Searching for effective components of cognitive rehabilitation for children and adolescents with acquired brain injury: A systematic review.

AIM: Cognitive rehabilitation is of interest after paediatric acquired brain injury (ABI). The present systematic review examined studies investigating cognitive rehabilitation interventions for children with ABI, while focusing on identifying effective components. Components were categorized as (1) metacognition and/or strategy use, (2) (computerized) drill-based exercises, and (3) external aids. METHODS: The databases PubMed (including MEDLINE), PsycInfo, and CINAHL were searched until 22nd June 2017. Additionally, studies were identified through cross-referencing and by consulting experts in the field. RESULTS: A total of 20 articles describing 19 studies were included. Metacognition/strategy use trainings (five studies) mainly improved psychosocial functioning. Drill-based interventions (six studies) improved performance on tasks similar to training tasks. Interventions combining these two components (six studies) benefited cognitive and psychosocial functioning. External aids (two studies) improved everyday memory. No studies combined external aids with drill-based interventions or all three components. CONCLUSION: Available evidence suggests that multi-component rehabilitation, e.g. combining metacognition/strategy use and drill-based training is most promising, as it can lead to improvements in both cognitive and psychosocial functioning of children with ABI. Intervention setting and duration may play a role. Conclusions remain tentative due to small sample sizes of included studies heterogeneity regarding outcome measures, intervention and therapist variables, and patient characteristics.

Parent and teacher perceptions of emerging special health care needs.

AIM: A fifth of children enter school with special health care needs (SHCN) impacting on their physical, psychosocial or educational development, including many with emerging SHCN who often do not qualify for additional supports. This study aimed to compare the perceptions of parents and teachers on children's emerging SHCN, and explore correlates of conflicting reports. METHODS: The Longitudinal Study of Australian Children (LSAC) is a nationally representative study of Australian children, which includes the abbreviated Children with Special Health Care Needs Screener. Data were analysed from a subsample of n = 720 children from the LSAC Kindergarten cohort (n = 4983) for whom teachers also completed the Australian Early Development Index checklist, a measure of early childhood development that includes teacher reported SHCN. RESULTS: Teachers (n = 120, 17.34%) identified more emerging SHCN than parents (n = 74, 10.74%), and reports were often discrepant. Children were more likely to have consistent reports of emerging SHCN when their parents had high levels of involvement at school (OR 4.86; 95% CI 1.08-21.80; P < 0.05), whereas children who came from disadvantaged family backgrounds were more likely to have teacher-only identified difficulties (OR 3.66; 95% CI 1.17-11.50; P < 0.05). CONCLUSION: Parents and teachers bring different perspectives to children's development and additional support needs, each of which is valuable. Greater attention should be given to ensuring that common understandings about a child's needs at school are established early in children's educational pathways.

Prevalence and predictors of externalizing behavior in young adult survivors of pediatric traumatic brain injury.

OBJECTIVES: To investigate rates of clinically significant externalizing behavior (EB) in young adult survivors of pediatric traumatic brain injury (TBI) and evaluate the contribution of pre- and postinjury risk and resilience factors to EB outcomes 16 years after injury. SETTING: Melbourne, Australia. PARTICIPANTS: Fifty-five young adults (mean age = 23.85 years; injury age: 1.0-12 years) admitted to an emergency department following TBI between 1993 and 1997. DESIGN: Longitudinal prospective study with data collected at the acute, 10-year, and 16-year postinjury time points. MAIN MEASURES: Severity of TBI, adaptive functioning, family functioning, full-scale IQ, executive functioning, social communication, and symptoms of EB. RESULTS: One of every 4 young people with a history of pediatric TBI demonstrated clinical or subthreshold levels of EB in young adulthood. More frequent EB was associated with poorer preinjury adaptive functioning, lower full-scale IQ, and more frequent pragmatic communication difficulty. CONCLUSION: Pediatric TBI is associated with an elevated risk for externalizing disorders in the transition to adulthood. Results underscore the need for screening and assessment of TBI among young offenders and suggest that early and long-term targeted interventions may be required to address risk factors for EB in children and young people with TBI.

Evaluation of an attention and memory intervention post-childhood acquired brain injury: Preliminary efficacy, immediate and 6 months post-intervention.

OBJECTIVE: Impairments in attention and memory are common sequelae following paediatric acquired brain injury (ABI). While it has been established that such impairments are long-term and, therefore, affect quality-of-life, there is a scarcity of evidence-based interventions to treat these difficulties. The current study aimed to pilot the efficacy of the Amsterdam Memory and Attention Training for Children (Amat-c: English version) using both neuropsychological and ecologically sensitive measures. It was expected that children with attention and memory difficulties post-ABI would show improved performance post-intervention on cognitive and ecological measures, with maintenance at 6 months post-intervention. METHODS AND PROCEDURES: Ten children with an ABI, between the ages of 8-13 years at the time of recruitment were identified through audits of presentations to a metropolitan paediatric hospital. Each child underwent screening, the 18 week intervention programme, pre-intervention, immediate and 6 month post-intervention assessments. OUTCOMES/RESULTS: Findings supported the hypothesis that children would show post-intervention (immediate and 6 month) improvement in areas of attention and memory, with generalization to everyday life. CONCLUSIONS/IMPLICATIONS: Preliminary results provide support for the efficacy of the Amat-c post-childhood ABI. A larger study is needed to confirm these findings, as a reduction in attention and memory difficulties will enhance everyday functioning.

Preliminary efficacy of an attention and memory intervention post-childhood brain injury.

OBJECTIVE: Impairments in attention and memory are common consequences following paediatric acquired brain injury (ABI). Despite this, there is a scarcity of evidence-based interventions for these difficulties. The current study aimed to pilot the feasibility and efficacy of the English version of the Amsterdam Memory and Attention Test for Children (Amat-c) and to identify ecologically valid measures sensitive to post-evaluation improvements. It was expected that children with attention and memory difficulties post-TBI would show improved performance post-intervention on traditional cognitive measures and on measures of everyday performance. METHODS AND PROCEDURES: Three children (case study design) with an acquired brain injury (near drowning, birth delivery complications, fall from a horse) and currently between the ages of 8-13 were identified through audits of presentations to a metropolitan paediatric hospital. Each child underwent screening, pre-intervention and post-intervention assessments (immediate and 6 months). OUTCOMES/RESULTS: Results indicated improved performance in the areas of attention and memory from pre- to post-intervention, with gains maintained at 6 months post-intervention. CONCLUSIONS AND IMPLICATIONS: Findings demonstrate initial support for efficacy of the Amat-c and its use with survivors of child ABI to alleviate common cognitive and functional consequences. A larger study is needed to further confirm these findings.

Who is @ease? Visitors' characteristics and working method of professionally supported peer-to-peer youth walk-in centres, anonymous and free of charge.

AIM: Although mental disorders often emerge early in life, only a minority of young people receive timely and appropriate mental health care. A worldwide youth mental health movement aims to prevent development and persistence of psychiatric disorders. As part of this movement, the first four @ease centres were opened in the Netherlands. @ease is a youth driven, professionally supported initiative, providing peer-to-peer counselling, anonymous and free of charge, for people aged 12-25. METHODS: Data consist of a detailed description of the working method of @ease, combined with characteristics of all young people accessing the services between its inception (January 2018) and July 2020. RESULTS: Young-adult peers, including experts by experience, served as counsellors after training in listening, motivational interviewing and solution-focused strategies. They were supervised by a diverse group of healthcare professionals. A total of 291 visitors, aged 21 on average, were satisfied to very satisfied with @ease's services. Psychosocial distress, social functioning and quality of life measures at first visit showed moderate to severe levels of impairment, and almost half of all visitors reported skipping classes. One third reported parental mental illness, 28% suicidal ideations, and 11% had made specific plans. Less than a third of visitors had received mental health care in the 3 months prior to their visit. CONCLUSION: This study showed the need for and feasibility of a youth driven, professionally supported organization offering peer-to-peer counselling in the Netherlands. Its flexible and individualized working method enables @ease to normalize problems when possible and intervene when necessary.

Barriers and facilitators on the pathway to mental health care among 12-25 year olds.

PURPOSE: The mismatch between the number of young people that require mental health care and who actually receive it, questions access to care. This study aims to gain in-depth understanding of barriers and facilitators in the pathway to mental health care among 12 to 25 year olds as experienced by visitors of youth walk-in centres of the Dutch @ease Foundation. METHODS: Open interviews were conducted to explore participants' experiences and attitudes towards mental health care. Following inductive thematic analysis, barriers and facilitators in participants' pathways towards care were described. RESULTS: Fifteen participants were included, heterogenic with regard to age, sex and nationality. Three main themes in the process of seeking help were 'attitudes towards mental health problems and seeking help', 'entrance to care' and 'in care itself'. A fourth theme consisted of suggestions for improvement. CONCLUSION: Negative attitudes towards mental health problems make young people to only seek help when problems begin to escalate. The lack of knowledge about mental health problems, treatment options and costs asks for more awareness and clear information. Updates about waiting lists and alternative options, informal settings with walk-in options and personalized care are feasible and crucial improvements to decrease the individual and societal burden.

Participation Restrictions among Children and Young Adults with Acquired Brain Injury in a Pediatric Outpatient Rehabilitation Cohort: The Patients' and Parents' Perspective.

Improving participation is an important aim in outpatient rehabilitation treatment. Knowledge regarding participation restrictions in children and young adults with acquired brain injury (ABI) is scarce and little is known regarding the differences in perspectives between patients and parents in the outpatient rehabilitation setting. The aims are to describe participation restrictions among children/young adults (5-24 years) with ABI and investigating differences between patients' and parents' perspectives. At admission in 10 rehabilitation centers, patients and parents were asked to complete the Child and Adolescent Scale of Participation (CASP; score 0-100; lower score = more restrictions) and injury/patient/family-related questions. CASP scores were categorized (full/somewhat-limited/limited/very-limited participation). Patient/parent-reported outcomes were compared using the Wilcoxon signed-rank test. 223 patients and 245 parents participated (209 paired-samples). Median patients' age was 14 years (IQR; 11-16), 135 were female (52%), 195 had traumatic brain injury (75%). The median CASP score reported by patients was 82.5 (IQR: 67.5-90) and by parents 91.3 (IQR: 80.0-97.5) (difference = p < 0.05). The score of 58 patients (26%) and 25 parents (10%) was classified as 'very-limited'. Twenty-six percent of children and young adults referred for rehabilitation after ABI had "very-limited" participation. Overall, parents rated their child's participation better than patients themselves. Quantifying participation restrictions after ABI and considering both perspectives is important for outpatient rehabilitation treatment.

Special Health Care Needs Across the School and Family Contexts: Implications for Service Utilization.

OBJECTIVE: A fifth of children enter school with special health care needs (SHCN), many of whom have difficulties that are milder or not yet formally diagnosed (emerging SHCN). This study aimed to investigate how differing perceptions of children's emerging SHCN across the family and school contexts relates to service utilization. METHODS: Sample: The nationally representative birth cohort of the Longitudinal Study of Australian Children, which includes parent reports on the abbreviated Children with Special Health Care Needs Screener. For a subsample of 2459 children teachers also completed the Australian Early Development Census, a measure of early childhood development at school entry that includes SHCN. ANALYSIS: Logistic regression analyses were conducted adjusting for severity of condition, gender, language background, and disadvantage. RESULTS: Overall 24.1% of children were identified by their parent and/or teacher as experiencing emerging SHCN. Compared with those with consistent reports, children with parent-only identified needs had lower odds of accessing school services (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.10-0.81). Similarly, children with parent-only (OR, 0.39; 95% CI, 0.20-0.75) and teacher-only (OR, 0.25; 95% CI, 0.14-0.46) identified needs had significantly lower odds of accessing services in the community. CONCLUSIONS: When parent and teacher perceptions of children's emerging SHCN were inconsistent, service use was lower at school and in the community. Further efforts are needed by health and education providers to ensure that common understandings about a child's needs at school are established early in children's educational careers.

The Trajectory of Long-Term Psychosocial Development 16 Years following Childhood Traumatic Brain Injury.

Childhood traumatic brain injury (CTBI) is one of the most common causes of impairment in children and adolescents, with psychosocial difficulties found to be the most persisting. Given that the transition into adolescence and adulthood can be a stressful period, it is likely that young people who have sustained a CTBI will be more vulnerable to developing psychosocial problems. To date, most research has focused on psychosocial development up to five years following a CTBI and it is unclear how survivors develop in the long-term as young adults. The aim of this research was to track the long-term psychosocial outcomes of children with CTBI and compare them with healthy controls over a period of 16 years. Seventy-five participants with a CTBI and 29 control participants were followed up at five time-points over a period of 16 years. To measure psychosocial functioning (social skills, internalizing, and externalizing symptoms), questionnaires were completed by the primary caregiver acutely (pre-injury baseline), then six months, five years, 10 years, and 16 years post-injury. No significant group differences were found regarding the developmental trajectory of social skills, or internalizing and externalizing symptoms between the CTBI and control groups. The severe CTBI group demonstrated a trend of lower social skills, while the mild CTBI group showed a trend of higher internalizing and externalizing skills at six months, five years, and ten years post-CTBI event, compared with other groups. The mild CTBI group scored in the borderline range for externalizing symptoms six months post-CTBI; however, all other mean scores were within the normal range. Over a period of 16 years, young adults with CTBI showed similar developmental trajectories regarding psychosocial outcomes, compared with healthy controls. This study confirmed previous literature that CTBI is associated with increased levels of psychosocial problems.

Agreement on and predictors of long-term psychosocial development 16 years post-childhood traumatic brain injury.

Childhood traumatic brain injury (CTBI) is one of the most common causes of childhood mortality and morbidity, with psychosocial impairment being among the most debilitating persisting consequences. Child and adolescent survivors of CTBI have fewer friends and lower self-esteem with a higher risk of developing a psychiatric disorder. In most research to date, findings in the psychosocial domain have been based on parent reports, with the child or adolescent only consulted infrequently. If there is a discrepancy identified between parent and child reported symptoms and behaviors, this is generally interpreted as resulting from impaired self-awareness in the child. The aim of this study was to 1) examine the agreement between self- and proxy-reported long-term psychosocial outcomes and 2) investigate the predictors of outcome 16 years post-CTBI. Thirty-three young adults (mean, 21.36 years; standard deviation, 2.75), with a CTBI sustained between 1 and 7 years of age, and a significant other completed questionnaires assessing the young adults' social and psychological functioning. Young adults and their significant other had good-to-excellent agreement on communication as well as alcohol and drug use scales. There was poorer agreement for the overall internalizing symptoms, anxious/depressed, withdrawn, thought, and rule-breaking behaviors. On the scales with poor agreement, there was no consistent contribution identified for any injury or preinjury factors. Preinjury adaptive behavior partly predicted withdrawn and overall internalizing symptoms, with a trend to also partly predict anxious/depressed and rule-breaking behavior reported by the significant other. Because young adults and significant others had poor agreement on the less-overt symptoms, these young adults may be at a higher risk of developing more-severe symptoms or disorders if it is not identified in time.

Predictors of very-long-term sociocognitive function after pediatric traumatic brain injury: evidence for the vulnerability of the immature "social brain".

Emotion perception (EP) forms an integral part of social communication and is critical to attain developmentally appropriate goals. This skill, which emerges relatively early in development, is driven by increasing connectivity among regions of a distributed sociocognitive neural network and may be vulnerable to disruption from early-childhood traumatic brain injury (TBI). The present study aimed to evaluate the very-long-term effect of childhood TBI on EP, as well as examine the contribution of injury- and non-injury-related risk and resilience factors to variability in sociocognitive outcomes. Thirty-four young adult survivors of early-childhood TBI (mean [M], 20.62 years; M time since injury, 16.55 years) and 16 typically developing controls matched for age, gender, and socioeconomic status were assessed using tasks that required recognition and interpretation of facial and prosodic emotional cues. Survivors of severe childhood TBI were found to have significantly poorer emotion perception than controls and young adults with mild-to-moderate injuries. Further, poorer emotion perception was associated with reduced volume of the posterior corpus callosum, presence of frontal pathology, lower SES, and a less-intimate family environment. Our findings lend support to the vulnerability of the immature "social brain" network to early disruption and underscore the need for context-sensitive rehabilitation that optimizes early family environments to enhance recovery of EP skills after childhood TBI.

Social communication mediates the relationship between emotion perception and externalizing behaviors in young adult survivors of pediatric traumatic brain injury (TBI).

Traumatic brain injury (TBI) is a common cause of childhood disability, and is associated with elevated risk for long-term social impairment. Though social (pragmatic) communication deficits may be among the most debilitating consequences of childhood TBI, few studies have examined very long-term communication outcomes as children with TBI make the transition to young adulthood. In addition, the extent to which reduced social function contributes to externalizing behaviors in survivors of childhood TBI remains poorly understood. The present study aimed to evaluate the extent of social communication difficulty among young adult survivors of childhood TBI (n=34, injury age: 1.0-7.0 years; M time since injury: 16.55 years) and examine relations among aspects of social function including emotion perception, social communication and externalizing behaviors rated by close-other proxies. Compared to controls the TBI group had significantly greater social communication difficulty, which was associated with more frequent externalizing behaviors and poorer emotion perception. Analyses demonstrated that reduced social communication mediated the association between poorer emotion perception and more frequent externalizing behaviors. Our findings indicate that socio-cognitive impairments may indirectly increase the risk for externalizing behaviors among young adult survivors of childhood TBI, and underscore the need for targeted social skills interventions delivered soon after injury, and into the very long-term.

Social function in children and adolescents after traumatic brain injury: a systematic review 1989-2011.

Clinical reports and case studies suggest that traumatic brain injury (TBI) can have significant social consequences, with social dysfunction reported to be the most debilitating problem for child and adolescent survivors. From a social neuroscience perspective, evidence suggests that social skills are not localized to a specific brain region, but are mediated by an integrated neural network. Many components of this network are susceptible to disruption in the context of TBI. In early development, a brain injury can disrupt this neural network while it is in the process of being established, resulting in social dysfunction. In order to clarify the prevalence and nature of social dysfunction after child TBI, studies of social outcomes in children and adolescents after TBI over the last 23 years have been reviewed. Despite casting a wide net initially, only 28 articles met review criteria. These studies were characterized by methodological weaknesses, including variations in definitions of TBI, limited assessment tools, reliance on parent reports, small sample sizes, and absent control groups. Despite these limitations, the weight of evidence confirmed an elevated risk of social impairment in the context of moderate and severe injury. While rarely examined, younger age at insult, pathology to frontal regions and the corpus callosum, and social disadvantage and family dysfunction may also increase the likelihood of social difficulties. More research is needed to obtain an accurate picture of social outcomes post-brain injury.