Beth S. Slomine

Cognitive Rehabilitation for Children with Acquired Brain Injury.

Cognitive deficits are frequent consequences of acquired brain injury (ABI) and often require intervention. We review the theoretical and empirical literature on cognitive rehabilitation in a variety of treatment domains including attention, memory, unilateral neglect, speech and language, executive functioning, and family involvement/education. Because there are more well-designed studies examining the efficacy of cognitive rehabilitation in adults with brain injury, the major findings from this body of literature are also highlighted. In addition, given that similar cognitive and behavioral concerns are often apparent in children with certain neurodevelopmental disorders, selected literature focusing on interventions for these groups of children is included. Limitations and challenges inherent in examining cognitive interventions in children with ABI are also discussed. Overall, despite the growing body of literature examining the efficacy of cognitive rehabilitation in children with ABI, there continues to be a great need to develop well-designed studies to examine the efficacy of these interventions.

Rationale, timeline, study design, and protocol overview of the therapeutic hypothermia after pediatric cardiac arrest trials

Objective: To describe the rationale, timeline, study design, and protocol overview of the Therapeutic Hypothermia after Pediatric Cardiac Arrest trials. Design: Multicenter randomized controlled trials. Setting: Pediatric intensive care and cardiac ICUs in the United States and Canada. Patients: Children from 48 hours to 18 years old, who have return of circulation after cardiac arrest, who meet trial eligibility criteria, and whose guardians provide written consent. Interventions: Therapeutic hypothermia or therapeutic normothermia. Measurements and Main Results: From concept inception in 2002 until trial initiation in 2009, 7 years were required to plan and operationalize the Therapeutic Hypothermia after Pediatric Cardiac Arrest trials. Two National Institute of Child Health and Human Development clinical trial planning grants (R21 and R34) supported feasibility assessment and protocol development. Two clinical research networks, Pediatric Emergency Care Applied Research Network and Collaborative Pediatric Critical Care Research Network, provided infrastructure resources. Two National Heart Lung Blood Institute U01 awards provided funding to conduct separate trials of in-hospital and out-of-hospital cardiac arrest. A pilot vanguard phase that included half the clinical sites began on March 9, 2009, and this was followed by full trial funding through 2015. Conclusions: Over a decade will have been required to plan, design, operationalize, and conduct the Therapeutic Hypothermia after Pediatric Cardiac Arrest trials. Details described in this report, such as participation of clinical research networks and clinical trial planning grants utilization, may be of utility for individuals who are planning investigator-initiated, federally supported clinical trials.

Differences in attention, executive functioning, and memory in children with and without ADHD after severe traumatic brain injury.

Although the development of Attention Deficit Hyperactivity Disorder (ADHD) after traumatic brain injury (TBI) has been described, it is unknown whether children with TBI and ADHD have greater neuropsychological impairments than children with TBI alone. This study examines attention, executive functioning, and memory in children with TBI-only and TBI + ADHD. Caregivers of 82 children with severe TBI completed structured psychiatric interviews at enrollment to diagnose premorbid ADHD and one-year after injury to diagnose post-injury ADHD. Children underwent neuropsychological testing one year after injury. One memory measure significantly differentiated children with TBI-only from children with newly developed ADHD [secondary ADHD (S-ADHD)] and those with premorbid ADHD that persisted after injury [persisting ADHD (P-ADHD)]. Compared with the TBI-only group, children with TBI + ADHD had worse performance on measures of attention, executive functioning, and memory. Results reveal that in children with severe TBI, the behavioral diagnosis of ADHD is associated with more difficulty in attention, executive functioning, and memory. Additionally, results suggest greater deficits in memory skills in the S-ADHD group compared with the P-ADHD group. Although findings provide preliminary support for distinguishing P-ADHD from S-ADHD, further research is needed to investigate neuropsychological differences between these subgroups of children with severe TBI.

The efficacy of donepezil hydrochloride on memory functioning in three adolescents with severe traumatic brain injury.

Objective: To explore efficacy of donepezil on memory in adolescents with severe traumatic brain injury (TBI). Design: Single subject, unblinded, multiple baseline design. Methods and procedures: Memory functioning was examined in three adolescents with TBI on and off medication (5 and 10u2009mg) using the Selective Reminding Test. Four variables were examined: Total recall (TR)u2009=u2009number of words total words recalled, Long Term Storage (LTS)u2009=u2009words recalled on two trials in a row, Consistency of Long Term Retrieval (CLTR)u2009=u2009words continuously recalled, Delayu2009=u2009number of words recalled after delay. Results: On medication, three out of three participants demonstrated better memory. Two showed greatest improvement on 10u2009mg. All participants demonstrated improvement in TR and LTS. Two participants demonstrated improved CLTR. No participants displayed improvement in Delay. No adverse side effects were reported. Conclusions: Results suggests that donepezil may be effective in improving memory in adolescents with severe TBI and warrant further examination.

Time to follow commands remains the most useful injury severity variable for predicting WeeFIM® scores 1 year after paediatric TBI

Abstract Objective: To investigate the relationship between injury severity variables, particularly time to follow commands (TFC) and long-term functional outcomes in paediatric traumatic brain injury (TBI). Methods and procedure: Participants included 40 children with moderate-to-severe TBI discharged from inpatient rehabilitation. Measures of severity were initial Glasgow Coma Scale score, TFC, duration of Post Traumatic Amnesia (PTA) and total duration of impaired consciousness (TFCu2009+u2009PTA). Functional outcome was measured by age-corrected Functional Independence Measure for Children (WeeFIM®) scores at 1-year after discharge. Results: Correlations indicated that injury severity variables (TFC, PTA and TFCu2009+u2009PTA) were all associated with functional outcome. Regression analyses revealed that TFC and TFCu2009+u2009PTA similarly accounted for 49% or 47% of the variance, respectively, in total WeeFIM® score. Thirty-seven of 40 children had good outcome; of the three children with TFC >26 days, two had poor outcome. Conclusion: PTA and TFCu2009+u2009PTA do not provide a benefit over TFC alone for prediction of long-term outcome and TFC is identified earlier in the recovery course. TFC remains an important predictor of functional outcome 1-year after discharge from inpatient rehabilitation after paediatric TBI.

Stability of neuropsychological testing during two years of maintenance electroconvulsive therapy in an autistic man

We report the stability of neuropsychological testing in a 21 yearold autistic man receiving maintenance electroconvulsive therapy (M-ECT) twice weekly since age 19 formajor depressive disorder with catatonic features complicated by severe self-injury and multiple suicide attempts. Neuropsychological testing performed two months after the acute ECT course, and repeated annually for two years indicated stability in full-scale IQ and other subset scores. Vineland Adaptive Behavior Scales remained stable as well. This is the first report of longitudinal cognitive and functional stability in M-ECT in autism, and adds to the literature of M-ECT safety in all patient populations. Case report: E. is a 21 year-old autistic male with major depressive disorder with catatonic features complicated by extreme self-injury and suicidality whose acute electroconvulsive therapy (ECT) course was previously reported (Wachtel et al., 2009). Attempts at reducing M-ECT frequency below twice weekly resulted in prompt return of suicidal comments, posturing and dangerous self-harm despite concomitant usage of lorazepam, lithium, duloxetine and riluzole. Longitudinal neuropsychological testing was pursued using the Wechsler Adult Intelligence Scales and Vineland Adaptive Behavior Scales to provide ongoing objective assessment of cognitive and adaptive functioning at the conclusion of the acute ECT course, one year later at 91 ECT and again the following year after 220 total ECT. Intellectual functioning. On the three occasions of testing administration, E.s performance was stable, and intellectual functioning fell within the baseline deficient range in all evaluations. 2003 testing using the Wechsler Intelligence Scale for Children had yielded a full-scale IQ=63. His index scores also remained notably stable over time, with no evidence for a decline in skill in any area. The following table demonstrates the specific results: Adaptive functioning: E.s adaptive skills were assessed using the Vineland Adaptive Behavior Scales. His baseline adaptive skills described by his mother were significantly below age expectations. E.s inpatient behavioral team reported on his level of functioning to determine if continued psychiatric stability translated to improvements in adaptive behavior, and to assess any impact of M-ECT on adaptive behavior. E.s adaptive functioning remained stable across assessments, with decreases in maladaptive behaviors noted since admission (Table 1). The usage of electroconvulsive therapy (ECT) in autistic patients has received increased attention in the past few years. Multiple reports document the efficacy and safety of ECT for acute catatonia in autism (Dhossche et al., 2009; Wachtel et al., 2009; Wachtel et al., 2008; Zaw et al., 1999). One case series presents the M-ECT courses of three different patients for autistic catatonia (Wachtel et al., 2010) where M-ECT was required to prevent catatonic relapse. One patient in this series was unable to procure maintenance ECT services and did relapse; the other two patients remained in remission having received 286 and 156 ECT. While formal cognitive testing was not undertaken

Family Burden After Out-of-Hospital Cardiac Arrest in Children.

Objectives: To describe family burden among caregivers of children who survived out-of-hospital cardiac arrest and who were at high risk for neurologic disability and examine relationships between family burden, child functioning, and other factors during the first year post arrest. Design: Secondary analysis of data from the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial. Setting: Thirty-six PICUs in the United States and Canada. Patients: Seventy-seven children recruited to the Therapeutic Hypothermia after Pediatric Cardiac Arrest Out-of-Hospital trial who had normal prearrest neurologic functioning and were alive 1 year post arrest. Interventions: Family burden was assessed using the Infant Toddler Quality of Life Questionnaire for children less than 5 years old and the Child Health Questionnaire for children 5 years old or older at baseline (reflecting prearrest status), 3 months, and 12 months post arrest. Child functioning was assessed using the Vineland Adaptive Behavior Scale II, the Pediatric Overall Performance Category, and Pediatric Cerebral Performance Category scales and caregiver perception of global functioning. Measurements and Main Results: Fifty-six children (72.7%) were boys, 48 (62.3%) were whites, and 50 (64.9%) were less than 5 years old prior to out-of-hospital cardiac arrest. Family burden at baseline was not significantly different from reference values. Family burden was increased at 3 and 12 months post arrest compared with reference values (p < 0.001). Worse Pediatric Overall Performance Category and Pediatric Cerebral Performance Category, lower adaptive behavior, lower global functioning, and higher family burden all measured 3 months post arrest were associated with higher family burden 12 months post arrest (p < 0.05). Sociodemographics and prearrest child functioning were not associated with family burden 12 months post arrest. Conclusions: Families of children who survive out-of-hospital cardiac arrest and have high risk for neurologic disability often experience substantial burden during the first year post arrest. The extent of child dysfunction 3 months post arrest is associated with family burden at 12 months.

Prevalence and predictors of affective lability after paediatric traumatic brain injury

Abstract Objective: Paediatric severe traumatic brain injury (TBI) is associated with significant post-injury affective and behavioural problems. Few studies have examined the prevalence and characteristics of affective lability after paediatric TBI. Methods: Ninety-seven children with severe TBI were evaluated 1 year post-injury for the presence of affective lability using the Children’s Affective Lability Scale (CALS). Demographic, clinical and brain lesion characteristics were also assessed. Results: Affective lability significantly increased after injury. Eighty-six children had a pre-injury CALS score of 1 SD or less from the group pre-injury mean (Mu2009=u20098.11, SDu2009=u20099.31), of which 35 and 15 children had a 1 SD and 2 SD increase in their CALS score from pre- to post-injury, respectively. A variety of affective shifts manifested post-injury including anxiety, silliness, dysphoria and irritability. The most severe symptoms were irritability and unpredictable temper outbursts. Risk factors for affective lability included elevated pre-injury affective lability and psychosocial adversity as well as greater damage to the orbitofrontal cortex. Post-injury affective lability was most frequently associated with a post-injury diagnosis of attention-deficit hyperactivity disorder. Conclusions: Affective lability is common after paediatric TBI and frequently manifests as irritability and unpredictable outbursts. Early intervention is needed to improve psychiatric outcomes.

Exploring the safety and efficacy of targeted temperature management amongst infants with out-of-hospital cardiac arrest due to apparent life threatening events.

OBJECTIVEnTo explore the safety and efficacy of targeted temperature management amongst infants with out-of-hospital cardiac arrest due to an apparent life threatening event (ALTE) recruited to the Therapeutic Hypothermia after Paediatric Cardiac Arrest Out-of-Hospital trial.nnnMETHODSnFifty-four infants (48h to <1year of age) with ALTE who received chest compressions for ≥2min, were comatose, and required mechanical ventilation after return of circulation were included. Infants were randomised to therapeutic hypothermia (33°C) (n=26) or therapeutic normothermia (36.8°C) (n=28) within six hours of return of circulation. Outcomes included 12-month survival with Vineland Adaptive Behaviour Scales, Second Edition (VABS-II) score ≥70, 12-month survival, change in VABS-II score from pre-arrest to 12 months post-arrest, and select safety measures.nnnRESULTSnAmongst infants with pre-arrest VABS-II ≥70 (n=52), there was no difference in 12-month survival with VABS-II ≥70 between therapeutic hypothermia and therapeutic normothermia groups (2/25 (8.0%) vs. 1/27 (3.7%); relative risk 2.16; 95% confidence interval 0.21-22.38, p=0.60). Amongst all evaluable infants (n=53), the change in VABS-II score from pre-arrest to 12 months post-arrest did not differ (p=0.078) between therapeutic hypothermia and therapeutic normothermia groups, nor did 12-month survival (5/26 (19.2%) vs. 1/27 (3.7%); relative risk 5.19; 95% confidence interval 0.65-41.50, p=0.10).nnnCONCLUSIONSnMortality was high amongst infants that were comatose after out-of-hospital cardiac arrest due to ALTE in both therapeutic hypothermia and therapeutic normothermia treated groups. Functional status was markedly reduced among survivors. (ClinicalTrials.gov, NCT00878644).

Burden of caregiving after a child's in-hospital cardiac arrest

OBJECTIVEnTo describe caregiver burden among those whose children survive in-hospital cardiac arrest and have high risk of neurologic disability, and explore factors associated with burden during the first year post-arrest.nnnMETHODSnThe study is a secondary analysis of the Therapeutic Hypothermia after Paediatric Cardiac Arrest In-Hospital (THAPCA-IH) trial. 329 children who had an in-hospital cardiac arrest, chest compressions for >2u202fmin, and mechanical ventilation after return of circulation were recruited to THAPCA-IH. Of these, 155 survived to one year, and caregivers of 138 were assessed for burden. Caregiver burden was assessed at baseline, and 3 and 12 months post-arrest using the Infant Toddler Quality of Life Questionnaire for children <5 years old and the Child Health Questionnaire for children >5 years. Child functioning was assessed using the Vineland Adaptive Behaviour Scales Second Edition (VABS-II), the Paediatric Overall Performance Category (POPC) and Paediatric Cerebral Performance Category (PCPC) scales, and caregiver perception of global functioning.nnnRESULTSnOf 138 children, 77 (55.8%) were male, 77 (55.8%) were white, and 109 (79.0%) were <5u202fyears old at the time of arrest. Caregiver burden was greater than reference norms at all time points. Worse POPC, PCPC and VABS-II scores at 3 months post-arrest were associated with greater caregiver burden at 12 months. Worse global functioning at 3 months was associated with greater burden at 12 months for children <5 years.nnnCONCLUSIONSnCaregiver burden is substantial during the first year after paediatric in-hospital cardiac arrest, and associated with the extent of the childs neurobehavioural dysfunction.