Measuring domain-specific deficits in self-awareness in children and adolescents with acquired brain injury: Component analysis of the Paediatric Awareness Questionnaire.

Self-awareness has been found to vary across different functional domains for adults with acquired brain injury (ABI); however, domain-specific self-awareness is yet to be investigated following paediatric ABI. This study aimed to validate the Paediatric Awareness Questionnaire (PAQ) as a multi-domain measure of self-awareness and to investigate domain-specific self-awareness in children with ABI. One hundred and ninety-seven children and adolescents (8-16 years, M = 12.44, SD = 2.62) with mixed causes of ABI (70% with traumatic brain injury) and their parents (n = 197) were recruited through consecutive rehabilitation appointments and completed the PAQ. The 37 items of the parent version of the PAQ were subjected to a principal component analysis with varimax rotation. A five-component solution (29 items) explained 64% of the variance in the PAQ items. Components revealed five domains of self-awareness: socio-emotional functioning, activities of daily living (ADLs), cognition, physical functioning, and communication. Internal consistency of the components ranged from acceptable to excellent (α = .70-.95). The analysis identified that children had poorer self-awareness of cognitive functioning than socio-emotional functioning, ADLs, and communication skills. Overall, the findings identify five components (i.e., functional domains) of self-awareness and provide some support that self-awareness varies across domains following paediatric ABI.

Impaired Self-Awareness after Pediatric Traumatic Brain Injury: Protective Factor or Liability?

Children and adolescents with traumatic brain injury (TBI) can experience impaired self-awareness, or difficulty in accurately perceiving their personal abilities. This study aimed to identify the neuro-developmental and socio-environmental factors associated with self-awareness impairment and determine how self-awareness is associated with psychosocial functioning. Parents and their children age 8-16 years with TBI (n = 107, 65.4% male, mean [M] age = 12.66 years, standard deviation [SD] = 2.6 years) were consecutively recruited from an outpatient clinic over a 4-year period. Children completed the Paediatric Awareness Questionnaire (PAQ) to report their functional abilities, and the Beck Youth Inventories to report their self-concept, and anxiety and depression symptoms. Parents completed the PAQ and measures of family functioning, parenting style, and children's emotional and behavioral problems. Self-awareness impairments were defined as more negative parent-child discrepancy scores on the PAQ. Younger age at injury, more severe injury, and more family dysfunction were significantly associated with poorer self-awareness. Poorer self-awareness was associated with worse parent-rated child adaptive functioning and emotional and behavioral problems. However, poorer self-awareness was also significantly associated with more positive self-concept and fewer symptoms of depression and anxiety as rated by children. Overall, impaired self-awareness seems to be both a liability and a benefit depending on the reporter (parent or child) and outcome of interest (adaptive function/behavior or self-concept/mood).

[Formula: see text] Investigation of children and adolescents' mood and self-concept after acquired brain injury.

Few studies have examined the self-reported mental health of children with an acquired brain injury (ABI). The current study aimed to: 1) identify levels of child-reported depressive and anxiety symptoms and poor self-concept, 2) investigate demographic and injury-related factors associated with children's mood and self-concept, and 3) examine associations between children's self-reported mental health and parents' reports of children's emotional and behavioral functioning in children specifically with traumatic brain injury (TBI). 122 children (66% male) aged 8-16 years with ABI of mixed etiology were consecutively recruited through an outpatient rehabilitation clinic. Children were administered the Beck Youth Inventories - Second Edition, and parents completed the Adaptive Behavior Assessment System and the Child Behavior Checklist (CBCL). Relative to the norms, 16.4% of children scored in the clinical range for the depression and anxiety scales, and 24.6% reported clinically low self-concept. Children with lower functional status had greater anxiety symptoms. Older children (13-16 years) reported significantly higher depressive and anxiety symptoms and lower self-concept than younger children (8-12 years). A significant interaction between age and sex indicated that older girls reported greater depressive and anxiety symptoms than younger girls whereas no age-based differences were found for boys. Parent-reported total emotional and behavioral problems were positively associated with children's self-reported depressive and anxiety symptoms and were negatively correlated with self-concept. These findings indicate that adolescents, particularly girls, may be at heightened risk of poor mental health following ABI. Further research investigating the reasons for these demographic differences may inform developmentally sensitive interventions.

A systematic review of factors related to children's quality of life and mental health after brain tumor.

PURPOSE: Brain tumor has been found to have a major impact on children's quality of life (QOL); yet, the subjective impact of the illness is still not well understood. This review aimed to investigate factors related to children's subjective well-being (SWB), or self-reported QOL and mental health after brain tumor. A further aim was to determine the consistency between child and parent-proxy ratings of children's SWB and common factors associated with both child and parent-proxy ratings. METHODS: A systematic search of PsycINFO, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and Scopus was conducted from 1980 to May 2018 to identify eligible studies. Methodological quality of these studies was assessed by 2 independent reviewers. RESULTS: Twenty studies investigated factors related to children's self-reported mental health or QOL. Fourteen studies examined these factors from the perspectives of both children and their parents. Overall, risk factors for poor QOL included infratentorial tumors, radiation, hydrocephalus, lower IQ, and behavioral problems. Only 5 studies examined mental health outcomes, the findings of which were mixed. Relatively few studies examined psychosocial variables related to children's SWB. CONCLUSIONS: Although several risk factors for poor QOL were identified, further research investigating mental health outcomes and the influence of psychosocial factors on children's SWB is needed to guide support interventions for pediatric brain tumor.

The impact of bariatric surgery on the resolution of obstructive sleep apnoea.

OBJECTIVE: Obesity is associated with a high incidence of obstructive sleep apnoea (OSA). Bariatric surgery is postulated to lead to OSA resolution, but there is inconclusive evidence on its efficacy. We used objective measurements to determine the rate of resolution or improvement of OSA in patients who had bariatric procedures in our unit. RESULTS: Data was analysed on all patients with OSA who underwent bariatric procedures [laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG)] between June 2012 and September 2016 in our unit. 47 patients (26.7%) were diagnosed with OSA. Mean age was 48.5 years. 63.8% were female. 43 required nocturnal continuous positive airway pressure (CPAP) support. Procedures were LRYGB (n = 26) and LSG (n = 21). Mean excess weight loss was 56.1%. Mean start apnoea-hypopnoea index (AHI) on CPAP was 6.4 events/hr and end AHI was 1.4 events/h. 14 patients (32.6%) had complete OSA resolution and 12 (27.9%) showed improvement in pressure support requirements. We demonstrated that 55.3% of patients had resolution or improvement in OSA following bariatric surgery. However, there was a high rate of non-attendance of follow-up appointments. Future efforts will involve analysis of the reasons for this to ensure more robust monitoring.

Development and preliminary validation of the Paediatric Awareness Questionnaire for children and adolescents with traumatic brain injury.

There is a lack of validated measures for assessing self-awareness of deficits after pediatric traumatic brain injury (TBI). The current study aimed to develop and examine the psychometric properties of the Paediatric Awareness Questionnaire (PAQ), and investigate factors related to self-awareness. The PAQ was administered to 32 children aged 8-16 years with mild to severe TBI (72% male, M age = 11.75, SD = 2.9), their parents, and treating clinicians, and to 32 age- and gender-matched typically developing controls and their parents. Children with TBI and their parents also completed the Knowledge of Injury Checklist (KIC), and parents completed the Depression Anxiety and Stress Scale 21. The PAQ was found to have fair to excellent (α = .79-.97) internal consistency for all versions across both groups and good concordance between parent and clinician total scores (ICC = .78). There was also evidence of convergent validity between the PAQ and KIC for both child (r = -.45, p < .05) and parent ratings (r = -.66, p < .001). Poorer self-awareness was significantly related to younger age at injury for the TBI group and lower parental education for the total sample. ANCOVA identified that children with TBI demonstrated significantly poorer awareness than controls after controlling for parental education. Children with TBI typically overestimated their functioning compared to their parents, whereas typically developing children tended to rate their functioning lower than their parents. These findings provide preliminary support for the reliability and validity of the PAQ for assessing self-awareness after pediatric TBI.

A randomised controlled trial of a web-based multi-modal therapy program to improve executive functioning in children and adolescents with acquired brain injury.

OBJECTIVE: To examine the efficacy of a multi-modal web-based therapy program, Move it to improve it (Mitii™) delivered at home to improve Executive Functioning (EF) in children with an acquired brain injury (ABI). DESIGN: Randomised Waitlist controlled trial. SETTING: Home environment. PARTICIPANTS: Sixty children with an ABI were matched in pairs by age and intelligence quotient then randomised to either 20-weeks of Mitii™ training or 20 weeks of Care As Usual (waitlist control; n=30; 17 males; mean age=11y, 11m (±2y, 6m); Full Scale IQ=76.24±17.84). Fifty-eight children completed baseline assessments (32 males; mean age=11.87±2.47; Full Scale IQ=75.21±16.76). MAIN MEASURES: Executive functioning was assessed on four domains: attentional control, cognitive flexibility, goal setting, and information processing using subtests from the Wechsler Intelligence Scale for Children (WISC-IV), Delis-Kaplan Executive Functioning System (D-KEFS), Comprehensive Trail Making Test (CTMT), Tower of London (TOL), and Test of Everyday Attention for Children (Tea-Ch). Executive functioning performance in everyday life was assessed via parent questionnaire (Behaviour Rating Inventory of Executive Functioning; BRIEF). RESULTS: No differences were observed at baseline measures. Groups were compared at 20-weeks using linear regression with no significant differences found between groups on all measures of EF. Out of a potential total dose of 60 hours, children in the Mitii™ group completed a mean of 17 hours of Mitii™ intervention. CONCLUSION: Results indicate no additional benefit to receiving Mitii™ compared to standard care. Mitii™, in its current form, was not shown to improve EF in children with ABI.

PREDICT-CP: study protocol of implementation of comprehensive surveillance to predict outcomes for school-aged children with cerebral palsy.

OBJECTIVES: Cerebral palsy (CP) remains the world's most common childhood physical disability with total annual costs of care and lost well-being of $A3.87b. The PREDICT-CP (NHMRC 1077257 Partnership Project: Comprehensive surveillance to PREDICT outcomes for school age children with CP) study will investigate the influence of brain structure, body composition, dietary intake, oropharyngeal function, habitual physical activity, musculoskeletal development (hip status, bone health) and muscle performance on motor attainment, cognition, executive function, communication, participation, quality of life and related health resource use costs. The PREDICT-CP cohort provides further follow-up at 8-12 years of two overlapping preschool-age cohorts examined from 1.5 to 5 years (NHMRC 465128 motor and brain development; NHMRC 569605 growth, nutrition and physical activity). METHODS AND ANALYSES: This population-based cohort study undertakes state-wide surveillance of 245 children with CP born in Queensland (birth years 2006-2009). Children will be classified for Gross Motor Function Classification System; Manual Ability Classification System, Communication Function Classification System and Eating and Drinking Ability Classification System. Outcomes include gross motor function, musculoskeletal development (hip displacement, spasticity, muscle contracture), upper limb function, communication difficulties, oropharyngeal dysphagia, dietary intake and body composition, participation, parent-reported and child-reported quality of life and medical and allied health resource use. These detailed phenotypical data will be compared with brain macrostructure and microstructure using 3 Tesla MRI (3T MRI). Relationships between brain lesion severity and outcomes will be analysed using multilevel mixed-effects models. ETHICS AND DISSEMINATION: The PREDICT-CP protocol is a prospectively registered and ethically accepted study protocol. The study combines data at 1.5-5 then 8-12 years of direct clinical assessment to enable prediction of outcomes and healthcare needs essential for tailoring interventions (eg, rehabilitation, orthopaedic surgery and nutritional supplements) and the projected healthcare utilisation. TRIAL REGISTRATION NUMBER: ACTRN: 12616001488493.

Randomized controlled trial of a web-based multi-modal therapy program for executive functioning in children and adolescents with unilateral cerebral palsy.

Purpose state: Determine the efficacy of Move-it-to-improve-it (Mitii™), a multi-modal web-based program, in improving Executive Function (EF) in children with unilateral cerebral palsy (UCP). METHOD: Participants (n = 102) were matched in pairs then randomized to: intervention (Mitii™ for 20 weeks; n = 51; 26 males; mean age = 11 years 8 months (SD = 2 years 4 months); Full Scale IQ = 84.65 (SD = 15.19); 28 left UCP; GMFCS-E&R (I = 20, II = 31) or waitlist control (n = 50; 25 males; mean age = 11 years 10 months (SD = 2 years 5 months); Full Scale IQ = 80.75 (SD = 19.81); 20 left UCP; GMFCS-E&R (I = 25, II = 25). Mitii™ targeted working memory (WM), visual processing (VP), upper limb co-ordination and physical activity. EF capacity was assessed: attentional control (DSB; WISC-IV); cognitive flexibility (inhibition and number-letter sequencing DKEFS); goal setting (D-KEFs Tower Test); and information processing (WISC-IV Symbol Search and Coding). EF performance was assessed via parent report (BRIEF). Groups were compared at 20 weeks using linear regression (SPSS 21). RESULTS: There were no significant between group differences in attentional control (DSB; p = 0.20;CI= -0.40,1.87); cognitive flexibility (Inhibition, p = 0.34; CI= -0.73,2.11; number/letter sequencing, p = 0.17; CI= -0.55,2.94); problem solving (Tower; p = 0.28; CI= -0.61,2.09), information processing (Symbol; p = 0.08; CI= -0.16, 2.75; Coding; p = 0.07; CI= -0.12,2.52) or EF performance (p = 0.13; CI= -10.04,1.38). CONCLUSION: In a large RCT, MitiiTM did not lead to significant improvements on measures of EF or parent ratings of EF performance in children with UCP. Implications for rehabilitation A large RCT of the multi-modal web based training; Move It to Improve It (MitiiTM) improves motor processing, visual perception, and physical capacity but does demonstrate statistically significant improvements or clinical significance in executive function in children with mild to moderate unilateral cerebral palsy (UCP). MitiiTM training completed by an intervention group was highly variable with few children reaching the target dosage of 60 h. Technical issues including server and internet connectively problems lead to disengagement with the program. Web-based training delivered in the home has the potential to increase therapy dose and accessibility, however, MitiiTM needs to be tailored to include tasks involving goal-setting, more complex problem solving using multi-dimensional strategies, mental flexibility, switching between two cognitively demanding tasks, and greater novelty in order to increase the cognitive component and challenge required to drive changes in EF.

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.

Availability, spatial accessibility, utilisation and the role of telehealth for multi-disciplinary paediatric cerebral palsy services in Queensland.

AIMS: The purpose of this study was to understand the methods of current delivery of health care services to cerebral palsy (CP) patients in Queensland, Australia. The study also examines the current use of telehealth by clinicians and their perceptions about telehealth use. METHODS: Patient records during July 2013-July 2014 were accessed from the Queensland Paediatric Rehabilitation Service (QPRS) to collect information relating to the service delivery for CP patients. Analysis was carried out to examine the patient locations and travel distances using ArcMap geoprocessing software. In addition, 13 face-to-face semi structured interviews were conducted with clinicians from the QPRS and the Cerebral Palsy Health Service (CPHS) to understand the perceptions of clinicians relating to the current level of health care delivery. We also examined the clinicians' current use of telehealth and their opinions about this method. RESULTS: Records of 329 paediatric CP patients were accessed and reviewed. The majority of patients (96%, n = 307) who attended the clinics at the Royal Children's Hospital (RCH), Brisbane, were from remote, rural or regional areas of Queensland. Only 4% of patients (n = 13) were from major cities. During 12 months, patients had attended nine outreach programmes that were conducted by the QPRS and CPHS. The study found that non-local patients were required to travel an average distance of 836 km to access QPRS and CPHS services in Brisbane. The average distance for receiving a consultation at an outreach clinic was 173 km. Clinicians perceived that access to health care services to CP patients in Queensland is inadequate. Nearly all clinicians interviewed had some experience in using telehealth. They had high satisfaction levels with the method. CONCLUSIONS: Traditional methods of delivering services to CP patients do not meet their needs. Clinicians have found telehealth is a feasible and satisfactory delivery method. However, the use of telehealth is still limited.

Mitii™ ABI: study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI).

BACKGROUND: Acquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. "Move it to improve it" (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial. METHODS/DESIGN: Sixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention. DISCUSSION: Mitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose. TRIAL REGISTRATION: ANZCTR12613000403730.

Awareness Deficits in Children and Adolescents After Traumatic Brain Injury: A Systematic Review.

OBJECTIVES: To systematically review empirical research on awareness deficits in children and adolescents following traumatic brain injury (TBI). METHODS: PsycINFO, MEDLINE, Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Education Resources Information Centre), PsycBITE, and Web of Science were searched from inception to August 8, 2013, using key terms relating to awareness of deficits and brain injury in childhood/adolescence. Studies of children or adolescents with traumatic brain injury (TBI), systematic measurement of awareness of deficits, and reporting of quantitative data were included. Details of participants, methodology, and findings were summarized for each study, and methodological quality was rated. RESULTS: Review of 12 eligible studies yielded mixed evidence concerning the presence of awareness deficits after childhood TBI. Awareness deficits were most evident both for memory and executive function impairments and for children and adolescents with severe TBI. Methodological variability, including sampling characteristics, objects of awareness, measurement issues, and approach to statistical analysis, contributed to the mixed findings. CONCLUSIONS: Further research focusing on factors contributing to awareness deficits following pediatric TBI, the course of recovery, and relation to functional outcomes is warranted.

Neurodevelopmental outcome following open heart surgery in infancy: 6-year follow-up.

BACKGROUND: Children undergoing open heart surgery are at risk of neurological injury. A cohort of 35 patients, who had undergone cardiac surgery during infancy, had a significant reduction in Bayley Scale of Infant Development scores at a 12-month assessment. This cohort has now reached an appropriate age to reassess developmental progress. METHODS: Detailed psychometric testing was conducted on 20 children from the original cohort using the Weschler Preschool and Primary Scale of Intelligence, the Wide Range Assessment of Memory and Learning, and the Wechsler Individual Achievement Test. Parents completed the Connor's Rating Scale, the Behaviour Rating Scale of Executive Functioning, and the Child Behaviour Checklist. RESULTS: The mean age of the cohort at assessment was 6.6 (standard deviation 0.4) years. Mean scores on all tests of intelligence, memory, academic achievement, and executive function fell within the average range. Of the children, 20-35% were found to have significant difficulties across these areas. Mean scores in the areas of social, emotional, behavioural, and psychological functioning also fell within the average range. Of the children studied, 35% had clinically significant problems in these areas. There was only a weak association between the 12-month scores and the Full-Scale Intelligence Quotient at 6 years. CONCLUSION: Detailed psychometric testing of these children suggests that they generally function in the average range; however, a significant proportion falls below age expectations in all the areas assessed. This highlights the importance of long-term follow-up with routine developmental screening to allow identification of a subgroup that may benefit from early educational and behavioural intervention.

Improving outcomes for people with COPD by developing networks of general practices: evaluation of a quality improvement project in east London.

BACKGROUND: Structured care for people with chronic obstructive pulmonary disease (COPD) can improve outcomes. Delivering care in a deprived ethnically diverse area can prove challenging. AIMS: Evaluation of a system change to enhance COPD care delivery in a primary care setting between 2010 and 2013 using observational data. METHODS: All 36 practices in one inner London primary care trust were grouped geographically into eight networks of 4-5 practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary group, including a respiratory specialist and the community respiratory team, developed a 'care package' for COPD management, with financial incentives based on network achievements of clinical targets and supported case management and education. Monthly electronic dashboards enabled networks to track and improve performance. RESULTS: The size of network COPD registers increased by 10% in the first year. Between 2010 and 2013 completed care plans increased from 53 to 86.5%, pulmonary rehabilitation referrals rose from 45 to 70% and rates of flu immunisation from 81 to 83%, exceeding London and England figures. Hospital admissions decreased in Tower Hamlets from a historic high base. CONCLUSIONS: Investment of financial, organisational and educational resource into general practice networks was associated with clinically important improvements in COPD care in socially deprived, ethnically diverse communities. Key behaviour change included the following: collaborative working between practices driven by high-quality information to support performance review; shared financial incentives; and engagement between primary and secondary care clinicians.

Aggregated n-of-1 trials of central nervous system stimulants versus placebo for paediatric traumatic brain injury--a pilot study.

BACKGROUND: In 2006 there were 432,700 people in Australia who had acquired brain injury (ABI) with some limitation of activities; 90% of these were traumatic brain injuries (TBIs) and nearly a third sustained injury below age 15 years. One to four years post injury, 20% to 46% of children with traumatic brain injury (TBI) have clinically significant disorders of attention. There is controversy as to whether central nervous system (CNS) stimulants can be an effective method of treating these.Objectives were to determine the efficacy of CNS stimulants for children with TBI, and to calculate the sample size for a larger trial using the Conners' 3 Parent Rating Scales Score as the primary endpoint. METHODS: Pilot series of aggregated prospective randomised, double-blind, n-of-1 trials of stimulant versus placebo within individual patients. SETTING: tertiary children's public hospital. PARTICIPANTS: ten children aged 6 to 16 years more than 12 months post TBI with attention, concentration and behavioral difficulties on stimulants. INTERVENTIONS: Three cycles of methylphenidate or dexamphetamine orally at doses titrated by physician compared to placebo. MAIN OUTCOME MEASURES: Conners 3 Parent (Conners 3-P) and Teacher (Conners 3-T) Rating Scales (Global Index), Behaviour Rating Inventory of Executive Function (BRIEF) and Eyberg Child Behaviour Inventory (ECBI). RESULTS: Five of ten patients completed the study. Data from 18 completed cycles from seven patients were analysed. The posterior mean difference between stimulant and placebo scores for the Conners 3-PS (Global Index) was 2.3 (SD 6.2; 95% credible region -1.0 to 6.1; posterior probability that this mean difference was greater than zero was 0.92), and for the Conners 3-T (Global Index) the posterior mean difference was 5.9 (SD 4.5; 95% credible region -3.1 to 14.9; posterior probability 0.93). Posterior mean differences suggest improvement in behaviour and executive function and a decrease in number and intensity of child behaviour problems when taking stimulants compared to placebo. Taken together these data are suggestive of a small benefit at group level. CONCLUSIONS: In this pilot study, there was sufficient evidence that stimulants may be useful in management of behavioral and cognitive sequelae following TBI, to warrant a larger trial. TRIAL REGISTRATION: he trial was registered with the Australian and New Zealand Clinical Trials Registry: registration number ACTRN12609000873224.

Everyday psychological functioning in children with unilateral cerebral palsy: does executive functioning play a role?

AIM: To identify whether executive functioning mediates the effect of having unilateral cerebral palsy (CP) on executive functioning in everyday life, psychological functioning, and social functioning. METHOD: A cross-sectional cohort of 46 children with unilateral CP (25 males, 21 females; mean age 11y 1mo, SD 2y 5mo; 24 right-sided, 22 left-sided) and 20 children with typical development (nine males, 11 females; mean age 10y 10mo, SD 2y 4mo). Cognitive executive functioning was tested using a neuropsychological battery. Executive functioning in everyday life was measured with the Behavior Rating Inventory of Executive Function (BRIEF; teacher and parent reports) and psychological and social functioning by the Strengths and Difficulties Questionnaire (SDQ). Analysis included analysis of covariance and bootstrapping. RESULTS: Children with unilateral CP were found to have significantly decreased functioning, compared with children with typical development, on the BRIEF Behavioral Regulation Index, the BRIEF Metacognition Index, and on the SDQ emotion, conduct, hyperactivity, and peer problems subscales. Group differences were mediated by cognitive executive functioning for the BRIEF Metacognition Index (teacher and parent report), the BRIEF Behavioral Regulation Index (parent report only), the SDQ conduct subscale, and the SDQ hyperactivity subscale. INTERPRETATION: This study suggests that the increased risk of children with unilateral CP experiencing executive functioning difficulties in everyday life, conduct problems, and hyperactivity can be partly explained by decreased cognitive executive functioning abilities relative to children with typical development.

Executive function in children and adolescents with unilateral cerebral palsy.

AIM: The aim of this study was to compare executive function in children with left- and right-sided unilateral cerebral palsy (CP) and typically developing children. METHOD: There was a cross-sectional cohort of 46 children with unilateral CP (24 right-side, 22 left-side; 25 males, 21 females; mean age 11y 1mo, SD 2y 5mo) and 20 typically developing children (nine males, 11 females; mean age 10y 10mo, SD 2y 4mo). Four cognitive domains of executive function were assessed: attentional control, cognitive flexibility, goal setting, and information processing. Subtests from the Delis-Kaplan Executive Function System, the Test of Everyday Attention for Children, the Rey-Osterrieth Complex figure, and the Wechsler Intelligence Scale for Children - Fourth Edition were utilized. Between-group differences (right unilateral CP, left unilateral CP, and typically developing children) were examined using analyses of covariance. RESULTS: Children with CP performed significantly more poorly than typically developing children on all executive function measures (aggregate executive function: F(1,63)=31.16; p<0.001; η(2) =0.33). There were no significant differences between children with left and right unilateral CP, except in the case of inhibition/switching total errors, with children with left unilateral CP making fewer errors than children with right unilateral CP (F(1,39)=4.14; p=0.049; η(2) =0.1). INTERPRETATION: Children and adolescents with unilateral CP experience difficulties across multiple executive function domains compared with typically developing children, irrespective of the side of hemiplegia. This finding supports an early vulnerability model of early brain injury and has implications for intervention for children with CP.

Central nervous system stimulants for secondary attention deficit-hyperactivity disorder after paediatric traumatic brain injury: a rationale and protocol for single patient (n-of-1) multiple cross-over trials.

BACKGROUND: It is estimated that 22,800 children were living with an Acquired Brain Injury (ABI) (0.6% of children aged under 15 years) in Australia during 2003. Many children after a traumatic brain injury will experience difficulties with attention and concentration; a condition termed secondary Attention Deficit-Hyperactivity Disorder. There is conflicting evidence on whether treatment with stimulant therapy with medications such as methylphenidate or dexamphetamine will improve the attention and behavior of children with this condition. METHODS/DESIGN: Single patient trials (n-of-1s or SPTs) evaluate the effect of titrated doses of psychostimulants methylphenidate or dexamphetamine compared to placebo on attention and behavior, in children with TBI and secondary ADHD. The aggregation of multiple SPTs will produce a population estimate of the benefit. Forty-two children will be registered into the trial through rehabilitation services at three large children's hospitals in Australia. Patients will complete up to 3 cycles of treatment. Each cycle is 2 weeks long comprising seven days each of treatment and placebo, with the first two days of each cycle considered a washout period and the data not analysed. The order of treatment and placebo is randomly allocated for each cycle. The Conners' Parent Rating Scales long forms will be employed to measure change in attention-deficit/hyperactivity and related problems of the child, and the primary outcome measure is the Conners' Global Index Parent Version. Secondary outcomes include the teacher and child (if aged > 12 years) Conners' Rating Scales, the Behaviour Rating Inventory of Executive Function among other measures. This study will provide high-level evidence using a novel methodological approach to inform clinicians about the most appropriate treatment for individual children. Through aggregation of individual trials, a population estimate of treatment effect will be provided to guide clinical practice in the treatment of children with secondary ADHD after a traumatic brain injury. DISCUSSION: This study employs an innovative methodological approach on the effectiveness of CNS stimulants for secondary ADHD from a brain injury. The findings will both guide clinicians on treatment recommendations, and inform the concept and acceptance of SPTs in paediatric research. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry. ACTRN12609000873224.