Longitudinal outcome of verbal discourse in children with traumatic brain injury: three-year follow-up

An international survey of assessment and treatment practice for discourse in paediatric Acquired Brain Injury

PURPOSE

Guidelines recommend routine discourse assessment and treatment in paediatric acquired brain injury (ABI) but provide little guidance for clinical practice. The degree to which this has influenced the nature of discourse assessment and treatment in clinical practice has not been examined in detail.

METHOD

Speech-language pathologists working in paediatric ABI (clients aged <18 years) in Australia, New Zealand, the UK, the USA, Canada, and the Asia Pacific region were invited to complete a survey of discourse assessment and intervention practices (n = 77).

RESULT

Clinicians from Australia and New Zealand comprised over half of a responses (53%). The largest proportion had over 10 years' experience (60%), worked in the metropolitan area (58%), and with secondary school-age children (64%). Routine discourse assessment was undertaken by 80% of respondents, focussing on a limited range of genres. No preferred intervention approach was identified. One-quarter of clinicians routinely considered holistic factors during clinical decision-making. Limited normative data and treatment evidence, insufficient time and training were identified as clinical barriers.

CONCLUSION

Assessment practices were consistent with guidelines, yet interventions were highly variable, reflecting limited evidence, client heterogeneity, time constraints, and limited training. A biopsychosocial approach to practice was evident, yet a focus on impairment level factors was prominent. Findings support the need for standardised discourse assessment and discourse intervention methods. Translation into practice guidelines would promote consistency and confidence in clinical practice.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

Discourse Performance in Adults With Mild Traumatic Brain Injury, Orthopedic Injuries, and Moderate to Severe Traumatic Brain Injury, and Healthy Controls

INTRODUCTION

Adults with mild traumatic brain injury (mTBI) are at risk for communication disorders, yet studies exploring cognitive-communication performance are currently lacking.

AIMS

This aim of this study was to characterize discourse-level performance by adults with mTBI on a standardized elicitation task and compare it to (a) healthy adults, (b) adults with orthopedic injuries (OIs), and (c) adults with moderate to severe TBI.

METHOD

This study used a cross-sectional design. The participants included mTBI and OI groups recruited prospectively from an emergency medicine department. Moderate to severe TBI and healthy data were acquired from TalkBank. One-way analyses of variance were used to compare mean linguistic scores.

RESULTS

Seventy participants across all groups were recruited. Groups did not differ on demographic variables. The study found significant differences in both content and productivity measures among the groups. Variables did not appear sensitive to differentiate between mTBI and OI groups.

DISCUSSION

Cognitive and language performance of adults with mTBI is a pressing clinical issue. Studies exploring language with carefully selected control groups can influence the development of sensitive measures to identify individuals with cognitive-communication deficits.

Bayesian Generalized Linear Mixed-Model Analysis of Language Samples: Detecting Patterns in Expository and Narrative Discourse of Adolescents With Traumatic Brain Injury

Purpose Generalized linear mixed-model (GLMM) and Bayesian methods together provide a framework capable of handling a wide variety of complex data commonly encountered across the communication sciences. Using language sample analysis, we demonstrate the utility of these methods in answering specific questions regarding the differences between discourse patterns of children who have experienced a traumatic brain injury (TBI), as compared to those with typical development. Method Language samples were collected from 55 adolescents ages 13-18 years, five of whom had experienced a TBI. We describe parameters relating to the productivity, syntactic complexity, and lexical diversity of language samples. A Bayesian GLMM is developed for each parameter of interest, relating these parameters to age, sex, prior history (TBI or typical development), and socioeconomic status, as well as the type of discourse sample (compare-contrast, cause-effect, or narrative). Statistical models are thoroughly described. Results Comparing the discourse of adolescents with TBI to those with typical development, substantial differences are detected in productivity and lexical diversity, while differences in syntactic complexity are more moderate. Female adolescents exhibited greater syntactic complexity, while male adolescents exhibited greater productivity and lexical diversity. Generally, our models suggest more advanced discourse among adolescents who are older or who have indicators of higher socioeconomic status. Differences relating to lecture type were also detected. Conclusions Bayesian and GLMM methods yield more informative and intuitive results than traditional statistical analyses, with a greater degree of confidence in model assumptions. We recommend that these methods be used more widely in language sample analysis. Supplemental Material https://doi.org/10.23641/asha.14226959.

Long term effects of early childhood traumatic brain injury on narrative discourse gist and psychosocial functioning

Purpose: To examine the long-term consequences of early childhood traumatic brain injury (TBI), approximately 6.8 years post-injury, on cognitive communication competency within a complex interplay of individual, contextual, and psychosocial factors. Additionally, we were interested in looking at the association of communication competence with social competence and overall functioning.Methods: 64 children with orthopedic injury, 40 children with moderate traumatic brain injury, and 14 children with severe traumatic brain injury who were between 3 years and 6 years 11 months at injury completed a narrative discourse task and clinical measures in a single visit at a longer term follow up in early adolescence, an average of 6.8 years post injury. Analyses of covariance were conducted to compare groups on the discourse task, and hierarchical linear regressions were conducted to examine the association of discourse measures with clinical measures of cognitive and psychosocial functioning.Results: Children with severe traumatic brain injury performed worse than children with moderate traumatic brain injury and orthopedic injury on all discourse indices and clinical measures. Injury severity, pragmatic skills, and socioeconomic status were associated with discourse gist. Discourse gist was the most sensitive measure of communication competence, and it was significantly associated with psychosocial outcomes independent of group.Conclusion: Children who sustain a severe traumatic brain injury in early childhood are at risk for long-term cognitive communication impairments that may be related to a complex interplay of injury, individual, and social factors.Implications for rehabilitationThe assessment and treatment of cognitive communication impairments after traumatic brain injury are complex and require consideration of individual, contextual, and psychosocial factors.Discourse, in general, and gist reasoning specifically, is a sensitive measure for detecting cognitive communication competence several years after pediatric traumatic brain injury.Treatments to address gist reasoning deficits may support improvements in global and social functioning.

Follow-Up on the Story Goodness Index for Characterizing Discourse Deficits Following Traumatic Brain Injury

Purpose The Story Goodness Index (SGI) is a hybrid analysis of narrative discourse combining 2 macrostructural measures: story grammar and story completeness. Initially proposed by Lê and colleagues ( Lê, Coelho, Mozeiko, & Grafman, 2011 ), the SGI is intended to characterize the discourse performance of individuals with cognitive-communication disorders. In this study, the SGI was utilized to examine the discourse of 2 groups, one with closed head injuries and another with non-brain injured (NBI) peers. The intent of this study was to ascertain whether the SGI could differentiate the discourse performance of the 2 groups, as was previously reported for individuals with penetrating traumatic brain injury and an NBI comparison group ( Lê, Coelho, Mozeiko, Krueger, & Grafman, 2012 ). Because of the retrospective nature of this study, the wordless visual narrative used to elicit discourse was different from the narrative used by Lê and colleagues (2012) . Method A retrospective analysis of discourse was performed on 55 individuals with a history of closed head injury and 47 NBI socioeconomically matched peers. During the initial assessment, participants were engaged in a narrative retell task. Each participant was shown a wordless picture story and then asked to retell the story to the examiner. Story narratives were reanalyzed for story grammar (organization) and completeness (critical content). Results A significant group difference was noted for the story grammar measure, but not for story completeness. Although the SGI plots depicted the heterogeneity in discourse performance of the 2 groups, a chi-square test of independence revealed no significant association between group membership and SGI quadrant. Conclusions Findings from this study were inconsistent with those of Lê and colleagues. The studies did not use identical SGI protocols; specifically, different picture stimuli were used to elicit the story retells. Therefore, this study cannot be considered a replication. The story used by Lê and colleagues was judged to be more complex, requiring more inference for story interpretation. Future studies should interpret findings within the context of the story stimuli presented.

Speech therapy for children with dysarthria acquired before three years of age

BACKGROUND

Children with motor impairments often have the motor speech disorder dysarthria, a condition which effects the tone, strength and co-ordination of any or all of the muscles used for speech. Resulting speech difficulties can range from mild, with slightly slurred articulation and breathy voice, to profound, with an inability to produce any recognisable words. Children with dysarthria are often prescribed communication aids to supplement their natural forms of communication. However, there is variation in practice regarding the provision of therapy focusing on voice and speech production. Descriptive studies have suggested that therapy may improve speech, but its effectiveness has not been evaluated.

OBJECTIVES

To assess whether any speech and language therapy intervention aimed at improving the speech of children with dysarthria is more effective in increasing children's speech intelligibility or communicative participation than no intervention at all , and to compare the efficacy of individual types of speech language therapy in improving the speech intelligibility or communicative participation of children with dysarthria.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 , Issue 7 ), MEDLINE, EMBASE, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to July 2015, handsearched relevant journals published between 1980 and July 2015, and searched proceedings of relevant conferences between 1996 to 2015. We placed no restrictions on the language or setting of the studies. A previous version of this review considered studies published up to April 2009. In this update we searched for studies published from April 2009 to July 2015.

SELECTION CRITERIA

We considered randomised controlled trials and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.

DATA COLLECTION AND ANALYSIS

One author (LP) conducted searches of all databases, journals and conference reports. All searches included a reliability check in which a second review author independently checked a random sample comprising 15% of all identified reports. We planned that two review authors would independently assess the quality and extract data from eligible studies.

MAIN RESULTS

No randomised controlled trials or group studies were identified.

AUTHORS' CONCLUSIONS

This review found no evidence from randomised trials of the effectiveness of speech and language therapy interventions to improve the speech of children with early acquired dysarthria. Rigorous, fully powered randomised controlled trials are needed to investigate if the positive changes in children's speech observed in phase I and phase II studies are generalisable to the population of children with early acquired dysarthria served by speech and language therapy services. Research should examine change in children's speech production and intelligibility. It must also investigate children's participation in social and educational activities, and their quality of life, as well as the cost and acceptability of interventions.

Does brain volume loss predict cognitive and narrative discourse performance following traumatic brain injury?

PURPOSE

In this study, the authors investigated the relationship between brain volume loss and performance on cognitive measures, including working memory, immediate memory, executive functions, and intelligence, and a narrative discourse production task. An underlying goal was to examine the prognostic potential of a brain lesion metric for discourse outcomes. It was hypothesized that brain volume loss would correlate with and predict cognitive and narrative discourse measures and have prognostic value for discourse outcomes.

METHOD

One hundred sixty-seven individuals with penetrating head injury participated. Correlational and regression analyses were performed for the percentages of total brain and hemispheric volume loss and scores on 4 cognitive measures (WMS-III Working Memory and Immediate Memory primary indexes, D-KEFS Sorting Test, and WAIS-III Full Scale IQ) and 7 narrative discourse measures (T-units, grammatical complexity, cohesion, local and global coherence, story completeness, and story grammar).

RESULTS

The volumetric measures had significant small-to-moderate correlations with all cognitive measures but only one significant correlation with the discourse measures. Findings from regression analyses were analogous but revealed several models that approached significance.

CONCLUSION

Findings suggest that an overall measure of brain damage may be more predictive of general cognitive status than of narrative discourse ability. Atrophy measures in specific brain regions may be more informative.

Individual profiles of predictors and their relations to 10 years outcome after childhood traumatic brain injury

BACKGROUND

Outcome after childhood traumatic brain injury (CTBI) is heterogeneous, with several predictors influencing long-term outcome.

METHOD

This exploratory study used person-oriented cluster analysis to investigate individual profiles of medical, psychological and social predictors and their relation to longitudinal development in a sample of 127 participants with mild, moderate and severe CTBI. Outcome of cognitive, adaptive and academic function was measured at 30 months and 10 years post-injury.

RESULTS

A nine-cluster solution, explaining 67% of the variance in the sample, resulted in two clusters with individuals with mostly mild injuries, five with mostly moderate injured individuals and two clusters with severely injured individuals. Best outcome at 10 years post-injury had a cluster with individuals with moderate injuries, young age at injury, average socioeconomic status (SES) and high pre-injury adaptive function. Worst outcome had a small cluster with severely injured individuals, young age at injury, average SES and average pre-injury adaptive function.

CONCLUSIONS

The findings suggest that pre-injury adaptive function is an influential predictor of outcome following moderate CTBI. Age at injury in the severe group appears to have increased influence over time, with younger age at injury associated with reduced outcome at 10 years after severe CTBI.

Characterizing discourse deficits following penetrating head injury: a preliminary model

PURPOSE

Discourse analyses have demonstrated utility for delineating subtle communication deficits following closed head injuries (CHIs). The present investigation examined the discourse performance of a large group of individuals with penetrating head injury (PHI). Performance was also compared across 6 subgroups of PHI based on lesion locale. A preliminary model of discourse production following PHI was proposed and tested.

METHOD

Story narratives were elicited from 2 groups of participants, 167 with PHI and 46 non brain-injured (NBI). Micro- and macrostructural components of each story were analyzed. Measures of memory, executive functions, and intelligence were also administered. All measures were compared across groups and PHI subgroups. The proposed model of discourse production was tested with a structural equation modeling procedure.

RESULTS

No differences for the discourse measures were noted across the six PHI subgroups. Three measures distinguished the PHI and NBI groups: narrative length, story grammar, and completeness. The proposed model of discourse production had an adequate-to-good fit with the cognitive and discourse data.

CONCLUSION

In spite of differing mechanisms of injury, the PHI group's discourse performance was consistent with what has been reported for individuals with CHI. The model tested represents a preliminary step toward understanding discourse production following traumatic brain injury.

Taking Care of Children After Traumatic Brain Injury

Purpose: The purpose of this article is to inform speech-language pathologists in the schools about issues related to the care of children with traumatic brain injury.

Method: Literature review of characteristics, outcomes and issues related to the needs serving children.

Results: Due to acquired changes in cognition, children with traumatic brain injury have unique needs in a school setting.

Conclusions: Speech-Language Pathologists in the school can take a leadership role with taking care of children after a traumatic brain injury and coordination of medical and educational information.

Emerging narrative discourse skills 18 months after traumatic brain injury in early childhood

This study examined the longer term effect of traumatic brain injury (TBI), approximately 18 months post-injury, on emerging narrative discourse skills of 85 children with orthopaedic injury (OI), 43 children with moderate TBI, and 19 children with severe TBI who were between 3 years and 6 years 11 months at injury. Children with TBI performed worse than children with OI on most discourse indices. Children with severe TBI were less proficient than children with moderate TBI at identifying unimportant story information. Age and pragmatic skills were predictors of discourse performance.

Cognitive Communicative Challenges in TBI: Assessment and Intervention in the Long Term

Neurocognitive stall is defined as a failure or lag in achieving later emerging cognitive milestones, representing an increasing “gap” in neurocognitive, social, and educational functioning after early brain injury (Chapman, 2006). This paper provides an overview of the subject in regard to pediatric traumatic brain injury (TBI), briefly discussing both ineffective and proactive methods for detecting and monitoring later emerging deficits associated with neurocognitive stall. The paper concludes with discussion of an emerging intervention to mitigate impairments in higher-order cognitive skills and enhance learning efficiency, including suggestions for use in rehabilitation settings and within school environments.

Measuring goodness of story narratives

PURPOSE

The purpose of this article was to evaluate a new measure of story narrative performance: story completeness. It was hypothesized that by combining organizational (story grammar) and completeness measures, story "goodness" could be quantified.

METHOD

Discourse samples from 46 typically developing adults were compared with those from 24 adults with acquired brain injuries. Story retellings were elicited and analyzed for episode structure (story grammar). Each story was also evaluated for the presence of 5 key components, yielding the story completeness score. Story goodness was quantified by combining the story grammar and completeness measures using a 2-coordinate grid system. A multivariate analysis of variance was performed as well as correlational analyses between the story grammar and story completeness scores.

RESULTS

There were significant group differences on both story grammar and story completeness. Moderate correlations were noted between the 2 measures, suggesting that the indices were not entirely measuring the same abilities. Plotting the 2 sets of scores into quadrants discriminated the comparison group and the group with brain injury into 4 distinct categories of story "goodness."

CONCLUSION

The combination of measures provided a more accurate depiction of discourse performance than either measure alone. Results suggest the measure is sensitive, is reliable, and has potential utility for investigating discourse deficits in clinical populations.

Effects of higher-order cognitive strategy training on gist-reasoning and fact-learning in adolescents

Improving the reasoning skills of adolescents across the United States has become a major concern for educators and scientists who are dedicated to identifying evidence-based protocols to improve student outcome. This small sample randomized, control pilot study sought to determine the efficacy of higher-order cognitive training on gist-reasoning and fact-learning in an inner-city public middle school. The study compared gist-reasoning and fact-learning performances after training in a smaller sample when tested in Spanish, many of the students’ native language, versus English. The 54 eighth grade students who participated in this pilot study were enroled in an urban middle school, predominantly from lower socio-economic status families, and were primarily of minority descent. The students were randomized into one of three groups, one that learned cognitive strategies promoting abstraction of meaning, a group that learned rote memory strategies, or a control group to ascertain the impact of each program on gist-reasoning and fact-learning from text-based information. We found that the students who had cognitive strategy instruction that entailed abstraction of meaning significantly improved their gist-reasoning and fact-learning ability. The students who learned rote memory strategies significantly improved their fact-learning scores from a text but not gist-reasoning ability. The control group showed no significant change in either gist-reasoning or fact-learning ability. A trend toward significant improvement in overall reading scores for the group that learned to abstract meaning as well as a significant correlation between gist-reasoning ability and the critical thinking on a state-mandated standardized reading test was also found. There were no significant differences between English and Spanish performance of gist-reasoning and fact-learning. Our findings suggest that teaching higher-order cognitive strategies facilitates gist-reasoning ability and student learning.

The neural architecture of discourse compression

Re-telling a story is thought to produce a progressive refinement in the mental representation of the discourse. A neuroanatomical substrate for this compression effect, however, has yet to be identified. We used a discourse re-listening task and functional magnetic resonance imaging (fMRI) to identify brain regions responsive to repeated discourse in twenty healthy volunteers. We found a striking difference in the pattern of activation associated with the first and subsequent presentations of the same story relative to rest. The first presentation was associated with a highly significant increase in blood oxygen level dependent (BOLD) signal in a bilateral perisylvian distribution, including auditory cortex. Listening to the same story on subsequent occasions revealed a wider network with activation extending into frontal, parietal, and subcortical structures. When the first and final presentations of the same story were directly compared, significant increments in activation were found in the middle frontal gyrus bilaterally, and the right inferior parietal lobule, suggesting that the spread of activation with re-listening reflected an active neural process over and above that required for comprehension of the text. Within the right inferior parietal region the change in BOLD signal was highly correlated with a behavioural index of discourse compression based in re-telling, providing converging evidence for the role of the right inferior parietal region in the representation of discourse. Our findings demonstrate, for the first time, the existence of a neural network underlying discourse compression, showing that parts of this network are common to re-telling and re-listening effects.

Speech therapy for children with dysarthria acquired before three years of age

BACKGROUND

Children with motor impairments often have the motor speech disorder dysarthria, a condition which effects the tone, power and coordination of any or all of the muscles used for speech. Resulting speech difficulties can range from mild, with slightly slurred articulation and low-pitched voice, to profound, with an inability to produce any recognisable words. Children with dysarthria are often prescribed communication aids to supplement their natural forms of communication. However, there is variation in practice regarding the provision of therapy focusing on voice and speech production. Descriptive studies have suggested that therapy may improve speech, but its effectiveness has not been evaluated.

OBJECTIVES

To assess whether direct intervention aimed at improving the speech of children with dysarthria is more effective than no intervention at all. To assess whether individual types of intervention are more effective than others in improving the speech intelligibility of children with dysarthria.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, CINAHL , LLBA, ERIC, PsychInfo, Web of Science, Scopus, UK National Research Register and Dissertation Abstracts up to April 2009, handsearched relevant journals published between 1980 and April 2009, and searched proceedings of relevant conferences between 1996-2009.

SELECTION CRITERIA

We considered randomised controlled trials and studies using quasi-experimental designs in which children were allocated to groups using non-random methods.

DATA COLLECTION AND ANALYSIS

L Pennington conducted searches of all databases and conference reports. L Pennington, N Miller and S Robson handsearched journals. All searches included a reliability check in which a second review author independently checked a random sample comprising 15% of all identified reports. We planned that two review authors would independently assess the quality and extract data from eligible studies.

MAIN RESULTS

No randomised controlled trials or group studies were identified.

AUTHORS' CONCLUSIONS

We found no firm evidence of the effectiveness of speech and language therapy to improve the speech of children with early acquired dysarthria. No change in practice is warranted at the present time. Rigorous research is needed to investigate if the positive changes in children's speech observed in small descriptive studies are shown in randomised controlled trials. Research should examine change in children's speech production and intelligibility. It should also investigate the secondary education, health and social care outcomes of intervention, including children's interaction with family, friends and teachers, their participation in social and educational activities, and their quality of life. Cost and acceptability of interventions must also be investigated.

Incentive effects on event-based prospective memory performance in children and adolescents with traumatic brain injury

Prospective memory (PM) is the formation of an intention and remembering to perform this intention at a future time or in response to specific cues. PM tasks are a ubiquitous part of daily life. Currently, there is a paucity of information regarding PM impairments in children with traumatic brain injury (TBI) and less empirical evidence regarding effective remediation strategies to mitigate these impairments. The present study employed two levels of a motivational enhancement (i.e., a monetary incentive) to determine whether event-based PM could be improved in children with severe TBI. In a crossover design, children with orthopedic injuries and mild or severe TBI were compared on two levels of incentive (dollars vs. pennies) given in response to accurate performance. All three groups performed significantly better under the high- versus low-motivation conditions. However, the severe TBI group's high-motivation condition performance remained significantly below the low-motivation condition performance of the orthopedic injury group. PM scores were positively and significantly related to age-at-test, but there were no age-at-injury or time-postinjury effects. Overall, these results suggest that event-based PM can be significantly improved in children with severe TBI.

Intervention for dysarthria associated with acquired brain injury in children and adolescents

BACKGROUND

The term 'acquired brain injury' (ABI) incorporates a range of aetiologies including cerebrovascular accident, brain tumour and traumatic brain injury. ABI is a common cause of disability in the paediatric population, and dysarthria is a common and often persistent sequelae associated with ABI in children.

OBJECTIVES

To assess the efficacy of intervention delivered by Speech and Language Pathologists/Therapists targeting dysarthric speech in children resulting from acquired brain injury.

SEARCH STRATEGY

We searched CENTRAL (Issue 4, 2006), MEDLINE (1966 to 02/2007), CINAHL (1982 to 02/2007), EMBASE (1980 to 02/2007), ERIC (1965 to 02/2007), Linguistics Abstracts Online (1985 to 02/07), PsycINFO (1872 to 02/2007). Additional references were also sought from reference lists studies.

SELECTION CRITERIA

The review considered randomised controlled trials (RCTs) and quasi-experimental design studies of children aged 3-16 years with acquired dysarthria grouped by aetiology (e.g., brain tumour, traumatic brain injury, cerebrovascular accident).

DATA COLLECTION AND ANALYSIS

Each author independently assessed the titles and abstracts for relevance (100% inter-rater reliability) and the full text version of all potentially relevant articles was obtained. No studies met inclusion criteria.

MAIN RESULTS

Of 2091 titles and abstracts identified, full text versions of only three (Morgan 2007; Murdoch 1999; Netsell 2001) were obtained. 2088 were excluded, largely on the basis of not including dysarthria, being diagnostic or descriptive papers, and for concerning adults rather than children. Morgan 2007 and Murdoch 1999 were excluded for not employing RCT or quasi-randomised methodology; Netsell 2001 on the basis of being a theoretical review paper, rather than an intervention study. Five references were identified and obtained from the bibliography of the Murdoch 1999 paper. All were excluded due to including populations without ABI, adults with dysarthria, or inappropriate design. Thus, no studies met inclusion criteria.

AUTHORS' CONCLUSIONS

The review demonstrates a critical lack of studies, let alone RCTs, addressing treatment efficacy for dysarthria in children with ABI. Possible reasons to explain this lack of data include i) a lack of understanding of the characteristics or natural history of dysarthria associated with this population; ii) the lack of a diagnostic classification system for children precluding the development of well targeted intervention programs; and iii) the heterogeneity of both the aetiologies and resultant possible dysarthria types of paediatric ABI. Efforts should first be directed at modest well-controlled studies to identify likely efficacious treatments that may then be trialed in multi-centre collaborations using quasi-randomised or RCT methodology.

Are children with congenital cardiac malformations at increased risk of deficits in social cognition?

In this review, I summarize observations suggesting that social cognition deficits are an important element of the neurodevelopmental morbidities of children with congenital cardiac malformations. Referred to as "theory of mind" deficits, they pertain to the ability to "read" other people, that is, to infer their internal states and thus to interpret their actions appropriately. I also hypothesize that children with such congenital cardiac malformations have difficulty identifying and describing their own internal states, which is referred to as alexithymia. These hypotheses are based on data collected as part of a prospective study of the neurologic outcomes of children with concordant atrioventricular and discordant ventriculo-arterial connections, or transposition. On a variety of tasks that assess pragmatic language and discourse skills, such as elicited personal narratives, free play with a parent, and written narratives, the children consistently performed below age-expected levels and in ways that suggested the presence of "theory of mind" deficits. Their narratives lacked coherence, failed to include critical information required by a listener, and made infrequent reference to internal states. In ongoing evaluations of the children as adolescents, we are testing these hypotheses more systematically by administering several instruments specifically developed to assess "theory of mind" and alexithymia.

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

Little is known about the long-term effects of traumatic brain injury (TBI) in very young children. This study used a prospective, cross-sectional design to investigate the impact of TBI on executive function (EF) outcomes in children who sustained a TBI before the age of seven. The study aimed to identify specific or global EF deficits five years post-TBI, and to explore factors that predicted outcomes. Fifty-four children with a TBI and 17 uninjured comparison children participated. Their performance on several cognitive and behavioral EF measures was examined. Results suggested that executive difficulties were present following severe TBI, however children with mild and moderate injuries were relatively unaffected. Skills that develop early appeared to be relatively robust. Injury severity was found to be most predictive of long-term EF, however other injury, child and family-related variables also contributed to outcomes.

Using the language characteristics of clinical populations to understand normal language development

The overall purpose of this article is to describe the speech and language abilities of children who have selected clinical conditions, not only to characterize the outcomes of those conditions, but also to understand fundamental requirements for language learning in typically developing children. This developmental cognitive neuroscience analysis conceptualizes the clinical conditions as naturalistic experimental manipulations, selectively altering factors in the language-learning situation that could not otherwise be ethically manipulated in a research study.

A SPECT study of language and brain reorganization three years after pediatric brain injury

Using single photon emission computed tomography (SPECT), we investigated brain plasticity in children 3 years after sustaining a severe traumatic brain injury (TBI). First, we assessed brain perfusion patterns (i.e., the extent of brain blood flow to regions of the brain) at rest in eight children who suffered severe TBI as compared to perfusion patterns in eight normally developing children. Second, we examined differences in perfusion between children with severe TBI who showed good versus poor recovery in complex discourse skills. Specifically, the children were asked to produce and abstract core meaning for two stories in the form of a lesson. Inconsistent with our predictions, children with severe TBI showed areas of increased perfusion as compared to normally developing controls. Adult studies have shown the reverse pattern with TBI associated with reduced perfusion. With regard to the second aim and consistent with previously identified brain-discourse relations, we found a strong positive association between perfusion in right frontal regions and discourse abstraction abilities, with higher perfusion linked to better discourse outcomes and lower perfusion linked to poorer discourse outcomes. Furthermore, brain-discourse patterns of increased perfusion in left frontal regions were associated with lower discourse abstraction ability. The results are discussed in terms of how brain changes may represent adaptive and maladaptive plasticity. The findings offer direction for future studies of brain plasticity in response to neurocognitive treatments.

MR spectroscopy: Predicting long-term neuropsychological outcome following pediatric TBI

PURPOSE

To identify useful acute indicators of long-term neurocognitive outcome beyond clinical variables for children and adolescents treated for a traumatic brain injury (TBI).

MATERIALS AND METHODS

The efficacy of magnetic resonance spectroscopy (MRS) acquired 6+/-4 days after TBI in 20 children/adolescents in predicting intellectual and neuropsychological functioning one to four years post injury was assessed. Short echo-time single voxel MRS (SVS) from normal-appearing brain was compared to intermediate echo-time multivoxel MR spectroscopic imaging (MRSI) from normal-appearing and visibly-injured brain acquired through the level of the corpus callosum (CC).

RESULTS

N-acetyl aspartate (NAA) was moderate to strongly correlated with cognitive scores. Mean NAA/creatine (Cre) from MRSI alone explained over 40% of the variance in cognitive scores and 18% of the variance above and beyond demographic and clinical variables alone. Mild to moderate associations were noted between SVS metabolites (glutamate/glutamine [Glx] and myoinositol [mI]) and cognitive scores, with no such associations apparent for choline (Cho) or Cre. Exploratory analyses revealed trends for regional neuroimaging data and specific cognitive abilities.

CONCLUSION

Acute MR spectroscopy of the pediatric brain injury patient improves prognostic ability and may provide valuable information for early treatment and intervention planning.

Neurodevelopmental outcome of young pediatric intensive care survivors of serious brain injury

OBJECTIVES

To determine the number of children with severe brain injury due to closed head injury or hypoxic-ischemic encephalopathy as a proportion of all admissions of children <3 yrs of age in the regional pediatric intensive care unit; to determine the outcome of these children at >6 mos postinjury; and to explore the relationship of outcome measures to predictors of outcome obtained within the first 24 hrs after brain injury.

DESIGN

Prospective, descriptive outcome study of an inception cohort.

RESULTS

Neonatal and Infant Follow-up Clinic, Glenrose Rehabilitation Hospital, Edmonton, Canada.

PATIENTS

Of a cohort of 53 children of <3 yrs of age (4% of pediatric intensive care unit admissions, 1995-1998) admitted for severe acquired brain injury (Glasgow Coma Score, <or=8), 12 (23%) died, three (6%) were lost to follow-up, and 38 (71%) survived and received multidisciplinary outcome assessments.

MEASUREMENTS AND MAIN RESULTS

Of 50 children with known outcome, 23 (46%) had a good recovery on the Glasgow Outcome Scale; however, only eight (16%) of these had average or above scores on both the mental and motor developmental indices of the Bayley Scales of Infant Development-II at 18-36 mos of age. Acute injury predictors of adverse outcome were apnea at scene, bolus epinephrine given for resuscitation, pupils nonreactive, arterial pH <or=7.2, and Glasgow Coma Score of 3. For 38 survivors, sensitivity and specificity from predictors for the Glasgow Outcome Scale were 73% and 83% respectively; for mental scores, 86% and 93%; for motor scores, 75% and 89%.

CONCLUSIONS

Of children of <3 yrs of age identified by a Glasgow Coma Score of <or=8 after acute brain injury, >80% have adverse outcome of death, disability, or mental or motor developmental scores below average. A Glasgow Outcome Scale of 5 overestimates good recovery. Universal registry and follow-up of these children are needed.

Discourse changes in early Alzheimer disease, mild cognitive impairment, and normal aging

The purpose of this study was to determine the sensitivity of discourse gist measures to the early cognitive-linguistic changes in Alzheimer disease (AD) and in the preclinical stages. Differences in discourse abilities were examined in 25 cognitively normal adults, 24 adults with mild probable AD, and 20 adults with mild cognitive impairment (MCI) at gist and detail levels of discourse processing. The authors found that gist and detail levels of discourse processing were significantly impaired in persons with AD and MCI as compared with normal control subjects. Gist-level discourse processing abilities showed minimal overlap between cognitively normal control subjects and those with mild AD. Moreover, the majority of the persons with MCI performed in the range of AD on gist measures. These findings indicate that discourse gist measures hold promise as a diagnostic complement to enhance early detection of AD. Further studies are needed to determine how early the discourse gist deficits arise in AD.