Attentional disturbance after pediatric closed head injury

A Systematic Scoping Review of New Attention Problems Following Traumatic Brain Injury in Children

Objective: To summarize existing knowledge about the characteristics of attention problems secondary to traumatic brain injuries (TBI) of all severities in children.

Methods: Computerized databases PubMed and PsychINFO and gray literature sources were used to identify relevant studies. Search terms were selected to identify original research examining new ADHD diagnosis or attention problems after TBI in children. Studies were included if they investigated any severity of TBI, assessed attention or ADHD after brain injury, investigated children as a primary or sub-analysis, and controlled for or excluded participants with preinjury ADHD or attention problems.

Results: Thirty-nine studies were included in the review. Studies examined the prevalence of and risk factors for new attention problems and ADHD following TBI in children as well as behavioral and neuropsychological factors associated with these attention problems. Studies report a wide range of prevalence rates of new ADHD diagnosis or attention problems after TBI. Evidence indicates that more severe injury, injury in early childhood, or preinjury adaptive functioning problems, increases the risk for new ADHD and attention problems after TBI and both sexes appear to be equally vulnerable. Further, literature suggests that cases of new ADHD often co-occurs with neuropsychiatric impairment in other domains. Identified gaps in our understanding of new attention problems and ADHD include if mild TBI, the most common type of injury, increases risk and what brain abnormalities are associated with the emergence of these problems.

Conclusion: This scoping review describes existing studies of new attention problems and ADHD following TBI in children and highlights important risk factors and comorbidities. Important future research directions are identified that will inform the extent of this outcome across TBI severities, its neural basis and points of intervention to minimize its impact.

Pediatric concussion working memory outcomes: a scoping review

Objective: Characterize the working memory (WM) profile of children and youth who have experienced concussion by systematically synthesizing existing literature on the neuropsychological outcomes of these injuries.Methods: Implemented a peer-reviewed search strategy combining key concepts of concussion/mild traumatic brain injury (mTBI), WM, and pediatrics across MedLine, Embase, PsycINFO, and CINAHL. Included studies written in English with extractable results on a WM outcome measure in individuals aged 21 and under who experienced concussion. Applied narrative synthesis to identify trends in the literature. Assessed risk of bias and quality using the NHLBI's Quality Assessment of Observational Cohort and Cross-Sectional Studies.Results: 40 articles met inclusion criteria. 34/40 studies compared WM performance in children or youth with concussion to healthy controls, pre-injury performance, or normative values, of which 15 reported significantly lower WM performance in the concussion sample. Visual/spatial WM was more consistently impacted than verbal WM. Cognitive demanding dual-task conditions were also reliably impacted.Conclusion: Literature indicated that WM is vulnerable to negative outcomes following pediatric concussion, yet the nature of outcomes is variable. Clinicians and researchers should implement comprehensive and theoretically motivated WM assessments to better understand the WM components impacted by injury.

The Use of Therapeutic Music Training to Remediate Cognitive Impairment Following an Acquired Brain Injury: The Theoretical Basis and a Case Study

Cognitive impairment is the most common sequelae following an acquired brain injury (ABI) and can have profound impact on the life and rehabilitation potential for the individual. The literature demonstrates that music training results in a musician's increased cognitive control, attention, and executive functioning when compared to non-musicians. Therapeutic Music Training (TMT) is a music therapy model which uses the learning to play an instrument, specifically the piano, to engage and place demands on cognitive networks in order to remediate and improve these processes following an acquired brain injury. The underlying theory for the efficacy of TMT as a cognitive rehabilitation intervention is grounded in the literature of cognition, neuroplasticity, and of the increased attention and cognitive control of musicians. This single-subject case study is an investigation into the potential cognitive benefit of TMT and can be used to inform a future more rigorous study. The participant was an adult male diagnosed with cognitive impairment as a result of a severe brain injury following an automobile accident. Pre- and post-tests used standardized neuropsychological measures of attention: Trail Making A and B, Digit Symbol, and the Brown- Peterson Task. The treatment period was twelve months. The results of Trail Making Test reveal improved attention with a large decrease in test time on both Trail Making A (-26.88 s) and Trail Making B (-20.33 s) when compared to normative data on Trail Making A (-0.96 s) and Trail Making B (-3.86 s). Digit Symbol results did not reveal any gains and indicated a reduction (-2) in free recall of symbols. The results of the Brown-Peterson Task reveal improved attention with large increases in the correct number of responses in the 18-s delay (+6) and the 36-s delay (+7) when compared with normative data for the 18-s delay (+0.44) and the 36-s delay (-0.1). There is sparse literature regarding music based cognitive rehabilitation and a gap in the literature between experimental research and clinical work. The purpose of this paper is to present the theory for Therapeutic Music Training (TMT) and to provide a pilot case study investigating the potential efficacy of TMT to remediate cognitive impairment following an ABI.

Influence of Methylphenidate on Long-Term Neuropsychological and Everyday Executive Functioning After Traumatic Brain Injury in Children with Secondary Attention Problems

OBJECTIVE

To investigate the effects of methylphenidate on long-term executive and neuropsychological functioning in children with attention problems following TBI, as well as the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and executive functioning and parent- or self-report measures of everyday executive functioning.

METHOD

26 children aged 6-17 years, who were hospitalized for moderate-to-severe blunt head trauma 6 or more months previously, were recruited from a large children's hospital medical center. Participants were randomized into a double-masked, placebo-controlled cross-over clinical trial. Participants completed a comprehensive neuropsychological battery and parent- and self-report ratings of everyday executive functioning at baseline, and at 4 weeks and 8 weeks following upward titration of medication to an optimal dose or while administered a placebo.

RESULTS

Methylphenidate was associated with significant improvements in processing speed, sustained attention, and both lab-based and everyday executive functioning. Significant treatment-by-period interactions were found on a task of sustained attention. Participants who were randomized to the methylphenidate condition for the first treatment period demonstrated random or erratic responding, with slower and more variable response times when given placebo during the second period.

CONCLUSION

Results indicate that methylphenidate treatment is associated with positive outcomes in processing speed, sustained attention, and both lab-based and everyday measures of executive functioning compared to placebo group. Additionally, results suggest sustained attention worsens when discontinuing medication. (JINS, 2019, 25, 740-749).

The Natural History of Postconcussion Recovery Among High School Athletes

OBJECTIVE

Evaluate postconcussive symptom reporting and recovery.

SETTING

Public high school.

PARTICIPANTS

Unmatched controls (n = 760); students who sustained a sports-related concussion (n = 77); matched controls (gender, grade, sport) (n = 77).

DESIGN

Prospective longitudinal cohort study.

OUTCOME MEASURE

Immediate Postconcussion Assessment and Cognitive Testing.

RESULTS

At baseline, athletes who went on to sustain concussions were more likely than unmatched controls to be younger (P = .02), male (P = .001), and participate in different sports (P < .0001) such as football (concussed = 52%, unmatched controls = 20%). Differences were also noted regarding a previous history of concussion (P = .045; concussed athletes = 26%; unmatched control athletes = 16%) and lifetime number of concussions (P = .05). At baseline, those whose sustained concussions during the study period were more likely than matched controls to report numbness (P = .01) and concentration problems (P = .01) and more likely than unmatched controls to report dizziness (P = .02), sensitivity to light (P = .01), sensitivity to noise (P = .002), and numbness (P = .02). However, when data were reanalyzed and those with a previous history of concussion were removed, differences between those who sustained concussions during the study period and matched controls were no longer significant; when compared to unmatched controls, sensitivity to light (P = .01) and vision problems (P = .04) remained significant. Among those who sustained concussions, median time to recovery was 6 days (95% confidence interval: 4-9), and 71 out of 77 (92%) recovered by the fourth postinjury evaluation (median: 20 days postinjury).

CONCLUSIONS

Course and time frame of recovery were variable. Data also suggest that a previous history of concussion may be contributing to baseline symptom reporting and highlight the potential enduring impact of history of concussion on sensorimotor function. However, further research as to whether preinjury measures of sensorimotor function may increase understanding regarding concussion risk is warranted.

Recovery of Working Memory Following Pediatric Traumatic Brain Injury: A Longitudinal Analysis

In a prospective longitudinal study, the trajectory of verbal and visual-spatial working memory (WM) development was examined 2-, 6-, 12-, and 24-months following complicated-mild to severe pediatric traumatic brain injury (TBI; n = 55) relative to an orthopedic injury comparison group (n = 47). Individual growth curve modeling revealed an interaction of age, severity, and time for verbal, but not visual-spatial WM. The youngest children with severe TBI had the lowest scores and slowest verbal WM growth. WM outcome is best understood in light of age at injury and TBI severity. Findings support the early vulnerability hypothesis and highlight the need for long-term follow-up.

Acute and Chronic Altitude-Induced Cognitive Dysfunction in Children and Adolescents

OBJECTIVE

To assess whether exposure to high altitude induces cognitive dysfunction in young healthy European children and adolescents during acute, short-term exposure to an altitude of 3450 m and in an age-matched European population permanently living at this altitude.

STUDY DESIGN

We tested executive function (inhibition, shifting, and working memory), memory (verbal, short-term visuospatial, and verbal episodic memory), and speed processing ability in: (1) 48 healthy nonacclimatized European children and adolescents, 24 hours after arrival at high altitude and 3 months after return to low altitude; (2) 21 matched European subjects permanently living at high altitude; and (3) a matched control group tested twice at low altitude.

RESULTS

Short-term hypoxia significantly impaired all but 2 (visuospatial memory and processing speed) of the neuropsychological abilities that were tested. These impairments were even more severe in the children permanently living at high altitude. Three months after return to low altitude, the neuropsychological performances significantly improved and were comparable with those observed in the control group tested only at low altitude.

CONCLUSIONS

Acute short-term exposure to an altitude at which major tourist destinations are located induces marked executive and memory deficits in healthy children. These deficits are equally marked or more severe in children permanently living at high altitude and are expected to impair their learning abilities.

"3 . . 2 . . 1 . . Impact [factor]: target [academic career] destroyed!": just another statistical casualty

"Publish or perish" is the time-honored "principle" for academicians who race to accumulate lines under the "publications" section of a curriculum vitae. The original intent of publication-to inform others of findings and further scientific knowledge-has been corrupted by factors including (1) exponential growth of journals and the journal industry, fueled in part by intrusion of the Internet into all aspects of academic life; and (2) adoption of journal metrics (rather than written content) as the measure of scientific quality. The proprietary Thomson Reuters Impact Factor is the most pernicious metric, having caused editors and publishers to change editorial practices to boost the number. At the same time, gullible administrators and government agencies have been persuaded that metrics for the journal in which materials are published can be used as a measure of the worth of individual investigators (and institutions) and their research efforts: simple numbers can be substituted for the burdensome effort required to read and assess research quality. Thus, granting of research funds, awarding of academic rank and tenure, and determination of salaries (including bonus payments) have become tied to manipulable journal metrics rather than the significance or quality of reported research. Therefore, it is no wonder that the integrity of science is more often being questioned. How should a young investigator approach the "publish or perish" dilemma? Performing sound research and preparing optimal materials for publication must remain the overriding goals: properly articulate the question addressed by the study; thoroughly document all methods and case information; carefully describe results including any conflicting or negative findings; discuss the importance of the findings along with how the results address the initial question and whether findings refute or confirm previous studies; prepare properly cited bibliographic references; list all author contributions, potential conflicts of interest, financial support, and required ethical approvals; and provide a catchy title and an abstract containing sufficient information that other investigators perusing scientific indices will be enticed to read the published article. Submit the completed manuscript to the most appropriate journal based on that journal's previously published content and relevance to the field of study regardless of journal metrics. On publication, notify investigators in the same field to ask for their comments on the work. Thus, an individual will become known for the quality of his or her work product and the worshiping of publication metrics will be unnecessary.

Early attention impairment and recovery profiles after childhood traumatic brain injury

OBJECTIVES

To examine recovery of attention from 3 to 6 months postinjury; to identify effects of injury severity and time since injury on performance; to explore whether complex attention skills (eg, shifting, divided attention, attentional control) are more vulnerable to traumatic brain injury (TBI), and slower to recover than simple attention skills (eg, attentional capacity, selective attention, sustained attention).

DESIGN

Prospective longitudinal investigation.

PARTICIPANTS

A total of 205 school-aged children with TBI were divided into groups according to injury severity (mild = 63%, moderate = 27%, severe = 10%).

SETTING

Emergency departments of 3 metropolitan children's hospitals across Australia.

MAIN MEASURES

Standardized clinical measures of both simple and complex attention were administered at 3 months and 6 months postinjury.

RESULTS

Attention skills were vulnerable to the impact of TBI. More severe injury affected attention skills most negatively. Significant recovery was observed over time. There were few interaction effects, with severity groups exhibiting similar levels of recovery over the 6 months post-TBI. No differences in recovery trajectories were detected for simple and complex attention.

CONCLUSIONS

These findings have important clinical and educational implications, suggesting that children with TBI, and particularly those with more serious injuries, are most vulnerable to attention deficits in the acute stages postinjury. It is important that schools and families are aware of these limitations and structure expectations accordingly. For example, gradual return to school should be considered, and in the early stages of recovery, children should be provided with sufficient rest time, with reduced expectations for tasks such as homework.

An FMRI study of auditory orienting and inhibition of return in pediatric mild traumatic brain injury

Studies in adult mild traumatic brain injury (mTBI) have shown that two key measures of attention, spatial reorienting and inhibition of return (IOR), are impaired during the first few weeks of injury. However, it is currently unknown whether similar deficits exist following pediatric mTBI. The current study used functional magnetic resonance imaging (fMRI) to investigate the effects of semi-acute mTBI (<3 weeks post-injury) on auditory orienting in 14 pediatric mTBI patients (age 13.50±1.83 years; education: 6.86±1.88 years), and 14 healthy controls (age 13.29±2.09 years; education: 7.21±2.08 years), matched for age and years of education. The results indicated that patients with mTBI showed subtle (i.e., moderate effect sizes) but non-significant deficits on formal neuropsychological testing and during IOR. In contrast, functional imaging results indicated that patients with mTBI demonstrated significantly decreased activation within the bilateral posterior cingulate gyrus, thalamus, basal ganglia, midbrain nuclei, and cerebellum. The spatial topography of hypoactivation was very similar to our previous study in adults, suggesting that subcortical structures may be particularly affected by the initial biomechanical forces in mTBI. Current results also suggest that fMRI may be a more sensitive tool for identifying semi-acute effects of mTBI than the procedures currently used in clinical practice, such as neuropsychological testing and structural scans. fMRI findings could potentially serve as a biomarker for measuring the subtle injury caused by mTBI, and documenting the course of recovery.

Neuropsychological and neurophysiological assessment of sport concussion in children, adolescents and adults

OBJECTIVE

To determine whether age differences exist with respect to neuropsychological and electrophysiological functioning following a sport concussion.

DESIGN

Cross-sectional study.

PARTICIPANTS

Ninety-six athletes (9-12 years, n = 32; 13-16 years, n = 34; adults, n = 30), half of whom had a sport concussion.

INTERVENTION

Cognitive functioning was assessed using standardized neuropsychological tests and event-related potentials elicited by a visual 3-stimulus oddball paradigm. The PCSS was used to assess symptoms experienced at the time of injury.

MAIN OUTCOME MEASUREMENTS

Neuropsychological assessment with an adaptation of the battery used by the National Hockey League. Latencies and amplitudes of the P3a and P3b were analysed in terms of group (concussed vs. control) and age.

RESULTS

All concussed athletes had significantly lower amplitude for the P3b component compared to their non-injured teammates (p > 0.05). Adolescents also showed persistent deficits in working memory (p > 0.05).

CONCLUSIONS

These data suggest persistent neurophysiological deficits that are present at least 6 months following a concussion. Moreover, adolescents are more sensitive to the consequences of concussions than are children or adults.

Stimulant Use in Paediatric Acquired: Brain Injury: Evaluation of a Protocol

Children with acquired brain injury (ABI) experience deficits in attentional skills such as, sustained attention, distractability and impulsivity, which have the potential to influence all aspects of their functioning. The use of central nervous system (CNS) stimulants is gaining increasing popularity in adult ABI literature. CNS stimulants have been successfully utilised in the management of attentional problems in attention deficit-hyperactivity disorder and are believed to have their therapeutic effect by modulating neurotransmitter function in the neocortex, an area of the brain implicated in the neurobehavioural sequelae of ABI. Research into the use of CNS stimulants in paediatric ABI reports contradictory findings. We present the case of LI a 7-year-old boy with a history of ABI who underwent a trial of stimulant medication for management of attentional deficits. The case is discussed with regard to the efficacy of the pharmacological intervention and the design of objective protocols for stimulant trials.

The Starship Post-Traumatic Amnesia Scale: Does It Predict Outcome After Mild to Moderate Traumatic Brain Injury in Children Aged 3 to 7 Years?

This study assesses whether the Starship Post-Traumatic Amnesia scale, developed for children aged 3 to 7 years, can predict neuropsychological impairment and behavioural outcome following mild to moderate traumatic brain injury. Participants are 19 children aged from 3 to 7 years with a GCS score of >13, and a PTA of 0–3 days. Neuropsychological outcome is measured by the NEPSY, and behavioural outcome by the Child Behaviour Checklist (CBCL) two months after the TBI. The duration of PTA contributed to the prediction of scores on the NEPSY memory and learning domain. In all cases the longer the duration of PTA, the poorer the memory scores were. The duration of PTA did not contribute to the prediction of NEPSY visuospatial processing or attention and executive functions domain scores, or to any of the CBCL scores. This preliminary study suggests that the Starship PTA scale has good sensitivity for this very young age group, even when the TBI is mild.

Attentional skills 10 years post-paediatric traumatic brain injury (TBI)

OBJECTIVE

To date no study has reported findings regarding attentional deficits following pre-school paediatric traumatic brain injury (TBI), as long as 10 years post-injury. It was predicted that more severe TBI would be associated with generalized deficits at 10 years post-TBI, particularly for skills not mastered at time of injury.

RESEARCH DESIGN

The sample comprised 40 prospectively-recruited children (42% of the original sample) who had sustained a mild, moderate or severe traumatic brain injury (TBI) between the ages of 1-7 years and 19 non-injured control participants. Children were assessed 10 years post-TBI, with a focus on measures of attentional ability.

OUTCOMES/RESULTS

While attentional deficits were not evident across all components of attentional ability, both early- and later-established attention skills were compromised, particularly following severe TBI. Environmental predictors were generally not successful predictors of attentional outcome at 10 years post-TBI. Age at injury and acute IQ were identified as contributing to attention at 10 years.

CONCLUSIONS/IMPLICATIONS

The present study shows that attentional deficits do occur and persist to 10 years following serious TBI. Clinicians may be able to screen for such deficits and so intervene in order to prevent or lessen the consequences of such difficulties.

Early bifrontal brain injury: disturbances in cognitive function development

We describe six psychomotor, language, and neuropsychological sequential developmental evaluations in a boy who sustained a severe bifrontal traumatic brain injury (TBI) at 19 months of age. Visuospatial, drawing, and writing skills failed to develop normally. Gradually increasing difficulties were noted in language leading to reading and spontaneous speech difficulties. The last two evaluations showed executive deficits in inhibition, flexibility, and working memory. Those executive abnormalities seemed to be involved in the other impairments. In conclusion, early frontal brain injury disorganizes the development of cognitive functions, and interactions exist between executive function and other cognitive functions during development.

Neurodevelopmental outcomes of pediatric traumatic brain injury

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

Remediation of attention deficits in children: a focus on childhood cancer, traumatic brain injury and attention deficit disorder

The purpose of this review is to examine the status of attention training in children. This body of literature is very small so the review examines available efficacy studies in three paediatric groups: children who have survived cancer affecting the central nervous system (CNS) or whose treatment has impacted the CNS, children with traumatic brain injury (TBI) and children with attention deficit disorder (ADD). Seven studies/case reports are reviewed. The results are encouraging, with six of seven describing some improvement on attention measures. An original case study is presented using Pay Attention! materials with a 6 year old survivor of acute lymphoblastic leukaemia (ALL). This represents only the third report of the use of attention training materials with a survivor of childhood cancer and the first case report of the use of these materials with a very young child (6 years of age).

Paediatric traumatic brain injury: A review of pertinent issues

Children with traumatic brain injury (TBI), regardless of the severity of the injury, often face challenges when living in home, school and community. Their needs are often overlooked and recognition of the long-term consequences is not always central to the management of the child in the school or community. This article provides references to pertinent literature and suggestions for intervention from the clinical experiences of four individuals with extensive experience of the family stresses, educational, cognitive-communicative and behavioural challenges that occur after TBI in children. It provides information regarding these issues, particularly educational situations, and suggests methods that may be useful for service providers and family members.

Saint or sinner? Teacher perceptions of a child with traumatic brain injury

PURPOSE

To examine influences on classroom performance and behaviour following traumatic brain injury (TBI).

METHODS

A case-study of one child who suffered a moderate TBI, with frontal brain damage, aged 8, followed up at ages 12 and 13 years. Parents and child were interviewed to establish pre- and post-injury behaviour and functioning. All 19 teachers who taught the child reported on classroom performance, behaviour and educational achievement in each of their subjects. The child completed a comprehensive neuropsychological assessment battery including the Weschler Intelligence Scale for Children (WISC-III(UK)), Children's Memory Scale (CMS) and Vineland Adaptive Behaviour Scales (VABS).

RESULTS

This child demonstrated above-average intelligence and good attention/concentration on the CMS. However, he was unable to focus or maintain attention in most classroom situations. His behaviour was erratic and disruptive in class and at home. At 5-year follow-up, his behaviour had deteriorated in both home and school situations, particularly in less structured environments.

CONCLUSIONS

Teachers of more structured subjects (maths and science) perceived the child as excitable but performing at average or above-average levels, whereas teachers of less structured subjects (art, drama, music) perceived him to be 'attention-seeking' and very disruptive in class. The influences of environmental factors are discussed.

Sustained attention in children and adolescents after traumatic brain injury: relation to severity of injury, adaptive functioning, ADHD and social background

PRIMARY OBJECTIVE

To examine the relationship of child and family psychosocial variables and traumatic brain injury (TBI) severity as it relates to sustained attention (the Paediatric Assessment of Cognitive Efficiency, PACE).

RESEARCH DESIGN

Forty-two children and adolescents were recruited and participated in a 2 year longitudinal study to evaluate sustained attention using the computerized testing metric, PACE. More specifically, errors of omission (inattention) and commission (impulsiveness) were measured.

MAIN OUTCOMES AND RESULTS

Significant improvement on inattention and impulsiveness were observed over time. High pre-injury psychosocial adversity and low pre-injury adaptive functioning significantly predicted a greater number of inattention errors. Severity of injury predicted the reduction of impulsiveness. Moreover, omission errors immediately after TBI predicted later secondary attention-deficit/hyperactivity disorder (SADHD, ADHD that emerges after TBI).

CONCLUSIONS

Based on these findings, it is important to consider pre-injury child and family psychosocial characteristics in addition to severity of injury when predicting outcome of TBI in children.

Working memory performance following paediatric traumatic brain injury

PRIMARY OBJECTIVE

The present study investigated working memory ability in children who sustained moderate-to-severe traumatic brain injuries in relation to pre-injury, injury-related and developmental factors. It was hypothesized that there would be a correlation between performance- and rater-based working memory measures; factors predictive of working memory impairment would include earlier age at injury, more severe injury, longer time since injury and poorer overall cognitive functioning; and working memory performance would be significantly impaired when compared to normative populations.

METHODS AND PROCEDURES

Working memory was assessed in 62 children using a traditional performance measure (digit span backward) and parent report (Behaviour Rating Inventory of Executive Function (BRIEF)).

MAIN OUTCOMES AND RESULTS

Contrary to prediction, there was no statistical association between performance- and rater-based measures of working memory. Regression analyses revealed injury severity, time-since-injury, overall cognitive ability and attention span were predictive of working memory performance. As a group, working memory was impaired relative to normative samples on both measures.

CONCLUSIONS

Performance- and rater-based working memory measures, while not significantly correlated, are both sensitive to acquired cognitive dysfunction following paediatric traumatic brain injury. Demographic and clinical factors may be used to predict cognitive outcomes, educate caregivers and design clinical interventions.

Neurocognitive outcomes and recovery after pediatric TBI: meta-analytic review of the literature

Traumatic Brain Injury (TBI) continues to be one of the leading causes of death and disability in the pediatric population. Although the literature on neurocognitive outcomes is relatively rich, studies vary significantly in the methods used to group subjects on several moderating variables, including age at injury, injury severity, and time since injury, making it difficult to combine and summarize the data for comparison. Further complicating this effort is the wide range of measures used to document functional outcomes in key neurocognitive domains. In this meta-analytic review, 28 publications (1988 to 2007) that met inclusion criteria were summarized based on three distinct injury severity and time post injury groups for 14 key neurocognitive domains. Effect sizes were calculated to reflect the extent to which the above groups differed in case-control and case-case studies, as well as address recovery based on longitudinal studies. To the best of our knowledge, this is the first published quantitative summary of the literature on neurocognitive outcomes after pediatric TBI. Limitations of the current state of the literature as well as recommendations for future studies are discussed.

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.

Traumatic brain injury in childhood: rehabilitation considerations

OBJECTIVE

The aims of this review were to: (i) briefly outline common sequelae following childhood traumatic brain injury (TBI); (ii) provide a summary of models and research in the area of intervention; (iii) discuss issues and obstacles in the evaluation of research in the area of intervention; (vi) discuss integrative and translational aspects of research in this area; (v) provide an example of intervention studies being conducted in the laboratory; and (vii) highlight the need for continued and collaborative work in the paediatric intervention field.

CONCLUSIONS

When reviewing the literature, it is clear that while challenging, the development and evaluation of intervention programs for children post traumatic brain injury, must be encourage and pursued. This in turn will lead to improved quality of life for these children and their families.

Traumatic brain injury in young children: postacute effects on cognitive and school readiness skills

Previous studies have documented weaknesses in cognitive ability and early academic readiness in young children with traumatic brain injury (TBI). However, few of these studies have rigorously controlled for demographic characteristics, examined the effects of TBI severity on a wide range of skills, or explored moderating influences of environmental factors on outcomes. To meet these objectives, each of three groups of children with TBI (20 with severe, 64 with moderate, and 15 with mild) were compared with a group of 117 children with orthopedic injuries (OI group). The children were hospitalized for their injuries between 3 and 6 years of age and were assessed an average of 1 1/2 months post injury. Analysis revealed generalized weaknesses in cognitive and school readiness skills in the severe TBI group and less pervasive effects of moderate TBI. Indices of TBI severity predicted outcomes within the TBI sample and environmental factors moderated the effects of TBI on some measures. The findings document adverse effects of TBI in early childhood on postacute cognitive and school readiness skills and indicate that these effects are related to both injury severity and the family environment.

Using interactive multimedia to teach parent advocacy skills: an exploratory study

OBJECTIVE

To examine the efficacy of Brain Injury Partners: Advocacy Skills for Parents, an interactive multimedia intervention that provides training in educational advocacy skills for parents of children with traumatic brain injury (TBI).

DESIGN

Randomized trial, with participants assigned to treatment (Brain Injury Partners CD-ROM) or control (alternate CD-ROM) conditions.

MAIN OUTCOME MEASURES

Knowledge; skill application; and attitude, behavioral intention, and self-efficacy to use key advocacy skills.

PARTICIPANTS

Thirty-one parents of children with TBI.

RESULTS

The Brain Injury Partners group reported higher postintervention adjusted means for application, knowledge, and attitudes scale scores than did the control group.

CONCLUSIONS

The results demonstrate the utility of a computer-delivered intervention for training parents in key skills for communicating with school personnel.

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.

Susceptibility-Weighted Imaging and Proton Magnetic Resonance Spectroscopy in Assessment of Outcome After Pediatric Traumatic Brain Injury

OBJECTIVE

To assess the role of magnetic resonance imaging, specifically magnetic resonance spectroscopy (MRS) and susceptibility-weighted imaging (SWI), in the evaluation of children with traumatic brain injury (TBI).

DATA SOURCES

Literature review and data from our recently published clinical studies.

STUDY SELECTION

Children with pediatric TBI who underwent SWI. SWI is a 3-dimensional high-resolution magnetic resonance imaging technique that is more sensitive in detecting hemorrhagic lesions seen with diffuse axonal injury (DAI) than conventional imaging. MRS acquires metabolite information that reflects neuronal integrity and function from multiple brain regions and offers early prognostic information regarding outcome.

DATA EXTRACTION

Literature review.

DATA SYNTHESIS

Literature review and review of recently published data from our institution.

CONCLUSIONS

The data suggest that more sensitive imaging techniques that provide early evidence of injury and that are better predictors of outcome are needed to identify children at risk for such deficits. Specifically, the number and volume of hemorrhagic DAI lesions as well as changes in spectral metabolites such as reduced N-acetylaspartate or elevations in choline-related compounds correlate with neurologic disability and impairments of global intelligence, memory, and attention.

Comparing attentional skills in children with acquired and developmental central nervous system disorders

Attentional impairments in children occur in the context of both developmental and acquired disorders involving the central nervous system (CNS) and may have implications for ongoing development, potentially impeding cognitive, educational, and behavioral functions. Using a continuous performance paradigm (CPT), this study compared attentional profiles of children with developmental and acquired conditions impacting on the CNS: (i) attention deficit-hyperactivity disorder (ADHD: n=27); (ii) moderate traumatic brain injury (TBI: n=41); (iii) acute lymphoblastic leukemia (n=31); and (iv) insulin-dependent diabetes mellitus (n=39). A healthy control group (n=46) was also examined. Groups were compared on measures of sustained attention, selective attention, and response inhibition. In addition, measures of performance variability and deterioration and processing speed were examined. Results showed that children with ADHD exhibited global and severe attentional impairments in contrast to all other groups. Children with moderate TBI displayed mild attentional difficulties, restricted to selective and sustained attention domains. In conclusion, although CPT parameters differentiated the ADHD group from all others, a disorder-specific profile was not observed.

Understanding predictors of functional recovery and outcome 30 months following early childhood head injury

Much is known about outcome following traumatic brain injury (TBI) in school-age children; however, recovery in early childhood is less well understood. Some argue that such injuries should lead to good outcome, because of the plasticity of the developing brain. Other purport that the young brain is vulnerable, with injury likely to result in a substantial impairment (H. G. Taylor & J. Alden, 1997). The aim of this study was to examine outcomes following TBI during early childhood, to plot recovery over the 30 months postinjury, and to identify predictors of outcome. The study compared 3 groups of children sustaining mild, moderate, and severe TBI, ages 2.0 to 6.11 years at injury, with healthy controls. Groups were comparable for preinjury adaptive and behavioral function, psychosocial characteristics, age, and gender. Results suggested a strong association between injury severity and outcomes across all domains. Further, 30-month outcome was predicted by injury severity, family factors, and preinjury levels of child function. In conclusion, children with more severe injuries and lower preinjury adaptive abilities, and whose families are coping poorly, are at greatest risk of long-term impairment in day-to-day skills, even several years postinjury.

Neuroanatomic correlates of CVLT-C performance following pediatric traumatic brain injury

Traumatic brain injury (TBI) frequently results in memory problems, and the degree of memory impairment is related to injury severity and is commonly associated with lesions in frontal and temporal brain areas. This study examined the relationship among injury severity, brain lesions, and memory in children with moderate to severe TBI using Donders' (1999) 5-factor model of performance on the California Verbal Learning Test-Children's Version (CVLT-C). Seventy-six children underwent magnetic resonance imaging (MRI) scans 3 months post-TBI and testing 1 year post-TBI. Results showed injury severity (Glasgow Coma Scale) was not predictive of performance on 4 of the 5 factors. Volume of frontal and/or temporal brain lesions was significantly predictive of performance on 3 of the 5 factors. Unexpectedly, lesion volume outside these areas (extra-frontotemporal) was predictive of performance on all 5 factors. In contrast, Verbal IQ at 1 year was most strongly associated with preinjury factors (socioeconomic status and special education involvement), although extra-frontotemporal lesions also contributed to the variability in this measure. Results suggest that in children with moderate to severe TBI, extra-frontal/temporal lesions are predictive of memory outcome 1 year postinjury above and beyond initial severity or frontal/temporal contusions. This finding may relate to widespread diffuse axonal injury, which potentially disconnects brain circuits mediating memory following moderate to severe TBI.

Susceptibility weighted imaging: neuropsychologic outcome and pediatric head injury

Traumatic brain injury is among the most frequent pediatric neurologic disorders in the United States, affecting multiple aspects of neuropsychologic functioning. This study assessed the efficacy of susceptibility weighted imaging as a predictor of long-term neuropsychologic functioning after pediatric brain injury compared with magnetic resonance spectroscopic imaging. Susceptibility weighted imaging is a relatively new method that is considered superior to traditional magnetic resonance imaging sequences for detecting hemorrhagic diffuse axonal injury. In this study, imaging and spectroscopy were acquired 6 +/- 4 days after injury. Measures of neuropsychologic functioning were administered to 18 children and adolescents 1-4 years post injury. Negative correlations between lesion number and volume with neuropsychologic functioning were demonstrated. Lesion volume explained over 32% of the variance in cognitive performance, explaining at least an additional 20% beyond injury severity and age at injury alone and 19% beyond magnetic resonance spectroscopic metabolite variables. Exploratory analyses resulted in notable trends, with lesions in deeper brain regions more strongly associated with poorer neuropsychologic performance. Improved detection of the extent of diffuse axonal injury following a brain injury will allow for a better understanding of its association with long-term outcome, which in turn can improve prognostic efficacy for effective treatment planning.

Differences in attention, executive functioning, and memory in children with and without ADHD after severe traumatic brain injury

Although the development of Attention Deficit Hyperactivity Disorder (ADHD) after traumatic brain injury (TBI) has been described, it is unknown whether children with TBI and ADHD have greater neuropsychological impairments than children with TBI alone. This study examines attention, executive functioning, and memory in children with TBI-only and TBI + ADHD. Caregivers of 82 children with severe TBI completed structured psychiatric interviews at enrollment to diagnose premorbid ADHD and one-year after injury to diagnose post-injury ADHD. Children underwent neuropsychological testing one year after injury. One memory measure significantly differentiated children with TBI-only from children with newly developed ADHD [secondary ADHD (S-ADHD)] and those with premorbid ADHD that persisted after injury [persisting ADHD (P-ADHD)]. Compared with the TBI-only group, children with TBI + ADHD had worse performance on measures of attention, executive functioning, and memory. Results reveal that in children with severe TBI, the behavioral diagnosis of ADHD is associated with more difficulty in attention, executive functioning, and memory. Additionally, results suggest greater deficits in memory skills in the S-ADHD group compared with the P-ADHD group. Although findings provide preliminary support for distinguishing P-ADHD from S-ADHD, further research is needed to investigate neuropsychological differences between these subgroups of children with severe TBI.

Long-term attention problems in children with traumatic brain injury

OBJECTIVE

To examine long-term attention problems and their cognitive correlates after childhood traumatic brain injury (TBI).

METHOD

Data were drawn from a prospective, longitudinal study conducted between 1992 and 2002. Participants included 41 children with severe TBI, 41 with moderate TBI, and 50 with orthopedic injury (OI), who were all between 6 and 12 years of age at the time of injury. Parent ratings of attention problems were obtained at a long-term follow-up on average 4 years post-injury and compared with ratings of premorbid attention problems obtained shortly after injury. At the long-term follow-up, children also completed several cognitive tests of attention and executive functions.

RESULTS

Hierarchical linear and logistic regression analyses indicated that the severe TBI group displayed significantly more attention problems than the OI group at 4 years post-injury, both behaviorally and cognitively, after controlling for race, socioeconomic status, and premorbid attention problems. At long-term follow-up, 46% of the severe TBI group displayed significant attention problems on the Child Behavior Checklist, as opposed to 26% of the OI group (odds ratio=3.38; 95% confidence interval, 1.15-9.94). On the Attention-Deficit/Hyperactivity Disorder Rating Scale, 20% of the severe TBI group displayed clinically significant attention problems compared with 4% in the OI group (odds ratio=9.59; 95% confidence interval, 1.24-73.99). However, group differences in behavioral symptoms were significantly larger for children with more premorbid symptoms than for children with fewer premorbid problems. Measures of executive functions were significantly related to behavioral attention problems, after controlling for group membership, race, and socioeconomic status.

CONCLUSIONS

Childhood TBI exacerbates premorbid attention problems. Long-term behavioral symptoms of attention problems are related to the cognitive deficits in attention and executive functions that often occur in association with childhood TBI.

A prospective study of the recovery of attention from acute to 2 years following pediatric traumatic brain injury

Limited research has investigated specific attentional sequelae following pediatric traumatic brain injury (TBI), such as sustained, selective, and shifting attention, as well as speed of processing. Little is known about the pattern of recovery of these skills or their interaction with ongoing development. The present study examined attentional abilities at acute, 6-, 12-, and 24-month time points postinjury in a group of 71 children who had sustained a mild, moderate, or severe TBI. Results indicated that children who sustained a severe TBI generally performed poorest, but showed most recovery over time. The pattern of recovery was dependent on the attentional component being measured. Specifically, deficits were most evident on more complex and timed tasks. While a number of areas showed recovery over time, for some attentional components, difficulties persisted to 24 months postinjury.

Attention function after childhood stroke

We investigated attentional outcome after childhood stroke and orthopedic diagnosis in medical controls. Twenty-nine children with focal stroke lesions and individually matched children with clubfoot or scoliosis were studied with standardized attention and neuroimaging assessments. Stroke lesions were quite varied in location and commonly involved regions implicated in Posner's model of attention networks. Children with stroke lesions performed significantly more poorly regarding attention function compared with controls. Performance on the Starry Night, a test demanding alerting and sensory-orienting but not executive attention function, was significantly associated with lesion size in the alerting and sensory-orienting networks but not the executive attention network. Furthermore, earlier age at lesion acquisition was significantly associated with poorer attention function even when lesion size was controlled. These findings support the theory of dissociable networks of attention and add to evidence from studies of children with diffuse and focal brain damage that early insults are associated with worse long-term outcomes in many domains of neuropsychological function. In addition, these results may provide clues towards the understanding of mechanisms underlying attention in children.

The Status of Empirical Support for Treatments of Attention Deficits

Deficits in attention and self-regulation are common complaints associated with a number of disorders across the lifespan. The need to address attentional deficits is based on the premise that attention is a precursor and prerequisite to information processing and related cognitive tasks as well as a key factor in the success of other rehabilitation efforts. Many treatment programs have been developed with the intention of restoring or rehabilitating the impaired components of attention; the number and variety of attention programs is increasing rapidly. The purpose of this article is to evaluate available empirical support regarding the efficacy of treatments for remediation of attention deficits across disorders and age levels. The search of the major databases yielded 83 studies that included treatment of attentional deficits. Empirical studies were reviewed and categorized by the type of trial, whether or not the study included a control group, and the nature of the control group. The methodology and results of each study were then rated. For each treatment identified, the aggregated studies were then considered by the disorder of the samples included in the studies. Results indicated that, regardless of the treatment program or population, the existing research does not provide sufficient evidence to reach any conclusions about the efficacy of programs designed to address attention deficits. Before any conclusions, positive or negative, can be drawn, there is a need for more rigorous study of available treatment programs across age levels and disorders, with sufficient baseline and outcome data as well as control or alternative treatment conditions.

Children's attentional skills 2 years post-traumatic brain injury

This study examined sustained attention abilities 24 months postinjury, in 3 groups of children who had suffered a traumatic brain injury (TBI): (a). mild TBI (n = 24), (b). moderate TBI (n = 31), and (c). severe TBI (n = 14). Three manipulations of the traditional Continuous Performance Test paradigm (CPT) were employed in the study, to delineate factors that might influence CPT performance, including speed of processing, attentional lapses, and stimulus complexity. No significant differences were evident among the TBI groups on a measure of simple reaction time, nor on a CPT version where the interstimulus interval was lengthened. However, there was a significant difference between the mild and severe TBI groups on the most complex task, which required speed, accuracy, and decision making, suggesting that these factors underlie impaired performances previously identified on the CPT in children with severe TBI. These findings have implications for the development of intervention programs for these children.

Predicting neuropsychologic outcome after traumatic brain injury in children

The ability to predict long-term neurologic and neuropsychologic outcomes in 22 children, ages 1 week to 14 years at the time of traumatic brain injury, was investigated using proton magnetic resonance spectroscopy acquired post injury and compared with standardized neurologic, intellectual, and neuropsychologic testing done 1-7 years later. Clinical indicators of acute injury severity including age at injury, electroencephalography, spectroscopy metabolite ratio variables (N-acetyl aspartate/choline, choline/creatine) and lactate presence accurately classified children as functioning above or below the average range for most intellectual and neuropsychologic outcome measures. Combined clinical and spectroscopy variables accounted for approximately 50% of the variance in cognitive and neuropsychologic outcome confirming the validity of their predictive use. Of the injury severity indictors, presence of lactate is a particularly important prognostic marker of poor long-term intellectual and neuropsychologic functioning. Our findings indicate the potential for providing accurate estimates of long-term intellectual and neuropsychologic function after traumatic brain injury in infants and children using proton magnetic resonance spectroscopy in combination with clinical variables.

Attention following pediatric head injury: a developmental perspective

This study investigated the relations between age at injury (AAI) and attentional functioning, and intellectual and academic achievement following pediatric head injury. The theoretical framework of attention proposed by Mirsky, Anthony, Duncan, Ahern, and Kellam (1991) provided the basis for this analysis, and the profile of attention found in uninjured children was evaluated for this sample. Thirty-three moderately head-injured individuals were recruited, with AAI ranging from 1 to 12 years. First, the development of attentional skills in this closed head injury (CHI) sample was found to be comparable to that of Mirsky et al.'s model. Second, AAI did not predict outcome and appeared not to be associated with the finding of mildly delayed acquisition of spelling and arithmetic skills. Also, AAI did not predict the behavioral symptoms of inattention present in this sample as indicated by parental report. It may be that AAI only influences development following severe CHI in which there is permanent cerebral pathology.