Long-Term Vocational Outcome at 15 Years from Severe Traumatic and Non-Traumatic Brain Injury in Pediatric Age.

BACKGROUND: Recent studies suggest that acquired brain injury with impaired consciousness in infancy is related to more severe and persistent effects and may have a cumulative effect on ongoing development. In this work, we aim to describe vocational outcome in a group of patients at 15 years from a severe brain lesion they suffered in developmental age. METHODS: This study included a total of 147 patients aged 1.5 to 14 years with acquired brain lesion. Clinical and functional details ("Glasgow Outcome Scale", "Functional Independent Measure" and Intelligence Quotient) were collected at the time of their first hospitalization and vocational outcome was determined after 15 years. RESULTS: 94 patients (63.9%) presented with traumatic brain injury, while 53 patients (36.1%) presented with a brain lesion of other origin. Traumatic patients had a higher probability of being partly or fully productive than non-traumatic ones: 75.5% of traumatic subjects were working-taking into account limitations due to the traumatic event-versus 62.3% of non-traumatic ones. A relationship between some clinical variables and the vocational outcome was found. CONCLUSIONS: Rehabilitation should adequately emphasize "vocational rehabilitation" because a significant proportion of people experiencing a disorder of consciousness in childhood may show good social integration in adult age.

Neuropsychological assessment through Coma Recovery Scale-Revised and Coma/Near Coma Scale in a sample of pediatric patients with disorder of consciousness.

BACKGROUND: The Coma Recovery Scale-Revised (CRS-R) has become a standard tool in assessing Disorders of consciousness (DoC) in adults. However, its measurement validity in pediatrics has only been ascertained in healthy cases. Increasing use of CRS-R in children with DoC imposes appropriate comparison against previously validated tools. The aims of the study were to describe the emergence to a conscious state (eMCS) in pediatric acquired brain injury (ABI); to explore the agreement between the CRS-R and Coma Near Coma Scale (CNCS) and to discuss the advantage of administering the CRS-R in pediatric age. MATERIALS AND METHODS: In this observational prospective study, 40 patients were recruited. Inclusion criteria were age 5 to 18 years, Glasgow Coma Scale (GCS) score ≤ 8 at the insult, and unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS) at admission. Patients were assessed with CRS-R, and CNCS was used as standard. RESULTS: The agreement between scales was moderate (r = - 0.71). The analysis of the CRS-R domain scores also confirmed that decreasing CNCS levels (from a coma to eMCS) corresponded to concurrent increas of CRS-R scores in all domains. Moreover, CRS-R better defined patients' status in the emergency phase from MCS. Conversely, CRS-R had lower DoC scoring ability in the presence of severe motor impairment. CONCLUSION: We show that CRS-R can track changes in DoC in children as young as 5 years old, and we provide evidence that the agreement with CNCS scores is good.

Feasibility Randomized Trial for an Intensive Memory-Focused Training Program for School-Aged Children with Acquired Brain Injury.

(1) Background: Memory deficits are common sequelae of pediatric Acquired Brain Injury (ABI). Only methods for non-focused cognitive remediation are available to the pediatric field. The aims of this feasibility trial are the description, implementation, and test of an intensive program specific to the training and re-adaptation of memory function in children, called Intensive Memory-Focused Training Program (IM-FTP); (2) Methods: Eleven children and adolescents with ABI (mean age at injury = 12.2 years, brain tumor survivors excluded) were clinically assessed and rehabilitated over 1-month through IM-FTP, including physio-kinesis/occupational, speech, and neuropsychology treatments. Each patient received a psychometric evaluation and a brain functional MRI at enrollment and at discharge. Ten pediatric controls with ABI (mean age at injury = 13.8 years) were clinically assessed, and rehabilitated through a standard program; (3) Results: After treatment, both groups had marked improvement in both immediate and delayed recall. IM-FTP was associated with better learning of semantically related and unrelated words, and larger improvement in immediate recall in prose memory. Imaging showed functional modification in the left frontal inferior cortex; (4) Conclusions: We described an age-independent reproducible multidisciplinary memory-focused rehabilitation protocol, which can be adapted to single patients while preserving inter-subject comparability, and is applicable up to a few months after injury. IM-FTP will now be employed in a powered clinical trial.

Joint Neuropsychological Assessment through Coma/Near Coma and Level of Cognitive Functioning Assessment Scales Reduces Negative Findings in Pediatric Disorders of Consciousness.

The present study aimed to: (a) characterize the emergence to a conscious state (CS) in a sample of children and adolescents with severe brain injury during the post-acute rehabilitation and through two different neuropsychological assessment tools: the Rappaport Coma/Near Coma Scale (CNCS) and Level of Cognitive Functioning Assessment Scale (LOCFAS); (b) compare the evolution in patients with brain lesions due to traumatic and non-traumatic etiologies; and (c) describe the relationship between the emergence to a CS and some relevant clinical variables. In this observational prospective longitudinal study, 92 consecutive patients were recruited. Inclusion criteria were severe disorders of consciousness (DOC), Glasgow Coma Scale (GCS) score ≤8 at insult, age 0 to 18 years, and direct admission to inpatient rehabilitation from acute care. The main outcome measures were CNCS and LOCFAS, both administered three and six months after injury. The cohort globally shifted towards milder DOC over time, moving from overall 'moderate/near coma' at three months to 'near/no coma' at six months post-injury. The shift was captured by both CNCS and LOCFAS. CNCS differentiated levels of coma at best, while LOCFAS was superior in characterizing the emergence from coma. Agreement between scales was fair, and reduced negative findings at less than 10%. Patients with traumatic brain injury (TBI) vs. non-traumatic brain injury (NTBI) were older and had neurosurgical intervention more frequently. No relation between age and the level of consciousness was found overall. Concurrent administration of CNCS and LOCFAS reduced the rate of false negatives and better detected signs of arousal and awareness. This provides indication to administer both tools to increase measurement precision.

Children sustaining a severe acquired brain lesion before age 3 years: a follow-up study at 1 year from insult.

PURPOSE: To describe the functional and cognitive outcome of acquired brain injury of different aetiologies in children before age 3 years, at initial hospitalization and at a 1-year follow-up, after a rehabilitation programme. METHOD: Data were collected at 6 months and at 12 months from the event; cognitive data were collected as soon as possible at T1. The full sample was divided into three groups according to aetiology. RESULTS: At T0, 74 patients showed so severe a cognitive impairment that they could not be evaluated, others presented with motor, linguistic and cognitive deficits. At T1, the proportion of non-evaluable patients decreased to 58 children. Patients with anoxic lesions showed the most unfavourable motor and visual outcome; patients with infectious lesions showed most frequently a motor global delay. CONCLUSIONS: At 1 year from insult about 50% of patients could undergo a cognitive evaluation. Improvement differed according to aetiology.

Comparison of Multi-class Machine Learning Methods for the Identification of Factors Most Predictive of Prognosis in Neurobehavioral assessment of Pediatric Severe Disorder of Consciousness through LOCFAS scale.

Severe Disorders of Consciousness (DoC) are generally caused by brain trauma, anoxia or stroke, and result in conditions ranging from coma to the confused-agitated state. Prognostic decision is difficult to achieve during the first year after injury, especially in the pediatric cases. Nevertheless, prognosis crucially informs rehabilitation decision and family expectations. We compared four multi-class machine learning classification approaches for the prognostic decision in pediatric DoC. We identified domains of a neurobehavioral assessment tool, Level of Cognitive Functioning Assessment Scale, mostly contributing to decision in a cohort of 124 cases. We showed the possibility to generalize to new admitted pediatric cases, thus paving the way for real employment of machine learning classifiers as an assistive tool to prognostic decision in clinics.

Psychological and behavioural difficulties following severe TBI in adolescence: a comparison with a sample of peers with brain lesions of other origin and with a control group.

OBJECTIVE: To describe behavioural and adjustment problems in a group of 57 adolescents with severe traumatic brain injury (TBI) and compare them with a clinical group of peers with brain lesions of other origin (N = 33) and a control group of healthy adolescents (N = 48). METHODS: All subjects received an age-appropriate assessment, including the child behaviour checklist (CBCL) 4/18, the strengths and difficulties questionnaire (SDQ) and the vineland adaptive behaviour scales (VABS). RESULTS: Compared with healthy peers, adolescents with TBI presented with more marked behavioural problems on most CBCL scales (Internalization and Externalization domains were both affected) and on the SDQ Hyperactivity and Peer problems scales. They also showed a more impaired functioning in most VABS domains. Compared with adolescents with brain lesions of other aetiology, patients with TBI showed more conduct problems on the SDQ scale, but no significant differences were found on the CBCL scales. Regarding the VABS, patients with other lesions presented with the worst outcome in the Motor and Daily Living Skills domains. CONCLUSIONS: Adolescents with TBI are exposed at a very high risk to develop behavioural and psychological disturbances with the potential to severely affect their social re-entry. Further knowledge is needed to plan early and well-timed interventions.

Altered Recruitment of the Attention Network Is Associated with Disability and Cognitive Impairment in Pediatric Patients with Acquired Brain Injury.

We assessed abnormalities of brain functional magnetic resonance imaging (fMRI) activity during a sustained attention task (Conners' Continuous Performance Test (CCPT)) in 20 right-handed pediatric acquired brain injury (ABI) patients versus 7 right-handed age-matched healthy controls, and we estimated the correlation of such abnormalities with clinical and cognitive deficits. Patients underwent the Wechsler Intelligence Scale for Children (WISC), Wisconsin Card Sorting Test, and Functional Independence Measure (FIM) evaluations. During fMRI, patients and controls activated regions of the attention network. Compared to controls, ABI patients experienced a decreased average fMRI recruitment of the left cerebellum and a decreased deactivation of the left anterior cingulate cortex. With increasing task demand, compared to controls, ABI patients had an impaired ability to increase the recruitment of several posterior regions of the attention network. They also experienced a greater activation of frontal regions, which was correlated with worse performance on FIM, WISC, and fMRI CCPT. Such abnormal brain recruitment was significantly influenced by the type of lesion (focal versus diffuse axonal injury) and time elapsed from the event. Pediatric ABI patients experienced an inability to optimize attention network recruitment, especially when task difficulty was increased, which likely contributes to their clinical and cognitive deficits.

Psychological problems, self-esteem and body dissatisfaction in a sample of adolescents with brain lesions: A comparison with a control group.

PRIMARY OBJECTIVES: This study aims to describe psychological problems, self-esteem difficulties and body dissatisfaction in a sample of adolescents with acquired brain lesions and to compare them with an age- and gender-matched control group. RESEARCH DESIGN: In an experimental design, the psychological profile of 26 adolescents with brain lesions of traumatic or vascular aetiology, aged 12-18 years, was compared with that of 18 typically-developing subjects. Moreover, within the clinical group, patients with TBI were compared with patients with vascular lesions. METHODS AND PROCEDURES: The psychological and adaptive profile of the adolescents was assessed by a specific protocol, including CBCL, VABS, RSES, EDI-2 and BES. MAIN OUTCOME AND RESULTS: Adolescents with brain lesions showed more marked psychological problems than their healthy peers; they also presented with a greater impairment of adaptive skills and a lower self-esteem. No significant differences were found between patients with traumatic lesions and patients with vascular lesions. CONCLUSIONS: Adolescents with acquired brain lesions were at higher risk to develop psychological and behavioural difficulties. Furthermore, in the clinical sample, some variables such as the long hospitalization and isolation from family and peers were associated to a greater psychological burden than the aetiology of the brain damage.

LOCFAS-Assessed Evolution of Cognitive and Behavioral Functioning in a Sample of Pediatric Patients With Severe Acquired Brain Injury in the Postacute Phase.

We studied 86 patients with severe acquired brain injuries of different etiology, aged 0 to 18 years, in a condition of vegetative state or minimally conscious state. During neurorehabilitation, we administered the Level of Cognitive Functioning Assessment Scale every 2 weeks in order to describe and compare the progressive improvement in their cognitive-behavioral functioning and responsiveness in different etiologies. Patients with traumatic brain injury showed more favorable clinical outcomes. The higher the level of functioning at the first evaluation, the better the outcome, and the higher the Glasgow Coma Scale score, the higher the Level of Cognitive Functioning Assessment Scale level reached at the end of hospitalization. Patients with an apparently stable clinical picture, too, showed a change in their ability to interact with the environment. This study underlines the importance of an individualized and early cognitive-behavioral intervention protocol that can reveal minimal and fluctuating responses.

Cognitive recovery after severe traumatic brain injury in children/adolescents and adults: similar positive outcome but different underlying pathways?

PRIMARY OBJECTIVE: Does younger age at the time of severe traumatic brain injury (STBI) protect from cognitive symptoms? To answer this question, the authors compared the neuropsychological profile of late school-age children/adolescents and young adult patients at mid- and long-term recovery periods (6 and 12 months post-STBI). METHODS AND PROCEDURES: Twenty-eight children/adolescents and 26 clinically matched adults were tested on measures of general intelligence, attention, executive functions, visuoperceptual, visuospatial and visuoconstructive abilities. Coma duration and the post-acute Glasgow Outcome Scale (GOS) score were used as predictor variables in a series of regression analyses. MAIN OUTCOMES AND RESULTS: Children/adolescents and adults similarly improved on most measures, except for visuospatial and visuoconstructive skills, which worsened in time for children/adolescents. Coma duration significantly predicted performance IQ and visuoperceptual scores in children/adolescents. The GOS score significantly predicted performance and verbal IQ, sustained attention, visuoconstructive and long-term memory skills. Coma duration predicted executive function skills in both age groups. CONCLUSIONS: (1) No evidence was found for a neuroprotective effect of younger age at STBI; and (2) Coma duration and GOS score predicted neuropsychological recovery in children/adolescents and adults, respectively. This suggests the existence of underlying age-specific recovery processes after STBI.

Psychological and adjustment problems due to acquired brain lesions in pediatric patients: a comparison of vascular, infectious, and other origins.

The aim of this study was to describe psychological, behavioral, and adjustment problems in children and adolescents with acquired brain lesions of different origins. Three groups of patients with acquired brain lesions (15 patients with infectious origin, 37 with vascular origin, and 15 with other origin), ranging in age from 4 to 18 years, received a psychological evaluation, including the Child Behavior Checklist for ages 4 to 18 and the Vineland Adaptive Behavior Scale. About half of the total sample (47.8%) showed psychological problems. Difficulties varied according to the cause of the brain lesions. The most problematic patients were children with brain lesions of infectious origin, whereas children with brain lesions of vascular origin scored lower on most of the Child Behavior Checklist scales. The authors conclude that psychological and behavioral difficulties are very common among school-aged children with acquired brain lesions, and their relevance and impact must necessarily be considered.

Evolution of the cognitive profile in school-aged patients with severe TBI during the first 2 years of neurorehabilitation.

OBJECTIVE: Persistent post-injury cognitive, academic and behavioural deficits have been documented in children who sustained severe TBI during the school-age years. The major aim of this study was to examine and follow-up for 2 years the cognitive profile of a sample of post-injured patients (aged 6-16.11), in order to verify to what extent they recovered their intellectual functions after rehabilitation. METHOD: Twenty-six patients who received a specific neuropsychological treatment and three cognitive evaluations with WISC-III were selected from a pool of 77. RESULTS: This group of patients showed a mild cognitive deficit at baseline, which improved over the 2 years to a borderline level. Despite the improvement in intellectual quotients and single sub-test scores achieved through rehabilitation, different recovery times were seen according to the function under study. The most common deficits are in processing speed, inferential and lexical-semantic skills. CONCLUSIONS: Detailed analysis of the WISC-III sub-tests allows for an accurate description of single cognitive functions after TBI. This allows one to make differential diagnoses between functional profiles and plan individualized rehabilitation treatments. Post-injured school-aged patients should receive rehabilitation for a period of at least 2 years, which is the time necessary for an at-least partial reorganization of basic cognitive functions.

Cognitive and adaptive functioning after severe TBI in school-aged children.

OBJECTIVE: Persistent cognitive and behavioural deficits have been documented in children suffering severe TBI. The aim of the present study was to examine the cognitive and adaptive profile of children of school age with severe TBI. METHODS: This study selected 118 patients and divided them into three groups according to the severity of their clinical-functional picture. All the patients received a functional assessment using the Wee-FIM. Subjects with reduced responsiveness were evaluated by LOCFAS. Last, the cognitive profile children with a better recovery were described with WISC-III and Leiter-R and their adaptive behaviour with VABS. RESULTS: Group 1 (n = 77) showed a borderline cognitive level with a disharmonious profile between VIQ and PIQ, significant deficits in the Processing Speed and Perceptual Organization Indices, lastly specific adaptive behavioural deficits. Length of coma correlated with their cognitive and adaptive profile. Group 2 (n = 14) included subjects with severe language and/or motor disabilities presenting with a partial cognitive functioning level moderately impaired. Group 3 (n = 27) included patients with reduced responsiveness (LOCFAS ≤ 3). CONCLUSIONS: In the first 12 months following severe TBI, 22.9% children stayed in minimal responsiveness, 11.9% showed debilitating language and motor deficits and 65.2% showed a more favourable cognitive recovery and could be assessed by WISC-III.

Psychological and adjustment problems due to acquired brain lesions in pre-school-aged patients.

OBJECTIVE: To describe and compare psychological, behavioural and adjustment problems in pre-school patients with acquired brain lesions of different aetiology. METHODS: Three groups of patients with acquired brain lesions (14 patients post-TBI, 18 brain tumour survivors and 23 patients with vascular or infectious brain lesions), ranging in age between 24-47 months, received a psychological evaluation, including the Child Behavior Checklist for Ages 2-3 (CBCL) and the Vineland Adaptive Behavior Scales (VABS). RESULTS: About half of the total sample (47.2%) showed psychological and behavioural problems. Difficulties vary according to the aetiology of the brain lesions. Brain tumour survivors showed more marked internalizing problems, whereas children with vascular or infectious brain lesions scored higher on the CBCL externalizing scales. Children with traumatic brain injury reported intermediate scores on most of the CBCL scales. CONCLUSIONS: Psychological and behavioural difficulties are very common, not only among school-aged children and adolescents, but also among pre-schoolers with acquired brain lesions. The relevance and the impact of these difficulties must necessarily be considered when developing psychological treatment and rehabilitation plans and planning for social re-entry.

Efficacy of cognitive behavioural therapy for children and adolescents with traumatic brain injury.

PURPOSE: Behavioural and psychological disorders after traumatic brain injury (TBI) are very common. The purposes of this study were to estimate the frequency of these problems in our sample, to evaluate the effectiveness of cognitive behavioural therapy (CBT) and to assess the predictive value of important clinical variables for the treatment outcome. METHOD: Forty patients aged 4-18 years were included in this study. Twenty-eight patients received CBT at our Institute (clinical group), while 12 patients did not receive any treatment at all (control group). The CBCL/4-18 and the VABS were administered to parents at the beginning of the study and after 12 months. RESULTS: A high frequency of psychological and behavioural problems was found in both groups of patients. After CBT, the clinical group showed a significant advantage on several CBCL scales and a greater increase in adaptive behaviour on the VABS Socialisation domain. The Glasgow Coma Scale score, days of unconsciousness and age at injury were not predictors of the severity of psychological problems at the follow-up for the patients of the clinical group. CONCLUSIONS: Our results suggest that CBT is an effective intervention for young patients with psychological problems after TBI.

Psychological intervention in young brain tumor survivors: the efficacy of the cognitive behavioural approach.

PURPOSE: Cognitive and behavioural therapy (CBT) is often used to treat behavioural and emotional disorders in children, and its efficacy has been described in several studies. As behavioural and emotional disorders are frequent sequelae in brain tumor survivors, the goal of this work is to describe the efficacy of a CBT intervention in the treatment of young brain tumor survivors. METHODS: Forty young patients, aged 4-18 years, were included in the study. The treatment group, composed of 17 patients, received sessions of CBT. The Child Behaviour Checklist 4-18 (CBCL/4-18) and the Vineland Adaptive Behavioural Scales (VABS) were administered to parents at the beginning and at the end of the hospitalisation. The statistical significance of changes for clinical subjects during the CBT administration was estimated. RESULTS: With regard to the CBCL/4-18, the clinical group showed a significant advantage on the withdrawn, somatic complaints, social problems, attention problems, internalising and total problem scales. On the VABS, the treatment group improved to a significantly greater extent in the social skills domain. CONCLUSIONS: These results substantiate our assumption that CBT is an effective intervention for young patients surviving brain tumors and may be particularly helpful to younger individuals in managing cancer-related limitations.

Language and cognition in a bilingual child after traumatic brain injury in infancy: long-term plasticity and vulnerability.

PRIMARY OBJECTIVE: This study aimed at investigating the long-term effects of the combination of severity of injury and time of injury in a 6-year-old bilingual Arabic-Italian child who sustained a severe left traumatic brain injury at the age of 7 months. METHODS AND PROCEDURES: Standard neurological, cognitive and neuropsychological assessments were administered at 40 days after surgery and again at 18, 31, 62 and 73 months. MAIN OUTCOMES AND RESULTS: The child presented with developmental arrest at 18 and 31 months. Later on, right hemiparetic and oculomotor signs gradually improved to a significant extent, as well as dysexecutive, visuospatial and praxic deficits. At present, persistent language disorders in a fluent speech characterize the child's profile to a similar extent and type in both languages, suggesting common underlying learning strategies which are ineffective for procedurally acquiring language. CONCLUSIONS: This case confirms that children who sustain severe left hemisphere traumatic brain injury in infancy present with increased vulnerability to linguistic deficits. Left frontotemporal, cortical-subcortical lesions which occur during very early language development may permanently disrupt the procedural language acquisition network required for first language acquisition.