Psychological and adjustment problems due to acquired brain lesions in pre-school-aged patients

[Formula: see text] Interventions to improve executive functions in children and adolescents with acquired brain injury: a systematic review and multilevel meta-analysis

To investigate the effectiveness of interventions aiming to improve hot and cold executive functions (EFs) in children and adolescents with acquired brain injury (ABI) and to examine whether characteristics of the intervention, participants, etiology of ABI (Traumatic-brain-injury [TBI] or non-TBI), time of assessment, or study quality moderate intervention effects. Whereas cold EFs refer to purely cognitive EFs, hot EFs refer to the affective aspects of these cognitive skills. A total of 970 participants from 23 randomized-controlled-trial studies (112 effect sizes [ES]) were included. A three-level random effects approach (studies, ES, individual participants) was used. Moderation analyses were conducted through meta-regressions. The three-level random effects model showed a better fit than the two-level model. Almost all individual studies showed non-significant ES across outcomes but in combination interventions were effective (Cohen's d = 0.38, CI 0.16 ~ 0.61). Lower methodological quality, inclusion of participants with non-TBI, and parental participation predicted larger ES. Participants' age, time of assessment, number of sessions, and focus on hot or cold EFs were not related to ES. We found no evidence of publication bias. Interventions are effective with small to medium ES according to conventional criteria. Intervention effects do not seem to fade away with time. Parent participation in the intervention is important to improve EFs. The efficacy of interventions seems larger when non-TBI is part of the etiology of ABI. Variation between studies is relevant for tracing the effective intervention characteristics. Most studies are conducted in adolescence, and studies in early childhood are needed.

Long-Term Vocational Outcome at 15 Years from Severe Traumatic and Non-Traumatic Brain Injury in Pediatric Age

BACKGROUND

Recent studies suggest that acquired brain injury with impaired consciousness in infancy is related to more severe and persistent effects and may have a cumulative effect on ongoing development. In this work, we aim to describe vocational outcome in a group of patients at 15 years from a severe brain lesion they suffered in developmental age.

METHODS

This study included a total of 147 patients aged 1.5 to 14 years with acquired brain lesion. Clinical and functional details ("Glasgow Outcome Scale", "Functional Independent Measure" and Intelligence Quotient) were collected at the time of their first hospitalization and vocational outcome was determined after 15 years.

RESULTS

94 patients (63.9%) presented with traumatic brain injury, while 53 patients (36.1%) presented with a brain lesion of other origin. Traumatic patients had a higher probability of being partly or fully productive than non-traumatic ones: 75.5% of traumatic subjects were working-taking into account limitations due to the traumatic event-versus 62.3% of non-traumatic ones. A relationship between some clinical variables and the vocational outcome was found.

CONCLUSIONS

Rehabilitation should adequately emphasize "vocational rehabilitation" because a significant proportion of people experiencing a disorder of consciousness in childhood may show good social integration in adult age.

Neurobehavioral Impairment in Pediatric Brain Tumor Survivors: A Meta-Analysis

Purpose: The neurocognitive outcomes of pediatric brain tumor survivors have been extensively studied but the risk and predictors for neurobehavioral impairment are less clearly defined. We systematically analyzed the rates of emotional, psychosocial, and attention problems in pediatric brain tumor survivors. Methods: PubMed, Web of Science, Embase, Scopus, and Cochrane were searched for articles published between January 2012 to April 2022. Eligible studies reported neurobehavioral outcomes for PBTS aged 2 to <23 years with a brain tumor diagnosis before 18 years of age. A random-effect meta-analysis was performed in R. Results: The search yielded 1187 unique publications, of which 50 were included in the quantitative analysis. The estimated risk of having emotional, psychosocial, and attention problems were 15% (95%CI 10−20%), 12% (95%CI 9−16%), and 12% (95%CI 9−16%), respectively. PBTS were more likely to have emotional difficulties (Hedge’s g = 0.43 [95%CI 0.34−0.52]), psychosocial problems (Hedge’s g = 0.46 [95%CI 0.33−0.58]), and attention problems (Hedge’s g = 0.48 [95%CI 0.34−0.63]) compared to normal/healthy control subjects. There was no significant difference in the rates of neurobehavioral impairment between children with and without history of cranial radiotherapy. Conclusions: PBTS are at elevated risk of neurobehavioral impairment. Neurobehavioral monitoring should be considered as the standard of care for PBTS.

Self-perception and behavioural outcomes of early acquired brain injury

Acquired brain injury (ABI) occurs commonly in young children. Despite this, the psychosocial implications of ABI in young children are not established, with little understood about the impacts on self-perception and self-esteem. In this study we investigated self-perception, self-esteem and behaviour of children with early ABI. Children with an ABI (n = 47) before six years were compared to 17 typically developing controls (TDCs) matched on demographics. Children were aged 6-12 years and completed the Harter Self-Perception Profile. One parent completed the Child Behavior Checklist. No differences for self-perception and self-esteem were found between the groups. Parents of children with an early ABI reported more internalizing and externalizing behaviours. Children with more externalizing behaviour and social skill problems had more negative self-perceptions. Interaction effects were seen between socioeconomic status (SES) and child self-perception and behaviour. Specifically, children from families of higher SES had a more positive perception of their appearance and children from lower SES backgrounds had more externalizing behaviours and social problems. The study suggests that the relationship between ABI and self-perception and self-esteem is complicated and that children with behavioural problems have lowered feelings of competence. SES has an important role in self-perception and behavioural outcomes.

What About the Little Ones? Systematic Review of Cognitive and Behavioral Outcomes Following Early TBI

There is increasing empirical focus on the effects of early traumatic brain injuries (TBI; i.e., before the age of six years) on child development, but this literature has never been synthetized comprehensively. This systematic review aimed to document the cognitive, academic, behavioral, socio-affective, and adaptive consequences of early TBI. Four databases (Medline, PsycNET, CINAHL, PubMed) were systematically searched from 1990 to 2019 using key terms pertaining to TBI and early childhood. Of 12, 153 articles identified in the initial search, 43 were included. Children who sustain early TBI are at-risk for a range of difficulties, which are generally worse when injury is sustained at a younger age, injury severity is moderate to severe, and injury mechanisms are non-accidental. Early childhood is a sensitive period for the emergence and development of new skills and behaviors, and brain disruption during this time is not benign. Research, clinical management, intervention, and prevention efforts should be further developed with consideration of the unique characteristics of the early childhood period.

[Formula: see text] Investigation of children and adolescents' mood and self-concept after acquired brain injury

Few studies have examined the self-reported mental health of children with an acquired brain injury (ABI). The current study aimed to: 1) identify levels of child-reported depressive and anxiety symptoms and poor self-concept, 2) investigate demographic and injury-related factors associated with children's mood and self-concept, and 3) examine associations between children's self-reported mental health and parents' reports of children's emotional and behavioral functioning in children specifically with traumatic brain injury (TBI). 122 children (66% male) aged 8-16 years with ABI of mixed etiology were consecutively recruited through an outpatient rehabilitation clinic. Children were administered the Beck Youth Inventories - Second Edition, and parents completed the Adaptive Behavior Assessment System and the Child Behavior Checklist (CBCL). Relative to the norms, 16.4% of children scored in the clinical range for the depression and anxiety scales, and 24.6% reported clinically low self-concept. Children with lower functional status had greater anxiety symptoms. Older children (13-16 years) reported significantly higher depressive and anxiety symptoms and lower self-concept than younger children (8-12 years). A significant interaction between age and sex indicated that older girls reported greater depressive and anxiety symptoms than younger girls whereas no age-based differences were found for boys. Parent-reported total emotional and behavioral problems were positively associated with children's self-reported depressive and anxiety symptoms and were negatively correlated with self-concept. These findings indicate that adolescents, particularly girls, may be at heightened risk of poor mental health following ABI. Further research investigating the reasons for these demographic differences may inform developmentally sensitive interventions.

Home-based cognitive training in pediatric patients with acquired brain injury: preliminary results on efficacy of a randomized clinical trial

Cognitive rehabilitation may compensate for cognitive deficits of children with acquired brain injury (ABI), capitalizing on the use-dependent plasticity of a developing brain. Remote computerized cognitive training (CCT) may be delivered to patients in ecological settings, ensuring rehabilitation continuity. This work evaluated cognitive and psychological adjustment outcomes of an 8-week multi-domain, home-based CCT (Lumosity Cognitive Training) in a sample of patients with ABI aged 11–16 years. Two groups of patients were engaged in five CCT sessions per week for eight weeks (40 sessions). According to a stepped-wedge research design, one group (Training-first Group) started the CCT immediately, whereas the other group (Waiting-first Group) started the CCT after a comparable time of waiting list. Changes after the training and after the waiting period were compared in the two groups. Both groups improved in visual-spatial working memory more after the training than after the waiting-list period. The Training-first group improved also in arithmetic calculation speed. Findings indicate that a multi-domain CCT can produce benefits in visual-spatial working memory, probably because, in accordance with previous research, computer games heavily tax visuo-spatial abilities. This suggests that the prolonged stimulation of the same cognitive ability may generate the greatest benefits in children with ABI.

Tools for the assessment of neuropsychomotor profile in the rehabilitation of children with central nervous system tumor: a systematic review

Objective:

This study reviews the scientific literature to identify and describe which assessment tools (ATs) are used in pediatric oncology and neuro-oncology rehabilitation and which development neuropsychomotor (DNPM) ATs were built for children with central nervous system (CNS) tumors.

Methods:

A systematic review was performed searching PubMed, CINAHL, PEDro, Science Direct, and Catalog of National Institute of Tumors databases and specialized journals. The search covered 7 years (2010–2017) and used relevant keywords in different combinations. A further search was carried out on DNPM rehabilitation manuals and academic thesis.

Results:

The review retrieved 35 eligible articles containing 63 ATs. The most common ATs were the Behavioral Rating Inventory of Executive Function (BRIEF) and the Wechsler Intelligence Scale for Children (WISC). Most of the ATs covered a single area of child development among behavioral/psychological, cognitive, and motor areas. A total of 159 ATs were found in manuals and thesis, and only 17 of them were already identified in the journal search. None of the ATs identified in both searches had been specifically developed for children with CNS tumor.

Conclusion:

The results highlight the need to develop and validate a global multidimensional AT for children with CNS tumor, overcoming the fragmentation of the assessment procedures and promoting standardized rehabilitation protocols.

Adaptive behavior impaired in children with low-grade glioma

BACKGROUND

Adaptive behavior, i.e., the performance on daily activities required for personal and social independence, is essential to estimate in children with low-grade glioma (LGG) since most of them are long-term survivors. Our aim was to investigate adaptive behavior in children with LGG.

METHODS

In a cross-sectional study, adaptive behavior was assessed using the paper pencil version of the Parent Form of the Vineland Adaptive Behavior Scales 2nd edition (VABS-II) testing communication, daily living skills, social skills, and motor skills. Scores of children with LGG, younger than 20 years, and diagnosed between 2004 and 2014 were compared with family controls. Correlations between clinical variables and adaptive behavior were explored.

RESULTS

Fifty-six children with LGG (median age, 12.1 years; 52% male) and 46 controls (median age, 11.0 years; 43% male) were included in the analyses. Compared with controls, the LGG group was more impaired on total adaptive behavior, communication, and motor skills and in the subdomain gross motor skills (effect sizes d, 0.64-0.86, P < 0.003). Younger age at diagnosis (r = -0.357, P < 0.01) and chemotherapy (r = -0.342, P < 0.05) were associated with poorer motor skills. Residual disease was associated with poorer total adaptive behavior (r = -0.282, P < 0.05). No other significant correlations were found.

CONCLUSION

At the group level, adaptive functioning of children with LGG is impaired compared with family controls. Regular structured monitoring of adaptive behavior is recommended to be able to define the needs for tailored rehabilitation in daily life at home as well as at school.

Psychological and behavioural difficulties following severe TBI in adolescence: a comparison with a sample of peers with brain lesions of other origin and with a control group

OBJECTIVE

To describe behavioural and adjustment problems in a group of 57 adolescents with severe traumatic brain injury (TBI) and compare them with a clinical group of peers with brain lesions of other origin (N = 33) and a control group of healthy adolescents (N = 48).

METHODS

All subjects received an age-appropriate assessment, including the child behaviour checklist (CBCL) 4/18, the strengths and difficulties questionnaire (SDQ) and the vineland adaptive behaviour scales (VABS).

RESULTS

Compared with healthy peers, adolescents with TBI presented with more marked behavioural problems on most CBCL scales (Internalization and Externalization domains were both affected) and on the SDQ Hyperactivity and Peer problems scales. They also showed a more impaired functioning in most VABS domains. Compared with adolescents with brain lesions of other aetiology, patients with TBI showed more conduct problems on the SDQ scale, but no significant differences were found on the CBCL scales. Regarding the VABS, patients with other lesions presented with the worst outcome in the Motor and Daily Living Skills domains.

CONCLUSIONS

Adolescents with TBI are exposed at a very high risk to develop behavioural and psychological disturbances with the potential to severely affect their social re-entry. Further knowledge is needed to plan early and well-timed interventions.

Pediatric low-grade gliomas: next biologically driven steps

Despite the fact that they are not typically life-threatening, low-grade gliomas (LGGs) remain a significant clinical challenge in pediatric neuro-oncology due to comorbidities associated with these tumors and/or their treatments, and their propensity to multiply recurs. LGGs, in total the most common brain tumors arising in childhood, can often become a chronic problem requiring decades of management. The Second International Consensus Conference on Pediatric Low-Grade Gliomas held in Padua, Italy in 2016 was convened in an attempt to advance the pace of translating biological discoveries on LGGs into meaningful clinical benefit. Topics discussed included: the implications of our growing biological understanding of the genomics underlying these tumors; the assessment of the model systems available; the implications of the molecular and histopathologic differences between adult and pediatric diffuse gliomas; and steps needed to expedite targeted therapy into late-stage clinical trials for newly diagnosed cases. Methods for the diagnostic assessment of alterations in the Ras/mitogen-activated protein kinase pathway, typical for these tumors, were also considered. While the overall tone was positive, with a consensus that progress is being and will continue to be made, the scale of the challenge presented by this complex group of tumors was also acknowledged. The conclusions and recommendations of the meeting panel are provided here as an outline of current thinking and a basis for further discussion.

Psychological and adjustment problems due to acquired brain lesions in pediatric patients: a comparison of vascular, infectious, and other origins

The aim of this study was to describe psychological, behavioral, and adjustment problems in children and adolescents with acquired brain lesions of different origins. Three groups of patients with acquired brain lesions (15 patients with infectious origin, 37 with vascular origin, and 15 with other origin), ranging in age from 4 to 18 years, received a psychological evaluation, including the Child Behavior Checklist for ages 4 to 18 and the Vineland Adaptive Behavior Scale. About half of the total sample (47.8%) showed psychological problems. Difficulties varied according to the cause of the brain lesions. The most problematic patients were children with brain lesions of infectious origin, whereas children with brain lesions of vascular origin scored lower on most of the Child Behavior Checklist scales. The authors conclude that psychological and behavioral difficulties are very common among school-aged children with acquired brain lesions, and their relevance and impact must necessarily be considered.