Working memory training in children who have survived an acquired brain injury (Dr Anna Adlam)

This stream of work is funded by the British Academy and Action Medical Research. We are conducting a multi-site (South West and East Anglia) randomised controlled trial to investigate the efficacy of computerised working memory training (working memory is the ability to store and manipulate information in mind over a brief period of time) with children (aged 8 – 16 years) who have survived a brain injury. We are interested in finding out whether children show training gains on measures of working memory (near transfer) immediately after training and after 6-months, and whether gains are also shown on measures of maths and literacy (far transfer), and other cognitive and psychosocial measures. If you would like to find out more about this study, or would like to take part, then please contact the research team (ccnr@exeter.ac.uk). Related to this stream of work, we are also conducting studies to investigate memory and attention in children with neurological vulnerability such as, children born prematurely, children with attention deficit hyperactivity disorder, and children with genetic risk factors.

Prospective memory training in adolescents who have survived an acquired brain injury (Dr Anna Adlam)

Following our recent study (with Dr Rebecca Rous, Cambridge Cognition, in preparation for publication), we are conducting a repeated single case series to investigate whether adolescents who have survived a brain injury benefit from an intervention to improve executive function (e.g., problem-solving, planning, organisation skills) and prospective memory (the ability to keep goals and intended actions in mind). We are interested in finding out whether adolescents show improvements on a prospective memory task and the performance of ‘real world’ goals that they set themselves. This study will soon be recruiting adolescents in the South West. If you would like to find out more about this study, or would like to take part, then please contact the research team (ccnr@exeter.ac.uk). Related to this stream of work, we are working with colleagues in the USA to evaluate web-based interventions for executive function in adolescents who have survived a brain injury.

Neural correlates of neurocognitive interventions (Dr Anna Adlam & Dr Fraser Milton)

We are interested in understanding the mechanisms underpinning neurocognitive interventions, particularly during development and following brain injury. This work involves neuroimaging techniques such as structural magnetic resonance imaging, functional magnetic resonance imaging, and diffusion tensor imaging.

Criminal Justice System (Professor Huw Williams)

Following on from our work showing the elevated levels of TBI in prisoners, and links to violence and recidivism, we have a range of projects exploring the symptoms of TBI, and problems in emotional control and understanding (Theory of Mind and Empathy)  in youth in custody and in the community offenders services. We are also working closely with the Offender Health Research Network, Youth Justice Board and Disabilities Trust to imporve assessment and management of TBI in the Criminal Justice System.

The Ravello Profile - neuropsychological assessment in eating disorders (Dr. Ian Frampton, Professor Huw Williams, Professor Emeritus Bryan Lask, Marie-Claire Reville)

This international collaborative research project aims to develop a standard neuropsychological assessment for research and clinical use in eating disorders. Participating centres from Europe, Scandinavia, North and South America have established a joint database to help us understand more about the neuropsychological consequences (and potential causes) of eating disorders. Generous funding by the Rosetree's Trust, Care UK, the Huntercombe Group, the Ellern Mede Centre for Eating Disorders and Helse Sør Øst, Norway has supported this project. For further details, see www.ravelloprofile.org.

Functional neuroimaging in eating disorders (Dr. Ian Frampton, Professor Huw Williams, Professor Emeritus Bryan Lask, Marie-Claire Reville)

Our studies in this area are exploring how brain function is affected by starvation during the acute phase of eating disorders, and also testing our noradrenergic hypothesis (Nunn et al, 2012) that dysfunction of a neural network incorporating the insula cortex in the brain could be an underlying risk factor. With the support of Helse Sør Øst, Norway (www.rasp.no) and colleagues from the Centre for Neuroimaging Sciences at the University of London (www.neuroimagingsciences.com), we have developed and tested a novel hypothesis using functional neuroimaging techniques. We are now developing our research into potential neuroscience-based treatments for eating disorders in collaboration with the Exeter MR Research Centre (centres.exeter.ac.uk/pmrrc/).

Mood disorders in individuals with neurological conditions (Dr Anna Adlam, Dr Phil Yates, Dr David Llewellyn, & Professor Huw Williams)

Acquired Brain Injury (ABI) can lead to major challenges in life and well being. We have shown how ABI can be linked to many mood disorders (e.g., leading to PTSD, rumination, and challenges in adaptive social identity). Building on our previous work, we are working with colleagues at the Mood Disorders Centre and the University of Exeter Medical School to understand the development and maintenance of mood disorders in individuals with neurological disorders (e.g., stroke, traumatic brain injury, dementia). We are also developing and evaluating targeted interventions.

Does working memory training reduce rumination and depression? (Dr Anna Adlam & Dr Henrietta Roberts)

We have recently been awarded Wellcome Trust Seed Corn Funding to investigate whether working memory training reduced repetitive negative thought and symptoms of depression. The findings from this study will inform future research examining neurocognitive interventions in adults with dementia who experience depression.

Brief cognitive assessment and diagnostic pathways for dementia (Dr David Llewellyn & Dr Anna Adlam)

Dr Llewellyn joined the Scientific Advisory Board of the English Longitudinal Study of Ageing (ELSA) in 2013 and is collaborating with the team to improve the cognitive assessments in future waves of data collection. Ongoing projects also include a diagnostic accuracy study of brief cognitive assessments suitable for use in primary care, and a test development project investigating whether existing measures can be improved by using contemporary psychometric approaches. We are also interested in whether the potential harms of dementia screening can be minimized by using an adaptive targeted approach whilst improving dementia diagnosis rates by enhancing clinical decision making.

Vitamin D and neurocognitive dysfunction (Dr David Llewellyn)

We are conducting an ancillary Study to the NHLBI-funded Cardiovascular Health Study (CHS) investigating vitamin D levels in relation to Alzheimer‘s disease, dementia and neuroimaging abnormalities (supported by the Alzheimer‘s Association, the NIHR Peninsula Collaboration for Leadership in Applied Health Research and Care [PenCLAHRC] and other funders). This follows on from our ealier work which established that low serum vitamin D levels increase the odds of cognitive impairment in older English and US adults, and increases the risk of cognitive decline in older Italian adults. Vitamin D supplementation offers an inexpensive and well tolerated way to increase vitamin D levels thus raising new possibilities for dementia prevention and treatment.

Metabolic dysfunction, lifestyle factors and dementia (Dr David Llewellyn)

It is now estimated that up to half of all cases of dementia could be prevented by targeting modifiable risk factors. This programme of work therefore investigates a range of potentially modifiable risk factors for dementia including parathyroid hormone levels, leptin, obesity, and alcohol consumption (supported by the NIHR PenCLAHRC, the Norman Family Charitable Trust and other funders). This includes a Health and Retirement Study (HRS) 2014 Experimental Module on alcohol consumption and drinking history.

Vascular aspects of cognitive impairment and dementia (Dr David Llewellyn)

We are currently investigating the vascular aspects of neurocognitive dysfunction in a range of clinical and population-based studies including the HRS (supported by the Mary Kinross Charitable Trust and other funders). For example we are currently conducting a systematic review and Monte Carlo simulation study incorporating quasi-experimental analyses to establish whether coronary artery bypass graft surgery (CABG) increases the long-term risk of cognitive decline or dementia.

Emergency care of Traumatic Brain Injury (Professor Huw Williams)

We have identified key risk periods for TBI and what types and levels of injury and emotional factors (such as acute stress) influence outcome. This has led to a clinic in the Emergency Dept in which we work closely with A&E Consultants on testing patients within hours of mild trauma on computerised measures to identify those at risk of poor recovery.

Sports Related Concussion (SRC) (Professor Huw Williams)

We work with a premiership rugby team and University of Exeter squads, on projects exploring potential changes in brain connectivity and functions after SRC. These projects are in collaboration with Prof Dave Sharp (Imperial College, London) and Dr Andrew Gardner (University of Newcastle, Australia). This will help us develop better systems for identifying athletes at risk of poor recovery, and potential for improved interventions.

The TIME project (Professor Adam Zeman and Dr Fraser Milton)

This project was launched in 2003 to study interactions between epilepsy and memory, in particular the syndrome of Transient Epileptic Amnesia and its associated interictal memory disorders: accelerated long-term forgetting, autobiographical and topographical amnesia. This fruitful project, led from Exeter, involves collaborators in Oxford, Edinburgh, Sydney and Buenos Aires. It has generated around 25 publications, and continues to recruit patients actively with the help of the British Neurological Surveillance Unit (BNSU). For more information see projects.exeter.ac.uk/time.

Other projects led by Professor Adam Zeman

We have described a series of informative single cases using neuropsychology and neuroimaging, including, recently, the first PET study of a patient with Cotard’s Syndrome (Cortex, 2013) and an fMRI study of a patient with an exceptionally pure disorder of visual imagery generation (Neuropsychologia, 2010). We collaborated with members of the English Department at Exeter University in the first fMRI study comparing brain activation by poetry and prose (JCS, 2013).

Expanding the International Public Awareness of Aphasia (Professor Chris Code)

This project will result in the development of a web resource hosted by the National Aphasia Association (USA) and is funded by a British Academy Small Grant.

Singing for People with Aphasia (SPA) (Professor Chris Code)

A grant application has been submitted with colleagues in the Peninsula Collaboration for Applied Leadership in Health Research and Care (PenCLAHRC)  - "Singing for People with Aphasia (SPA): A Pilot Randomised Controlled Trial of a Group Singing Intervention to Improve Wellbeing" to NIHR RfPB.

The application of poetry in aphasia rehabilitation (Professor Chris Code)

This is a project with Andrew McMillan from the John Moore’s University in Liverpool. A grant application is in progress.

Date Completed: 31 March 2019

The TOPS-UK Study was funded by a grant from the National Institute for Health Research Research for Patient Benefit and ran from December 2016 to March 2019. The Chief Investigator, Prof Anna Adlam, is a clinical psychologist and an associate professor at the University of Exeter. The Peninsula Clinical Trials Unit (PenCTU) undertook trial and data management for the study. The study was conducted in collaboration with colleagues at the University of Exeter Medical School, Professor Shari Wade from Cincinnati Children’s Hospital, Ohio, USA, the Child Brain Injury Trust, UK, and sponsored by the Royal Devon and Exeter NHS Foundation Trust.

Background: Brain injuries (through illness or accident) during childhood are common, and may lead to serious long term disability and problems which can impact on the whole family. Such problems may affect thinking, emotion, behaviour and relationships, An online problem solving programme was developed for adolescents in the USA where it was shown to be beneficial and adapted for use in the UK.

Aims and objectives: Our aim was to test the processes for a larger trial, specifically to see if doctors could identify potential participants, whether families felt able to give consent and complete questionnaires online, what they felt about the online intervention, how many completed the study, and to estimate of the costs of a full trial.

Methods: Participants: 12 adolescents who had survived a brain injury, and their parent, were recruited to the study, half of whom were randomly allocated to continue to receive their usual treatment and access to the online intervention, supported by weekly video-conference calls with a therapist, while half continued to receive their usual treatment only.

Trial and Data Management: This was the first study to be managed entirely online with no face-to-face contact with any researcher. PenCTU built a bespoke website for the study allowing the adolescent and parent participants to access study information, give online consent and complete study measures at a time and place convenient to them. Research nurses used the website to enter clinical research data and to follow the progress of their participants. The website was stored in a secure, encrypted SQL server (a database management system with restricted access, which maintains confidentiality). The intervention was provided via a website at Cincinnati Children’s Hospital, and the US-based TOPS treatment content was edited to include British spelling, narration and video clips, and UK resource links. The original content was also adapted to be appropriate for young people with all types of brain injuries.

Key findings: Hospital doctors found it difficult to identify potential participants because many adolescents had already been discharged, and around half of those who approached did not respond. Of the 12 adolescents who did take part, 11 completed follow-up questionnaires and took part in interviews. These suggested that the intervention was acceptable (most reported it as enjoyable) and changes to the study procedure were suggested to help future studies.

Dissemination, outputs and impact: The research team will publish findings in peer-reviewed journals and these will also be available on the University of Exeter and other relevant websites. The results will help researchers plan a future study with the aim of facilitating the online intervention to be available through the NHS in future.

Further information: If you would like any further information about the TOPS-UK Study, or about the TOPS-UK intervention, please contact Prof Anna Adlam by email: a.r.adlam@exeter.ac.uk

“We knew our lives were changed forever from that point.” Parental Adjustment and the Role of Social Support in Paediatric Acquired Brain Injury: An Interpretative Phenomenological Analysis (Sian Hocking, Dr Phil Yates, & Dr Anna Adlam)

Date Completed: 6th May 2015

Aims: The study aimed to add to the evidence-base by exploring parental experiences and the role of social support in adjustment to paediatric acquired brain injury (pABI). The study aimed to answer the following research questions: (i) How do participants make sense of their experiences as parents of a child with pABI? (ii) What are the experiences of psychological adjustment for parents of children with pABI? (iii) How do parents of children with pABI make sense of the role of social support in their experience of adjustment?

Methods: The study used interpretative phenomenological analysis (IPA) to explore the experiences of adjustment and social support of parents of children with pABI. Purposive sampling was used to recruit 10 parents, of which 8 were mothers and 2 were fathers. Participants were individually interviewed.

Results and conclusions: Five superordinate themes emerging from the data were identified: 1) Lives changed forever, 2) Sense of self, 3) Interaction with services, 4) The psychological experience, 5) Coping and adjustment. Parents described feelings of shock, anxiety, anger, depression and loss following their child’s pABI. The findings suggested that psychological defense mechanisms, personal resilience and characteristics, cognitive strategies, and support from others all played a role in facilitating the adjustment of parents.

Implications: The findings of the study highlight a need for the availability of psychological assessment, formulation, and intervention during the initial aftermath of the pABI, and following discharge from hospital,  for parents and their families to manage difficult emotional and psychological experiences.  The study has indicated that the provision of support groups, and the facilitation of informal events, where parents can meet with those who are in a similar stage following the pABI, may aid parent’s adjustment and coping. Additionally, the study detailed the lack of public knowledge and awareness of pABI. The development of information sheets that detail common symptoms, and corresponding management strategies, following pABI, would be useful for parents to disseminate, particularly to schools.

(Steve Mahan, Dr Anna Adlam, & Prof Ed Watkins)

Date completed: 5th May 2015
Age range of participants: 10-15 years old
Participants: 3 participants with a diagnosis of TBI, 1 participant with a diagnosis of epilepsy, 1 participant under investigation for epilepsy, 3 participants with prospective memory deficits of unknown cause

Aims: To build upon the work of Rous (2011) and optimise the effectiveness of brief  ‘Remembering Goals’ Training (RGT) and external content-free cueing (in the form of “STOP” text messages) on Prospective Memory task performance and the achievement of real-life goals.

Methods: The Prospective Memory task required participants to send three text messages at set times and to complete three real-life goals each working day for a four-week period. After a baseline period, participants completed brief RGT via Skype twice during the study (once following baseline, and again half way through the study). The brief RGT supporting thinking skills that supported participants to stop, think about their goals for the day, and to organise and plan their activities accordingly. Participants learnt to associate texts reading “STOP” with mentally reviewing their goals and tasks for that day. Six “STOP” text messages (cues) were sent at random times on half of the days of the intervention. The number and accuracy of texts messages, and the achievement of real-life goals, were compared across cued and un-cued days to evaluate the effectiveness of the intervention for each participant.

Overall findings: Five participants demonstrated improved PM text message performance and seven participants demonstrated improved performance in real-life goals. Most of the participants reported positive gains in self-reported PM abilities, and most parents of children with acquired neurological conditions reported reduced levels of family stress and burden following the intervention.

Implications: This research offers some evidence in support of the effectiveness of content-free cueing and RGT for supporting Prospective Memory abilities. The majority of participants engaged in more frequent and accurate Prospective Memory tasks and, most importantly, achieved more of their real-life goals as a result of the intervention.