Goal management training for improving fatigue in children and adolescents with acquired brain injuries: A 2-year follow-up of a randomised controlled trial.

To explore the long-term effectiveness of a paediatric adaptation of Goal Management Training (pGMT), relative to a psychoeducative program (pBHW), in reducing fatigue after pABI 2 years post-intervention. Thirty-eight youths and their parents completed the Paediatric Quality of Life - Multidimensional Fatigue Scale. Primary outcome measures were Total Fatigue Score, General fatigue, Cognitive fatigue, and Sleep/rest fatigue (parent-report). No significant differences in fatigue symptoms by the parental report was observed between the intervention groups at the 2-year follow-up (total score: F = .16, p = .69; general fatigue: F = .36, p = .55; sleep/rest: F = .48, p = .49; and cognitive fatigue: F = .09, p = .76), nor any time*group interactions (total score: F = .25, p = .86; general fatigue: F = .39, p = .76; sleep/rest: F = .20, p = .89; and cognitive fatigue: F = .08, p = .97). In total, 45% of the participants in the pGMT group and 25% in the pBHW group demonstrated a reliable positive clinical change. The significant improvements in fatigue symptoms that were demonstrated 6 months post-intervention could not be confirmed in this 2-year follow-up study. However, a continued positive tendency on most dimensions of fatigue for the participants in the pGMT group could be observed, suggesting that cognitive rehabilitation may help reduce fatigue.

Validity of the Behavioural Assessment of the Dysexecutive Syndrome for Children (BADS-C) in children and adolescents with pediatric acquired brain injury.

The Behavioural Assessment of the Dysexecutive Syndrome for Children (BADS-C) was developed to address the need for a standardized ecologically valid test of executive function (EF) in the pediatric population. Our study aimed to investigate the discriminant, concurrent, and ecological validity of BADS-C in a sample with pediatric acquired brain injury (pABI). Seventy-four participants with pABI aged 10-17 years were included to a pre-registered randomized controlled trial, and baseline assessment was used for the current study. Controls consisted of 60 participants aged 10-17 years. Participants with pABI were assessed with neuropsychological tests and questionnaires of EF, and measurements of general intellectual ability (IQ). Results showed that all BADS-C subtests discriminated between participants with pABI and controls, except for the Playing Cards Test. Concurrent and ecological validity was demonstrated through associations between BADS-C total score, Key Search Test, and Zoo Map Test 1, and neuropsychological tests and teacher questionnaire ratings of EF. Key Search Test and Zoo Map Test 1 predicted teacher ratings of EF, beyond IQ and other neuropsychological test of EF. These findings provide support for BADS-C as a valid clinical assessment tool that can detect everyday executive dysfunction in the pABI population, and guide rehabilitation and treatment decisions.

Metacognitive strategy training versus psychoeducation for improving fatigue in children and adolescents with acquired brain injuries: A randomized controlled trial.

OBJECTIVE: The present study aims to explore the relative effectiveness of two group-based cognitive rehabilitation programs for reducing fatigue in pediatric acquired brain injury (pABI). METHOD: This is an exploratory study of secondary endpoints in a blinded, parallel-randomized controlled trial with children and adolescents (ages 10-17 years) with pABI and reported executive dysfunction. It investigates the effectiveness of a metacognitive program (pediatric goal management training, n = 36) compared to a psychoeducational program (pediatric brain health workshop, n = 37) for reducing fatigue (Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale), 8 weeks and 6 months postintervention. RESULTS: Seventy-three participants completed the allocated interventions, and 71 attended the 6-month follow-up. The results showed a significant decrease in parent-reported fatigue for both interventions from baseline to the 6-month follow-up. Forty percent of the total sample had a reliable change. There was no significant difference between the intervention groups, but a tendency in favor of the psychoeducational approach. Only subscales cognitive and sleep/rest fatigue showed significant reductions. In regression analyses, several factors predicted fatigue at 6 months follow-up, but only better global outcome and executive attention predicted a decrease in fatigue symptoms after 6 months. CONCLUSIONS: Group-based cognitive rehabilitation in the chronic phase of pABI, including education of parents and teachers, may be helpful in reducing fatigue. Global outcome and executive attention at baseline predicted fatigue improvement. Developmental factors are important to consider when tailoring pediatric interventions, as well as modifiable factors associated with fatigue. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Fatigue following pediatric acquired brain injury: Interplay with associated factors in a clinical trial population compared to healthy controls.

OBJECTIVE: The aims of the present study were to compare fatigue levels in children with pediatric acquired brain injury (pABI) with healthy controls (HCs), and examine the interplay of fatigue with associated factors. METHOD: We used baseline data from a preregistered randomized controlled trial. Seventy-six children aged 10-17 (median 13 years) with pABI in the chronic phase (88% with confirmatory cerebral imaging findings) and executive function (EF) complaints were included, most with moderate disability according to The Glasgow Outcome Scale Extended (GOSE-E) categorization. HCs consisted of 60 children aged 10-17 (median 13 years). All 127 participants completed measures of fatigue and intelligence. pABI participants were also assessed for behavioral problems, health-related quality of life (HRQoL), and EF. Nonparametric statistics were employed, in addition to a network analysis to model the unique associations between parent-reported fatigue and related factors. RESULTS: Parents reported significantly more fatigue in the pABI-group (75% of scores in clinical range; < 70) compared to HCs (11.7% of scores in clinical range). No strong associations were found between fatigue and injury characteristics, but findings indicated more fatigue in the older than younger age-group for pABI participants. Network modeling revealed a central role for HRQoL, behavioral, and EF symptoms in relation to fatigue. CONCLUSIONS: Fatigue is reported to be highly prevalent in the chronic phase of pABI. When addressing fatigue, our findings demonstrate the advantage of including multidimensional measures of fatigue and examining associated psychological and cognitive constructs, such as HRQoL, behavioral problems, and EF. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Paediatric goal management training in patients with acquired brain injury: study protocol for a randomised controlled trial.

INTRODUCTION: Compromised integrity of the brain due to paediatric acquired brain injury (pABI) has been associated with cognitive impairment, particularly executive dysfunction, in addition to somatic and emotional symptoms and reduced everyday function. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with ABI. The purpose of the present study is to determine the efficacy of a recently developed paediatric version of GMT (pGMT) for children and adolescents with ABI and reported executive dysfunction. METHODS AND ANALYSIS: This study protocol describes a parallel randomised controlled trial including allocation concealment and assessor blinding. Eighty survivors after pABI, aged 10-17 years at the time of intervention, will be recruited. Participants will be randomly allocated to either pGMT (n=40) or a psychoeducative control intervention (n=40; paediatric Brain Health Workshop). Both interventions consist of seven group sessions for participants and parents, followed by external cueing and telephone counselling. The study also includes involvement of teachers. Assessments will be performed at baseline, immediately postintervention and at 6 months' follow-up. Primary outcome measure will be changes in daily life EF as reported by parents (The Behavior Rating Inventory of Executive Function). Secondary outcomes include other assessments of EF (neuropsychological tests and questionnaires). Furthermore, we aim to assess generalisation effects of pGMT on other cognitive functions, as well as emotional, behavioural, adaptive and family function, academic performance, fatigue and quality of life. ETHICS AND DISSEMINATION: Results from this study will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals, in addition to presentations at scientific conferences. The study will be conducted in accordance with the Helsinki declaration and the Ethical Research Involving Children (ChildWatch International and Unicef). In accordance to Good Clinical Practice our study includes safety and quality monitoring guarantees in compliance with research ethics and safety. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items for Reporting in Trials recommendations, in addition to being registered at ClinicalTrials.gov. The study has been approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/772). TRIAL REGISTRATION NUMBER: NCT03215342.

Incidence and mortality of moderate and severe traumatic brain injury in children: A ten year population-based cohort study in Norway.

OBJECTIVE: In this study we wanted to estimate population-based rates of incidence and mortality of moderate and severe traumatic brain injury (TBI) in children in one specific region in Norway. METHODS: In the region there are seven acute care hospitals (ACHs) in addition to a Level 1 trauma centre. Of 702 869 inhabitants (2014), 145 395 were children aged 0-16 years. Data were collected during ten years (2004-2014). All children aged 0-16 years with moderate (Glasgow Coma Scale [GCS] score 9-13) or severe (GCS score ≤ 8) TBI admitted to the Level 1 trauma centre were prospectively included. Children treated outside the Level 1 trauma centre were retrospectively included from the ACHs. Children who died from TBI prehospitally were included from the National Cause of Death Registry. Poisson regression was used to estimate incidence rate ratios (with a 95% confidence interval) comparing age, sex, and time periods. RESULTS: A total of 71 children with moderate or severe TBI were identified. Crude incidence rates were 2·4 (95% CI 1·7-3·3) for moderate and 2·5 (95% CI 1·8-3·4) for severe TBI per 100 000 person-years (py). Mortality rate from TBI was 1·2 (95% CI 0·7-1·9) per 100 000 py, and 88% were prehospital deaths. CONCLUSION: The incidence rates and mortality of moderate and severe TBI were low compared to international reports. Most likely explained by successful national prevention of TBI.

Life after Adolescent and Adult Moderate and Severe Traumatic Brain Injury: Self-Reported Executive, Emotional, and Behavioural Function 2-5 Years after Injury.

Survivors of moderate-severe Traumatic Brain Injury (TBI) are at risk for long-term cognitive, emotional, and behavioural problems. This prospective cohort study investigated self-reported executive, emotional, and behavioural problems in the late chronic phase of moderate and severe TBI, if demographic characteristics (i.e., age, years of education), injury characteristics (Glasgow Coma Scale score, MRI findings such as traumatic axonal injury (TAI), or duration of posttraumatic amnesia), symptoms of depression, or neuropsychological variables in the first year after injury predicted long-term self-reported function. Self-reported executive, emotional, and behavioural functioning were assessed among individuals with moderate and severe TBI (N = 67, age range 15-65 years at time of injury) 2-5 years after TBI, compared to a healthy matched control group (N = 72). Results revealed significantly more attentional, emotional regulation, and psychological difficulties in the TBI group than controls. Demographic and early clinical variables were associated with poorer cognitive and emotional outcome. Fewer years of education and depressive symptoms predicted greater executive dysfunction. Younger age at injury predicted more aggressive and rule-breaking behaviour. TAI and depressive symptoms predicted Internalizing problems and greater executive dysfunction. In conclusion, age, education, TAI, and depression appear to elevate risk for poor long-term outcome, emphasising the need for long-term follow-up of patients presenting with risk factors.

Altered Cognitive Control Activations after Moderate-to-Severe Traumatic Brain Injury and Their Relationship to Injury Severity and Everyday-Life Function.

This study investigated how the neuronal underpinnings of both adaptive and stable cognitive control processes are affected by traumatic brain injury (TBI). Functional magnetic resonance imaging (fMRI) was undertaken in 62 survivors of moderate-to-severe TBI (>1 year after injury) and 68 healthy controls during performance of a continuous performance test adapted for use in a mixed block- and event-related design. Survivors of TBI demonstrated increased reliance on adaptive task control processes within an a priori core region for cognitive control in the medial frontal cortex. TBI survivors also had increased activations related to time-on-task effects during stable task-set maintenance in right inferior parietal and prefrontal cortices. Increased brain activations in TBI survivors had a dose-dependent linear positive relationship to injury severity and were negatively correlated with self-reported cognitive control problems in everyday-life situations. Results were adjusted for age, education, and fMRI task performance. In conclusion, evidence was provided that the neural underpinnings of adaptive and stable control processes are differently affected by TBI. Moreover, it was demonstrated that increased brain activations typically observed in survivors of TBI might represent injury-specific compensatory adaptations also utilized in everyday-life situations.

A longitudinal magnetic resonance imaging study of the apparent diffusion coefficient values in corpus callosum during the first year after traumatic brain injury.

The objective of this study was to explore the evolution of apparent diffusion coefficient (ADC) values in magnetic resonance imaging (MRI) in normal-appearing tissue of the corpus callosum during the 1st year after traumatic brain injury (TBI), and relate findings to outcome. Fifty-seven patients (mean age 34 [range 11-63] years) with moderate to severe TBI were examined with diffusion weighted MRI at three time points (median 7 days, 3 and 12 months), and a sex- and age-matched control group of 47 healthy individuals, were examined once. The corpus callosum was subdivided and the mean ADC values computed blinded in 10 regions of interests without any visible lesions in the ADC map. Outcome measures were Glasgow Outcome Scale Extended (GOSE) and neuropsychological domain scores at 12 months. We found a gradual increase of the mean ADC values during the 12 month follow-up, most evident in the posterior truncus (r=0.19, p<0.001). Compared with the healthy control group, we found higher mean ADC values in posterior truncus both at 3 months (p=0.021) and 12 months (p=0.003) post-injury. Patients with fluid-attenuated inversion recovery (FLAIR) lesions in the corpus callosum in the early MRI, and patients with disability (GOSE score ≤6) showed evidence of increased mean ADC values in the genu and posterior truncus at 12 months. Mean ADC values in posterior parts of the corpus callosum at 3 months predicted the sensory-motor function domain score (p=0.010-0.028). During the 1st year after moderate and severe TBI, we demonstrated a slowly evolving disruption of the microstructure in normal appearing corpus callosum in the ADC map, most evident in the posterior truncus. The mean ADC values were associated with both outcome and ability to perform speeded, complex sensory-motor action.

Differentiated patterns of cognitive impairment 12 months after severe and moderate traumatic brain injury.

OBJECTIVE: To assess cognitive function at 12 months after moderate and severe traumatic brain injury (TBI) separately, as well as improvement from 3 to 12 months and relationship to global outcome. METHODS: Cognitive function among patients with moderate (n = 30, Glasgow Coma Scale score (GCS) 9-3) and severe traumatic brain injury (n = 20, GCS score ≤ 8), recruited from an unselected neurosurgical cohort, all with MRI performed in the early phase were assessed with a neuropsychological test battery and Glasgow Outcome Scale Extended. Healthy volunteers (n = 47) matched for age, gender and years of education served as controls. RESULTS: Executive function was reduced at 12-months post-injury in patients with both moderate and severe TBI. However, motor function, processing speed and memory were reduced only among patients with severe TBI. Both patients with moderate and severe TBI improved their processing speed and visual memory. Patients with moderate TBI also improved motor function, while patients with severe TBI also improved executive function. CONCLUSION: Differentiating between patients with moderate and severe TBI yields a more accurate description of cognitive deficits and their improvement over time. Further, executive dysfunction and attention problems affected the ability to resume independent living and employment regardless of injury severity and age.