Executive function outcomes following traumatic brain injury in young children: a five year follow-up

Delineating the impact of childhood traumatic brain injury (TBI) on long-term depressive symptom severity: Does sub-acute brain morphometry prospectively predict 2-year outcome?

Despite evidence of a link between childhood TBI and heightened risk for depressive symptoms, very few studies have examined early risk factors that predict the presence and severity of post-injury depression beyond 1-year post injury. This longitudinal prospective study examined the effect of mild-severe childhood TBI on depressive symptom severity at 2-years post-injury. It also evaluated the potential role of sub-acute brain morphometry and executive function (EF) in prospectively predicting these long-term outcomes. The study involved 81 children and adolescents with TBI, and 40 age-and-sex matched typically developing (TD) controls. Participants underwent high-resolution structural magnetic resonance imaging (MRI) sub-acutely at five weeks post-injury (M = 5.55; SD = 3.05 weeks) and EF assessments were completed at 6-months post-injury. Compared to TD controls, the TBI group had significantly higher overall internalizing symptoms and were significantly more likely to exhibit clinically significant depressive symptoms at 2-year follow-up. The TBI group also displayed significantly lower EF and altered sub-acute brain morphometry in EF-related brain networks, including the default-mode network (DMN), salience network (SN) and central executive network (CEN). Mediation analyses revealed significant indirect effects of CEN morphometry on depression symptom severity, such that lower EF mediated the prospective association between altered CEN morphometry and higher depression symptoms in the TBI group. Parallel mediation analyses including grey matter morphometry of a non-EF brain network (i.e., the mentalising network) were not statistically significant, suggesting some model specificity. The findings indicate that screening for early neurostructural and neurocognitive risk factors may help identify children at elevated risk of depressive symptoms following TBI. For instance, children at greatest risk of post-injury depression symptoms could be identified based in part on neuroimaging of networks implicated in EF and post-acute assessments of executive function, which could support more effective allocation of limited intervention resources.

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

History of pediatric TBI hospitalization and current child-parent relationship quality in China

BACKGROUND

Long-term child-parent relationship quality following hospitalization for pediatric traumatic brain injury (TBI) remains poorly understood.

OBJECTIVE

We tested whether current child-parent conflict and closeness were related to the children's history of TBI-related experiences and contemporary child/family characteristics.

METHODS

The sample included 202 Chinese children (Boys: 60.4%) with a history of hospitalization for TBI. On average, the children were 11.2 years old (SD = 1.59) and sustained TBI at 8.5 years old (SD = 1.6). TBI-related data were obtained from hospital medical records. Parents provided data on child-parent closeness, child-parent conflict, and parental efficacy 2-4 years (M = 2.7, SD = 0.7) after discharge.

RESULTS

Forty-nine children (24.3%) had mild TBI, 139 (68.8%) had moderate TBI, and 14 (6.9%) had severe TBI. Surgical intervention occurred among 128 (63.4%) of the 202 children. Contemporaneous child and family characteristics explained 19% of the variance, history of surgery, length of hospitalization, and recovery status explained another 7%, and the interaction between length of hospitalization and parental efficacy explained another 4% in child-parent conflict. Contemporaneous child and family characteristics explained 29% of the variance, and TBI-related variables explained another 2% in child-parent closeness.

CONCLUSION

Post-TBI child-parent relationship was more associated with child/family characteristics than with TBI variables. Practitioners and families should be aware of the long-term challenges to child-parent relationship following hospitalization for pediatric TBI.

Proceedings of the First Pediatric Coma and Disorders of Consciousness Symposium by the Curing Coma Campaign, Pediatric Neurocritical Care Research Group, and NINDS: Gearing for Success in Coma Advancements for Children and Neonates

This proceedings article presents the scope of pediatric coma and disorders of consciousness based on presentations and discussions at the First Pediatric Disorders of Consciousness Care and Research symposium held on September 14th, 2021. Herein we review the current state of pediatric coma care and research opportunities as well as shared experiences from seasoned researchers and clinicians. Salient current challenges and opportunities in pediatric and neonatal coma care and research were identified through the contributions of the presenters, who were Jose I. Suarez, MD, Nina F. Schor, MD, PhD, Beth S. Slomine, PhD Erika Molteni, PhD, and Jan-Marino Ramirez, PhD, and moderated by Varina L. Boerwinkle, MD, with overview by Mark Wainwright, MD, and subsequent audience discussion. The program, executively planned by Varina L. Boerwinkle, MD, Mark Wainwright, MD, and Michelle Elena Schober, MD, drove the identification and development of priorities for the pediatric neurocritical care community.

Orienting network impairment of attention in patients with mild traumatic brain injury

The incomplete understanding of mild traumatic brain injury (MTBI)-related cognitive impairment in the acute stage and the low cognitive needs of patients in the later stage might be the main reasons for the neglect of clinical symptoms in patients with MTBI. Patients often experience attention deficits; however, it is unclear whether these patients suffer from general deficits or selective impairment of the brain attention network. Therefore, we investigated deficits in the attention function of patients with mild brain traumatic injury. Patients (n = 50) and matched healthy controls (n = 49) completed a general neuropsychological background test and the Attention Network Test, which provided an independent assessment of the three attention networks (alerting, orienting, and executive control). We found that patients had significant deficits in the orienting network but none in the alerting and executive control networks. Furthermore, patients' cognitive task scores in attention, memory, and information processing tasks were significantly lower than the scores of the controls. Our results demonstrated that patients with MTBI had selective impairment in the orienting network and extensive cognitive impairments, including those related to general attention, memory, and information processing speed.

The clinical utility of the Children's Communication Checklist-2 in children with early childhood traumatic brain injury

ObjectivePediatric traumatic brain injury (TBI) is associated with long-term cognitive and behavioral deficits. Social communication impairments are common and impact functional outcomes, such as social engagement and academic performance. There are many barriers to identifying social communication deficits following TBI, including the absence of a standardized parent-reported communication measure for use in this population. The Children's Communication Checklist-Second Edition (CCC-2) has demonstrated utility in identifying communication deficits in diagnoses other than TBI. This study investigated the clinical utility of the CCC-2's social communication scales in children with TBI. Method: 203 children who sustained TBI or orthopedic injuries between the ages of 36 and 83 months were recruited as part of a larger, longitudinal study. We analyzed social communication subscale scores from the CCC-2 an average of 3.5 years postinjury. We used binary logistic regression analyses to examine the measure's accuracy in classifying children with and without social communication deficits on other measures of pragmatic language and social competence. Correlation analyses and linear mixed models were used to examine the construct validity of the CCC-2. Results: The CCC-2 was able to accurately classify those with and without pragmatic language impairments on the Comprehensive Assessment of Spoken Language 92% of the time (sensitivity = 55%) and 96% of the time on the Home and Community Social Behavior scale (sensitivity = 72%). The CCC-2 demonstrated strong correlations with and predictive validity for measures of social communication and competence. Conclusions: The findings offer support for the clinical utility of the CCC-2 in the pediatric TBI population.

Parent- and Adolescent-reported Executive Functioning in the Context of Randomized Controlled Trials of Online Family Problem-Solving Therapy

OBJECTIVE

We examined parent- and adolescent-reported executive functioning (EF) behaviors following pediatric traumatic brain injury (TBI) in the context of Online Family Problem-Solving Therapy (OFPST) and moderators of change in EF behaviors.

METHOD

In total, 274 families were randomized to OFPST or an internet resource comparison group. Parents and adolescents completed the Behavior Rating Inventory of Executive Function at four time points. Mixed models were used to examine EF behaviors, assessing the effects of visit, treatment group, rater, TBI severity, age, socioeconomic status, and family functioning.

RESULTS

Parents rated their adolescents' EF as poorer (F(3,1156) = 220.15, p < .001; M = 58.11, SE = 0.73) than adolescents rated themselves (M = 51.81, SE = 0.73). Across raters, EF behaviors were poorer for adolescents whose parents had less education (F(3,1156) = 8.60, p = .003; M = 56.76, SE = 0.98) than for those with more education (M = 53.16, SE = 0.88). Age at baseline interacted with visit (F(3,1156) = 5.05, p = .002), such that families of older adolescents reported improvement in EF behaviors over time. Family functioning also interacted with visit (F(3, 1156) = 2.61, p = .049), indicating more improvement in EF behaviors over time in higher functioning families. There were no effects of treatment or TBI severity.

CONCLUSION

We identified a discrepancy between parent- and adolescent-reported EF, suggesting reduced awareness of deficits in adolescents with TBI. We also found that poorer family functioning and younger age were associated with poorer recovery after TBI, whereas adolescents of parents with less education were reported as having greater EF deficits across time points.

An Exploration of Sleep and Family Factors in Young Children at Familial Risk for ADHD

Objective: The aim of the current study was to examine relations between sleep problems and family factors and early markers of ADHD in young children with and without a familial risk for ADHD.Methods: Differences in sleep behavior and family functioning in children under 6 years with (n = 72) and without (n = 139) a familial risk for ADHD were investigated. The influence of family and sleep factors on the development of early temperament markers of ADHD (effortful control and negative affect) was explored. Parents/caregivers completed questionnaires on family functioning, child sleep behavior, and general regulatory behaviors.Results: A significant difference was observed between high-risk and low-risk groups for family functioning in the infant/toddler (<3 years) and preschool (>3 years) cohorts. Parents of infants/toddlers in the high-risk group reported poorer infant sleep. However, there were no sleep differences reported for the preschool cohort. Family functioning was found to predict effortful control, while sleep quality predicted negative affect.Conclusion: The results of this study highlight potential family and sleep issues for young children with a familial history of ADHD and the potential influence of these factors on early temperament markers of ADHD. Future research should explore these relations further in order to better establish whether early sleep and family interventions could mitigate later ADHD symptomatology.

Dopamine-Related Genes Moderate the Association Between Family Environment and Executive Function Following Pediatric Traumatic Brain Injury: An Exploratory Study

OBJECTIVE

This study examined whether carrying dopamine-related "risk" genes-either the dopamine transporter (DAT1) 10-repeat allele or dopamine receptor-4 (DRD4) 7-repeat allele-moderated the association of family environment and executive function (EF) following traumatic brain injury (TBI) in early childhood.

METHODS

Caregivers of children with TBI or orthopedic injury (OI) completed the Behavior Rating Inventory of Executive Function (BRIEF) at postinjury visits. General linear models examined gene by environment interactions as moderators of the effects of TBI on EF at 12 months and 7 years postinjury.

RESULTS

At 12 months, we did not find any significant gene by environment interactions. At 7 years, we found a significant 3-way interaction among combined carrier status, level of permissive parenting, and injury type. For children exposed to more optimal parenting, carriers of DAT1 and/or DRD4 risk alleles with TBI showed significantly worse parent-reported EF than carriers with OI. In those with less optimal parenting, carriers and noncarriers with TBI, as well as carriers with OI, showed significantly worse parent-reported EF than noncarriers with OI, with medium to large effect sizes.

CONCLUSIONS

The findings highlight the importance of considering polygenetic and environmental factors in future studies of recovery following TBI and other injuries in childhood.

Impact of Secondary ADHD on Long-Term Outcomes After Early Childhood Traumatic Brain Injury

OBJECTIVE

To examine the impact of secondary attention-deficit/hyperactivity disorder (SADHD) on long-term global and executive functioning in adolescents after traumatic brain injury (TBI).

SETTING

Three tertiary cared children's hospitals and 1 general hospital.

PARTICIPANTS

One hundred twenty children (TBI: n = 54; orthopedic injury: n = 66) without preinjury ADHD evaluated approximately 6.8 years postinjury.

DESIGN

Cross-sectional data analysis from a prospective, longitudinal study.

MAIN MEASURES

Outcomes included functional impairment (Child and Adolescent Functional Assessment Scale) and executive functioning (Behavior Rating Inventory of Executive Function [BRIEF]).

RESULTS

SADHD moderated the association of injury type with the BRIEF-Behavioral Regulation Index (F1,113 = 4.42, P = .04) and the Child and Adolescent Functional Assessment Scale (F1,112 = 8.95, P = .003). TBI was only associated with poorer outcomes in the context of SADHD. SADHD was also associated with poorer outcomes on the BRIEF-Global Executive Composite (F1,113 = 52.92, P < .0001) and BRIEF-Metacognitive Index scores (F1,113 = 48.64, P < .0001) across groups. Adolescents with TBI had greater BRIEF-Global Executive Composite scores than those with orthopedic injury (F1,113 = 5.00, P = .03).

CONCLUSIONS

Although SADHD was associated with poorer functioning across groups, its adverse effects on behavioral regulation and overall functioning were amplified following TBI. TBI + SADHD may confer an elevated risk for significant impairments in early adolescence.

The Impact of Traumatic Injury to the Immature Human Brain: A Scoping Review with Insights from Advanced Structural Neuroimaging

Traumatic brain injury (TBI) during critical periods of early-life brain development can affect the normal formation of brain networks responsible for a range of complex social behaviors. Because of the protracted nature of brain and behavioral development, deficits in cognitive and socioaffective behaviors may not become evident until late adolescence and early adulthood, when such skills are expected to reach maturity. In addition, multiple pre- and post-injury factors can interact with the effects of early brain insult to influence long-term outcomes. In recent years, with advancements in magnetic-resonance-based neuroimaging techniques and analysis, studies of the pediatric population have revealed a link between neurobehavioral deficits, such as social dysfunction, with white matter damage. In this review, in which we focus on contributions from Australian researchers to the field, we have highlighted pioneering longitudinal studies in pediatric TBI, in relation to social deficits specifically. We also discuss the use of advanced neuroimaging and novel behavioral assays in animal models of TBI in the immature brain. Together, this research aims to understand the relationship between injury consequences and ongoing brain development after pediatric TBI, which promises to improve prediction of the behavioral deficits that emerge in the years subsequent to early-life injury.

Parent and Teacher-Reported Child Outcomes Seven Years After Mild Traumatic Brain Injury: A Nested Case Control Study

Background: Increasing evidence suggests potential lifetime effects following mild traumatic brain injury (TBI) in childhood. Few studies have examined medium-term outcomes among hospitalized and non-hospitalized samples. Study aims were to describe children's behavioral and emotional adjustment, executive function (EF), quality of life, and participation at 7-years following mild TBI using parents' and teachers' reports. Methods: Nested case control study of 86 children (68% male, mean age at assessment = 11.27 years; range 7-17 years) who sustained a mild TBI 7-years previously, identified from a prospective, population-based study. They were compared to 69 children free from TBI (61% male, mean age at assessment = 11.12 years; range 5-17 years). In addition to parent-reported socio-demographic details, parents (mild TBI n = 86, non-TBI n = 69) completed age-appropriate standardized questionnaires about children's health-related quality of life, behavioral and emotional adjustment, EF, and social participation. Parents own mood was assessed using the Hospital Anxiety and Depression Scale. Teachers (mild TBI n = 53, non-TBI n = 42) completed questionnaires about children's behavioral and emotional adjustment, and EF. Results: Parent reports showed median group-level scores for cases were statistically significantly greater than controls for emotional symptoms, conduct problems, hyperactivity/inattention, total behavioral difficulties, inhibitory control, shifting, planning/organizing, and Global Executive Composite (total) EF difficulties (p-values 0.001-0.029). Parent reports of child quality of life and social participation were similar, as were teacher reports of child behavioral and emotional adjustment, and EF (p > 0.05). When examining clinical cut-offs, compared to controls, cases had a higher risk of parent-reported total EF difficulties (odds ratio = 3.00) and, to a lesser extent, total behavior problems (odds ratio = 2.51). Conclusions: As a group, children with a history of mild TBI may be at elevated risk for clinically significant everyday EF difficulties in the medium-term compared to non-TBI controls, as judged by their parents. Further multi-informant longitudinal research is required, following larger samples. Aspects requiring particular attention include pre-injury characteristics, such as sleep disturbances and comorbidities (e.g., headaches), that may act as potential confounders influencing the association between mild TBI and child behavioral problems.

The Effect of Childhood Traumatic Brain Injury on Verbal Fluency Performance: A Systematic Review and Meta-Analysis

Verbal fluency is a neuropsychological measure commonly used to examine cognitive-linguistic performance as reported in pediatric TBI literature. We synthesized the scholarly literature of verbal fluency performance in pediatric TBI and estimated the effects of TBI according to: (i) type of verbal fluency task (phonemic or semantic), (ii) severity of TBI, and (iii) time post-injury. Meta-analysis revealed that childhood TBI negatively impacted phonemic fluency and semantic fluency and that effect sizes were larger for children with more severe TBI. The negative effect of TBI was evident across time post injury within each level of severity. Verbal fluency tasks are efficient indicators of potential underlying impairments in lexical knowledge and executive functioning in children with TBI regardless of severity of injury or time post injury. Future research employing verbal fluency tasks are encouraged to explore if age at injury differentiates semantic versus phonemic fluency outcomes across severity levels.

Driving after pediatric traumatic brain injury: Impact of distraction and executive functioning

OBJECTIVE

The objective of the current study was to examine the driving performance of young drivers with a history of moderate to severe traumatic brain injury (TBI) compared with an uninjured control group. The impact of cell phone related distraction (conversation and texting) and executive functioning (EF) were also explored.

METHOD

Individuals aged 16-25 years with (n = 19) and without (n = 19) a history of TBI engaged in a simulated drive under 3 distraction conditions (no distraction, cell phone conversation, and texting). Mean speed, maximum speed, standard deviation of speed, standard deviation of lane position, and crash rates were used as outcomes. The Global Executive Composite (GEC) from the Behavior Rating Inventory of Executive Functioning (BRIEF) was used to measure EF.

RESULTS

Significant Injury × Distraction × GEC interaction effects were noted on max speed and speed variability, with a trending Distraction × GEC interaction noted for lane position variability. The effect of distraction was most notable among individuals with greater GEC scores, across both injury groups.

CONCLUSIONS

A history of pediatric TBI did not specifically impact driving performance independent of EF, with EF playing a central role in functioning across domains of driving performance. Consistent effect of EF suggests that deficits in driving performance may be associated with EF specifically, with individuals with EF difficulties following TBI at greater risk for poor driving performance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Executive functions and attention 7years after severe childhood traumatic brain injury: Results of the Traumatisme Grave de l'Enfant (TGE) cohort

OBJECTIVES

Severe childhood traumatic brain injury (TBI) leads to long-standing executive function and attention deficits, with negative consequences for participation, academic outcome and independence. This study aimed to assess executive function and attention 7 years after severe childhood TBI in comparison with a matched control group and to investigate associated factors.

METHODS

Children (<15years) with severe accidental TBI consecutively admitted in a single trauma center over 3years were included in the Traumatisme Grave de l'Enfant (TGE) prospective longitudinal study. Of the 81children initially included, 65survived. At 7years post-TBI, executive functions and attention were assessed in 27participants (42 % of the 65 survivors) by using a combination of computerized tasks from the Test of Attentional Performance (TAP) and the Behavioral Rating of Executive Functions (BRIEF) questionnaire. Patients were compared to a group of 27typically developing controls who were matched for sex, age and parental education level.

RESULTS

Among the 27participants, mean (SD) age at injury was 7.7 (4.6)years, and mean length of coma 5.6 (4.6) days. Regarding the TAP, the number of errors was significantly higher (P=0.003) and reaction time marginally slower (P=0.08) in the TBI than control group. The BRIEF questionnaire completed by parents indicated significantly more executive difficulties in the TBI than control group (Behavior Regulation Index, P=0.005; Metacognitive index, P=0.02; Global Executive Composite, P=0.012). Correlations between BRIEF and TAP scores did not reach statistical significance. BRIEF total score was correlated moderately with length of coma (r=0.40, P=0.037), and TAP scores were correlated with the Full-Scale Intellectual Quotient (total number of errors: r=-0.48; P=0.01; mean reaction time: r=-0.51; P=0.009).

CONCLUSIONS

Executive and attention deficits were evident 7 years after severe childhood TBI. Computerized tasks and questionnaires provide complementary and non-redundant information. Systematic long-term follow-up should be provided until the transition to adulthood, to assess ongoing development and to implement timely tailored interventions.

Executive function and probabilities of engaging in long-term sedentary and high calorie/low nutrition eating behaviors in early adolescence

PURPOSE

Consumption of high calorie/low nutrition (HCLN) foods, as well as high levels of sedentary behavior (SB), may play a substantial role in the development of childhood overweight and obesity. However, the choice to engage or not engage in this behavior may be impacted by limits in executive functioning (EF) - a set of higher order functions related to decision making, planning, and inhibitory processes.

METHODS

The present study, as part of a large multiple health risk behavior trial designed to prevent substance use and obesity, evaluated the relationship between specific subdomains of EF and long-term patterns of HCLN food consumption and SB among a population of elementary school students (n = 709).

RESULTS

Utilizing a form of mixture modeling based on a latent transition analysis framework, subdomains of EF were found to influence the probability that students would report high levels of HCLN food consumption and SB over a thirty-month period. Gender and socioeconomic status further influenced the likelihood that students with poor EF would repeatedly engage in these unhealthy behaviors.

CONCLUSIONS

HCLN food consumption and SB in childhood can lead to an increased risk of becoming overweight or obese. Findings suggest that long term EF training, as well as the creation of environments that support appropriate decision-making, could be an important focus of future health promotion and education.

Cognitive and spectral coherence of EEG alterations in resting state in children with chronic TBI

Introduction. TBI is associated with alterations in cortico-subcortical connectivity. However, little attention has been paid to its clinical characteristics and functional connectivity in pediatric patients with chronic TBI. Objective. To evaluate the cognitive performance and spectral coherence of a group of children with TBI in non-acute phase. Method. Cross-sectional study of 15 children with chronic TBI and 17 healthy children. The Neuropsychological Assessment of Children (Evaluación Neuropsicológica Infantil, ENI) was used and the resting activity of the EEG with eyes-closed was recorded. Offline, two-second epochs of the EEG of each participant were chosen and the spectral coherence was estimated in a range of 1.6 to 30 Hz. The cognitive performance between groups was compared with T-test/Mann-Whitney U Test and MANOVA for the coherence values. Results. The TBI group showed a lower performance (p ≤ 0.05) in metalinguistic, visuospatial skills, attention, memory, non-verbal flexibility, planning, and organization. Differences (p ≤ 0.000) were found both inter and intrahemispherically in the spectral coherence between the groups, particularly on F1-F3 (95% CI: 0.543 - 0.557) over the whole frequency range and F3-C3 (95% CI: 0.503 - 0.515) in delta, theta, alpha2, and beta frequencies. Discussion and conclusión. Our findings suggest alterations of hypo and hyper functional connectivity, particularly on the frontal and parietal lobes of both hemispheres, even after several years of a TBI. It is possible that a subtle difference in the degree of connectivity is crucial in the genesis or successful development of attentional, mnesic, executive, and visuospatial processes.

Executive Function Profiles in Pediatric Traumatic Brain Injury

Traumatic brain injury (TBI) results in heterogeneous patterns of neuropsychological impairment. This study investigated heterogeneity in executive function (EF) using the Comprehensive Trail Making Test (CTMT) to evaluate 121 children and adolescents with TBI and 121 matched normal controls. The TBI group performed approximately two standard deviations below controls. Cluster analyses indicated that a three-cluster solution best classified the TBI group and a four-cluster solution best classified controls. Greater impairment in EF was associated with lower intellectual, achievement, and neuropsychological test performance in the TBI group. Results suggest that EF deficits reflected in CTMT performance may be useful for classifying severity of TBI.

Executive Functions and Their Relation to Sleep Following Mild Traumatic Brain Injury in Preschoolers

OBJECTIVES

Traumatic brain injury (TBI) sustained during childhood is known to impact children's executive functioning. However, few studies have focused specifically on executive functioning after preschool TBI. TBI has also been associated with sleep disturbances, which are known to impair executive functions in healthy children. The aim of this study was to investigate executive functions in preschoolers with mild TBI, and to determine the role of sleep in the links between TBI and executive functioning.

METHODS

The sample was drawn from a longitudinal study and included 167 children, aged 18 to 60 months, divided into 2 groups: children with accidental mild TBI (n=84) and typically developing children (n=83). Children were assessed 6 months post-injury on executive function measures (inhibition and cognitive flexibility) and sleep measures (actigraphy data and parental rating of sleep problems).

RESULTS

The two groups did not differ in their executive abilities. However, relative to controls, children with mild TBI and shorter nighttime sleep duration or increased sleep problems exhibited poorer executive functions.

CONCLUSIONS

These results support a "double hazard" effect, whereby the combination of sleep disturbances and mild TBI results in poorer executive functions. The findings highlight the importance of assessing and monitoring the quality of sleep even after mild head injuries. Poor sleep may place children at risk for increased cognitive difficulties. (JINS, 2018, 24, 769-780).

The Moderating Effect of the Ankyrin Repeat and Kinase Domain Containing One Gene on the Association of Family Environment with Longitudinal Executive Function following Traumatic Brain Injury in Early Childhood: A Preliminary Study

This study examined whether the ankyrin repeat and kinase domain containing 1 gene (ANKK1) C/T single-nucleotide polymorphism (SNP) rs1800497 moderated the association of family environment with long-term executive function (EF) following traumatic injury in early childhood. Caregivers of children with traumatic brain injury (TBI) and children with orthopedic injury completed the Behavior Rating Inventory of Executive Function (BRIEF) at post-injury visits. DNA was collected to identify the rs1800497 genotype in the ANKK1 gene. General linear models examined gene-environment interactions as moderators of the effects of TBI on EF at two times post-injury (12 months and 7 years). At 12 months post-injury, analyses revealed a significant three-way interaction of genotype with level of permissive parenting and injury type. Post hoc analyses showed genetic effects were more pronounced for children with TBI from more positive family environments, such that children with TBI who were carriers of the risk allele (T-allele) had significantly poorer EF compared with non-carriers only when they were from more advantaged environments. At 7 years post-injury, analyses revealed a significant two-way interaction of genotype with level of authoritarian parenting. Post hoc analyses found that carriers of the risk allele had significantly poorer EF compared with non-carriers only when they were from more advantaged environments. These results suggest a gene-environment interaction involving the ANKK1 gene as a predictor of EF in a pediatric injury population. The findings highlight the importance of considering environmental influences in future genetic studies on recovery following TBI and other traumatic injuries in childhood.

Working Memory From the Psychological and Neurosciences Perspectives: A Review

Since the concept of working memory was introduced over 50 years ago, different schools of thought have offered different definitions for working memory based on the various cognitive domains that it encompasses. The general consensus regarding working memory supports the idea that working memory is extensively involved in goal-directed behaviors in which information must be retained and manipulated to ensure successful task execution. Before the emergence of other competing models, the concept of working memory was described by the multicomponent working memory model proposed by Baddeley and Hitch. In the present article, the authors provide an overview of several working memory-relevant studies in order to harmonize the findings of working memory from the neurosciences and psychological standpoints, especially after citing evidence from past studies of healthy, aging, diseased, and/or lesioned brains. In particular, the theoretical framework behind working memory, in which the related domains that are considered to play a part in different frameworks (such as memory’s capacity limit and temporary storage) are presented and discussed. From the neuroscience perspective, it has been established that working memory activates the fronto-parietal brain regions, including the prefrontal, cingulate, and parietal cortices. Recent studies have subsequently implicated the roles of subcortical regions (such as the midbrain and cerebellum) in working memory. Aging also appears to have modulatory effects on working memory; age interactions with emotion, caffeine and hormones appear to affect working memory performances at the neurobiological level. Moreover, working memory deficits are apparent in older individuals, who are susceptible to cognitive deterioration. Another younger population with working memory impairment consists of those with mental, developmental, and/or neurological disorders such as major depressive disorder and others. A less coherent and organized neural pattern has been consistently reported in these disadvantaged groups. Working memory of patients with traumatic brain injury was similarly affected and shown to have unusual neural activity (hyper- or hypoactivation) as a general observation. Decoding the underlying neural mechanisms of working memory helps support the current theoretical understandings concerning working memory, and at the same time provides insights into rehabilitation programs that target working memory impairments from neurophysiological or psychological aspects.

"Trying to Get a Grip": Language Competence and Self-Reported Satisfaction With Social Relationships Three Decades Post-Childhood Traumatic Brain Injury

OBJECTIVE

(1) To investigate outcomes in language competence and self-reported satisfaction with social relationships in long-term survivors of childhood traumatic brain injury (TBI); and (2) to establish whether language competence contributes to self-reported satisfaction with social relationships decades after sustaining childhood TBI.

PARTICIPANTS

Twelve females and 8 males aged 30 to 55 (mean = 39.80, standard deviation = 7.54) years who sustained a TBI during childhood and were on average 31 years postinjury (standard deviation = 9.69). An additional 20 participants matched for age, sex, handedness, years of education, and socioeconomic status constituted a control group.

MAIN MEASURES

Test of Language Competence-Expanded Edition and the Quality of Life in Brain Injury questionnaire.

RESULTS

Individuals with a history of childhood TBI performed significantly poorer than their non-injured peers on 2 (Ambiguous Sentences and Oral Expression: Recreating Sentences) out of the 4 Test of Language Competence-Expanded Edition subtests used and on the Quality of Life in Brain Injury subscale assessing satisfaction with social relationships. In the TBI group, scores obtained on the Ambiguous Sentences subtest were found to be a significant predictor of satisfaction with social relationships, explaining 25% of the variance observed.

CONCLUSIONS

The implication of high-level language skills to self-reported satisfaction with social relationships many decades post-childhood TBI suggests that ongoing monitoring of emerging language skills and support throughout the school years and into adulthood may be warranted if adult survivors of childhood TBI are to experience satisfying social relationships.

Influence of Catechol-O-methyltransferase on Executive Functioning Longitudinally After Early Childhood Traumatic Brain Injury: Preliminary Findings

OBJECTIVE

To elucidate the association of a functional catechol-O-methyltransferase (COMT) genotype (rs4680) with recovery of executive functions up to 18 months after early childhood traumatic brain injury (TBI) compared with an orthopedic injury (OI) group.

SETTING

Outpatient.

PARTICIPANTS

A total of 134 children with a moderate to severe TBI (n = 63) or OI (n = 71) between the ages of 3 and 6 years who were followed 18 months postinjury.

DESIGN

Case-comparison, longitudinal cohort

MAIN MEASURES

: The Behavior Rating Inventory of Executive Function, developmental NEuroPSYchological Assessment (NEPSY) of Verbal Fluency, and a modified Stroop Test for young children (Shape School).

RESULTS

The low-activity COMT enzyme genotype (AA) was associated with better scores on the developmental NEPSY of Verbal Fluency (F = 3.80; P = .02) and the Shape School (F = 2.89; P = .06) in all participants when controlling for injury type (TBI vs OI) over the first 18 months after injury. Injury type (TBI vs OI) did not significantly moderate the effect of the COMT genotypes on executive function recovery.

CONCLUSION

This study provides preliminary evidence for a role of COMT genotypes in long-term recovery of executive function after pediatric TBI and OI. Larger studies are needed to determine the exact link between genetic variation in the COMT gene and TBI recovery in children.

Brain volumetric correlates of inhibition and cognitive flexibility 16 years following childhood traumatic brain injury

Executive functions (EFs), such as inhibition and cognitive flexibility, are essential for everyday functioning, including regulation of socially appropriate emotional responses. These skills develop during childhood and continue maturing into early adulthood. The current study aimed to investigate the very long-term impact of childhood traumatic brain injury (TBI) on inhibition and cognitive flexibility, and to examine whether global white matter is associated with these abilities. Twenty-eight young adult survivors of childhood TBI (mean age at 16-year follow-up = 21.67 years, SD = 2.70) and 16 typically developing controls (TDCs), group-matched for age, sex, and socioeconomic status, completed tests of inhibition and cognitive flexibility and underwent structural MRI. Survivors of childhood TBI did not significantly differ from TDCs on EF or white matter volume. However, the relationship between EF and white matter volume differed between survivors of TBI and TDCs. Survivors of TBI did not mimic the brain behavior relationship that characterized EF in TDCs. The inverse brain behavior relationship, exhibited by childhood TBI survivors, suggests disruptions in the whole brain underpinning EF following childhood TBI.

Is Computerized Cognitive Testing Useful in Children and Adolescents with Moderate-to-Severe Traumatic Brain Injury?

OBJECTIVES

Children and adolescents with moderate-to-severe traumatic brain injury (TBI) present with short and long-term neuropsychological deficits following their injury. The aim of this study was to investigate the utility of a brief computerized test battery for evaluating cognitive functioning sub-acutely following a TBI.

METHODS

Participants (n=33) sustained a moderate-to-severe TBI, were between 8 and 18 years old, and were assessed using CNS Vital Signs (CNSVS) within 6 months post-injury (median=0.6 month). Participants with TBI were matched to 33 healthy controls based on age, sex, and handedness to compare their cognitive functioning on the CNSVS battery.

RESULTS

Children and adolescents with moderate-to-severe TBI had significantly lower scores and large effect sizes on Reaction Time, Complex Attention, and Cognitive Flexibility domains, as well as medium effect sizes on two Visual Memory test scores and one Psychomotor Speed test score. A significantly higher percentage of participants with TBI had cognitive impairment on Reaction Time domain score compared to the control group. Finally, CNSVS domain scores correctly categorized 76% of participants as either group with TBI or control group.

CONCLUSIONS

CNSVS may be a useful tool for screening cognitive abilities in children and adolescents who are early in their recovery from a moderate-to-severe TBI, particularly when a rapid screening evaluation can help guide management, interventions, and track recovery. (JINS, 2017, 23, 304-313).

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.

Mild head injury and attention deficit hyperactivity disorder in children

PURPOSE

Post-concussion syndrome is a well-described complication following moderate and severe head trauma but whether it occurs after mild head injury in children remains unclear. The aim of this study was to evaluate whether exposure to mild head injury with potential additional risk factors (non-surgical lesion on computed tomographic, high kinetic trauma, or Glasgow Coma Scale <15) is associated with attention deficit hyperactivity disorder (ADHD) after the head trauma.

METHODS

This study was performed in an emergency department on children admitted between 2009 and 2013. It compared victims of mild head injury aged 6-16 years with matched children presenting isolated non-surgical forearm fracture (ratio1/2). ADHD was assessed using Conners' Global Index-Parent short version 3-40 months after the trauma. The patients were compared using chi-square test or Fisher's exact test, t test or u-test as appropriate with a p value set at 0.05.

RESULTS

During the study period, 676 patients were admitted for mild head injury. Among them, 34 (5 %) fulfilled the inclusion criteria and were compared with 64 matched patients admitted for a forearm fracture. The groups were comparable. ADHD was observed in both groups (18 % in the mild head injury group, 11 % in the control group) with no significant differences between groups. The prevalence was high when compared to an expected frequency of 3.5-5.6 % in children aged 6-12 years in the general population.

CONCLUSIONS

These results suggest that pre-existing ADHD may have contributed to injury proneness in both groups and does not argue for a specific risk of ADHD induced by mild head injury. The diagnosis of ADHD should be evoked at admission of children aged 6-16 years presenting with a trauma.

Executive function after severe childhood traumatic brain injury - Age-at-injury vulnerability periods: The TGE prospective longitudinal study

BACKGROUND

Executive function (EF) impairment is a major predictor of overall outcome after traumatic brain injury (TBI). TBI severity is a factor of poor outcome, but most studies include a majority of children with mild and moderate TBI. The aims of this study were to estimate EF impairment after severe childhood TBI and to explore factors predicting EF outcome. The secondary aim was to compare recovery trajectories by age-at-injury groups.

METHODS

This was a prospective longitudinal study of children with severe TBI who were tested for EFs by performance-based tests and questionnaires at 3, 12 and 24 months.

RESULTS

Children with TBI (n=65) showed significant impairment in working memory, inhibition, attention and global EF, with little or no recovery at 24 months. For flexibility and performance-based EF score, children were impaired at 3 months only and showed normal scores by 12 months. No impairment was found in planning. At 3 and 24 months, Glasgow Coma Scale score and parental education predicted global EF. Coma length was not a significant predictor of outcome. Age at injury predicted progress in EF, but the relationship was not linear; children 10-12 years old at injury showed better outcome than older and younger children.

CONCLUSIONS

EFs are impaired after severe TBI in childhood. The relationship between age at injury and outcome is not linear. Relying on only performance-based EF tests can underestimate EF impairment.

Long-Term Neuropsychological Profiles and Their Role as Mediators of Adaptive Functioning after Traumatic Brain Injury in Early Childhood

The objectives of the study were to characterize long-term neuropsychological outcomes following traumatic brain injury (TBI) sustained during early childhood, and determine whether identified neuropsychological impairments mediated the effect of TBI on long-term adaptive functioning. Participants included 16 children with severe TBI, 42 children with moderate TBI, and 72 children with orthopedic injuries (OI) sustained between ages 3 and 7 years. Children completed neuropsychological tests and caregivers completed a structured interview of child adaptive functioning at 6.9 (±1.10) years post-injury. Profile analysis and multiple mediator modeling were employed. Children with severe TBI demonstrated poorer fluid reasoning and inhibitory control than both children with moderate TBI and OI, as well as slower processing speed than the OI group. Both fluid reasoning and processing speed were significant independent mediators of the effect of severe TBI on adaptive functioning. No neuropsychological measure significantly mediated the effect of moderate TBI on adaptive functioning. Children sustaining early severe TBI demonstrate persisting neuropsychological impairments into adolescence and young adulthood. The impact of severe TBI on children's long-term adaptive functioning is mediated in part by its effects on fluid reasoning and processing speed.

Describing the attention profile of children and adolescents with acquired brain injury using the Virtual Classroom

OBJECTIVES

The objectives of the study were: (1) to describe the attention deficits profile of children with significant acquired brain injury (ABI) in comparison to matched controls, using the virtual classroom (VC); (2) to assess the utility of the VC in detecting attention deficits in children with ABI, as compared to classical neuropsychological tests and questionnaire-based assessment of attention; and (3) to determine how performance in the VC is affected by demographic and injury severity variables.

METHODS

Forty-one children with ABI and 35 age- and gender-matched controls, aged 8-16, were assessed with the VC. The results of the VC were compared to sub-tests of the Test of Everyday Attention for Children (TEA-Ch), the Conners' Parent Rating Scales-Revised: Short (CPRS-R:S) questionnaire and analysed according to demographic and injury severity variables.

RESULTS

Significant differences were found between the groups regarding the number of targets correctly identified in the VC. Significant inter-correlations were obtained between the VC variables. Significant correlations were found between the VC variables, the sub-tests of TEA-Ch and the CPRS-R:S and the demographic characteristics of the sample.

CONCLUSION

The VC appears to be a sensitive and ecologically valid assessment tool for use in the diagnosis of attention deficits among children with ABI.

Factor structure of the Behavior Rating Inventory of Executive Functions (BRIEF-P) at age three years

The preschool period is an important developmental period for the emergence of cognitive self-regulatory skills or executive functions (EF). To date, evidence regarding the structure of EF in preschool children has supported both unitary and multicomponent models. The aim of the present study was to test the factor structure of early EF as measured by the Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P). BRIEF-P consists of five subscales and three broader indexes, hypothesized to tap into different subcomponents of EF. Parent ratings of EF from a nonreferred sample of children recruited from the Norwegian Mother and Child Cohort Study (N = 1134; age range 37-47 months) were subjected to confirmatory factor analyses (CFA). Three theoretically derived models were assessed; the second-order three-factor model originally proposed by the BRIEF-P authors, a "true" first-order one-factor model and a second-order one-factor model. CFA fit statistics supported the original three-factor solution. However, the difference in fit was marginal between this model and the second-order one-factor model. A follow-up exploratory factor analysis (EFA) supported the existence of several factors underlying EF in early preschool years, with a considerable overlap with the five BRIEF-P subscales. Our results suggest that some differentiation in EF has taken place at age 3 years, which is reflected in behavior ratings. The internal consistency of the BRIEF-P five clinical subscales is supported. Subscale interrelations may, however, differ at this age from those observed in the preschool group as a whole.

Executive function, adherence, and glycemic control in adolescents with type 1 diabetes: a literature review

The aim of the present review was to examine and report findings from published research to date that has examined associations between executive function (EF), adherence, and glycemic control in youth with type 1 diabetes. A review of the published research is presented with the objectives of reporting the following: (1) the associations between EF and adherence, (2) the associations between EF and glycemic control, (3) proposed methodological considerations needed to advance related research, (4) recommendations for future research, and (5) clinical recommendations. The major conclusions of this review support the presence of an association between EF, adherence, and glycemic control. Additional prospective and controlled studies are necessary to fully understand the impact of EF on the ability of youth to independently manage type 1 diabetes.

Long-term benefits of an early online problem-solving intervention for executive dysfunction after traumatic brain injury in children: a randomized clinical trial

IMPORTANCE

Executive dysfunction after traumatic brain injury (TBI) in children is common and leads to significant short- and long-term problems in functioning across multiple settings. We hypothesized that improvements in short-term executive function would be maintained to 24 months after injury and that improvements would increase over time in a counselor-assisted problem-solving (CAPS) intervention.

OBJECTIVE

To evaluate the efficacy of a CAPS intervention administered within 7 months of complicated mild to severe TBI compared with an Internet resource condition in improving long-term executive dysfunction.

DESIGN, SETTING, AND PARTICIPANTS

Multisite, assessor-blinded, randomized clinical trial at 3 tertiary pediatric hospitals and 2 tertiary general medical centers. Participants included 132 adolescents aged 12 to 17 years who sustained a moderate to severe TBI 1 to 7 months before study enrollment.

INTERVENTION

Web-based CAPS intervention.

MAIN OUTCOMES AND MEASURES

The primary outcome was the parent-reported Global Executive Composite (GEC) of the Behavior Rating Inventory of Executive Function. Secondary outcomes included the Behavioral Regulation Index (BRI) and Metacognition Index (MI) of the GEC.

RESULTS

In older (>14 to 17 years) adolescents, the CAPS intervention was associated with lower GEC ratings at 12 (β = -0.46; P = .03) and 18 (β = -0.52; P = .02) months after enrollment. Trends were also observed for older adolescents toward lower GEC ratings at 6 months (β = -0.40; P = .05), lower BRI ratings at 12 (β  = -0.40; P = .06) and 18 (β  = -0.47; P = .04) months, and lower MI ratings at 6 (β  = -0.41; P = .05), 12 (β  = -0.46; P = .03), and 18 (β  = -0.50; P = .03) months. In younger (12-14 years) adolescents, no group differences were found on the GEC, BRI, or MI ratings.

CONCLUSIONS AND RELEVANCE

Delivery of the CAPS intervention early after TBI in older adolescents improves long-term executive function. This trial is, to our knowledge, one of the few large, randomized clinical treatment trials performed in pediatric TBI to demonstrate the efficacy of an intervention for management of executive dysfunction and long-term benefits of an intervention delivered soon after injury. Use of the CAPS intervention clinically should be considered; however, further research should explore ways to optimize delivery.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00409448.

Interventions for attention problems after pediatric traumatic brain injury: what is the evidence?

OBJECTIVE

To gain an understanding of the current state of the evidence for management of attention problems after traumatic brain injury (TBI) in children, determine gaps in the literature, and make recommendations for future research. TYPE: Focused systematic review.

LITERATURE SURVEY

PubMed/Medline and PsychINFO databases were searched for relevant articles published in English during the last 20 years. Keywords included "attention" "attention deficit and disruptive behavior disorders," and "brain injuries." Studies were limited to children.

METHODOLOGY

Titles were examined first and eliminated based on lack of relevancy to attention problems after brain injury in children. This was followed by an abstract and full text review. Article quality was determined based on the US Preventative Services Task Force recommendations for evidence grading.

SYNTHESIS

Four pharmacologic and 10 cognitive therapy intervention studies were identified. These studies varied in level of evidence quality but were primarily nonrandomized or cohort studies.

CONCLUSIONS

There are studies that demonstrate benefits of varying pharmacologic and cognitive therapies for the management of attention problems after TBI. However, there is a paucity of evidence available to definitively guide management of attention problems after pediatric TBI. Larger randomized, controlled trials and multicenter studies are needed to elucidate optimal treatment strategies in this population.

Comparing Performance within a Virtual Supermarket of Children with Traumatic Brain Injury to Typically Developing Children: A Pilot Study

The purpose of this study was to determine the usability of a virtual reality environment for pediatric traumatic brain injury (TBI) by assessing the performance of a simple virtual shopping task and comparing their results to typically developing peers. Twenty children with TBI and 20 typically developing children, matched in age and sex, “shopped” for four items in a virtual supermarket (VMall). A short feedback questionnaire, Borg's scale of perceived exertion, and the Zoo Map subtest from the Behavioral Assessment of the Dysexecutive Syndrome for Children were also administered. All of the children were able to complete a four-item test within the VMall. Overall, good usability was obtained. A significant difference in shopping performance was found between the two groups; the mean shopping time and number of mistakes was higher for the children with TBI. The use of a short shopping test within a functional virtual environment enabled detection of poorer performance of children with TBI that may be due to executive function deficits. Because the task was enjoyable and motivating, the VMall may also be used to enhance participation in instrumental activities of daily living and play for children with TBI.

Online problem-solving therapy for executive dysfunction after child traumatic brain injury

OBJECTIVE

Executive dysfunction after traumatic brain injury (TBI) in children is common and leads to significant problems in functioning across multiple settings. The objective of this study was to evaluate the efficacy of a web-based counselor-assisted problem solving (CAPS) intervention compared with an Internet resource comparison (IRC) for treatment of executive dysfunction within 12 months after complicated mild to severe TBI in adolescents. We hypothesized that CAPS would significantly improve parent ratings of executive dysfunction compared with an IRC.

METHODS

Participants included 132 adolescents aged 12 to 17 years who sustained a complicated mild to severe TBI within 1 to 6 months before study enrollment. Study design was a multisite, assessor-blinded, randomized controlled trial. Study sites included 3 tertiary pediatric hospitals and 2 tertiary general medical centers. The main outcome measure was primary caregiver Behavioral Rating Inventory of Executive Function Global Executive Composite at baseline and 6-month follow-up. Generalized linear models that controlled for baseline scores were used to compare the CAPS and IRC scores.

RESULTS

In older teens, the CAPS group showed significant improvement in executive function behaviors at 6-month follow-up compared with the IRC group (F = 6.74, P = .01, Cohen's d = 0.63).

CONCLUSIONS

Findings indicate that web-based CAPS improves primary caregiver-rated executive functioning within the first 12 months after TBI in older adolescents. Future research needs to define the optimal timing after injury for delivery of CAPS and characteristics of individuals and families who are most likely to benefit from CAPS.

Contribution of rating scales to the assessment of executive functions

Executive functions play a vital role in the everyday functioning of healthy individuals across the lifespan and have been implicated in a wide variety of clinical conditions. Historically, the assessment of executive functions in clinical and research settings relied on performance-based measures. A number of authors have argued, however, that such measures have limited ecological validity. In response to this limitation of performance-based measures, several rating scales have been developed that seek to gauge a person's or their knowledgeable informant's (e.g., parent or teacher) subjective view of executive functioning in everyday life. In this article we review evidence supporting the use of rating scales of executive function including profiles in clinical populations, biological correlates, relationships to relevant outcome measures such as academic performance, and correlations with performance-based measures. We conclude that performance-based and rating scale measures provide complementary information with respect to a child's executive functions, offering a more comprehension view than either approach alone.

Association of parent ratings of executive function with global- and setting-specific behavioral impairment after adolescent traumatic brain injury

OBJECTIVE

To determine the association of primary caregiver-rated behavioral and metacognitive aspects of executive function (EF) with impaired functioning after adolescent traumatic brain injury (TBI).

DESIGN

Multicenter cross-sectional study.

SETTING

Outpatient.

PARTICIPANTS

Primary caregivers and children (N=132) aged 12 to 17 years who sustained a moderate or severe TBI within the past 1 to 6 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Primary caregiver ratings of EF, tests of memory and processing speed (PS), and a structured parent interview to assess clinical impairments in behavioral functioning were used. Logistic regression was used to examine the relation of ratings of EF with clinical ratings of impairment in global adolescent functioning and in functioning in the home, school, and community settings after controlling for sex, race, socioeconomic status, injury severity, and performance on the tests of memory and PS.

RESULTS

Caregiver ratings of poor EF were associated with impairment in both global behavioral functioning (odds ratio [OR]=4.73; 95% confidence interval [CI], 1.54-14.52; P<.01) and community functioning (OR=13.28; 95% CI, 1.94-90.87; P<.01).

CONCLUSIONS

Caregiver ratings of deficits in EF were associated with impaired behavioral functioning after adolescent TBI and were independent of performance on tests of memory and processing speed. Understanding the relation of EF with clinical impairments as manifested in different settings will help hone assessment batteries and focus treatments where they are needed most.

Ecological assessment of cognitive functions in children with acquired brain injury: a systematic review

BACKGROUND

Childhood acquired brain injury (ABI) often leads to impairment in cognitive functioning, resulting in disabilities in both the home and school environment. Assessing the impact of these cognitive deficits in everyday life using traditional neuropsychological tests has been challenging. This study systematically reviewed ecological measures of cognitive abilities available for children with ABI.

METHOD

Eight databases were searched (until October 2011) for scales: (1) focused on ecological assessment of cognitive functioning; (2) with published data in an ABI population; (3) applicable to children up to 17;11 years of age; and (4) in English. The title and abstract of all papers were reviewed independently by two reviewers.

RESULTS

Database searches yielded a total of 12 504 references, of which 17 scales met the inclusion criteria for the review, focusing on executive functions (n = 9), memory (n = 3), general cognitive abilities (n = 2), visuo-spatial skills (n = 2) and attention (n = 1). Four tasks used observation of actual performance in a natural environment, five were proxy-reports and six were functional paper and pencil type tasks, performed in an office.

CONCLUSION

Overall, few measures were found; eight were still experimental tasks which did not provide norms. Executive functions were better represented in ecological assessment, with relatively more standardized scales available.

Recommendations for the use of common outcome measures in pediatric traumatic brain injury research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroup's recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

The essential role of psychosocial risk and protective factors in pediatric traumatic brain injury research

This article builds upon Traumatic Brain Injury Common Data Elements (TBI CDE) version 1.0 and the pediatric CDE Initiative by emphasizing the essential role of psychosocial risk and protective factors in pediatric TBI research. The goals are to provide a compelling rationale for including psychosocial risk and protective factors in addition to socioeconomic status (SES), age, and sex in the study design and analyses of pediatric TBI research and to describe recommendations for core common data elements in this domain. Risk and protective factor research is based on the ecological theory of child development in which children develop through a series of interactions with their immediate and more distant environments. Home, school, religious, and social influences are conceptualized as risk and/or protective factors. Child development and TBI researchers have interpreted risk and protective variables as main effects or as interactions and have used cumulative risk indices and moderation models to describe the relationship among these variables and outcomes that have to do with development and with recovery from TBI. It is likely that the number, type, and interaction among risk and protective factors each contribute unique variance to study outcomes. Longitudinal designs in TBI research will be essential to understanding the reciprocal relationships between risk/protective factors and the recovery/outcome made by the child. The search for effective interventions to hasten TBI recovery mandates the need to target modifiable risks and to promote protective factors in the child's environment.

Development and Evaluation of an Ecological Task to Assess Executive Functioning Post Childhood TBI: The Children's Cooking Task

Purpose:Traumatic brain injury (TBI) often leads to executive functions deficits, which may be responsible for severe and longstanding disabilities in everyday activities. Sensitivity and ecological validity of neuropsychological tests of executive functions have been questioned. The aims of this study were to pilot an ecological open-ended assessment of executive functions in children, the ‘Children's Cooking Task’ (CCT), specifically to report its reliability, discriminant validity and concurrent validity.Methods:Twenty-five children with mild (n= 10) or moderate-to-severe TBI (n= 15), and 21 matched controls (aged 8 to 20 years) participated in the study. An open-ended cooking task was designed to test multi-tasking abilities. It required the preparation of two simple recipes using specific instructions. Outcome measures included the number of errors and an overall qualitative analysis of the task. Validating measures of executive functions included the Delis Kaplan Executive Function System, the Six-Part Test and two questionnaires completed by the child's primary care-giver: the Behavior Rating Inventory of Executive Function and the Dysexecutive Questionnaire for Children.Results:Internal consistency of the Children's Cooking Task was high (Cronbach's alpha = .86), as was test–retest reliability (ICC = .89). Children with moderate-to-severe TBI, as well as children with mild TBI made significantly more errors in the Children's Cooking Task in comparison to controls (p< .001). The CCT was correlated with several tests and one questionnaire of executive functioning (Trails, verbal fluency, sorting, 20 questions, Dysexecutive Questionnaire).Discussion and Conclusion:The Children's Cooking Task has good interrater and test–retest reliability, as well as good discriminant and concurrent validity.