Krasny-Pacini Agata, Limond Jennifer, Evans Jonathan, Hiebel Jean, Bendjelida Karim, Chevignard Mathilde
a Institut Universitaire de Réadaptation Clemenceau-Strasbourg , Strasbourg , France .
b Paediatric Surgery Department , Hautepierre Strasbourg University Hospital , Strasbourg , France .
Disabil Rehabil. 2015;37(22):2092-106. doi: 10.3109/09638288.2014.998783. Epub 2015 Feb 12.
To compare three ways of assessing self-awareness in children with traumatic brain injury (TBI) and to propose a model of child anosognosia.
Five single cases of children with severe TBI, aged 8-14, undergoing metacognitive training. Awareness was assessed using three different measures: two measures of metacognitive knowledge/intellectual awareness (a questionnaire and illustrated stories where child characters have everyday problems related to their executive dysfunction) and one measure of on-line/emergent awareness (post-task appraisal of task difficulty).
All three measures showed good feasibility. Analysis of awareness deficit scores indicated large variability (1-100%). Three children showed dissociated scores.
Based on these results, we propose a model of child self-awareness and anosognosia and a framework for awareness assessment for rehabilitation purposes. The model emphasizes (1) the role of on-line error detection in the construction of autobiographical memories that allow a child to build a self-knowledge of his/her strengths and difficulties; (2) the multiple components of awareness that need to be assessed separately; (3) the implications for rehabilitation: errorless versus error-based learning, rehabilitation approaches based on metacognition, rationale for rehabilitation intervention based on child's age and impaired awareness component, ethical and developmental consideration of confrontational methods.
Self-awareness has multiple components that need to be assessed separately, to better adapt cognitive rehabilitation. Using questionnaires and discrepancy scores are not sufficient to assess awareness, because it does not include on-line error detection, which can be massively impaired in children, especially those with impaired executive functions. On-line error detection is important to promote and error-based learning is useful to allow a child to build a self-knowledge of his/her strengths and difficulties, in the absence of severe episodic memory problems. Metacognitive trainings may not be appropriate for younger children who have age appropriate developmentally immature self-awareness, nor for patients with brain injury if they suffer anosognosia because of their brain injury.
比较评估创伤性脑损伤（TBI）儿童自我意识的三种方法，并提出儿童疾病感缺失模型。
五例8 - 14岁重度TBI儿童接受元认知训练。使用三种不同方法评估意识：两种元认知知识/智力意识评估方法（一份问卷和配有插图的故事，故事中的儿童角色存在与执行功能障碍相关的日常问题）以及一种在线/即时意识评估方法（任务难度的任务后评估）。
所有三种方法均显示出良好的可行性。意识缺陷分数分析表明存在较大差异（1 - 100%）。三名儿童的分数呈分离状态。
基于这些结果，我们提出儿童自我意识和疾病感缺失模型以及用于康复目的的意识评估框架。该模型强调：（1）在线错误检测在自传体记忆构建中的作用，自传体记忆使儿童能够建立对自身优势和困难的自我认知；（2）需要分别评估的意识的多个组成部分；（3）对康复的启示：无错误学习与基于错误的学习、基于元认知的康复方法、基于儿童年龄和受损意识组成部分的康复干预原理、对抗性方法的伦理和发育考量。
自我意识有多个组成部分，需要分别评估，以更好地调整认知康复。使用问卷和差异分数不足以评估意识，因为它不包括在线错误检测，而在线错误检测在儿童中可能会严重受损，尤其是那些执行功能受损的儿童。在线错误检测对于促进学习很重要，基于错误的学习有助于儿童在没有严重情景记忆问题的情况下建立对自身优势和困难的自我认知。元认知训练可能不适用于自我意识在发育上不成熟且年龄较小的儿童，也不适用于因脑损伤而患有疾病感缺失的脑损伤患者。
