risk of human immunodeficiency virus (HIV) infection. Comorbidity of HIV and injection drug use is highly prevalent in the United States and disproportionately elevated in surrounding territories such as Puerto Rico. While both HIV status and injection drug use are independently known to be associated with cognitive deficits, the interaction of these effects remains largely unknown. The aim of this study was to determine how HIV status and injection drug use are related to cognitive functioning in a group of Puerto Rican participants. Additionally, we investigated the degree to which type and frequency of substance use predict cognitive abilities.
Participants and Methods:96 Puerto Rican adults completed the Neuropsi Attention and Memory-3rd Edition battery for Spanish-speaking participants. Injection substance use over the previous 12 months was also obtained via clinical interview. Participants were categorized into four groups based on HIV status and injection substance use in the last 30 days (HIV+/injector, HIV+/non-injector, HIV/injector, HIV-/non-injector). One-way analysis of variance (ANOVA) was conducted to determine differences between groups on each index of the Neuropsi battery (Attention and Executive Function; Memory; Attention and Memory). Multiple linear regression was used to determine whether type and frequency of substance use predicted performance on these indices while considering HIV status.
Results:The one-way ANOVAs revealed significant differences (p’s < 0.01) between the healthy control group and all other groups across all indices. No significant differences were observed between the other groups. Injection drug use, regardless of the substance, was associated with lower combined attention and memory performance compared to those who inject less than monthly (Monthly: p = 0.04; 2-3x daily: p < 0.01; 4-7x daily: p = 0.02; 8+ times daily: p < 0.01). Both minimal and heavy daily use predicted poorer memory performance (p = 0.02 and p = 0.01, respectively). Heavy heroin use predicted poorer attention and executive functioning (p = 0.04). Heroin use also predicted lower performance on tests of memory when used monthly (p = 0.049), and daily or almost daily (2-6x weekly: p = 0.04; 4-7x daily: p = 0.04). Finally, moderate injection of heroin predicted lower scores on attention and memory (Weekly: p = 0.04; 2-6x weekly: p = 0.048). Heavy combined heroin and cocaine use predicted worse memory performance (p = 0.03) and combined attention and memory (p = 0.046). HIV status was not a moderating factor in any circumstance.
Conclusions:As predicted, residents of Puerto Rico who do not inject substances and are HIVnegative performed better in domains of memory, attention, and executive function than those living with HIV and/or inject substances. There was no significant difference among the affected groups in cognitive ability. As expected, daily injection of substances predicted worse performance on tasks of memory. Heavy heroin use predicted worse performance on executive function and memory tasks, while heroin-only and combined heroin and cocaine use predicted worse memory performance. Overall, the type and frequency of substance is more predictive of cognitive functioning than HIV status.
Neuropsychological functioning predicts psychosocial adjustment after postacute rehabilitation for traumatic brain injury
- Jeremy A. Feiger, Jeffry Snell, Kathy S. Chiou
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue 4 / May 2023
- Published online by Cambridge University Press:
- 06 October 2022, pp. 410-414
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Objectives:
To examine neuropsychological functioning as a predictor of psychosocial adjustment difficulties at discharge from a postacute residential rehabilitation facility for traumatic brain injury (TBI) and depression as a potential mediator.
Methods:A retrospective record review was conducted of 172 adults who received rehabilitation services for TBI. Individuals completed a full battery of neuropsychological tests, depression assessment, and functional assessments at admission. Functional assessments were also obtained at discharge.
Results:A two-phase structural equation model analysis was performed. The first phase specified a good fitting model of a cognitive functioning (CF) latent construct with four indicators of cognitive domains measuring verbal fluency, cognitive flexibility, verbal learning, and working memory. Worse CF was associated with greater psychosocial adjustment impairment at discharge, but not related to depression. Psychosocial adjustment impairment at admission was positively associated with depression when controlling for CF, however depression did not predict psychosocial adjustment at discharge. Thus, depression was not found to be a significant mediator of psychosocial adjustment impairment at discharge.
Conclusions:Results provide support for neuropsychological functioning at the start of postacute rehabilitation for TBI as an important predictor of psychosocial functioning difficulties that remain upon discharge and highlights the need to examine mechanisms beyond depression.
Benefits of Order: The Influence of Item Sequencing on Metacognition in Moderate and Severe Traumatic Brain Injury
- Kathy S. Chiou, Frank G. Hillary
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- Journal of the International Neuropsychological Society / Volume 18 / Issue 2 / March 2012
- Published online by Cambridge University Press:
- 09 February 2012, pp. 379-383
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The ability to appraise one's own ability has been found to have an important role in the recovery and quality of life of clinical populations. Examinee and task variables have been found to influence metacognition in healthy students; however the effect of these variables on the metacognitive accuracy of adults with neurological insult, such as traumatic brain injury (TBI), remains unknown. Twenty-two adults with moderate and severe TBI and a matched sample of healthy adults participated in this study examining the influence of item sequencing on metacognitive functioning. Retrospective confidence judgments were collected while participants completed a modified version of the Matrix Reasoning subtest. Significant influence of item sequence order was found, revealing better metacognitive abilities and performance when participants completed tasks where item difficulty progressed in order from easy to difficult. We interpret these findings to suggest that the sequencing of item difficulty offers “anchors” for gauging and adjusting to task demands. (JINS, 2012, 18, 379–383)
Metacognitive Monitoring in Moderate and Severe Traumatic Brain Injury
- Kathy S. Chiou, Richard A. Carlson, Peter A. Arnett, Stephanie A. Cosentino, Frank G. Hillary
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- Journal of the International Neuropsychological Society / Volume 17 / Issue 4 / 21 June 2011
- Published online by Cambridge University Press:
- 04 May 2011, pp. 720-731
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The ability to engage in self-reflective processes is a capacity that may be disrupted after neurological compromise; research to date has demonstrated that patients with traumatic brain injury (TBI) show reduced awareness of their deficits and functional ability compared to caretaker or clinician reports. Assessment of awareness of deficit, however, has been limited by the use of subjective measures (without comparison to actual performance) that are susceptible to report bias. This study used concurrent measurements from cognitive testing and confidence judgments about performance to investigate in-the-moment metacognitive experiences after moderate and severe traumatic brain injury. Deficits in metacognitive accuracy were found in adults with TBI for some but not all indices, suggesting that metacognition may not be a unitary construct. Findings also revealed that not all indices of executive functioning reliably predict metacognitive ability. (JINS, 2011, 17, 720–731)