The Behavioral Dyscontrol Scale-II: A Unique Measure of Executive Functioning VISN 6 MIRECC Mental Illness Research, Education & Clinical Center Cognitive and Neuropsychiatric Functioning of OIF/OEF/OND Veterans 1. Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC), VISN 6; 2. Hefner VA Medical Center, Salisbury, NC; 3. Wake Forest School of Medicine, Winston-Salem, NC VA CARE HEALTH Defining in the 21st Century EXCELLENCE Robert D. Shura, 1-3 Jared A. Rowland, 1-3 & Ruth E. Yoash-Gantz 1-3 INTRODUCTION The Behavioral Dyscontrol Scale (BDS; Grigsby & Kaye, 1996) is a 9-item measure of dynamic motor behavior, a subdomain of executive function that is thought to involve inhibiting automatic behaviors, detecting inconsistent behaviors, and correcting behavioral action in accordance with error detection (Garavan, Ross, Murphy, Roche, & Stein, 2002). The BDS evaluates dynamic motor control, alphanumeric sequencing, and insight. The initial normative and validity studies focused on geriatric samples, creating a ceiling effect when used with younger individuals. The BDS-II scoring system was created to increase the ceiling and improve the normality of scores, thus increasing variability in higher functioning individuals, and more effectively discriminating high functioning individuals. Few studies have examined the psychometric properties of the BDS-II scoring system or its effect on the factor structure. Only one previous study has examined the use of the BDS-II in a strictly non-geriatric sample, and the measure’s use in non-geriatric adults remains undetermined. There were significant correlations among the BDS-II Total score and at least one measure from each of the major cognitive domains evaluated except sensation, suggesting the possibility that the BDS-II is a broad measure of general cognitive functioning, or perhaps demonstrating the involvement of functions of the frontal lobes across a wide range of cognitive processes. Thus, initial evaluation of the BDS-II suggests the measure is more of a general test of cerebral functioning than a specifically executive measure. CORRELATIONS Hierarchical linear regressions were conducted for each of the BDS-II outcome variables. Each model included demographic variables (age, gender, race, and years education) in the first step, as well as all variables significantly correlated with that outcome variable in step 2. All assumptions and power were adequate. Table 4 (left) shows results of the final step for each model. Finger Tapping Dominant and PASAT were significant predictors of the BDS-II Total and Factor 1 scores. CPT-II Commissions and PASAT were significant predictors of the BDS-II Factor 2 score. This suggests that the BDS-II is related to working memory, processing speed, fine motor output. Factor 2 is related to working memory, processing speed, and impulsivity. REGRESSIONS PASAT .03 .000 Dom .08 .006 Model Measures B p R 2 change p of F change R 2 .37 .32 .000 F change 6 08 . 4.18 6 49 . Tap WAIS III DSC - CPT II OM - WAIS III LNS - CVLT II LDFR - CPT II COM - COWAT WAIS-III BD CVLT-II 1-5 WAIS-III SIM .00 .02 - 11 . .10 .01 .07 .02 -.03 .02 .998 .402 .164 .243 .845 .519 .715 .418 .433 BDS II Factor 1 - .31 .27 .000 Tap WAIS III DSC - WAIS III BD - CPT II OM - WAIS III LNS - CVLT II LDFR - BVMT R DR - WAIS COWAT Dom PASAT CVLT-II 1-5 CVLT-II d’ -III SIM .06 .00 .01 -.06 .01 .04 .04 -.05 .22 .02 - .01 .02 .003 .764 .595 .296 .005 .487 .091 .600 .420 .876 .807 .315 BDS II Factor 2 - .21 .19 .000 Tap Dom WAIS III DSC - PASAT WAIS III LNS - CPT-II COM .02 -.00 .01 .04 - .05 .255 .782 .002 .455 .013 BDS II total - Table 4. Final Steps of Regressions RESULTS: Aim 2, Validity Domain Measure Age Years Education BDS -II Total BDS - II F1 BDS - II F2 Demographics Age -- .17* -.10 -.13 -.02 Education .17* -- .09 .08 .06 BDS -II BDS -II Total -.10 .19* -- .84** .73** BDS -II F1 -.13 .16* .84** -- .24** BDS -II F2 -.02 .14 .73** .24** -- Sensation UPSIT -.09 .07 .01 .10 -.11 Motor Tap Dom -.03 .00 .29** .27** .18* Peg Dom .15* -.01 -.09 -.11 -.02 PS WAIS -III DSC -.13 .25** .34** .35** .17* V-S WAIS -III BD -.15 .10 .22** .23** .11 Attentional CPT -II OM -.05 -.03 -.23** -.26** -.09 CPT -II ISI -.11 .04 .05 .06 .02 TMT Ratio .01 -.04 .02 -.06 .12 PASAT .04 .22** .47** .40** .35** WAIS -III LNS .01 .19* .45** .42** .28** Memory CVLT -II 1-5 -.07 .09 .17* .26** -.02 CVLT -II LDFR -.04 .06 .18* .21** .05 CVLT -II d’ -.21** .06 .15 .20* .02 BVMT -R Trial 3 -.26** .05 .07 .12 -.03 BVMT -R DR -.21** .07 .12 .17* -.01 RCFT Recog -.35** .03 .03 .05 -.01 EF WAIS -III SIM .01 .17* .20* .17* .14 WCST -64 Errors .15 -.09 .00 -.05 .07 RCFT Copy -.12 .11 .03 .03 .02 Stroop Ratio -.21** -.03 -.04 -.05 -.00 CPT -II COM -.21** -.15 -.25** -.15 -.26** COWAT -.10 .11 .21** .25** .06 Table 3. Correlations among the Behavioral Dyscontrol Scale-II, Demographic Variables, and Other Neurocognitive Measures Note. BDS-II = Behavioral Dyscontrol Scale-II; F1 = BDS-II Factor 1; F2 = BDS-II Factor 2; PS = processing speed; V-S = visual-spatial/construction ability; EF = executive functions; UPSIT = University of Pittsburg Smell Identification Test; Tap = Finger Tapping Test; Dom = dominant hand; Peg = Grooved Peg- board; WAIS-III = Wechsler Adult Intelligence Scale-III; DSC = Digit-Symbol Coding; BD = Block Design; CPT-II = Conners’ Continuous Performance Test- II; OM = Omissions; ISI = Hit Reaction Time Inter-Stimulus Interval Change; TMT Ratio = Trail Making Test Ratio score; PASAT = Paced Auditory Serial Addition Test Total score; LNS = Letter Number Sequencing; CVLT-II = California Verbal Learning Test-II; 1-5 = Trials 1-5 Correct; LDFR = Long Delay Free Recall; d’ = Total Recognition Discriminability; BVMT-R = Brief Visuospatial Memory Test-Revised; DR = Delayed Recall; RCFT = Rey Complex Figure Test; Recog = Recognition Total Correct; SIM = Similarities; WCST-64 = Wisconsin Card Sort Test-64; COM = Commissions; COWAT = Controlled Oral Word Association Test (CFL). n = 154 to 164. *= p < .05 (two-tailed); ** = p < .01 (two-tailed). METHOD Variable Age Years Education Male Caucasian Service Connected Deployment TBI Any Current DSM-IV Diagnosis Current PTSD Current Depression M (SD, range) or Total (%) 34.94 (9.00, 21-60) 13.90 (1.77, 11-19) 141 (86.0%) 120 (73.2%) 94 (57.3%) 32 (19.5%) 86 (52.0%) 55 (33.5%) 27 (16.5%) Tests and Selection : Tests were selected based on domains and sub-domains in Lezak, Howieson, Bigler, and Tranel (2012), descriptions in test manuals, and reliability data. Included : 164 Veterans who served post-9/11; recruited for larger, multi-site study; collected from 06/2006 to 04/2014. Excluded : failed WMT (n = 44); did not complete BDS-II (n = 1) RESULTS: Aim 1, Factor Structure Factor 1 Range: 0-15 Factor 2 Range: 0-12 Structure Loading Structure Loading BDS-II Total Range: 0-27 Item/Ability 1. Dynamic Motor Organization 2. Dynamic Motor Organization 3. Disinhibition 4. Echopraxia 7. Monitoring 8. Attention Flexibility 9. Insight 5. Motoric Procedural Learning 6. Motoric Procedural Learning .403 .530 .558 .383 .482 -.635 -.593 -.408 -.284 alpha = .54 alpha = .53 alpha = .59 Table 2. BDS-II Factor Structure This research was supported by resources of the W.G. “Bill” Hefner Veterans Affairs Medical Center, the Mid-Atlantic Mental Illness Research Education and Clinical Center, and the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment. There are no conflicts of interest to disclose. The views expressed in this poster are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the Department of Defense, or the U.S. government. DISCUSSION Our analyses support a two factor solutions, which contrasts with research on the original BDS supporting a three factor solution (Motor Programming, Environmental Independence, and Fluid Intelligence; Ecklund-Johnson, et al., 2004; Grigsby, et al., 1992). Reasons for this discrepancy include differences in: statistical analyses, age ranges of samples, sample sizes, and psychometric properties of the BDS and BDS-II scoring systems (Leahy et al., 2003; Shura, et al., 2014). The PASAT is the strongest predictor of performance on each of the BDS-II outcomes after accounting for other tests and demographic variables. PASAT is the third most popular test of attention (Rabin, Barr, & Burton, 2005), and relies on processing speed, attention, concentration, executive control, and working memory. Neuroimaging studies have correlated PASAT performance to numerous areas of the brain (Tombaugh, 2006). The relationship between the BDS-II and PASAT suggests that the BDS-II is a broad measure of general cerebral functioning and mental efficiency. Post hoc analyses found that after removing PASAT, WAIS-III LNS was the strongest predictor of BDS-II outcomes.Thus, although the BDS-II is related to many different cognitive abilities, working memory seems to be the strongest ability tapped by the BDS-II. Exploratory t-tests for the BDS-II variables across groups based on DSM-IV diagnoses and history of TBI were not significant. This preliminary finding supports that the BDS-II is sensitive to neurological injury regardless of psychopathology. This would enhance the utility of the BDS-II, as many cognitive measures, such as memory and attention tests, can be impaired in populations with psychopathology. Additional research is warranted to further evaluate these relationships. STUDY STRENGTHS Improved analyses and sample size compared to previous studies. Used reliable measures from all neurocognitive domains except language. STUDY LIMITATIONS Homogeneity and young age of sample. Results limited to neurologically healthy. Maximum likelihood EFA with direct oblimin rotation were used. Scree and Monte Carlo analyses suggested 2-factor model. Two-factor results (see Table 2 to left) explained a total of 40.90% of the variance (Factor 1 = 25.59%, Factor 2 = 15.31%). The two factors were significantly but weakly correlated at r = .24. At the item level, the sample performed quite well, with only item 8 showing a mean below 2. Table 1. Sample Descriptive Statistics RESULTS: Aim 3, Neuropsychiatric A series of independent t-tests were run using the three BDS-II variables and dichotomous groups based on DSM-IV diagnoses (SCID) common to post-deployed Veterans (PTSD, MDD, and a global any disorder variable) and on a structured interview for TBI (both any TBI over the lifespan and TBI that occurred while deployed). After correcting for Type I error, none of the t-tests were significant. Thus, the BDS-II might be quite sensitive to neurological injury regardless of psychopathology or remote concussion. t values (p) a BDS-II Variable Any DSM Disorder PTSD MDD Lifetime TBI Deployment TBI Total 1.85 (.066) -1.89 (.061) 1.40 (.168) 1.72 (.088) 1.46 (.147) F1 2.49 (.014) -2.36 (.020) 0.80 (.433) 1.90 (.059) 2.18 (.030) F2 0.18 (.854) -0.41 (.682) 1.58 (.121) 0.66 (.510) -0.14 (.890) Note. BDS-II = Behavioral Dyscontrol Scale-II; DSM = Diagnostic and Statistical Manual of Mental Disorders-IV; PTSD = posttraumatic stress disorder; MDD = major depressive disorder; TBI = traumatic brain injury. a Significance set at p < .003 to correct for Type I error; no t-test was significant. Table 5. BDS-II and Neuropsychiatric Variables RESULTS: Aim 2, Exploratory PASAT was consistently a significant predictor of BDS-II variables. The regressions were re- run without the PASAT. In all three models, WAIS-III LNS became a significant predictor, and other predictors did not change. This suggests a heavy working memory aspect to BDS-II performance. CPT-II Hit Reaction Time was not significantly correlated with Factor 1 (r = -.12, ns) or Factor 2(r = .09, ns). CPT-II Commissions was significantly and negatively correlated to CPT-II Reaction Time (r = -.55, p < .001). Thus, commissions reflected impulsivity, not inattention. TMT Ratio was not significantly correlated to any BDS-II item; TMT B was significantly correlated with Item 8 (r = -.29, p < .001) and Item 9 (r = -.18, p = .021); and TMT A was significantly correlated to Item 2 (r = -.24, p = .002), Item 4 (r = -.16, p = .046), Item 8 (r = -.28, p < .001), and Item 9 (r = -.16, p = .048). This suggests that variability in processing speed rather than divided attention accounts for the variability in performance on Item 8. Item 3 was not significantly correlated with Commissions or Stroop Ratio, but was significantly correlated with Stroop Color (r = .29, p < .001) and Stroop Color-Word (r = .23, p = .004), providing further support for the role of processing speed in BDS-II performance. BDS *Predicts functional independence (Grigsby, Kaye, Kowalsky, & Kramer, 2002a, b; Kaye, Grigsby, Robbins, & Korzun, 1990; Suchy, Blint, & Osmon, 1997) *Distinguishes normal aging from dementia and mild cognitive impairment (Belanger et al., 2005; Hall & Harvey, 2008) *Found useful in numerous population: MS (Grigsby, Kravcisin, Ayarbe, & Busenbark, 1993), stroke (Grigsby, Kaye, Kowalsky, & Kramer, 2002), andType II diabetes (Tran, Baxter, Hamman, & Grigsby, 2013) BDS-II *Differentiates frontal from non-frontal lesions in traumatic brain injury (TBI) patients (Leahy, Suchy, Sweet, & Lam, 2003) *Improves on psychometric properties from original scoring system (Leahy, Suchy, Sweet, & Lam, 2003; Shura, Rowland, & Yoash-Gantz, 2014) SPECIFIC AIMS 1. To determine the latent factor structure of the BDS-II in a sample of non-elderly subjects. 2. To examine the construct validity of BDS-II factors using measures of numerous cognitive domains 3. To evaluate the sensitivity of the BDS-II to neuropsychiatric conditions common in post-deployed Veterans.