Rehabilitation of Executive Function in Pediatric Traumatic Brain Injury (REPeaT): Outcomes of a pilot randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of Cogmed Working Memory Training (Cogmed) in improving working memory (WM) and decision making (DM) in childhood traumatic brain injury (TBI), and any associated increases in functional outcomes such as academic achievement in mathematics, behavior, social skills, and quality of life.

METHOD

A randomized controlled trial of the Cogmed (RM version) intervention for children with TBI. A total of 69 children post-TBI were screened for WM impairments, of which 31 eligible participants (Mage: 10.6 years; male n = 21) were recruited and randomized to either the treatment group (Cogmed, n = 16) or the active-control group (Lexia Reading Core5, n = 15). Both groups completed computerized training for 5 weeks with clinician support via an online video platform. Immediately posttraining and at 6 months follow-up, primary (WM and DM) and secondary functional outcomes were assessed.

RESULTS

Immediately postintervention, significant improvement was found in one primary outcome (WM verbal component) for the Cogmed group, but this was not maintained at the 6 months follow-up. No immediate improvements or maintenance gains (small effect sizes) in other primary outcomes of visuospatial WM or DM were reported in the Cogmed group. No other significant group differences were detected for other functional outcomes.

CONCLUSIONS

Despite the limited benefits observed in this small randomized controlled trial, it will be beneficial to investigate Cogmed's efficacy in a case-series methodology, to further determine its effectiveness in a pediatric TBI population. Furthermore, a cautious approach in clinical implementation of Cogmed is advised. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Nature and correlates of self-esteem in young adult survivors of childhood traumatic brain injury

Despite growing research linking childhood traumatic brain injury (TBI) with reduced wellbeing, self-esteem, and psycho-social health, very few studies have examined self-esteem and its correlates in young adult survivors of childhood TBI. This very-long-term follow-up study evaluated self-esteem in 29 young adults with a history of childhood TBI (M time since injury = 13.84 years; SD = 0.74), and 10 typically developing controls (TDCs). All participants were originally recruited into a larger, longitudinal case-control study between 2007 and 2010. In the current follow-up study, both groups completed well-validated measures of self-esteem and mental health in young adulthood. Although group means for self-esteem did not significantly differ between TBI and TDC groups, a higher proportion of TBI participants rated their self-esteem in the clinical range (TBI group = 17%; TDC group = 0%). While self-esteem was not significantly associated with injury or pre-injury child or family characteristics, lower self-esteem was significantly correlated with greater concurrent feelings of loneliness (p = 0.007) and higher concurrent mood symptoms (p < 0.001).Our results suggest that social isolation and low mood may represent meaningful targets for psycho-social interventions to address poor self-worth in young adults with a history of childhood TBI.

Biopsychosocial correlates of fatigue in young adult survivors of childhood traumatic brain injury: A prospective cohort study

This prospective cohort study aimed to evaluate the potential role of injury, socio-demographic and individual psychological factors in predicting long-term fatigue outcomes in young adult survivors of childhood TBI at 16-years post-injury. The study included 51 young adults diagnosed with childhood TBI from 2-12 years of age. Twenty age-and-sex-matched controls were included for comparison. Findings showed that almost one-in-four TBI participants (24%) endorsed clinically elevated fatigue at 16-years post-injury. Despite the relatively large proportion of TBI participants endorsing clinically significant fatigue, group comparisons revealed that the TBI and control groups did not significantly differ on fatigue symptom severity or rates of clinically elevated fatigue. For the TBI group, post-injury fatigue was significantly associated with socio-demographic and psychological factors, including lower educational level, higher depression symptom severity, and more frequent substance use. Higher fatigue was also associated with lower self-reported quality of life (QoL) in the physical, psychological, and environmental domains, even after controlling for depressive symptom severity, socio-demographic, and injury-related factors. Overall, findings show that a substantial proportion of young adults with a history of childhood TBI experience clinically elevated fatigue at 16-years post-injury. Identification and treatment of modifiable risk-factors (e.g. depression symptoms, substance use) has potential to reduce fatigue.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

A randomized controlled trial of cognitive behavioural therapy for managing anxiety in adolescents with acquired brain injury

The aim of this randomized controlled trial was to evaluate an adapted cognitive behavioural therapy (CBT) programme for treating anxiety in adolescents with acquired brain injury (ABI). Participants with ABI (12-19 years, N = 36) recruited from two sites were randomly allocated into either the intervention receiving 11 sessions of CBT (n = 19) or a wait-list control group (n = 17). The primary outcome was participants' anxiety and secondary outcomes were participants' depression, self-perception, and participation in daily activities, and parental stress, measured at (i) pre-intervention, (ii) immediately post-intervention, (iii) 2 months post-intervention and (iv) 6 months post-intervention. Repeated measures ANOVAs revealed significant treatment effects with the intervention group demonstrating greater improvements in self-reported anxiety, as well as self- and parent-reported depression from pre- to immediately post-treatment, compared to wait-list controls. Little evidence of treatment effects was found for the remaining outcomes (parent-reported anxiety, self-perception, daily participation, and parental stress). Significant improvement in self-reported anxiety found immediately post-treatment was maintained at two- and six-month follow-up. Findings provide support for adapted CBT as an effective means of reducing anxious and depressive symptomatology in adolescents with ABI compared to waitlist controls, and offer support for the use of these techniques to manage anxiety in this population.

Associations Between Peer Relationships and Self-Esteem After Childhood Traumatic Brain Injury: Exploring the Mediating Role of Loneliness

Pediatric traumatic brain injury (TBI) can impact psycho-social functioning, including friendships and experiences of loneliness; however, few studies have explored associations between these factors and self-esteem. To address this gap, the objective of this study was to document inter-relationships between friendship quality, peer-related loneliness, and self-esteem 12 months post-injury. The sample in this prospective, longitudinal observational study consisted of 135 children, including 92 children with TBI (57 mild, 35 moderate-severe TBI) and 43 typically developing control (TDC) children. Children rated their friendship quality, loneliness, and self-esteem. Parents completed questionnaires measuring socioeconomic status and children's pre-injury functioning. At 12-month follow-up, ratings of friendship quality (perceived support and satisfaction with friendships), peer-related loneliness, and self-esteem were comparable between TBI and TDC participants. In mediation models, poorer quality friendships were associated with greater peer-related loneliness, and greater peer-related loneliness was related to reduced athletic and social self-esteem, at 12 months post-TBI. Loneliness with peers mediated the effects of both friendship support and friendship satisfaction on children's social self-esteem. Our preliminary findings suggest that regular monitoring of social interactions post-TBI might facilitate early identification of children who are likely to benefit from interventions targeting peer-related loneliness, which in turn may lower risk for poorer self-esteem.

The decision-making task: Development and evaluation in a paediatric traumatic brain injury population

Assessment measures that quantify decision-making abilities in children and adolescents are limited. In the current study, a novel computerized Decision-Making Task (DMT), which identifies the process that is involved in decision-making, was developed based on an existing information-boards paradigm. The overall aim was to validate the DMT in a paediatric TBI population. This prospective study investigated the performance on the DMT for children post-TBI (n = 49; 7-15 years) compared to typically developing controls (n = 22; 7-15 years), and investigated the psychometric properties of the DMT by examining internal consistency-related reliability, convergent validity (measures of decision-making, working memory, functional outcomes, and behaviour), and divergent validity (vocabulary). Significant differences were detected for performance on the DMT between children post-TBI and the control group. Psychometric properties of the DMT were acceptable, with variable findings for convergent validity (working memory, functional outcomes, and behaviour). This is the first study to develop and investigate a novel computerised task to assess decision-making skills in a paediatric TBI population. Results cautiously suggest that the DMT is a valid and a reliable measure of decision-making in our clinical sample.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Post-Concussive Symptoms in Preschool Children up to Three Months Post-Injury

BACKGROUND AND AIMS

Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI.

METHODS

Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS.

RESULTS

The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up.

CONCLUSION

Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report.

Behaviour outcomes three months after mild TBI in preschool children

This study examined parents' report of behaviour in preschoolers after a mild traumatic brain injury (mTBI), compared the proportion of preschoolers with elevated behaviour ratings between the mTBI and limb injury (LI) groups, and explored injury, premorbid child, and parent variables that may be associated with parents' report of behaviour at three months post-injury. Children aged 2-5 years with a mTBI (n = 13) or mild LI (n = 6) were recruited from the emergency department. Behaviour was assessed using the Child Behaviour Checklist. Preliminary findings showed that post-injury behaviour ratings remained in the normal range. The mTBI group had higher scores than the LI group at three months post-injury in terms of sleep; however, this may have been pre-existing. Two children with mTBI received borderline-clinically significant ratings on diagnostic-level anxiety problems at the three-month follow-up, while none of the limb-injured controls obtained elevated behaviour ratings. Parent-rated post-injury behaviour was significantly associated with premorbid child functioning and parental stress, which needs to be explored in greater detail using larger preschool mTBI samples.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

School-based interventions for children and adolescents following traumatic brain injury: A systematic review

BACKGROUND

Childhood traumatic brain injury (TBI) can result in impairments in learning, cognition, and behaviour; all of which can adversely influence educational outcomes. Schools can play a crucial role in rehabilitation, therefore it is important that evidence-based supports are available in these settings.

OBJECTIVE

The aim of this systematic review was to evaluate the effectiveness of school-based supports and interventions available following childhood TBI.

METHODS

A comprehensive search strategy involved eight research databases, grey literature, and backward reference searching.

RESULTS

The search identified 19 studies, reporting on sixteen distinct interventions, which used a variety of person-centred and systemic approaches, and typically contained multiple components, including: psychoeducation, behavioural scripts, and attention training. While offering some indication for future directions in intervention, the evidence base for individual interventions was typically limited, and does not take account of cost or issues in sustainability.

CONCLUSION

While there appears to be great potential to support students who may otherwise not gain access to services, there is insufficient evidence to guide widespread policy or practice change without further research. Greater collaboration between researchers, clinical practitioners, and educators is necessary to ensure that all interventions developed are robustly evaluated and disseminated.

Prospective Associations of Susceptibility-Weighted Imaging Biomarkers with Fatigue Symptom Severity in Childhood Traumatic Brain Injury

Fatigue may be among the most profound and debilitating consequences of pediatric traumatic brain injury (TBI); however, neurostructural risk factors associated with post-injury fatigue remain elusive. This prospective study aimed to evaluate the independent value of susceptibility-weighted imaging (SWI) biomarkers, over-and-above known risk factors, to predict fatigue symptom severity in children with TBI. Forty-two children were examined with structural magnetic resonance imaging (sMRI), including a SWI sequence, within eight weeks post-injury. The PedsQL Multi-Dimensional Fatigue Scale (MFS) was administered 24 months post-injury. Compared with population expectations, the TBI group displayed significantly higher levels of general fatigue (Cohen d = 0.44), cognitive fatigue (Cohen d = 0.59), sleep/rest fatigue (Cohen d = 0.37), and total fatigue (Cohen d = 0.63). In multi-variate models adjusted for TBI severity, child demographic factors, and depression, we found that subacute volume of SWI lesions was independently associated with all fatigue symptom domains. The magnitude of the brain-behavior relationship varied by fatigue symptom domain, such that the strongest relationships were observed for the cognitive fatigue and total fatigue symptom scales. Overall, we found that total subacute volume of SWI lesions explained up to 24% additional variance in multi-dimensional fatigue, over-and-above known risk factors. The subacute SWI has potential to improve prediction of post-injury fatigue in children with TBI. Our preliminary findings suggest that volume of SWI lesions may represent a novel, independent biomarker of post-injury fatigue, which could help to identify high-risk children who are likely to benefit from targeted psychoeducation and/or preventive strategies to minimize risk of long-term post-injury fatigue.

The Australian and New Zealand brain injury lifespan cohort protocol: Leveraging common data elements to characterise longitudinal outcome and recovery

INTRODUCTION

Cognitive, behavioural, academic, mental health and social impairments are common following paediatric traumatic brain injury (TBI). However, studies are often reliant on small samples of children drawn from narrow age bands, and employ highly variable methodologies, which make it challenging to generalise existing research findings and understand the lifetime history of TBI.

METHOD AND ANALYSIS

This study will synthesise common data sets from national (Victoria, New South Wales, Queensland) and international (New Zealand) collaborators, such that common data elements from multiple cohorts recruited from these four sites will be extracted and harmonised. Participant-level harmonised data will then be pooled to create a single integrated data set of participants including common cognitive, social, academic and mental health outcome variables. The large sample size (n=1816), consisting of participants with mild, moderate and severe TBI, will provide statistical power to answer important questions that cannot be addressed by small, individual cohorts. Complex statistical modelling, such as generalised estimation equation, multilevel and latent growth models, will be conducted.

ETHICS AND DISSEMINATION

Ethics approval was granted by the Human Research Ethics Committee (HREC) of the Royal Children's Hospital (RCH), Melbourne (HREC Reference Number 2019.168). The approved study protocol will be used for all study-related procedures. Findings will be translated into clinical practice, inform policy decisions, guide the appropriate allocation of limited healthcare resources and support the implementation of individualised care.

Content Validity and Inter-rater Reliability of the Music Interventions in Pediatric DoC Behavior Observation Record

Aligned with best practice guidelines for patients presenting with a disorder of consciousness (DoC), music therapy interventions with this population aim to increase arousal and awareness to support emergence to consciousness. There is a significant evidence base supporting music therapy for adults with a DoC; however, there are currently no published tools that systematically capture behavioral responses of this population during rehabilitative music therapy interventions. Further, the developmentally specific response to severe brain injury in the pediatric population means pediatric-specific research is required. The Music Interventions in Pediatric DoC Behavior Observation Record (Music Behavior Record [MBR]) was developed to objectively record responses during music therapy interventions for children presenting with a DoC. To establish content validity and inter-rater reliability, a pragmatic pilot study was undertaken. Results established that the MBR has content validity with 100% agreement among participants. Overall fair-substantial inter-rater reliability in >70% of the behavioral responses recorded in the MBR indicate the MBR is an early but promising tool to objectively capture responses during music therapy interventions. The use of the MBR may ultimately support clinical advancement and intervention research to optimize consciousness recovery for the pediatric DoC population.

Self-perception and behavioural outcomes of early acquired brain injury

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

Global and domain-specific self-esteem after pediatric traumatic brain injury: Contribution of injury characteristics and parent mental health

This prospective, longitudinal case-control study examined global and domain-specific aspects of self-esteem 6-months following pediatric traumatic brain injury (TBI) and evaluated the contribution of injury-related factors and parent mental health to child self-esteem. Participants included 103 children with mild-severe TBI representing consecutive admissions to the emergency department of the Royal Children's Hospital, Melbourne, Australia. Forty-three age-and-sex matched typically developing controls were recruited for comparison. Information regarding injury characteristics including age at injury and clinical indicators of TBI severity were collected for participants at recruitment, with research magnetic resonance imaging conducted 2-8 weeks later. At 6 months post-injury, children rated their global and domain-specific self-esteem (Harter Self-Perception Profile for Children), and ratings of parent mental health were collected (General Health Questionnaire). Self-esteem for behavioural and academic domains was significantly poorer for children with TBI relative to TD children. In the TBI group, higher child-rated scores of global and domain-specific aspects of self-esteem were associated with more severe TBI, presence of frontal neuropathology, younger age at injury, and lower parental symptoms of anxiety/insomnia. Given the psychological status of parents represents a potentially modifiable risk factor, it may form the target of clinical interventions designed to bolster child self-esteem following pediatric TBI.

Paediatric traumatic brain injury and the dysregulation profile: The mediating role of decision-making

Decision-making is often impacted by paediatric traumatic brain injury (TBI). However, there are few tools available to assess these skills in children, with even less research on the consequences of decision-making deficits on dysregulation following TBI. This prospective preliminary study investigated whether decision-making mediated the effect of TBI on dysregulation in children. The performance of school-aged children aged between 7 and 15 years with TBI (n = 49) and that of typically developing controls (n = 22) was compared on The Decision-making Task, and on parent ratings of the dysregulation profile as characterized by the Child Behaviour Checklist-Dysregulation Profile. Relative to the Control group, the TBI group performed more poorly on the decision-making task, and parents of the TBI group rated their children to be more poorly on the dysregulation profile. Mediation analyses indicated that decision-making mediated the relationship between TBI and the dysregulation profile. Our preliminary findings suggest the need for further research in the area of decision-making, and its impact on dysregulated behaviours in children following TBI.

Structural-covariance networks identify topology-based cortical-thickness changes in children with persistent executive function impairments after traumatic brain injury

Paediatric traumatic brain injury (pTBI) results in inconsistent changes to regional morphometry of the brain across studies. Structural-covariance networks represent the degree to which the morphology (typically cortical-thickness) of cortical-regions co-varies with other regions, driven by both biological and developmental factors. Understanding how heterogeneous regional changes may influence wider cortical network organization may more appropriately capture prognostic information in terms of long term outcome following a pTBI. The current study aimed to investigate the relationships between cortical organisation as measured by structural-covariance, and long-term cognitive impairment following pTBI. T1-weighted magnetic resonance imaging (MRI) from n = 83 pTBI patients and 33 typically developing controls underwent 3D-tissue segmentation using Freesurfer to estimate cortical-thickness across 68 cortical ROIs. Structural-covariance between regions was estimated using Pearson's correlations between cortical-thickness measures across 68 regions-of-interest (ROIs), generating a group-level 68 × 68 adjacency matrix for patients and controls. We grouped a subset of patients who underwent executive function testing at 2-years post-injury using a neuropsychological impairment (NPI) rule, defining impaired- and non-impaired subgroups. Despite finding no significant reductions in regional cortical-thickness between the control and pTBI groups, we found specific reductions in graph-level strength of the structural covariance graph only between controls and the pTBI group with executive function (EF) impairment. Node-level differences in strength for this group were primarily found in frontal regions. We also investigated whether the top n nodes in terms of effect-size of cortical-thickness reductions were nodes that had significantly greater strength in the typically developing brain than n randomly selected regions. We found that acute cortical-thickness reductions post-pTBI are loaded onto regions typically high in structural covariance. This association was found in those patients with persistent EF impairment at 2-years post-injury, but not in those for whom these abilities were spared. This study posits that the topography of post-injury cortical-thickness reductions in regions that are central to the typical structural-covariance topology of the brain, can explain which patients have poor EF at follow-up.

The mediating role of ADHD symptoms between executive function and social skills in children with neurofibromatosis type 1

Children with neurofibromatosis type 1 (NF1) often experience executive dysfunction, attention deficit/hyperactivity disorder (ADHD) symptoms and poor social skills, however, the nature of the relationships between these domains in children with NF1 is unclear. This study investigated these relationships using primary caregiver ratings of executive functions, ADHD symptoms and social skills in children with NF1. Participants were 136 children with NF1 and 93 typically developing (TD) controls aged 3-15 years recruited from 3 multidisciplinary neurofibromatosis clinics in Melbourne and Sydney, Australia, and Washington DC, USA. Mediation analysis was performed on primary outcome variables: parent ratings of executive functions (Behavior Rating Inventory of Executive Function, Metacognition Index), ADHD symptoms (Conners-3/Conners ADHD Diagnostic and Statistical Manual for Mental Disorders Scales) and social skills (Social Skills Improvement System-Rating Scale), adjusting for potential confounders (full scale IQ, sex, and social risk). Results revealed significantly poorer executive functions, elevated ADHD symptoms and reduced social skills in children with NF1 compared to controls. Poorer executive functions significantly predicted elevated ADHD symptoms and poorer social skills. Elevated ADHD symptoms significantly mediated the relationship between executive functions and social skills problems although did not fully account for social dysfunction. This study provides evidence for the importance of targeting ADHD symptoms as part of future interventions aimed at promoting prosocial behaviors in children with NF1.

Pediatric Moderate-Severe Traumatic Brain Injury and Gray Matter Structural Covariance Networks: A Preliminary Longitudinal Investigation

Pediatric traumatic brain injury (TBI) is prevalent and can disrupt ongoing brain maturation. However, the long-term consequences of pediatric TBI on the brain's network architecture are poorly understood. Structural covariance networks (SCN), based on anatomical correlations between brain regions, may provide important insights into brain topology following TBI. Changes in global SCN (default-mode network [DMN], central executive network [CEN], and salience network [SN]) were compared sub-acutely (<90 days) and in the long-term (approximately 12-24 months) after pediatric moderate-severe TBI (n = 16), and compared to typically developing children assessed concurrently (n = 15). Gray matter (GM) volumes from selected seeds (DMN: right angular gyrus [rAG], CEN: right dorsolateral prefrontal cortex [rDLPFC], SN: right anterior insula) were extracted from T1-weighted images at both timepoints. No group differences were found sub-acutely; at the second timepoint, the TBI group showed significantly reduced structural covariance within the DMN seeded from the rAG and the (1) right middle frontal gyrus, (2) left superior frontal gyrus, and (3) left fusiform gyrus. Reduced structural covariance was also found within the CEN, that is, between the rDLPFC and the (1) calcarine sulcus, and (2) right occipital gyrus. In addition, injury severity was positively associated with GM volumes in the identified CEN regions. Over time, there were no significant changes in SCN in either group. The findings, albeit preliminary, suggest for the first time a long-term effect of pediatric TBI on SCN. SCN may be a complementary approach to characterize the global effect of TBI on the developing brain. Future work needs to further examine how disruptions of these networks relate to behavioral and cognitive difficulties.

Concussive Symptoms Following Pediatric Mild Traumatic Brain Injury

OBJECTIVES

To determine the proportion of children with postconcussive symptoms (PCSs) and to explore the influence of noninjury and injury factors on parents' PCS report at 3 months postinjury.

DESIGN

A cross-sectional analysis of the 3-month postinjury data from a larger, prospective, longitudinal study.

METHODS

Parents and their child aged 2 to 12 years who presented at the emergency department with either a mild traumatic brain injury (mTBI) or a superficial injury to the head (SIH) were recruited. Parents reported their child's symptoms at the time of injury and at 3 months postinjury. Child, family/parent, and injury characteristics were considered as potential predictors. Logistic regression was conducted to determine which factors increase the likelihood of parents' PCS report.

RESULTS

At 3 months postinjury, 30% and 13% of children in the mTBI and SIH groups exhibited 1 or more symptoms, respectively. On the other hand, 18% (mTBI) and 8% (SIH) continued to have ongoing problems when 2 or more symptoms were considered at follow-up. The final model, which included child's sex, injury group, number of symptoms at the time of injury, and parental stress, had a significant predictive utility in determining parents' report of 1 or more symptoms at follow-up. Only parental stress continued to be a significant predictor when considering 2 or more symptoms at 3 months postinjury.

CONCLUSIONS

Children with mTBI have worse outcomes than children with SIH at follow-up, with parents more likely to report 1 or more ongoing symptoms if their children had an mTBI. Postinjury assessment of parental stress and ongoing symptom monitoring in young children with mTBI will allow for timely provision of support for the family.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Post-concussive Signs and Symptoms in Preschool Children: A Systematic Review

Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery.

The Neurophysiological Processing of Music in Children: A Systematic Review With Narrative Synthesis and Considerations for Clinical Practice in Music Therapy

Introduction: Evidence supporting the use of music interventions to maximize arousal and awareness in adults presenting with a disorder of consciousness continues to grow. However, the brain of a child is not simply a small adult brain, and therefore adult theories are not directly translatable to the pediatric population. The present study aims to synthesize brain imaging data about the neural processing of music in children aged 0-18 years, to form a theoretical basis for music interventions with children presenting with a disorder of consciousness following acquired brain injury. Methods: We conducted a systematic review with narrative synthesis utilizing an adaptation of the methodology developed by Popay and colleagues. Following the development of the narrative that answered the central question "what does brain imaging data reveal about the receptive processing of music in children?", discussion was centered around the clinical implications of music therapy with children following acquired brain injury. Results: The narrative synthesis included 46 studies that utilized EEG, MEG, fMRI, and fNIRS scanning techniques in children aged 0-18 years. From birth, musical stimuli elicit distinct but immature electrical responses, with components of the auditory evoked response having longer latencies and variable amplitudes compared to their adult counterparts. Hemodynamic responses are observed throughout cortical and subcortical structures however cortical immaturity impacts musical processing and the localization of function in infants and young children. The processing of complex musical stimuli continues to mature into late adolescence. Conclusion: While the ability to process fundamental musical elements is present from birth, infants and children process music more slowly and utilize different cortical areas compared to adults. Brain injury in childhood occurs in a period of rapid development and the ability to process music following brain injury will likely depend on pre-morbid musical processing. Further, a significant brain injury may disrupt the developmental trajectory of complex music processing. However, complex music processing may emerge earlier than comparative language processing, and occur throughout a more global circuitry.

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

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

Sleep Disturbances in Young Adults with Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life

OBJECTIVE

This study assessed the consequences of childhood traumatic brain injury (TBI) on sleep, fatigue, depression, and quality of life (QoL) outcomes and explored the relationships between these variables at 20 years following childhood TBI.

PARTICIPANTS

We followed up 54 young adults with mild, moderate, and severe TBI, and 13 typically developing control (TDC) participants, recruited at the time of TBI.

METHODS

Sleep was assessed with the Pittsburgh Sleep Quality Index and actigraphy.

RESULTS

At 20 years postinjury, results showed no significant difference between whole TBI group and TDC participants on subjective sleep quality; however, the moderate TBI group reported significantly poorer subjective sleep quality compared to those with severe TBI. Poorer subjective sleep was associated with increased symptoms of fatigue, depression, and poorer perceptions of General Health in the TBI group. Actigraphic sleep efficiency, fatigue, depression, and QoL outcomes were not significantly different between TBI and TDC or among TBI severity groups.

CONCLUSIONS

These preliminary findings underscore associations between subjective sleep disturbance, fatigue, depression, and QoL in this TBI sample, and mostly comparable outcomes in sleep, fatigue, depression, and QoL between the TBI and TDC groups. Further research is required to clarify these findings.

A Parenting Program to Reduce Disruptive Behavior in Hispanic Children with Acquired Brain Injury: A Randomized Controlled Trial Conducted in Mexico

Children with acquired brain injury (ABI) are at risk of impairments in self-regulation and disruptive behavior. We aimed to investigate the effectiveness of the Signposts program to reduce disruptive behavior and improve self-regulation in Hispanic children with ABI, and reduce parental stress and improve parenting practices. Using a randomized controlled trial design, we assigned children (n = 71) and their parents to Signposts or generic telephone support. Blinded assessors conducted assessments at pre-intervention, immediately post-intervention, and at 3 months post-intervention. Signposts was effective in reducing dysfunctional parenting practices. Further, when analyzing participants at risk of behavioral disturbance (n = 46), Signposts was effective in reducing child disruptive behavior in the home environment and emotional self-regulation. No differences were found for parental stress, parent sense of competence, child disruptive behaviors at school, and child cognitive and behavioral self-regulation. The reduction in disruptive behavior was associated with the implementation of authoritative parenting practices (external regulation), and not associated with child self-regulation.

Developmental divergence of structural brain networks as an indicator of future cognitive impairments in childhood brain injury: Executive functions

Brain insults during childhood can perturb the already non-linear trajectory of typical brain maturation. The diffuse effects of injury can be modelled using structural covariance networks (SCN), which change as a function of neurodevelopment. However, SCNs are estimated at the group-level, limiting applicability to predicting individual-subject outcomes. This study aimed to measure the divergence of the brain networks in paediatric traumatic brain injury (pTBI) patients and controls, and investigate relationships with executive functioning (EF) at 24 months post-injury. T1-weighted MRI acquired acutely in 78 child survivors of pTBI and 33 controls underwent 3D-tissue segmentation to estimate cortical thickness (CT) across 68 atlas-based regions-of-interest (ROIs). Using an 'add-one-patient' approach, we estimate a developmental divergence index (DDI). Our approach adopts a novel analytic framework in which age-appropriate reference networks to calculate the DDI were generated from control participants from the ABIDE dataset using a sliding-window approach. Divergence from the age-appropriate SCN was related to reduced EF performance and an increase in behaviours related to executive dysfunctions. The DDI measure showed predictive value with regard to executive functions, highlighting that early imaging can assist in prognosis for cognition.

Training attention in children with acquired brain injury: a study protocol of a randomised controlled trial of the TALI attention training programme

INTRODUCTION

Childhood inattention has been linked with poor academic outcomes, and increased lifetime social, occupational and psychiatric morbidity. Children with an acquired brain injury (ABI) are particularly susceptible to attention deficits and may benefit from interventions aimed at enhancing attention. The primary objective of this study is to evaluate the short-term efficacy of the TALI Train programme, compared with a placebo, on the outcome of attention in children with ABI.

METHODS AND ANALYSIS

The study is a parallel, double-blind, randomised controlled trial. Participants will consist of 80 children with a diagnosis of ABI aged 4-9 years 11 months. Participants will be randomly allocated to either (1) TALI Train (intervention group), an adaptive game-based attention training programme, or (2) a non-adaptive placebo programme (control group). Both programmes are delivered on a touchscreen tablet, and children complete five 20 min sessions per week for a 5-week period at home. Assessment of selective, sustained and executive attention (primary outcomes), and behavioural attention, working memory, social skills and mathematics ability (secondary outcomes) will occur at baseline, post-training, and at 3-month and 6-month follow-up to assess immediate and long-term efficacy of TALI Train compared with placebo. Assessments will be completed at the Royal Children's Hospital in Melbourne, Australia. All assessments and analyses will be undertaken by researchers blinded to group membership. Latent growth curve modelling will be employed to examine primary and secondary outcomes.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Royal Children's Hospital Human Research Ethics Committee (HREC) (38132) and the Monash University HREC (17446). Results will be disseminated through peer-reviewed journals, conference presentations, media outlets, the internet and various community/stakeholder activities.

TRIAL REGISTRATION NUMBER

ACTRN12619000511134.

A Systematic Review of Interventions for Hot and Cold Executive Functions in Children and Adolescents With Acquired Brain Injury

Objective

We investigated interventions, which aimed to improve cold and hot executive functions (EFs) in children and adolescents with a diagnosis of acquired brain injury (ABI).

Methods

The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between 1990 and July 2017 in English or Spanish, including children and adolescents. Articles were read and classified according to the levels of evidence of the Australian National Health and Medical Research Council and the Downs and Black checklist was used for Measuring Study Quality.

Results

Thirty studies are reported in this systematic review. Level of evidence, quality of the studies, characteristics of the participants, interventions implemented, and outcomes are described.

Conclusions

The study of rehabilitation for executive dysfunction in children with ABI is emerging. Although few high-quality intervention studies exist in this area, which limits conclusions regarding intervention efficacy, results of existing studies suggest that education for parents may be an important component of intervention. Moreover, caregiver involvement may improve the effectiveness of hot EFs rehabilitation interventions, while high intervention session frequency may be important in improving cold EFs. Positive behavior supports and specific training based on a cognitive model provided some promising findings, which require further evaluation.

Facial emotion perception and social competence in children (8 to 16 years old) with genetic generalized epilepsy and temporal lobe epilepsy

Facial emotion perception (FEP) impairments are common in adults with epilepsy and associated with impaired psychosocial functioning. Research into the presence of FEP deficits in children with epilepsy and the functional implications of these deficits is limited. The primary aims of this study were to assess FEP abilities in children (8 to 16 years old) with genetic generalized epilepsy (GGE) and temporal lobe epilepsy (TLE) and examine whether FEP is related to everyday social functioning. Forty-four children (8 to 16 years) with epilepsy (22 GGE, 22 TLE) and 22 typically developing controls completed the Pictures of Facial Affect (POFA) battery to assess FEP and a brief test of intellectual functioning (intelligence quotient [IQ]). Parents completed questionnaires assessing social competence of their child. Neurologists completed the Global Assessment of Severity of Epilepsy (GASE) scale as a measure of overall epilepsy severity. Demographic and clinical information was obtained from medical records and clinical interviews with parents. Findings revealed significant, overall FEP impairments and reduced social competence in children with GGE and TLE compared to controls. The magnitude of FEP impairment (i.e., across all emotions) was comparable in the two epilepsy groups, yet different emotions were impaired in each group: children with GGE were impaired in recognizing anger and disgust, whereas children with TLE were impaired in sadness and disgust, compared to controls. Contrary to expectations, total FEP accuracy was not significantly correlated with social competence in either epilepsy group. In conclusion, children with GGE and TLE have significant impairments recognizing emotional expressions on faces. Further research is needed to examine whether underlying FEP impairments relate to social and emotional functioning in children with epilepsy.

Altered resting-state functional connectivity within the developing social brain after pediatric traumatic brain injury

Traumatic brain injury (TBI) in childhood and adolescence can interrupt expected development, compromise the integrity of the social brain network (SBN) and impact social skills. Yet, no study has investigated functional alterations of the SBN following pediatric TBI. This study explored functional connectivity within the SBN following TBI in two independent adolescent samples. First, 14 adolescents with mild complex, moderate or severe TBI and 16 typically developing controls (TDC) underwent resting‐state functional magnetic resonance imaging 12–24 months post‐injury. Region of interest analyses were conducted to compare the groups' functional connectivity using selected SBN seeds. Then, replicative analysis was performed in an independent sample of adolescents with similar characteristics (9 TBI, 9 TDC). Results were adjusted for age, sex, socioeconomic status and total gray matter volume, and corrected for multiple comparisons. Significant between‐group differences were detected for functional connectivity in the dorsomedial prefrontal cortex and left fusiform gyrus, and between the left fusiform gyrus and left superior frontal gyrus, indicating positive functional connectivity for the TBI group (negative for TDC). The replication study revealed group differences in the same direction between the left superior frontal gyrus and right fusiform gyrus. This study indicates that pediatric TBI may alter functional connectivity of the social brain. Frontal‐fusiform connectivity has previously been shown to support affect recognition and changes in the function of this network could relate to more effortful processing and broad social impairments.

Theory of mind and social competence in children and adolescents with temporal lobe epilepsy

OBJECTIVE

The primary aim of this study was to examine theory of mind (ToM) and its relationship to social competence in children and adolescents with temporal lobe epilepsy (TLE). The secondary aim was to explore the relationship between ToM, social competence, epilepsy variables, and executive functioning (EF).

METHOD

Twenty-two children and adolescents (8-16 years old) with TLE and 22 typically developing controls completed two advanced behavioural tests of ToM (faux-pas, strange stories), measures of EF and verbal IQ. Parents completed questionnaires assessing ToM and social competence of their child. Epilepsy variables were obtained from treating neurologists and interviews with parents.

RESULTS

Children and adolescents with TLE had significant impairments in cognitive and affective ToM, reduced social competence, and lower verbal IQ than controls. Although verbal IQ was reduced in the TLE group, it was not related to ToM or social functioning. ToM impairment (a single score encompassing cognitive and affective ToM) was significantly correlated with social competence problems in our TLE group. Longer duration of epilepsy was related to reduced ToM and social competence, while earlier onset of seizures was related to social competence problems only. Finally, EF was neither impaired nor related to ToM or social problems in children and adolescents with TLE.

CONCLUSION

This study revealed marked ToM impairments and associated social difficulties in children and adolescents with TLE. The results support studies demonstrating similar impairments in children with other epilepsy subtypes and highlight the importance of detecting and treating ToM and social difficulties in this group. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective sleep outcomes 20 years after traumatic brain injury in childhood

Purpose: To assess objective sleep outcomes and correlates in young adults with a history of childhood traumatic brain injury.Materials and methods: Participants included 45 young adults who sustained brain injury in childhood (mild = 12, moderate = 22, and severe = 11) and 13 typically developing control participants. Sleep was assessed with actigraphy and sleep diaries recorded over 14 consecutive days. Rates of good sleep (sleep efficiency ≥ 85%) and poor sleep (sleep efficiency < 85%) were also evaluated.Results: At 20-years postinjury, participants with traumatic brain injury and controls presented with similar outcomes across the objective sleep parameters (all p > 0.050) and rates of poor sleepers were also similar between these groups (p = 0.735): 67% and 77%, respectively. However, moderate and severe traumatic brain injury and female sex were associated with longer sleep duration.Conclusions: These findings provide preliminary insights into objective sleep outcome and associated factors in the very-long-term after childhood brain injuries. They also indicate the need to monitor sleep outcomes in young adults with and without traumatic brain injury.Implication for rehabilitationSustaining traumatic brain injury in childhood can impact on several functional domains including sleep.Sleep disturbances, particularly insomnia-related symptoms, are common in this population, with evidence of poor outcomes reported until adolescence postinjury, while outcomes beyond adolescence remain unexplored.In this first investigation of objective sleep outcomes in young adults with a history of childhood traumatic brain injury, we showed that insomnia-related symptoms are highly prevalent in both young adults with traumatic brain injury (67%) and healthy controls (77%).These findings suggest the need to routinely evaluate and treat sleep problem in young adults in general, irrespective of history of childhood traumatic brain injury.

Parenting and the dysregulation profile predict executive functioning in children with acquired brain injury

Background: Children with acquired brain injury (ABI) present with high rates of psychological disorders commonly accompanied by deficits in hot and cold executive functions (EFs). Impairments in EFs have been reported to precede mental health problems. Moreover, children who are vulnerable to developing mental health problems in adulthood frequently present with a dysregulation profile in childhood, characterized by impairments in cognitive, behavioral and emotional regulation. Objective: To identify profiles of behaviors associated with impairment in hot and cold EFs and compare injury factors, environmental stressors and dysregulation profile between them. Methods: A latent profile analysis was conducted with 77 children with ABI aged between 6 and 12. Injury factors, child IQ, environmental stressors and the dysregulation profile were compared between these behavioral profiles. Logistic regressions were conducted to predict profile membership. Results: Two profiles were identified: Profile M, with mild deficits (1-2 SD above the mean) in working memory and social skills, and profile C, presenting clinically significant deficits (2-3 SD above the mean) in shift, initiate, working memory, planning and social skills and mild deficits in inhibit, emotional control and task monitor. Proximal environmental stressors (dysfunctional parenting practices, parental stress, parent's executive dysfunction, anxiety-trait, and depressive symptoms) and dysregulation symptoms predicted profile membership, whereas injury factors, child IQ and distal environmental stressors did not. Conclusion: Following ABI, children with profile C are at risk of mental health problems and present with more proximal stressors. The dysregulation profile may be useful as a proxy for risk for later mental health problems in children with ABI.

A novel cognitive behavioural intervention with Theory of Mind (ToM) training for children with epilepsy: protocol for a case series feasibility study

BACKGROUND

Children with epilepsy have significant social impairments, yet evidence-based interventions to address these social difficulties are lacking. Emerging research has shown that social difficulties in children with epilepsy relate to underlying impairments in Theory of Mind (ToM). This paper outlines the protocol for a pilot study that will evaluate the feasibility, acceptability, and efficacy of a novel cognitive behavioural intervention with ToM training for children with epilepsy.

METHODS

The intervention will be evaluated in a single-arm case series feasibility study. Ten to 12 children with common forms of epilepsy (8 to 12 years old) will be recruited to participate in 4 small group workshops, held over 4 consecutive weeks. Parents will attend a brief review at the end of each session with their child. Children will complete 4 one-to-one assessments with an investigator assessing ToM and social competence: twice at baseline (4 weeks and 1 day before the intervention), at post-intervention (last day of the intervention) and at follow-up (4 weeks post intervention). Parents will complete online questionnaires at these same 4 time points assessing ToM and social competence of their child. Parents and children will both complete a weekly measure of social competence from baseline 1 to follow-up. Following completion of the intervention, parents will complete two standardised questionnaires assessing treatment acceptability and barriers and facilitators to attendance; children will complete a single questionnaire on treatment acceptability. Information about feasibility outcomes (i.e. recruitment and retention, processing time, suitability of tasks) will be gathered by investigators during the trial. Together, outcomes will be used to refine research methods and make a decision about whether the intervention should be evaluated in a larger scale trial.

DISCUSSION

To our knowledge, this is the first psychosocial intervention to address social competence problems in children with epilepsy. Findings will provide information about a potentially effective treatment that could improve longer term social outcomes for this group.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12618000974202, registered June 8 2018.

Age-dependent differences in the impact of paediatric traumatic brain injury on executive functions: A prospective study using susceptibility-weighted imaging

Childhood and adolescence represent sensitive developmental periods for brain networks implicated in a range of complex skills, including executive functions (EF; inhibitory control, working memory, and cognitive flexibility). As a consequence, these skills may be particularly vulnerable to injuries sustained during these sensitive developmental periods. The present study investigated 1) whether age at injury differentially affects EF 6 months and 2 years after TBI in children aged 5-15 years, and 2) whether the association between brain lesions and EF depend on age at injury. Children with TBI (n = 105) were categorized into four age-at-injury groups based on previous studies and proposed timing of cerebral maturational spurts: early childhood (5-6 years, n = 14), middle childhood (7-9 years, n = 24), late childhood (10-12 years, n = 52), and adolescence (13-15 years, n = 15). EF were assessed with performance-based tasks and a parent-report of everyday EF. TBI patients' EF scores 6 months and 2 years post-injury were compared to those of typically developing (TD) controls (n = 42). Brain lesions were identified using susceptibility weighted imaging (SWI). Results indicated that inhibitory control performance 2 years post-injury was differentially affected by the impact of TBI depending on age at injury. Follow-up analyses did not reveal significant differences within the age groups, preventing drawing strong conclusions regarding the contribution of age at injury to EF outcome after TBI. Tentatively, large effect sizes suggest that vulnerability is most apparent in early childhood and adolescence. Everyday inhibitory control behaviour was worse for children with TBI than TD children across childhood and adolescence at the 2-year assessment. There was no evidence for impairment in working memory or cognitive flexibility after TBI at the group level. Given small group sizes, findings from analyses into correlations between EF and SWI lesions should be interpreted with caution. Extent, number and volume of brain lesions correlated with adolescent everyday EF behaviour 6 months post-injury. Taken together, the results emphasize the need for long-term follow-up after paediatric TBI during sensitive developmental periods given negative outcomes 2-year post injury. Inhibitory control seems to be particular vulnerable to the impact of TBI. Findings of associations between EF and SWI lesions need to be replicated with larger samples.

Rehabilitation of Executive function in Paediatric Traumatic brain injury (REPeaT): protocol for a randomized controlled trial for treating working memory and decision-making

BACKGROUND

Working memory allows us to hold information in an active state for short periods of time, and is essential in facilitating goal directed cognitive functioning. Difficulties in working memory and decision-making are common post childhood Traumatic Brain Injury (TBI). Despite this, there is a paucity of research pertaining to implementation and effectiveness of interventions to reduce these common difficulties which impact significantly on one's ability to function independently. One such intervention, Cogmed Working Memory Training Program, has shown success in improving working memory in other childhood clinical populations, but has received little evaluation in the TBI area. This study aims to evaluate whether Cogmed improves working memory and decision-making post childhood TBI and whether these benefits generalize to functional areas.

METHODS

The study is a randomized controlled trial (RCT) of the Cogmed (RM version) intervention for children post-TBI. Children aged 7-15 years are initially screened for working memory impairments. Eligible participants are then randomized into either the treatment group (Cogmed) or the active-control group (Lexia Reading). Each group trains online for 50 min each day, 5 days per week, for 5 consecutive weeks. The online training is supported by online clinician meetings each week. Outcome neuropsychological and functional assessments are carried out immediately at the completion of the intervention and at 6 months follow-up.

DISCUSSION

This study follows gold standard methodology in intervention research; uses a novel measure of decision-making; measures the effects of intervention on functional outcomes immediately and longer-term post intervention; uses online clinician support in order to allow more families easy access to the program; and promotes the use of technology to improve health services. If efficacious in improving working memory, decision-making, and functional outcomes, our team will then take a key role in implementing Cogmed into clinical care.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12617000085370 . Trial Registration Date: 16/01/2017. Protocol Version/Date: HREC 35181G/18.08.2017. Study Status: Ongoing.

Community-based interventions for adolescents following traumatic brain injury: A systematic review

BACKGROUND

Chronic impairment following childhood traumatic brain injury has the potential to increase risk of negative outcomes. This highlights potential value in community-based rehabilitation programs.

OBJECTIVES

To identify research studies examining existing intervention programmes available in community-based rehabilitation to adolescents following TBI to assist with the transition back into the community.

METHODS

A systematic review of community-based interventions was conducted across different national contexts. All included studies involved a clinical population with TBI, aged 11 to 25 years inclusive. Risk of bias was rated for each included study.

RESULTS

Seventeen studies were identified for inclusion in the review, of these eleven distinct interventions were found. The quality of evidence was largely weak and highly variable.

CONCLUSION

The results suggest some improvement in adolescent outcomes following community-based interventions, however higher quality evidence is needed to support specific interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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