Sustained attention in children and adolescents after traumatic brain injury: relation to severity of injury, adaptive functioning, ADHD and social background

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

The influence of methylphenidate on sustained attention in paediatric acquired brain injury: a meta-analytical review

Impairment in sustained attention is a common consequence of childhood Acquired Brain Injury (ABI). Whilst methylphenidate provides promise in enhancing "attention" as a unitary construct, little work has explored its effectiveness upon individual attentional domains. The current systematic review and meta-analysis evaluates the utility of methylphenidate on sustained attentional performance across childhood ABI groups. Five databases (PsycINFO, MEDLINE, Embase, Scopus & Cochrane Library) were searched for relevant articles from their inception to March 2022. A purpose-developed evaluation tool was used to assess each study's research quality (QuEST:MAP). Nine of the 1600 identified articles were included within this review (n = 259). Meta-analytical findings reported an overall significant benefit of methylphenidate on sustained attention in childhood ABI (g = -0.33, 95% CI: -0.62 to -0.04). Associated summary effect sizes were relatively small, particularly when adjusting for outlier cases. Subgroup analyses identified a significantly greater benefit of methylphenidate in clinical subgroups with comorbid ADHD diagnoses (p < .01). The current evidence base is characterized by small-scale clinical trials with variable research quality and low generalizability. Further robust research is needed to quantify methylphenidate utility upon individual attentional domains in larger and more representative ABI samples.

A Systematic Scoping Review of New Attention Problems Following Traumatic Brain Injury in Children

Objective: To summarize existing knowledge about the characteristics of attention problems secondary to traumatic brain injuries (TBI) of all severities in children.

Methods: Computerized databases PubMed and PsychINFO and gray literature sources were used to identify relevant studies. Search terms were selected to identify original research examining new ADHD diagnosis or attention problems after TBI in children. Studies were included if they investigated any severity of TBI, assessed attention or ADHD after brain injury, investigated children as a primary or sub-analysis, and controlled for or excluded participants with preinjury ADHD or attention problems.

Results: Thirty-nine studies were included in the review. Studies examined the prevalence of and risk factors for new attention problems and ADHD following TBI in children as well as behavioral and neuropsychological factors associated with these attention problems. Studies report a wide range of prevalence rates of new ADHD diagnosis or attention problems after TBI. Evidence indicates that more severe injury, injury in early childhood, or preinjury adaptive functioning problems, increases the risk for new ADHD and attention problems after TBI and both sexes appear to be equally vulnerable. Further, literature suggests that cases of new ADHD often co-occurs with neuropsychiatric impairment in other domains. Identified gaps in our understanding of new attention problems and ADHD include if mild TBI, the most common type of injury, increases risk and what brain abnormalities are associated with the emergence of these problems.

Conclusion: This scoping review describes existing studies of new attention problems and ADHD following TBI in children and highlights important risk factors and comorbidities. Important future research directions are identified that will inform the extent of this outcome across TBI severities, its neural basis and points of intervention to minimize its impact.

Attention-Deficit/Hyperactivity Disorder Status and Sex Moderate Mild Traumatic Brain Injury Symptom Severity in Children and Adolescents: Implications for Clinical Management

OBJECTIVE

To investigate the impact of pediatric mild traumatic brain injury (mTBI), using a broad parent-reported measure, and to determine whether parent-ratings of mTBI symptoms are higher among those with premorbid attention-deficit/hyperactivity disorder (ADHD) and females.

DESIGN

Retrospective case-control.

SETTING

Hospital-based sports medicine clinic.

PARTICIPANTS

The retrospective chart review included 1346 (age: M = 13.11 years, SD = 2.6; 61.7% male) pediatric patients with (n = 209) and without (n = 1137) ADHD.

INDEPENDENT VARIABLES

Group membership (ADHD vs non-ADHD) and sex (male vs female).

MAIN OUTCOME MEASURES

Baseline and current Post-Concussion Symptom Inventory-Parent Report Form (PCSI-P) Physical, Emotional, Cognitive, and Fatigue subscale scores. This study used a retrospective chart review; therefore, the hypotheses reported for the current study were formed after data were collected.

RESULTS

Controlling for patient age and days from mTBI, patients with ADHD had significantly higher retrospective parent-reported pre-mTBI ratings of physical, emotional, and cognitive symptoms (ds = 0.17-0.62) and higher post-mTBI ratings across all 4 symptom domains (ds = 0.18-0.57) than those without ADHD. There was no group × time interaction for any of the PCSI-P subscales. Females overall had higher retrospective parent-reported pre-injury Fatigue and Emotional symptoms (ds = 0.13-0.19) and higher post-mTBI symptoms in all 4 PCSI-P symptom domains (ds = 0.23-0.35), relative to males.

CONCLUSIONS

Attention-deficit/hyperactivity disorder-related postinjury exacerbations in parent-reported symptoms can be explained, in part, by elevated retrospective parent-reported ADHD-related pre-mTBI ratings. These results highlight the importance of assessing a patient's baseline symptoms post-mTBI. These data also indicate that ADHD status and sex should be considered when interpreting mTBI symptom severity during clinical evaluation of concussion.

Abnormal Functional Network Topology and Its Dynamics during Sustained Attention Processing Significantly Implicate Post-TBI Attention Deficits in Children

Traumatic brain injury (TBI) is highly prevalent in children. Attention deficits are among the most common and persistent post-TBI cognitive and behavioral sequalae that can contribute to adverse outcomes. This study investigated the topological properties of the functional brain network for sustained attention processing and their dynamics in 42 children with severe post-TBI attention deficits (TBI-A) and 47 matched healthy controls. Functional MRI data during a block-designed sustained attention task was collected for each subject, with each full task block further divided into the pre-, early, late-, and post-stimulation stages. The task-related functional brain network was constructed using the graph theoretic technique. Then, the sliding-window-based method was utilized to assess the dynamics of the topological properties in each stimulation stage. Relative to the controls, the TBI-A group had significantly reduced nodal efficiency and/or degree of left postcentral, inferior parietal, inferior temporal, and fusiform gyri and their decreased stability during the early and late-stimulation stages. The left postcentral inferior parietal network anomalies were found to be significantly associated with elevated inattentive symptoms in children with TBI-A. These results suggest that abnormal functional network characteristics and their dynamics associated with the left parietal lobe may significantly link to the onset of the severe post-TBI attention deficits in children.

Detecting mental health problems after paediatric acquired brain injury: A pilot Rasch analysis of the strengths and difficulties questionnaire

The parent-reported Strengths and Difficulties Questionnaire (SDQ-P) is commonly used to assess for mental health problems, but its psychometric properties have not been studied in the paediatric Acquired Brain Injury (ABI) population. This study investigated the properties of the SDQ-P and its subscales in this population using Rasch analysis. One hundred and forty-three SDQ-Ps and 123 Impact Supplements were analyzed. Sixty-nine percent of SDQ-Ps were completed by female carers, 59% of young people were male, and 58% had Traumatic Brain Injury (TBI). In this population the SDQ-P Total Difficulties Scale and the Conduct Problems subscale showed questionable construct validity. The individual subscales and Impact Supplement did not meet the criteria for reliability. Two items had disordered thresholds. The individual subscales showed mistargeting and 13-24% person misfit. Two items were significantly underdiscriminating. There was differential item functioning with age and time post-injury, and local dependence between subscale items. The Total Difficulties scale was multidimensional. The most easily endorsed items were in keeping with common symptoms of brain injury. These findings suggest the SDQ-P in its current form may not be a reliable and valid assessment measure for mental health difficulties in the paediatric ABI population and requires further investigation.

Secondary Attention-Deficit/Hyperactivity Disorder in Children and Adolescents 5 to 10 Years After Traumatic Brain Injury

IMPORTANCE

After traumatic brain injury (TBI), children often experience impairment when faced with tasks and situations of increasing complexity. Studies have failed to consider the potential for attention problems to develop many years after TBI or factors that may predict the development of secondary attention-deficit/hyperactivity disorder (SADHD). Understanding these patterns will aid in timely identification of clinically significant problems and appropriate initiation of treatment with the hope of limiting additional functional impairment.

OBJECTIVE

To examine the development of SADHD during the 5 to 10 years after TBI and individual (sex, age at injury, and injury characteristics) and environmental (socioeconomic status and family functioning) factors that may be associated with SADHD.

DESIGN, SETTING, AND PARTICIPANTS

Concurrent cohort/prospective study of children aged 3 to 7 years hospitalized overnight for TBI or orthopedic injury (OI; used as control group) who were screened at 3 tertiary care children's hospitals and 1 general hospital in Ohio from January 2003 to June 2008. Parents completed assessments at baseline (0-3 months), 6 months, 12 months, 18 months, 3.4 years, and 6.8 years after injury. A total of 187 children and adolescents were included in the analyses: 81 in the TBI group and 106 in the OI group.

MAIN OUTCOMES AND MEASURES

Diagnosis of SADHD was the primary outcome. Assessments were all completed by parents. Secondary ADHD was defined as an elevated T score on the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale of the parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or current treatment with stimulant medication not present at the baseline assessment. The Family Assessment Device-Global Functioning measurement was used to assess family functioning; scores ranged from 1 to 4, with greater scores indicating poorer family functioning.

RESULTS

The analyzed sample included 187 children with no preinjury ADHD. Mean (SD) age was 5.1 (1.1) years; 108 (57.8%) were male, and 50 (26.7%) were of nonwhite race/ethnicity. Of the 187 children, 48 (25.7%) met our definition of SADHD. Severe TBI (hazard ratio [HR], 3.62; 95% CI, 1.59-8.26) was associated with SADHD compared with the OI group. Higher levels of maternal education (HR, 0.33; 95% CI, 0.17-0.62) were associated with a lower risk of SADHD. Family dysfunction was associated with increased risk of SADHD within the TBI group (HR, 4.24; 95% CI, 1.91-9.43), with minimal association within the OI group (HR, 1.32; 95% CI, 0.36-4.91).

CONCLUSIONS AND RELEVANCE

Early childhood TBI was associated with increased risk for SADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with TBI.

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.

Do Children Who Sustain Traumatic Brain Injury in Early Childhood Need and Receive Academic Services 7 Years After Injury?

OBJECTIVE

To examine the prevalence of academic need, academic service utilization, and unmet need as well as factors associated with academic service utilization 6.8 years after traumatic brain injury (TBI) in early childhood.

METHODS

Fifty-eight (16 severe, 14 moderate, 28 complicated mild) children with TBI and 72 children with orthopedic injury (OI) completed the long-term follow-up 6.8 years after injury in early childhood (ages 3-7 years). Injury group differences in rates of need for academic services, academic service utilization, and unmet need as well as factors associated with service utilization and unmet need were examined.

RESULTS

Students with moderate and severe TBI had significantly greater rates of need than those with OI. A greater proportion of the severe TBI sample was receiving academic services at long-term follow-up than the OI and complicated mild groups however, among those with an identified need, injury group did not affect academic service utilization. Below average IQ/achievement scores was the only area of need predictive of academic service utilization. Rates of unmet need were high and similar across injury groups (46.2%-63.6%).

CONCLUSION

The need for academic services among patients who sustained a TBI during early childhood remains high 6.8 years post injury. Findings underscore the importance of continued monitoring of behaviors and academic performance in students with a history of early childhood TBI. This may be especially true among children with less severe injuries who are at risk for being underserved.

Association of traumatic brain injury in childhood and attention-deficit/hyperactivity disorder: a population-based study

BACKGROUND

We evaluated the risk of attention-deficit hyperactivity disorder (ADHD) following childhood traumatic brain injury (TBI).

METHODS

Using Taiwan's National Health Insurance Research Database, we included 10,416 newly diagnosed TBI children (aged ≤12 y) between 2001 and 2002 and 41,664 children without TBI, who were frequency matched by sex, age, and year of the index medical service with each TBI child, as controls. Children who had been diagnosed with ADHD prior to their medical service index were excluded. Each individual was followed for 9 y to identify ADHD diagnosis. We also compared the ADHD risk in children who were treated for fractures but not TBI as sensitivity analysis.

RESULTS

During the 9-y follow-up period, children with TBI had a higher ADHD risk (adjusted hazard ratio (AHR) = 1.32, 95% confidence interval (CI) = 1.19, 1.45) than did those without TBI. Furthermore, children with mild and severe TBI had higher AHRs for ADHD than did those without TBI (AHR = 1.30; 95% CI = 1.10, 1.53; and AHR = 1.37; 95% CI = 1.22, 1.55). However, no significant association was observed between fractures and ADHD.

CONCLUSION

TBI in childhood is associated with a greater likelihood of developing ADHD.

The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986

OBJECTIVE

We examined the risk of hospital-treated injuries related to the symptoms/diagnosis of ADHD.

METHOD

The study population (N = 6,111) was composed from the Northern Finland Birth Cohort 1986. At the age of 8, symptoms of hyperactivity and at the age of 15, symptoms of ADHD were assessed by the parents while the clinical diagnoses of ADHD were set in adolescence. Information on injuries was obtained from national register.

RESULTS

The risk for hospital-treated injuries during ages 0 to 7 was 1.7-fold increased among those with symptoms of hyperactivity assessed at age 8. Also, injuries during ages 7 to 15 years were more common among those with symptoms of ADHD at age 15 with respect to any injury, fractures, and intracranial injuries, and among those with the diagnosis of ADHD with respect to any injury.

CONCLUSION

The present study shows an association between hospital-treated injuries and symptoms of ADHD in a large epidemiological sample of 0- to 15-year-old children.

The effect of premorbid attention-deficit/hyperactivity disorder on neuropsychological functioning in individuals with acute mild traumatic brain injuries

INTRODUCTION

Mild traumatic brain injury (mTBI) is a frequent, yet undertreated condition that typically manifests with transient neurological and cognitive symptoms that resolve over the course of several weeks. In contrast, attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that presents initially in childhood but often persists into adulthood. mTBI and ADHD include overlapping symptomatology, making it difficult for clinicians to disentangle the sequelae of each condition when they co-occur in the same individual. We hypothesized that neuropsychological tests would be sensitive to preexisting ADHD in inpatients with acute mTBIs.

METHOD

We retrospectively examined the medical charts of 100 inpatients, aged 18-40 years (96% Caucasian; 77% male) with mTBIs in an acute care setting, half of whom had self-reported the presence of premorbid ADHD, and half of whom were matched controls. We analyzed group differences across neuropsychological tests of attention, processing speed, and executive functions, examined the profile ratings of independent, blinded, board-certified neuropsychologists, and correlated cognitive performance with time from traumatic injury to testing.

RESULTS

Individuals with premorbid ADHD (a) performed significantly worse than their matched counterparts on several tests of attention, processing speed, and working memory, and (b) were significantly more likely to produce profiles later rated as impaired by independent, board-certified clinical neuropsychologists. In addition, time from traumatic injury to testing was found to be negatively correlated with neurocognitive performance.

CONCLUSIONS

These findings (a) argue for the utility of a brief assessment of premorbid ADHD in the acute care of individuals with mTBIs and (b) provide clinicians with a barometer for gauging the relative contributions of premorbid ADHD to neuropsychological impairments in the neurocognitive profiles of individuals with mTBIs. Reported effect sizes will assist clinicians in accurately weighing the impact of premorbid ADHD when interpreting such profiles.

Neuropsychological performance of youth with secondary attention-deficit/hyperactivity disorder 6- and 12-months after traumatic brain injury

The present study compared executive dysfunction among children with attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (S-ADHD), pre-injury ADHD and children with TBI only (i.e., no ADHD). Youth aged 6-16 years admitted for TBI to five trauma centers were enrolled (n=177) and evaluated with a semi-structured psychiatric interview scheduled on three occasions (within 2 weeks of TBI, i.e., baseline assessment for pre-injury status; 6-months and 12-months post-TBI). This permitted the determination of 6- and 12-month post-injury classifications of membership in three mutually exclusive groups (S-ADHD; pre-injury ADHD; TBI-only). Several executive control measures were administered. Unremitted S-ADHD was present in 17/141 (12%) children at the 6-month assessment, and in 14/125 (11%) children at 12-months post-injury. The study found that children with S-ADHD exhibited deficient working memory, attention, and psychomotor speed as compared to children with pre-injury ADHD. Furthermore, the children with S-ADHD and the children with TBI-only were impaired compared to the children with pre-injury ADHD with regard to planning. No group differences related to response inhibition emerged. Age, but not injury severity, gender, or adaptive functioning was related to executive function outcome. Neuropsychological sequelae distinguish among children who develop S-ADHD following TBI and those with TBI only. Moreover, there appears to be a different pattern of executive control performance in those who develop S-ADHD than in children with pre-injury ADHD suggesting that differences exist in the underlying neural mechanisms that define each disorder, underscoring the need to identify targeted treatment interventions.

Utilization of behavioral therapy services long-term after traumatic brain injury in young children

OBJECTIVE

To examine associations of clinical need, defined by elevated parent ratings of child behavior problems and utilization of behavioral health services in young children with traumatic brain injury (TBI) and an orthopedic injury (OI) comparison group.

DESIGN

Parents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months postinjury.

SETTING

Children's hospitals and a general hospital.

PARTICIPANTS

Participants included parents of 3 groups of children injured between 3 and 7 years of age (N=139): 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Parents completed ratings of child behavior, mental health symptomology, and family functioning at both visits; at the extended follow-up, they reported utilization of behavior therapy or counseling services since the 18-month follow-up visit.

RESULTS

Children with TBI had more behavior problems than those with OI. Although clinical need at both follow-ups was associated with greater service utilization at the extended follow-up, all groups had unmet needs as defined by a clinical need in the absence of services. Lower socioeconomic status was associated with higher rates of unmet need across groups.

CONCLUSIONS

The results document unmet long-term behavioral health needs after both TBI and OI in children and underscore the importance of monitoring and treatment of postinjury behavior problems.

Neuropsychiatry of pediatric traumatic brain injury

Pediatric traumatic brain injury (TBI) is a major public health problem. Psychiatric disorders with onset before the injury are more common than population base rates. Novel (postinjury onset) psychiatric disorders (NPD) are also common and complicate child function after injury. Novel disorders include personality change due to TBI, secondary attention-deficit/hyperactivity disorder, other disruptive behavior disorders, and internalizing disorders. This article reviews preinjury psychiatric disorders as well as biopsychosocial risk factors and treatments for NPD.

The impact of attention deficit hyperactivity disorder on recovery from mild traumatic brain injury

OBJECT

Attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) are significant independent public health concerns in the pediatric population. This study explores the impact of a premorbid diagnosis of ADHD on outcome following mild TBI.

METHODS

The charts of all patients with a diagnosis of mild closed head injury (CHI) and ADHD who were admitted to Children's Hospital of Pittsburgh between January 2003 and December 2010 were retrospectively reviewed after institutional review board approval was granted. Patient demographics, initial Glasgow Coma Scale (GCS) score, hospital course, and King's Outcome Scale for Childhood Head Injury (KOSCHI) score were recorded. The results were compared with a sample of age-matched controls admitted with a diagnosis of CHI without ADHD.

RESULTS

Forty-eight patients with mild CHI and ADHD, and 45 patients with mild CHI without ADHD were included in the statistical analysis. Mild TBI due to CHI was defined as an initial GCS score of 13-15. The ADHD group had a mean age of 12.2 years (range 6-17 years), and the control group had a mean age of 11.14 years (range 5-16 years). For patients with mild TBI who had ADHD, 25% were moderately disabled (KOSCHI Score 4b), and 56% had completely recovered (KOSCHI Score 5b) at follow-up. For patients with mild TBI without ADHD, 2% were moderately disabled and 84% had completely recovered at follow-up (p < 0.01). Patients with ADHD were statistically significantly more disabled after mild TBI than were control patients without ADHD, even when controlling for age, sex, initial GCS score, hospital length of stay, length of follow-up, mechanism of injury, and presence of other (extracranial) injury.

CONCLUSIONS

Patients who sustain mild TBIs in the setting of a premorbid diagnosis of ADHD are more likely to be moderately disabled by the injury than are patients without ADHD.

Age at injury and long-term behavior problems after traumatic brain injury in young children

OBJECTIVE

This study examined the effects of age at injury on the persistence of behavior problems and social skill deficits in young children with complicated mild to severe traumatic brain injury (TBI).

METHOD

A concurrent cohort/prospective research design was used with repeated assessments of children with TBI (n = 82) or Orthopedic Injury (OI) (n = 114). Parents completed the Child Behavior Checklist, the Behavior Rating Inventory of Executive Functions, and the Preschool and Kindergarten Behavior Scales or the Home and Community Social and Behavior Scales shortly after injury to assess preinjury functioning, and at an extended follow-up an average of 38 months postinjury. Generalized linear modeling was used to examine the relationship of age at injury to the maintenance of behavior problems, and logistic regression was used to examine the persistence of clinically significant behavior problems.

RESULTS

At the extended follow-up, severe TBI was associated with significantly greater anxiety problems relative to the Group OI. With increasing time since injury, children who sustained a severe TBI at an earlier age had significantly higher levels of parent-reported symptoms of ADHD and anxiety than children who were older at injury.

CONCLUSIONS

Findings suggest that longer-term treatment for behavior problems may be needed after severe TBI, particularly for those injured at an earlier age.

Deficits in two versions of a sustained attention test in adolescents with cerebral palsy

OBJECTIVE

To evaluate sustained attention in adolescents with cerebral palsy (CP). CP affects motor control as well as certain cognitive processes such as attention, but its influence on the latter remains largely unexplored.

METHODS

Manual (Experiment 1) and oculomotor (Experiment 2) versions of the Continuous Performance Test were performed by adolescents with spastic CP and healthy age-matched controls (n = 10 per group in each experiment).

RESULTS

In both experiments, patients with CP showed more omissions and their reaction time was more variable than controls. In Experiment 2, patients also showed more commissions. This problem was not observed in Experiment 1, possibly because of the presence of a hand movement deficit in CP.

CONCLUSION

Taken together, the results show that sustained attention and inhibition capabilities are affected in CP. The present study also proposes that eye movements could constitute an interesting alternative for measuring sustained attention when hand movement is affected.

Inhibitory control after traumatic brain injury in children

Inhibitory control describes a number of distinct processes. Effortless inhibition refers to acts of control that are automatic and reflexive. Effortful inhibition refers to voluntary, goal-directed acts of control such as response flexibility, interference control, cancellation inhibition, and restraint inhibition. Disruptions to a number of inhibitory control processes occur as a consequence of childhood traumatic brain injury (TBI). This paper reviews the current knowledge of inhibition deficits following childhood TBI, and includes an overview of the inhibition construct and a discussion of the specific deficits shown by children and adolescents with TBI and the factors that mediate the expression of these deficits, including injury-related variables and the expression of pre- and post-injury attention-deficit/hyperactivity disorder. The review illustrates that inhibitory control processes differ in terms of measurement, assessment, and neurological underpinnings, and also that childhood TBI may selectively disrupt particular forms of inhibition.

Caregiver ratings of long-term executive dysfunction and attention problems after early childhood traumatic brain injury: family functioning is important

OBJECTIVE

To evaluate the relationship of family and parenting factors to long-term executive dysfunction and attention problems after early childhood traumatic brain injury (TBI). We hypothesized that the magnitude of executive dysfunction and attention problems would be moderated by family and parenting factors.

DESIGN

A multicenter, prospective cohort study that included an orthopedic injury (OI) reference group.

SETTING

Three tertiary academic children's hospital medical centers and one general medical center.

PARTICIPANTS

Children, ages 3-7 years, hospitalized for OI, moderate TBI, or severe TBI. METHODS AND OUTCOME MEASUREMENTS: Parental ratings of family functioning and parenting styles were obtained 18 months after the injury occurred. The main outcome measurements, which were parental ratings of children's executive function and attention, were performed at least 24 months after the injury occurred (mean, 39 months; range, 25-63 months).

ANALYSIS

Group comparisons were conducted with use of t-tests, χ(2) analysis, analysis of variance, and Pearson and Spearman correlations. Regression analysis was used to examine associations of the outcomes with family functioning and parenting styles and to test moderating effects of these factors on group differences.

RESULTS

Participants with severe TBI demonstrated increased executive dysfunction and attention problems compared with those who sustained moderate TBI or OI. Lower levels of family dysfunction were associated with better executive function and attention across groups but did not moderate group differences. However, attention deficits after severe TBI were exacerbated under conditions of more permissive parenting relative to attention deficits after OIs.

CONCLUSIONS

Executive function and attention problems persisted on a long-term basis (>24 months) after early childhood TBI, and positive global family functioning and nonpermissive parenting were associated with better outcomes. Better characterization of the optimal family environment for recovery from early childhood TBI could help target future interventions.

Attentional skills 10 years post-paediatric traumatic brain injury (TBI)

OBJECTIVE

To date no study has reported findings regarding attentional deficits following pre-school paediatric traumatic brain injury (TBI), as long as 10 years post-injury. It was predicted that more severe TBI would be associated with generalized deficits at 10 years post-TBI, particularly for skills not mastered at time of injury.

RESEARCH DESIGN

The sample comprised 40 prospectively-recruited children (42% of the original sample) who had sustained a mild, moderate or severe traumatic brain injury (TBI) between the ages of 1-7 years and 19 non-injured control participants. Children were assessed 10 years post-TBI, with a focus on measures of attentional ability.

OUTCOMES/RESULTS

While attentional deficits were not evident across all components of attentional ability, both early- and later-established attention skills were compromised, particularly following severe TBI. Environmental predictors were generally not successful predictors of attentional outcome at 10 years post-TBI. Age at injury and acute IQ were identified as contributing to attention at 10 years.

CONCLUSIONS/IMPLICATIONS

The present study shows that attentional deficits do occur and persist to 10 years following serious TBI. Clinicians may be able to screen for such deficits and so intervene in order to prevent or lessen the consequences of such difficulties.

Traumatic brain injury and secondary attention-deficit/hyperactivity disorder in children and adolescents: the effect of reward on inhibitory control

Poor inhibitory control and abnormalities in responding to rewards are characteristic of the developmental or primary form of attention-deficit/hyperactivity disorder (P-ADHD). A secondary form of ADHD (S-ADHD) may occur as a consequence of childhood traumatic brain injury (TBI), but the similarities and differences between these two forms of ADHD have not been well characterized. To address these issues, we studied two inhibitory control tasks under different reward conditions in four groups of children and adolescents: TBI who did not exhibit S-ADHD, TBI who did exhibit S-ADHD, P-ADHD, and healthy controls. Participants with TBI exhibited poor cancellation inhibition relative to controls. Although reward facilitated both cancellation and restraint inhibition similarly across groups, poor performance persisted in the P-ADHD group, and participants with S-ADHD exhibited a selective deficit in cancellation inhibition.

Behavioral consequences of pediatric traumatic brain injury

Behavioral problems are common after pediatric traumatic brain injury (TBI), but poorly understood. In this article we review ten common behavioral problems observed in children after TBI and consider the factors that appear to contribute to their expression. Both neurological and non-neurological variables can interact in a complicated way to produce behavioral problems in school-age children following TBI. We conclude with suggestions for the management and treatment of these behavioral problems in a manner that hopefully will reduce parental distress and disruptive behaviors of the child in school.

Training of attention and memory deficits in children with acquired brain injury

This pilot study concerns cognitive rehabilitation of children with acquired brain injury (ABI).

AIM

The aim is threefold; to determine (1) whether the Amsterdam Memory and Attention Training for Children (AMAT-C) programme for children with ABI can be integrated in the child's school, (2) whether supervision in the school-setting maintains the child's motivation throughout the training programme and (3) whether positive changes in memory, attention and executive functions are found with this implementation of the training method.

METHODS

Seven children with memory and/or attention deficits after ABI were trained with AMAT-C. Measures used were programme evaluation questions, neuropsychological tests and a questionnaire concerning executive functions.

RESULTS

Overall, children, parents and trainers were satisfied with the programme and the children were motivated throughout the programme. The children showed significant improvements in neuropsychological subtests, primarily in tests of learning and memory. No overall change in executive functions was noted.

CONCLUSION

Provision of AMAT-C training and supervision at the child's school appears to ensure (1) satisfaction with the programme, (2) sustaining of motivation and (3) improvements in learning and memory.

Predicting social and functional outcomes for individuals sustaining paediatric traumatic brain injury

OBJECTIVE

To determine the efficacy of models employing the classification of severity of injury, based on either GCS scores or clinical findings using standardized test scores for Occupational Therapy, Physiotherapy and Psychology in predicting outcomes associated with paediatric traumatic brain injury (TBI).

METHOD

Medical records were reviewed to obtain GCS scores and standardized tests used in the clinically based classification of severity of injury for 30 individuals who sustained a paediatric TBI and were patients of a brain injury treatment programme. Interviews were conducted with parents to obtain current data on social participation, cognitive functioning and environmental factors.

RESULTS

Three variables emerged as significant predictors of outcome: age at injury, clinical ratings of injury severity and environmental factors.

CONCLUSION

Findings offer preliminary support for the idea that a combination of factors, including age at injury, clinical expertise and the environment, provide the best estimate of long-term outcome.

Long-term neural processing of attention following early childhood traumatic brain injury: fMRI and neurobehavioral outcomes

Attentional deficits are common and significant sequelae of pediatric traumatic brain injury (TBI). However, little is known about how the underlying neural processes that support different components of attention are affected. The present study examined brain activation patterns using fMRI in a group of young children who sustained a TBI in early childhood (n = 5; mean age = 9.4), and a group of age-matched control children with orthopedic injuries (OI) (n = 8) during a continuous performance task (CPT). Four children in the TBI group had moderate injuries, and one had a severe injury. Performance on the CPT task did not differ between groups. Both TBI and OI children activated similar networks of brain regions relevant to sustained attention processing, but the TBI group demonstrated several areas of significantly greater activation relative to controls, including frontal and parietal regions. These findings of over-activation of the relevant attention network in the TBI group contrast with those obtained in imaging studies of Attention-Deficit/Hyperactivity Disorder where under-activation of the attention network has been documented. This study provides evidence that young children's brains function differently following a traumatic brain injury, and that these differences persist for years after the injury.

Differences in attention, executive functioning, and memory in children with and without ADHD after severe traumatic brain injury

Although the development of Attention Deficit Hyperactivity Disorder (ADHD) after traumatic brain injury (TBI) has been described, it is unknown whether children with TBI and ADHD have greater neuropsychological impairments than children with TBI alone. This study examines attention, executive functioning, and memory in children with TBI-only and TBI + ADHD. Caregivers of 82 children with severe TBI completed structured psychiatric interviews at enrollment to diagnose premorbid ADHD and one-year after injury to diagnose post-injury ADHD. Children underwent neuropsychological testing one year after injury. One memory measure significantly differentiated children with TBI-only from children with newly developed ADHD [secondary ADHD (S-ADHD)] and those with premorbid ADHD that persisted after injury [persisting ADHD (P-ADHD)]. Compared with the TBI-only group, children with TBI + ADHD had worse performance on measures of attention, executive functioning, and memory. Results reveal that in children with severe TBI, the behavioral diagnosis of ADHD is associated with more difficulty in attention, executive functioning, and memory. Additionally, results suggest greater deficits in memory skills in the S-ADHD group compared with the P-ADHD group. Although findings provide preliminary support for distinguishing P-ADHD from S-ADHD, further research is needed to investigate neuropsychological differences between these subgroups of children with severe TBI.

Cognitive outcome in traumatic brain injury survivors

PURPOSE OF REVIEW

This review discusses recent studies investigating the cognitive and psychiatric outcome of posttraumatic brain injury. In addition, it aims to highlight key areas for future research.

RECENT FINDINGS

Detailed cognitive assessments have revealed particular deficits in processing speed in the visual domain and the detrimental impact of interference on attentional performance. A pilot functional imaging study revealed neural changes in survivors performing a response inhibition task, even when matched to controls on behavioural indices. Recent psychiatric studies highlight the incidence of these disorders in the survivors and attempt to characterize distinct psychiatric profiles. Adult and child survivors appear to show differential difficulties. Successful rehabilitation strategies addressing these psychiatric and cognitive deficits include holistic intensive neuropsychological interventions and the introduction of electronic devices. Systematic randomized trials are needed to provide an adequate evidence base for clinical practice. The potential for cognitive enhancement using psychopharmacological agents has yet to be exploited. These treatments may lead to improved quality of life for traumatic brain injury survivors and their families.

SUMMARY

Survivors of head injury show a diverse pattern of cognitive and psychiatric profiles. Recent research highlights the nature of some of these deficits and possible ways to enhance functioning. However, the area is well poised for rapid progress in the understanding of cognitive and emotional dysfunction following traumatic brain injury (TBI) and its rehabilitation through neuropsychological and psychopharmacological means.

Long-term attention problems in children with traumatic brain injury

OBJECTIVE

To examine long-term attention problems and their cognitive correlates after childhood traumatic brain injury (TBI).

METHOD

Data were drawn from a prospective, longitudinal study conducted between 1992 and 2002. Participants included 41 children with severe TBI, 41 with moderate TBI, and 50 with orthopedic injury (OI), who were all between 6 and 12 years of age at the time of injury. Parent ratings of attention problems were obtained at a long-term follow-up on average 4 years post-injury and compared with ratings of premorbid attention problems obtained shortly after injury. At the long-term follow-up, children also completed several cognitive tests of attention and executive functions.

RESULTS

Hierarchical linear and logistic regression analyses indicated that the severe TBI group displayed significantly more attention problems than the OI group at 4 years post-injury, both behaviorally and cognitively, after controlling for race, socioeconomic status, and premorbid attention problems. At long-term follow-up, 46% of the severe TBI group displayed significant attention problems on the Child Behavior Checklist, as opposed to 26% of the OI group (odds ratio=3.38; 95% confidence interval, 1.15-9.94). On the Attention-Deficit/Hyperactivity Disorder Rating Scale, 20% of the severe TBI group displayed clinically significant attention problems compared with 4% in the OI group (odds ratio=9.59; 95% confidence interval, 1.24-73.99). However, group differences in behavioral symptoms were significantly larger for children with more premorbid symptoms than for children with fewer premorbid problems. Measures of executive functions were significantly related to behavioral attention problems, after controlling for group membership, race, and socioeconomic status.

CONCLUSIONS

Childhood TBI exacerbates premorbid attention problems. Long-term behavioral symptoms of attention problems are related to the cognitive deficits in attention and executive functions that often occur in association with childhood TBI.