Neuropsychological benefits of computerized cognitive rehabilitation training in Ugandan children surviving severe malaria: A randomized controlled trial

Perceptions and behaviors of healthcare providers towards rehabilitation support to children with severe malaria-related disability in Ethiopia: A qualitative descriptive study using the Theoretical Domains Framework

INTRODUCTION

Severe malaria often results in childhood disability. The prevalence of disability related to severe malaria is significant and is estimated to affect up to 53% of severe malaria survivors. In contrast, information is sparse about how healthcare providers in Africa think about or provide rehabilitation support in acute and post-acute phases respectively. Understanding the perceptions and behaviors of healthcare providers treating malaria could help inform malaria-related disability research, policy, and practice, aimed at the providers themselves. This study explored the perceptions and behaviors of healthcare providers towards rehabilitation for children with severe malaria-related disability. The Theoretical Domains Framework was used to describe the findings relative to wider literature on health provider behavior change.

METHODS

A qualitative descriptive approach was used to interview thirteen healthcare providers recruited purposively based on their clinical professions, roles, and settings. Data were analyzed using directed content analysis. We decided on the most prominent theoretical domains considering the frequency of specific perceptions and behaviors across the participants, the frequency of perceptions and behaviors in each domain, and evidence of strong perceptions and behaviors.

RESULTS

Nine out of fourteen theoretical domains were identified. These domains were: Beliefs about consequences, environmental context and resources, goals, knowledge, skills, optimism, reinforcement, social influences, and social or professional role and identity. Healthcare providers' beliefs about their roles in screening for disability or referring to rehabilitation were less positive.

CONCLUSIONS

The findings of this study suggest the need for interventions to support healthcare providers in acute phases (prevention and control of severe malaria) and post-acute phases (disability screening, referral, and rehabilitation care). Recommended interventions should focus on developing clinical guidelines, training clinicians, addressing institutional factors, and modifying external social influences such as socio-cultural factors.

Is Neurodevelopmental Assessment in Early Childhood Predictive of Performance Assessed Later in Childhood and Adolescence in Sub-Saharan Africa? A Systematic Review of the Literature

BACKGROUND

Most neurodevelopmental tests used to assess child development in sub-Saharan Africa were developed in western or high-income countries, raising the question of their usefulness with African children.

OBJECTIVE

This systematic review identified and synthesized key findings from studies measuring development in children in Sub-Saharan Africa in early childhood and again at school age, to assess neurocognitive associations longitudinally from infancy through middle childhood.

METHODS

The study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, selecting articles referenced in the PubMed, PsycInfo, and Embase databases using the following inclusion criteria: published between 2000 and 2022, written in French or English, and presenting results dealing with the objective assessment of child's neurodevelopment. All articles were registered in the Zotero reference manager and analyzed by title, abstract, and full text.

RESULTS

Several of the seven selected studies confirmed that attention and working memory in infancy can predict children's neurocognitive performance, including mathematical ability, at school age. In two of the studies, children with poor mental development at 1 year of age are more likely to present with poorer behavioral development at school age, including learning difficulties in school and risk for grade repetition.

CONCLUSION

Cognitive ability assessed in early childhood is strongly associated with performance at school age in cohorts of African children followed longitudinally. Even with assessments adapted cross-culturally, infants and preschoolers at risk for poor developmental outcomes can be identified to better receive strategic early interventions to enhance their development.

Association of severe malaria with cognitive and behavioural outcomes in low- and middle-income countries: a meta-analysis and systematic review

BACKGROUND

Malaria affects 24 million children globally, resulting in nearly 500,000 child deaths annually in low- and middle-income countries (LMICs). Recent studies have provided evidence that severe malaria infection results in sustained impairment in cognition and behaviour among young children; however, a formal meta-analysis has not been published. The objective was to assess the association between severe malaria infection with cognitive and behavioural outcomes among children living in LMICs.

METHODS

Six online bibliographic databases were searched and reviewed in November 2022. Studies included involved children < 18 years of age living in LMICs with active or past severe malaria infection and measured cognitive and/or behaviour outcomes. The quality of studies was assessed. Definitions of severe malaria included cerebral malaria, severe malarial anaemia, and author-defined severe malaria. Results from all studies were qualitatively summarized. For studies with relevant data on attention, learning, memory, language, internalizing behaviour and externalizing behaviour, results were pooled and a meta-analysis was performed. A random-effects model was used across included cohorts, yielding a standardized mean difference between the severe malaria group and control group.

RESULTS

Out of 3,803 initial records meeting the search criteria, 24 studies were included in the review, with data from 14 studies eligible for meta-analysis inclusion. Studies across sub-Saharan Africa assessed 11 cohorts of children from pre-school to school age. Of all the studies, composite measures of cognition were the most affected areas of development. Overall, attention, memory, and behavioural problems were domains most commonly found to have lower scores in children with severe malaria. Meta-analysis revealed that children with severe malaria had worse scores compared to children without malaria in attention (standardized mean difference (SMD) -0.68, 95% CI -1.26 to -0.10), memory (SMD -0.52, 95% CI -0.99 to -0.06), and externalizing behavioural problems (SMD 0.45, 95% CI 0.13-0.78).

CONCLUSION

Severe malaria is associated with worse neuropsychological outcomes for children living in LMICs, specifically in attention, memory, and externalizing behaviours. More research is needed to identify the long-term implications of these findings. Further interventions are needed to prevent cognitive and behavioural problems after severe malaria infection.

TRIAL REGISTRATION

This systematic review was registered under PROSPERO: CRD42020154777.

Association between maternal psychological factors and offspring executive function: analysis of African-American mother-child dyads

BACKGROUND

Executive function (EF) develops throughout childhood and adolescence; however, little is known about whether and how early life factors are associated with EF during these two stages. This secondary analysis examined the associations between maternal psychological characteristics at 2 years after childbirth and offspring EF at 6 and 18 years.

METHODS

Data were from the 18-year New Mothers' Study in Memphis, TN. Women who self-identified as African-American were included (mother-child dyads: N = 414). Maternal psychological characteristics (e.g., depressive symptoms, self-esteem) were assessed using standardized questionnaires; offspring EF at 6 (i.e., working memory, response inhibition) and 18 years (e.g., working memory, sustained attention) were assessed using age-appropriate cognitive tasks. Statistical analyses included principal component analysis (PCA) and regression models.

RESULTS

PCA reduced the correlated psychological characteristics to two factors: emotionality (depressive symptoms, emotional instability) and psychological resources (self-esteem, mastery, active coping). After controlling for maternal IQ, maternal emotionality was associated with worse working memory and response inhibition (marginally significant) at 6 years. Maternal psychological resources were marginally associated with better working memory at 6 years.

CONCLUSIONS

Maternal psychological characteristics may be associated with later EF in offspring. Future studies are needed to replicate these findings and to explore potential mediators.

IMPACT

African-American mothers' depressive symptoms and emotional instability at 2 years after childbirth were associated with offspring executive function at 6 and 18 years. African-American mothers' psychological resources at 2 years after childbirth were marginally associated with offspring working memory at 6 years. Maternal IQ attenuated all of the associations observed between maternal psychological status and offspring executive function.

Artificial Cognitive Systems Applied in Executive Function Stimulation and Rehabilitation Programs: A Systematic Review

This article presents a systematic review of studies on cognitive training programs based on artificial cognitive systems and digital technologies and their effect on executive functions. The aim has been to identify which populations have been studied, the characteristics of the implemented programs, the types of implemented cognitive systems and digital technologies, the evaluated executive functions, and the key findings of these studies. The review has been carried out following the PRISMA protocol; five databases have been selected from which 1889 records were extracted. The articles were filtered following established criteria, to give a final selection of 264 articles that have been used for the purposes of this study in the analysis phase. The findings showed that the most studied populations were school-age children and the elderly. The most studied executive functions were working memory and attentional processes, followed by inhibitory control and processing speed. Many programs were commercial, customizable, gamified, and based on classic tasks. Some more recent initiatives have begun to incorporate user-machine interfaces, robotics, and virtual reality, although studies on their effects remain scarce. The studies recognize multiple benefits of computerized neuropsychological stimulation and rehabilitation programs for executive functions in different age groups, but there is a lack of studies in specific population sectors and with more rigorous research designs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13369-022-07292-5.

Malaria Related Neurocognitive Deficits and Behavioral Alterations

Typical of tropical and subtropical regions, malaria is caused by protozoa of the genus Plasmodium and is, still today, despite all efforts and advances in controlling the disease, a major issue of public health. Its clinical course can present either as the classic episodes of fever, sweating, chills and headache or as nonspecific symptoms of acute febrile syndromes and may evolve to severe forms. Survivors of cerebral malaria, the most severe and lethal complication of the disease, might develop neurological, cognitive and behavioral sequelae. This overview discusses the neurocognitive deficits and behavioral alterations resulting from human naturally acquired infections and murine experimental models of malaria. We highlighted recent reports of cognitive and behavioral sequelae of non-severe malaria, the most prevalent clinical form of the disease worldwide. These sequelae have gained more attention in recent years and therapies for them are required and demand advances in the understanding of neuropathogenesis. Recent studies using experimental murine models point to immunomodulation as a potential approach to prevent or revert neurocognitive sequelae of malaria.

Daily Training efficiency during computerized cognitive rehabilitation training (CCRT): an analysis from a randomized trial in Ugandan children with and without severe malaria

Children in Uganda are at risk for significant cognitive sequelae from severe malaria. Computerized cognitive rehabilitation training (CCRT) represents a potential method to improve working memory, behavior, and executive functioning, cognitive domains most at risk following severe malaria. The primary aim of this study was to complete a secondary analysis of data from a concluded CCRT randomized control trial in order to compare the training efficiency of a commonly used CCRT program under conditions of titrated (adaptive) or non-titrated (non-adaptive) training and with children with increasing malaria severity to determine how various factors may affect potential CCRT improvement. A total of 201 school-aged children (66.2% boys) who were either healthy (n = 102) or previously diagnosed with severe or cerebral malaria (n = 99) were randomized into two active treatment arms (titrated and non-titrated learning). Each child received 24 one-hour sessions of training over 8 weeks using Captain's Log® CCRT by BrainTrain, which includes a comprehensive set of CCRT tasks. Children generally benefited from CCRT over the 24 training sessions, but titrated CCRT showed a clear advantage over non-titrated. Severity of illness or factors such as BMI, did not moderate CCRT performance indicators. These findings support our hypothesis that titrated CCRT would result in steeper improvement in learning, but do not support our hypothesis that history of recent significant illness would affect learning proficiency. Findings were evident across all CCRT performance scores, even given that children were from generally rural, low-resource settings and were generally unfamiliar with computers.ABBREVIATIONS:Computerized Cognitive Rehabilitation Training (CCRT); Mental Processing Index (MPI); Home Observation for the Measurement of the Environment (HOME); Socioeconomic Status (SES); least square means (LSM).

Coding in Primary Grades Boosts Children's Executive Functions

Several programs have been developed worldwide to improve children’s executive functions (EFs). Yet, the role played in EF development by learning activities embedded in the school curriculum has received scarce attention. With two studies, we recently tested the effects of computational thinking (CT) and coding—a new element of the primary school curriculum—on the development of children’s EFs. CT stimulates the ability to define a clear and orderly sequence of simple and well-specified steps to solve a complex problem. We conjecture that CT skills are associated to such EF processes as response inhibition and planning. In a first between-group cluster-randomized controlled trial, we tested the effects of 1-month coding activities on 76 first graders’ planning and response inhibition against those of 1-month standard STEM activities of a control group. In a second study, we tested the effects of 1-month coding activities of 17 second graders in two ways: within group (longitudinally), against 7 months of standard activities experienced by the same children (experimental group); and between groups, in comparison to the effects of standard STEM activities in a control group of 19 second graders. The results of the two studies show significant benefits of learning to code: children exposed to coding improved significantly more in planning and inhibition tasks than control children did. The longitudinal data showed that improvements in planning and inhibition skills after 1 month of coding activities (eight lessons) were equivalent to or greater than the improvement attained after 7 months of standard activities. These findings support the hypothesis that learning CT via coding can significantly boost children’s spontaneous development of EFs.

Outcomes measures in children after acute central nervous system infections and malaria

PURPOSE OF REVIEW

Acute central nervous system (CNS) infections in children result in significant mortality and neurologic morbidity worldwide. This article summarizes the recent pediatric literature published on outcomes measures used after acute infectious meningitis, encephalitis, and cerebral malaria, and highlights ongoing research efforts to standardize outcomes measurements. Search terms were geared toward functional, cognitive, behavioral, and other outcome assessments.

RECENT FINDINGS

Recent data suggest that, depending on microbiological cause, there are differences in currently used outcome measures following acute CNS infections. Outcomes assessments include a variety of formal psychological tests (structured interviews and neuropsychological tests of cognitive and motor functioning) and dichotomized or ordinal scales. Standardization of outcome measures, however, is lacking. Global efforts to standardize outcomes that encompass both the child and family are ongoing.

SUMMARY

Centers worldwide can track and measure a variety of cognitive, behavioral, and functional outcomes after acute CNS infections. Standardized documentation and coding of clinically important outcomes is needed. Further research to evaluate effective practices using acute adjunctive and rehabilitation therapies will be aided by outcome measure standardization.

Working with memory: Computerized, adaptive working memory training for adolescents living with HIV

This study investigated working memory (WM) training for adolescents with perinatal HIV infection, since WM is negatively impacted by the virus, and adolescence is a time of considerable brain reorganization, during which WM functioning reaches maturation. We posed three main questions: 1) whether WM could be trained in adolescents living with HIV, and if so, whether these effects were maintained over a six-month period during which no further training was received; 2) whether there were differential effects of training on the components of WM (verbal and visuospatial storage, verbal and visuospatial processing); 3) whether the WM training transferred to cognate tasks, and if so, whether these transfer effects were maintained over six months. Sixty-three HIV+ adolescents (10-16 years) from two children's homes were assigned to the training (n = 31) or control (n = 32) group. The training group received 32 hours of supervised training in an adaptive, computerized WM intervention, while the control group received a supervised, placebo computerized program for the same hours. Comprehensive WM and neuropsychological batteries were administered to both groups at pretest, immediately following the intervention, and six months later. Significant improvements were found in verbal WM for the training group, which were maintained six months later. Transfer effects were evident in attention, executive function, memory, language and fluid intelligence. There were no significant posttest improvements in visuospatial storage, and minimal changes in verbal storage and visuospatial WM. These findings represent an important step in exploring ways to improve cognitive functioning in an at-risk population.

Evaluating Immunopathogenic Biomarkers During Severe Malaria Illness as Modifiers of the Neuropsychologic Benefits of Computer Cognitive Games Rehabilitation in Ugandan Children

BACKGROUND

We explored 3 immunopathogenic biomarkers collected during acute malaria illness as potential moderators of gains from a computerized cognitive rehabilitation training (CCRT) intervention.

METHOD

Von Willebrand Factor (vWF), tumor necrosis factor (TNF) and Regulated on Activation, Normal T Expressed and Secreted (RANTES) were assayed from plasma and cerebral spinal fluid (CSF) of children during acute severe malaria anemia or cerebral malaria. Two years after acute malaria illness, 150 surviving children and 150 nonmalaria community controls (CCs) from their households 6-12 years old entered a 3-arm randomized controlled trial of titrating and nontitrating CCRT against no CCRT. Tests of cognition [Kaufman Assessment Battery for Children (KABC)], Tests of Variables of Attention and Achenbach Child Behavior Checklist (CBCL) were administered before and after 24 CCRT sessions over a 3-month period, and at 1-year follow-up. Differences in outcomes by trial arms and biomarker levels were evaluated using linear mixed effects models.

RESULTS

Severe malaria survivors with lower levels of vWF, lower CSF levels of TNF and higher levels of plasma and CSF RANTES had better KABC cognitive performance after both titrating and nontitrating CCRT compared with no CCRT. For the CBCL, high plasma RANTES was associated with no benefit from either the titrating and nontitrating CCRT, whereas high TNF plasma was predictive of the benefit for both interventions. These biomarker moderating effects were not evident for CC children.

CONCLUSIONS

Severe malaria immunopathogenic biomarkers may be related to poorer long-term brain/behavior function as evidenced by diminished benefit from a computerized cognitive rehabilitation intervention.