Honing in on the Social Difficulties Associated With Sluggish Cognitive Tempo in Children: Withdrawal, Peer Ignoring, and Low Engagement.

Sluggish cognitive tempo (SCT) symptoms are associated with social difficulties in children, though findings are mixed and many studies have used global measures of social impairment. The present study tested the hypothesis that SCT would be uniquely associated with aspects of social functioning characterized by withdrawal and isolation, whereas attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms would be uniquely associated with aspects of social functioning characterized by inappropriate responding in social situations and active peer exclusion. Participants were 158 children (70% boys) between 7-12 years of age being evaluated for possible ADHD. Both parents and teachers completed measures of SCT, ADHD, ODD, and internalizing (anxiety/depression) symptoms. Parents also completed ratings of social engagement and self-control. Teachers also completed measures assessing asociality and exclusion, as well as peer ignoring and dislike. In regression analyses controlling for demographic characteristics and other psychopathology symptoms, parent-reported SCT symptoms were significantly associated with lower social engagement (e.g., starting conversations, joining activities). Teacher-reported SCT symptoms were significantly associated with greater asociality/withdrawal and ratings of more frequent ignoring by peers, as well as greater exclusion. ODD symptoms and ADHD hyperactive-impulsive symptoms were more consistently associated with other aspects of social behavior, including peer exclusion, being disliked by peers, and poorer self-control during social situations. Findings provide the clearest evidence to date that the social difficulties associated with SCT are primarily due to withdrawal, isolation, and low initiative in social situations. Social skills training interventions may be effective for children displaying elevated SCT symptomatology.

Profiles of Executive Function Across Children with Distinct Brain Disorders: Traumatic Brain Injury, Stroke, and Brain Tumor.

OBJECTIVES: This study examined whether children with distinct brain disorders show different profiles of strengths and weaknesses in executive functions, and differ from children without brain disorder. METHODS: Participants were children with traumatic brain injury (N=82; 8-13 years of age), arterial ischemic stroke (N=36; 6-16 years of age), and brain tumor (N=74; 9-18 years of age), each with a corresponding matched comparison group consisting of children with orthopedic injury (N=61), asthma (N=15), and classmates without medical illness (N=68), respectively. Shifting, inhibition, and working memory were assessed, respectively, using three Test of Everyday Attention: Children's Version (TEA-Ch) subtests: Creature Counting, Walk-Don't-Walk, and Code Transmission. Comparison groups did not differ in TEA-Ch performance and were merged into a single control group. Profile analysis was used to examine group differences in TEA-Ch subtest scaled scores after controlling for maternal education and age. RESULTS: As a whole, children with brain disorder performed more poorly than controls on measures of executive function. Relative to controls, the three brain injury groups showed significantly different profiles of executive functions. Importantly, post hoc tests revealed that performance on TEA-Ch subtests differed among the brain disorder groups. CONCLUSIONS: Results suggest that different childhood brain disorders result in distinct patterns of executive function deficits that differ from children without brain disorder. Implications for clinical practice and future research are discussed. (JINS, 2017, 23, 529-538).

Neurocognitive profile of a young adolescent with DK phocomelia/von Voss phocomelia/von Voss Cherstvoy syndrome.

DK phocomelia/von Voss Cherstvoy syndrome is a rare condition characterized by upper limb and urogenital abnormalities and various brain anomalies. Previously reported cases have noted significant developmental delays, although no formal testing of cognitive abilities has been reported. In this paper we describe results from a comprehensive neuropsychological evaluation of a 12-year-old male with DK phocomelia syndrome. Test findings indicated mild impairment in intellectual functioning, with more significant impairment in adaptive skills and academic achievement. The neuropsychological profile converged with neurological findings, showing a distinct pattern of strengths and weaknesses that suggests functional compromise of posterior brain regions with relatively well-preserved functioning of more anterior regions. Specifically, impairments were evident in perceptual reasoning, visual perception, and visuomotor integration, whereas normal or near normal functioning was evident in memory, receptive language, social cognition, attention, and most aspects of executive functioning. To our knowledge this is the first report to describe the neurocognitive profile of an individual with DK phocomelia syndrome.

Hot and Cool Executive Functions in Children with Attention-Deficit/Hyperactivity Disorder and Comorbid Oppositional Defiant Disorder.

While neuropsychological deficits in both "hot" and "cool" executive functions (EFs) have been documented among individuals with attention-deficit/hyperactivity disorder (ADHD), these EF deficits are not universal across all individuals with this diagnosis. One potential moderator of executive dysfunction may be the presence of comorbid oppositional defiant disorder (ODD). This study examined the association between "hot" and "cool" EFs and comorbid ODD in children with ADHD. Thirty-three children with ADHD and comorbid ODD (ADHD+ODD), 67 with ADHD without ODD (ADHD-ODD), and 30 typically developing controls participated. Children were 7-12 years of age. "Cool" EFs were assessed with a spatial span task and a card sorting test. "Hot" EFs were assessed using a delay discounting task and a gambling task. ADHD-ODD and ADHD+ODD groups performed more poorly on "cool" EF tasks than controls, but did not differ from each other. Furthermore, the number of ADHD symptoms, but not ODD symptoms, was associated with "cool" EF scores. The three groups did not differ on "hot" EF tasks and the number of ADHD or ODD symptoms was unrelated to "hot" EF scores. In sum, children with ADHD presented with "cool" EF deficits which appear to be unrelated to ODD comorbidity. However, "hot" EF deficits were not present among children with ADHD, irrespective of comorbid ODD status.

Web-Based Parenting Skills Program for Pediatric Traumatic Brain Injury Reduces Psychological Distress Among Lower-Income Parents.

OBJECTIVE: To examine changes in parent depression, psychological distress, parenting stress, and self-efficacy among participants in a randomized trial of a Web-based parent training program for pediatric traumatic brain injury (TBI). METHODS: Primary caregivers of 37 children aged 3 to 9 years who sustained a moderate/complicated mild to severe TBI were randomly assigned to the intervention or control group, and both groups were equipped with home Internet access. The online parent training program was designed to increase positive parenting skills and improve caregiver stress management. It consisted of 10 core sessions and up to 4 supplemental sessions. Each session included self-guided Web content, followed by a videoconference call with a therapist to discuss content and practice parenting skills with live feedback. Families in the control group received links to TBI Web resources. RESULTS: Parent income moderated treatment effects on parent functioning. Specifically, lower-income parents in the parenting skills group reported significant reductions in psychological distress compared with lower-income parents in the control group. No differences were found among higher-income parents for depression, parenting stress, or caregiver efficacy. CONCLUSIONS: Parent training interventions post-TBI may be particularly valuable for lower-income parents who are vulnerable to both environmental and injury-related stresses.

Neurodevelopmental functioning in children being evaluated for heart transplant prior to 2 years of age.

Cardiac defects represent the most common type of birth defect and children with these abnormalities are known to experience a variety of developmental and neuropsychological delays. Children receiving heart transplants may be at the highest risk for delays as they tend to represent the most severely ill patients with heart disease. This study investigates neurocognitive and adaptive functioning in 20 children under 2 years of age who were undergoing evaluation for heart transplant, comparing their performance to that of normative samples. The results indicate delays across various domains of neurocognition, including general cognitive, receptive language, expressive language, fine motor, and gross motor skills. In addition, adaptive and social-emotional functioning fell significantly below that of normative samples. No significant differences were found when comparing the test performance of patients with congenital heart defects (n = 12) to patients with cardiomyopathy (n = 8). Secondary analyses investigating the impact of genetic conditions, premature birth, and non-English language dominance showed minor changes in results across some domains, although this may have been due, at least in part, to decreased power to detect differences. Overall, this study's results support the need for early evaluation, intensive intervention (e.g., speech, occupational, and physical therapy), and continued monitoring of these patients' neurodevelopmental/neuropsychological functioning over time. Future research should examine longitudinal changes in development using both pre- and post-transplant data and should investigate the impact of early intervention.

Negative Consequences of Poor Driving Outcomes Reported by Adolescents With and Without ADHD.

OBJECTIVE: Although adolescents with ADHD report less driving experience, a greater proportion of adolescents with ADHD report receiving at least one ticket; however, no study has examined the severity of infractions committed by adolescent drivers with ADHD. METHOD: A total of 61 adolescents (28 ADHD, 33 controls) aged 16 to 17 with a valid driver's license completed a self-report Driving History Questionnaire (DHQ), which asked about months of driving experience, negative driving outcomes, and severity of consequences. RESULTS: A greater proportion of adolescents with ADHD reported receiving fines, points on their driver's license, and remedial driving class. Furthermore, adolescents with ADHD reported attending a greater number of hours in remedial driving class, and a greater expense associated with fines. CONCLUSION: Importantly, ADHD-related negative driving outcomes manifest early in driving careers. Furthermore, increased negative consequences of poor and/or risky driving among adolescents with ADHD were evident despite having fewer months of independent driving.

Neuropsychological functioning in preschool-aged children undergoing evaluation for organ transplant.

OBJECTIVE: The purpose of this study was to review the current literature on neuropsychological functioning in two groups of children requiring organ transplants (liver or heart) and present recent clinical data collected through the liver and cardiac transplantation programs at a large pediatric academic medical center. METHOD: Data included in this study came from 18 patients who completed evaluations for heart transplant (n = 8) or liver transplant (n = 10) between the ages of 2 and 6 years (inclusive). Measures examining neurocognitive, emotional-behavioral, and adaptive functioning were collected as part of standard pre-transplant clinical neuropsychological evaluations. Within each organ group, mean scores were calculated and compared with normative population mean scores using one sample t-tests. In addition, non-parametric binomial tests were calculated to examine whether the proportion of individuals falling more than one standard deviation below the population mean was significantly greater in the patient groups than the normative population base rate of 16%. RESULTS: Patients in both groups performed below normative expectation in several neurocognitive and adaptive domains. However, neither group showed significant difficulties in behavioral or emotional regulation. CONCLUSIONS: Results from this study document cognitive delays in preschool-aged children undergoing evaluations for liver transplant or heart transplant, highlighting the importance of intervention and long-term monitoring of these two patient populations, as well as the need for neuropsychologist involvement with transplant teams.

Attention, processing speed, and executive functioning in pediatric brain tumor survivors treated with proton beam radiation therapy.

BACKGROUND AND PURPOSE: This study examines attention, processing speed, and executive functioning in pediatric brain tumor survivors treated with proton beam radiation therapy (PBRT). MATERIAL AND METHODS: We examined 39 survivors (age 6-19years) who were 3.61years post-PBRT on average. Craniospinal (CSI; n=21) and focal (n=18) subgroups were analyzed. Attention, processing speed, and executive functioning scores were compared to population norms, and clinical/demographic risk factors were examined. RESULTS: As a group, survivors treated with focal PBRT exhibited attention, processing speed, and executive functioning that did not differ from population norms (all p>0.05). Performance in the CSI group across attention scales was normative (all p>0.05), but areas of relative weakness were identified on one executive functioning subtest and several processing speed subtests (all p<0.01). CONCLUSIONS: Survivors treated with PBRT may exhibit relative resilience in cognitive domains traditionally associated with radiation late effects. Attention, processing speed, and executive functioning remained intact and within normal limits for survivors treated with focal PBRT. Among survivors treated with CSI, a score pattern emerged that was suggestive of difficulties in underlying component skills (i.e., processing speed) rather than true executive dysfunction. No evidence of profound cognitive impairment was found in either group.

Neurocognitive and Behavioral Predictors of Math Performance in Children With and Without ADHD.

OBJECTIVE: This study examined neurocognitive and behavioral predictors of math performance in children with and without ADHD. METHOD: Neurocognitive and behavioral variables were examined as predictors of (a) standardized mathematics achievement scores, (b) productivity on an analog math task, and (c) accuracy on an analog math task. RESULTS: Children with ADHD had lower achievement scores but did not significantly differ from controls on math productivity or accuracy. N-back accuracy and parent-rated attention predicted math achievement. N-back accuracy and observed attention predicted math productivity. Alerting scores on the attentional network task predicted math accuracy. Mediation analyses indicated that n-back accuracy significantly mediated the relationship between diagnostic group and math achievement. CONCLUSION: Neurocognition, rather than behavior, may account for the deficits in math achievement exhibited by many children with ADHD.

Extended Visual Glances Away from the Roadway are Associated with ADHD- and Texting-Related Driving Performance Deficits in Adolescents.

The purpose of the research study was to determine whether ADHD- and texting-related driving impairments are mediated by extended visual glances away from the roadway. Sixty-one adolescents (ADHD =28, non-ADHD =33; 62% male; 11% minority) aged 16-17 with a valid driver's license were videotaped while engaging in a driving simulation that included a No Distraction, Hands-Free Phone Conversation, and Texting condition. Two indicators of visual inattention were coded: 1) percentage of time with eyes diverted from the roadway; and 2) number of extended (greater than 2 s) visual glances away from the roadway. Adolescents with ADHD displayed significantly more visual inattention to the roadway on both visual inattention measures. Increased lane position variability among adolescents with ADHD compared to those without ADHD during the Hands-Free Phone Conversation and Texting conditions was mediated by an increased number of extended glances away from the roadway. Similarly, texting resulted in decreased visual attention to the roadway. Finally, increased lane position variability during texting was also mediated by the number of extended glances away from the roadway. Both ADHD and texting impair visual attention to the roadway and the consequence of this visual inattention is increased lane position variability. Visual inattention is implicated as a possible mechanism for ADHD- and texting-related deficits and suggests that driving interventions designed to address ADHD- or texting-related deficits in adolescents need to focus on decreasing extended glances away from the roadway.

Parent-teacher agreement on ADHD symptoms across development.

Parent-teacher agreement on attention-deficit/hyperactivity disorder (ADHD) symptom ratings ranges from low to moderate. Most studies evaluating parent-teacher agreement have not assessed measurement invariance across raters. Hence, it is unclear whether discordance across raters is due to differing ADHD constructs across raters or other factors (e.g., subjective differences across raters). Additionally, the effect of development on parent-teacher agreement is relatively unknown. To address these limitations, the present study used parent and teacher ADHD ratings from a large (N = 6,659) developmentally diverse (ages 4-17) sample. Using exploratory structural equation modeling on half the sample, and then confirmatory factor analysis (CFA) on the other half of the sample, confirmed a 2-factor structure with significant cross-loadings for the 18 ADHD symptoms. CFA invariance analyses demonstrated that the 2-factor symptom structure was similar across raters and age groups. After confirming measurement invariance, the correlation between latent factors within and across raters was examined for each age group as well as across age groups. Parents reported greater severity of ADHD symptoms than did teachers, and both parents and teachers reported higher levels of hyperactivity/impulsivity in younger children than in older children and consistent levels of inattention across development. Finally, correlations between parent-teacher ratings of like factors were weak for inattention and moderate-strong for hyperactivity/impulsivity, and the magnitude of parent-teacher agreement did not vary across development. In conclusion, while parent and teacher ratings of ADHD behaviors are only weakly to moderately correlated, each reporter provides unique and valid clinical information as it relates to ADHD symptom presentation.

The relationship between suboptimal effort and post-concussion symptoms in children and adolescents with mild traumatic brain injury.

This retrospective chart review study explored the relationship between suboptimal effort and post-concussion symptoms in pediatric mild traumatic brain injury (mTBI). Participants were 382 clinically referred children and adolescents between 8 and 16 years of age who sustained an mTBI. Suboptimal effort was identified using reliable digit span and age-corrected scaled scores from the Numbers subtest of the Children's Memory Scale (CMS); 20% of the sample were classified as non-credible performers. Chi-square analyses and t-tests were used to examine differences in post-concussion symptoms and neuropsychological test performance between credible and non-credible performers. Linear regression was used to examine whether CMS Numbers performance predicted post-concussion symptoms after controlling for baseline symptoms and other relevant demographic- and injury-related factors. We found that non-credible performers presented with a greater number of post-concussion symptoms as compared with credible performers. Additionally, non-credible performers demonstrated comparatively poorer performance on neuropsychological tests of focused attention and processing speed. These results suggest that children and adolescents with mTBI who fail effort testing might have a greater tendency to exaggerate post-concussion symptoms and cognitive impairment. The clinical implications of these findings are discussed.

A pilot randomized trial of an online parenting skills program for pediatric traumatic brain injury: improvements in parenting and child behavior.

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

Web-based parenting skills to reduce behavior problems following abusive head trauma: a pilot study.

Pediatric abusive head trauma causes significant cognitive and behavioral morbidity, yet very few post-acute interventions exist to facilitate long-term recovery. To meet the needs of this vulnerable population, we piloted a web-based intervention with live coaching designed to improve positive parenting and child behavior. The efficacy of this parenting skills intervention was compared with access to Internet resources on brain injury. Participants included seven families (four randomized to the parenting intervention and three randomized to receive Internet resources). Parenting skills were observed and child behavior was rated at baseline and intervention completion. At completion, parents who received the parenting skills intervention showed significantly more positive parenting behaviors and fewer undesirable behaviors during play than parents who received access to Internet resources. Additionally, during play, children in the parenting skills intervention group were more compliant following parent commands than children in the Internet resources group. Lastly, parents who received the parenting intervention reported less intense oppositional and conduct behavior problems in their children post-intervention than did parents in the Internet resources group. These findings provide preliminary evidence for the use of this web-based positive parenting skills intervention to improve parenting skills and child behavior following abusive head trauma.

Mediators of methylphenidate effects on math performance in children with attention-deficit hyperactivity disorder.

OBJECTIVE: Stimulant medications, such as methylphenidate (MPH), improve the academic performance of children with attention-deficit hyperactivity disorder (ADHD). However, the mechanism by which MPH exerts an effect on academic performance is unclear. We examined MPH effects on math performance and investigated possible mediation of MPH effects by changes in time on-task, inhibitory control, selective attention, and reaction time variability. METHODS: Children with ADHD aged 7 to 11 years (N = 93) completed a timed math worksheet (with problems tailored to each individual's level of proficiency) and 2 neuropsychological tasks (Go/No-Go and Child Attention Network Test) at baseline, then participated in a 4-week, randomized, controlled, titration trial of MPH. Children were then randomly assigned to their optimal MPH dose or placebo for 1 week (administered double-blind) and repeated the math and neuropsychological tasks (posttest). Baseline and posttest videorecordings of children performing the math task were coded to assess time on-task. RESULTS: Children taking MPH completed 23 more math problems at posttest compared to baseline, whereas the placebo group completed 24 fewer problems on posttest versus baseline, but the effects on math accuracy (percent correct) did not differ. Path analyses revealed that only change in time on-task was a significant mediator of MPH's improvements in math productivity. CONCLUSIONS: MPH-derived math productivity improvements may be explained in part by increased time spent on-task, rather than improvements in neurocognitive parameters, such as inhibitory control, selective attention, or reaction time variability.

Behavioral correlates of reaction time variability in children with and without ADHD.

OBJECTIVE: Reaction time (RT) variability is often purported to indicate behavioral attention. This study seeks to examine whether RT variability in children with Attention Deficit Hyperactivity Disorder (ADHD) is associated with observed behavioral indicators of attention. METHOD: One-hundred 47 participants with and without ADHD completed five computerized neuropsychological tasks and an analog math task. Linear mixed models were utilized to examine the relationship between observations of behavioral inattention during the analog task and measures of RT variability from the neuropsychological tasks. RESULTS: Significant associations were observed between RT variability and mean duration of on-task behavior on the analog math task. Secondary analyses indicated that on-task behavior during the math task was also related to accuracy on the neuropsychological tasks. CONCLUSIONS: RT variability, especially the portion of RT variability characterized by long RTs, appears to measure a cognitive phenomenon that relates to successful on-task academic behavior across children with and without ADHD. The relationship between RT variability and on-task behavior is present across multiple neuropsychological tasks and does not appear to be moderated by age, sex, or the presence of anxiety or depression.

Impact of distraction on the driving performance of adolescents with and without attention-deficit/hyperactivity disorder.

IMPORTANCE: This study extends the literature regarding attention-deficit/hyperactivity disorder (ADHD)-related driving impairments to a newly licensed, adolescent population. OBJECTIVE: To investigate the combined risks of adolescence, ADHD, and distracted driving (cell phone conversation and text messaging) on driving performance. DESIGN, SETTING, AND PARTICIPANTS: Adolescents aged 16 to 17 years with (n = 28) and without (n = 33) ADHD engaged in a simulated drive under 3 conditions (no distraction, cell phone conversation, and texting). During each condition, one unexpected event (eg, another car suddenly merging into driver's lane) was introduced. INTERVENTIONS: Cell phone conversation, texting, and no distraction while driving. MAIN OUTCOMES AND MEASURES: Self-report of driving history, average speed, standard deviation of speed, standard deviation of lateral position, and braking reaction time during driving simulation. RESULTS: Adolescents with ADHD reported fewer months of driving experience and a higher proportion of driving violations than control subjects. After controlling for months of driving history, adolescents with ADHD demonstrated more variability in speed and lane position than control subjects. There were no group differences for braking reaction time. Furthermore, texting negatively impacted the driving performance of all participants as evidenced by increased variability in speed and lane position. CONCLUSIONS: To our knowledge, this study is one of the first to investigate distracted driving in adolescents with ADHD and adds to a growing body of literature documenting that individuals with ADHD are at increased risk for negative driving outcomes. Furthermore, texting significantly impairs the driving performance of all adolescents and increases existing driving-related impairment in adolescents with ADHD, highlighting the need for education and enforcement of regulations against texting for this age group.

An online positive parenting skills programme for paediatric traumatic brain injury: feasibility and parental satisfaction.

We examined the feasibility of and parental satisfaction with a training programme for parents with children who had suffered traumatic brain injury (TBI). Families who did not have a home computer and/or webcam were loaned the necessary equipment. Skype was used for videoconferencing. After the initial treatment session in the family's home, the remaining nine sessions were conducted online. Each session had two parts: (1) a self-guided web session with information about a particular skill; (2) a videoconference session with the therapist. Three of the 20 families (15%) dropped out prior to the final 6-month follow-up visit. Of the remaining 17 families, 13 (65% of those enrolled) completed 9-14 sessions. Almost all of the caregivers (87%) said that the Skype sessions were helpful compared to a conventional office visit. Almost all parents were satisfied with the programme and the technology that was used. Parental satisfaction with the programme was not influenced by prior computer ownership or comfort with technology. The programme appears to be feasible for a wide range of parents of children with TBI and provides an alternative to conventional office-based sessions that may not be accessible to all families.

Reaction time variability in ADHD: a review.

For the past decade, intra-individual variability in reaction times on computerized tasks has become a central focus of cognitive research on Attention-Deficit/Hyperactivity Disorder (ADHD). Numerous studies document increased reaction time variability among children and adults with ADHD, relative to typically developing controls. However, direct comparisons with other disorders with heightened reaction time variability are virtually nonexistent, despite their potential to inform our understanding of the phenomenon. A growing literature examines the sensitivity of reaction time variability to theoretically and clinically relevant manipulations. There is strong evidence that stimulus treatment reduces reaction time variability during a range of cognitive tasks, but the literature is mixed regarding the impact of motivational incentives and variation in stimulus event rate. Most studies of reaction time variability implicitly assume that heightened reaction time variability reflects occasional lapses in attention, and the dominant neurophysiological interpretation suggests this variability is linked to intrusions of task-negative brain network activity during task performance. Work examining the behavioral and neurophysiological correlates of reaction time variability provides some support for these hypotheses, but considerably more work is needed in this area. Finally, because conclusions from each of domains reviewed are limited by the wide range of measures used to measure reaction time variability, this review highlights the need for increased attention to the cognitive and motivational context in which variability is assessed and recommends that future work always supplement macro-level variability indices with metrics that isolate particular components of reaction time variability.