Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury

Systematic review of the effectiveness of innovative, gamified interventions for cognitive training in paediatric acquired brain injury

Effectiveness of innovative, gamified interventions (i.e., Augmented Reality, Computer-Based Cognitive Retraining [CBCR], and Virtual Reality [VR] in conjunction with a Serious Game) for cognitive training in paediatric ABI was evaluated. Studies were identified on PsycINFO, PubMed and Scopus; last searched 4 January 2022. Eligibility criteria were participants diagnosed with ABI and aged ≤ 18 years, experimental intervention to train cognition, cognition assessed pre- and post-intervention at: (1) The level of function, or (2) The level of activity, and written in English. ROB 2 and ROBINS-I were utilised to assess risk of bias. Extracted study characteristics were methods, participants, interventions, outcomes, and results. Seven studies were included, comprising six CBCR studies and one VR study, with 182 participants. Following CBCR: (1) Improvements were observed in several cognitive functions, but there was inconsistent evidence; (2) Improvements were reported in attention and executive functions (EF) at home and at school. Following VR: (1) Improvements were observed in attention and EF; (2) Not evaluated. Due to the small number of included studies with (relatively) small and heterogeneous samples, only a cautious interpretation of the evidence was provided. There is a need for carefully designed studies with more attention to inter-individual differences and generalisation to daily life.

A neuropsychological approach in a paediatric acquired brain injury unit under the public health system

INTRODUCTION

Paediatric acquired brain injury (ABI) causes cognitive and behavioural difficulties and alters the course of child development. The ABI unit at Hospital Infantil Universitario Niño Jesús is the first within the public Spanish health system to provide comprehensive coverage to these patients and their families.

OBJECTIVE

This study aims to show the working methodology followed with patients and their families, and to describe the clinical characteristics of the patients treated and the outcomes of treatment.

PATIENTS

Fifty-three patients aged between 3 months and 16 and a half years received treatment. The conditions treated were brain tumours, stroke, traumatic brain injury, damage secondary to epilepsy surgery, and hypoxia.

METHODS

All patients were evaluated at admission and at discharge. Treatments were adapted to each patient's difficulties and their severity, as well as to the patient's age. Families received individual and group therapy.

RESULTS

Older age was associated with better cognitive recovery and shorter duration of treatment. Different conditions show differential impact on intelligence quotient and developmental quotient scores at the beginning of treatment, with hypoxia and encephalitis being associated with greatest severity. Intelligence quotient and developmental quotient scores and visual memory and attention scores at discharge improved significantly after the faceted neuropsychological treatment with respect to scores registered at admission.

CONCLUSIONS

The care of patients with ABI should include neuropsychological rehabilitation programmes and provide emotional support to the family so that they may actively participate in the recovery of the child or adolescent.

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.

Evaluating the feasibility and efficacy of the Amsterdam memory and attention training for children (Amat-c) following acquired brain injury (ABI): protocol for a pilot study with online clinician support

Background:

Attention and memory deficits are common following paediatric acquired brain injury (ABI). However, there are few evidence-based interventions to improve these domains and benefit the everyday life of children post-injury. The Amsterdam Memory and Attention Training for children (Amat-c) has been translated from Dutch to English and shown to improve attention and memory skills in children following ABI. This protocol describes a study to expand accessibility of the program by using online, clinician-supported delivery with children post-ABI.

Method/design:

The study is a randomized controlled trial. Participants will be 40 children aged 8–16 a minimum of one-year post-ABI. Participants in the treatment group will complete 18 weekly sessions of the Amat-c program with weekly online clinician support. Participants in the active-control group will be administered ABI psychoeducation via a booklet for parents, with weekly online clinician contact. Attention and memory will be assessed at three time points up to six months post-intervention.

Results:

Analysis will be repeated measures multivariate planned comparisons; using the Statistical Package for the Social Sciences (IBM SPSS Statistics) General Linear Model procedure will compare pre- and post-intervention and six-month follow-up outcomes.

Discussion:

If shown efficacious in improving attention and memory, our team will then take a key role in implementing Amat-c into clinical care.

Rationale and description of BrainLevel: Computerized repeated practice with strategy use instruction for children with acquired brain injury

OBJECTIVE

In this paper, we provide the rationale behind and a description of BrainLevel, a new cognitive rehabilitation intervention for children with acquired brain injury.

RATIONALE

Children with acquired brain injury frequently report cognitive problems and consequently problems in participation, psychosocial functioning, family functioning and quality of life. Computerized repeated practice of specific cognitive tasks (so-called 'brain training') improves performance on those specific or highly similar tasks, but rarely leads to better daily life functioning. Adding strategy use instruction as an intervention component, with the aim to transfer task-specific effects to other contexts, may yield positive effects on cognitive and daily life functioning of children with acquired brain injury.

DESCRIPTION OF THE NEW INTERVENTION

In BrainLevel, computerized repeated practice is offered via the online training programme BrainGymmer. For the strategy use instruction, we developed a protocol to provide and practice function-specific and metacognitive strategies. The intervention period is 6 weeks, during which children train five times per week for 30 minutes per day at home with BrainGymmer. Additionally, they attend a weekly 45-minute strategy use instruction session on the basis of our protocol with a cognitive rehabilitation specialist.

DISCUSSION

BrainLevel is innovative in combining computerized repeated practice with strategy use instruction as cognitive rehabilitation for children with acquired brain injury. Currently, we are investigating the effectiveness of BrainLevel. In this paper, possible adaptations to tailor BrainLevel to other games or contexts, or to incorporate novel scientific insights, for example regarding optimal intervention duration and intensity, are discussed.

Alcohol and Tobacco use While Breastfeeding and Risk of Autism Spectrum Disorder or Attention Deficit/Hyperactivity Disorder

Research has linked prenatal alcohol and tobacco use with Attention Deficit Hyperactivity Disorder (ADHD), and variably with Autism Spectrum Disorder (ASD). Lactational use has been scantly considered. This study examined whether it may alter ADHD or ASD risk. Participants were 5107 infants recruited in 2004 and assessed longitudinally for the Growing Up in Australia Study. Logistic regression did not find any associations between maternal alcohol and tobacco use while breastfeeding and ADHD or ASD diagnosis at ages 6–7 or 10–11 years. Alcohol and tobacco use during lactation may not increase ADHD or ASD risk. Abstaining from alcohol and tobacco, however, may still be the safest option. Analyses were limited by lack of alcohol timing and retrospective variables that future research should address.

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.

A neuropsychological approach in a paediatric acquired brain injury unit under the public health system

INTRODUCTION

Paediatric acquired brain injury (ABI) causes cognitive and behavioural difficulties and alters the course of child development. The ABI unit at Hospital Infantil Universitario Niño Jesús is the first within the public Spanish health system to provide comprehensive coverage to these patients and their families.

OBJECTIVE

This study aims to show the working methodology followed with patients and their families, and to describe the clinical characteristics of the patients treated and the outcomes of treatment.

PATIENTS

Fifty-three patients aged between three months and 16 and a half years received treatment. The conditions treated were brain tumours, stroke, traumatic brain injury, damage secondary to epilepsy surgery, and hypoxia.

METHODS

All patients were evaluated at admission and at discharge. Treatments were adapted to each patient's difficulties and their severity, as well as to the patient's age. Families received individual and group therapy.

RESULTS

Older age was associated with better cognitive recovery and shorter duration of treatment. Different conditions show differential impact on intelligence quotient and developmental quotient scores at the beginning of treatment, with hypoxia and encephalitis being associated with greatest severity. Intelligence quotient and developmental quotient scores and visual memory and attention scores at discharge improved significantly after the faceted neuropsychological treatment with respect to scores registered at admission.

CONCLUSIONS

The care of patients with ABI should include neuropsychological rehabilitation programmes and provide emotional support to the family so that they may actively participate in the recovery of the child or adolescent.

Assessment of memory functioning over two years following severe childhood traumatic brain injury: results of the TGE cohort

The aims of this study were (1) to prospectively measure memory functioning following severe childhood Traumatic Brain Injury (TBI), and its evolution over 2 years; (2) to assess demographic and medical factors associated with memory function and recovery; (3) to explore relations between memory and other TBI outcomes. Methods: Children (aged 0-15 years; n= 65) consecutively admitted in a single trauma center over a 3-year period, who survived severe non-inflicted TBI, were included in a prospective longitudinal study. Memory was assessed in 38 children aged 5-15 years at injury, using the Children's Memory Scale at 3, 12, and 24 months post-injury. Results: Mean general memory score was low at 3 months (M = 90.2, SD = 20.3) but within the normal range at 12 and 24 months (M = 100.6, SD = 23.1 and M = 108.6, SD = 24.1, respectively), with high variability. Improvement was stronger for immediate visual memory than for other memory indices. Lower general memory score was associated with higher injury severity, lower intellectual ability and functional status, higher overall disability, and ongoing education. Conclusion: Memory functioning is highly variable following severe childhood TBI, related to injury severity and functional, cognitive and educational outcomes; improvement is significant during the first-year post-injury, but varies according to the type of memory.

Age-dependent differences in the impact of paediatric traumatic brain injury on executive functions: A prospective study using susceptibility-weighted imaging

Childhood and adolescence represent sensitive developmental periods for brain networks implicated in a range of complex skills, including executive functions (EF; inhibitory control, working memory, and cognitive flexibility). As a consequence, these skills may be particularly vulnerable to injuries sustained during these sensitive developmental periods. The present study investigated 1) whether age at injury differentially affects EF 6 months and 2 years after TBI in children aged 5-15 years, and 2) whether the association between brain lesions and EF depend on age at injury. Children with TBI (n = 105) were categorized into four age-at-injury groups based on previous studies and proposed timing of cerebral maturational spurts: early childhood (5-6 years, n = 14), middle childhood (7-9 years, n = 24), late childhood (10-12 years, n = 52), and adolescence (13-15 years, n = 15). EF were assessed with performance-based tasks and a parent-report of everyday EF. TBI patients' EF scores 6 months and 2 years post-injury were compared to those of typically developing (TD) controls (n = 42). Brain lesions were identified using susceptibility weighted imaging (SWI). Results indicated that inhibitory control performance 2 years post-injury was differentially affected by the impact of TBI depending on age at injury. Follow-up analyses did not reveal significant differences within the age groups, preventing drawing strong conclusions regarding the contribution of age at injury to EF outcome after TBI. Tentatively, large effect sizes suggest that vulnerability is most apparent in early childhood and adolescence. Everyday inhibitory control behaviour was worse for children with TBI than TD children across childhood and adolescence at the 2-year assessment. There was no evidence for impairment in working memory or cognitive flexibility after TBI at the group level. Given small group sizes, findings from analyses into correlations between EF and SWI lesions should be interpreted with caution. Extent, number and volume of brain lesions correlated with adolescent everyday EF behaviour 6 months post-injury. Taken together, the results emphasize the need for long-term follow-up after paediatric TBI during sensitive developmental periods given negative outcomes 2-year post injury. Inhibitory control seems to be particular vulnerable to the impact of TBI. Findings of associations between EF and SWI lesions need to be replicated with larger samples.

Drinking or Smoking While Breastfeeding and Later Cognition in Children

BACKGROUND AND OBJECTIVES

Although prenatal alcohol and nicotine exposure are associated with reduced cognition in children, associations between consumption of alcohol during lactation and cognition have not been examined. We aimed to examine whether drinking or smoking while breastfeeding lowers children's cognitive scores. We hypothesized that increased drinking or smoking would be associated with dose-dependent cognitive reductions.

METHODS

Data were sourced from Growing Up in Australia: The Longitudinal Study of Australian Children. Participants were 5107 Australian infants recruited in 2004 and assessed every 2 years. Multivariable linear regression analyses assessed relationships between drinking and smoking habits of breastfeeding mothers and children's Matrix Reasoning, Peabody Picture Vocabulary Test-Third Edition and Who Am I? scores at later waves.

RESULTS

Increased or riskier wave 1 maternal alcohol consumption was associated with reductions in Matrix Reasoning scores at age 6 to 7 years in children who had been breastfed (B = -0.11; SE = 0.03; 95% confidence interval: -0.18 to -0.04; P = .01). This relationship was not evident in infants who had never breastfed (B = -0.02; SE = 0.10; 95% confidence interval = -0.20 to 0.17; P = .87). Smoking during lactation was not associated with any outcome variable.

CONCLUSIONS

Exposing infants to alcohol through breastmilk may cause dose-dependent reductions in their cognitive abilities. This reduction was observed at age 6 to 7 years but was not sustained at age 10 to 11 years. Although the relationship is small, it may be clinically significant when mothers consume alcohol regularly or binge drink. Further analyses will assess relationships between alcohol consumption or tobacco smoking during lactation and academic, developmental, physical, and behavioral outcomes in children.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A systematic review of pediatric cognitive rehabilitation in the elementary and middle school systems

BACKGROUND

Cognitive Rehabilitation Therapy (CRT) is efficacious in remediating cognitive deficits, and has been demonstrated to be effective in a school setting.

OBJECTIVE

The purpose of this paper is to review the literature on pediatric CRT as it relates to successful re-integration of TBI survivors into the school system and community.

METHODS

This systematic review of the literature suggests that social re-integration strategies which incorporate problem-solving, reasoning, self-awareness, and positive social skills within a developmental framework are the most effective techniques for Pediatric CRT.

RESULTS

Children and adolescents with cognitive impairments benefit from a holistic approach to rehabilitation which incorporates developmental, social, and emotional considerations, as well as, cognitive rehabilitation techniques.

CONCLUSIONS

This systematic review identifies several avenues for effective therapeutic interventions for school aged TBI survivors. Many are supported by laboratory based efficacy studies. Future research should investigate optimal ages for particular treatments, as well as, the effectiveness of treatments across different social settings.

Low brain oxygenation and differences in neuropsychological outcomes following severe pediatric TBI

PURPOSE

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Preventing secondary injury by controlling physiological parameters (e.g. intracranial pressure [ICP], cerebral perfusion pressure [CPP] and brain tissue oxygen [PbtO2]) has a potential to improve outcome. Low PbtO2 is independently associated with poor clinical outcomes in both adults and children. However, no studies have investigated associations between low PbtO2 and neuropsychological and behavioural outcomes following severe pediatric TBI (pTBI).

METHODS

We used a quasi-experimental case-control design to investigate these relationships. A sample of 11 TBI patients with a Glasgow Coma Scale score ≤8 who had PbtO2 and ICP monitoring at the Red Cross War Memorial Children's Hospital underwent neuropsychological evaluation ≥1 year post-injury. Their performance was compared to that of 11 demographically matched healthy controls. We then assigned each TBI participant into one of two subgroups, (1) children who had experienced at least one episode of PbtO2 ≤ 10 mmHg or (2) children for whom PbtO2 > 10 mmHg throughout the monitoring period, and compared their results on neuropsychological evaluation.

RESULTS

TBI participants performed significantly more poorly than controls in several cognitive domains (IQ, attention, visual memory, executive functions and expressive language) and behavioural (e.g. externalizing behaviour) domains. The PbtO2 ≤ 10 mmHg group performed significantly worse than the PbtO2 > 10 mmHg group in several cognitive domains (IQ, attention, verbal memory, executive functions and expressive language), but not on behavioural measures.

CONCLUSION

Results demonstrate that low PbtO2 may be prognostic of not only mortality but also neuropsychological outcomes.

Evaluation of an attention and memory intervention post-childhood acquired brain injury: Preliminary efficacy, immediate and 6 months post-intervention

OBJECTIVE

Impairments in attention and memory are common sequelae following paediatric acquired brain injury (ABI). While it has been established that such impairments are long-term and, therefore, affect quality-of-life, there is a scarcity of evidence-based interventions to treat these difficulties. The current study aimed to pilot the efficacy of the Amsterdam Memory and Attention Training for Children (Amat-c: English version) using both neuropsychological and ecologically sensitive measures. It was expected that children with attention and memory difficulties post-ABI would show improved performance post-intervention on cognitive and ecological measures, with maintenance at 6 months post-intervention.

METHODS AND PROCEDURES

Ten children with an ABI, between the ages of 8-13 years at the time of recruitment were identified through audits of presentations to a metropolitan paediatric hospital. Each child underwent screening, the 18 week intervention programme, pre-intervention, immediate and 6 month post-intervention assessments.

OUTCOMES/RESULTS

Findings supported the hypothesis that children would show post-intervention (immediate and 6 month) improvement in areas of attention and memory, with generalization to everyday life.

CONCLUSIONS/IMPLICATIONS

Preliminary results provide support for the efficacy of the Amat-c post-childhood ABI. A larger study is needed to confirm these findings, as a reduction in attention and memory difficulties will enhance everyday functioning.

Memory outcomes following cognitive interventions in children with neurological deficits: A review with a focus on under-studied populations

Given the primary role of memory in children's learning and well-being, the aim of this review was to examine the outcomes of memory remediation interventions in children with neurological deficits as a function of the affected memory system and intervention method. Fifty-seven studies that evaluated the outcome of memory interventions in children were identified. Thirty-four studies met the inclusion criteria, and were included in a systematic review. Diverse rehabilitation methods for improving explicit and implicit memory in children were reviewed. The analysis indicates that teaching restoration strategies may improve, and result in the generalisation of, semantic memory and working memory performance in children older than 7 years with mild to moderate memory deficits. Factors such as longer protocols, emotional support, and personal feedback contribute to intervention efficacy. In addition, the use of compensation aids seems to be highly effective in prospective memory tasks. Finally, the review unveiled a lack of studies with young children and the absence of group interventions. These findings point to the importance of future evidence-based intervention protocols in these areas.

Cognitive-communication disorders in children with traumatic brain injury

Children with moderate to severe traumatic brain injury (TBI) are at risk of developing cognitive-communication disorders that have devastating effects on their school life, family life, and social life. These problems can be difficult for families to describe and may be overlooked by community-based providers who are unfamiliar with TBI sequelae. To support the identification and management of cognitive-communication disorders, we review the common signs and symptoms of these disorders in children with TBI and discuss principles of assessment and intervention.

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.

Taking a developmental and systemic perspective on neuropsychological rehabilitation with children with brain injury and their families

This paper reviews current approaches and models in the neuropsychological rehabilitation of children following Traumatic Brain Injury (TBI) and cites a large evidence base for a developmental and family systems perspective to neuropsychological rehabilitation of children post-TBI. The paper describes the application and efficacy of a systemic and developmental perspective to rehabilitation of children with TBI, with a clinical case example of this approach. The paper describes the development of a community-based child neuropsychology rehabilitation service integrating applied developmental neuropsychology and systems ideas as a way of working effectively with children with TBI and their families.

Practitioner review: beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury?

BACKGROUND

Traumatic brain injury (TBI) in infancy is relatively common, and is likely to lead to poorer outcomes than injuries sustained later in childhood. While the headlines have been grabbed by infant TBI caused by abuse, often known as shaken baby syndrome, the evidence base for how to support children following TBI in infancy is thin. These children are likely to benefit from ongoing assessment and intervention, because brain injuries sustained in the first year of life can influence development in different ways over many years.

METHODS

A literature search was conducted and drawn together into a review aimed at informing practitioners working with children who had a brain injury in infancy. As there are so few evidence-based studies specifically looking at children who have sustained a TBI in infancy, ideas are drawn from a range of studies, including different age ranges and difficulties other than traumatic brain injury.

RESULTS

This paper outlines the issues around measuring outcomes for children following TBI in the first year of life. An explanation of outcomes which are more likely for children following TBI in infancy is provided, in the areas of mortality; convulsions; endocrine problems; sensory and motor skills; cognitive processing; language; academic attainments; executive functions; and psychosocial difficulties. The key factors influencing these outcomes are then set out, including severity of injury; pre-morbid situation; genetics; family factors and interventions.

CONCLUSIONS

Practitioners need to take a long-term, developmental view when assessing, understanding and supporting children who have sustained a TBI in their first year of life. The literature suggests some interventions which may be useful in prevention, acute care and longer-term rehabilitation, and further research is needed to assess their effectiveness.

Long-term cognitive outcome after neurosurgically treated childhood traumatic brain injury

OBJECTIVE

To explore the cognitive long-term outcome of two cohorts of patients neurosurgically treated for childhood traumatic brain injury (CTBI), either in 1987-1991 according to an older concept or 1997-2001 with a stronger emphasis on volume targeted interventions.

RESEARCH DESIGN AND METHODS

Participants in the two cohorts were subject to an extensive neuropsychological assessment, 13.2 and 6.1 years post-injury, respectively. In a between-group design, assessment results of the two cohorts, n = 18 and n = 23, were compared to each other and to controls. Data were analysed with multivariate analyses of variance.

RESULTS

Long-term cognitive deficits for both groups of similar magnitude and character were observed in both groups. Abilities were especially low regarding executive and memory function and verbal IQ. The cognitive results are discussed in terms of vulnerability of verbal functions and decreased executive control over memory-functions.

CONCLUSIONS

There is a definite need for long-term follow-up of cognitive deficits after neurosurgically treated CTBI, also with the newer neurosurgical concept. Verbal learning and the executive control over memory functions should be addressed with interventions aimed at restoration, coping and compensation.

Head trauma in children, part 3: clinical and psychosocial outcome after head trauma in children

With the aim of determining long-term outcome, the authors approached 38 families (average 2.1 years after trauma) with a questionnaire, following the acute-clinical treatment of head trauma of their children. Long-term damage was restricted almost exclusively to patients presenting with a Glasgow Coma Score < or =8. Paresis (16%), cranial nerve damage (13%), incontinence (5%), or coordinative disturbances (18%) continued. The older children stated that they influenced their life to a great extent (11%). Furthermore, many had mental and cognitive problems that occur quite frequently even in children with light head trauma and often only manifest after release from hospital. This causes problems and results in inferior performance (26%), especially at school, which is further complicated through lengthy periods of absence. The parents, especially, mentioned behavioral problems such as social withdrawal or aggressive demeanor, which led to tension also inside the family. A persistent vegetative state is rare after head trauma in children.

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.

A comprehensive model of care for rehabilitation of children with acquired brain injuries

BACKGROUND

Acquired brain injury (ABI) is a leading cause of death and lifelong acquired disability in children and remains a significant public health issue. Deficits may only become fully apparent when developmental demands increase and once cognitive processes are expected to be fully developed. It is therefore necessary to provide organized long-term follow-up for children post ABI. Despite these recommendations, it has been shown that only a small proportion of children received specialized rehabilitation and adequate follow-up after ABI.

AIMS

The aims are: (i) to describe a comprehensive model of care devoted to children with acquired brain injuries; and (ii) to provide descriptive data analysing the characteristics of children followed up, the type/amount of services provided and general outcomes.

PROGRAMME DESCRIPTION

The programme features an in- and outpatient rehabilitation facility, where multidisciplinary rehabilitation and specialized schooling are provided. The ultimate goal of the programme is to promote each child's successful reintegration in school and in the community. Adequate preparation of discharge is essential, long-term follow-up is organized, and an outreach programme has been developed to deal with the complex delayed psychosocial issues.

RESULTS

Overall outcome, as measured by the Glasgow Outcome Scale, improved dramatically between admission (3.3; SD = 0.45) and discharge (2.15; SD = 0.74). Most of the children were discharged home with an adequate personalized plan for ongoing rehabilitation and school adaptations. Analysis of the outreach programme underlines the more challenging issues arising in late adolescence-early adulthood.

CONCLUSION

Given the specificities of childhood ABI, long-term specific care must be organized and co-ordinated, regardless of injury severity.

An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock

OBJECTIVE

To evaluate self-reported health-related quality of life, anxiety, depression, and cognitive function in pediatric septic shock survivors.

DESIGN

A retrospective cohort study.

SETTING

A 14-bed tertiary pediatric intensive care unit.

PATIENTS

Children aged >or=8 yrs at the time of the follow-up who were admitted between 1995 and 2004 for septic shock. Inotropic and or vasoconstrictive agents were administered to these patients for >or=24 hrs.

INTERVENTION

Health-related quality of life was assessed with the KIDSCREEN-52, anxiety with the State Trait Anxiety Inventory for Children, depression with the Children's Depression Inventory, and cognitive function with the cognitive scale of the TNO-AZL Children's Quality of Life Questionnaire Child Form.

MEASUREMENTS AND MAIN RESULTS

Fifty of 82 eligible pediatric septic shock survivors were evaluated. The median age of the children at pediatric intensive care unit admission was 4.2 yrs (range, 0.0-17.0 yrs); the median age at follow-up was 10.7 yrs (range, 8.0-20.4 yrs). Health-related quality of life and anxiety scores were comparable to the age-related Dutch norm population. Depression scores were significantly better than the norm population, whereas cognitive function was significantly lower than the norm population. We found that 44% of the children had cognitive scores <25% of the norm population. Young age at the time of pediatric intensive care unit admission was predictive of cognitive problems, and cognitive problems were associated with lower emotional function.

CONCLUSIONS

In this group of septic shock survivors, health-related quality of life, anxiety, and depression are equal to or slightly better than the age-related Dutch norm population. Cognitive function is decreased, especially in children admitted at younger ages. Follow-up studies with adequate neuropsychological testing are warranted to evaluate the association between septic shock, cognitive function, and risk factors for cognitive problems.

Evaluation of functionality after head injury in adolescents

BACKGROUND

The Occupational Therapy Head Injury Mini Screen (OT HIMS) is a screening tool for patients admitted with traumatic brain injury (TBI) in the acute care setting. It is a combination of the Galveston Orientation and Amnesia Test (GOAT) and the Cognistat (formally the Neurobehavioral Cognitive Status Examination). Its purpose is to identify cognitive deficits in patients and to provide education for patients on the impact of these deficits on daily living. Our hypothesis for this study was that cognitive functionality outcome varies with severity of head injury (manifested by Glasgow Coma Scale [GCS]) at admission and tests that identify cognitive deficits can be reserved for patients admitted with severe head injury.

METHODS

Data were prospectively collected for all patients with TBI (DRG International Classification of Diseases-9th Rev.-Clinical Modification codes 800.0-801.99 + 850-859.9), aged 13-21 years, over 10 years. The inclusion criteria are patients had to be awake and have adequate physical function to complete the test. Patients with cognitive deficits were identified using GOAT and Cognistat. Preexistent deficits were also identified. Scores on OT HIMS were compared with GCS at admission. Outcomes also included discharge to home or rehabilitation centers. Hospital deaths were not included in the study.

RESULTS

Six hundred nine patients were reviewed, and 248 were administered the OT HIMS. Eighty-three suffered some impairment. The mean GCS for the 248 patients was 13.96 (+/-2.16). A coefficient of correlation between GCS and GOAT score of only 0.224 and an R2 value of 0.050 indicated no correlation between these results. Comparing GCS and the presence of impairment identified by Cognistat yielded an R2 value of 0.093, indicating no correlation between these parameters. Among the patients whose results showed cognitive deficits on OT HIMS, 38% had impairments before injury. Interestingly, only 58% of patients with deficits before injury also demonstrated impairments on OT HIMS. Of the 248 patients, 12 went to rehabilitation centers and this was not correlated with GCS.

CONCLUSIONS

In this study, admission GCS did not predict performance on the OT HIMS after injury in this cohort of patients with adequate recovery to take the examination. Cognitive functionality can be impaired after TBI of even minimal degree. All patients admitted for TBI should be screened for cognitive deficits before discharge. Long-term follow-up for this group must be performed for maximal therapy and optimal outcomes.

Assessment of executive functioning in children after TBI with a naturalistic open-ended task: a pilot study

PURPOSE

Traumatic brain injury (TBI) often leads to executive functions (EF) deficits, resulting in severe longstanding disabilities in daily life activities. The sensitivity and ecological validity of neuropsychological tests have been questioned. The aim of this study was to pilot a novel open-ended naturalistic task and to compare it to other standardized assessments of EF in children post-TBI.

METHODS

Ten children aged 8-14, with moderate-to-severe TBI, and 18 matched controls participated in the study. The clinical group was assessed using cognitive tests and parent-based questionnaires of EF. An interactive ecological cooking task was designed.

RESULTS

Analyses indicated mild-to-moderate executive deficits in the cognitive tests in approximately half of the TBI group. For the experimental cooking task, all quantitative and qualitative variables were significantly impaired for the TBI group compared to the control group and failure in the cooking task was associated with lower scores in cognitive tests of EF. The task was able to discriminate the TBI children from the control group.

CONCLUSION

This pilot study highlights the role of naturalistic assessments, to complement standardized tests in assessing patients' dysexecutive impairments in complex activities of daily living post-childhood TBI.

Neurobehavioral Outcomes After Early Versus Late Childhood Traumatic Brain Injury

OBJECTIVES

To examine differences in outcomes at transition age (17-21 years) between individuals who sustained complicated mild-to-severe traumatic brain injury (TBI) in early or middle childhood and those who were injured in late adolescence.

PARTICIPANTS

Fifteen persons who sustained TBI between the ages of 6 and 12 years (early-onset) and 30 persons who sustained TBI between the ages of 16 and 20 years (late-onset).

MEASURES

Peabody Picture Vocabulary Test-Third Edition, Trail-Making Test, Buschke Selective Reminding Test, Benton Visual Retention Test, Dysexecutive Questionnaire, Community Integration Questionnaire, Satisfaction with Life Scale.

RESULTS

The groups did not differ in overall cognitive ability level, postinjury education or vocational accomplishments, or current living situation. However the early-onset group demonstrated worse outcomes in higher-level cognitive skills, social integration, driving, and legal guardianship.

CONCLUSIONS

Complicated mild-to-severe TBI earlier in childhood is associated with worse long-term neurocognitive and psychosocial outcomes than injury sustained in late adolescence. Findings provide further support for theories that early brain injury onset interferes with development of immature or rapidly developing skills, and may be associated with further magnification of deficits during the course of later development.