Permutation-based true discovery proportions for functional magnetic resonance imaging cluster analysis.

We propose a permutation-based method for testing a large collection of hypotheses simultaneously. Our method provides lower bounds for the number of true discoveries in any selected subset of hypotheses. These bounds are simultaneously valid with high confidence. The methodology is particularly useful in functional Magnetic Resonance Imaging cluster analysis, where it provides a confidence statement on the percentage of truly activated voxels within clusters of voxels, avoiding the well-known spatial specificity paradox. We offer a user-friendly tool to estimate the percentage of true discoveries for each cluster while controlling the family-wise error rate for multiple testing and taking into account that the cluster was chosen in a data-driven way. The method adapts to the spatial correlation structure that characterizes functional Magnetic Resonance Imaging data, gaining power over parametric approaches.

A cross-sectional and longitudinal network analysis approach to understanding connections among social anxiety components in youth.

As proposed in a prominent developmental model, social anxiety has different manifestations: social fear, shy temperament, anxious cognitions, and avoidance of social situations. Drawing from this model, we used the network approach to psychopathology to gain a detailed understanding of specific social anxiety components and their associations. The current article investigated (a) how social anxiety components are interconnected within a network, and (b) the consistency of the network over time, in a community sample of children and adolescents. Data from 3 waves of a longitudinal study were used. At Time 1 (T1) the total sample comprised 331 participants (Mage = 13.34 years); at Time 3 (T3) there were 236 participants (Mage = 17.48 years). Social anxiety components were assessed with self-report questionnaires. Networks of 15 nodes (i.e., components) were estimated. Network analysis of T1 components revealed 4 communities: cognitive, social-emotional, avoidance of performance, and avoidance of interaction situations. There were no direct connections between the cognitive and behavioral communities; social-emotional nodes appeared to act as bridge components between the 2 communities. A similar pattern of component associations and communities was found in the T2 and T3 networks, and the longitudinal network incorporating node change trajectories. Networks were estimated on group-level observational data and conclusions about cause-effect relationships are tentative. Although the sample size decreased across the 3 waves, the reliability of parameter estimates were minimally affected. Findings attest to the potential value of applying the network approach to investigate the pattern of associations among social anxiety components in youth. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Are individual differences quantitative or qualitative? An integrated behavioral and fMRI MIMIC approach.

In cognitive neuroscience there is a growing interest in individual differences. We propose the Multiple Indicators Multiple Causes (MIMIC) model of combined behavioral and fMRI data to determine whether such differences are quantitative or qualitative in nature. A simulation study revealed the MIMIC model to have adequate power for this goal, and parameter recovery to be satisfactory. The MIMIC model was illustrated with a re-analysis of Van Duijvenvoorde et al. (2016) and Blankenstein et al. (2018) decision making data. This showed individual differences in Van Duijvenvoorde et al. (2016) to originate in qualitative differences in decision strategies. Parameters indicated some individuals to use an expected value decision strategy, while others used a loss minimizing strategy, distinguished by individual differences in vmPFC activity. Individual differences in Blankenstein et al. (2018) were explained by quantitative differences in risk aversion. Parameters showed that more risk averse individuals preferred safe over risky choices, as predicted by heightened vmPFC activity. We advocate using the MIMIC model to empirically determine, rather than assume, the nature of individual differences in combined behavioral and fMRI datasets.

The bridge between cognition and behavior in acquired brain injury: A graph theoretical approach.

BACKGROUND: The assumption is that executive dysfunctions (EF), associated with frontal lobe injury, are responsible for behavioral disturbances. Some studies do not find a relationship between EF and behavior following frontal lobe lesions. Our main goal of this study was to use a novel statistical method, graph theory, to analyze this relationship in different brain injury groups; frontal lobe damage, non-frontal lobe damage, and controls. Within the frontal group, we expect to find a pattern of executive nodes that are highly interconnected. METHODS: For each group, we modeled the relationship between executive functions and behavior as a network of interdependent variables. The cognitive tests and the behavioral questionnaire are the "nodes" in the network, while the relationships between the nodes were modeled as the correlations between two nodes corrected for the correlation with all other nodes in the network. Sparse networks were estimated within each group using graphical LASSO. We analyzed the relative importance of the nodes within a network (centrality) and the clustering (modularity) of the different nodes. RESULTS: Network analysis showed distinct patterns of relationships between EF and behavior in the three subgroups. The performance on the verbal learning test is the most central node in all the networks. In the frontal group, verbal memory forms a community with working memory and fluency. The behavioral nodes do not differentiate between groups or form clusters with cognitive nodes. No other communities were found for cognitive and behavioral nodes. CONCLUSION: The cognitive phenotype of the frontal lobe damaged group, with its stability and proportion, might be theoretically interpreted as a potential "buffer" for possible cognitive executive deficits. This might explain some of the ambiguity found in the literature. This alternative approach on cognitive test scores provides a different and possibly complimentary perspective of the neuropsychology of brain-injured patients.

Stimulant treatment profiles predicting co-occurring substance use disorders in individuals with attention-deficit/hyperactivity disorder.

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of developing substance use disorders (SUDs) and nicotine dependence (ND). It remains unclear whether and how stimulant treatment may affect this risk. We aimed to investigate how stimulant use profiles influence the risk of SUDs and ND, using a novel data-driven community detection analysis to construct different stimulant use profiles. Comprehensive lifetime stimulant prescription data and data on SUDs and ND were available for 303 subjects with ADHD and 219 controls, with a mean age 16.3 years. Community detection was used to define subgroups based on multiple indicators of treatment history, start age, treatment duration, total dose, maximum dose, variability, stop age. In stimulant-treated participants, three subgroups with distinct medication trajectories were distinguished (late-and-moderately dosed, n = 91; early-and-moderately dosed, n = 51; early-and-intensely dosed, n = 103). Compared to stimulant-naïve participants (n = 58), the early-and-intense treatment group had a significantly lower risk of SUDs and ND (HR = 0.28, and HR = 0.29, respectively), while the early-and-moderate group had a significantly lower risk of ND only (HR = 0.30). The late-and-moderate group was at a significantly higher risk of ND compared to the other two treatment groups (HR = 2.66 for early-and-moderate, HR = 2.78 for early-and-intense). Our findings show that in stimulant-treated adolescents with ADHD, long-term outcomes are associated with treatment characteristics, something that is often ignored when treated individuals are compared to untreated individuals.

Neurocognitive Profiles in Children With ADHD and Their Predictive Value for Functional Outcomes.

OBJECTIVE: We examined whether neurocognitive profiles could be distinguished in children with ADHD and typically developing (TD) children, and whether neurocognitive profiles predicted externalizing, social, and academic problems in children with ADHD. METHOD: Neurocognitive data of 81 children with ADHD and 71 TD children were subjected to confirmatory factor analysis. The resulting factors were used for community detection in the ADHD and TD group. RESULTS: Four subgroups were detected in the ADHD group, characterized by (a) poor emotion recognition, (b) poor interference control, (c) slow processing speed, or (d) increased attentional lapses and fast processing speed. In the TD group, three subgroups were detected, closely resembling Subgroups (a) to (c). Neurocognitive subgroups in the ADHD sample did not differ in externalizing, social, and academic problems. CONCLUSION: We found a neurocognitive profile unique to ADHD. The clinical validity of neurocognitive profiling is questioned, given the lack of associations with functional outcomes.

Course of Cognitive Functioning in Institutionalized Persons With Moderate to Severe Dementia: Evidence From the Severe Impairment Battery Short Version.

OBJECTIVES: To adequately monitor the course of cognitive functioning in persons with moderate to severe dementia, relevant cognitive tests for the advanced dementia stages are needed. We examined the ability of a test developed for the advanced dementia stages, the Severe Impairment Battery Short version (SIB-S), to measure cognitive change over time. Second, we examined type of memory impairment measured with the SIB-S in different dementia stages. METHODS: Participants were institutionalized persons with moderate to severe dementia (N = 217). The SIB-S was administered at 6-month intervals during a 2-year period. Dementia severity at baseline was classified according to Global Deterioration Scale criteria. We used mixed models to evaluate the course of SIB-S total and domain scores, and whether dementia stage at baseline affected these courses. RESULTS: SIB-S total scores declined significantly over time, and the course of decline differed significantly between dementia stages at baseline. Persons with moderately severe dementia declined faster in mean SIB-S total scores than persons with moderate or severe dementia. Between persons with moderate and moderately severe dementia, there was only a difference in the rate of decline of semantic items, but not episodic and non-semantic items. CONCLUSIONS: Although modest floor and slight ceiling effects were noted in severe and milder cases, respectively, the SIB-S proved to be one of few available adequate measures of cognitive change in institutionalized persons with moderate to severe dementia. (JINS, 2019, 25, 204-214).

Heterogeneity in Cognitive and Socio-Emotional Functioning in Adolescents With On-Track and Delayed School Progression.

Adolescence is characterized by considerable changes in cognitive and socio-emotional skills. There are considerable differences between adolescents with regards to the development of these skills. However, most studies examine adolescents' average functioning, without taking into account this heterogeneity. The current study applies network analysis in order to examine heterogeneity of cognitive and socio-emotional functioning in adolescents on-track or delayed in their school progression. Data was collected at two time-points for on-track (n = 320) and delayed (n = 69) adolescents (Mage = 13.30 years, SDage = 0.77). Repeated measures ANOVA showed no significant differences between the groups in cognitive and socio-emotional functioning (p's > 0.05). Network analysis revealed that executive functions play a key role in the network of cognitive, social, and emotional functioning. This is especially the case in the delayed group where executive functions are even more central, both at T1 (inhibition and shifting) and T2 (shifting). Subsequent community analysis revealed three profiles in both groups: a well-adapted and well-balanced group, a group with high levels of need for arousal and risk-taking, and a group with regulation problems. Compared to on-track adolescents, delayed adolescents showed even higher levels of risk-taking in the second profile and higher levels of executive function problems in the third profile at T1. These differences were leveled out at T2, indicating adolescents in the delayed group catch up with their peers. This study highlights the intricate balance between cognitive, social and emotional functioning in adolescents in relation to school performance and provides preliminary evidence of the importance of taking individual differences within groups into account.

All-Resolutions Inference for brain imaging.

The most prevalent approach to activation localization in neuroimaging is to identify brain regions as contiguous supra-threshold clusters, check their significance using random field theory, and correct for the multiple clusters being tested. Besides recent criticism on the validity of the random field assumption, a spatial specificity paradox remains: the larger the detected cluster, the less we know about the location of activation within that cluster. This is because cluster inference implies "there exists at least one voxel with an evoked response in the cluster", and not that "all the voxels in the cluster have an evoked response". Inference on voxels within selected clusters is considered bad practice, due to the voxel-wise false positive rate inflation associated with this circular inference. Here, we propose a remedy to the spatial specificity paradox. By applying recent results from the multiple testing statistical literature, we are able to quantify the proportion of truly active voxels within selected clusters, an approach we call All-Resolutions Inference (ARI). If this proportion is high, the paradox vanishes. If it is low, we can further "drill down" from the cluster level to sub-regions, and even to individual voxels, in order to pinpoint the origin of the activation. In fact, ARI allows inference on the proportion of activation in all voxel sets, no matter how large or small, however these have been selected, all from the same data. We use two fMRI datasets to demonstrate the non-triviality of the spatial specificity paradox, and its resolution using ARI. We verify that the endless circularity permitted by ARI does not render its estimates overly conservative using both simulation, and a data split.

Neural substrates of the influence of emotional cues on cognitive control in risk-taking adolescents.

Adolescence is a period characterised by increases in risk-taking. This behaviour has been associated with an imbalance in the integration of the networks involved in cognitive control and motivational processes. We examined whether the influence of emotional cues on cognitive control differs between adolescents who show high or low levels of risk-taking behaviour. Participants who scored especially high or low on a risky decision task were subsequently administered an emotional go/no-go fMRI task comprising angry, happy and calm faces. Both groups showed decreased cognitive control when confronted with appetitive and aversive emotional cues. Activation in the inferior frontal gyrus (IFG) increased in line with the cognitive control demands of the task. Though the risk taking groups did not differ in their behavioural performance, functional connectivity analyses revealed the dorsal striatum plays a more central role in the processing of cognitive control in high than low risk-takers. Overall, these findings suggest that variance in fronto-striatal circuitry may underlie individual differences in risk-taking behaviour.

Community structure analysis of rejection sensitive personality profiles: A common neural response to social evaluative threat?

Monitoring social threat is essential for maintaining healthy social relationships, and recent studies suggest a neural alarm system that governs our response to social rejection. Frontal-midline theta (4-8 Hz) oscillatory power might act as a neural correlate of this system by being sensitive to unexpected social rejection. Here, we examined whether frontal-midline theta is modulated by individual differences in personality constructs sensitive to social disconnection. In addition, we examined the sensitivity of feedback-related brain potentials (i.e., the feedback-related negativity and P3) to social feedback. Sixty-five undergraduate female participants (mean age = 19.69 years) participated in the Social Judgment Paradigm, a fictitious peer-evaluation task in which participants provided expectancies about being liked/disliked by peer strangers. Thereafter, they received feedback signaling social acceptance/rejection. A community structure analysis was employed to delineate personality profiles in our data. Results provided evidence of two subgroups: one group scored high on attachment-related anxiety and fear of negative evaluation, whereas the other group scored high on attachment-related avoidance and low on fear of negative evaluation. In both groups, unexpected rejection feedback yielded a significant increase in theta power. The feedback-related negativity was sensitive to unexpected feedback, regardless of valence, and was largest for unexpected rejection feedback. The feedback-related P3 was significantly enhanced in response to expected social acceptance feedback. Together, these findings confirm the sensitivity of frontal midline theta oscillations to the processing of social threat, and suggest that this alleged neural alarm system behaves similarly in individuals that differ in personality constructs relevant to social evaluation.

Error blindness and motivational significance: Shifts in networks centering on anterior insula co-vary with error awareness and pupil dilation.

This investigation aims to further our understanding of the brain mechanisms underlying the awareness of one's erroneous actions. While all errors are registered as such in the rostral cingulate zone, errors enter awareness only when the anterior insula cortex is activated. Aware but not unaware errors elicit autonomic nervous system reactivity. Our aim is to investigate the hypothesis that activation in the insula during error awareness is related to autonomic arousal and to inter-regional interactions with other areas of the brain. To examine the role of the anterior insula in error awareness, we assessed its functional connectivity to other brain regions along with autonomic nervous system reactivity in young healthy participants who underwent simultaneous pupil-diameter and functional magnetic resonance imaging measurements while performing a complex and error-prone task. Error blindness was associated with failures to engage sufficient autonomic reactivity. During aware errors increased pupil-diameter along with increased task-related activation within, and increased connectivity between anterior insula and task-related networks suggested an increased capacity for action-control information transfer. Increased pupil-diameter during aware errors was furthermore associated with decreased activation of the default-mode network along with decreased insular connectivity with regions of the default mode system, possibly reflecting decreased task-irrelevant information processing. This shifting mechanism may be relevant to a better understanding of how the brain and the autonomic nervous system interact to enable efficient adaptive behavior during cognitive challenge.

Stimulant Treatment Trajectories Are Associated With Neural Reward Processing in Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: The past decades have seen a surge in stimulant prescriptions for the treatment of attention-deficit/hyperactivity disorder (ADHD). Stimulants acutely alleviate symptoms and cognitive deficits associated with ADHD by modulating striatal dopamine neurotransmission and induce therapeutic changes in brain activation patterns. Long-term functional changes after treatment are unknown, as long-term studies are scarce and have focused on brain structure. In this observational study (2009-2012), we investigated associations between lifetime stimulant treatment history and neural activity during reward processing. METHODS: Participants fulfilling DSM-5 criteria for ADHD (N = 269) were classified according to stimulant treatment trajectory. Of those, 124 performed a monetary incentive delay task during magnetic resonance imaging, all in their nonmedicated state (nEARLY&INTENSE = 51; nLATE&MODERATE = 49; nEARLY&MODERATE = 9; nNAIVE = 15; mean age = 17.4 years; range, 10-26 years). Whole-brain analyses were performed with additional focus on the striatum, concentrating on the 2 largest treatment groups. RESULTS: Compared to the late-and-moderate treatment group, the early-and-intense treatment group showed more activation in the supplementary motor area and dorsal anterior cingulate cortex (SMA/dACC) during reward outcome (cluster size = 8,696 mm³; PCLUSTER < .001). SMA/dACC activation of the control group fell in between the 2 treatment groups. Treatment history was not associated with striatal activation during reward processing. CONCLUSIONS: Our findings are compatible with previous reports of acute increases of SMA/dACC activity in individuals with ADHD after stimulant administration. Higher SMA/dACC activity may indicate that patients with a history of intensive stimulant treatment, but currently off medication, recruit brain regions for cognitive control and/or decision-making upon being rewarded. No striatal or structural changes were found.

Risk factors for comorbid oppositional defiant disorder in attention-deficit/hyperactivity disorder.

Oppositional defiant disorder (ODD) is highly prevalent in attention-deficit/hyperactivity disorder (ADHD). Individuals with both ADHD and ODD (ADHD + ODD) show a considerably worse prognosis compared with individuals with either ADHD or ODD. Therefore, identification of risk factors for ADHD + ODD is essential and may contribute to the development of (early) preventive interventions. Participants were matched for age, gender, and ADHD-subtype (diagnostic groups), and did not differ in IQ. Predictors included pre- and perinatal risk factors (pregnancy duration, birth weight, maternal smoking during pregnancy), transgenerational factors (parental ADHD; parental warmth and criticism in diagnostic groups), and postnatal risk factors (parental socioeconomic status [SES], adverse life events, deviant peer affiliation). Three models were assessed, investigating risk factors for ADHD-only versus controls (N = 86), ADHD + ODD versus controls (N = 86), and ADHD + ODD versus ADHD-only (N = 90). Adverse life events and parental ADHD were risk factors for both ADHD + ODD and ADHD-only, and more adverse life events were an even stronger risk factor for comorbid ODD compared with ADHD-only. For ADHD + ODD, but not ADHD-only, parental criticism, deviant peer affiliation, and parental SES acted as risk factors. Maternal smoking during pregnancy acted as minor risk factor for ADHD-only, while higher birth weight acted as minor risk factor for ADHD + ODD. No effects of age were present. Findings emphasise the importance of these factors in the development of comorbid ODD. The identified risk factors may prove to be essential in preventive interventions for comorbid ODD in ADHD, highlighting the need for parent-focused interventions to take these factors into account.

Pediatric traumatic brain injury affects multisensory integration.

OBJECTIVE: To investigate the impact of pediatric traumatic brain injury (TBI) on multisensory integration in relation to general neurocognitive functioning. METHOD: Children with a hospital admission for TBI aged between 6 and 13 years (n = 94) were compared with children with trauma control (TC) injuries (n = 39), while differentiating between mild TBI without risk factors for complicated TBI (mildRF-; n = 19), mild TBI with ≥1 risk factor (mildRF+; n = 45), and moderate/severe TBI (n = 30). We measured set-shifting performance based on visual information (visual shift condition) and set-shifting performance based on audiovisual information, requiring multisensory integration (audiovisual shift condition). Effects of TBI on set-shifting performance were traced back to task strategy (i.e., boundary separation), processing efficiency (i.e., drift rate), or extradecisional processes (i.e., nondecision time) using diffusion model analysis. General neurocognitive functioning was measured using estimated full-scale IQ (FSIQ). RESULTS: The TBI group showed selectively reduced performance in the audiovisual shift condition (p = .009, Cohen's d = -0.51). Follow-up analyses in the audiovisual shift condition revealed reduced performance in the mildRF+ TBI group and moderate/severe TBI group (ps ≤ .025, ds ≤ -0.61). These effects were traced back to lower drift rate (ps ≤ .048, ds ≤ -0.44), reflecting reduced multisensory integration efficiency. Notably, accuracy and drift rate in the audiovisual shift condition partially mediated the relation between TBI and FSIQ. CONCLUSION: Children with mildRF+ or moderate/severe TBI are at risk for reduced multisensory integration efficiency, possibly contributing to decreased general neurocognitive functioning. (PsycINFO Database Record

Learning curves of theta/beta neurofeedback in children with ADHD.

Neurofeedback is widely applied as non-pharmacological intervention aimed at reducing symptoms of ADHD, even though efficacy has not been unequivocally established. Neuronal changes during the neurofeedback intervention that resemble learning can provide crucial evidence for the feasibility and specificity of this intervention. A total of 38 children (aged between 7 and 13 years) with a DSM-IV-TR diagnosis of ADHD, completed on average 29 sessions of theta (4-8 Hz)/beta (13-20 Hz) neurofeedback training. Dependent variables included training-related measures as well as theta and beta power during baseline and training runs for each session. Learning effects were analyzed both within and between sessions. To further specify findings, individual learning curves were explored and correlated with behavioral changes in ADHD symptoms. Over the course of the training, there was a linear increase in participants' mean training level, highest obtained training level and the number of earned credits (range b = 0.059, -0.750, p < 0.001). Theta remained unchanged over the course of the training, while beta activity increased linearly within training sessions (b = 0.004, 95% CI = [0.0013-0.0067], p = 0.005) and over the course of the intervention (b = 0.0052, 95% CI = [0.0039-0.0065], p < 0.001). In contrast to the group analyses, significant individual learning curves were found for both theta and beta over the course of the intervention in 39 and 53%, respectively. Individual learning curves were not significantly correlated with behavioral changes. This study shows that children with ADHD can gain control over EEG states during neurofeedback, although a lack of behavioral correlates may indicate insufficient transfer to daily functioning, or to confounding reinforcement of electromyographic activity. CLINICAL TRIALS REGISTRATION: This trial is registered at the US National Institutes of Health (ClinicalTrials.gov, ref. no: NCT01363544); https://clinicaltrials.gov/show/NCT01363544 .

Neural Mechanisms Underlying Compensatory and Noncompensatory Strategies in Risky Choice.

Individuals may differ systematically in their applied decision strategies, which has critical implications for decision neuroscience but is yet scarcely studied. Our study's main focus was therefore to investigate the neural mechanisms underlying compensatory versus noncompensatory strategies in risky choice. Here, we compared people using a compensatory expected value maximization with people using a simplified noncompensatory loss-minimizing choice strategy. To this end, we used a two-choice paradigm including a set of "simple" items (e.g., simple condition), in which one option was superior on all attributes, and a set of "conflict" items, in which one option was superior on one attribute but inferior on other attributes. A binomial mixture analysis of the decisions elicited by these items differentiated between decision-makers using either a compensatory or a noncompensatory strategy. Behavioral differences were particularly pronounced in the conflict condition, and these were paralleled by neural results. That is, we expected compensatory decision-makers to use an integrated value comparison during choice in the conflict condition. Accordingly, the compensatory group tracked the difference in expected value between choice options reflected in neural activation in the parietal cortex. Furthermore, we expected noncompensatory, compared with compensatory, decision-makers to experience increased conflict when attributes provided conflicting information. Accordingly, the noncompensatory group showed greater dorsomedial PFC activation only in the conflict condition. These pronounced behavioral and neural differences indicate the need for decision neuroscience to account for individual differences in risky choice strategies and to broaden its scope to noncompensatory risky choice strategies.

Clinical Pain and Neuropsychological Functioning in Parkinson's Disease: Are They Related?

Introduction. Pain is an important nonmotor symptom of Parkinson's disease (PD). Brain areas such as the hippocampus and the prefrontal cortex play an important role in the processing of pain. Since these brain areas are also involved in cognitive functioning, for example, episodic memory and executive functions, respectively, we examined whether a relationship exists between cognitive functioning and spontaneous pain in PD. Methods. Forty-eight patients with PD and 57 controls participated. Cognitive functioning was measured by a comprehensive battery of neuropsychological tests. Both the sensory-discriminative aspect and the motivational-affective aspect of pain were assessed. Multiple linear regression analyses were performed to assess a relation between cognition and pain. Results. Cognition was related to neither the sensory nor the affective aspect of pain in our sample of PD patients. Variance in pain measures was primarily explained by symptoms of depression and anxiety. Discussion. The difference between the affective and the sensory aspect of pain might be due to the neuropathology of PD, which is mainly present in areas processing the affective aspect of pain. Pain treatment might improve when mood is taken into account. We provide several explanations for the lack of an association between pain and cognition.

Impaired Visual Integration in Children with Traumatic Brain Injury: An Observational Study.

BACKGROUND: Axonal injury after traumatic brain injury (TBI) may cause impaired sensory integration. We aim to determine the effects of childhood TBI on visual integration in relation to general neurocognitive functioning. METHODS: We compared children aged 6-13 diagnosed with TBI (n = 103; M = 1.7 years post-injury) to children with traumatic control (TC) injury (n = 44). Three TBI severity groups were distinguished: mild TBI without risk factors for complicated TBI (mildRF- TBI, n = 22), mild TBI with ≥1 risk factor (mildRF+ TBI, n = 46) or moderate/severe TBI (n = 35). An experimental paradigm measured speed and accuracy of goal-directed behavior depending on: (1) visual identification; (2) visual localization; or (3) both, measuring visual integration. Group-differences on reaction time (RT) or accuracy were tracked down to task strategy, visual processing efficiency and extra-decisional processes (e.g. response execution) using diffusion model analysis. General neurocognitive functioning was measured by a Wechsler Intelligence Scale short form. RESULTS: The TBI group had poorer accuracy of visual identification and visual integration than the TC group (Ps ≤ .03; ds ≤ -0.40). Analyses differentiating TBI severity revealed that visual identification accuracy was impaired in the moderate/severe TBI group (P = .05, d = -0.50) and that visual integration accuracy was impaired in the mildRF+ TBI group and moderate/severe TBI group (Ps < .02, ds ≤ -0.56). Diffusion model analyses tracked impaired visual integration accuracy down to lower visual integration efficiency in the mildRF+ TBI group and moderate/severe TBI group (Ps < .001, ds ≤ -0.73). Importantly, intelligence impairments observed in the TBI group (P = .009, d = -0.48) were statistically explained by visual integration efficiency (P = .002). CONCLUSIONS: Children with mildRF+ TBI or moderate/severe TBI have impaired visual integration efficiency, which may contribute to poorer general neurocognitive functioning.