Association of parent ratings of executive function with global- and setting-specific behavioral impairment after adolescent traumatic brain injury

Delineating the impact of childhood traumatic brain injury (TBI) on long-term depressive symptom severity: Does sub-acute brain morphometry prospectively predict 2-year outcome?

Despite evidence of a link between childhood TBI and heightened risk for depressive symptoms, very few studies have examined early risk factors that predict the presence and severity of post-injury depression beyond 1-year post injury. This longitudinal prospective study examined the effect of mild-severe childhood TBI on depressive symptom severity at 2-years post-injury. It also evaluated the potential role of sub-acute brain morphometry and executive function (EF) in prospectively predicting these long-term outcomes. The study involved 81 children and adolescents with TBI, and 40 age-and-sex matched typically developing (TD) controls. Participants underwent high-resolution structural magnetic resonance imaging (MRI) sub-acutely at five weeks post-injury (M = 5.55; SD = 3.05 weeks) and EF assessments were completed at 6-months post-injury. Compared to TD controls, the TBI group had significantly higher overall internalizing symptoms and were significantly more likely to exhibit clinically significant depressive symptoms at 2-year follow-up. The TBI group also displayed significantly lower EF and altered sub-acute brain morphometry in EF-related brain networks, including the default-mode network (DMN), salience network (SN) and central executive network (CEN). Mediation analyses revealed significant indirect effects of CEN morphometry on depression symptom severity, such that lower EF mediated the prospective association between altered CEN morphometry and higher depression symptoms in the TBI group. Parallel mediation analyses including grey matter morphometry of a non-EF brain network (i.e., the mentalising network) were not statistically significant, suggesting some model specificity. The findings indicate that screening for early neurostructural and neurocognitive risk factors may help identify children at elevated risk of depressive symptoms following TBI. For instance, children at greatest risk of post-injury depression symptoms could be identified based in part on neuroimaging of networks implicated in EF and post-acute assessments of executive function, which could support more effective allocation of limited intervention resources.

Processing Speed in Children with Traumatic Brain Injury

Abstract: Traumatic brain injury (TBI) is a common cause of childhood morbidity and mortality. Information processing speed (IPS) is a central construct of neuropsychology and a mediator for a range of cognitive functions. In adults, the negative effects of TBI on IPS are well documented. This review qualitatively describes the impact of TBI on IPS in children and adolescents and examines various influencing factors. We included a total of 37 studies in the review that explored IPS using various clinical assessments. These clinical assessments often examine other neuropsychological functions besides IPS. In 29 of these studies, we found a negative effect of TBI on IPS. While injury severity has small but consistent effects on IPS, the effects of age at injury, time since injury, and gender were less evident. Because it is a central construct of neuropsychological functions, IPS should be assessed after TBI.

More to the story than executive function: Effortful control soon after injury predicts long-term functional and social outcomes following pediatric traumatic brain injury in young children

OBJECTIVE

To examine the impact of early traumatic brain injury (TBI) on effortful control (EC) over time and the relationship of EC and executive functioning (EF) to long-term functional and social outcomes.

METHOD

Parents of children (N = 206, ages 3-7) with moderate-to-severe TBI or orthopedic injuries (OIs) rated EC using the Child Behavior Questionnaire at 1 (pre-injury), 6, 12, and 18 months post-injury. Child functioning and social competence were assessed at 7 years post-injury. Mixed models examined the effects of injury, time since injury, and their interaction on EC. General linear models examined the associations of pre-injury EC and EC at 18 months with long-term functional and social outcomes. Models controlled for EF to assess the unique contribution of EC to outcomes.

RESULTS

Children with severe TBI had significantly lower EC than both the OI and moderate TBI groups at each post-injury time point. Both pre-injury and 18-month EC were associated with long-term outcomes. Among those with low EC at baseline, children with moderate and severe TBI had more functional impairment than those with OI; however, no group differences were noted at high levels of EC. EC had main effects on parent-reported social competence that did not vary by injury type.

CONCLUSIONS

Findings suggest that EC is sensitive to TBI effects and is a unique predictor of functional outcomes, independent of EF. High EC could serve as a protective factor, and as such measures of EC could be used to identify children for more intensive intervention.

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.

Behavior Problems Following Childhood TBI: The Role of Sex, Age, and Time Since Injury

OBJECTIVE

To examine the frequency of behavioral problems after childhood traumatic brain injury (TBI) and their associations with injury severity, sex, and social environmental factors.

SETTING

Children's hospitals in the Midwestern/Western United States.

PARTICIPANTS

381 boys and 210 girls with moderate (n = 359) and severe (n = 227) TBI, with an average age at injury of 11.7 years (range 0.3-18) who were injured ≤3 years ago.

DESIGN

Secondary data analysis of a multistudy cohort.

MAIN MEASURES

Child Behavior Checklist (CBCL) administered pretreatment.

RESULTS

Thirty-seven percent had borderline/clinical elevations on the CBCL Total Problem Scale, with comparable rates of Internalizing and Externalizing problems (33% and 31%, respectively). Less parental education was associated with higher rates of internalizing, externalizing, and total problems. Time since injury had a linear association with internalizing symptoms, with greater symptoms at longer postinjury intervals. Younger boys had significantly higher levels of oppositional defiant symptoms than girls, whereas older girls had significantly greater attention-deficit hyperactivity disorder symptoms than boys.

CONCLUSIONS

Pediatric TBI is associated with high rates of behavior problems, with lower socioeconomic status predicting substantially elevated risk. Associations of higher levels of internalizing symptoms with greater time since injury highlight the importance of tracking children over time.

Cognitive Dysfunction After Analgesia and Sedation: Out of the Operating Room and Into the Pediatric Intensive Care Unit

In the midst of concerns for potential neurodevelopmental effects after surgical anesthesia, there is a growing awareness that children who require sedation during critical illness are susceptible to neurologic dysfunctions collectively termed pediatric post-intensive care syndrome, or PICS-p. In contrast to healthy children undergoing elective surgery, critically ill children are subject to inordinate neurologic stress or injury and need to be considered separately. Despite recognition of PICS-p, inconsistency in techniques and timing of post-discharge assessments continues to be a significant barrier to understanding the specific role of sedation in later cognitive dysfunction. Nonetheless, available pediatric studies that account for analgesia and sedation consistently identify sedative and opioid analgesic exposures as risk factors for both in-hospital delirium and post-discharge neurologic sequelae. Clinical observations are supported by animal models showing neuroinflammation, increased neuronal death, dysmyelination, and altered synaptic plasticity and neurotransmission. Additionally, intensive care sedation also contributes to sleep disruption, an important and overlooked variable during acute illness and post-discharge recovery. Because analgesia and sedation are potentially modifiable, understanding the underlying mechanisms could transform sedation strategies to improve outcomes. To move the needle on this, prospective clinical studies would benefit from cohesion with regard to datasets and core outcome assessments, including sleep quality. Analyses should also account for the wide range of diagnoses, heterogeneity of this population, and the dynamic nature of neurodevelopment in age cohorts. Much of the related preclinical evidence has been studied in comparatively brief anesthetic exposures in healthy animals during infancy and is not generalizable to critically ill children. Thus, complementary animal models that more accurately "reverse translate" critical illness paradigms and the effect of analgesia and sedation on neuropathology and functional outcomes are needed. This review explores the interactive role of sedatives and the neurologic vulnerability of critically ill children as it pertains to survivorship and functional outcomes, which is the next frontier in pediatric intensive care.

A Systematic Review of Cognitive Functioning After Traumatic Brain Injury in Individuals Aged 10-30 Years

Given the importance of the period of life from 10 to 30 years in terms of cognitive development and education, combined with the high incidence of traumatic brain injury (TBI) during this period, and limited consensus as to the pattern and degree of cognitive impairment post TBI during this period, we conducted a systematic review to investigate cognitive performance across a range of domains among individuals between the ages of 10 and 30 years who had sustained a TBI. We searched five databases and identified 799 unique records; 52 met our inclusion criteria. These studies reported cognitive function for intelligence, attention, memory, processing speed, and executive function. The majority of the studies reported significant effects, suggesting that TBI is associated with cognitive impairments in these domains. Nine of the studies used physiological tests (EEG and fMRI), the outcomes of which supported behaviorally demonstrated cognitive deficits. In the studies we reviewed, individuals aged 10-30 years who had experienced a TBI performed worse than healthy controls on cognitive function measures-specifically for attention, memory, processing speed, and executive function. In the studies that subjected the individuals with TBI to EEG and fMRI, atypical activation in associated brain regions was demonstrated while the individuals were undergoing cognitive tasks. However, caution should be taken when interpreting the overall results due to the high risk of bias across the majority of the studies. The broader implications of reduced cognitive performance after TBI across this age range are yet to be fully understood.

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.

Is diffuse axonal injury on susceptibility weighted imaging a biomarker for executive functioning in adolescents with traumatic brain injury?

Traumatic brain injury (TBI) is a heterogeneous disorder in which diffuse axonal injury (DAI) is an important component contributing to executive dysfunction. During adolescence, developing brain networks are especially vulnerable to acceleration-deceleration forces. We aimed to examine the correlation between DAI (number and localization) and executive functioning in adolescents with TBI. We recruited 18 adolescents with a mean age of 15y8m (SD = 1y7m), averaging 2.5 years after sustaining a moderate-to-severe TBI with documented DAI. Susceptibility Weighted Imaging sequence was administered to localize the DAI lesions. The adolescents performed a neurocognitive test-battery, addressing different aspects of executive functioning (working memory, attention, processing speed, planning ability) and their parents completed the Behavior Rating Inventory of Executive Function (BRIEF) - questionnaire. Executive performance of the TBI-group was compared with an age and gender matched control group of typically developing peers. Based on these results we focused on the Stockings of Cambridge test and the BRIEF to correlate with the total number and location of DAI. Results revealed that the anatomical distribution of DAI, especially in the corpus callosum and the deep brain nuclei, may have more implications for executive functioning than the total amount of DAI in adolescents. Results of this study may help guide targeted rehabilitation to redirect the disturbed development of executive function in adolescents with TBI.

Exploration of gray matter correlates of cognitive training benefit in adolescents with chronic traumatic brain injury

Sustaining a traumatic brain injury (TBI) during adolescence has a profound effect on brain development and can result in persistent executive functioning deficits in daily life. Cognitive recovery from pediatric-TBI relies on the potential of neuroplasticity, which can be fostered by restorative training-programs. However the structural mechanisms underlying cognitive recovery in the immature brain are poorly understood. This study investigated gray matter plasticity following 2 months of cognitive training in young patients with TBI. Sixteen adolescents in the chronic stage of moderate-severe-TBI (9 male, mean age = 15y8m ± 1y7m) were enrolled in a cognitive computerized training program for 8 weeks (5 times/week, 40 min/session). Pre-and post-intervention, and 6 months after completion of the training, participants underwent a comprehensive neurocognitive test-battery and anatomical Magnetic Resonance Imaging scans. We selected 9 cortical-subcortical Regions-Of-Interest associated with Executive Functioning (EF-ROIs) and 3 control regions from the Desikan-Killiany atlas. Baseline analyses showed significant decreased gray matter density in the superior frontal gyri p = 0.033, superior parietal gyri p = 0.015 and thalamus p = 0.006 in adolescents with TBI compared to age and gender matched controls. Linear mixed model analyses of longitudinal volumetric data of the EF-ROI revealed no strong evidence of training-related changes in the group with TBI. However, compared to the change over time in the control regions between post-intervention and 6 months follow-up, the change in the EF-ROIs showed a significant difference. Exploratory analyses revealed a negative correlation between the change on the Digit Symbol Substitution test and the change in volume of the putamen (r = −0.596, p = 0.015). This preliminary study contributes to the insights of training-related plasticity mechanisms after pediatric-TBI.

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Longitudinal data on cortical – subcortical volume before and after training.

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Post-training significant difference in change between ROI and control regions.

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Post-training significant correlation Digit Symbol Substitution test and putamen.

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Theory of an impaired capacity of plasticity in an immature traumatized brain.

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Exploring plasticity is essential to provide foundation for rehab interventions.

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

Executive function after severe childhood traumatic brain injury - Age-at-injury vulnerability periods: The TGE prospective longitudinal study

BACKGROUND

Executive function (EF) impairment is a major predictor of overall outcome after traumatic brain injury (TBI). TBI severity is a factor of poor outcome, but most studies include a majority of children with mild and moderate TBI. The aims of this study were to estimate EF impairment after severe childhood TBI and to explore factors predicting EF outcome. The secondary aim was to compare recovery trajectories by age-at-injury groups.

METHODS

This was a prospective longitudinal study of children with severe TBI who were tested for EFs by performance-based tests and questionnaires at 3, 12 and 24 months.

RESULTS

Children with TBI (n=65) showed significant impairment in working memory, inhibition, attention and global EF, with little or no recovery at 24 months. For flexibility and performance-based EF score, children were impaired at 3 months only and showed normal scores by 12 months. No impairment was found in planning. At 3 and 24 months, Glasgow Coma Scale score and parental education predicted global EF. Coma length was not a significant predictor of outcome. Age at injury predicted progress in EF, but the relationship was not linear; children 10-12 years old at injury showed better outcome than older and younger children.

CONCLUSIONS

EFs are impaired after severe TBI in childhood. The relationship between age at injury and outcome is not linear. Relying on only performance-based EF tests can underestimate EF impairment.

Adaptive functioning following pediatric traumatic brain injury: Relationship to executive function and processing speed

OBJECTIVE

Pediatric traumatic brain injury (TBI) may affect children's ability to perform everyday tasks (i.e., adaptive functioning). Guided by the American Association for Intellectual and Developmental Disabilities (AAIDD) model, we explored the association between TBI and adaptive functioning at increasing levels of specificity (global, AAIDD domains, and subscales). We also examined the contributions of executive function and processing speed as mediators of TBI's effects on adaptive functioning.

METHOD

Children (ages 8-13) with severe TBI (STBI; n = 19), mild-moderate TBI (MTBI; n = 50), or orthopedic injury (OI; n = 60) completed measures of executive function (TEA-Ch) and processing speed (WISC-IV) an average of 2.7 years postinjury (SD = 1.2; range: 1-5.3). Parents rated children's adaptive functioning (ABAS-II, BASC-2, CASP).

RESULTS

STBI had lower global adaptive functioning (η2 = .04-.08) than the MTBI and OI groups, which typically did not differ. Deficits in the STBI group were particularly evident in the social domain, with specific deficits in social participation, leisure, and social adjustment (η2 = .06-.09). Jointly, executive function and processing speed were mediators of STBI's effects on global adaptive functioning and in conceptual and social domains. In the STBI group, executive function mediated social functioning, and processing speed mediated social participation.

CONCLUSIONS

Children with STBI experience deficits in adaptive functioning, particularly in social adjustment, with less pronounced deficits in conceptual and practical skills. Executive function and processing speed may mediate the effects of STBI on adaptive functioning. Targeting adaptive functioning and associated cognitive deficits for intervention may enhance quality of life for pediatric TBI survivors. (PsycINFO Database Record

Long-Term Neuropsychological Profiles and Their Role as Mediators of Adaptive Functioning after Traumatic Brain Injury in Early Childhood

The objectives of the study were to characterize long-term neuropsychological outcomes following traumatic brain injury (TBI) sustained during early childhood, and determine whether identified neuropsychological impairments mediated the effect of TBI on long-term adaptive functioning. Participants included 16 children with severe TBI, 42 children with moderate TBI, and 72 children with orthopedic injuries (OI) sustained between ages 3 and 7 years. Children completed neuropsychological tests and caregivers completed a structured interview of child adaptive functioning at 6.9 (±1.10) years post-injury. Profile analysis and multiple mediator modeling were employed. Children with severe TBI demonstrated poorer fluid reasoning and inhibitory control than both children with moderate TBI and OI, as well as slower processing speed than the OI group. Both fluid reasoning and processing speed were significant independent mediators of the effect of severe TBI on adaptive functioning. No neuropsychological measure significantly mediated the effect of moderate TBI on adaptive functioning. Children sustaining early severe TBI demonstrate persisting neuropsychological impairments into adolescence and young adulthood. The impact of severe TBI on children's long-term adaptive functioning is mediated in part by its effects on fluid reasoning and processing speed.

Poor organisational strategy differentiates cognitively impaired and unimpaired HIV-positive adults

Many HIV-positive individuals manifest symptoms indicative of central nervous system injury. Frequently, those symptoms include cognitive impairment in domains supported by cortical and/or subcortical processing (e.g., executive functioning). The present study investigated one aspect of executive functioning, namely, organisational strategy (i.e., the strategy a person uses when attempting to complete a complex task efficiently). The Rey Complex Figure Test was administered to a group of HIV-positive individuals ( n = 63) and a matched group of HIV-negative individuals ( n = 63). Organisational strategy in completing the task was measured using the Rey Complex Figure Organizational Strategy Score system, which is a quantitative capture of the quality of the approach taken to the task. There were no significant between-group differences in Rey Complex Figure Organizational Strategy Scores, but within the HIV-positive group, increased level of overall cognitive impairment was associated with increasingly poor organisational strategy. These findings suggest that assessment of organisational strategy (and, more generally, assessment of executive functioning) in completing complex tasks may be a valuable component of neuropsychological batteries that attempt to describe the degree of cognitive impairment (and, by implication, the extent of functional impairment) experienced by people living with HIV.

Executive functions and theory of mind as predictors of social adjustment in childhood traumatic brain injury

This study examined whether executive function and theory of mind mediate the effects of pediatric traumatic brain injury (TBI) on social adjustment, relative to children with orthopedic injury (OI). Participants included 19 children with severe TBI, 41 children with complicated mild/moderate TBI, and 57 children with OI. They completed measures of executive function, as well as cognitive, affective, and conative theory of mind. Parents provided ratings of children's social adjustment. Children with severe TBI performed more poorly than children with OI on executive function and theory of mind tasks and were rated by parents as having more behavioral symptoms and worse communication and social skills. Executive function and theory of mind were positively correlated with social skills and communication skills, and negatively correlated with behavioral symptoms. In multiple mediator models, theory of mind and executive function were not significant direct predictors of any measure of social adjustment, but mediated the association between injury and adjustment for children with severe TBI. Theory of mind was a significant independent mediator when predicting social skills, but executive function was not. TBI in children, particularly severe injury, is associated with poor social adjustment. The impact of TBI on children's social adjustment is likely mediated by its effects on executive function and theory of mind.

Comparing memory and meta-memory abilities between children with acquired brain injury and healthy peers

This study compared visual memory and meta-memory abilities of children with ABI to that of healthy peers. Participants included 16 children (aged 13.55 ± 3.29 years) with moderate or severe ABI and 16 healthy children (aged 12.44 ± 3.24 years) with typical development. Children completed the Contextual Memory Test for Children (CMT-CH). The study group showed significantly lower immediate and delayed recall abilities. While the controls used the context for better memorizing, most of the children with ABI used rehearsals. In both groups better delayed recall correlated with the use of a more efficient strategy. Meta-memory should be an integral part of the assessment for children with ABI. Therapists should enhance child's self-awareness to his/her abilities and encourage the use of strategies (e.g. context) for memorizing in daily life.

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

IMPORTANCE

Executive dysfunction after traumatic brain injury (TBI) in children is common and leads to significant short- and long-term problems in functioning across multiple settings. We hypothesized that improvements in short-term executive function would be maintained to 24 months after injury and that improvements would increase over time in a counselor-assisted problem-solving (CAPS) intervention.

OBJECTIVE

To evaluate the efficacy of a CAPS intervention administered within 7 months of complicated mild to severe TBI compared with an Internet resource condition in improving long-term executive dysfunction.

DESIGN, SETTING, AND PARTICIPANTS

Multisite, assessor-blinded, randomized clinical trial at 3 tertiary pediatric hospitals and 2 tertiary general medical centers. Participants included 132 adolescents aged 12 to 17 years who sustained a moderate to severe TBI 1 to 7 months before study enrollment.

INTERVENTION

Web-based CAPS intervention.

MAIN OUTCOMES AND MEASURES

The primary outcome was the parent-reported Global Executive Composite (GEC) of the Behavior Rating Inventory of Executive Function. Secondary outcomes included the Behavioral Regulation Index (BRI) and Metacognition Index (MI) of the GEC.

RESULTS

In older (>14 to 17 years) adolescents, the CAPS intervention was associated with lower GEC ratings at 12 (β = -0.46; P = .03) and 18 (β = -0.52; P = .02) months after enrollment. Trends were also observed for older adolescents toward lower GEC ratings at 6 months (β = -0.40; P = .05), lower BRI ratings at 12 (β  = -0.40; P = .06) and 18 (β  = -0.47; P = .04) months, and lower MI ratings at 6 (β  = -0.41; P = .05), 12 (β  = -0.46; P = .03), and 18 (β  = -0.50; P = .03) months. In younger (12-14 years) adolescents, no group differences were found on the GEC, BRI, or MI ratings.

CONCLUSIONS AND RELEVANCE

Delivery of the CAPS intervention early after TBI in older adolescents improves long-term executive function. This trial is, to our knowledge, one of the few large, randomized clinical treatment trials performed in pediatric TBI to demonstrate the efficacy of an intervention for management of executive dysfunction and long-term benefits of an intervention delivered soon after injury. Use of the CAPS intervention clinically should be considered; however, further research should explore ways to optimize delivery.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00409448.

Evaluation of the short-term executive plus intervention for executive dysfunction after traumatic brain injury: a randomized controlled trial with minimization

OBJECTIVE

To determine whether the Short-Term Executive Plus (STEP) cognitive rehabilitation program improves executive dysfunction after traumatic brain injury (TBI).

DESIGN

Randomized, waitlist controlled trial with minimization and blinded outcome assessment.

SETTING

Community.

PARTICIPANTS

Participants with TBI and executive dysfunction (N=98; TBI severity 50% moderate/severe; mean time since injury ± SD, 12±14y; mean age ± SD, 45±14y; 62% women; 76% white).

INTERVENTION

STEP program: 12 weeks (9h/wk) of group training in problem solving and emotional regulation and individual sessions of attention and compensatory strategies training.

MAIN OUTCOME MEASURES

Factor analysis was used to create a composite executive function measure using the Problem Solving Inventory, Frontal Systems Behavior Scale, Behavioral Assessment of the Dysexecutive Syndrome, and Self-Awareness of Deficits Interview. Emotional regulation was assessed with the Difficulties in Emotion Regulation Scale. The primary attention measure was the Attention Rating and Monitoring Scale. Secondary measures included neuropsychological measures of executive function, attention, and memory and measures of affective distress, self-efficacy, social participation, and quality of life.

RESULTS

Intention-to-treat mixed-effects analyses revealed significant treatment effects for the composite executive function measure (P=.008) and the Frontal Systems Behavior Scale (P=.049) and Problem Solving Inventory (P=.016). We found no between-group differences on the neuropsychological measures or on measures of attention, emotional regulation, self-awareness, affective distress, self-efficacy, participation, or quality of life.

CONCLUSIONS

The STEP program is efficacious in improving self-reported post-TBI executive function and problem solving. Further research is needed to identify the roles of the different components of the intervention and its effectiveness with different TBI populations.

Behavioral predictors of outpatient mental health service utilization within 6 months after traumatic brain injury in adolescents

OBJECTIVES

To characterize utilization of mental health services and determine the ability of a behavior problem and clinical functioning assessment to predict utilization of such services within the first 6 months after moderate and severe traumatic brain injury in a large cohort of adolescents.

DESIGN

Multicenter cross-sectional study.

SETTING

Outpatient setting of 4 tertiary pediatric hospitals, 2 tertiary general medical centers, and 1 specialized children's hospital.

PARTICIPANTS

Adolescents age 12-17 years (n = 132), 1-6 months after moderate-to-severe traumatic brain injury.

METHODS

Logistic regression was used to determine the association of mental health service utilization with clinical functioning as assessed by the Child and Adolescent Functional Assessment Scale and behavior problems assessed by the Child Behavioral Checklist.

MAIN OUTCOME MEASUREMENT

Mental health service utilization measured by the Service Assessment for Children and Adolescents.

RESULTS

Behavioral or functional impairment occurred in 37%-56%. Of the total study population, 24.2% reported receiving outpatient mental health services, 8.3% reported receiving school services, and 28.8% reported receiving any type of mental health service. Use of any (school or outpatient) mental health service was associated with borderline to impaired total Child and Adolescent Functional Assessment Scale (odds ratio 3.50 [95% confidence interval, 1.46-8.40]; P < .01) and the Child Behavioral Checklist Total Competence (odds ratio 5.08 [95% confidence interval, 2.02-12.76]; P < .01).

CONCLUSIONS

A large proportion of participants had unmet mental health needs. Both the Child and Adolescent Functional Assessment Scale and the Child Behavioral Checklist identified individuals who would likely benefit from mental health services in outpatient or school settings. Future research should focus on methods to ensure early identification by health care providers of adolescents with traumatic brain injury in need of mental health services.