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.     

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 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).     

Impaired discourse gist and working memory in children after brain injury

Emerging evidence suggests that a traumatic brain injury (TBI) in childhood may disrupt the ability to abstract the central meaning or gist-based memory from connected language (discourse). The current study adopts a novel approach to elucidate the role of immediate and working memory processes in producing a cohesive and coherent gist-based text in the form of a summary in children with mild and severe TBI as compared to typically developing children, ages 8-14 years at test. Both TBI groups showed decreased performance on a summary production task as well as retrieval of specific content from a long narrative. Working memory on n-back tasks was also impaired in children with severe TBI, whereas immediate memory performance for recall of a simple word list in both TBI groups was comparable to controls. Interestingly, working memory, but not simple immediate memory for a word list, was significantly correlated with summarization ability and ability to recall discourse content.     

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.     

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.     

Memory in traumatic brain injury: The effects of injury severity and effort on the Wechsler Memory Scale‐III

This study examined the effects of traumatic brain injury (TBI) on Wechsler Memory Scale‐III (WMS‐III) performance. Since poor effort potentially contaminates results, effort was explicitly assessed and controlled using two well‐validated cognitive validity indicators, the Portland Digit Recognition Test (PDRT) and Reliable Digit Span (RDS). Participants were 44 mild TBI patients with good effort, 48 mild TBI patients with poor effort, and 40 moderate–severe TBI patients with good effort. A dose–response relationship between injury severity and WMS‐III performance was demonstrated. Effect size calculations showed that the good effort mild TBI patients did not differ from normal (average Cohen's d= 0.07) while moderate–severe TBI had a moderate effect on WMS‐III scores (average Cohen's d=?0.52). Consistent with previous literature, the moderate–severe TBI group scored the lowest on WMS‐III Visual indices. Effort had a larger effect than injury severity on WMS‐III scores (average Cohen's d=?1.27). Clinical implications of these findings are discussed.     

Social problem-solving skills in children with traumatic brain injury: long-term outcomes and prediction of social competence.

The effects of childhood traumatic brain injury (TBI) on social problem-solving were examined in 35 children with severe TBI, 40 children with moderate TBI, and 46 children with orthopedic injuries (OI). The children were recruited prospectively following injuries that occurred between 6 and 12 years of age. They were followed longitudinally, and ranged from 9 to 18 years of age at the time of the current study, which occurred on average 4 years post injury. They were administered a semi-structured interview used in previous research on social problem-solving to assess the developmental level of their responses to hypothetical dilemmas involving social conflict. Children in the severe TBI group defined the social dilemmas and generated alternative strategies to solve those dilemmas at the same developmental level as did children in the OI group. However, they articulated lower-level strategies as the best way to solve the dilemmas and used lower-level reasoning to evaluate the effectiveness of the strategies. After controlling for group membership, race, socioeconomic status, IQ, and age, children's social problem-solving, and particularly the developmental level of their preferred strategies for resolving conflicts, predicted parents ratings of children's social skills, peer relationships, aggressive behavior, and academic performance. The findings indicate that children with severe TBI demonstrate selective, long-term deficits in their social problem-solving skills that may help to account for their poor social and academic outcomes.     

Social Problem-Solving Skills in Children with Traumatic Brain Injury: Long-Term Outcomes and Prediction of Social Competence

The effects of childhood traumatic brain injury (TBI) on social problem-solving were examined in 35 children with severe TBI, 40 children with moderate TBI, and 46 children with orthopedic injuries (OI). The children were recruited prospectively following injuries that occurred between 6 and 12 years of age. They were followed longitudinally, and ranged from 9 to 18 years of age at the time of the current study, which occurred on average 4 years post injury. They were administered a semi-structured interview used in previous research on social problem-solving to assess the developmental level of their responses to hypothetical dilemmas involving social conflict. Children in the severe TBI group defined the social dilemmas and generated alternative strategies to solve those dilemmas at the same developmental level as did children in the OI group. However, they articulated lower-level strategies as the best way to solve the dilemmas and used lower-level reasoning to evaluate the effectiveness of the strategies. After controlling for group membership, race, socioeconomic status, IQ, and age, children's social problem-solving, and particularly the developmental level of their preferred strategies for resolving conflicts, predicted parents ratings of children's social skills, peer relationships, aggressive behavior, and academic performance. The findings indicate that children with severe TBI demonstrate selective, long-term deficits in their social problem-solving skills that may help to account for their poor social and academic outcomes.     

The effect of age-at-testing on verbal memory among children following severe traumatic brain injury

Memory deficits are a common sequelae following childhood traumatic brain injury (TBI), which often have serious implications on age-related academic skills. The current study examined verbal memory performance using the Rey Auditory Verbal Learning Test (RAVLT) in a pediatric TBI sample. Verbal memory abilities as well as the effect of age at-testing on performance were examined. A sample of 67 children following severe TBI (age average = 12.3 ± 2.74) and 67 matched controls were evaluated using the RAVLT. Age effect at assessment was examined using two age groups: above and below 12 years of age during evaluation. Differences between groups were examined via the 9 RAVLT learning trials and the 7 composite scores conducted out of them. Children following TBI recalled significantly less words than controls on all RAVLT trials and had significantly lower scores on all composite scores. However, all of these scores fell within the low average range. Further analysis revealed significantly lower than average performance among the older children (above 12 years), while scores of the younger children following TBI fell within average limits. To conclude, verbal memory deficits among children following severe TBI demonstrate an age-at-testing effect with more prominent problems occurring above 12 years at the time of evaluation. Yet, age-appropriate performance among children below 12 years of age may not accurately describe memory abilities at younger ages following TBI. It is therefore recommended that clinicians address child’s age at testing and avoid using a single test as an indicator of verbal memory functioning post TBI.     

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.     

Prevalence and correlates of depressive symptoms following traumatic brain injuries in children.

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.     

Prevalence and Correlates of Depressive Symptoms Following Traumatic Brain Injuries in Children

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.     

The female advantage: sex as a possible protective factor against emotion recognition impairment following traumatic brain injury

Although moderate to severe traumatic brain injury (TBI) leads to facial affect recognition impairments in up to 39% of individuals, protective and risk factors for these deficits are unknown. The aim of the current study was to examine the effect of sex on emotion recognition abilities following TBI. We administered two separate emotion recognition tests (one static and one dynamic) to 53 individuals with moderate to severe TBI (females = 28) and 49 demographically matched comparisons (females = 22). We then investigated the presence of a sex-by-group interaction in emotion recognition accuracy. In the comparison group, there were no sex differences. In the TBI group, however, females significantly outperformed males in the dynamic (but not the static) task. Moreover, males (but not females) with TBI performed significantly worse than comparison participants in the dynamic task. Further analysis revealed that sex differences in emotion recognition abilities within the TBI group could not be explained by lesion location, TBI severity, or other neuropsychological variables. These findings suggest that sex may serve as a protective factor for social impairment following TBI and inform clinicians working with TBI as well as research on the neurophysiological correlates of sex differences in social 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.     

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.     

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.     

Assessment of performance validity in the Stroop Color and Word Test in mild traumatic brain injury patients: A criterion‐groups validation design

The current study assessed performance validity on the Stroop Color and Word Test (Stroop) in mild traumatic brain injury (TBI) using criterion‐groups validation. The sample consisted of 77 patients with a reported history of mild TBI. Data from 42 moderate–severe TBI and 75 non‐head‐injured patients with other clinical diagnoses were also examined. TBI patients were categorized on the basis of Slick, Sherman, and Iverson (1999) criteria for malingered neurocognitive dysfunction (MND). Classification accuracy is reported for three indicators (Word, Color, and Color–Word residual raw scores) from the Stroop across a range of injury severities. With false‐positive rates set at approximately 5%, sensitivity was as high as 29%. The clinical implications of these findings are discussed.     

Long-term executive function deficits in children with traumatic brain injuries: assessment using the Behavior Rating Inventory of Executive Function (BRIEF).

Long-term deficits in executive functions following childhood traumatic brain injuries (TBI) were examined using the Behavior Rating Inventory of Executive Function (BRIEF). Parents completed the BRIEF approximately 5 years postinjury as part of a prospective study of children injured between the ages of 6 and 12. The children were between 10 and 19 years of age at the time of the assessment, and included 33 with severe TBI, 31 with moderate TBI, and 34 with orthopedic injuries. Parents also rated children's adaptive functioning and completed several other measures of parent and family functioning. Children were administered a neuropsychological test battery that included several measures of executive functions. The groups displayed a significant linear trend in BRIEF scores, with the largest deficits in executive functions reported in children with severe TBI. BRIEF scores were related consistently across groups to a test of working memory, but not to other neuropsychological measures. BRIEF scores also predicted children's adaptive functioning and behavioral adjustment, as well as parent psychological distress, perceived family burden, and general family functioning. The findings indicate that TBI results in long-term deficits in executive functions that are related to children's psychosocial outcomes, as well as to parent and family functioning.