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Experience Sharing

Seminar

“Cognitive and

vocational

rehabilitation for drug

rehabilitees”

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Cognitive Rehabilitation for Vocational

Training of Primarily Ketamine Users:

A Randomized Control Trial

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Goal

– To investigate the efficacy and effectiveness of virtual

reality-based vocational training system (VTS) as a

cognitive intervention for enhancing vocational

outcomes in ketamine users

Objectives:

• To improve the cognitive function and vocational outcomes of

youngsters who were primarily ketamine users through vocational

training systems (VTS).

• To investigate if there was any significant differences among two

treatment groups (virtual reality-based group /VRG, tutor-

administered group/TAG) and a wait-listing control group/CG) in

terms of cognitive performance, vocational outcomes and work-

related self-efficacy, during pre-test, post-test, 3-month and 6-month

follow up.

3

Content• Goal & objectives

• Brief literature review and conceptualization

• Research questions and methodology

• Summary of key results

– Effectiveness of VR- and Tutor-based training

– Correlations between rehabilitee’s cognitive

function and work status

• Discussion & conclusions

– Experience gained

2

Literature review :

• Ketamain was the top one psychotropic drug taken by secondary students (Li, Tam & Tam, 2010; Tsui et al.,2011).

• Cognitive problems have also been documented (Amann,2009; Morgan 2006; Stewart 2001; Rowland et al., 2005)

– Cognitive impairments such as attention, memory and executive function weresuggested to slow down the progress in work rehabilitation (Liberman, 1996)

• Cognitive functioning was one of the significant predictors ofvocational outcomes (Diller, Copeland & Jansen, 2008; Hougue, 2010)

• Minimizing the effect on this cognitive factor was thus hypothesized toimprove work rehabilitation outcomes and ultimately employability

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The impact of cognitive impairment on vocational outcome in ketamine

users

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Literature review

• VR can be defined as “...a way for humans to visualize, manipulate,and interact with computers and extremely complex data.” (Aukstakalnis and

Blatner, 1992).

• An advanced form of computer interface that allowed the user to“interact” with and become “immersed” within a computer generatedenvironment.

• VR training in CR can be explained by– Environmental enrichment (EE; Kolb, 1999)

– Contextual learning (CL).

• EE is referred to as simulation from a complex environment

– VR offers rich and vivid visual and auditory stimulations.

– A relatively complex and stimulating environment has a better trainingeffect than an impoverished environment.

• CL refers to the learning that takes place when day-to-day problems inreal-life situations are encountered (Gordon, Cantor, Ashman and Brown, 2006).

– More effective than learning isolated cognitive skills that are not clearlyrelated to the performance of functional tasks.

5

What is Virtual Reality (VR)? How VR works?

Figure 1: Application of the virtual reality-based vocational training system (VTS) in ketamine users’ rehabilitation

to enhance cognitive functioning and vocational outcomes in people with schizophrenia

Drug users

Cognitive deficits

Drilling and

practice in a work

context

Integrated

cognitive

processes

Facilitate work skills learning and

target cognitive deficits

Relevant to

user’s personal

goal

Controllable

Stimulus and

gradable

training

Increase self-efficacy and

intrinsic motivation

Tailor made to

fit individual

needs

Interactive and

dynamic

Promote task engagement in

the training process

Improved vocational

outcome

Virtual reality-based vocational training system (VTS)

-Attention

-Memory

-Executive

function

Ecological valid

Enriched environment

Contextual learning

Improved cognitive

functioning

6

Research questions

• Did VTS enhance cognitive performance in ketamine users?

– What was its impact of VTS on cognitive performance?

• Did VTS enhance vocational outcomes in people with

schizophrenia?

– What was the impact?

• Were there any significant differences between the three groups

(virtual reality-based training group: VRG; tutor-administered

group: TAG and control group: CG)

– in terms of cognitive performance

– vocational outcomes and

– work-related self-efficacy?

7

Research Hypotheses

• After completion of the 10-session vocational-

based cognitive training, the VRG would show

more improvements than the TAG and that

there would be no significant improvements in

the CG in the following aspects:

– Basic cognitive functions such as attention, memory and

executive functioning

– Work performance in doing sales-related tasks

– Self-efficacy score in doing sales-related tasks

– Vocational outcomes

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Methodology

Sampling:

Inclusion criteria:

• Use of ketamine with frequency at least twice per month over 6 months withinthe last 2 years and no other illicit psychotropic drug used up to once per month within the last 2 year.

• Chinese ethnicity of both genders

• Age between 15 and 30

• Under treatment and rehabilitation following abstinence

• Negative results obtained from the rapid urinary test of Ketamine

• Able and willing to provide informed consent to participate in the study

Exclusion criteria:

• Mental retardation

• Neurological disorder

• Physical handicaps, for example blindness

• Significant medical diseases requiring regular medication

• Poly-drug group (use ketamine with other illicit psychotropic drug such as Ectascy or methamphetamine, with frequency at least twice per month over 6months within the last 2 years)

9

Simple structure of VTS

• The training module is divided into 3 levels:– Pre-trainee level, trainee level and sales level.

– Patient has to complete elementary training tasks (pre-trainee and

trainee level) under the supervision of a “manager “(computer

instructions).

– After the patient completed all the training in each level, he/she has to

pass a test before they entered the sales level which involved problem

solving tasks.

– As a salesperson, patient has to complete some preparation work (e.g.

sorting clothes and checking clothes) before the shop open and handle

requests raised by the customers

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Instrumentation

Difference Similarities

VRG Cued stimuli or visualization

tactics were provided by the

computer program

• Received conventional skills

training

• Both VRG and TAG attended

individual training sessions, 30-45

mins per session, twice per week

for 5 weeks.

• The participants received training of

a similar content and structure but

with different delivery modes in

either VRG and TAG.

TAG -Practice tutorials guided by a

therapist

CG -No training in any sales-related

activities

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VRVTS

Snapshot of the VR program (entrance)

Snapshot of the VR program (inner shop)

Snapshot of the VR program (store room)

Hardware of VRVTS

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Outcome measures

- - -

Instrument Domain

Primary outcomes

The Test of Non-verbal Intelligence – Version III (TONI-III;

Brown, Sherbenou & Johnsen, 1997)

Overall cognitive

functioning

Digit Vigilance Test (DVT; Lewis, 1992) Attention

Rivermead Behavioural Memory Test (RBMT; Man and Li,

2001; Wilson et al., 1985)

Memory

Wisconsin Card Sorting Test-Computer Version 4 (WCST-

CV4; PAR)

Executive function

Employment status Open-employment to

unemployment

Secondary outcomes

On site test (self-designed checklist) Work performance

Self-efficacy score (self-designed) Self-efficacy

Cognitive and vocational outcomes before/ after training, at 3 month and 6 months follow ups16

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Data analysis

• According Shapiro-Wilk Test of normality, the

criteria for normality was not met in most of the

dependent variables.

• Non-parametric alternative tests were used– Friedman Test (a non-parametric statistics similar to parametric

repeated measures ANOVA),

– Kruskall Wallist test (a non-parametric test to compare 2 or more

sample data) were used instead to test the differences.

– Post-hoc analysis was thus conducted by Wilcoxin Signed

Ranks Tests, instead of typical tests like the Tukey’s test.

ResultsBaseline measurement

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Group comparisons over time

19 20

p p

- -

- -

21

Summary of findings• TONI3 (nonverbal intelligence)

– Result: No significant difference in change of TONI3 score among 3 groups, suggesting that allgroups had similar improvement across time.

– Interpretation: The change in TONI3 score was accounted by main time effect only. No groupeffect was observed. Maturation effect may account for the change. The result may alsosuggest that VRG and TAG have no additional benefit in improving intelligence.

• DVT (attention)– Result: Only VRG had significant improvement in DVT score, with large effect size

– Interpretation: The improvement in DVT score indicated significant improvement in sustainedattention. The result indicated that VRG had distinctive treatment effect in improving attention.The result may be accountable by the mode of training in VRG which more intensively requiredsustained attention.

• RBMT (memory)– Result: Only VRG showed significant improvement in RBMT score immediately after and 3

month after treatment, with large effect size.

– Interpretation: The improvement in DVT score indicated significant improvement in memory.The result indicated that VRG had distinctive treatment effect in improving memory and theeffect can be maintained for 3 months.

• WCST (executive functioning)– Result: Significant improvement across all treatment groups, no significant difference in change

observed among the groups

– Interpretation: The change in WCST score was accounted by main time effect only. No groupeffect is observed. Practice effect and maturation effect may explain the improvement in thescore across the time as the WCST score continued to increase with the number of trial. Theresult may suggest that VRG and TAG had no additional benefit in improving executivefunctioning.

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Vocational status3 month follow up

(6 month follow up)

VRG (%) TAG (%) CG (%)

Unemployment100% (50%) 100% (83.3%) 100% (86.4%%)

Sheltered workshop0% (0%) 0% (0%) 0% (0%)

Supported employment0% (0%) 0% (0%) 0% (0%)

Part-time employment0% (18.2%) 0% (0%) 0%(0%)

Full-time employment0% (31.8%) 0% (16.7%%) 0% (13.6%)

Total 100% (100%) 100% (100%) 100% (100%)22

• Onsite Test (sales-related activities)– Result: Both VRG and TAG showed significant improvement in onsite test. The

improvement was shown immediately after treatment, and at 3 months and 6months follow-ups. Post-hoc analysis showed that the improvement in TAG was significantly larger than that of VRG at 3 months and 6 months follow-ups.

• Interpretation: Both VRG and TAG showed significant effect in enhancing salesjob skills. TAG was superior in sustaining the training effect when compared withVRG. The result may suggest that job skills learned in real environment or under real person instruction may be more sustainable than virtual reality.

• Self-efficacy (sales-related activities)– Result: Both VRG and TAG showed significant improvement in Self-efficacy

immediately after treatment but the effect did not last for 3 months and 6 monthsfollow-ups. Post hoc test showed that TAG had a larger improvement comparingwith VRG.

• Interpretation: Both VRG and TAG enhanced self-efficacy but the effect did notsustain. TAG was more effective than VRG in improving participants’ self-efficacyin sales-related activities. The result may suggest that human contact and realperson instruction may be more effective in enhancing self-efficacy in vocationaltraining.

• All the subjects at 3-month follow up were unemployed. And there were nostatistically significant difference in employment status at 6-month follow upacross the three groups respectively (χ2= 5.875; p=0.209) though VRG hadgot more open employment (VRG=31.8%) than TAG (16.7%) and CG group(13.6%); part-time employment (VRG=18.2%; TAG= 0%; CG=0%), lower percentage in unemployment (VRG=50%; TAG=83.3%; CG=86.4%).

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Relationship between cognitive

status and outcomes• The canonical correlation between cognitive

function and work status for those successful

follow ups at the 3-month and 6-month follow-

ups were 0.363 and 0.477, respectively.

• When cognitive functioning was used to predict

work status, the overall classification rates were

65.3% (at the 3-month follow-up) and 54.7% (at

the 6-month follow-up).

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⍫≈侭シ夳Comments from the subjects

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2. Improvement in overall memory Discussionperformance in the VRG

1. VRG showed significant improvement in • due to greater spatial processing demand with

cognitive functions in respect of attention and virtual environment that could induce activity in

memory across time, but not in the TAG and the posterior hippocampus and parahippocampal

CG. cortex (Rose et al., 2005; Lee & Rudebeck, 2010).

• capacity of working memory may be enhanced– might be due to its unique mode of training, though

the VRG because of the activation of the corresponding

brain regions (Lee & Rudebeck, 2010; Baumann, et. al., 2003).– had to pay attention to the instructions and choices

– had to concentrate on multi-modal (visual andauditory) stimulus in an extended period of time

31 32

3. Both the VRG and the TAG showed significant

improvement in on-site vocational skills test

compared to that of the CG,

– They had a similar effect on the difference of learning

vocational skills in sales-related activities across time.

• Improvement in self-efficacy in the TAG was

greater than that of the VRG.

– could be related to greater skills competency and skill

generalization perceived by participants in the TAG

compared to that in the VRG.

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5. Generalizability

of the study

• The subjects were required to complete a work

performance test in a boutique. They had to

perform tasks that were very similar to those that

they performed in the training scenarios.

• It was assumed that any improvements in work

performance would be mainly due to the transfer

effects of VR training or tutor training.

• Both the VRG and TAG showed significant

improvements in the on-site tests compared to the

CG, these results indicate that both treatment

groups showed good generalization effects.

35

4. Suitability of applying

VR in ketamine users

Highly relevant to the ketamine users’ perspective

� When people valued the tasks as being meaningful

and useful for reaching their future goals, they were

more intrinsically motivated to learn and possibly

benefit more from the learning task (Expectancy-value

theory, Choi et al, 2010, Fishbein and Ajzen, 1975)

� Learning, achievement performance and task

engagement to perceptions of self-efficacy and task

value were linked (Eccles and Wigfield, 2002).

� Perceptions of self-competency (self-efficacy), task

difficulty and the relative value of a task to an individual

can affect a person’s choice of whether or not to

engage in a learning activity or task.

Task

meaningful

Self

efficacy

Task

difficulty

Intrinsic

motivation

Task

engagement

LearningTask

achievement

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6. Use of mixed mode of training?

– Effectiveness of virtual-reality based mixed

with tutor administered

7. Use of mobile technology in training

modes ?

– Apps

– Smart phone, tablet PC version

– “Work stations” incorporating cognitive training

8. Knowledge and technology transfer to

service sectors?

Conclusion

Conclusions

1. The use of VR technology in cognitive

remediation showed initial promising results to

improve the cognitive function, self-efficacy

and work skills for ketamine users

2. Potential use by service provider to ketamine

users

37

~ Thank you~

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