Executive functions and theory of mind as predictors of social adjustment in childhood traumatic brain injury

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.

Association of neurostructural biomarkers with secondary attention-deficit/hyperactivity disorder (ADHD) symptom severity in children with traumatic brain injury: a prospective cohort study

BACKGROUND

Despite a well-established link between childhood traumatic brain injury (TBI) and elevated secondary attention-deficit/hyperactivity disorder (s-ADHD) symptomology, the neurostructural correlates of these symptoms are largely unknown. Based on the influential 'triple-network model' of ADHD, this prospective longitudinal investigation aimed to (i) assess the effect of childhood TBI on brain morphometry of higher-order cognitive networks proposed to play a key role in ADHD pathophysiology, including the default-mode network (DMN), salience network (SN) and central executive network (CEN); and (ii) assess the independent prognostic value of DMN, SN and CEN morphometry in predicting s-ADHD symptom severity after childhood TBI.

METHODS

The study sample comprised 155 participants, including 112 children with medically confirmed mild-severe TBI ascertained from consecutive hospital admissions, and 43 typically developing (TD) children matched for age, sex and socio-economic status. High-resolution structural brain magnetic resonance imaging (MRI) sequences were acquired sub-acutely in a subset of 103 children with TBI and 34 TD children. Parents completed well-validated measures of ADHD symptom severity at 12-months post injury.

RESULTS

Relative to TD children and those with milder levels of TBI severity (mild, complicated mild, moderate), children with severe TBI showed altered brain morphometry within large-scale, higher-order cognitive networks, including significantly diminished grey matter volumes within the DMN, SN and CEN. When compared with the TD group, the TBI group showed significantly higher ADHD symptomatology and higher rates of clinically elevated symptoms. In multivariable models adjusted for other well-established risk factors, altered DMN morphometry independently predicted higher s-ADHD symptomatology at 12-months post-injury, whilst SN and CEN morphometry were not significant independent predictors.

CONCLUSIONS

Our prospective study findings suggest that neurostructural alterations within higher-order cognitive circuitry may represent a prospective risk factor for s-ADHD symptomatology at 12-months post-injury in children with TBI. High-resolution structural brain MRI has potential to provide early prognostic biomarkers that may help early identification of high-risk children with TBI who are likely to benefit from early surveillance and preventive measures to optimise long-term neuropsychiatric outcomes.

What predicts persisting social impairment following pediatric traumatic brain injury: contribution of a biopsychosocial approach

BACKGROUND

Psychosocial deficits, such as emotional, behavioral and social problems, reflect the most common and disabling consequences of pediatric traumatic brain injury (TBI). Their causes and recovery likely differ from physical and cognitive skills, due to disruption to developing brain networks and the influence of the child's environment. Despite increasing recognition of post-injury behavioral and social problems, there exists a paucity of research regarding the incidence of social impairment, and factors predicting risk and resilience in the social domain over time since injury.

METHODS

Using a prospective, longitudinal design, and a bio-psychosocial framework, we studied children with TBI (n = 107) at baseline (pre-injury function), 6 months, 1 and 2-years post-injury. We assessed intellectual ability, attention/executive function, social cognition, social communication and socio-emotional function. Children underwent structural magnetic resonance imaging (MRI) at 2-8 weeks post-injury. Parents rated their child's socio-emotional function and their own mental health, family function and perceived burden.

RESULTS

We distinguished five social recovery profiles, characterized by a complex interplay between environment and pre- and post-TBI factors, with injury factors playing a lesser role. Resilience in social competence was linked to intact family and parent function, intact pre-injury adaptive abilities, post-TBI cognition and social participation. Vulnerability in the social domain was related to poor pre- and post-injury adaptive abilities, greater behavioral concerns, and poorer pre- and post-injury parent health and family function.

CONCLUSIONS

We identified five distinct social recovery trajectories post-child-TBI, each characterized by a unique biopsychosocial profile, highlighting the importance of comprehensive social assessment and understanding of factors contributing to social impairment, to target resources and interventions to children at highest risk.

Social Functioning and Autistic Behaviors in Youth Following Acquired Brain Injury

Children and adolescents who survive the pediatric intensive care unit (PICU) with an acquired brain injury (ABI) often demonstrate a variety of physical, cognitive, emotional/behavioral, and social sequelae termed post-intensive care syndrome (PICS). Social communication and interaction challenges have also been observed clinically, and there is growing literature documenting these occurrences in youth following ABI. The extent of these social changes varies among patients, and a subset of patients go on to exhibit social and behavioral profiles closely resembling those of autistic youth. We reviewed empirical research regarding social functioning in youth following ABI, as well as the overlap between individuals with ABI and autistic youth, published from January 2009 to August 2022 on PubMed and Scopus databases. Clinical case examples from a well-established post-PICU follow-up program are also provided to exemplify the complexity of this phenomenon.

Cognitive predictors of social adjustment in pediatric brain tumor survivors treated with photon versus proton radiation therapy

BACKGROUND

Pediatric brain tumor survivors are at risk for poor social outcomes. It remains unknown whether cognitive sparing with proton radiotherapy (PRT) supports better social outcomes relative to photon radiotherapy (XRT). We hypothesized that survivors treated with PRT would outperform those treated with XRT on measures of cognitive and social outcomes. Further, we hypothesized that cognitive performance would predict survivor social outcomes.

PROCEDURE

Survivors who underwent PRT (n = 38) or XRT (n = 20) participated in a neurocognitive evaluation >1 year post radiotherapy. Group differences in cognitive and social functioning were assessed using analysis of covariance (ANCOVA). Regression analyses examined predictors of peer relations and social skills.

RESULTS

Age at evaluation, radiation dose, tumor diameter, and sex did not differ between groups (all p > .05). XRT participants were younger at diagnosis (XRT M = 5.0 years, PRT M = 7.6 years) and further out from radiotherapy (XRT M = 8.7 years, PRT M = 4.6 years). The XRT group performed worse than the PRT group on measures of processing speed (p = .01) and verbal memory (p < .01); however, social outcomes did not differ by radiation type. The proportion of survivors with impairment in peer relations and social skills exceeded expectation; χ² (1) = 38.67, p < .001; χ² (1) = 5.63, p < .05. Household poverty predicted peer relation difficulties (t = 2.18, p < .05), and verbal memory approached significance (t = -1.99, p = .05). Tumor diameter predicted social skills (t = -2.07, p < .05).

CONCLUSIONS

Regardless of radiation modality, survivors are at risk for social challenges. Deficits in verbal memory may place survivors at particular risk. Results support monitoring of cognitive and social functioning throughout survivorship, as well as consideration of sociodemographic risk factors.

Development of the mentalizing network structures and theory of mind in extremely preterm youth

Adolescents born preterm (<37 weeks of gestation) are at elevated risk for deficits in social cognition and peer relationships. Theory of Mind (ToM) is a complex form of social cognition important for regulating social interactions. ToM and the underlying mentalizing network continue to develop across adolescence. The present study recruited 48 adolescents (12-17 years old) who were either born extremely preterm (EPT; <28 weeks of gestation) or full-term (FT) at birth. Cortical thickness, gray matter volume and surface area were measured in four regions of the mentalizing network: the temporoparietal junction, anterior temporal cortex, posterior superior temporal sulcus and frontal pole (mBA10). We also assessed the adolescents' performance on a ToM task. Findings revealed both group differences and group-by-age interaction effects in the gray matter indices within the temporal lobe regions of the mentalizing network. The EPT group also performed significantly worse than the FT group on the ToM task. The cortical structural measures that discriminated the EPT and FT groups were not related to ToM performance. These results highlight altered developmental changes in brain regions underlying mentalizing functions in EPT adolescents relative to FT controls.

Cognitive Reserve, Early Cognitive Screening, and Relationship to Long-Term Outcome after Severe Traumatic Brain Injury

The objective was to investigate the relationship between early global cognitive functioning using the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) and cognitive flexibility (Trail Making Test (TMT), TMT B-A), with long-term outcome assessed by the Mayo-Portland Adaptability Index (MPAI-4) in severe traumatic brain injury (sTBI) controlling for the influence of cognitive reserve, age, and injury severity. Of 114 patients aged 18–65 with acute Glasgow Coma Scale 3–8, 41 patients were able to complete (BNIS) at 3 months after injury and MPAI-4 5–8 years after injury. Of these, 33 patients also completed TMT at 3 months. Global cognition and cognitive flexibility correlated significantly with long-term outcome measured with MPAI-4 total score (r_BNIS = 0.315; r_TMT = 0.355). Global cognition correlated significantly with the participation subscale (r = 0.388), while cognitive flexibility correlated with the adjustment (r = 0.364) and ability (r = 0.364) subscales. Adjusting for cognitive reserve and acute injury severity did not alter these relationships. The effect size for education on BNIS and TMT scores was large (d ≈ 0.85). Early screenings with BNIS and TMT are related to long-term outcome after sTBI and seem to measure complementary aspects of outcome. As early as 3 months after sTBI, educational level influences the scores on neuropsychological screening instruments.

Social adjustment across the lifespan in survivors of pediatric acute lymphoblastic leukemia (ALL): a systematic review

PURPOSE

The objectives of this review were to (1) summarize studies that described social adjustment in survivors of pediatric ALL across the lifespan, (2) summarize social adjustment outcomes reported across studies, and (3) examine associations between social adjustment and disease/treatment- and non-treatment-related factors.

METHODS

Searched databases included EMBASE (Ovid), MEDLINE (Ovid), PsycINFO (EBSCO Information Services), and Web of Science (Thomson Reuters). Eligible studies included: (1) original research; (2) published in English; (3) a diagnosis of cancer between 0 and 21 years; (4) survivors at least 5 years from diagnosis and/or 2 years from therapy completion; and (5) quantitative assessment of social adjustment.

RESULTS

The literature search yielded 3698 articles of which 43 were included in the final review. Risk of bias was assessed using domains adapted from the Cochrane risk-of-bias tool. Quality of evidence was evaluated following the Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria. There was some evidence that school-aged and adolescent/young adult survivors experienced worse social adjustment compared to controls. There was some evidence suggesting cranial radiation therapy (CRT) is associated with social adjustment difficulties among young adult survivors. Inconsistent evidence was found for relapse, age at diagnosis and study, sex, and late effects in relation to social adjustment.

CONCLUSION

Survivors of pediatric ALL were at higher risk of social adjustment difficulties compared to controls. However, evidence for treatment and non-treatment risk and resilience factors require stronger evidence.

IMPLICATIONS FOR CANCER SURVIVORS

Information on modifiable factors that modulate social adjustment may influence targets of intervention and follow-up guidelines.

Social adjustment in survivors of acute lymphoblastic leukemia without cranial radiation therapy

OBJECTIVE

To evaluate group differences in social adjustment in survivors of pediatric acute lymphoblastic leukemia (ALL) compared to survivor siblings and controls; identify disease-related predictors of social adjustment in survivors; and explore whether executive functioning explained differences in social adjustment across groups and between disease-related predictors.

METHODS

Survivors of pediatric ALL (n = 38, average age at diagnosis = 4.27 years [SD = 1.97]; average time off treatment = 4.83 years [SD = 1.52]), one sibling (if available, n = 20), and one parent from each family were recruited from a long-term survivor clinic. Healthy age- and sex-matched controls (n = 38) and one parent from each family were recruited from the community. Parents completed the Behavioral Assessment System for Children, Parent Rating Scale (BASC-3) Social Withdrawal subscale as a measure of social adjustment, and the Behavior Rating Inventory of Executive Functions (BRIEF-2) as a measure of executive function for each of their children. Multilevel modeling and mediation analysis were used to achieve the study aims.

RESULTS

Parents reported that survivors had significantly worse social adjustment compared to controls (b = 6.34, p = .004), but not survivor siblings. Among survivors, greater time off treatment (b = 2.06, p = .058) and poorer executive functioning (b = 0.42, p = .006) were associated with worse social adjustment. Executive function did not mediate differences in social withdrawal between survivors and controls or the relationship between time off treatment and social withdrawal among survivors.

CONCLUSIONS

Survivors of pediatric ALL presenting to follow-up programs should be screened for difficulties with social adjustment. Future research should examine treatment- and nontreatment-related factors contributing to poorer social outcomes.

Surface-based abnormalities of the executive frontostriatial circuit in pediatric TBI

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Cortical thickness of the dorsolateral prefrontal cortex is reduced in pediatric TBI.

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Shape abnormalities of the caudate and mediodorsal nucleus of the thalamus are a feature of pediatric TBI.

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Surface-based abnormalities of the dorsolateral prefrontal loop do not appear to relate to executive functioning.

Childhood traumatic brain injury (TBI) is one of the most common causes of acquired disability and has significant implications for executive functions (EF), such as impaired attention, planning, and initiation that are predictive of everyday functioning. Evidence has suggested attentional features of executive functioning require behavioral flexibility that is dependent on frontostriatial circuitry. The purpose of this study was to evaluate surface-based deformation of a specific frontostriatial circuit in pediatric TBI and its role in EF. Regions of interest included: the dorsolateral prefrontal cortex (DLPFC), caudate nucleus, globus pallidus, and the mediodorsal nucleus of the thalamus (MD). T1-weighted magnetic resonance images were obtained in a sample of children ages 8–13 with complicated mild, moderate, or severe TBI (n = 32) and a group of comparison children with orthopedic injury (OI; n = 30). Brain regions were characterized using high-dimensional surface-based brain mapping procedures. Aspects of EF were assessed using select subtests from the Test of Everyday Attention for Children (TEA-Ch). General linear models tested group and hemisphere differences in DLPFC cortical thickness and subcortical shape of deep-brain regions; Pearson correlations tested relationships with EF. Main effects for group were found in both cortical thickness of the DLPFC (F_1,60 = 4.30, p = 0.042) and MD mean deformation (F_1,60 = 6.50, p = 0.01) all with lower values in the TBI group. Statistical surface maps revealed significant inward deformation on ventral-medial aspects of the caudate in TBI relative to OI, but null results in the globus pallidus. No significant relationships between EF and any region of interest were observed. Overall, findings revealed abnormalities in multiple aspects of a frontostriatial circuit in pediatric TBI, which may reflect broader pathophysiological mechanisms. Increased consideration for the role of deep-brain structures in pediatric TBI can aid in the clinical characterization of anticipated long-term developmental effects of these individuals.

Executive function mediates the prospective association between neurostructural differences within the central executive network and anti-social behavior after childhood traumatic brain injury

BACKGROUND

Despite increasing evidence of a link between early life brain injury and anti-social behavior, very few studies have assessed factors that explain this association in children with traumatic brain injury (TBI). One hypothesis suggests that childhood TBI elevates risk for anti-social behavior via disruption to anatomically distributed neural networks implicated in executive functioning (EF). In this longitudinal prospective study, we employed high-resolution structural neuroimaging to (a) evaluate the impact of childhood TBI on regional morphometry of the central executive network (CEN) and (b) evaluate the prediction that lower EF mediates the prospective relationship between structural differences within the CEN and postinjury anti-social behaviors.

METHODS

This study involved 155 children, including 112 consecutively recruited, hospital-confirmed cases of mild-severe TBI and 43 typically developing control (TDC) children. T1-weighted brain magnetic resonance imaging (MRI) sequences were acquired sub-acutely in a subset of 137 children [TBI: n = 103; TDC: n = 34]. All participants were evaluated using direct assessment of EF 6 months postinjury, and parents provided ratings of anti-social behavior 12 months postinjury.

RESULTS

Severe TBI was associated with postinjury volumetric differences within the CEN and its putative hub regions. When compared with TD controls, the TBI group had significantly worse EF, which was associated with more frequent anti-social behaviors and abnormal CEN morphometry. Mediation analysis indicated that reduced EF mediated the prospective association between postinjury volumetric differences within the CEN and more frequent anti-social behavior.

CONCLUSIONS

Our longitudinal prospective findings suggest that detection of neurostructural abnormalities within the CEN may aid in the early identification of children at elevated risk for postinjury executive dysfunction, which may in turn contribute to chronic anti-social behaviors after early life brain injury. Findings underscore the potential value of early surveillance and preventive measures for children presenting with neurostructural and/or neurocognitive risk factors.

The Utility of the Test of Memory Malingering Trial 1 in Differentiating Neurocognitive, Emotional, and Behavioral Functioning in a Pediatric Concussion Population

OBJECTIVE

In concussion populations, suboptimal task engagement detected by performance validity tests (PVTs) has been associated with poorer neuropsychological scores and greater post-concussive symptoms (PCS). This study examined if Pass/Fail status on the Test of Memory Malingering-TOMM Trial 1-differentiated the neurocognitive, emotional, and behavioral profile of pediatric patients with concussion.

METHOD

This study utilized archival data from 93 patients (mean age = 14.56 and SD = 2.01) with a history of concussion who were assessed at ~5-6 weeks post-injury (mean days = 40.27 and SD = 35.41). Individuals were divided into "Pass" and "Fail" groups based on TOMM Trial 1 performance. The testing battery included ACT, CPT-II and III, HVLT-R, WJ-III and IV ACH, ImPACT, BASC-2, and BRIEF.

RESULTS

The overall pass rate on Trial 1 was 70% (mean = 46.04 and SD = 4.55). Findings suggested that a passing score on Trial 1 may be associated with adequate performance across the remaining two trials of the TOMM. The Fail group scored significantly lower across attention, memory, and processing speed measures when compared with the Pass group. On rating scales, significantly more concerns were endorsed with the Fail group for attention and executive functioning relative to the Pass group. Parents generally endorsed significantly more concerns for executive functioning when compared with their children's self-reported symptoms. There was a trend for the Fail group to report more PCS; however, they did not significantly differ from the Pass group for depression, anxiety, or somatization.

CONCLUSIONS

This study highlights the importance of utilizing PVTs when evaluating concussion recovery.

Graph Theoretical Analysis of Brain Network Characteristics in Brain Tumor Patients: A Systematic Review

Graph theory is a branch of mathematics that allows for the characterization of complex networks, and has rapidly grown in popularity in network neuroscience in recent years. Researchers have begun to use graph theory to describe the brain networks of individuals with brain tumors to shed light on disrupted networks. This systematic review summarizes the current literature on graph theoretical analysis of magnetic resonance imaging data in the brain tumor population with particular attention paid to treatment effects and other clinical factors. Included papers were published through June 24^th, 2020. Searches were conducted on Pubmed, PsycInfo, and Web of Science using the search terms (graph theory OR graph analysis) AND (brain tumor OR brain tumour OR brain neoplasm) AND (MRI OR EEG OR MEG). Studies were eligible for inclusion if they: evaluated participants with a primary brain tumor, used graph theoretical analyses on structural or functional MRI data, MEG, or EEG, were in English, and were an empirical research study. Seventeen papers met criteria for inclusion. Results suggest alterations in network properties are often found in people with brain tumors, although the directions of differences are inconsistent and few studies reported effect sizes. The most consistent finding suggests increased network segregation. Changes are most prominent with more intense treatment, in hub regions, and with factors such as faster tumor growth. The use of graph theory to study brain tumor patients is in its infancy, though some conclusions can be drawn. Future studies should focus on treatment factors, changes over time, and correlations with functional outcomes to better identify those in need of early intervention.

Social Cognition in Paediatric Traumatic Brain Injury: A Systematic Review and Meta-analysis

Recent evidence suggests social cognitive deficits may be among the most profound and disabling consequences of childhood traumatic brain injury (TBI); however, it is only over the last decade that this area has received increasing research attention. This study aims to systematically review all studies reporting on the effects of childhood TBI on social cognition. Meta-analytic techniques were employed to determine the magnitude of social cognitive deficits in childhood TBI. Literature searches were conducted in electronic databases (Medline/PubMed, Scopus, Cochrane, EMBASE, PsycINFO and CINAHL) to retrieve relevant articles on social cognitive outcomes of paediatric TBI published from 2007-2019. The systematic review identified fourteen eligible studies, which examined the effect of paediatric TBI on five dimensions of social cognition, including emotion recognition or perception, theory of Mind (ToM), pragmatic language, moral reasoning, and social problem solving. Of these studies, eleven articles were included in subsequent meta-analyses, which included 482 children with TBI. Meta-analysis using a random-effects model revealed non-significant differences between TBI and typically developing (TD) control groups on measures of emotion perception or recognition. In contrast, children and adolescents with TBI performed significantly worse than control groups on ToM and pragmatic language tasks, with small and medium effect sizes, respectively (Hedge's g = -0.46; -0.73). Meta-regression indicated that post-injury social cognitive deficits were not moderated by child age. While the effect of time since injury was not statistically significant, poorer social cognitive outcomes are documented soon after injury. Despite relatively intact basic social cognitive skills (i.e. emotion perception or recognition) children and adolescents with TBI are vulnerable to deficits in higher-order aspects of social cognition, including ToM and pragmatic language. These findings underscore the importance of further research, using well-validated, standardised outcome instruments, in larger paediatric TBI samples. Furthermore, longitudinal prospective studies are needed to evaluate the respective contribution of injury and non-injury factors to individual variation in outcome and recovery of social cognition after paediatric TBI.

Theory of Mind after Pediatric Traumatic Brain Injury: A Scoping Review

This scoping review aims to synthesize existing literature regarding theory of mind (ToM) outcomes, the neuropathology associated with ToM outcomes, and the relationship between ToM outcomes and social functioning in children and adolescents with traumatic brain injury (TBI). We searched MEDLINE^® and PsycINFO databases to identify all literature that examined ToM following pediatric TBI until July 2019. A total of 29 articles met inclusion and exclusion criteria and were included in the results. These articles examined a variety of aspects of ToM, which could be broadly grouped into those focused on cognitive, cognitive-affective, and pragmatic factors. The existing literature suggests that children and adolescents with TBI, compared with their typically developing peers and peers with orthopedic injuries, are more likely to have deficits in ToM. The evidence further shows that the age at which brain injury occurs contributes to ToM disruption. Neuroimaging techniques have offered crucial insights into how TBI may impact ToM performance in children and adolescents. Finally, this review provides evidence that disruption in ToM plays a role in the difficulties in social functioning demonstrated by children and adolescents with TBI. Limitations and gaps in the existing literature warrant future research in this field.

Delineating the Nature and Correlates of Social Dysfunction after Childhood Traumatic Brain Injury Using Common Data Elements: Evidence from an International Multi-Cohort Study

Although childhood traumatic brain injury (TBI) has been linked to heightened risk of impaired social skills and behavior, current evidence is weakened by small studies of variable methodological quality. To address these weaknesses, this international multi-cohort study involved synthesis of data from two large observational cohort studies of complicated mild-severe child TBI in Australia and North America. Both studies adopted a unified approach to data collection and coding procedures, providing the opportunity to merge datasets from multiple, well-characterized cohorts for which gold standard measures of social outcomes were collected during the chronic recovery phase. The study involved 218 children, including 33 children with severe TBI, 83 children with complicated mild-moderate TBI, 59 children with orthopedic injury, and 43 age- and sex-matched typically developing control children. All injured children were recruited from academic children's hospitals and underwent direct cognitive assessments including measures of theory of mind (ToM) at least 1-year post- injury. Parents rated their child's social adjustment using standardized measures of social skills, communication and behavior. Results showed a brain-injury specific effect on ToM abilities, such that children with both complicated mild to moderate and severe TBI displayed significantly poorer ToM than children without TBI. In mediator models, poorer ToM predicted poorer parent-rated self-direction and social skills, as well as more frequent behavioral symptoms. The ToM mediated the effect of severe TBI on parent ratings of communication and social skills, as well as on overall behavior symptoms. The findings suggest that deficits in ToM are evident across the spectrum of TBI severity and represent one mechanism linking severe child TBI to long-term social adjustment difficulties. The findings underscore the value of large-scale data harmonization projects to increase the quality of evidence regarding the outcomes of TBI. Clinical and scientific implications are discussed.

The mentalizing network and theory of mind mediate adjustment after childhood traumatic brain injury

Childhood traumatic brain injury (TBI) affects over 600 000 children per year in the United States. Following TBI, children are vulnerable to deficits in psychosocial adjustment and neurocognition, including social cognition, which persist long-term. They are also susceptible to direct and secondary damage to related brain networks. In this study, we examine whether brain morphometry of the mentalizing network (MN) and theory of mind (ToM; one component of social cognition) mediates the effects of TBI on adjustment. Children with severe TBI (n = 15, M_age = 10.32), complicated mild/moderate TBI (n = 30, M_age = 10.81) and orthopedic injury (OI; n = 42, M_age = 10.65) completed measures of ToM and executive function and underwent MRI; parents rated children’s psychosocial adjustment. Children with severe TBI demonstrated reduced right-hemisphere MN volume, and poorer ToM, vs children with OI. Ordinary least-squares path analysis indicated that right-hemisphere MN volume and ToM mediated the association between severe TBI and adjustment. Parallel analyses substituting the central executive network and executive function were not significant, suggesting some model specificity. Children at greatest risk of poor adjustment after TBI could be identified based in part on neuroimaging of social brain networks and assessment of social cognition and thereby more effectively allocate limited intervention resources.

Theory of Mind and Parental Nurturance as Predictors of Peer Relationships After Childhood Traumatic Brain Injury: A Test of Moderated Mediation

OBJECTIVE

Traumatic brain injury (TBI) sustained in childhood is associated with poor social outcomes. This study investigated the role of theory of mind (ToM) as a mediator of the relation between TBI and peer rejection/victimization and reciprocated friendships, as well as the moderating effect of parental nurturance on those relationships.

METHOD

Participants were children of 8-13 years old (M = 10.45, SD = 1.47), including 13 with severe TBI, 39 with complicated mild/moderate TBI, and 32 children with orthopedic injuries. Data on peer rejection/victimization and friendship were collected in school classrooms using the Extended Class Play and friendship nominations. Parents rated parental nurturance using the Child-Rearing Practices Report. Finally, ToM was measured based on children's average performance across three tasks measuring different aspects of ToM.

RESULTS

Severe TBI was associated with poorer ToM, greater peer rejection/victimization, and fewer reciprocated friendships. ToM mediated the relation between severe TBI and peer rejection/victimization (i.e., severe TBI predicted poorer ToM, which in turn predicted greater rejection/victimization). Parental nurturance significantly moderated this relation, such that the mediating effect of ToM was significant only at low and average levels of parental nurturance, for both severe and complicated mild/moderate TBI groups. Neither the mediating effect of ToM nor the moderating effect of parental nurturance was significant for reciprocated friendships.

CONCLUSION

High parental nurturance may mitigate the negative effects of ToM deficits on risk of peer rejection/victimization among children with TBI. Interventions designed to increase parental nurturance or ToM may promote better social outcomes among children with TBI.

The Relationship Between Social Communication and Social Functioning in Pediatric TBI: A Pilot Study

Objective: Social communication presents a significant difficulty for children with traumatic brain injury (TBI). Although several measures are used to examine social communication, there is no gold-standard assessment tool. The present pilot study examined the ability of the Social Communication Disorders Checklist (SCDC) to detect social communication difficulties in pediatric TBI. Further, we examined the relationship between social communication and social functioning as assessed by parental ratings of behavior and objective measures of social cognition.

Methods: Sixteen children with pediatric TBI and 20 age, education and sex matched healthy controls (HCs) participated. All participants participated in a neuropsychological evaluation and parents filled out questionnaires. Parents rated their children's social communication abilities using the SCDC, as well as the Behavior Assessment System for Children, Second Edition (BASC-2). The pediatric subjects completed a task of social cognition, specifically Theory of Mind (ToM).

Results: The pediatric TBI group had significantly lower scores on the SCDC compared to the HCs (p = 0.001). In the pediatric group, SCDC scores correlated significantly with scores on the BASC-2, as well as performance on the ToM task, indicating that children with lower parent-rated social communication abilities also had lower scores on the objective measure of social cognition.

Conclusions: These data provide preliminary evidence that children with TBI have difficulties with social communication, as evidenced by lower scores on the SCDC, and that SCDC scores correlate with subjective and objective measures of social cognition and behavior in pediatric TBI.

Moral reasoning and decision-making in adolescents who sustain traumatic brain injury

Objective: Emerging evidence suggests that moral processes are disrupted by traumatic brain injury (TBI). The objective of this study was to explore moral reasoning (MR) and decision-making in adolescents with TBI, and to examine potential associations with global manifestations of social competence.Design: This retrospective, cross-sectional research design compared MR and decision-making in adolescents with mild TBI (n = 20), moderate-severe TBI (n = 23) and typically developing controls (n = 93).Methods: Participants completed a visual task of socio-moral reasoning (SoMoral) and the Index of Empathy for Children and Adolescents. Their parents completed questionnaires documenting their child's behavior (Child Behavior Checklist) and adaptive functioning (Adaptive Behavior Assessment System-Second Edition).Main results: Adolescents with both mild and moderate-severe TBI displayed more immature MR than typically developing peers. Participants with TBI also provided fewer socially adapted decisions. Closer inspection revealed that this difference was apparent only in the mild TBI group. No significant group differences were observed for empathy, behavior or adaptive skills.Conclusions: Sustaining TBI appears to affect adolescents' ability to provide mature moral justifications when faced with moral dilemmas representative of everyday social conflicts. These difficulties do not appear to be associated with behavior problems, reduced empathy, or adaptive functioning.

Preliminary findings of altered functional connectivity of the default mode network linked to functional outcomes one year after pediatric traumatic brain injury

PURPOSE AND METHOD

This study examined functional connectivity of the default mode network (DMN) and examined brain-behavior relationships in a pilot cohort of children with chronic mild to moderate traumatic brain injury (TBI).

RESULTS

Compared to uninjured peers, children with TBI demonstrated less anti-correlated functional connectivity between DMN and right Brodmann Area 40 (BA 40). In children with TBI, more anomalous less anti-correlated) connectivity between DMN and right BA 40 was linked to poorer performance on response inhibition tasks.

CONCLUSION

Collectively, these preliminary findings suggest that functional connectivity between DMN and BA 40 may relate to longterm functional outcomes in chronic pediatric TBI.

Childhood Traumatic Brain Injury and the Associations With Risk Behavior in Adolescence and Young Adulthood: A Systematic Review

OBJECTIVE

To systematically review the evidence that childhood traumatic brain injury (TBI) is associated with risk behavior in adolescence and young adulthood. Risk behavior included one or more of the following: use of substances, including alcohol, tobacco, and illicit substances; involvement in criminal behavior; and behavioral issues with conduct.

METHODS

A literature search was conducted using these terms: child, pediatric, traumatic brain injury, head injury, adolescent, psychosocial, antisocial, conduct, substance use. Studies describing original research were included if they reported outcomes over the age of 13 years in participants who sustained a TBI between birth and age 13 years.

RESULTS

Six journal articles were reviewed based on 4 separate studies. Three articles indicated a relationship between childhood TBI and increased problematic substance use in adolescence and young adulthood. Three articles supported an association between childhood TBI and later externalizing behavior; however, 2 articles did not support this link.

CONCLUSION

More research is warranted to explore the association between childhood TBI and later risk behavior as the relationship is not currently understood. Future research should build on existing longitudinal research with continued use of medical records for identifying TBI and inclusion of a non-brain-related trauma group to control for general injury effects.

Teen online problem solving for teens with traumatic brain injury: Rationale, methods, and preliminary feasibility of a teen only intervention

PURPOSE/OBJECTIVE

To describe the Teen Online Problem Solving-Teen Only (TOPS-TO) intervention relative to the original Teen Online Problem Solving-Family (TOPS-F) intervention, to describe a randomized controlled trial to assess intervention efficacy, and to report feasibility and acceptability of the TOPS-TO intervention. Research method and design: This is a multisite randomized controlled trial, including 152 teens (49 TOPS-F, 51 TOPS-TO, 52 IRC) between the ages of 11-18 who were hospitalized for a moderate to severe traumatic brain injury in the previous 18 months. Assessments were completed at baseline, 6-months post baseline, and 12-months post baseline. Data discussed include adherence and satisfaction data collected at the 6-month assessment (treatment completion) for TOPS-F and TOPS-TO.

RESULTS

Adherence measures (sessions completed, dropout rates, duration of treatment engagement, and rates of program completion) were similar across treatment groups. Overall, teen and parent reported satisfaction was high and similar across groups. Teens spent a similar amount of time on the TOPS website across groups, and parents in the TOPS-F spent more time on the TOPS website than those in the TOPS-TO group (p = .002). Parents in the TOPS-F group rated the TOPS website as more helpful than those in the TOPS-TO group (p = .05).

CONCLUSIONS/IMPLICATIONS

TOPS-TO intervention is a feasible and acceptable intervention approach. Parents may perceive greater benefit from the family based intervention. Further examination is required to understand the comparative efficacy in improving child and family outcomes, and who is likely to benefit from each approach. (PsycINFO Database Record

White matter microstructure predicts longitudinal social cognitive outcomes after paediatric traumatic brain injury: a diffusion tensor imaging study

BACKGROUND

Deficits in social cognition may be among the most profound and disabling sequelae of paediatric traumatic brain injury (TBI); however, the neuroanatomical correlates of longitudinal outcomes in this domain remain unexplored. This study aimed to characterize social cognitive outcomes longitudinally after paediatric TBI, and to evaluate the use of sub-acute diffusion tensor imaging (DTI) to predict these outcomes.

METHODS

The sample included 52 children with mild complex-severe TBI who were assessed on cognitive theory of mind (ToM), pragmatic language and affective ToM at 6- and 24-months post-injury. For comparison, 43 typically developing controls (TDCs) of similar age and sex were recruited. DTI data were acquired sub-acutely (mean = 5.5 weeks post-injury) in a subset of 65 children (TBI = 35; TDC = 30) to evaluate longitudinal prospective relationships between white matter microstructure assessed using Tract-Based Spatial Statistics and social cognitive outcomes.

RESULTS

Whole brain voxel-wise analysis revealed significantly higher mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) in the sub-acute TBI group compared with TDC, with differences observed predominantly in the splenium of the corpus callosum (sCC), sagittal stratum (SS), dorsal cingulum (DC), uncinate fasciculus (UF) and middle and superior cerebellar peduncles (MCP & SCP, respectively). Relative to TDCs, children with TBI showed poorer cognitive ToM, affective ToM and pragmatic language at 6-months post-insult, and those deficits were related to abnormal diffusivity of the sCC, SS, DC, UF, MCP and SCP. Moreover, children with TBI showed poorer affective ToM and pragmatic language at 24-months post-injury, and those outcomes were predicted by sub-acute alterations in diffusivity of the DC and MCP.

CONCLUSIONS

Abnormal microstructure within frontal-temporal, limbic and cerebro-cerebellar white matter may be a risk factor for long-term social difficulties observed in children with TBI. DTI may have potential to unlock early prognostic markers of long-term social outcomes.

Recovery Trajectories of Executive Functioning After Pediatric TBI: A Latent Class Growth Modeling Analysis

OBJECTIVE

To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across recovery trajectories using latent class growth modeling (LCGM).

METHOD

A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups.

RESULTS

Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories.

CONCLUSION

The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries.

Clinical and therapeutic role of mentalization in schizophrenia-a review

Recent empirical findings from clinical and genetic studies suggest that mentalization, a key area of social cognition, is a distinct construct, although it is closely related to the neurocognitive deficits and symptoms of schizophrenia. Mentalization contributes a great deal to impaired social functioning. Current measures often display methodological problems, and many aspects should be taken into account when assessing mentalization. Moreover, advances in cognitive and affective neurosciences have led to the development of more advanced behavioral methods to assess the relationship between cognitive functions, symptoms, and social cognition based on their underlying neural mechanisms. The development of assessment tools that better examine the neural circuitry of such relationships may lead to the development of new psychosocial and pharmacological treatments.

Uncovering the neuroanatomical correlates of cognitive, affective and conative theory of mind in paediatric traumatic brain injury: a neural systems perspective

Deficits in theory of mind (ToM) are common after neurological insult acquired in the first and second decade of life, however the contribution of large-scale neural networks to ToM deficits in children with brain injury is unclear. Using paediatric traumatic brain injury (TBI) as a model, this study investigated the sub-acute effect of paediatric traumatic brain injury on grey-matter volume of three large-scale, domain-general brain networks (the Default Mode Network, DMN; the Central Executive Network, CEN; and the Salience Network, SN), as well as two domain-specific neural networks implicated in social-affective processes (the Cerebro-Cerebellar Mentalizing Network, CCMN and the Mirror Neuron/Empathy Network, MNEN). We also evaluated prospective structure-function relationships between these large-scale neural networks and cognitive, affective and conative ToM. 3D T1- weighted magnetic resonance imaging sequences were acquired sub-acutely in 137 children [TBI: n = 103; typically developing (TD) children: n = 34]. All children were assessed on measures of ToM at 24-months post-injury. Children with severe TBI showed sub-acute volumetric reductions in the CCMN, SN, MNEN, CEN and DMN, as well as reduced grey-matter volumes of several hub regions of these neural networks. Volumetric reductions in the CCMN and several of its hub regions, including the cerebellum, predicted poorer cognitive ToM. In contrast, poorer affective and conative ToM were predicted by volumetric reductions in the SN and MNEN, respectively. Overall, results suggest that cognitive, affective and conative ToM may be prospectively predicted by individual differences in structure of different neural systems-the CCMN, SN and MNEN, respectively. The prospective relationship between cerebellar volume and cognitive ToM outcomes is a novel finding in our paediatric brain injury sample and suggests that the cerebellum may play a role in the neural networks important for ToM. These findings are discussed in relation to neurocognitive models of ToM. We conclude that detection of sub-acute volumetric abnormalities of large-scale neural networks and their hub regions may aid in the early identification of children at risk for chronic social-cognitive 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.

Frontal Lobe Contusion in Mice Chronically Impairs Prefrontal-Dependent Behavior

Traumatic brain injury (TBI) is a major cause of chronic disability in the world. Moderate to severe TBI often results in damage to the frontal lobe region and leads to cognitive, emotional, and social behavioral sequelae that negatively affect quality of life. More specifically, TBI patients often develop persistent deficits in social behavior, anxiety, and executive functions such as attention, mental flexibility, and task switching. These deficits are intrinsically associated with prefrontal cortex (PFC) functionality. Currently, there is a lack of analogous, behaviorally characterized TBI models for investigating frontal lobe injuries despite the prevalence of focal contusions to the frontal lobe in TBI patients. We used the controlled cortical impact (CCI) model in mice to generate a frontal lobe contusion and studied behavioral changes associated with PFC function. We found that unilateral frontal lobe contusion in mice produced long-term impairments to social recognition and reversal learning while having only a minor effect on anxiety and completely sparing rule shifting and hippocampal-dependent behavior.

Investigating a Proposed Model of Social Competence in Children With Traumatic Brain Injuries

OBJECTIVE

The goal of the current study was to test a proposed model of social competence for children who have suffered a traumatic brain injury (TBI). We hypothesized that both peer and teacher reports of social behavior would mediate the relation between intraindividual characteristics (e.g., executive function) and peer acceptance.

METHODS

Participants were 52 children with TBI (M age = 10.29; M time after injury: 2.46 years). Severity of TBI ranged from complicated mild to severe. Classroom and laboratory measures were used to assess executive function, social behavior, and peer acceptance.

RESULTS

Analyses revealed that peer reports of social behavior were a better mediator than teacher reports of the associations between executive function, social behaviors, and peer acceptance.

DISCUSSION

The results underscore the importance of including peer reports of social behavior when developing interventions designed to improve the social, emotional, and behavioral outcomes of children with TBI.

Social competence in pediatric brain tumor survivors: breadth versus depth

PURPOSE OF REVIEW

The purpose of this article is to review the literature in the area of social competence in pediatric brain tumor survivors published in the last year.

RECENT FINDINGS

Research published over the past year examining the social competence of pediatric brain tumor survivors has seen the consistent application of a comprehensive conceptual framework that pertains specifically to children with brain disorders. Subsequent to the application of a comprehensive conceptual framework, more sophisticated research approaches have begun to advance our understanding of deficits among this population. Specifically, operationalization of social competence is evolving.

SUMMARY

Continued application of a conceptual framework and investigation into the components that comprise the framework will enhance the depth of our understanding of social competence deficits among this population. Research must continue to use innovative approaches to measuring social competence. Considerable gaps still exist with respect to identifying risk and resilience factors for social competence deficits.

Theory of mind mediates the prospective relationship between abnormal social brain network morphology and chronic behavior problems after pediatric traumatic brain injury

Childhood and adolescence coincide with rapid maturation and synaptic reorganization of distributed neural networks that underlie complex cognitive-affective behaviors. These regions, referred to collectively as the 'social brain network' (SBN) are commonly vulnerable to disruption from pediatric traumatic brain injury (TBI); however, the mechanisms that link morphological changes in the SBN to behavior problems in this population remain unclear. In 98 children and adolescents with mild to severe TBI, we acquired 3D T1-weighted MRIs at 2-8 weeks post-injury. For comparison, 33 typically developing controls of similar age, sex and education were scanned. All participants were assessed on measures of Theory of Mind (ToM) at 6 months post-injury and parents provided ratings of behavior problems at 24-months post-injury. Severe TBI was associated with volumetric reductions in the overall SBN package, as well as regional gray matter structural change in multiple component regions of the SBN. When compared with TD controls and children with milder injuries, the severe TBI group had significantly poorer ToM, which was associated with more frequent behavior problems and abnormal SBN morphology. Mediation analysis indicated that impaired theory of mind mediated the prospective relationship between abnormal SBN morphology and more frequent chronic behavior problems. Our findings suggest that sub-acute alterations in SBN morphology indirectly contribute to long-term behavior problems via their influence on ToM. Volumetric change in the SBN and its putative hub regions may represent useful imaging biomarkers for prediction of post-acute social cognitive impairment, which may in turn elevate risk for chronic behavior problems.

Right frontal pole cortical thickness and executive functioning in children with traumatic brain injury: the impact on social problems

Cognitive and social outcomes may be negatively affected in children with a history of traumatic brain injury (TBI). We hypothesized that executive function would mediate the association between right frontal pole cortical thickness and problematic social behaviors. Child participants with a history of TBI were recruited from inpatient admissions for long-term follow-up (n = 23; average age = 12.8, average time post-injury =3.2 years). Three measures of executive function, the Trail Making Test, verbal fluency test, and the Conners' Continuous Performance Test-Second edition (CPT-II), were administered to each participant while caregivers completed the Childhood Behavior Checklist (CBCL). All participants underwent brain magnetic resonance imaging following cognitive testing. Regression analysis demonstrated right frontal pole cortical thickness significantly predicted social problems. Measures of executive functioning also significantly predicted social problems; however, the mediation model testing whether executive function mediated the relationship between cortical thickness and social problems was not statistically significant. Right frontal pole cortical thickness and omission errors on the CPT-II predicted Social Problems on the CBCL. Results did not indicate that the association between cortical thickness and social problems was mediated by executive function.

Mental Health Implications of Traumatic Brain Injury (TBI) in Children and Youth

OBJECTIVE

Traumatic brain injury (TBI) is the most common cause of death and disability in children and adolescents. Psychopathology is an established risk factor for, and a frequent consequence of, TBI. This paper reviews the literature relating psychopathology and TBI.

METHOD

Selective literature review.

RESULTS

The risk of sustaining a TBI is increased by pre-existing psychopathology (particularly ADHD and aggression) and psychosocial adversity. Even among individuals with no psychopathology prior to the injury, TBI is frequently followed by mental illness especially ADHD, personality change, conduct disorder and, less frequently, by post-traumatic stress and anxiety disorders. The outcome of TBI can be partially predicted by pre-injury adjustment and injury severity, but less well by age at injury. Few individuals receive treatment for mental illness following TBI.

CONCLUSION

TBI has substantial relevance to mental health professionals and their clinical practice. Available evidence, while limited, indicates that the risk for TBI in children and adolescents is increased in the presence of several, potentially treatable mental health conditions and that the outcome of TBI involves a range of mental health problems, many of which are treatable. Prevention and management efforts targeting psychiatric risks and outcomes are an urgent priority. Child and adolescent mental health professionals can play a critical role in the prevention and treatment of TBI through advocacy, education, policy development and clinical practice.