Neuropathological determinants of acquired attention disorders in traumatic brain injury

Attentional disorders are frequently mentioned neuropsychological sequalae following traumatic brain injury (TBI). However, little is known about the recovery of attention, or the determinants of variability of attentional functioning following TBI. The present study was undertaken to examine (1) the extent to which attentional disorders are present among patients at various chronicity stages following TBI, (2) differences in performance on a number of measures of attention as a function of different clinical-neuropathological syndromes. A sample of 70 TBI subjects were rated according to different clinical-neuropathological syndromes and neuropsychologically evaluated. The results suggest that TBI patients of different chronicity stages, with significantly different lengths of coma, did not significantly differ in terms of the type or severity of attentional disorders. However, when the same patients were classified according to clinical-neuropathological syndromes, significant differences in the severity and type of attentional disorders were evident. The findings were interpreted to suggest that typical indices of severity of TBI do not correlate with the severity and type of attentional disorders and that qualitative aspects of the subjects' pathology may be more important in determining the nature of the attentional disorders.     

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.     

Posttraumatic stress symptoms in children following orthopedic or traumatic brain injury.

Examined posttraumatic stress (PTS) symptoms in children following pediatric traumatic brain injury (TBI). Children (ages 6-12) with TBI (n = 81) and orthopedic injury (OI; n = 59) were assessed 6 and 12 months postinjury. Parents of children with severe TBI reported higher levels of child PTS symptoms than did parents of children with moderate TBI or OI at the 6- and 12-month follow-ups. Group differences in child-reported PTS symptoms emerged at the 12-month follow-up with higher symptom levels reported by children with severe TBI than by those with moderate TBI or OI. At both follow-ups, rates of clinically significant symptom levels were higher in the severe TBI group than in the moderate TBI or OI groups. The group differences in parent and child reports were significant even after taking ethnicity, social disadvantage, and age at injury into account. Parent and child reports of child PTS symptoms were related to family socioeconomic status. Implications for clinical intervention with children and families following pediatric TBI are discussed.     

Neuropsychological correlates of impaired emotion recognition following traumatic brain injury

Previous research has shown that individuals with traumatic brain injury (TBI) are significantly impaired on emotion recognition tasks. In this study, the relationship between neuropsychological functioning and emotion recognition was examined in 11 individuals with moderate to severe TBI and a control group of 13 individuals matched for age,sex, and education. Emotion recognition stimuli were from Ekman and Friesen's pictures of facial affect. The group with TBI showed neuropsychological deficits consistent with those commonly found following moderate to severe TBI. The group with TBI also identified significantly fewer emotion recognition stimuli than the control group.The number of correctly identified emotion recognition stimuli was significantly correlated with measures of verbal cognitive processing in the group with TBI. These findings suggest that the role of left hemisphere brain mechanisms in the recognition of facial (nonverbal)emotion may be more important than previously recognized.     

Counter‐intuitive moral judgement following traumatic brain injury

Several neurological patient populations, including traumatic brain injury (TBI), appear to produce an abnormally ‘utilitarian’ pattern of judgements to moral dilemmas; they tend to make judgements that maximize the welfare of the majority, rather than deontological judgements based on the following of moral rules (e.g., do not harm others). However, this patient research has always used extreme dilemmas with highly valued moral rules (e.g., do not kill). Data from healthy participants, however, suggest that when a wider range of dilemmas are employed, involving less valued moral rules (e.g., do not lie), moral judgements demonstrate sensitivity to the psychological intuitiveness of the judgements, rather than their deontological or utilitarian content (Kahane et al., Social Cognitive and Affective Neuroscience, 7, 2011, 393). We sought the moral judgements of 30 TBI participants and 30 controls on moral dilemmas where content (utilitarian/deontological) and intuition (intuitive/counter‐intuitive) were measured concurrently. Overall TBI participants made utilitarian judgements in equal proportions to controls; disproportionately favouring utilitarian judgements only when they were counter‐intuitive, and deontological judgements only when they were counter‐intuitive. These results speak against the view that TBI causes a specific utilitarian bias, suggesting instead that moral intuition is broadly disrupted following TBI.     

Regional cortical volume and cognitive functioning following traumatic brain injury

There has been limited examination of the effect of brain pathology on subsequent function. The current study examined the relationships between regional variation in grey matter volume, age and cognitive impairment using a semi-automated image analysis tool. This study included 69 individuals with mild-to-severe TBI, 41 of whom also completed neuropsychological tests of attention, working memory, processing speed, memory and executive functions. A widespread reduction in grey matter volume was associated with increasing age. Regional volumes that were affected also related to the severity of injury, whereby the most severe TBI participants displayed the most significant pathology. Poorer retention of newly learned material was associated with reduced cortical volume in frontal, parietal, and occipital brain regions. In addition, poorer working memory and executive control performance was found for individuals with lower cortical volume in temporal, parietal, and occipital regions. These findings are largely in line with previous literature, which suggests that frontal, temporal, and parietal regions are integral for the encoding of memories into long-term storage, memory retrieval, and working memory. The present study suggests that automated image analysis methods may be used to explore the relationships between regional variation in grey matter volume and cognitive function following TBI.     

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

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

Emotional and pain-related factors in neuropsychological assessment following mild traumatic brain injury

A critical issue in the field of clinical neuropsychology is the idea that emotional or pain-related factors may compromise the validity of neuropsychological assessment. In this study, 53 individuals suffering from mild traumatic brain injury related to motor vehicle accident injury completed commonly used measures of emotional and pain-related functioning. A battery of commonly used neuropsychological tests, assessing attention, learning and memory, language, visuospatial and visuomotor functions, speeded processing, fine-motor skill, and symptom validity, was administered concurrently. Findings revealed a significant and negative correlation between anxiety and impaired delayed verbal memory, suggesting that as anxiety increased, delayed verbal memory decreased. The results otherwise provided little support for the idea that emotional or pain-related factors are detrimental to neuropsychological test performance following mild traumatic brain injury.     

Recovery and predictors of language skills two years following pediatric traumatic brain injury

Subtle language processing difficulties may adversely affect scholastic performance, as well as communication and social skills. It is therefore crucial that language skills are monitored following traumatic brain injury (TBI) in childhood. The present study examined language skills in a group of 68 children who had sustained a mild, moderate or severe TBI. Results indicated that during the acute stage a dose-response relationship was evident, where severe TBI was associated with poorest performance and mild TBI with least deficits. By 24 months post-TBI, it was clear that for some language functions, the severe TBI group showed substantial recovery, and at times performed better than the moderate TBI group. Predictors of language and literacy skills at 24 months post TBI included pre-injury communication skills, socio-economic status, age at injury, and Vocabulary, as measured by the Wechsler Intelligence Scale for Children (WISC-111).     

Family response to traumatic brain injury

The stress experienced by families with a member who has experienced a traumatic brain injury (TBI) has recently been addressed in the counselling and rehabilitation literature. Given that rehabilitation centres have physical restoration of the patient as a primary mandate, the emotional and social adjustment needs of family members are often overlooked. Information on TBI and its effect on families will help counsellors and psychologists contribute to the family adjustment process.     

Sexual offenses and traumatic brain injury

A sample of 476 male sexual offenders, seen at a university psychiatric hospital for forensic assessment, was examined for the incidence of traumatic head injuries. A total of 49.3% had sustained head injuries that led to unconsciousness and of these 22.5% sustained significant neurological insults. A major causative factor was motor vehicle accidents, but lifestyle variables including alcohol and drug abuse and history of violence also contributed. The brain-injured group was convicted for a wide range of sexual offenses and was comparable to the non-injured group in this respect, but tended more often to offend against adults than against children and to show somewhat more exhibiting and polymorphous sexual behavior. In spite of the serious legal implications for these men and the additional distress to their families, psychologists, psychiatrists, and the professional literature have been relatively silent on the subject which calls for more attention to sexual behavior as part of assessments and treatment planning.     

Changes in coping style following traumatic brain injury and their relationship to productivity status

The use of maladaptive coping strategies following traumatic brain injury (TBI) is known to be associated with increased depression and a lower productivity status. What is not known is whether coping behaviours change following TBI and if they do change whether these changes account for significant variance in outcome. Seventy-three significant others of TBI survivors were recruited at the time their friend/family member was injured and followed prospectively. They reported on their friend/family member's pre-injury and 6-month coping behaviours using the Coping with Health Injuries and Problems Scale. The use of emotional pre-occupation coping (p = .02) increased significantly and approached significance for distraction coping(p = .08). These changes in coping also accounted for significant variance (22%, p = .02) in productivity status over and above that accounted for by demographics and injury severity. Whether maladaptive coping changes can be prevented with a view to improving outcomes is a question that now needs to be explored.     

Cognitive remediation in pediatric traumatic brain injury

Robinson's (1970) elaborative encoding technique (PQRST) was implemented as the active cognitive intervention strategy to address verbal memory deficits in 2 fourth-grade boys following mild or moderate traumatic brain injury (TBI). A metacognitive reading comprehension technique (Smith & Dauer, 1984) was also implemented for comparison purposes. Single-case methodology was employed using a counter-balanced crossover of the two intervention strategies controlling for the effects of attention. The performance of both boys was significantly better during strategy training with the PQRST technique and approached the performance level of the normal comparison subject. In contrast, the performance of both subjects with TBI remained at, or returned to, baseline levels during the metacognitive intervention. These findings suggest that Robinson's cognitive remediation intervention holds promise in addressing memory and reading comprehension deficits following pediatrie traumatic brain injury. Future research should focus on enhancing generalization and transfer of training to classroom assignments.     

Social problem‐solving skills following childhood traumatic brain injury and its association with self‐regulation and social and behavioural functioning

This study examines social problem‐solving skills following childhood traumatic brain injury (TBI) and its association with self‐regulation, and social and behavioural functioning. Participants included 65 children with moderate to severe TBI and 65 children without TBI, all between 6 and 11 years of age. Social problem‐solving, self‐regulation, and social and behavioural functioning were assessed 2–5 years following injury. Children were administered a newly developed semi‐structured task to assess their solutions to hypothetical situations involving social problems or dilemmas. When compared with uninjured children, those with TBI suggested avoidant and aggressive solutions more often and assertive solutions less often in response to the hypothetical situations. Children's self‐regulatory skills, as measured by the Matching Familiar Figures Test (MFFT), Test of Everyday Attention for Children (TEA‐Ch) and the Delay of Gratification Task (DGT), collectively accounted for significant variance in their solutions to social problems, such that better self‐regulation predicted more assertive solutions and fewer aggressive solutions. Assertive solutions were positively related to parent‐ and teacher‐rated social and behavioural outcomes, whereas aggressive solutions were negatively related to the outcomes. The difficulties in social problem‐solving skills demonstrated by children with TBI may help account for their poor social and behavioural functioning.     

Working memory outcomes following traumatic brain injury in children: A systematic review with meta-analysis

The aim of this review is to systematically examine the literature concerning multicomponent working memory (WM)—comprising a central executive (CE), two storage components (phonological loop, PL and visuo-spatial sketchpad, VSSP), and episodic buffer (EB)—in pediatric traumatic brain injury (TBI). Electronic searches were conducted of MEDLINE, PsychINFO and EMBASE up to October 2014 with the inclusion criteria of children and adolescents with TBI, and quantitative methods to assess at least one component of WM. Meta-analytic procedures calculated pooled effect sizes for WM outcomes. Of the studies examined, 27 met the inclusion criteria. Children with TBI exhibited deficits in the CE and PL, but not in the VSSP, and no study could be found which examined the EB. Qualitative analysis found that greater TBI severity was associated with poorer CE functioning in five out of nine studies. Differences in patterns of brain activation were evident in four out of five fMRI studies that examined WM in TBI children and controls. Deficits in CE were associated with poorer mathematical skills in the only study that examined relations between WM and academic deficits. Notwithstanding the heterogeneity of the studies reviewed, TBI places children at risk of WM deficits. Moreover, this meta-analysis suggests that various components of WM have differential vulnerability to pediatric TBI, with significant deficits found in the CE and PL, but not in the VSSP (although the VSSP has rarely been examined to date). Future studies should be theoretically driven, employ tasks assessing all components of the WM model and examine the functional ramifications (including academic outcomes) of WM deficits in this population.     

Lack of inhibition: a motivational deficit in children with attention deficit/hyperactivity disorder and children with traumatic brain injury.

Recent research has demonstrated that both brain-injured children and children with attention deficit/hyperactivity disorder (ADHD) suffer from response inhibition deficits. To investigate whether these deficits can be influenced by motivational factors, the stop-signal task was performed with and without reward contingencies for successful inhibition. Three groups of children between 8 and 12 years of age, participated in the study: 31 children with ADHD, 37 with traumatic brain injuries (TBI), and 26 normal controls. Results indicated that, although all groups showed comparable learning effects, reward contingencies had different effects on the groups. Whereas the performance of children with ADHD under reward contingencies were brought up to the performance level of normal controls, rewards were found less effective at improving response inhibition in children with TBI. The results further support a motivational/energetic explanation of the inhibitory deficit in children with ADHD, and of a primary response inhibition deficit due to structural brain damage in children with TBI.     

Children's spatial behavior is differentially affected after traumatic brain injury.

Spatial behavior in 20 children with severe traumatic brain injury (TBI) and 20 healthy controls was investigated using the Kiel Locomotor Maze. Children had to remember defined locations in an experimental chamber with completely controlled intra- and extra-maze cues until learning criterion was reached. In a second experiment, spatial orientation strategies were assessed. Children with TBI were shown to be impaired in spatial learning and spatial memory. Spatial orientation was found to be deficient even in cases where spatial learning and memory proved to be unimpaired, especially in tasks that demanded the use of relational place strategies. Children who suffered a TBI at an early age proved to be more severely impaired in spatial learning and orientation than older children.     

Central executive system impairment in traumatic brain injury

The aim of the present study was to identify cognitive functions affected by traumatic brain injury (TBI) and to verify the mechanism underlying cognitive impairment. More precisely, cognitive deficits following TBI can be considered as a consequence of (a) a speed processing deficit, that is a general slowing of perceptual, motor and cognitive subroutines; (b) an impairment of the Central Executive System of working memory (CES).Thirty-seven patients were submitted to a neuropsychological battery, aimed to evaluate different cognitive functions.Results showed severe deficits in speed processing, divided attention,working memory, executive functions and long term memory.Regression analyses, performed to test the two hypotheses, showed that the working memory deficit hypothesis is able to explain divided attention, executive functions and long term memory deficits more than speed processing hypothesis.