Effective connectivity in the default mode network after paediatric traumatic brain injury

Children who experience a traumatic brain injury (TBI) are at elevated risk for a range of negative cognitive and neuropsychological outcomes. Identifying which children are at greatest risk for negative outcomes can be difficult due to the heterogeneity of TBI. To address this barrier, the current study applied a novel method of characterizing brain connectivity networks, Bayesian multi-subject vector autoregressive modelling (BVAR-connect), which used white matter integrity as priors to evaluate effective connectivity-the time-dependent relationship in functional magnetic resonance imaging (fMRI) activity between two brain regions-within the default mode network (DMN). In a prospective longitudinal study, children ages 8-15 years with mild to severe TBI underwent diffusion tensor imaging and resting state fMRI 7 weeks after injury; post-concussion and anxiety symptoms were assessed 7 months after injury. The goals of this study were to (1) characterize differences in positive effective connectivity of resting-state DMN circuitry between healthy controls and children with TBI, (2) determine if severity of TBI was associated with differences in DMN connectivity and (3) evaluate whether patterns of DMN effective connectivity predicted persistent post-concussion symptoms and anxiety. Healthy controls had unique positive connectivity that mostly emerged from the inferior temporal lobes. In contrast, children with TBI had unique effective connectivity among orbitofrontal and parietal regions. These positive orbitofrontal-parietal DMN effective connectivity patterns also differed by TBI severity and were associated with persisting behavioural outcomes. Effective connectivity may be a sensitive neuroimaging marker of TBI severity as well as a predictor of chronic post-concussion symptoms and anxiety.

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.

Pediatric traumatic brain injury and abusive head trauma

Childhood traumatic brain injury (TBI) commonly occurs during brain development and can have direct, immediately observable neurologic, cognitive, and behavioral consequences. However, it can also disrupt subsequent brain development, and long-term outcomes are a combination of preinjury development and abilities, consequences of brain injury, as well as delayed impaired development of skills that were immature at the time of injury. There is a growing number of studies on mild TBI/sport-related concussions, describing initial symptoms and their evolution over time and providing guidelines for effective management of symptoms and return to activity/school/sports. Mild TBI usually does not lead to long-term cognitive or academic consequences, despite reports of behavioral/psychologic issues postinjury. Regarding moderate to severe TBI, injury to the brain is more severe, with evidence of a number of detrimental consequences in various domains. Patients can display neurologic impairments (e.g., motor deficits, signs of cerebellar disorder, posttraumatic epilepsy), medical problems (e.g., endocrine pituitary deficits, sleep-wake abnormalities), or sensory deficits (e.g., visual, olfactory deficits). The most commonly reported deficits are in the cognitive-behavioral field, which tend to be significantly disabling in the long-term, impacting the development of autonomy, socialization and academic achievement, participation, quality of life, and later, independence and ability to enter the workforce (e.g., intellectual deficits, slow processing speed, attention, memory, executive functions deficits, impulsivity, intolerance to frustration). A number of factors influence outcomes following pediatric TBI, including preinjury stage of development and abilities, brain injury severity, age at injury (with younger age at injury most often associated with worse outcomes), and a number of family/environment factors (e.g., parental education and occupation, family functioning, parenting style, warmth and responsiveness, access to rehabilitation and care). Interventions should identify and target these specific factors, given their major role in postinjury outcomes. Abusive head trauma (AHT) occurs in very young children (most often <6 months) and is a form of severe TBI, usually associated with delay before appropriate care is sought. Outcomes are systematically worse following AHT than following accidental TBI, even when controlling for age at injury and injury severity. Children with moderate to severe TBI and AHT usually require specific, coordinated, multidisciplinary, and long-term rehabilitation interventions and school adaptations, until transition to adult services. Interventions should be patient- and family-centered, focusing on specific goals, comprising education about TBI, and promoting optimal parenting, communication, and collaborative problem-solving.

Results of scoping review do not support mild traumatic brain injury being associated with a high incidence of chronic cognitive impairment: Commentary on McInnes et al. 2017

A recently published review of 45 studies concluded that approximately half of individuals who sustain a single mild traumatic brain injury (MTBI) experience long-term cognitive impairment (McInnes et al. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS ONE 2017;12:e0174847). Stratified by age, they reported that 50% of children and 58% of adults showed some form of cognitive impairment. We contend that the McInnes et al. review used a definition of “cognitive impairment” that was idiosyncratic, not applicable to individual patients or subjects, inconsistent with how cognitive impairment is defined in clinical practice and research, and resulted in a large number of false positive cases of cognitive impairment. For example, if a study reported a statistically significant difference on a single cognitive test, the authors concluded that every subject with a MTBI in that study was cognitively impaired–an approach that cannot be justified statistically or psychometrically. The authors concluded that impairment was present in various cognitive domains, such as attention, memory, and executive functioning, but they did not analyze or report the results from any of these specific cognitive domains. Moreover, their analyses and conclusions regarding many published studies contradicted the interpretations provided by the original authors of those studies. We re-reviewed all 45 studies and extracted the main conclusions from each. We conclude that a single MTBI is not associated with a high incidence of chronic cognitive impairment.

The first signs of prospective memory

We conducted a study to examine the impact of motivation and length of delay on performance on prospective memory (PM) tasks in 2-year of children. A total of 158 children aged exactly 24 months were asked to perform a naturalistic PM task. Length of delay (10 min; 35 min) and motivation (high; very high) were between-subjects factors. Two thirds of children had to be excluded from the analysis because of poor retrospective memory for the PM task instructions which were no longer remembered at the end of the session. For the children who did remember the instructions, both motivation and delay had significant effects on PM. Also, their PM performance was reliably above zero, even after the long delay. The findings indicate that when children as young as 24 months are able to remember the PM task instructions they can reliably succeed in PM tasks that are intrinsically motivating for them.

Development of Children's Use of External Reminders for Hard-to-Remember Intentions

This study explored under what conditions young children would set reminders to aid their memory for delayed intentions. A computerized task requiring participants to carry out delayed intentions under varying levels of cognitive load was presented to 63 children (aged between 6.9 and 13.0 years old). Children of all ages demonstrated metacognitive predictions of their performance that were congruent with task difficulty. Only older children, however, set more reminders when they expected their future memory performance to be poorer. These results suggest that most primary school-aged children possess metacognitive knowledge about their prospective memory limits, but that only older children may be able to exercise the metacognitive control required to translate this knowledge into strategic reminder setting.

Episodic future thinking as a predictor of children's prospective memory

The primary goal of this study was to investigate the relationship among retrospective memory, episodic future thinking, and event-based prospective memory performance in preschool, first-grade, and second-grade children. A total of 160 children took part in the experiment. The study included participants from four age groups: 4-year-olds, 5-year-olds, 6-year-olds, and 7-year-olds. Participants were administered a recognition memory task, a task to test the ability to pre-experience future events, and an event-based prospective memory task. Data were submitted to correlational analyses, analyses of variance (ANOVAs), and logistic regression analyses. Results showed that, overall, all of these abilities improve with age and are significantly correlated with one another. However, when partialling out age and retrospective memory, episodic future thinking and prospective memory performance remained correlated. Logistic regression further showed that age and episodic future thinking abilities were significant predictors of prospective memory performance independent of retrospective memory abilities.

A large-scale comparison of prospective and retrospective memory development from childhood to middle age

We present the first large-scale comparison of prospective memory (PM) and retrospective memory (RM) from 8 to 50 years of age ( N = 318,614). Participants in an Internet study were asked to remember to click on a smiley face (single-trial event-based PM test) and to indicate whether/where a picture had changed from study to test (single-trial RM test), in both cases after retention intervals filled with working-memory tests and questionnaires. Both PM and RM improved during childhood; however, whereas maximal PM was reached by teenagers, with approximately linear decline through the 20s–40s, RM continued to improve through the 20s and 30s. On both tests, females outperformed males and achieved maximal success at earlier ages. Strikingly, 10–11-year-old girls performed significantly better than females in their late 20s on the PM test. The presence of the smiley face at encoding and temporal uncertainty (expecting it “later” rather than at the “end” of the test) both benefited PM; these effects decreased and increased, respectively, from childhood to middle age. The findings demonstrate that in a cross-sectional study (a) developmental trajectories are qualitatively different between PM and RM, and (b) the relative influence of PM cues differs between younger and older ages.

Event-based prospective memory performance during subacute recovery following moderate to severe traumatic brain injury in children: Effects of monetary incentives

There are very few studies investigating remediation of event-based prospective memory (EB-PM) impairments following traumatic brain injury (TBI). To address this, we used 2 levels of motivational enhancement (dollars vs. pennies) to improve EB-PM in children with moderate to severe TBI in the subacute recovery phase. Children with orthopedic injuries (OI; n = 61), moderate (n = 28), or severe (n = 30) TBI were compared. Significant effects included Group x Motivation Condition (F(2, 115) = 3.73, p < .03). The OI (p < .002) and moderate TBI (p < .03) groups performed significantly better under the high- versus low-incentive condition; however, the severe TBI group failed to demonstrate improvement (p = .38). EB-PM performance was better in adolescents compared to younger children (p < .02). These results suggest that EB-PM can be significantly improved in the subacute phase with this level of monetary incentives in children with moderate, but not severe, TBI. Other strategies to improve EB-PM in these children at a similar point in recovery remain to be identified and evaluated.

Neurodevelopmental outcomes of pediatric traumatic brain injury

Pediatric traumatic brain injury is a major cause for concern when considering both the number of children sustaining injuries and the large number of children incurring life-long difficulties that impact on quality of life. Research is continuing to investigate outcomes and predictors of recovery in both cognitive and behavioral domains. Findings have contributed to better identification of children at high risk for neurobehavioral difficulties. The challenge is to now develop intervention programs to prevent or lessen the impact of such difficulties.

Rehabilitation for cognitive impairments after cerebral malaria in African children: strategies and limitations

Cerebral malaria results in short- to long-term cognitive impairments in many of its child survivors. Although some of the risk factors for impairments have been identified, no attempts have been made to address the plight of those who develop cognitive impairments. This paper discusses the burden of cognitive impairment caused by cerebral malaria and suggests some rehabilitation strategies based on brain injury and cognitive rehabilitation studies. Potential cognitive rehabilitation solutions such as cognitive exercises, environmental enrichment, nutritional supplementation, physical therapy and speech therapy are highlighted. The limitations of implementing these interventions and solutions are discussed in light of the limited human resources and infrastructure of the developing countries that are malaria endemic.

Planning and realization of complex intentions in traumatic brain injury and normal aging

The realization of delayed intentions (i.e., prospective memory) is a highly complex process composed of four phases: intention formation, retention, re-instantiation, and execution. The aim of this study was to investigate if executive functioning impairments are related to problems in the formation, re-instantiation, and execution of a delayed complex intention. In this context, it was another aim of the study to investigate the executive functioning hypothesis of cognitive aging in prospective memory performance. It was, therefore, explored if age-related prospective memory decline leads to similar decrements in the process of prospective remembering as executive functioning-related decline in young patients with traumatic brain injury. A group of patients with traumatic brain injury with retrospective memory within normal limits but impaired executive functions, a group of healthy older and a group of healthy younger adults completed a complex prospective memory task that allows for the separate assessment of the four phases of the prospective memory process. All groups showed a similarly high performance in the intention retention phase, whereas the patients with deficits in executive functioning and the older participants performed worse than the healthy young participants in the intention formation, re-instantiation and execution phases. The importance of executive functioning for prospective remembering in traumatic brain injury and normal aging is discussed.

Changes in Working Memory After Traumatic Brain Injury in Children

The impact of traumatic brain injury (TBI) on working memory (WM) was studied in 144 children (79 with mild, 23 with moderate, and 42 with severe injuries) who underwent magnetic resonance imaging (MRI) at 3 months and were tested at baseline and at 3, 6, 12, and 24 months postinjury. An n-back WM task for letter identity was administered with memory load ranging from 1- to 3-back and a 0-back condition. A TBI Severity x Quadratic Tune interaction showed that net percentage correct (correct detections of targets minus false alarms) was significantly lower in severe than in mild TBI groups. The Left Frontal Lesions x Age interaction approached significance. Mechanisms mediating late decline in WM and the effects of left frontal lesions are discussed.