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.     

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.     

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).     

Attention After Pediatric Traumatic Brain Injury: A Multidimensional Assessment

Attentional disturbance is a common complaint after TBI in children and adolescents, however, few studies have assessed post-traumatic attentional functions. The attentional constructs proposed by Mirsky, Anthony, Duncan, Ahearn, and Kellam (1991) provided a multidimensional framework for prospective assessment of late attentional disturbance after mild-moderate (n = 34) and severe (n = 57) traumatic brain injury (TBI). Attention was evaluated from 5 to 8 years after TBI in children ages 0 to 15 years at the time of injury. Children with severe TBI performed more poorly than children with mild-moderate TBI on tests comprising the focus/execute and shift constructs. Younger children scored below older children irrespective of injury severity on the Digit Span subtest and interstimulus interval scores from an adaptive rate continuous performance test reflecting the encode and sustain constructs of Mirsky et al. (1991). Age × Severity interaction effects were found for speeded perceptual-motor tests; scores were reduced following mild-moderate and severe TBI in younger children and following severe TBI in older patients. Results are discussed in terms of the vulnerability of skills in a rapid stage of development to disruption by acquired brain injury.     

Age at injury and long-term behavior problems after traumatic brain injury in young children

Objective: This study examined the effects of age at injury on the persistence of behavior problems and social skill deficits in young children with complicated mild to severe traumatic brain injury (TBI). Method: A concurrent cohort/prospective research design was used with repeated assessments of children with TBI (n = 82) or Orthopedic Injury (OI) (n = 114). Parents completed the Child Behavior Checklist, the Behavior Rating Inventory of Executive Functions, and the Preschool and Kindergarten Behavior Scales or the Home and Community Social and Behavior Scales shortly after injury to assess preinjury functioning, and at an extended follow-up an average of 38 months postinjury. Generalized linear modeling was used to examine the relationship of age at injury to the maintenance of behavior problems, and logistic regression was used to examine the persistence of clinically significant behavior problems. Results: At the extended follow-up, severe TBI was associated with significantly greater anxiety problems relative to the Group OI. With increasing time since injury, children who sustained a severe TBI at an earlier age had significantly higher levels of parent-reported symptoms of ADHD and anxiety than children who were older at injury. Conclusions: Findings suggest that longer-term treatment for behavior problems may be needed after severe TBI, particularly for those injured at an earlier age. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Impairments of attention following childhood traumatic brain injury.

Attentional deficits are commonly reported following traumatic brain injury (TBI) in adults, although the occurrence of such problems is less well documented in young children. This study aimed to investigate residual attentional abilities associated with TBI during childhood, by examining a number of aspects of attention including sustained, focussed, and divided attention, attentional shift, and response inhibition. Eighteen children with a history of TBI, aged between 8 and 14 years and 18 non-injured matched controls participated in the study. Results show that attentional skills may be differentially impaired after TBI, with children who have sustained moderate-to-severe TBI exhibiting significant deficits on the following attentional domains: sustain, focus, and response inhibition. These findings support the view that attentional impairments following pediatric TBI, while not global, may be more generalized than those reported for adult samples, perhaps reflecting the relative immaturity of attentional skills at the time of injury.     

Impairments of Attention Following Childhood Traumatic Brain Injury

Attentional deficits are commonly reported following traumatic brain injury (TBI) in adults, although the occurrence of such problems is less well documented in young children. This study aimed to investigate residual attentional abilities associated with TBI during childhood, by examining a number of aspects of attention including sustained, focussed, and divided attention, attentional shift, and response inhibition. Eighteen children with a history of TBI, aged between 8 and 14 years and 18 non-injured matched controls participated in the study. Results show that attentional skills may be differentially impaired after TBI, with children who have sustained moderate-to-severe TBI exhibiting significant deficits on the following attentional domains: sustain, focus, and response inhibition. These findings support the view that attentional impairments following pediatric TBI, while not global, may be more generalized than those reported for adult samples, perhaps reflecting the relative immaturity of attentional skills at the time of injury.     

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.     

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.     

Theory of mind skills 1 year after traumatic brain injury in 6- to 8-year-old children

This study examined the longer-term effects of traumatic brain injury (TBI) on theory of mind (ToM) skills of children who were between the ages of 5 and 7 years at the time of injury. Fifty-two children with orthopaedic injury, 30 children with moderate TBI, and 12 children with severe TBI were evaluated approximately 1 year post-injury (mean age=6.98 years, SD=0.59, range=6.02–8.26). Children with severe TBI did not engage in representation of first- and second-order mental states at a developmental level comparable to their peers, suggesting stagnation or lack of development, as well as regression of putatively existing ToM skills. Age, task-specific cognitive demands, and verbal abilities were strong predictors of ToM performance. However, even after taking those factors into account, children with severe TBI had poorer ToM performance than children with orthopaedic injuries.     

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.     

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.     

Response inhibition in children with and without ADHD after traumatic brain injury

Children with attention‐deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) show deficient response inhibition. ADHD itself is a common consequence of TBI, known as secondary ADHD (S‐ADHD). Similarity in inhibitory control in children with TBI, S‐ADHD, and ADHD would implicate impaired frontal‐striatal systems; however, it is first necessary to delineate similarities and differences in inhibitory control in these conditions. We compared performance of children with ADHD and those with TBI without pre‐injury ADHD on a stop signal, response inhibition task. Participants were 274 children aged 6–14 years. There were 92 children with ADHD, 103 children with TBI, and 79 typically developing children who served as controls. Among the TBI participants, injury severity ranged from mild to severe. Children with ADHD and TBI showed deficient inhibition. The deficit in children with ADHD was as great as or greater than that in children with TBI, regardless of degree of TBI severity or the presence of S‐ADHD. The finding indicates that TBI results in deficient inhibition regardless of the development of S‐ADHD.     

Metamemory following childhood brain injury: A consequence of executive impairment

In this study, we investigated the influence of children’s level of executive functioning on two types of metamemory knowledge following a traumatic brain injury (TBI). For this purpose, 22 children (aged 7 to 14 years) who had sustained a moderate to severe TBI and 44 typically developing children were recruited. The children with TBI were divided into two groups according to the severity of their executive impairment. Injury severity was determined by the Glasgow Coma Scale (GCS) score on admission or by the duration of unconsciousness. All children were then tested on both their knowledge of general memory functioning and their level of memory self-awareness, respectively assessed using the total number of correct responses on an adapted version of a metamemory interview and a self-other discrepancy score on a questionnaire evaluating everyday memory abilities. Data analyses revealed that participants with TBI who suffered impaired executive functions demonstrated less general metamemory knowledge, and underestimated the frequency of their memory problems, compared with children with TBI who had preserved executive functions and with control participants. Considering the well-established effect of metamemory knowledge on people’s spontaneous implementation of strategies, the interest and the importance of these findings on both theoretical and clinical grounds 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.     

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.     

A Pilot Randomized Trial of an Online Parenting Skills Program for Pediatric Traumatic Brain Injury: Improvements in Parenting and Child Behavior

This pilot study examined changes in parenting skills and child behavior following participation in an online positive parenting skills program designed for young children with traumatic brain injury (TBI). Thirty-seven families with a child between 3 and 9 years of age who sustained a moderate to severe TBI were randomly assigned to one of two interventions: online parenting skills training (n = 20) or access to Internet resources on managing brain injury (n = 17). Parent–child interaction observations and parent ratings of child behavior were collected pre- and post-treatment. Generalized estimating equations and mixed models were used to examine changes in parenting skills and child behavior problems as well as the moderating role of family income on treatment response. Participants in the parenting skills group displayed significant improvements in observed positive parenting skills relative to participants in the Internet resource group. Income moderated improvements in parent ratings of child behavior, with participants in the low-income parenting skills group and high-income Internet resource group reporting the greatest improvements in behavior. This is the first randomized controlled trial examining online parenting skills training for families of young children with TBI. Improvements in positive parenting skills and child behavior support the utility of this intervention, particularly for families from lower socioeconomic backgrounds.