Long-term benefits of an early online problem-solving intervention for executive dysfunction after traumatic brain injury in children: a randomized clinical trial

[Formula: see text] Interventions to improve executive functions in children and adolescents with acquired brain injury: a systematic review and multilevel meta-analysis

To investigate the effectiveness of interventions aiming to improve hot and cold executive functions (EFs) in children and adolescents with acquired brain injury (ABI) and to examine whether characteristics of the intervention, participants, etiology of ABI (Traumatic-brain-injury [TBI] or non-TBI), time of assessment, or study quality moderate intervention effects. Whereas cold EFs refer to purely cognitive EFs, hot EFs refer to the affective aspects of these cognitive skills. A total of 970 participants from 23 randomized-controlled-trial studies (112 effect sizes [ES]) were included. A three-level random effects approach (studies, ES, individual participants) was used. Moderation analyses were conducted through meta-regressions. The three-level random effects model showed a better fit than the two-level model. Almost all individual studies showed non-significant ES across outcomes but in combination interventions were effective (Cohen's d = 0.38, CI 0.16 ~ 0.61). Lower methodological quality, inclusion of participants with non-TBI, and parental participation predicted larger ES. Participants' age, time of assessment, number of sessions, and focus on hot or cold EFs were not related to ES. We found no evidence of publication bias. Interventions are effective with small to medium ES according to conventional criteria. Intervention effects do not seem to fade away with time. Parent participation in the intervention is important to improve EFs. The efficacy of interventions seems larger when non-TBI is part of the etiology of ABI. Variation between studies is relevant for tracing the effective intervention characteristics. Most studies are conducted in adolescence, and studies in early childhood are needed.

Executive control training for adolescents with ADHD: Study protocol for a randomised controlled trial

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental conditions diagnosed during childhood and adolescence. In addition to the commonly observed symptoms of inattention, hyperactivity, and impulsivity, individuals with ADHD often experience impairments in executive functions (EFs). Goal management training (GMT) is a cognitive remediation intervention targeting EFs, with empirical support from studies with adult populations, including ADHD. The objective of the upcoming trial is to assess the effectiveness of GMT for adolescents with ADHD.

METHODS

This pre-registered protocol outlines a multi-centre randomised controlled trial (RCT) comparing GMT to treatment as usual (TAU) to improve EFs. We aim to recruit 120 participants, aged 12 to 18 years, recently diagnosed with ADHD. Participants will be randomly allocated to the group-based GMT intervention in addition to TAU, or the TAU condition, through block randomisation with site stratification. GMT will be delivered in groups of four to six participants, with weekly two-hour sessions for seven weeks, complemented by separate parent and teacher sessions. TAU is standard community mental health treatment. The primary outcome measure will be parent-reported EF assessed with the Behaviour Rating Inventory of Executive Function 2 (BRIEF-2). Secondary outcomes will include ADHD symptom measures, social functioning, quality of life, and neuropsychological tests (attention span, inhibition, working memory, and visuo-motor speed). The outcome assessments will be conducted at baseline, 12 weeks, 12 months, and 24 months post-treatment.

CONCLUSION

The study findings will contribute to determine the effectiveness of a non-pharmacological ADHD treatment, including outcome trajectories up to 24 months post-treatment.

Traumatic Brain Injury Positive Strategies for Families: A Pilot Randomized Controlled Trial of an Online Parent-Training Program

OBJECTIVE

To determine program satisfaction and preliminary efficacy of Traumatic Brain Injury Positive Strategies (TIPS), a web-based training for parenting strategies after child brain injury.

DESIGN

A randomized controlled trial with parallel assignment to TIPS intervention or usual-care control (TAU). The three testing time-points were pretest, posttest within 30 days of assignment, and 3-month follow-up. Reported in accordance with CONSORT extensions to randomized feasibility and pilot trials SETTING: Online.

PARTICIPANTS

Eighty-three volunteers recruited nationally who were 18 years of age or older, U.S. residents, English speaking and reading, had access to high-speed internet, and were living with and caring for a child who was hospitalized overnight with a brain injury (ages 3-18 years, able to follow simple commands; N=83).

INTERVENTIONS

Eight interactive behavioral training modules on parent strategies. The usual-care control was an informational website.

MAIN OUTCOME MEASURES

The proximal outcomes were User Satisfaction, Usefulness, Usability, Feature Preference, Strategy Utilization and Effectiveness, and Learning and Self-Efficacy for TIPS program participants. The primary outcomes were: Strategy Knowledge, Application, and Strategy-Application Confidence; Family Impact Module of Pediatric Quality of Life Inventory (PedsQL); and Caregiver Self-Efficacy Scale. The secondary outcomes were TIPS vs TCore PedsQL and Health Behavior Inventory (HBI) RESULTS: Pre- and posttest assessments were completed by 76 of 83 caregivers; 74 completed their 3-month follow-up. Linear growth models indicated that relative to TAU, TIPS yielded greater increases in Strategy Knowledge over the 3-month study (d=.61). Other comparisons did not reach significance. Outcomes were not moderated by child age, SES, or disability severity measured by Cognitive Function Module of PedsQL. All TIPS participants were satisfied with the program.

CONCLUSIONS

Of the 10 outcomes tested, only TBI knowledge significantly improved relative to TAU.

Problem solving and collaborative involvement among adolescents with spinal cord injury and their caregivers

Objective

To determine the relationship between constructive adolescent problem solving (positive problem-solving orientation and rational problem-solving style) and caregiver problem solving and collaborative involvement with primary caregiver among adolescents with spinal cord injuries (SCIs). Positive constructive adolescent problem solving was hypothesized to be predicted by more effective caregiver problem solving and higher collaborative involvement.

Methods

Participants in this cross-sectional study were 79 adolescent and primary caregiver dyads recruited from a pediatric rehabilitation care system in North America. All participants completed a standardized problem-solving instrument and adolescent participants completed an adapted measure of collaborative parent involvement.

Results

More effective caregiver problem solving and adolescent perceptions of more collaboration with caregivers around SCI care were significantly associated with higher positive problem-solving orientation and higher rational problem-solving style among adolescents.

Conclusions

Results underscore the importance of caregiver problem-solving skills and their collaboration with adolescents with SCI when addressing care needs. Clinically, findings highlight opportunities for parent involvement and skill-building as an important factor of rehabilitation for adolescents with SCI.

Cognitive rehabilitation in paediatric acquired brain injury-A 2-year follow-up of a randomised controlled trial

Background

Goal management training (GMT), a metacognitive rehabilitation method that has been demonstrated to improve executive function (EF) in adults with acquired brain injury (ABI), could potentially be effective for children in the chronic phase of ABI. In a previously published randomised controlled trial (RCT), the efficacy of a paediatric adaptation of GMT (pGMT) compared to a psychoeducative control intervention (paediatric Brain Health Workshop, pBHW) was investigated. Comparable improvements in EF in both groups were found at 6-month follow-up. However, a specific effect of pGMT could not be conclusively proven. The present study reports 2-year follow-up data (T4; T1: baseline, T2: post-intervention, T3: 6-month follow-up, and T4: 2-year follow-up) from this original RCT.

Methods

A total of 38 children and adolescents and also their parents completed questionnaires tapping into daily life EF. Explorative analyses were conducted comparing the 2-year follow-up data (T4) with the baseline (T1) and 6-month follow-up data (T3) for T4-participants in the two intervention groups (pGMT; n = 21, pBHW; n = 17), and we also assessed T4-participants vs. non-responders (n = 38) in the RCT. Primary outcome measures were the Behavioural Regulation Index (BRI) and the Metacognition Index (MI) derived from the Behaviour Rating Inventory of Executive Function (BRIEF) parent report.

Results

No difference between intervention groups was found (BRI, F = 2.25, p = 0.143, MI, F = 1.6, p = 0.213), and no time^*group interaction (BRI, F = 0.07, p = 0.976, MI, F = 0.137, p = 0.937) could be seen at the 2-year follow-up. Nevertheless, both pGMT and the pBHW groups improved daily EF as measured by parental reports over time from the baseline to T4 (p = 0.034). T4 participants and non-responders shared similar baseline characteristics.

Conclusion

Our results extend the findings from the 6-month follow-up previously published. Both pGMT and pBHW groups sustained their improvements in daily life EFs from the baseline, but additional effectiveness of pGMT relative to pBHW was not found.

Speech-Language Pathology Treatment of Cognitive-Communication Deficits in School-Aged Children With Traumatic Brain Injury: A Scoping Review

PURPOSE

The purpose of this scoping review was to synthesize the current evidence-based treatment practices used with school-aged children with any severity of traumatic brain injury (TBI) that could benefit the practice of speech-language pathologists (SLPs).

METHOD

A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Included studies were assigned thematic labels based on a modified version of the Rehabilitation Treatment Specification System.

RESULTS

A total of 27 articles that covered 16 different treatment approaches met inclusion criteria for this study. Most studies included adolescent or teenage participants with moderate-severe TBIs. Treatment targets included executive functioning (n = 15), social competence (n = 6), postconcussive symptoms (n = 5), behavior (n = 3), family functioning (n = 1), and health-related quality of life (n = 1). The majority of current interventions for school-aged children with TBI include a multidisciplinary approach and components of family involvement education.

CONCLUSIONS

Further research is needed on interventions that are specifically implemented by SLPs as well as protocols that include more heterogeneous samples (e.g., varied sociodemographic factors and injury severity) to allow for the development and testing of ecologically valid intervention practice. SLPs can use the results of this scoping review to individualize treatment based on the child's areas of need while considering individual characteristics and to provide person-centered intervention for children with school-aged TBI.

The Cerebellar Mutism Syndrome: Risk Assessment, Prevention and Treatment

Cerebellar mutism syndrome (CMS) has received increasing attention over the last decades as a complication of posterior fossa tumour surgery in children. Risk factors, aetiological aspects, and treatment measures of the syndrome have been investigated, yet the incidence of CMS remains unchanged. Overall, we are currently able to identify patients at risk, but we are unable to prevent it from occurring.Once CMS sets in, several symptomatic pharmacological treatments have been suggested, but only in smaller case series and not in randomized controlled trials, and it is not clear whether the treatment or time itself had a helpful effect.Within weeks to months, most patients regain their ability to speak after a phase with mutism or severely reduced speech; however, many patients continue to have speech and language deficits. At this point, anti-cancer treatment with chemotherapy and radiotherapy may be of focus more than the prognosis of CMS; however, many patients continue to have speech and language problems for months and years to come, and they are at high risk of other neurocognitive sequelae as well.Without reliable measures to prevent or treat the syndrome, we may look towards improving the prognosis of speech and neurocognitive functioning in these patients. As speech and language impairment is the cardinal symptom and late effect of CMS, the effect of intense and early-onset speech and language therapy as a standard of care in these patients should be investigated in relation to its effect on regaining speech capacity.

Usage Patterns of an mHealth Symptom Monitoring App Among Adolescents With Acute Mild Traumatic Brain Injuries

OBJECTIVE

To understand usage patterns of SMART (Self-Monitoring Activity Regulation and Relaxation Treatment) mHealth app among adolescents with acute mild traumatic brain injuries (mTBIs) and to identify individual characteristics that influenced app usage.

METHODS

SETTING

Emergency departments of tertiary care children's medical center.

PARTICIPANTS

Children aged 11 to 18 years with mTBI in the past 2 weeks, English-speaking, no evidence of severe TBI, and no preexisting neurological impairment.

DESIGN

Nested cohort of the intervention arm of a randomized clinical trial (n = 34).

MHEALTH APP INTERVENTION

SMART was a month-long educational program on mTBI designed to promote self-monitoring and management of recovery. SMART included digital symptom and activity self-monitoring surveys, feedback on symptom changes, and 8 modules providing psychoeducation, strategies for symptom management, and training in active problem solving.

MAIN MEASURES

App usage time, navigation, and interaction data were automatically collected. Usage involved inputting symptom ratings/activities and reviewing modules. Patterns of symptom/activity reporting and completion of learning modules data were analyzed. Predictors of app utilization, including individual characteristics, resilience (Connor-Davidson Resilience Scale), and coping (Coping Strategies Inventory-Short Form), were analyzed using Spearman correlations.

RESULTS

Participants completed symptom monitoring an average of 9 days over the month. Participants completed an average of 1.87 learning modules out of 7. Parent income and education, comorbid attention-deficit/hyperactivity disorder (ADHD), and emotional engagement coping style predicted symptom monitoring. Parental income, comorbid ADHD, and greater reliance on emotional engagement coping predicted module completion.

SIGNIFICANT ADVERSE EVENTS

None.

CONCLUSION

Adolescents of higher socioeconomic status and those who manage their emotions using active engagement spent more time on both components of the SMART program.

Parent- and Adolescent-reported Executive Functioning in the Context of Randomized Controlled Trials of Online Family Problem-Solving Therapy

OBJECTIVE

We examined parent- and adolescent-reported executive functioning (EF) behaviors following pediatric traumatic brain injury (TBI) in the context of Online Family Problem-Solving Therapy (OFPST) and moderators of change in EF behaviors.

METHOD

In total, 274 families were randomized to OFPST or an internet resource comparison group. Parents and adolescents completed the Behavior Rating Inventory of Executive Function at four time points. Mixed models were used to examine EF behaviors, assessing the effects of visit, treatment group, rater, TBI severity, age, socioeconomic status, and family functioning.

RESULTS

Parents rated their adolescents' EF as poorer (F(3,1156) = 220.15, p < .001; M = 58.11, SE = 0.73) than adolescents rated themselves (M = 51.81, SE = 0.73). Across raters, EF behaviors were poorer for adolescents whose parents had less education (F(3,1156) = 8.60, p = .003; M = 56.76, SE = 0.98) than for those with more education (M = 53.16, SE = 0.88). Age at baseline interacted with visit (F(3,1156) = 5.05, p = .002), such that families of older adolescents reported improvement in EF behaviors over time. Family functioning also interacted with visit (F(3, 1156) = 2.61, p = .049), indicating more improvement in EF behaviors over time in higher functioning families. There were no effects of treatment or TBI severity.

CONCLUSION

We identified a discrepancy between parent- and adolescent-reported EF, suggesting reduced awareness of deficits in adolescents with TBI. We also found that poorer family functioning and younger age were associated with poorer recovery after TBI, whereas adolescents of parents with less education were reported as having greater EF deficits across time points.

Pilot Executive Functioning Intervention in Epilepsy: Behavioral and Quality of Life Outcomes

OBJECTIVE

To examine changes in emotional and behavioral functioning and health-related quality of life (HRQOL) following a web-based executive functioning (EF) intervention open pilot trial (e.g., Epilepsy Journey) for adolescents with epilepsy.

METHODS

Adolescents with an established diagnosis of epilepsy, EF deficits, and without developmental disorders participated in a single-arm trial of Epilepsy Journey. Epilepsy Journey is a gamified, online learning environment comprised of 10 learning modules targeting EF deficits (e.g., working memory, organization) and tailored to epilepsy with accompanying telehealth problem-solving sessions. Adolescents completed questionnaires assessing emotional and behavioral functioning and HRQOL at baseline, posttreatment, and 2 follow-ups . Longitudinal mixed models and logistic regression analyses were used for these secondary analyses.

RESULTS

39 adolescents were recruited for Epilepsy Journey (Mage=15.3 years; 67% female; 87% White: Non-Hispanic; 39% experienced seizures in the past 3 months). Preliminary data indicate significant improvements in caregiver-reported Externalizing symptoms, Behavioral Symptom Index scores and Adaptive Skills from baseline to 5-month follow-up. Significant improvements were observed for caregiver-reported Mood/Behavior and self-reported Impact, Cognitive Functioning, Executive Functioning, and Sleep subscales of the PedsQL Epilepsy Module. Clinically significant improvements (e.g., clinical/at-risk to normative levels) in behavioral and quality of life domains were also noted.

CONCLUSION

Epilepsy Journey appears to contribute to changes in emotional and behavioral functioning and HRQOL in adolescents with epilepsy. Given the proof of concept trial format of this study, an important future direction is to conduct a randomized controlled trial with a larger, generalizable cohort of adolescents with epilepsy.

Telehealth in trauma: A scoping review

BACKGROUND

The purpose of this scoping review was to ascertain how 'telehealth' is utilised within health care, from pre hospital to admission, discharge and post discharge, with patients who have suffered major trauma.

METHODS

A scoping review of the literature published in English since 1980 was conducted using MEDLINE, Ovid EMBASE, PsychINFO, CINAHL, Austhealth, Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane library) and Web of Science MEDLINE and MEBASE to identify relevant studies.

RESULTS

We included 77 eligible studies with both randomised controlled trial and cohort design methodology. A variety of trauma was included such as traumatic brain injuries (n = 52; 67.5%), spinal cord injury (n = 14; 18.2%) and multi-trauma (n = 9; 11.7%) to both adult (n = 38) and paediatric (n = 32) participants. Telehealth is used in pre-hospital and acute-care settings (n = 11; 14.3%) to facilitate assessment, and in rehabilitation and follow-up (n = 61; 79.2%) to deliver therapy. Effects on health were reported the most (n = 46), with no negative outcomes. The feasibility of telehealth as a delivery mode was established, but coordination and technical issues are barriers to use. Overall, both patients and clinicians were satisfied using this mode of delivery.

CONCLUSION

This review demonstrates how telehealth is utilised across a spectrum of patients with traumatic injuries and to facilitate delivery of therapy, specialist consultations and assessments, with many studies reporting improvements to health. There is a paucity of high-quality rigorous research, which makes replication of findings and uptake of the intervention problematic. Future telehealth and trauma research should focus on the quality and reproducibility of telehealth interventions and the economic feasibility of using this platform to deliver trauma care.

Allocation of Treatment Responsibility in Adolescents With Epilepsy: Associations With Cognitive Skills and Medication Adherence

Objectives

To describe allocation of treatment responsibility (ATR) in adolescents with epilepsy, investigate associations between cognitive skills and ATR, and examine whether ATR for antiepileptic drugs (AEDs) predicted electronically monitored adherence.

Method

Sixty adolescents with epilepsy and their caregivers completed the Allocation of Treatment Responsibility Scale and a battery of self-report measures. Medical chart review data and electronically monitored AED adherence were collected for 1 year. Descriptive data assessed ATR for caregivers and adolescents; multivariate hierarchical regressions tested associations between variables.

Results

ATR for labs and clinic appointments was greatest for caregivers, while ATR for AEDs was more likely to be shared between caregiver and adolescent. Poorer attention was associated with greater caregiver responsibility for AEDs. Greater caregiver responsibility for AEDs was associated with higher electronically monitored adherence over 12 months.

Conclusions

In adolescents with epilepsy, caregivers are responsible for most treatment tasks, although responsibility for taking medication was shared with the adolescent. Greater caregiver responsibility for medication results in better long-term AED adherence. ATR is an important construct that warrants further attention in research and clinical practice, especially in the context of transition and health outcomes in pediatric epilepsy.

A Systematic Review of Behavioral Intervention Technologies for Youth With Chronic Health Conditions and Physical and Intellectual Disabilities: Implications for Adolescents and Young Adults With Spina Bifida

OBJECTIVE

Behavioral intervention technologies (BITs) stand as a promising delivery mechanism that overcomes multiple condition-specific and access barriers for self-management interventions for adolescents and young adults with spina bifida (AYA-SB). The purpose of the current review was to synthesize the behavioral and self-management intervention literature in conditions that have overlapping symptoms with youth with SB and to develop a model of likely user needs for AYA-SB that promotes self-management.

METHOD

The search strategy was conducted by a medical research librarian in the following databases: MEDLINE (Ovid), EMBASE (Elsevier), PsycINFO (EbscoHost), the Cochrane Library (Wiley), and Web of Science (Thomson Reuters) databases. The review was based on a systematic narrative synthesis framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number CRD42018092342).

RESULTS

In total, 18 articles were included in the current BIT review. The majority of included studies (1) targeted the management of chronic health conditions, (2) were informed by evidence-based approaches, (3) relied on content delivery, (4) were Web-based, (5) used linear or user-driven workflows, (6) included professional human support, and (7) included a control condition.

CONCLUSIONS

Many of the evaluated BITs resulted in acceptable usage and maintained or improved targeted symptoms. A user needs model for AYA-SB is proposed with the intention that future research will promote further refinement and ultimate deployment of a BIT for AYA-SB to promote self-management.

A Systematic Review of Interventions for Hot and Cold Executive Functions in Children and Adolescents With Acquired Brain Injury

Objective

We investigated interventions, which aimed to improve cold and hot executive functions (EFs) in children and adolescents with a diagnosis of acquired brain injury (ABI).

Methods

The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between 1990 and July 2017 in English or Spanish, including children and adolescents. Articles were read and classified according to the levels of evidence of the Australian National Health and Medical Research Council and the Downs and Black checklist was used for Measuring Study Quality.

Results

Thirty studies are reported in this systematic review. Level of evidence, quality of the studies, characteristics of the participants, interventions implemented, and outcomes are described.

Conclusions

The study of rehabilitation for executive dysfunction in children with ABI is emerging. Although few high-quality intervention studies exist in this area, which limits conclusions regarding intervention efficacy, results of existing studies suggest that education for parents may be an important component of intervention. Moreover, caregiver involvement may improve the effectiveness of hot EFs rehabilitation interventions, while high intervention session frequency may be important in improving cold EFs. Positive behavior supports and specific training based on a cognitive model provided some promising findings, which require further evaluation.

Online Problem Solving for Adolescent Brain Injury: A Randomized Trial of 2 Approaches

OBJECTIVE

Adolescent traumatic brain injury (TBI) contributes to deficits in executive functioning and behavior, but few evidence-based treatments exist. We conducted a randomized clinical trial comparing Teen Online Problem Solving with Family (TOPS-Family) with Teen Online Problem Solving with Teen Only (TOPS-TO) or the access to Internet Resources Comparison (IRC) group.

METHODS

Children, aged 11 to 18 years, who sustained a complicated mild-to-severe TBI in the previous 18 months were randomly assigned to the TOPS-Family (49), TOPS-TO (51), or IRC group (52). Parent and self-report measures of externalizing behaviors and executive functioning were completed before treatment and 6 months later. Treatment effects were examined using linear regression models, adjusting for baseline symptom levels. Age, maternal education, and family stresses were examined as moderators.

RESULTS

The TOPS-Family group had lower levels of parent-reported executive dysfunction at follow-up than the TOPS-TO group, and differences between the TOPS-Family and IRC groups approached significance. Maternal education moderated improvements in parent-reported externalizing behaviors, with less educated parents in the TOPS-Family group reporting fewer symptoms. On the self-report Behavior Rating Inventory of Executive Functions, treatment efficacy varied with the level of parental stresses. The TOPS-Family group reported greater improvements at low stress levels, whereas the TOPS-TO group reported greater improvement at high-stress levels. The TOPS-TO group did not have significantly lower symptoms than the IRC group on any comparison.

CONCLUSION

Findings support the efficacy of online family problem solving to address executive dysfunction and improve externalizing behaviors among youth with TBI from less advantaged households. Treatment with the teen alone may be indicated in high-stress families.

Investigating the Connection Between Traumatic Brain Injury and Posttraumatic Stress Symptoms in Adolescents

OBJECTIVE

To identify potentially modifiable individual and social-environmental correlates of posttraumatic stress symptoms (PTSS) among adolescents hospitalized for traumatic brain injury (TBI).

SETTING

Four pediatric hospitals and 1 general hospital in the United States.

PARTICIPANTS

Children ages 11 to 18 years, hospitalized for moderate-severe TBI within the past 18 months.

DESIGN

Retrospective cross-sectional analysis.

MAIN MEASURES

The University of California at Los Angeles (UCLA) Post-traumatic Stress Disorder (PTSD) Reaction Index and the Youth Self-Report (YSR) PTSD subscale.

RESULTS

Of 147 adolescents enrolled, 65 (44%) had severe TBI, with an average time since injury of 5.8 ± 4 months. Of the 104 who completed the UCLA-PTSD Reaction Index, 22 (21%) reported PTSS and 9 (8%) met clinical criteria for PTSD. Of the 143 who completed the YSR-PTSD subscale, 23 (16%) reported PTSS and 6 (4%) met clinical criteria for PTSD. In multivariable analyses, having a negative approach to problem solving and depressive symptoms were both associated (P < .001) with higher levels of PTSS based on the UCLA-PTSD Reaction Index (β = 0.41 and β = 0.33, respectively) and the YSR-PTSD subscale (β = 0.33 and β = 0.40, respectively).

CONCLUSION

Targeting negative aspects of problem solving in youths after brain injury may mitigate PTSS.

Remote Technology-Based Training Programs for Children with Acquired Brain Injury: A Systematic Review and a Meta-Analytic Exploration

Introduction

Multidisciplinary rehabilitation interventions are considered to be a need for children with acquired brain injury (ABI), in order to remediate the important sequelae and promote adjustment. Technology-based treatments represent a promising field inside the rehabilitation area, as they allow delivering interventions in ecological settings and creating amusing exercises that may favor engagement. In this work, we present an overview of remote technology-based training programs (TP) addressing cognitive and behavioral issues delivered to children with ABI and complement it with the results of a meta-analytic exploration.

Evidence Acquisition

We performed the review process between January and February 2019. 32 studies were included in the review, of which 14 were further selected to be included in the meta-analysis on TP efficacy.

Evidence Synthesis

Based on the review process, the majority of TP addressing cognitive issues and all TP focusing on behavioral issues were found to be effective. Two meta-analytic models examining the means of either cognitive TP outcomes or behavioral TP outcomes as input outcome yielded a nonsignificant effect size for cognitive TP and a low-moderate effect size for behavioral TP. Additional models on outcomes reflecting the greatest beneficial effects of TP yielded significant moderate effect sizes for both types of TP. Nevertheless, consistent methodological heterogeneity was observed, pointing to cautious interpretation of findings. A subgroup analysis on visuospatial skill outcomes showed a smaller yet significant effect size of cognitive TP, with low heterogeneity, providing a more reliable estimation of overall cognitive TP effects.

Conclusions

Promising results on remote cognitive and behavioral TP efficacy emerged both at the review process and at the meta-analytic investigation. Nevertheless, the high heterogeneity that emerged across studies prevents us from drawing definite conclusions. Further research is needed to identify whether specific training characteristics and population subgroups are more likely to be associated with greater training efficacy.

Effectiveness of paediatric occupational therapy for children with disabilities: A systematic review

INTRODUCTION

Paediatric occupational therapy seeks to improve children's engagement and participation in life roles. A wide variety of intervention approaches exist. Our aim was to summarise the best-available intervention evidence for children with disabilities, to assist families and therapists choose effective care.

METHODS

We conducted a systematic review (SR) using the Cochrane methodology, and reported findings according to PRISMA. CINAHL, Cochrane Library, MEDLINE, OTSeeker, PEDro, PsycINFO were searched. Two independent reviewers: (i) determined whether studies met inclusion: SR or randomised controlled trial (RCT); an occupational therapy intervention for children with a disability; (ii) categorised interventions based on name, core components and diagnostic population; (iii) rated quality of evidence and determined the strength of recommendation using GRADE criteria; and (iv) made recommendations using the Evidence Alert Traffic Light System.

RESULTS

129 articles met inclusion (n = 75 (58%) SRs; n = 54 (42%)) RCTs, measuring the effectiveness of 52 interventions, across 22 diagnoses, enabling analysis of 135 intervention indications. Thirty percent of the indications assessed (n = 40/135) were graded 'do it' (Green Go); 56% (75/135) 'probably do it' (Yellow Measure); 10% (n = 14/135) 'probably don't do it' (Yellow Measure); and 4% (n = 6/135) 'don't do it' (Red Stop). Green lights were: Behavioural Interventions; Bimanual; Coaching; Cognitive Cog-Fun & CAPS; CO-OP; CIMT; CIMT plus Bimanual; Context-Focused; Ditto; Early Intervention (ABA, Developmental Care); Family Centred Care; Feeding interventions; Goal Directed Training; Handwriting Task-Specific Practice; Home Programs; Joint Attention; Mental Health Interventions; occupational therapy after toxin; Kinesiotape; Pain Management; Parent Education; PECS; Positioning; Pressure Care; Social Skills Training; Treadmill Training and Weight Loss 'Mighty Moves'.

CONCLUSION

Evidence supports 40 intervention indications, with the greatest number at the activities-level of the International Classification of Function. Yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions could be discontinued because effective alternatives existed.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies for parents of children and adolescents with chronic illness aim to improve parenting behavior and mental health, child functioning (behavior/disability, mental health, and medical symptoms), and family functioning.This is an updated version of the original Cochrane Review (2012) which was first updated in 2015.

OBJECTIVES

To evaluate the efficacy and adverse events of psychological therapies for parents of children and adolescents with a chronic illness.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, and trials registries for studies published up to July 2018.

SELECTION CRITERIA

Included studies were randomized controlled trials (RCTs) of psychological interventions for parents of children and adolescents with a chronic illness. In this update we included studies with more than 20 participants per arm. In this update, we included interventions that combined psychological and pharmacological treatments. We included comparison groups that received either non-psychological treatment (e.g. psychoeducation), treatment as usual (e.g. standard medical care without added psychological therapy), or wait-list.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcomes post-treatment and at first available follow-up. Primary outcomes were parenting behavior and parent mental health. Secondary outcomes were child behavior/disability, child mental health, child medical symptoms, and family functioning. We pooled data using the standardized mean difference (SMD) and a random-effects model, and evaluated outcomes by medical condition and by therapy type. We assessed risk of bias per Cochrane guidance and quality of evidence using GRADE.

MAIN RESULTS

We added 21 new studies. We removed 23 studies from the previous update that no longer met our inclusion criteria. There are now 44 RCTs, including 4697 participants post-treatment. Studies included children with asthma (4), cancer (7), chronic pain (13), diabetes (15), inflammatory bowel disease (2), skin diseases (1), and traumatic brain injury (3). Therapy types included cognitive-behavioural therapy (CBT; 21), family therapy (4), motivational interviewing (3), multisystemic therapy (4), and problem-solving therapy (PST; 12). We rated risk of bias as low or unclear for most domains, except selective reporting bias, which we rated high for 19 studies due to incomplete outcome reporting. Evidence quality ranged from very low to moderate. We downgraded evidence due to high heterogeneity, imprecision, and publication bias.Evaluation of parent outcomes by medical conditionPsychological therapies may improve parenting behavior (e.g. maladaptive or solicitous behaviors; lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.28, 95% confidence interval (CI) -0.43 to -0.13; participants = 664; studies = 3; SMD -0.21, 95% CI -0.37 to -0.05; participants = 625; studies = 3; I² = 0%, respectively, low-quality evidence), chronic pain post-treatment and follow-up (SMD -0.29, 95% CI -0.47 to -0.10; participants = 755; studies = 6; SMD -0.35, 95% CI -0.50 to -0.20; participants = 678; studies = 5, respectively, moderate-quality evidence), diabetes post-treatment (SMD -1.39, 95% CI -2.41 to -0.38; participants = 338; studies = 5, very low-quality evidence), and traumatic brain injury post-treatment (SMD -0.74, 95% CI -1.25 to -0.22; participants = 254; studies = 3, very low-quality evidence). For the remaining analyses data were insufficient to evaluate the effect of treatment.Psychological therapies may improve parent mental health (e.g. depression, anxiety, lower scores are better) in children with cancer post-treatment and follow-up (SMD -0.21, 95% CI -0.35 to -0.08; participants = 836, studies = 6, high-quality evidence; SMD -0.23, 95% CI -0.39 to -0.08; participants = 667; studies = 4, moderate-quality evidence, respectively), and chronic pain post-treatment and follow-up (SMD -0.24, 95% CI -0.42 to -0.06; participants = 490; studies = 3; SMD -0.20, 95% CI -0.38 to -0.02; participants = 482; studies = 3, respectively, low-quality evidence). Parent mental health did not improve in studies of children with diabetes post-treatment (SMD -0.24, 95% CI -0.90 to 0.42; participants = 211; studies = 3, very low-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent mental health.Evaluation of parent outcomes by psychological therapy typeCBT may improve parenting behavior post-treatment (SMD -0.45, 95% CI -0.68 to -0.21; participants = 1040; studies = 9, low-quality evidence), and follow-up (SMD -0.26, 95% CI -0.42 to -0.11; participants = 743; studies = 6, moderate-quality evidence). We did not find evidence for a beneficial effect for CBT on parent mental health at post-treatment or follow-up (SMD -0.19, 95% CI -0.41 to 0.03; participants = 811; studies = 8; SMD -0.07, 95% CI -0.34 to 0.20; participants = 592; studies = 5; respectively, very low-quality evidence). PST may improve parenting behavior post-treatment and follow-up (SMD -0.39, 95% CI -0.64 to -0.13; participants = 947; studies = 7, low-quality evidence; SMD -0.54, 95% CI -0.94 to -0.14; participants = 852; studies = 6, very low-quality evidence, respectively), and parent mental health post-treatment and follow-up (SMD -0.30, 95% CI -0.45 to -0.15; participants = 891; studies = 6; SMD -0.21, 95% CI -0.35 to -0.07; participants = 800; studies = 5, respectively, moderate-quality evidence). For the remaining analyses, data were insufficient to evaluate the effect of treatment on parent outcomes.Adverse eventsWe could not evaluate treatment safety because most studies (32) did not report on whether adverse events occurred during the study period. In six studies, the authors reported that no adverse events occurred. The remaining six studies reported adverse events and none were attributed to psychological therapy. We rated the quality of evidence for adverse events as moderate.

AUTHORS' CONCLUSIONS

Psychological therapy may improve parenting behavior among parents of children with cancer, chronic pain, diabetes, and traumatic brain injury. We also found beneficial effects of psychological therapy may also improve parent mental health among parents of children with cancer and chronic pain. CBT and PST may improve parenting behavior. PST may also improve parent mental health. However, the quality of evidence is generally low and there are insufficient data to evaluate most outcomes. Our findings could change as new studies are conducted.

Improving empathy with motivational strategies in batterer intervention programmes: Results of a randomized controlled trial

OBJECTIVES

Empathy (i.e., the ability to decode emotions, as well as cognitive and emotional empathy) is involved in moral reasoning, prosocial behaviour, social and emotional adequacy, mood and behaviour regulation. Hence, alterations in these functions could reduce behaviour control and the adoption of specific types of violence such as intimate partner violence (IPV). Although interventions for IPV perpetrators focus on reducing IPV risk factors and increasing protective factors to prevent this kind of violence, the study of the effectiveness of these programmes in promoting changes in empathy (cognitive and emotional) has been neglected.

DESIGN

Hence, the main aim of this study was to compare the effectiveness of two different modalities of IPV intervention programmes (Standard Batterer Intervention Programs [SBIP] vs. SBIP + Individualized Motivational Plan [IMP]) in promoting empathic improvements after both interventions.

METHOD

Participants were randomly assigned to receive SBIP (n = 40) or SBIP + IMP (n = 53). The effectiveness of the intervention in the total sample and the group effects were evaluated with general linear model repeated-measures ANOVA.

RESULTS

Results revealed that only the IPV perpetrators who received the SBIP + IMP were more accurate in decoding emotional facial signals and presented better cognitive empathy (perspective taking) after the intervention programme.

CONCLUSIONS

Our study reinforces the view that different modalities of IPV intervention might lead to different cognitive outcomes after the intervention. Thus, these results may help professionals to develop specific intervention programmes focused on improving cognitive abilities in order to reduce IPV recidivism.

PRACTITIONER POINTS

Interventions for batterers' neglected empathic changes after these programmes. Not enough randomized controlled trials for these kinds of interventions. An improvement in the ability to decode emotions after the intervention programme. An improvement in cognitive empathy (perspective taking) after the intervention programme. Different modalities of IPV intervention might lead to different cognitive outcomes after the intervention.

Behavioral Clinical Trials in Moderate to Severe Pediatric Traumatic Brain Injury: Challenges, Potential Solutions, and Lessons Learned

: The purpose of this commentary is to outline the challenges encountered when conducting clinical trials of interventions for pediatric traumatic brain injury (TBI) and share potential solutions for surmounting these issues. This commentary grows out of our experience implementing 8 randomized clinical trials (RCTs) of family-centered interventions to reduce child behavior problems and caregiver/parent distress following pediatric brain injury. These studies, involving more than 600 participants from 8 clinical centers, support the feasibility of conducting RCTs with children who have sustained TBIs while highlighting potential challenges and threats to validity. The challenges of behavioral trials for pediatric TBI are apparent but not insurmountable. Careful consideration of the clinical trial issues outlined in this commentary can inform design choices and analyses when planning a clinical trial. It is critically important that investigators share their failures as well their successes to move the field of pediatric TBI intervention research forward.

Feasibility of a home-based computerized cognitive training for pediatric patients with congenital or acquired brain damage: An explorative study

Objectives

Pediatric brain damage is associated with various cognitive deficits. Cognitive rehabilitation may prevent and reduce cognitive impairment. In recent years, home-based computerized cognitive training (CCT) has been introduced in clinical practice to increase treatment opportunities for patients (telerehabilitation). However, limited research has been conducted thus far on investigating the effects of remote CCT for the juvenile population in contexts other than English-speaking countries. The aim of the present study was to investigate the feasibility of a home-based CCT in a group of Italian adolescents with brain damage. A commercially available CCT (Lumosity) developed in the English language was used due to the lack of telerehabilitation programs in the Italian language that allow stimulation of multiple cognitive domains and, at the same time, remote automatic collection of data. Thus, this investigation provides information on the possibility of introducing CCT programs available in foreign languages in countries with limited investment in the telerehabilitation field.

Methods

32 adolescents aged 11–16 with a diagnosis of congenital or acquired (either traumatic or non-traumatic) brain damage participated in the study. They received 40 training sessions (5 days/week for 8 weeks). Before starting the training program, they received face-to-face demonstration of training exercises and written instructions in their mother tongue. The feasibility of both training and study design and procedures was assessed through 9 criteria taken from extant literature.

Results

All 9 feasibility criteria were met. 31 out of the 32 participants demonstrated adherence to the training program. 94.2% of training sessions were completed in the recommended timeframe. No significant technical issue was found.

Conclusions

Telerehabilitation seems to be a feasible practice for adolescents with brain damage. A training program developed in a foreign language can be used to counter the unavailability of programs in patients’ mother tongue.

Trial registration

The trial is registered with the ISRCTN registry with study ID ISRCTN59250807

Use of Mental Health Services by Adolescents After Traumatic Brain Injury: A Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mental health problems are common after pediatric traumatic brain injury (TBI). Many patients in need of mental health services do not receive them, but studies have not consistently used prospective and objective methods or followed samples for more than 1 year.

OBJECTIVE

To examine adolescents' use of mental health services after TBI.

DESIGN

Secondary analysis from multicenter prospective randomized controlled trial.

SETTING

Five level 1 U.S. trauma centers.

PARTICIPANTS

Adolescents aged 12-17 years with moderate-to-severe TBI were recruited for a randomized clinical trial (n = 132 at baseline, 124 at 6 months, 113 at 12 months, and 101 at 18 months).

METHODS

Participants were randomly assigned to counselor-assisted problem-solving or Internet resource comparison. Follow-up assessments were completed at 6, 12, and 18 months after baseline. Generalized estimating equations with a logit link were used to examine use of mental health services. Treatment group and participant impairment were examined as predictors of use.

MAIN OUTCOME MEASUREMENTS

Mental health care use was measured with the Service Assessment for Children and Adolescents; daily functioning and clinical outcome with the Child and Adolescent Functional Assessment Scale; behavioral and emotional functioning with the Child Behavior Checklist; and executive dysfunction with the Behavior Rating Inventory of Executive Function.

RESULTS

Use of mental health services ranged from 22% to 31% in the 2 years post-TBI. Participants with impairments were about 3 times more likely than those without impairments to receive services (odds ratio 4.61; 95% confidence interval 2.61-8.14; P < .001). However, 50%-68% of patients identified as impaired had unmet mental health care needs.

CONCLUSIONS

Less than one half of adolescents with behavioral health needs after TBI received mental health services. Future studies are needed to examine barriers associated with seeking services after TBI and psychoeducation as preventive care for this population.

LEVEL OF EVIDENCE

II.

Searching for effective components of cognitive rehabilitation for children and adolescents with acquired brain injury: A systematic review

AIM

Cognitive rehabilitation is of interest after paediatric acquired brain injury (ABI). The present systematic review examined studies investigating cognitive rehabilitation interventions for children with ABI, while focusing on identifying effective components. Components were categorized as (1) metacognition and/or strategy use, (2) (computerized) drill-based exercises, and (3) external aids.

METHODS

The databases PubMed (including MEDLINE), PsycInfo, and CINAHL were searched until 22nd June 2017. Additionally, studies were identified through cross-referencing and by consulting experts in the field.

RESULTS

A total of 20 articles describing 19 studies were included. Metacognition/strategy use trainings (five studies) mainly improved psychosocial functioning. Drill-based interventions (six studies) improved performance on tasks similar to training tasks. Interventions combining these two components (six studies) benefited cognitive and psychosocial functioning. External aids (two studies) improved everyday memory. No studies combined external aids with drill-based interventions or all three components.

CONCLUSION

Available evidence suggests that multi-component rehabilitation, e.g. combining metacognition/strategy use and drill-based training is most promising, as it can lead to improvements in both cognitive and psychosocial functioning of children with ABI. Intervention setting and duration may play a role. Conclusions remain tentative due to small sample sizes of included studies heterogeneity regarding outcome measures, intervention and therapist variables, and patient characteristics.

Feasibility and Potential Benefits of a Web-Based Intervention Delivered Acutely After Mild Traumatic Brain Injury in Adolescents: A Pilot Study

BACKGROUND

There is a paucity of evidence-based interventions for mild traumatic brain injury (mTBI).

OBJECTIVE

To evaluate the feasibility and potential benefits of an interactive, Web-based intervention for mTBI.

SETTING

Emergency department and outpatient settings.

PARTICIPANTS

Of the 21 adolescents aged 11 to 18 years with mTBI recruited from November 2013 to June 2014 within 96 hours of injury, 13 completed the program.

DESIGN

Prospective, open pilot.

INTERVENTION

The Web-based Self-Management Activity-restriction and Relaxation Training (SMART) program incorporates anticipatory guidance and psychoeducation, self-management and pacing of cognitive and physical activities, and cognitive-behavioral principles for early management of mTBI in adolescents.

MAIN MEASURES

Primary: Daily Post-Concussion Symptom Scale (PCSS). Secondary: Daily self-reported ratings of activities and satisfaction survey.

RESULTS

Average time from injury to baseline testing was 14.0 (standard deviation = 16.7) hours. Baseline PCSS was 23.6 (range: 0-46), and daily activity was 1.8 (range: 0-5.75) hours. Repeated-measures, generalized linear mixed-effects model analysis demonstrated a significant decrease of PCSS at a rate of 2.0 points per day that stabilized after about 2 weeks. Daily activities, screen time, and physical activity increased by 0.06 (standard error [SE] = 0.04, P = .09), 0.04 (SE = 0.02, P = .15), and 0.03 (SE = 0.02, P = .05) hours per day, respectively, over the 4-week follow-up. Satisfaction was rated highly by parents and youth.

CONCLUSIONS

Self-Management Activity-restriction and Relaxation Training is feasible and reported to be helpful and enjoyable by participants. Future research will need to determine the comparative benefits of SMART and ideal target population.

Technology-assisted rehabilitation interventions following pediatric brain injury

INTRODUCTION

Following traumatic brain injury (TBI), children experience a variety of physical, motor, speech, and cognitive deficits that can have a long-term detrimental impact. The emergence and popularity of new technologies has led to research into the development of various apps, gaming systems, websites, and robotics that might be applied to rehabilitation. The objective of this narrative review was to describe the current literature regarding technologically-assisted interventions for the rehabilitation of motor, neurocognitive, behavioral, and family impairments following pediatric TBI.

EVIDENCE ACQUISITION

We conducted a series of searches for peer-reviewed manuscripts published between 2000 and 2017 that included a technology-assisted component in the domains of motor, language/communication, cognition, behavior, social competence/functioning, family, and academic/school-based functioning.

EVIDENCE SYNTHESIS

Findings suggested several benefits of utilizing technology in TBI rehabilitation including facilitating engagement/adherence, increasing access to therapies, and improving generalizability across settings. There is fairly robust evidence regarding the efficacy of online family problem-solving therapy in improving behavior problems, executive functioning, and family functioning. There was less compelling, but still promising, evidence regarding the efficacy other technology for motor deficits, apps for social skills, and computerized programs for cognitive skills. Overall, many studies were limited in the rigor of their methodology due to small heterogeneous samples and lack of control groups.

CONCLUSIONS

Technology-assisted interventions have the potential to enhance pediatric rehabilitation after TBI. Future research is needed to further support their efficacy with larger controlled trials and to identify characteristics of children who are most likely to benefit.

The development and evaluation of a web-based programme to support problem-solving skills following brain injury

BACKGROUND AND AIM

Cognitive impairments following brain injury, including difficulty with problem solving, can pose significant barriers to successful community reintegration. Problem-solving strategy training is well-supported in the cognitive rehabilitation literature. However, limitations in insurance reimbursement have resulted in fewer services to train such skills to mastery and to support generalization of those skills into everyday environments. The purpose of this project was to develop and evaluate an integrated, web-based programme, ProSolv, which uses a small number of coaching sessions to support problem solving in everyday life following brain injury.

METHOD

We used participatory action research to guide the iterative development, usability testing, and within-subject pilot testing of the ProSolv programme. The finalized programme was then evaluated in a between-subjects group study and a non-experimental single case study.

RESULTS

Results were mixed across studies. Participants demonstrated that it was feasible to learn and use the ProSolv programme for support in problem solving. They highly recommended the programme to others and singled out the importance of the coach. Limitations in app design were cited as a major reason for infrequent use of the app outside of coaching sessions.

CONCLUSIONS

Results provide mixed evidence regarding the utility of web-based mobile apps, such as ProSolv to support problem solving following brain injury. Implications for Rehabilitation People with cognitive impairments following brain injury often struggle with problem solving in everyday contexts. Research supports problem solving skills training following brain injury. Assistive technology for cognition (smartphones, selected apps) offers a means of supporting problem solving for this population. This project demonstrated the feasibility of a web-based programme to address this need.

Brain biomarkers and pre-injury cognition are associated with long-term cognitive outcome in children with traumatic brain injury

Background

Children with traumatic brain injury (TBI) are frequently at risk of long-term impairments of attention and executive functioning but these problems are difficult to predict. Although deficits have been reported to vary with injury severity, age at injury and sex, prognostication of outcome remains imperfect at a patient-specific level. The objective of this proof of principle study was to evaluate a variety of patient variables, along with six brain-specific and inflammatory serum protein biomarkers, as predictors of long-term cognitive outcome following paediatric TBI.

Method

Outcome was assessed in 23 patients via parent-rated questionnaires related to attention deficit hyperactivity disorder (ADHD) and executive functioning, using the Conners 3rd Edition Rating Scales (Conners-3) and Behaviour Rating Inventory of Executive Function (BRIEF) at a mean time since injury of 3.1 years. Partial least squares (PLS) analyses were performed to identify factors measured at the time of injury that were most closely associated with outcome on (1) the Conners-3 and (2) the Behavioural Regulation Index (BRI) and (3) Metacognition Index (MI) of the BRIEF.

Results

Higher levels of neuron specific enolase (NSE) and lower levels of soluble neuron cell adhesion molecule (sNCAM) were associated with higher scores on the inattention, hyperactivity/impulsivity and executive functioning scales of the Conners-3, as well as working memory and initiate scales of the MI from the BRIEF. Higher levels of NSE only were associated with higher scores on the inhibit scale of the BRI.

Conclusions

NSE and sNCAM show promise as reliable, early predictors of long-term attention-related and executive functioning problems following paediatric TBI.

Adolescents with Mild Traumatic Brain Injury Get SMART: An Analysis of a Novel Web-Based Intervention

BACKGROUND

There have been few trials of interventions to facilitate recovery following mild traumatic brain injury (mTBI) in adolescence. To address this gap, we developed and piloted a novel Web-based intervention, entitled Self-Management Activity Restriction and Relaxation Training (SMART), and examined its impact on symptom burden, functional disability, and executive functioning during the month following mTBI in adolescents.

MATERIALS AND METHODS

Open-label, single arm study. Adolescents with recent mTBI and a parent were recruited from the emergency department and provided access upon discharge to SMART-a Web-based program designed to facilitate recovery via self-management and education about symptoms and sequelae associated with mTBI. Symptom burden, functional disability, and executive functioning were rated by both the adolescent and the parent initially and at assessments at 1-, 2- and 4-weeks postinjury. Mixed models analyses were used to examine trajectories on these outcomes.

RESULTS

Of the 21 adolescent/parent dyads enrolled, 13 engaged in the program and reported significant improvement in symptoms over the 4-week program (adolescent, p = 0.0005; parent, p = 0.004). Adolescents spent a median of 35.5 min (range 1.1-107.6) using the program. Parent ratings of the adolescent's functional disability and executive functioning significantly improved over the 4-week period from baseline (p = 0.009 and p = 0.03, respectively), whereas adolescents themselves did not report significant changes in either outcome. All participants improved and there were no adverse outcomes.

CONCLUSION

The SMART program, a novel Web-based intervention, may serve as a self-management tool for adolescents and their parents to assist with the recovery following a recent mTBI.

Development of a web-based executive functioning intervention for adolescents with epilepsy: The Epilepsy Journey

INTRODUCTION

Youth with epilepsy exhibit significant deficits in executive functioning (EF), yet there are few interventions to improve EF for adolescents. The aims of the current study were to develop an individually-tailored intervention, called Epilepsy Journey, to improve aspects of EF through an iterative, patient-centered process including focus groups and usability testing.

METHODS

Five adolescents and caregivers participated in focus groups. This input was used to develop ten learning modules based on subscales of the Behavioral Rating Inventory of Executive Functions and key issues that may impact EF in adolescents. Six adolescents participated in usability testing and a usability expert conducted a heuristic evaluation. Demographic information, chart reviews and measures of EF were also completed.

RESULTS

Focus group participants and their parents reported difficulties with memory, attention, organization, monitoring, initiation, impulsivity, emotional control, sleep, awareness in schools and managing stress. They also identified successful strategies to address memory and organizational difficulties. Usability testing of the resultant Epilepsy Journey modules revealed problems with navigation and identified features that promoted usability, including progress bars and interactive modules. Program modifications were made after each usability trial resulting in a relatively brief, interactive and readily navigable program. Perceived utility was high with all but one participant. Participants rated the content as helpful and indicated they would recommend Epilepsy Journey to others.

CONCLUSIONS

Feedback from the focus group and usability testing yielded a feasible, acceptable, relevant and user-friendly web-based intervention for adolescents with epilepsy. The Epilepsy Journey program will be further tested in an open pilot with adolescents with epilepsy and associated EF deficits.

The use of telemedicine in the care of the pediatric trauma patient

Telemedicine is increasingly becoming an important part of the health care system as it has the potential to help deliver quality medical care to underserved areas. When implemented correctly, it can be a cost-effective way of expanding access to excellent medical care. However, because it is a relatively new and quickly changing field, there are multiple issues and challenges that need to be addressed. This article reviews the current literature on various modalities of telemedicine, evidence for teletrauma, and challenges and barriers related to telemedicine.

Feasibility of a Mobile Cognitive Intervention in Childhood Absence Epilepsy

Children with childhood absence epilepsy (CAE) frequently present with cognitive comorbidities and school performance concerns. The present study evaluated the feasibility of an intervention for such comorbidities using a mobile cognitive therapy application on an iPad. Eight children with CAE and school concerns aged 7–11 participated in a 4-week intervention. They were asked to use the application for 80 min per week (20 min/day, 4 times/week). Parents and children completed satisfaction surveys regarding the application. Participants were evaluated before and after the intervention using the Cognitive Domain of the NIH Toolbox and by parental completion of the Behavioral Rating Inventory of Executive Function. All eight patients completed the study, using the iPad for an average of 78 min/week. Children and parents reported high satisfaction with the application. Though a demonstration of efficacy was not the focus of the study, performance improvements were noted on a processing speed task and on a measure of fluid intelligence. An iPad based cognitive therapy was found to be a feasible intervention for children with CAE.

A randomized problem-solving trial for adolescent brain injury: Changes in social competence

PURPOSE/OBJECTIVE

Traumatic brain injury (TBI) in adolescence has well documented effects on social competence. Few studies have examined the effects of behavioral interventions on social competence or identified factors associated with changes in social competence after injury. Research Method/Design: Adolescents with moderate to severe TBI ages 12-17 years were randomized within 6 months of injury to either a problem solving and communication (CAPS) group that received online counseling (n = 65) or an Internet resources comparison (IRC) group (n = 67) for a comparative effectiveness trial. Parent-report measures of social competence (Child Behavior Checklist, CBCL; Home and Community Social Behavior Scales, HCSBS; Behavioral and Emotional Rating Scale, BERS-2) were administered at baseline (preintervention) and approximately 6 months later. Analyses examined these measures in relation to treatment group, TBI severity, and age. Regression analyses were also conducted to examine baseline measures of cognition as predictors of social competence after TBI.

RESULTS

CAPS had a more positive effect than the comparison condition on the HCSBS and BERS-2 for younger teens with moderate TBI and older teens with severe TBI. More parent-rated executive dysfunction at baseline was related to both lower concurrent levels of social competence and less positive gains in competence over time, whereas higher baseline IQ predicted greater gains in competence.

CONCLUSIONS/IMPLICATIONS

CAPS may be effective for improving social competence for teens after TBI, with benefits dependent on the teen's age and injury severity. Parent-rated executive dysfunction, moreover, has utility in predicting both lower concurrent levels of social competence and subsequent postinjury gains in competence. (PsycINFO Database Record

[Monitoring intracranial pressure in severe traumatic brain injury]

INTRODUCTION

Severe traumatic brain injury (TBI) is a serious condition. Intracranial pressure (ICP) monitoring can be used to direct treatment, which is of limited access in developing countries.

OBJECTIVE

To describe the clinical experience of pediatric patients with severe TBI.

PATIENTS AND METHOD

A clinical experience in patients with severe TBI was conducted. Age was 1-17 years, exclusion criteria were chronic illness and psicomotor retardation. Informed consent was obtained in each case. Two groups were formed based on the criterion of neurosurgeons: with and without intracraneal pressure (ICP) monitoring. PIC monitoring was performed through a 3PN Spiegelberg catheter and a Spiegelberg HDM 26 monitor. Patients were treated according international pediatric guides. The characteristics of both groups are described at 6 months of follow-up.

RESULTS

Forty-two patients (CM=14 and SM=28). Those in the CM Group had lower Glasgow coma scale score and Marshall classification with poorer prognosis. Among them survival rate was lower, although the outcome was from moderate to good. No complications were reported with the use of the ICP catheter.

CONCLUSION

Patients with ICP monitoring had greater severity at admission and an increased mortality; however, the outcome for the survivors was from moderate to good. It is necessary to conduct randomized clinical trials to define the impact of ICP monitoring on survival and quality of life in severe TBI patients.

Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status

OBJECTIVE

The objective of this study was to explore associations between English proficiency, insurance status, outpatient rehabilitation service availability, and travel time for children with traumatic brain injury.

DESIGN

The authors used an ecologic cross-sectional design. Data were analyzed from a cohort of 82 children with moderate to severe traumatic brain injury and rehabilitation providers in Washington State. Main measures included availability and travel time to services.

RESULTS

Less than 20% of providers accepted children with Medicaid and provided language interpretation. Mental health services were most limited. Adjusted for median household income, multilingual service availability was lowest in counties with greater language diversity; for every 10% increase in persons older than 5 yrs speaking a language other than English at home, there was a 34% decrease in availability of multilingual services (prevalence ratio, 0.66; 95% confidence interval, 0.48-0.90). Adjusted for education and Medicaid status, children from Spanish-speaking families had significantly longer travel times to services (mean, 16 additional minutes to mental health; 9 to other therapies).

CONCLUSIONS

Children in households with limited English proficiency and Medicaid faced significant barriers in availability and proximity of outpatient rehabilitation services. Innovative service strategies are needed to equitably improve availability of rehabilitation for children with traumatic brain injury. Similar studies in other regions will inform one's understanding of the scope of these disparities.

Technological aids for the rehabilitation of memory and executive functioning in children and adolescents with acquired brain injury

BACKGROUND

The use of technology in healthcare settings is on the increase and may represent a cost-effective means of delivering rehabilitation. Reductions in treatment time, and delivery in the home, are also thought to be benefits of this approach. Children and adolescents with brain injury often experience deficits in memory and executive functioning that can negatively affect their school work, social lives, and future occupations. Effective interventions that can be delivered at home, without the need for high-cost clinical involvement, could provide a means to address a current lack of provision.We have systematically reviewed studies examining the effects of technology-based interventions for the rehabilitation of deficits in memory and executive functioning in children and adolescents with acquired brain injury.

OBJECTIVES

To assess the effects of technology-based interventions compared to placebo intervention, no treatment, or other types of intervention, on the executive functioning and memory of children and adolescents with acquired brain injury.

SEARCH METHODS

We ran the search on the 30 September 2015. We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic + EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), CINAHL Plus (EBSCO), two other databases, and clinical trials registers. We also searched the internet, screened reference lists, and contacted authors of included studies.

SELECTION CRITERIA

Randomised controlled trials comparing the use of a technological aid for the rehabilitation of children and adolescents with memory or executive-functioning deficits with placebo, no treatment, or another intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles and abstracts identified by the search strategy. Following retrieval of full-text manuscripts, two review authors independently performed data extraction and assessed the risk of bias.

MAIN RESULTS

Four studies (involving 206 participants) met the inclusion criteria for this review.Three studies, involving 194 participants, assessed the effects of online interventions to target executive functioning (that is monitoring and changing behaviour, problem solving, planning, etc.). These studies, which were all conducted by the same research team, compared online interventions against a 'placebo' (participants were given internet resources on brain injury). The interventions were delivered in the family home with additional support or training, or both, from a psychologist or doctoral student. The fourth study investigated the use of a computer program to target memory in addition to components of executive functioning (that is attention, organisation, and problem solving). No information on the study setting was provided, however a speech-language pathologist, teacher, or occupational therapist accompanied participants.Two studies assessed adolescents and young adults with mild to severe traumatic brain injury (TBI), while the remaining two studies assessed children and adolescents with moderate to severe TBI. Risk of biasWe assessed the risk of selection bias as low for three studies and unclear for one study. Allocation bias was high in two studies, unclear in one study, and low in one study. Only one study (n = 120) was able to conceal allocation from participants, therefore overall selection bias was assessed as high.One study took steps to conceal assessors from allocation (low risk of detection bias), while the other three did not do so (high risk of detection bias). Primary outcome 1: Executive functioning: Technology-based intervention versus placeboResults from meta-analysis of three studies (n = 194) comparing online interventions with a placebo for children and adolescents with TBI, favoured the intervention immediately post-treatment (standardised mean difference (SMD) -0.37, 95% confidence interval (CI) -0.66 to -0.09; P = 0.62; I(2) = 0%). (As there is no 'gold standard' measure in the field, we have not translated the SMD back to any particular scale.) This result is thought to represent only a small to medium effect size (using Cohen's rule of thumb, where 0.2 is a small effect, 0.5 a medium one, and 0.8 or above is a large effect); this is unlikely to have a clinically important effect on the participant.The fourth study (n = 12) reported differences between the intervention and control groups on problem solving (an important component of executive functioning). No means or standard deviations were presented for this outcome, therefore an effect size could not be calculated.The quality of evidence for this outcome according to GRADE was very low. This means future research is highly likely to change the estimate of effect. Primary outcome 2: MemoryOne small study (n = 12) reported a statistically significant difference in improvement in sentence recall between the intervention and control group following an eight-week remediation programme. No means or standard deviations were presented for this outcome, therefore an effect size could not be calculated. Secondary outcomesTwo studies (n = 158) reported on anxiety/depression as measured by the Child Behavior Checklist (CBCL) and were included in a meta-analysis. We found no evidence of an effect with the intervention (mean difference -5.59, 95% CI -11.46 to 0.28; I(2) = 53%). The GRADE quality of evidence for this outcome was very low, meaning future research is likely to change the estimate of effect.A single study sought to record adverse events and reported none. Two studies reported on use of the intervention (range 0 to 13 and 1 to 24 sessions). One study reported on social functioning/social competence and found no effect. The included studies reported no data for other secondary outcomes (that is quality of life and academic achievement).

AUTHORS' CONCLUSIONS

This review provides low-quality evidence for the use of technology-based interventions in the rehabilitation of executive functions and memory for children and adolescents with TBI. As all of the included studies contained relatively small numbers of participants (12 to 120), our findings should be interpreted with caution. The involvement of a clinician or therapist, rather than use of the technology, may have led to the success of these interventions. Future research should seek to replicate these findings with larger samples, in other regions, using ecologically valid outcome measures, and reduced clinician involvement.

Costs of Development and Maintenance of an Internet Program for Teens with Type 1 Diabetes

Many adolescents with type 1 diabetes (T1D) have difficulty completing self-management tasks within the context of their social environments. Group-based approaches to psycho-educational support have been shown to prevent declines in glucose control, but are challenging to implement due to youths' many activities and costs. A novel solution is providing psycho-educational support via the internet. The purpose of this study is to describe the cost of developing and maintaining two internet psycho-educational programs, both of which have been shown to improve health outcomes in adolescents with T1D. We calculated actual costs of personnel and programming in the development of TEENCOPE^™ and Managing Diabetes, two highly interactive programs that were evaluated in a multi-site clinical trial (n=320). Cost calculations were set at U.S. dollars and converted to value for 2013 as expenses were incurred over 6 years. Development costs over 1.5 years totaled $324,609, with the majority of costs being for personnel to develop and write content in a creative and engaging format, to get feedback from teens on content and a prototype, and IT programming. Maintenance of the program, including IT support, a part-time moderator to assure safety of the discussion board (0.5-1 hour/week), and yearly update of content was $43,845/year, or $137.00 per youth over 4.5 years. Overall, program and site development were relatively expensive, but the program reach was high, including non-white youth from 4 geographically distinct regions. Once developed, maintenance was minimal. With greater dissemination, cost-per-youth would decrease markedly, beginning to offset the high development expense.

Psychological interventions for parents of children and adolescents with chronic illness

BACKGROUND

Psychological therapies have been developed for parents of children and adolescents with a chronic illness. Such therapies include interventions directed at the parent only or at parent and child/adolescent, and are designed to improve parent, child, and family outcomes. This is an updated version of the original Cochrane review published in Issue 8, 2012, (Psychological interventions for parents of children and adolescents with chronic illness).

OBJECTIVES

To evaluate the efficacy of psychological therapies that include parents of children and adolescents with chronic illnesses including painful conditions, cancer, diabetes mellitus, asthma, traumatic brain injury (TBI), inflammatory bowel diseases (IBD), skin diseases, or gynaecological disorders. We also aimed to evaluate the adverse events related to implementation of psychological therapies for this population. Secondly, we aimed to evaluate the risk of bias of included studies and the quality of outcomes using the GRADE assessment.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO for randomised controlled trials (RCTs) of psychological interventions that included parents of children and adolescents with a chronic illness. Databases were searched to July 2014.

SELECTION CRITERIA

Included studies were RCTs of psychological interventions that delivered treatment to parents of children and adolescents with a chronic illness compared to an active control, waiting list, or treatment as usual control group.

DATA COLLECTION AND ANALYSIS

Study characteristics and outcomes were extracted from included studies. We analysed data using two categories. First, we analysed data by each individual medical condition collapsing across all treatment classes at two time points. Second, we analysed data by each individual treatment class; cognitive behavioural therapy (CBT), family therapy (FT), problem solving therapy (PST) and multisystemic therapy (MST) collapsing across all medical conditions. For both sets of analyses we looked immediately post-treatment and at the first available follow-up. We assessed treatment effectiveness for two primary outcomes: parent behaviour and parent mental health. Five secondary outcomes were extracted; child behaviour/disability, child mental health, child symptoms, family functioning, and adverse events. Risk of bias and quality of evidence were assessed.

MAIN RESULTS

Thirteen studies were added in this update, giving a total of 47 RCTs. The total number of participants included in the data analyses was 2985, 804 of whom were added to the analyses in the update. The mean age of the children was 14.6 years. Of the 47 RCTs, the studies focused on the following paediatric conditions: n = 14 painful conditions, n = 13 diabetes, n =10 cancer, n = 5 asthma, n = 4 TBI, and n = 1 atopic eczema. We did not identify any studies treating parents of children with gynaecological disorders or IBD. Risk of bias assessments of included studies were predominantly unclear. Evidence quality, assessed using the GRADE criteria, was judged to be of low or very low quality.Analyses of separate medical conditions, across all treatment types, revealed two beneficial effects of psychological therapies for our primary outcomes. First, psychological therapies led to improved adaptive parenting behaviour in parents of children with cancer post-treatment (standardised mean difference (SMD) -0.20, 95% confidence interval (CI) -0.36 to -0.04, Z = 2.44, p = 0.01). In addition, therapies also improved parent mental health at follow-up in this group (SMD = -0.18, 95% CI -0.32 to -0.04, Z = 2.58, p = 0.01). We did not find any effect of therapies for parent behaviour for parents of children with a painful condition post-treatment or at follow-up, or for parent mental health for parents of children with cancer, diabetes, asthma, or TBI post-treatment. For all other primary outcomes, no analysis could be conducted due to lack of data.Across all medical conditions, three effects were found for the primary outcomes of psychological therapies. PST had a beneficial effect on parent adaptive behaviour (SMD = -0.25, 95% CI -0.39 to -0.11, Z = 3.59, p < 0.01) and parent mental health (SMD= -0.24, 95% CI -0.42 to -0.05, Z = 2.50, p = 0.01) immediately post-treatment and this effect was maintained at follow-up for parent mental health (SMD= -0.19, 95% CI -0.34 to -0.04, Z = 2.55, p = 0.01). The remaining analysis for PST on parent behaviour found no effect. No effects were found for CBT post-treatment or at follow-up for either parent outcome. For FT, only one analysis could be run on parent mental health and no effect was found. Due to lack of data, the remaining analyses of primary outcomes could not be run. For MST, no parent outcomes could be analysed due to lack of data.Secondary outcome analyses are presented in the Results section. Five studies reported that there were no adverse events during the trial. The remaining 42 studies did not report adverse events.

AUTHORS' CONCLUSIONS

This update includes 13 additional studies, although our conclusions have not changed from the original version. There is little evidence for the efficacy of psychological therapies that include parents on most outcome domains of functioning, for a large number of common chronic illnesses in children. However, psychological therapies are efficacious for some outcomes. CBT that includes parents is beneficial for reducing children's primary symptoms, and PST that includes parents improved parent adaptive behaviour and parent mental health. There is evidence that the beneficial effects can be maintained at follow-up for diabetes-related symptoms in children, and for the mental health of parents of children with cancer and parents who received PST.

Online problem-solving therapy after traumatic brain injury: a randomized controlled trial

BACKGROUND

Pediatric traumatic brain injury (TBI) contributes to impairments in functioning in everyday settings. Evidence suggests that online family problem-solving therapy (FPST) may be effective in reducing adolescent behavioral morbidity. This article examines the efficacy of Counselor-Assisted Problem Solving (CAPS), a form of online FPST in improving long-term functional outcomes of adolescents with TBI relative to Internet resources only.

METHODS

Children, aged 12 to 17 years, who were hospitalized in the previous 7 months for TBI were enrolled in a multisite, assessor-blinded randomized controlled trial. Consented participants were randomly assigned to CAPS or an Internet resource comparison (IRC) condition. Outcomes were assessed at baseline and at follow-ups 6, 12, and 18 months postbaseline. The Child and Functional Assessment Scale and the Iowa Family Interaction Rating Scale (IFIRS) served as primary outcomes of child and family functioning respectively.

RESULTS

For the Child and Functional Assessment Scale total, we found a significant group × time interaction, with less impaired functioning for the CAPS group than for the IRC group at the final follow-up. Parent education moderated the efficacy of CAPS on overall rates of impairment and school/work functioning, with the advantage of CAPS over IRC evident at the final follow-up only for participants with less-educated parents. Neither group differences nor group × time interactions were found for the IFIRS.

CONCLUSIONS

Relatively brief, online treatment shortly after injury may result in long-term improvements in child functioning, particularly among families of lower socioeconomic status. Clinical implementation of CAPS during the initial months postinjury should be considered.

Personality Change Due to Traumatic Brain Injury in Children and Adolescents: Neurocognitive Correlates

Personality change due to traumatic brain injury (PC) in children is an important psychiatric complication of injury and is a form of severe affective dysregulation. This study aimed to examine neurocognitive correlates of PC. The sample included 177 children 5-14 years old with traumatic brain injury who were enrolled from consecutive admissions to five trauma centers. Patients were followed up prospectively at baseline and at 6 months, and they were assessed with semistructured psychiatric interviews. Injury severity, socioeconomic status, and neurocognitive function (measures of attention, processing speed, verbal memory, IQ, verbal working memory, executive function, naming/reading, expressive language, motor speed, and motor inhibition) were assessed with standardized instruments. Unremitted PC was present in 26 (18%) of 141 participants assessed at 6 months postinjury. Attention, processing speed, verbal memory, IQ, and executive function were significantly associated with PC even after socioeconomic status, injury severity, and preinjury attention deficit hyperactivity disorder were controlled. These findings are a first step in characterizing concomitant cognitive impairments associated with PC. The results have implications beyond brain injury to potentially elucidate the neurocognitive symptom complex associated with mood instability regardless of etiology.

Effects of a Web-Based Intervention on Family Functioning Following Pediatric Traumatic Brain Injury

OBJECTIVE

Investigate effectiveness of an online Counselor-Assisted Problem-Solving (CAPS) intervention on family functioning after traumatic brain injury.

METHODS

Participants were randomized to CAPS (n = 65) or Internet resource comparison (IRC; n = 67). CAPS is a counselor-assisted web-based program. IRC was given access to online resources. Outcomes were examined at 6, 12, and 18 months after baseline. Injury severity, age, and socioeconomic status were examined as moderators.

RESULTS

A main effect of time was noted for teen-reported conflict and parent-reported problem solving. CAPS had decreased parent-reported conflict and a reduction in parental effective communication. Effects were specific to subsets of the sample.

CONCLUSION

CAPS, a family-based problem-solving intervention designed to address problem behaviors, had modest effects on some aspects of family functioning compared with IRC. Effects were generally limited to subsets of the families and were not evident across all follow-up assessments.