Cognitive Orientation to daily Occupational Performance to improve occupational performance goals for children with executive function deficits after acquired brain injury.

AIM: To determine the effectiveness of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach in improving the occupational performance goals of children and young people with executive function deficits after acquired brain injury (ABI) (e.g. etiologies such as stroke, encephalitis, brain tumor, and traumatic brain injury). METHOD: A replicated single-case experimental study using a randomized multiple baseline design across participants and goals was used. Three clusters of four participants (12 participants, nine males and three females, aged 8-16 years) were included. The intervention consisted of 14 individual CO-OP sessions. Each participant chose four goals; three goals were trained during the intervention sessions and a fourth goal served as the control. The Goal Attainment Scale (GAS) was used as a repeated measure to determine goal achievement while the Canadian Occupational Performance Measure (COPM) was used to identify the perceived goal achievement of children, young people, and their parents. RESULTS: For 26 of the 35 trained goals, the intervention led to statistically significant improvements in the GAS. Perceived occupational performance and satisfaction improved significantly for the trained goals (30 out of 35 goals for the COPM performance and satisfaction of participants; 26 out 31 goals for the COPM performance of parents; 24 out of 31 goals for the COPM satisfaction of parents) and were maintained at the follow-up. Almost all COPM control goal results were significant, but these changes were not supported by the GAS measures or the statistical analysis. INTERPRETATION: The generally positive results of this study provide evidence of the benefits of using the CO-OP approach with this population.

How to assess and take into account trend in single-case experimental design data.

One of the data features that are expected to be assessed when analyzing single-case experimental designs (SCED) data is trend. The current text deals with four different questions that applied researchers can ask themselves when assessing trend and especially when dealing with improving baseline trend: (a) What options exist for assessing the presence of trend?; (b) Once assessed, what criterion can be followed for deciding whether it is necessary to control for baseline trend?; (c) What strategy can be followed for controlling for baseline trend?; and (d) How to proceed in case there is baseline trend only in some A-B comparisons? Several options are reviewed for each of these questions in the context of real data, and tentative recommendations are provided. A new user-friendly website is developed to implement the options for fitting a trend line and a criterion for selecting a specific technique for that purpose. Trend-related and more general data analytical recommendations are provided for applied researchers.Trial registration: ClinicalTrials.gov identifier: NCT04560777.

A pilot rating system to evaluate the quality of goal attainment scales used as outcome measures in rehabilitation.

Goal Attainment Scaling (GAS) is a method for writing person-centred approach evaluation scales that can be used as an outcome measure in clinical or research settings in rehabilitation. To be used in a research setting, it requires a high methodological quality approach. The aim of this study was to explore the feasibility and reliability of the GAS quality rating system, to ensure that GAS scales used as outcome measures are valid and reliable. Secondary objectives were: (1) to compare goal attainment scores' reliability according to how many GAS levels are described in the scale; and (2) to explore if GAS scorings are influenced by who scores goal attainment. The GAS scales analysed here were set collaboratively by 57 cognitively impaired adults clients and their occupational therapist. Goals had to be achieved within an inpatient one-month stay, during which clients participated in an intervention aimed at improving planning skills in daily life. The GAS quality rating system proved to be feasible and reliable. Regarding GAS scores, interrater reliability was higher when only three of the five GAS levels were described, i.e., "three milestone GAS" (0.74-0.92), than when all five levels were described (0.5-0.88), especially when scored by the clients (0.5 -0.88).

Single-case experimental designs for child neurological rehabilitation and developmental disability research.

Single-case experimental designs (SCEDs) are a group of methodologies of growing interest, aiming to test the effectiveness of an intervention at the single-participant level, using a rigorous and prospective methodology. SCEDs may promote flexibility on how we design research protocols and inform clinical decision-making, especially for personalized outcome measures, inclusion of families with challenging needs, measurement of children's progress in relation to parental implementation of interventions, and focus on personal goals. Design options for SCEDs are discussed in relation to an expected on/off effect of the intervention (e.g. school/environmental adaptation, assistive technology devices) or, alternatively, on an expected carry-on/maintenance of effects (interventions aiming to develop or restore a function). Randomization in multiple-baseline designs and 'power' calculations are explained. The most frequent reasons for not detecting an intervention effect in SCEDs are also presented, especially in relation to baseline length, trend, and instability. The use of SCEDs on the front and back ends of randomized controlled trials is discussed. WHAT THIS PAPER ADDS: Single-case experimental designs (SCEDs) may promote flexibility on how we design research protocols. Randomization in multiple-baseline designs allows 'power' calculations based on randomization tests. Whenever feasible, N-of-1 trials should be preferred to other SCEDs and to group randomized controlled trials.

Improving autobiographical memory in schizophrenia using wearable cameras: A single-case experimental study.

Autobiographical memory (AM) impairments influence both sense of identity and social functioning of patients with schizophrenia. However, cognitive remediation methods addressing these difficulties do not sufficiently consider the heterogeneity of this disorder and frequently face methodological limitations. The aim of the present study was to evaluate the efficacy of a method using a wearable camera (NarrativeClip®), through an alternating treatments design across two types of AM training. In parallel, repeated measures were used to appreciate the efficacy, specificity, and generalizability of the programme's benefits. Three patients were invited to wear the camera during 24 personal events. Ten of these events memories were trained by visual cueing (wearable camera condition), 10 others by verbal cueing (written diary condition) and 4 were not trained (control condition). Using pictures collected by the wearable camera seemed particularly relevant, since it promoted more detailed recalls than the diary method, from the first training session and until the end of a one-year follow-up. In addition, the repeated measures performed revealed (1) the efficacy (improvement in AM capacities after participating in the programme), (2) specificity (persistence of working memory deficits), and (3) generalizability (improvement in measures of episodic memory) of our cognitive remediation programme's effects.

Ecological Assessment of Everyday Executive Functioning at Home and at School Following Childhood Traumatic Brain Injury Using the BRIEF Questionnaire.

OBJECTIVES: To describe dysexecutive symptoms in children with traumatic brain injury (TBI) using the Behavior Rating Inventory of Executive Function (BRIEF); to compare parent- and teacher-ratings, to analyze the differential impairment in the BRIEF subscales, and factors influencing outcome. PARTICIPANTS: Children aged 5 to 18 years 11 months, referred to a rehabilitation department following TBI. OUTCOME MEASURES: Parent- and teacher reports of the BRIEF. RESULTS: A total of 194 patients participated in the study: mild (n = 13), moderate (n = 12), severe (n = 169); mean 4.92 (standard deviation = 3.94) years post-injury. According to parent ratings (n = 193), all BRIEF subscales and indices were significantly elevated (23.8%-48% in the clinical range). The Working Memory subscale score was significantly higher than all other subscales. Results of teacher ratings (n = 28) indicated similar significantly elevated scores in all subscales (39.3%-57.2% in the clinical range). No significant difference was found between parent and teacher ratings, which were significantly correlated. Regression analyses indicated that, in children with severe TBI, parental BRIEF overall and metacognition indices were significantly predicted by younger age at injury and older age at assessment, whereas no significant predictor of behavioral regulation index was identified. DISCUSSION AND CONCLUSION: This study highlights significant executive dysfunction in everyday life several years after childhood TBI, evident in home and school environments.

Proposed Criteria for Appraising Goal Attainment Scales Used as Outcome Measures in Rehabilitation Research.

Goal Attainment Scaling (GAS) is a method for writing personalized evaluation scales to quantify progress toward defined rehabilitation goals. In the published literature, GAS methodology is used with different levels of rigor, ranging from precisely written GAS scales that ensure minimal bias and explicitly describe 5 levels of goal attainment to subjective ratings of goal attainment by adjectives (eg, worse/better than expected), which are transformed into a T score, wrongly giving the reader the impression of a truly standardized, interval scale. A drawback of GAS methodology is that it is highly dependent on the ability of the GAS setting team/person to generate valid, reliable, and meaningful scales; therefore, reliability and validity of GAS scales are idiosyncratic to each study. The aims of this article were to (1) increase awareness of potential sources of bias in GAS processes; (2) propose GAS quality appraisal criteria, allowing judgment of the quality of GAS methodology in individual rehabilitation studies; and (3) propose directions to improve GAS implementation to increase its reliability and validity as a research measurement tool. Our proposed quality appraisal criteria are based on critical appraisal of GAS literature and published GAS validity studies that have demonstrated that precision, validity, and reliability can be obtained when using GAS as an outcome measure in clinical trials. We recommend that authors using GAS report accurately how GAS methodology was used based on these criteria.

Context-sensitive goal management training for everyday executive dysfunction in children after severe traumatic brain injury.

OBJECTIVES: To assess the effectiveness of a metacognitive training intervention, based on an adapted Goal Management Training and Ylvisaker's principles, on 3 activity domains of executive functions: (1) prospective memory (PM) performance in ecological setting, (2) complex cooking task management, and (3) daily executive functioning (EF) at home and at school. PARTICIPANTS: Five children aged 8 to 14 years, who were 3 to 11 years post-severe traumatic brain injury, experiencing severe EF difficulties in daily life. DESIGN: Single-case experimental design and assessment of EF twice prior to intervention, postintervention, and 3 and 6 months postintervention. Progress was monitored by a weekly ecological PM score. The effect on EF was assessed using the Children's Cooking Task. Transfer to the child's natural context was assessed by parental and teacher questionnaires and Goal Attainment Scaling. RESULTS: All children improved both on the measure of PM and on questionnaires of daily EF. Two children improved on the Children's Cooking Task but returned to their preintervention level in a novel cooking task at follow-up. Participation of school personnel and parents in the program was low. CONCLUSIONS: It is feasible but challenging to use Goal Management Training in children with traumatic brain injury. Further research is needed in relation to how to promote generalization and how to increase the involvement of the child's "everyday people" in the intervention.

An exploratory study of dialectical behaviour therapy for emotional dysregulation and challenging behaviours after acquired brain injury.

BACKGROUND: Challenging behaviours and emotional dysregulation are common sequelae of acquired brain injury (ABI), but treatment remain underdeveloped. Dialectical behaviour therapy is an evidence-based therapy for emotional dysregulation. OBJECTIVE: To explore the feasibility and preliminary efficacy of dialectical behaviour therapy for ABI. METHODS: An exploratory longitudinal study that compared thirty adults with brain injury presenting persistent emotion dysregulation or challenging behaviours. Control group received a personalized multidisciplinary program only (n = 13). The dialectical behaviour therapy group received five months of emotion regulation skills learning as an add-on (n = 17). Preliminary efficacy was measured on Difficulties in Emotion Regulation Scale-16 and Quality of Life after Brain Injury total score and emotion subscore. RESULTS: Fourteen participants completed the dialectical behaviour therapy. This study provided preliminary evidence for the feasibility and acceptability of dialectical behaviour therapy. Repeated measures revealed improvement on the Difficulties in Emotion Regulation Scale-16 (-7.6 [-17.3; 1.7]; Pr = 0.95) and on the Quality Of Life emotion subscore (13.5 [-3.8; 30.9]; Pr = 0.94). CONCLUSION: This study raises important questions regarding the type of patients who can benefit from this intervention, necessary adaptations of dialectical behaviour therapy and the way it can help post-traumatic growth and identity reconstruction after ABI.

Compassion focused therapy for self-stigma and shame in autism: a single case pre-experimental study.

Introduction: Exposure to public stigma can lead to the internalization of autism-related stigma (i.e., self-stigma), associated with negative health, occupational and social outcomes. Importantly, self-stigma is linked to shame and social isolation. Although elevated self-stigma has been reported in autistic adults, to the best of our knowledge, interventions designed to target this issue are lacking. Compassion is an effective way to reduce the emotional correlates of self-stigma (i.e., shame) and their impacts on mental health. However, no study has investigated whether compassion focused therapy (CFT) can effectively reduce self-stigma in autistic adults. The present study aims at investigating whether and how self-compassion improvement following CFT may reduce self-stigma and shame in an autistic individual. Methods: A single case pre-experimental design (SCED) was used with weekly repeated measures during four phases: (i) pure baseline without any intervention (A), (ii) case conceptualization (A'), (iii) intervention (B) where CFT was delivered, (iv) follow-up without intervention (FU). The participant is a 46-year-old autistic man with high self-stigma and shame. Self-report measures of self-compassion and self-stigma and a daily idiographic measure of shame were used. Results: There was a large increase in self-compassion between pure baseline (A) and the intervention phase (A'B) (Tau-U = 0.99), maintained at follow-up. Similarly, there was a moderate decrease of self-stigma (Tau-U = 0.32). In contrast, when we compared the whole baseline phase AA' (i.e., considering the conceptualisation phase as baseline) to the intervention (B), there was no change in self-stigma (Tau-U = -0.09). There was no change in self-stigma between the intervention (B) and follow-up (Tau-U = -0.19). There was a moderate decrease in daily shame reports between the baseline (AA') and the intervention (B) (Tau-U = 0.31) and a moderate decrease between the pure baseline (A) and intervention phase (A'B) (Tau-U = 0.51). Conclusion: CFT was feasible for this autistic client and our results show that CFT led to the improvement of self-compassion. Changes on self-stigma measures were moderate. Self-stigma may need more time to change. Because self-stigma is involved in poorer social functioning and mental health in autistic adults, our results are promising and suggesting conducting more large-scale studies on CFT in autistic adults.

Daily socket comfort in transtibial amputee with a vacuum-assisted suspension system: study protocol of a randomized, multicenter, double-blind multiple N-of-1 trial.

BACKGROUND: The main aim of this paper is to present the feasibility of rigorously designed multiple N-of-1 design in prosthetics research. While research of adequate power and high quality is often lacking in rehabilitation, N-of-1 trials can offer a feasible alternative to randomized controlled group trials, both increasing design power at group level and allowing a rigorous, statistically confirmed evaluation of effectiveness at a single patient level. The paper presents a multiple N-of-1 trial protocol, which aim is to evaluate the effectiveness of Unity, a prosthetic add-on suspension system for amputees, on patient-reported comfort during daily activities (main outcome measure), prosthesis wearing time, perception of limb-prosthesis fitting and stump volume and functional walking parameters. METHODS: Multicenter, randomized, prospective, double-blind multiple N-of-1 trial using an introduction/withdrawal design alternating Unity connected/disconnected phases of randomized length on twenty patients with unilateral transtibial amputation. The primary outcome measure is the Prosthetic Socket Comfort Score (SCS), a validated measure of comfort, administered daily by an phone app designed for the study. Secondary outcomes measures will be collected during the 50 days period of the N-of-1 trial: (1) by the same app, daily for patient-reported limb-prosthesis fitting, stump volume variation, and daily wearing time of the prosthesis; (2) by a pedometer for the number of steps per day; (3) by blind assessors in the rehabilitation center during adjustment visits for functional walking parameter (L-Test, 6-minute walk test), and by the patient for the QUEST, and ABC-S. Effectiveness of the Unity system regarding SCS and daily secondary outcome measures will be tested by randomization test. The secondary outcome measures assessed during visits in the rehabilitation center will be analyzed by Non Overlap of All pairs. An estimate of the effect on the amputee population will be generated by aggregating each individual clinical trial (N-of-1 trial) by Hierarchical Bayesian methods. DISCUSSION: This study protocol was designed to answer the question "which device is best for THIS patient" and to conclude at a group level on the effectiveness of a new devic, using a Multiple N-of-1 trial, which is promising but underused in prosthetics research so far. TRIAL REGISTRATION: N° ID-RCB 2020-A01309-30 Clintrial.gov : NCT04804150 - Retrospectively registered March 20th 2021.

Goal Attainment Scaling in rehabilitation: An educational review providing a comprehensive didactical tool box for implementing Goal Attainment Scaling.

CONTEXT: Goal Attainment Scaling (GAS) is a person-centered and collaborative approach, allowing to assess the effectiveness of an intervention on personally relevant goals. However, GAS is not a "scale" but a heterogeneous group of methodologies, including many variations and lack of consensus on high quality GAS. OBJECTIVE: The aim of this communication is to: 1. provide updated didactical information on GAS use in PRM practice and research; 2. increase awareness of GAS methodological challenges; 3. guide use of GAS as an integrated process of rehabilitation after goal setting and; 4. provide updated resources for self-directed learning and extensive supplemental material to increase knowledge and practical skills in GAS use. METHODS: Educational literature review about current GAS applications relevant to PRM fields. RESULTS: Practical advice is provided regarding clinical challenges in GAS: definition of 0 level, time-frame and means employed to attain the goal, dealing with unforeseen pattern of improvement, synthesizing the numerous significations of "SMART" goal acronym to guide best use of GAS, and thinking flexibility on the type of relevant goals that can be set. Challenges with GAS in rehabilitation research are presented in order to promote researcher's and reviewer's awareness on reliable use of GAS and encouraging best-use of GAS.

Comprehensive assessment of executive functioning following childhood severe traumatic brain injury: clinical utility of the child executive functions battery.

Objectives: To perform a detailed description of executive functioning following moderate-to-severe childhood traumatic brain injury (TBI), and to study demographic and severity factors influencing outcome. Methods: A convenience sample of children/adolescents aged 7-16 years, referred to a rehabilitation department after a TBI (n = 43), was compared to normative data using a newly developed neuropsychological test battery (Child Executive Functions Battery-CEF-B) and the BRIEF. Results: Performance in the TBI group was significantly impaired in most of the CEF-B subtests, with moderate to large effect sizes. Regarding everyday life, patients were significantly impaired in most BRIEF clinical scales, either in parent or in teacher reports. Univariate correlations in the TBI group did not yield significant correlations between the CEF-B and socio-economic status, TBI severity, age at injury, or time since injury. Conclusion: Executive functioning is severely altered following moderate-to-severe childhood TBI and is best assessed using a combination of developmentally appropriate neuropsychological tests and behavioral ratings to provide a comprehensive understanding of children's executive functions.

Charlie Chaplin and gesture training in severe aphasia: A controlled double-blind single-case experimental design.

BACKGROUND: Aphasia following a stroke is a frequent and disabling condition that decreases quality of life. The use of gesture has been proposed as a way to enhance aphasia recovery. OBJECTIVE: We aimed to explore whether 2 types of gesture interventions could improve communication in individuals with severe aphasia. METHODS: This was a pilot study performed at home in routine care by an outreach team. The study had a controlled double-blind single-case experimental design (SCED): a controlled multiple baseline design across 3 participants and 2 behaviors (gesture and naming). Three male patients with stroke-induced severe chronic aphasia, non-functional perseverative speech and severe associated impairments underwent a passive gesture intervention, in which participants watched movies selected for their intensive use of gesture, and an active gesture intervention, in which they actively practiced gestures by using visual action therapy. The main outcome measures were naming score, gesture score and nonverbal subscale score of the Lillois Test of Communication, with 3-month follow-up. RESULTS: In all 3 participants, gesture interventions improved the ability to gesture a list of words (Tau-U=0.38-0.67 for combined gesture intervention effect) and increased nonverbal communication activity. Benefits were maintained at 3-month follow-up. CONCLUSIONS: Mute films that use intensive nonverbal communication may be a useful add-on to speech therapy for individuals with aphasia. Improving naming in severe and chronic aphasia may not be feasible, and more effort could be devoted to improving gesture-based and nonverbal communication.

Exploring the use of the Cognitive Orientation to daily Occupational Performance approach (CO-OP) with children with executive functions deficits after severe acquired brain injury: A single case experimental design study.

Children with acquired brain injury (ABI) often have cognitive and behavioral impairments that affect participation in everyday activities. Among them, executive function (EF) deficits are frequent. Cognitive Orientation to Daily Occupational Performance (CO-OP) is an individualized treatment that teaches cognitive strategies necessary to support successful performance. Few studies have examined the effectiveness of CO-OP in children with EF deficits after ABI. OBJECTIVES: to assess whether the use of CO-OP could be of interest in children with EF deficits after ABI, to improve their occupational performance, their executive functioning in everyday life and their cognitive processes constituting EF. METHODS: This was a single case experimental study with multiple baselines across individuals and behaviors. We included 2 children at least 6 months after severe ABI. The children received 14 individual sessions of the CO-OP intervention. Each child set 3 goals by using the Canadian Occupational Performance Measure; 2 goals were trained and the third was a control goal. The achievement of the goals was measured by using repeated measures of Goal Attainment Scales (GASs). Ecological assessments of EF included the Children's Cooking Task and parent and teacher ratings of the Behavior Rating Inventory of Executive Function (BRIEF) questionnaire. RESULTS: both children improved their performance on both trained goals (and, to a lesser extent, on untrained goals). We found significant improvement on tests of EF and on the BRIEF questionnaire, reflecting executive functioning in everyday life, at home and at school. CONCLUSIONS: these results are encouraging and suggest the feasibility and effectiveness of CO-OP for children with EF deficits after ABI. They should be replicated in a larger number of cases. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04718688).

Cognitive Training Targeting Planning Dysfunction in Adults with Prader-Willi Syndrome: Brief Report of a Study Protocol.

Background: Prader-Willi syndrome (PWS) is a neurodevelopmental genetic disorder involving executive deficits notably with planning. The main objective of the study is to assess the effectiveness of cognitive training on daily life planning difficulties in PWS patients. Methods/design: The study is a double-blind randomized controlled trial which will compare the effectiveness of a metacognitive strategy intervention designed to improve planning difficulties for PWS patients to usual occupational therapy. Sixty adults will be included over 20 months. The main outcome measure will be the performance on the Modified Six Elements Test from the BADS; secondary outcome measures will be computerized executive tasks and questionnaires. Daily life planning difficulties will be identified and transformed into measurable goals using Goal Attainment Scaling. Discussion: The project will provide knowledge on the difficulties experienced by PWS patients, in relation to their executive functioning in order to implement effective intervention for planning in daily life.

Single-case experimental designs to assess intervention effectiveness in rehabilitation: A practical guide.

Single-case experimental designs (SCED) are experimental designs aiming at testing the effect of an intervention using a small number of patients (typically one to three), using repeated measurements, sequential (±randomized) introduction of an intervention and method-specific data analysis, including visual analysis and specific statistics. The aim of this paper is to familiarise professionals working in different fields of rehabilitation with SCEDs and provide practical advice on how to design and implement a SCED in clinical rehabilitation practice. Research questions suitable for SCEDs and the different types of SCEDs (e.g., alternating treatment designs, introduction/withdrawal designs and multiple baseline designs) are reviewed. Practical steps in preparing a SCED design are outlined. Examples from different rehabilitation domains are provided throughout the paper. Challenging issues such as the choice of the repeated measure, assessment of generalisation, randomization, procedural fidelity, replication and generalizability of findings are discussed. Simple rules and resources for data analysis are presented. The utility of SCEDs in physical and rehabilitation medicine (PRM) are discussed.

Ecological prospective memory assessment in children with acquired brain injury using the Children's Cooking Task.

Prospective memory (PM) has been shown to be impaired in children with acquired brain injuries (ABI) and is a major concern for parents. Few studies have addressed this issue and most used tasks that are not ecologically valid. The aims of this study were (1) to explore if children who have sustained an ABI suffer PM impairment, measured both by the Children's Cooking task (CCT) PM score and using the 2 PM subtests of the Rivermead Behavioral Memory Test (RBMT), and (2) to explore if the CCT PM score is sensitive to developmental changes in PM in typically developing children and in children with ABI. Fifty-four children with ABI and 33 typically developing controls participated in the study. Children with ABI had significantly lower PM scores and poorer performance in the CCT than their typically developing peers. PM scores increased significantly with age, indicating developmental progress of PM performance.

Prospective memory 7 years after severe childhood traumatic brain injury - the TGE 2 prospective longitudinal study.

OBJECTIVE: To investigate the long-term outcome in prospective memory (PM), seven years after childhood severe traumatic brain injury (TBI), in a prospective longitudinal cohort. PARTICIPANTS: 76 young individuals (aged 7-22 years): 39 patients with a severe accidental TBI included prospectively seven years earlier, aged 0-15 years at injury, and 37 controls individually matched on age, gender and parental education. MAIN OUTCOME MEASURES: Three novel short PM tasks varying in the delay, motivation and context (ecological versus paper and pencil task). RESULTS: Individuals with severe TBI showed significantly poorer PM than matched controls in the two low-motivation PM tasks: (1) the ecological long-delay task consisting of sending a letter on a rainy day (p=0.047, odds ratio = 2.6); (2) the non-ecological short-delay task consisting of taking off post-its while identifying facial emotions (p=0.004, r=0.34). Differences in PM on the high motivation were not significant. PM is impaired several years post severe TBI.

Executive function after severe childhood traumatic brain injury - Age-at-injury vulnerability periods: The TGE prospective longitudinal study.

BACKGROUND: Executive function (EF) impairment is a major predictor of overall outcome after traumatic brain injury (TBI). TBI severity is a factor of poor outcome, but most studies include a majority of children with mild and moderate TBI. The aims of this study were to estimate EF impairment after severe childhood TBI and to explore factors predicting EF outcome. The secondary aim was to compare recovery trajectories by age-at-injury groups. METHODS: This was a prospective longitudinal study of children with severe TBI who were tested for EFs by performance-based tests and questionnaires at 3, 12 and 24 months. RESULTS: Children with TBI (n=65) showed significant impairment in working memory, inhibition, attention and global EF, with little or no recovery at 24 months. For flexibility and performance-based EF score, children were impaired at 3 months only and showed normal scores by 12 months. No impairment was found in planning. At 3 and 24 months, Glasgow Coma Scale score and parental education predicted global EF. Coma length was not a significant predictor of outcome. Age at injury predicted progress in EF, but the relationship was not linear; children 10-12 years old at injury showed better outcome than older and younger children. CONCLUSIONS: EFs are impaired after severe TBI in childhood. The relationship between age at injury and outcome is not linear. Relying on only performance-based EF tests can underestimate EF impairment.