Measuring behavioural disturbances exhibited by children and adolescents in post-traumatic amnesia: Development of a scale.

Behavioural disturbances are often observed, but (to our knowledge) not systematically assessed, in children who are in post-traumatic amnesia (PTA) following traumatic brain injury (TBI). Therefore, we aimed to develop a prototype scale that measures the full range of behavioural disturbances exhibited by school-aged children in PTA. Quantitative and qualitative feedback was collected via online surveys. First, experts (n = 7) evaluated the relevance and developmental appropriateness of 37 behavioural items, extracted from the scoping literature review. Second, clinicians (n = 20) evaluated the preliminary scale for its suitability (acceptability, feasibility and usability). Analyses included descriptive statistics and qualitative analyses. First, experts eliminated nine items, adjusted the wording of three retained items and categorised 18 of the remaining 28 items into one of eight categories. Ten items were not consistently categorised. All experts highlighted that the scale needed to be short and easy to administer. Hence, categorised items were bundled, arriving at an 18-item preliminary scale. Second, clinicians deemed the preliminary scale highly suitable, easy to implement and addressing a gap in current clinical practice. The layout of the scale and wording of three items was modified according to qualitative feedback, arriving at an 18-item prototype. To our knowledge, this is the first scale designed to assess the full range of behavioural disturbances in children in PTA. The scale has the potential to systematically assess behaviour and streamline documentation of behavioural recovery in this population, inform management and rehabilitation, track responses to interventions and facilitate discussion with affected families.

Post-traumatic amnesia: a scoping review & content analysis of behavioral disturbances.

OBJECTIVE: The aim of this scoping review was to identify behavioral disturbances exhibited by patients in post-traumatic amnesia (PTA). While behavioral disturbances are common in PTA, research into their presentation and standardized measures for their assessment are limited. DESIGN: The study protocol was registered with PROSPERO (CRD42021268275). A scoping review of databases was performed according to pre-determined criteria on 29 July 2021 and updated on 13 July 2022. A conventional content analysis was used to examine and categorize behavioral disturbances. RESULTS: Thirty papers met the inclusion criteria, of which 27 reported observations and/or scores obtained on behavioral scales, and 3 on clinician interviews and surveys. None focused exclusively on children. Agitation was the most frequently assessed behavior, and Agitated Behavior Scale was the most used instrument. Content analysis, however, bore eight broad behavioral categories: disinhibition, agitation, aggression, lability, lethargy/low mood, perceptual disturbances/psychotic symptoms, personality change and sleep disturbances. CONCLUSION: Our study revealed that while standardized assessments of behavior of patients in PTA are often limited to agitation, clinical descriptions include a range of behavioral disturbances. Our study highlights a significant gap in the systematic assessment of a wide range of behavioral disturbances observed in PTA.

Predictive validity of the Westmead Post-Traumatic Amnesia Scale for functional outcomes in school-aged children who sustained traumatic brain injury.

The Westmead Post-Traumatic Amnesia Scale (WPTAS) is routinely used for the assessment of post-traumatic amnesia (PTA) in children who sustained traumatic brain injury (TBI). Yet, the WPTAS' predictive validity for functional outcomes is largely unknown. We aimed to determine whether PTA duration measured by the WPTAS (i) differentially predicts functional outcomes and (ii) contributes to predictions of outcomes beyond the Glasgow Coma Scale (GCS) in children who sustained TBI. Participants were children and adolescents with moderate-to-severe TBI (n = 55) aged 8-15 years. PTA duration was assessed with the WPTAS. Outcomes at the first outpatient follow-up were scored on the Kings Outcome Scale for Childhood Head Injury (KOSCHI) and the TBI Outcome Domain Scale-Extended (ODS-E). Longer PTA and lower GCS were both significantly correlated with worse (i) global outcomes: presence of disability on the KOSCHI and lower score on the ODS-E and (ii) select specific outcomes on the ODS-E: mobility, mood and cognition. PTA duration predicted cognitive outcome on the ODS-E independently, beyond GCS. Together, PTA duration and GCS, predicted the global KOSCHI outcome, as well as the ODS-E mobility and mood outcomes. Neither GCS nor PTA duration correlated with the ODS-E communication, impulsivity/disinhibition, headache, fatigue, sensory impairments or somatic complaints outcomes. PTA duration measured by the WPTAS is a significant unique predictor of functional cognitive outcomes in children who sustained moderate-to-severe TBI, and in combination with the GCS, a significant predictor of global, and several specific functional outcomes.

Convergent validity of the child behavior checklist sleep items in children with moderate to severe traumatic brain injury.

AIM: The Child Behavior Checklist (CBCL) includes several sleep items. We aimed to examine the convergent validity of CBCL sleep scores with validated sleep measures, and to explore their functional correlates. METHODS: This cross-sectional study included 44 children with moderate to severe TBI, aged 6-15 years. Parents completed the CBCL and Sleep Disturbance Scale for Children (SDSC), and children wore actigraphy watches. RESULTS: We found significant, albeit differential, associations between CBCL and SDSC sleep scores. Specifically: (i) "trouble sleeping" with SDSC total score, (ii) "trouble sleeping" and "nightmares" with SDSC initiating and maintaining sleep, (iii) "talks/walks in sleep" with SDSC arousal, and (iv) "overtired," "sleeps more" and CBCL sleep composite with SDSC excessive somnolence. The CBCL item "sleeps less" was the only significant predictor of functioning; children who slept less had lower social competence. No associations were found between CBCL sleep scores and actigraphy. CONCLUSIONS: The CBCL does not provide a comprehensive assessment of sleep disturbances in children with moderate to severe TBI. Nevertheless, certain CBCL sleep items demonstrate initial convergent validity with subscales of the SDSC assessing select types of sleep disturbances. The CBCL may be useful in research and clinical situations when administration of more comprehensive assessment sleep tools is not viable.

Physical performance of children with longitudinal fibular deficiency (fibular hemimelia).

PURPOSE: Longitudinal fibular deficiency (LFD) is the most common congenital long bone deficiency. This study aimed to objectively assess the physical performance of children and adolescents with LFD compared with unaffected peers, and to examine trends over age for subgroups of the LFD population. METHODS: Differences between children with LFD and unaffected peers were examined with hand-held dynamometry for lower-limb muscle strength, Six-Minute Walk Test, Timed up and down stairs test, Star Excursion Balance Test, and Standing long jump. RESULTS: Thirty-nine children with LFD and 284 unaffected peers participated. Children with LFD performed at a lower level than their unaffected peers, on all measures of physical performance (mean 2.1 z-scores lower, all p < 0.01), except in long jump (p = 0.27). When comparing the performance of children with LFD to their unaffected peers across four age groups, there was a significant between-groups difference on all strength measures, and on the Six-Minute Walk distance, between children with and without LFD. These differences were smallest in young children (3-6 years) and largest in the older children (15-18 years) (all p < 0.01). Children with no lengthening surgery performed better on the Six-Minute Walk Test, covering a greater distance during the test, than those who had surgery (mean difference 83 metres, p < 0.01). There were no significant differences between children who had or had not undergone an amputation. CONCLUSIONS: Children with LFD performed at a significantly lower level than unaffected peers on all measures of physical performance other than jumping. The largest differences were in older children. This paper provides baseline functional data for future interventions in LFD. LEVEL OF EVIDENCE: Cross-sectional study.Implications for RehabilitationThis paper provides the first baseline functional data using validated objective measures on a consecutive cohort of children and adolescents with longitudinal fibular deficiency.Children with LFD performed significantly worse than their unaffected peers on all measures of physical performance other than jumping, with children falling further behind their peers as they age.Children who undergo an amputation typically have the most severe anatomical presentation and yet perform at an equivalent functional level.This paper identifies multiple modifiable impairments that represent potential opportunities for rehabilitation professionals to target with conservative treatment options to improve functional performance.

Chemosensory Loss during a Traumatic Brain Injury Suggests a Central Pathway for the Rehabilitation of Anosmia.

Currently, no method has been developed for rehabilitating olfaction in anosmic patients following a traumatic brain injury (TBI). Here a method for rehabilitation is described which is based on a recent finding that the human posterior pyriform cortex (PPC) generates predictive odor "search images" in advance of an encounter with an olfactory stimulus. The search image enhances perceptual sensitivity and allows the odor it represents to be identified without input occurring from the olfactory receptors or bulbs. Furthermore, based on the finding here that anosmics with a TBI often have normal trigeminal and gustatory function, it is proposed that normality in these chemosensory systems may indicate that key cortical regions including the PPC are intact in anosmics and capable of processing olfactory information. In addition, the results of chemosensory tests of the olfactory, gustatory, and intranasal trigeminal systems of 18 patients with a TBI are given that identify which patients would most likely benefit from the rehabilitation procedure.

The persistence of sleep disturbance and its correlates in children with moderate to severe traumatic brain injury: A longitudinal study.

OBJECTIVES: The primary aim was to examine whether sleep disturbances persist in children in the chronic stage of recovery from moderate or severe traumatic brain injury (TBI). The secondary aim was to examine whether memory difficulties and/or other previously identified factors relate to sleep disturbances in children with moderate to severe TBI. METHODS: This longitudinal study included 21 children with moderate to severe TBI, 8-18 years old, recruited from an urban tertiary paediatric specialised brain injury rehabilitation unit. Participants were seen 5 years and again 7 years post-injury, on average. Sleep disturbances were assessed with Sleep Disturbance Scale for Children (SDSC). Correlates that were considered included indicators of TBI severity, and questionnaires assessing everyday memory, fatigue, internalizing and externalizing behaviors and pain intensity. RESULTS: The SDSC scores of children with moderate to severe TBI indicated greater disturbances in initiating and maintaining sleep, arousal, sleep-wake transition, and excessive somnolence relative to the norms, at follow-up. The mean SDSC scores and the number of participants with subclinical to clinical sleep disturbances on the SDSC remained unchanged from baseline to follow-up. At follow-up, the SDSC initiating and maintaining sleep, and excessive somnolence scales were associated with poorer everyday memory and greater fatigue. CONCLUSIONS: Children with moderate to severe TBI experience ongoing sleep disturbances for years post-injury. Greater sleep disturbances are associated with worse functional outcomes. Further research into sleep disturbances and development of treatments is important, as it could improve the outcomes of children with TBI.

Children who sustained traumatic brain injury take longer to fall asleep compared to children who sustained orthopedic injuries: actigraphy findings.

Objective:Primary: to examine objective sleep outcomes in children who sustained moderate to severe traumatic brain injury (TBI). Secondary: to examine the relation of objective sleep with subjective sleep, fatigue, and injury variables.Setting: A single tertiary brain injury unit.Participants: Children (5-15 years) with moderate to severe TBI (n = 23) or orthopedic injury (OI; n = 13).Design: Cohort study.Measures: Primary: objective sleep measure (actigraphy watch). Secondary: subjective sleep measure (questionnaire), fatigue questionnaire, and injury variables.Results: On actigraphy, children with TBI had longer sleep onset latency compared to children with OI. On the sleep questionnaire, children with TBI obtained higher scores for total sleep disturbance, initiating and maintaining sleep, and excessive somnolence. On the fatigue questionnaire, greater difficulties were found for total, sleep/rest, and cognitive fatigue for the TBI group. In the TBI group, actigraphy data did not correlate with sleep questionnaire, fatigue, or injury variables.Conclusion: Our study showed evidence of objective and subjective sleep disturbance in children with moderate to severe TBI, but these two types of sleep measures were not related. It is possible that distinct mechanisms underpin objective and subjective sleep disturbance, which may require different interventions.

A feasibility and acceptability study of cognitive behavioural treatment for insomnia in adolescents with traumatic brain injury: A-B with follow up design, randomized baseline, and replication across participants.

Difficulties falling asleep or staying asleep (symptoms of insomnia) are common following paediatric traumatic brain injury (TBI). Yet, interventions to treat insomnia in this population have not yet been reported. This single-case series examined the feasibility and acceptability of cognitive behavioral treatment for insomnia (CBT-I) for adolescents (n = 5, aged 11-13 years) with TBI, and explored changes in sleep and fatigue post-treatment. Adolescents were randomly assigned to two conditions: a 7- or 14-days baseline, followed by 4 weeks of manualised CBT-I delivered individually. To assess feasibility and acceptability we compared recruitment and retention rates, and questionnaire scores to a-priori set criteria. We explored treatment efficacy and functional gains in sleep and fatigue from baseline to follow-up using structured visual analysis of time-series graphs, and reliable change indices or changes in clinical classification. Feasibility and acceptability indicators met a-priori criteria, but therapists noticed limited adolescent engagement in sessions. Clinically significant improvements were found in sleep, in 3 out of 4 cases, and fatigue, in all cases. Our study provides preliminary evidence that CBT-I is feasible for insomnia treatment in adolescents with TBI and provides directions for development of future treatment studies.

Fatigue in Children With Moderate or Severe Traumatic Brain Injury Compared With Children With Orthopedic Injury: Characteristics and Associated Factors.

OBJECTIVE: To characterize fatigue in children with moderate or severe traumatic brain injury (TBI) and to identify associated factors. SETTING: Urban tertiary pediatric healthcare facility. PARTICIPANTS: Children aged 5 to 15 years with a moderate TBI (n = 21), severe TBI (n = 23), or an orthopedic injury (OI; n = 38). DESIGN: Case-control study. MAIN MEASURES: (i) Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (PedsQL-MFS), completed by parents and children; (ii) Sleep Disturbance Scale for Children, completed by parents. Data on injury-specific factors and other factors of interest were also collected. RESULTS: The 2 TBI groups did not differ on any of the fatigue outcomes (child or parent ratings). Relative to the OI group, parents rated children in both TBI groups as experiencing greater fatigue. However, on self-ratings, only children with moderate TBI endorsed greater fatigue. Sleep was commonly associated with fatigue, with child sleep disturbance and child sleep hygiene associated with parent-rated and self-rated child fatigue, respectively. Individually, there were no cases of "normal" fatigue coinciding with severe sleep disturbance. However, there were several cases of severe fatigue coinciding with normal sleep. Additional factors associated with fatigue were older age at injury, longer time since injury, and/or greater internalizing difficulties. CONCLUSION: Children with moderate and severe TBI experience greater fatigue than OI controls. Parent and child ratings of fatigue appear to be associated with different factors, indicating that fatigue management may require a broad range of treatments.

Opiate analgesics and testing of post traumatic amnesia in school-aged children.

OBJECTIVE: To assess the validity of the Westmead PTA scale in school-aged children treated with opiate analgesics. METHOD: Twenty-eight hospitalized children without brain injury, aged between 8 and 16 years treated with opiate analgesics for pain relief following surgery were tested on the Westmead PTA scale. Pain and stress levels were also self-reported each day. RESULTS: Only 29% (n = 7) of children assessed over four days obtained a maximum score of 12/12 on three consecutive days, thus 71% would have been deemed to have been in PTA when they were not. The percentage of children who obtained a maximum score significantly decreased over consecutive days of assessment, due to an increase in error rate on picture memory items. Self-reported pain and stress ratings were not correlated with PTA scores. CONCLUSIONS: Opiate analgesia can disrupt performance on the Westmead PTA scale in school-aged children resulting in a high false-positive error rate. It is therefore important to record pain medication schedules and interpret results cautiously when opiate analgesia is used following a TBI. Alteration of the method of administration of the memory items should be researched as this may increase the validity of the scale for children with TBI treated with opiate analgesics.

Longitudinal Fibular Deficiency: A Cross-Sectional Study Comparing Lower Limb Function of Children and Young People with That of Unaffected Peers.

Longitudinal fibular deficiency (LFD), or fibular hemimelia, is congenital partial or complete absence of the fibula. We aimed to compare the lower limb function of children and young people with LFD to that of unaffected peers. A cross-sectional study of Australian children and young people with LFD, and of unaffected peers, was undertaken. Twenty-three (12 males) children and young people with LFD (74% of those eligible) and 213 unaffected peers, all aged 7⁻21 years were subject to the Knee Osteoarthritis Outcome Score (KOOS/KOOS-Child) and the Cumberland Ankle Instability Tool (CAIT/CAIT-Youth). Linear regression models compared affected children and young people to unaffected peers. Participants with LFD scored lower in both outcomes (adjusted p < 0.05). The difference between participants with LFD and unaffected peers was significantly greater among younger participants than older participants for KOOS activities and sports domain scores (adjusted p ≤ 0.01). Differences in the other KOOS domains (pain/symptoms/quality of life) and ankle function (CAIT scores) were not affected by age (adjusted p ≥ 0.08). Children and young people with LFD on average report reduced lower limb function compared to unaffected peers. Knee-related activities and sports domains appear to be worse in younger children with LFD, and scores in these domains become closer to those of unaffected peers as they become older.

Selective, age-related autobiographical memory deficits in children with severe traumatic brain injury.

OBJECTIVES: Autobiographical memory (AM) is a complex function that involves re-experiencing of past personal events (episodic memory) scaffolded by personal facts (semantic memory). While AM is supported by a brain network and cognitive skills that are vulnerable to disruption by child traumatic brain injury (TBI), AM has not been examined in this patient population. DESIGN: Cross-sectional study. METHODS: Participants included children with severe closed TBI (n = 14) and healthy control (NC) children (n = 20) of comparable age, sex, and socioeconomic status. Participants completed (1) the Child Autobiographical Interview (Willoughby et al., 2012, Front. Psychol., 3, 53), which required recall of autobiographical events and distinguished episodic (internal) from non-episodic (external) details, and self-rating of event phenomenological qualities, and (2) a battery of neuropsychological tests. RESULTS: Children with TBI recalled significantly fewer internal details relative to NCs, but the between-group difference was eliminated when specific probes were provided. The groups did not differ in either recall of external details or in ratings of events' phenomenological qualities. The gap between the groups in recall of internal details increased with age, as the greater number of internal details was associated with older age in the NC group, but not in the TBI group. Poorer verbal memory and lower IQ were related to recall of fewer internal details in the TBI group. CONCLUSIONS: This study unveils, to our knowledge for the first time, that severe child TBI is associated with a selective deficit in autobiographical memory that involves episodic, but spares semantic details, and identifies the risk factors for this impairment.

Sleep Disturbance in Children With Moderate or Severe Traumatic Brain Injury Compared With Children With Orthopedic Injury.

OBJECTIVES: To characterize the sleep disturbance in children with moderate or severe traumatic brain injury (TBI), and to identify associated factors. SETTING: An urban tertiary pediatric healthcare facility. PARTICIPANTS: Children aged 5 to 15 years with a moderate TBI (n = 21), severe TBI (n = 23), or an orthopedic injury (OI; n =38) comparable in age, gender, and socioeconomic status. DESIGN: Cohort study. MEASURES: Primary: Sleep Disturbance Scale for Children (SDSC). Secondary: Injury-specific factors (TBI severity, age at injury, and time since injury), and other factors of interest (sleep hygiene; pain intensity; difficulties with internalizing, externalizing, or attention/hyperactivity; parental distress; and parental knowledge of TBI). RESULTS: On the SDSC, parents rated children with moderate TBI (but not severe TBI) as experiencing greater overall sleep disturbance, as well as excessive somnolence and sleep breathing disturbance, relative to OI controls. Children with severe TBI (but not moderate TBI) were rated as experiencing greater disturbance with initiating and maintaining sleep. The moderate and severe TBI groups did not differ on any of the sleep outcomes. Only 3 factors were associated with sleep disturbance in the combined TBI group: (1) lower TBI severity with greater excessive somnolence; (2) greater internalizing difficulties with greater overall sleep disturbance, and disturbance with initiating and maintaining sleep specifically; and (3) younger age at injury with greater overall sleep disturbance, and sleep breathing disturbance specifically. CONCLUSION: Children with moderate or severe TBI experience greater overall and/or specific forms of sleep disturbance. Different forms of sleep disturbance may be associated with different factors.

Preliminary validation study of the Sydney Post-Traumatic Amnesia Scale (SYPTAS) in children with traumatic brain injury aged 4 to 7 years.

The aim of this study was to assess the validity (developmental, concurrent, and predictive) of the Sydney Post-Traumatic Amnesia Scale (SYPTAS) for assessment of post-traumatic amnesia (PTA) in 4 to 7 year old children with traumatic brain injury (TBI). The design of this study is a retrospective cohort study. The SYPTAS was administered to 35 children (26 boys) aged 4.0 to 7.8 years who were consecutively admitted to a children's hospital with mild (n = 26), moderate (n = 3), or severe (n = 7) TBI. Concurrent validity of the SYPTAS was assessed against the Glasgow Coma Scale Scores (GCS). Predictive validity of the SYPTAS for functional outcomes was evaluated against the King's Outcome Scale for Childhood Head Injury (KOSCHI) at discharge and outpatient follow-ups. The length of PTA, measured by the SYPTAS, was invariant of children's chronological age, confirming the scale's developmental validity. Longer PTA was associated with lower GCS, endorsing concurrent validity of PTA duration measured by the SYPTAS, as a clinical indicator of TBI severity. PTA duration measured by the SYPTAS was a significant predictor of functional outcomes on the KOSCHI at discharge and follow-ups. This study provides evidence that the SYPTAS has good developmental, concurrent and predictive validity for assessment of PTA in children aged 4 to 7 years. PTA duration assessed by the SYPTAS is a clinical indicator of TBI severity and can aid rehabilitation planning post TBI.

Time-based prospective memory in children and adolescents with traumatic brain injury: Impact of working memory demands.

OBJECTIVE: Difficulties with prospective memory are frequently reported following pediatric traumatic brain injury (TBI), but rarely researched. We aimed to (i) investigate time-based prospective memory post-pediatric TBI; (ii) examine whether time-based prospective memory is differentially impacted by the demand placed on working memory; and (iii) explore which components of working memory (viz., central executive, phonological loop, and visuospatial sketchpad) are involved in time-based prospective memory under low and high cognitive load following pediatric TBI. METHOD: Thirty-nine children and adolescents (20 survivors of moderate-severe TBI and 19 healthy controls) completed (i) a newly developed time-based prospective memory task (TBPMT), embedded in an ongoing lexical-decision task, with two conditions: low and high working memory load; and (ii) tests of working memory components from the Automated Working Memory Assessment. RESULTS: Compared to controls, participants with TBI had significantly lower prospective memory accuracy on the TBPMT across working memory loads (low, high). In contrast, the groups did not differ in time monitoring or accuracy on the ongoing task. In the TBI group, higher scores on tests of the central executive (but not phonological loop or visuospatial sketchpad) were associated with higher prospective memory accuracy and time monitoring (controlling for age). CONCLUSIONS: Time-based prospective memory is impaired following moderate-severe pediatric TBI, irrespective of the level of working memory demand. Our findings suggest that children and adolescents with TBI may be at risk of failing to perform future intentions at the right time in daily life, especially for individuals identified as having deficits in central executive functioning. (PsycINFO Database Record

Imagining the Future in Children with Severe Traumatic Brain Injury.

Imagining future events is thought to rely on recombination and integration of past episodic memory traces into future events. Future and past events contain episodic and nonepisodic details. Children with severe traumatic brain injury (TBI) were found to have impaired recall of past episodic (but not semantic) event details. Here, we examined whether severe TBI impairs construction of future events. Children with severe TBI (n = 15) and healthy controls (NC; n = 33) 1) completed tests of anterograde (narrative and relational) memory and executive skills, 2) recalled past events and generated future events, and 3) rated events' phenomenological qualities. Events were scored for episodic (internal) and semantic (external) details. The groups did not differ in generating details of future events, although children with TBI recalled significantly fewer past internal (but not external) events' details relative to NCs. Moreover, the number of past internal details relative to future internal details was significantly higher in the NC group, but not in the TBI groups. Significant correlations between past and future were found for 1) internal details in both groups and 2) external details in the NC group. The TBI group rated their events as being less significant than did the NC group. The groups did not differ on ratings of visual intensity and rehearsal. Our study has shown that children who have sustained severe TBI had impoverished recall of past, but not generation of future, events. This unexpected dissociation between past and future event construction requires further research.

PTA scale for children aged 4 to 7 years: Selecting developmentally valid and reliable items.

The aim of this study was to select developmentally valid and reliable items for inclusion in criterion-referenced (pass > 90%) posttraumatic amnesia (PTA) scale for children aged 4 to 7 years in a prospective cohort study. Fifty-two typically developing children (26 male/26 female) aged 4 to 7 years were administered a set of 10 items (5 orientation, 5 memory) over 3-4 days. The total score obtained on the set of 10 items had poor developmental validity and test-retest reliability. Nevertheless, individual item analysis identified five items (three orientation and two memory items) that were consistently passed by >90% of the children on each day of testing. For these five items the total scores did not differ significantly either between age groups or between days of testing. Test-retest was extremely high (close to 1). The five items had excellent developmental validity and test-retest reliability. This study identified 5 (3 orientation and 2 memory) items that met our selection criterion and form a new PTA scale, the Sydney PTA scale (SYPTAS), for children aged 4 to 7 years.

Accelerated Long-Term Forgetting Is Not Epilepsy Specific: Evidence from Childhood Traumatic Brain Injury.

Accelerated long-term forgetting (ALF) is characterized by adequate recall after short, but not long delays. ALF is not detected by standardized neuropsychological memory tests. Currently, the prevailing conceptualization of ALF is of a temporal lobe seizure-related phenomenon. Nevertheless, Mayes and colleagues (2003) proposed that ALF may occur when any of the components of the brain network involved in long-term memory formation, or their interaction, is disrupted. This disruption does not have to be caused by temporal lobe seizures for ALF to occur. Here, we investigate this possibility in a group of school-age children who have sustained traumatic brain injury (TBI) (n = 28), as TBI typically disrupts the brain network that is important for long-term memory formation and recall. Healthy control children (n = 62) also participated. Contrary to the dominant conceptualization of ALF being a seizure-related phenomenon, children with TBI showed ALF. Sustaining a severe TBI and diffuse subcortical damage was related to ALF. Individually, 8 of the 13 children with severe TBI presented with ALF. ALF would remain undetected on standardized testing in six of these eight children. One child had the opposite pattern of dissociation, an impaired score on standardized testing, but an average long-term memory score. This is the first study, to our knowledge, to show ALF in patients with TBI, which has remained undiagnosed and untreated in this patient population. Our study also challenges the dominant hypothesis of ALF being a temporal lobe seizure-related phenomenon, and raises a possibility that short-term and long-term memory systems may be independent.

A series of n-of-1 trials of stimulants in brain injured children.

BACKGROUND: There is controversy about whether central nervous system stimulant (CNS) medication is an effective method of treating acquired attention deficits in children with acquired brain injury (ABI). OBJECTIVE: The primary objective was to determine the effectiveness of stimulants on attention, concentration and executive function in children with ABI. METHODS: Randomised, double-blind, placebo-controlled, multi-centre n-of-1 trials of stimulants assessing effect on attention, concentration and executive function in 53 children and adolescents with ABI who were outpatients of three tertiary hospitals in Australia. Trials consisted of 3 two-week cycles, each cycle consisting of stimulant medication at doses titrated by physician (1 week) and placebo (1 week) in random order. The effect on parent and teacher Conners' 3 and Behaviour Rating Inventory of Executive Function (BRIEF) was analysed using hierarchical Bayesian methods. RESULTS: Overall, Teacher Conners' Hyperactivity/Impulsivity and Teacher BRIEF Global Executive scales showed important improvement (T-score mean change 2.6; 95% credible interval (CI): 0.4, 4.9; posterior probability of mean change >0 : 0.99; T-score mean change 3.1; 95% CI: -0.1, 6.4; posterior probability of mean change >0 : 0.97). There were no important improvements in parent/guardian-reported primary outcomes. There was heterogeneity in response identified through individual results of the N-of-1 trials. CONCLUSIONS: N-of-1 trials have a clear role in identifying those children/adolescents with ABI and secondary Attention Deficit Hyperactivity Disorder (ADHD) who have important improvements, or worsening on stimulants. The results can only be generalized to children/adolescents who have an apparent pre-trial clinical effect from stimulants.