Neuropsychological function in a group of patients 25 years after sustaining minor head injuries as children and adolescents

Previous studies suggest that neuropsychological impairment following mild to moderate pediatric head injury may become persistent and interrupt the normal course of intellectual development. In this study 45 subjects were assessed with a standardized neuropsychological test battery 25 years after sustaining mild to moderate head injury as children. Although the group scores in the normal range, significant relations between head injury severity and current neuropsychological function were found. The most important predictor of poor outcome was length of PTA at injury, EEG pathology, and loss of consciousness at injury. No significant influence of pre- and post-injury risk factors on current neuropsychological function was evident. The findings support the view that complicated mild and moderate paediatric head injury may heighten the risk of developing subtle neuropsychological problems later in life.     

Knowledge-based inferencing after childhood head injury

Inferencing was studied with a story comprehension task that required inferences to be made from a controlled knowledge base. Despite similar rates of knowledge base acquisition, knowledge base retention, and speeded access to the knowledge base across groups, the 18 children with severe head injury had lower rates of inferencing than the 15 children with mild head injury or the 18 age-matched controls. Results suggest that cognitive functions such as working memory and metacognitive skill that are disrupted by severe head injury may also play a role in some of the text- and discourse-level deficits commonly reported in these children, notably those involving inferencing.     

Cognitive contributions to theory of mind ability in children with a traumatic head injury

The objective of the current study is to examine the contribution of intellectual abilities, executive functions (EF), and facial emotion recognition to difficulties in Theory of Mind (ToM) abilities in children with a traumatic head injury. Israeli children with a traumatic head injury were compared with their non-injured counterparts. Each group included 18 children (12 males) ages 7–13. Measurements included reading the mind in the eyes, facial emotion recognition, reasoning the other’s characteristics based on motive and outcome, Raven’s Coloured Progressive Matrices, similarities and digit span (Wechsler Intelligence Scale for Children – Revised 95 subscales), verbal fluency, and the Behaviour Rating Inventory of Executive Functions. Non-injured children performed significantly better on ToM, abstract reasoning, and EF measures compared with children with a traumatic head injury. However, differences in ToM abilities between the groups were no longer significant after controlling for abstract reasoning, working memory, verbal fluency, or facial emotion recognition. Impaired ToM recognition and reasoning abilities after a head injury may result from other cognitive impairments. In children with mild and moderate head injury, poorer performance on ToM tasks may reflect poorer abstract reasoning, a general tendency to concretize stimuli, working memory and verbal fluency deficits, and difficulties in facial emotion recognition, rather than deficits in the ability to understand the other’s thoughts and emotions. ToM impairments may be secondary to a range of cognitive deficits in determining social outcomes in this population.     

Acute Intellectual Effects of Pediatric Head Trauma

The current study compared Wechsler Intelligence Scale for Children-III (WISC-III) performances of 30 children who sustained head injury with the performance of orthopedic controls matched on gender, age, race, and parental education and occupational attainment. Children were followed during initial hospitalization, trauma severity variables were recorded, and duration of posttraumatic amnesia (PTA) was determined by serial testing of mental status. The WISC-III was administered immediately following resolution of amnesia. Although the majority of patients sustained mild injuries, children with head injuries obtained significantly lower IQ and factor scores than nonneurologically injured children. Consistent with past research, performance-based scores including Performance IQ, Perceptual Organization, and Processing Speed were more sensitive to head trauma than their verbal counterparts. Standardized measurement of PTA appeared to be a better predictor of IQ status following injury than Glasgow Coma Scale score on admission or length of unconsciousness.     

Cognitive effects of mild head injury in children and adolescents

A comprehensive review of recent neuropsychological studies of mild head injury (MHI) involving children and adolescents is presented. The seminal work of Rutter and his colleagues is reviewed. An alternative conceptualization of MHI as proposed by various researchers is elaborated and further research investigating the cognitive sequelae of MHI is reviewed. MHI is discussed within the context of development and information processing models. Finally, the sequelae of MHI are reviewed with respect to academic functioning. Methodological problems inherent in studies of MHI are identified and discussed. The studies reviewed here support the conclusion that both the cognitive and emotional consequences of MHI should receive serious evaluation.     

Inhibitory control differences following mild head injury

Complex inhibitory control, defined as the ability to inhibit a planned or ongoing action, was assessed in a sample of individuals with a history of mild head injury, case-matched with normal control subjects for age and gender. This central act of control was assessed using a modification of the stop-signal paradigm. The group with mild head injury took longer to inhibit their on going action and reported more accidents than the normal control subjects. The group that reported having had a mild head injury did not differ in terms of their go reaction time, number of correct responses, handedness, education level, or reported learning disabilities. Limitations of this design and directions for future research are discussed.     

Another look at paradoxical severity effects in head injury with the Personality Assessment Inventory

Previous investigations of psychiatric symptomatology after head injury using the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) have consistently revealed greater Basic scale elevations in mild injuries versus more severe injuries. In this study, we tested this pattern of paradoxical severity effects using the Personality Assessment Inventory (PAI; Morey, 1991). We gathered PAI and MMPI-2 data from 34 patients with moderate-to-severe head injuries and from 52 patients with mild head injuries. MMPI-2 Basic scale profiles were consistent with the paradoxical severity effect; mild injury patients had significantly more elevated scores on four Basic scales (Scales 1, 2, 3, and 7). PAI Clinical scale profiles showed significantly more elevated scores among mild injury patients on 2 scales, Somatization and Depression, and more elevated scores among moderate-to-severe patients on 2 scales, Antisocial Features and Alcohol Problems. We consider unique contributions of the PAI for the psychological assessment of head injury.     

Neuropsychological impairment as a consequence of football (soccer) play and football heading: a preliminary analysis and report on school students (13-16 years).

Footballers run the risk of incurring mild head injury from a variety of sources, including the intentional use of the head to play the ball, known as heading. This paper presents a preliminary exploratory analysis of data collected to examine whether cumulative incidence of mild head injury, or cumulative heading frequency, are related to neuropsychological functioning in male adolescent footballers. In a quasi-experimental cross-sectional design, neuropsychological test scores of school team footballers were compared with those of similarly aged rugby players and noncontact sport players. Cumulative mild head injury incidence was estimated using self-reports, and cumulative heading was estimated using a combination of observation and self-reports. No participants had sustained a head injury within 3 months of testing. There was no relationship between head injury and neuropsychological performance, and there were no decrements in either the footballers or the rugby players in comparison with the noncontact sport players. Within the footballers, cumulative heading did not predict any of the neuropsychological test scores. These findings indicate the absence of neuropsychological impairment arising due to cumulative mild head injury incidence, or cumulative heading. Although these null findings may be reassuring to players, parents, and football organizers, we stress that they are preliminary. Further data is being collected from the same populations to provide more reliable effect estimates.     

Neuropsychological impairment as a consequence of football (soccer) play and football heading: A preliminary analysis and report on school students (13–16 years)

Footballers run the risk of incurring mild head injury from a variety of sources, including the intentional use of the head to play the ball, known as heading. This paper presents a preliminary exploratory analysis of data collected to examine whether cumulative incidence of mild head injury, or cumulative heading frequency, are related to neuropsychological functioning in male adolescent footballers. In a quasi-experimental cross-sectional design, neuropsychological test scores of school team footballers were compared with those of similarly aged rugby players and noncontact sport players. Cumulative mild head injury incidence was estimated using self-reports, and cumulative heading was estimated using a combination of observation and self-reports. No participants had sustained a head injury within 3 months of testing. There was no relationship between head injury and neuropsychological performance, and there were no decrements in either the footballers or the rugby players in comparison with the noncontact sport players. Within the footballers, cumulative heading did not predict any of the neuropsychological test scores. These findings indicate the absence of neuropsychological impairment arising due to cumulative mild head injury incidence, or cumulative heading. Although these null findings may be reassuring to players, parents, and football organizers, we stress that they are preliminary. Further data is being collected from the same populations to provide more reliable effect estimates.     

A taxonomy of neurobehavioral functions applied to neuropsychological assessment after head injury

Neuropsychological dysfunctions after traumatic brain injury are classified into a taxonomy to plan a comprehensive examination, and organize and report findings for diagnosis and treatment: consciousness, information processing, sensorimotor, neurophysiological, cerebral personality disorders, intelligence, memory, language, stress, psychodynamic, identity and weltanschauung, adaptation, complex adaptive functions, and development of children. Widerange sampling enhances the detection of acute and late-developing dysfunctions, and diagnosis of complex syndromes. Historical, personality, and injury data are components of the assessment. Issues discussed include underestimation of brain injury, malingering, interaction of symptoms, symptom persistence, and noncerebral lesional contributors to impairment after mild head injury.     

Symptom cluster associated with mild traumatic brain injury in university students.

There is growing recognition that even a minor blow to the head can have serious consequences on physical, cognitive, behavioral, and social well-being. Previous studies have indicated that such changes may in turn have a dramatic effect on the ability of university students to carry out their studies. This survey measured the prevalence of mild traumatic brain injury in a nonclinical population of 1,075 university students from all disciplines. In addition to surveying the nature, cause, and sex distribution, it further investigated the relationships between the physical, cognitive, behavioral, and social repercussions of the incidents. Results replicated earlier findings and indicated a prevalence rate of mild traumatic brain injury of 34.9% (n = 375). Moreover, significant correlations were found among the physical, cognitive, behavioral, and social changes reported by the students, suggesting a cluster of symptoms associated with such incidents. Altogether, these results suggest that even currently enrolled and active university students may face unique and subtle challenges related to a mild traumatic brain injury.     

Attentional skills in the acute phase following pediatric traumatic brain injury.

Only a limited number of studies have investigated attention following pediatric head-injury. The present study examined sustained attention and processing speed in a group of children who had sustained a mild (n = 27), moderate (n = 33) or severe (n = 16) traumatic brain injury (TBI). No significant differences were evident between the TBI groups on reaction time measures. Results did show that the severe TBI group exhibited greater deficits in the area of sustained attention, in comparison to children with mild and moderate injuries, in the acute stage following traumatic brain injury. This difficulty may impact on the future development of skills dependent on intact attentional capacity.     

Attentional Skills in the Acute Phase Following Pediatric Traumatic Brain Injury

Only a limited number of studies have investigated attention following pediatric head-injury. The present study examined sustained attention and processing speed in a group of children who had sustained a mild (n = 27), moderate (n = 33) or severe (n = 16) traumatic brain injury (TBI). No significant differences were evident between the TBI groups on reaction time measures. Results did show that the severe TBI group exhibited greater deficits in the area of sustained attention, in comparison to children with mild and moderate injuries, in the acute stage following traumatic brain injury. This difficulty may impact on the future development of skills dependent on intact attentional capacity.     

Recovery in Memory Function,and its Relationship to Academic Success,at 24 Months Following Pediatric TBI*

While a number of research papers have reported findings on memory deficits following traumatic brain injury (TBI), only limited studies have monitored the recovery of these skills over time. The present study examined memory ability and its effect on academic success in a group of children who had sustained a mild, moderate, or severe traumatic brain injury (TBI). Results showed that the severe TBI group exhibited greater deficits on memory tasks, irrespective of modality, in the acute, 6-, 12-, and 24-month postinjury stages, in comparison to mild and moderate TBI groups. Performance on academic measures was dependent on both injury severity and task demands. Preinjury academic ability and verbal memory indices best predicted academic success.     

Recovery in memory function, and its relationship to academic success, at 24 months following pediatric TBI.

While a number of research papers have reported findings on memory deficits following traumatic brain injury (TBI), only limited studies have monitored the recovery of these skills over time. The present study examined memory ability and its effect on academic success in a group of children who had sustained a mild, moderate, or severe traumatic brain injury (TBI). Results showed that the severe TBI group exhibited greater deficits on memory tasks, irrespective of modality, in the acute, 6-, 12-, and 24-month postinjury stages, in comparison to mild and moderate TBI groups. Performance on academic measures was dependent on both injury severity and task demands. Preinjury academic ability and verbal memory indices best predicted academic success.     

Applying a traumatic stress approach to understanding PCS following pediatric mild TBI

Pediatric traumatic brain injury is a significant public health concern affecting hundreds of thousands of children each year. The majority of children who sustain traumatic brain injuries are classified as having a mild traumatic brain injury, and a subset of these children go on to experience persistent physical, cognitive, and emotional symptoms. These symptoms, known as postconcussive symptoms, can endure for months and even years after injury. The outcomes of mild traumatic brain injury are variable and not well understood for a small percentage of children who experience persistent symptoms. The current article explores the potential influence of children’s posttraumatic stress symptoms on persistent postconcussive symptoms. Despite the high incidence of posttraumatic stress symptoms after pediatric accidental injury, they have not yet been identified as an important factor for consideration in the understanding of pediatric postconcussive outcomes. The article will review the literature on posttraumatic stress and postconcussive symptoms after pediatric injury and consider neurobiological and cognitive factors to propose a model explaining a pathway through which posttraumatic stress reactions may serve as the mechanism for the expression and maintenance of postconcussive symptoms after mild traumatic brain injury. The clinical implications for the proposed relationship between posttraumatic stress symptoms and postconcussive symptoms are considered prior to the conclusion of the article, which acknowledges limitations in the current literature and provides suggestions for future research.     

Narrative discourse after closed head injury in children and adolescents.

This study examined narrative discourse in 20 children and adolescents at least 1 year after sustaining a head injury. Narratives were analyzed along the dimensions of language structure, information structure, and flow of information. Severity of impaired consciousness was associated with a significant reduction in the amount of language and information. The most important finding which emerged was the disruption in information structure. This pattern confirms the impression of disorganized discourse in severely injured children. Explanations for the disruption in information structure are explored in terms of the role of vocabulary, memory, and localization of lesion according to magnetic resonance imaging. In view of recent evidence that frontal lobe damage is associated with discourse formulation deficits in adults and is the most common site of focal lesion in closed head injury, we examined discourse patterns in individual patients with frontal lobe lesions. Preliminary data from our single-case studies suggest discourse patterns similar to those reported for adults with frontal lobe injuries.     

Reported head injury and sex differences in color naming, color matching, and digit-string matching.

It was hypothesized that the observed sex differences on three speeded tasks could be accounted for in terms of the greater incidence of head injury in men than in women. In two studies of 64 male and 66 female college students significant sex differences were found on digit-string matching and color-matching tasks. When the data from those 39 subjects with reported histories of head injury were eliminated from the analysis or head-injury reports were statistically controlled, significant sex differences remained. Digit-string matching times were significantly correlated with reported head injury in both studies, suggesting that this test is sensitive to residual effects of head injury.     

How Children with Head Injury Represent Real and Deceptive Emotion in Short Narratives

Narratives are not only about events, but also about the emotions those events elicit. Understanding a narrative involves not just the affective valence of implied emotional states, but the formation of an explicit mental representation of those states. In turn, this representation provides a mechanism that particularizes emotion and modulates its display, which then allows emotional expression to be modified according to particular contexts. This includes understanding that a character may feel an emotion but inhibit its display or even express a deceptive emotion. We studied how 59 school-aged children with head injury and 87 normally-developing age-matched controls understand real and deceptive emotions in brief narratives. Children with head injury showed less sensitivity than controls to how emotions are expressed in narratives. While they understood the real emotions in the text, and could recall what provoked the emotion and the reason for concealing it, they were less able than controls to identify deceptive emotions. Within the head injury group, factors such as an earlier age at head injury and frontal lobe contusions were associated with poor understanding of deceptive emotions. The results are discussed in terms of the distinction between emotions as felt and emotions as a cognitive framework for understanding other people's actions and mental states. We conclude that children with head injury understand emotional communication, the spontaneous externalization of real affect, but not emotive communication, the conscious, strategic modification of affective signals to influence others through deceptive facial expressions.     

Linguistic recovery after closed head injury

Recovery from acute aphasia after closed head injury was studied in 21 young adults at least 6 months after injury. Three profiles of scores were found using standardized language tests. Persistent expressive and receptive impairment was present in 6 patients who sustained severe diffuse brain injury resulting in global cognitive deficit. Residual expressive impairment, primarily of naming, was associated with mild diffuse brain injury though focal left-hemisphere injury was present in 3 of 6 cases. Patients who recovered to normal levels on all language tests generally had acute neurologic findings consistent with mild diffuse brain injury. Cranial computed tomography at the time of followup frequently disclosed ventricular enlargement.