Brian C. Kavanaugh

Neurocognitive deficits in children and adolescents following maltreatment: Neurodevelopmental consequences and neuropsychological implications of traumatic stress

ABSTRACT Childhood maltreatment is a significant risk factor for a host of psychiatric, developmental, medical, and neurocognitive conditions, often resulting in debilitating and long-term consequences. However, there is no available neuropsychological resource reviewing the literature on the associated neurocognitive deficits in children and adolescents. This review comprehensively examines the 23 prior studies that evaluated the intellectual, language, visual-spatial, memory, motor, and/or attention/executive functions in children and adolescents following an experience of childhood abuse and/or neglect. Neurocognitive impairments were frequently reported. Impairments in executive functions were the most frequent and severe reported impairments, although intelligence, language, visual-spatial skills, and memory are also at serious risk for compromised development following maltreatment. However, specific factors such as abuse/neglect duration, severity, type, and timing during development were all associated with neurocognition. This indicates that these factors are of greater importance than just the presence of abuse/neglect in identifying risk for neurocognitive compromise. Such neurocognitive deficits appear to be a consequence to the known neurobiological and brain development abnormalities of this population, suggesting traumatic stress can be a potential cause of neurodevelopmental disorders. These findings have critical implications for the clinical practice and research involving children following childhood maltreatment and other types of traumatic stress.

Parent-rated emotional-behavioral and executive functioning in childhood epilepsy.

The present study examined clinical and demographic risk factors associated with parent-rated emotional-behavioral and executive functioning in children and adolescents with epilepsy. The medical records of 152 children and adolescents with epilepsy referred for neuropsychological evaluation were reviewed. Results indicated that the sample displayed significantly elevated symptoms across the emotional-behavioral and executive domains assessed. Executive functioning and behavioral symptoms had the highest rates of clinically elevated scores, with lowest rates of elevated scores in internalizing and externalizing emotional problems. Only 34% of those participants with clinically significant emotional-behavioral or executive functioning difficulties had a history of psychological or counseling services, highlighting the underserved mental health needs of this population. In regard to clinical factors, the majority of seizure-related variables were not associated with emotional-behavioral or executive functioning. However, the frequency of seizures (i.e., seizure status) was associated with behavioral regulation aspects of executive functioning, and the age at evaluation was associated with externalizing problems and behavioral symptoms. Family psychiatric history (with the exception of ADHD) was associated with all domains of executive and emotional-behavioral functioning. In summary, emotional-behavioral and executive functioning difficulties frequently co-occur with seizures in childhood epilepsy, with both seizure-related and demographic factors contributing to the presentation of such neurobehavioral comorbidities. The present findings provide treatment providers of childhood epilepsy with important information to assist in better identifying children and adolescents who may be at risk for neurobehavioral comorbidities and may benefit from intervention.

Brief report: Neurocognitive functioning in adolescents following childhood maltreatment and evidence for underlying planning & organizational deficits

Children and adolescents with a history of childhood maltreatment are at risk for a host of psychiatric conditions, although the underlying neurocognitive functioning of these individuals remains largely understudied. This study examined the neurocognitive functioning of childhood maltreatment victims in an adolescent psychiatric inpatient setting. The sample consisted of adolescent inpatients (ages 13–19) that completed intellectual testing as part of a neuropsychological/psychological assessment during hospitalization (n = 39). The sample was grouped based on childhood maltreatment history with one group categorized by maltreatment history (n = 15) and the other group characterized by no maltreatment history (n = 24). Analyses revealed statistically significant differences (p < .01) between maltreatment groups on the majority of assessed domains. When controlling for intelligence, only performance differences on the RCFT remained. RCFT differences remained after controlling for the influence of visual-motor and visual-perceptual/visual-spatial functioning, highlighting the influence of organizational and planning difficulties in those individuals with maltreatment history. Group differences in the frequency of impaired performance for neuropsychological tasks were largest (p < .001) for FSIQ and RCFT. Compromised neurocognitive functioning may negatively contribute to the clinical presentation of this population, highlighting the importance of the child neuropsychologist in the effective treatment of children and adolescents with a history of childhood maltreatment.

A neuropsychological profile of childhood maltreatment within an adolescent inpatient sample

Recent research has begun to identify the neurocognitive and psychological effects of childhood maltreatment, although information is limited on the neuropsychological presentation of maltreatment in psychiatrically hospitalized adolescents. This study examined the executive-functioning and language abilities as well as psychopathological presentation of childhood maltreatment victims in an adolescent psychiatric inpatient setting. The sample consisted of adolescent inpatients (ages 13–19 years old) who completed a neuropsychological/psychological assessment during hospitalization (n = 122). The sample was grouped based on childhood maltreatment history, with one group categorized by maltreatment history (n = 49) and the other group characterized by no maltreatment history (n = 73). Analyses revealed statistically significant differences (p < .01) between maltreatment groups on executive functioning, as well as on measures of self-reported depression and anxiety symptoms. No group differences remained after controlling for posttraumatic stress disorder. Further, distinct neuropsychological profiles were identified for specific types of maltreatment experienced. These findings suggest that while childhood maltreatment is associated with a range of neuropsychological impairments, the specific type of maltreatment experienced may have a significant influence on the type and severity of impairments. These findings contribute to the growing body of research on the significant consequences of childhood maltreatment.

Executive Functioning and Self-Reported Depressive Symptoms Within an Adolescent Inpatient Population

Although the relationship between executive dysfunction and depressive disorders has been well established in the adult population, research within the adolescent population has produced mixed results. The present study examined executive-functioning subdomains in varying levels of self-reported depression within an adolescent inpatient sample diagnosed with primary mood disorders. Via retrospective chart review, the sample consisted of those adolescents (ages 13–18 years) who completed a combined psychological/neuropsychological assessment during hospitalization (N = 105). When the sample was divided into adolescents with mood disorders with self-reported depressive symptoms and adolescents with mood disorders without self-reported depressive symptoms, no differences in various executive functions were identified. There were also no correlations between overall self-reported depressive symptoms and overall executive functioning. However, there were negative correlations between select executive subdomains (e.g., problem solving and response inhibition) and certain depressive symptom subdomains (e.g., negative mood and interpersonal problems). Based on these findings, there was no difference in executive functions between mood disorders with depressive symptoms and mood disorders without depressive symptoms, although there may be select executive subdomains that are particularly involved in certain depressive symptoms, providing important information for the treatment of adolescent depression.

Intellectual and adaptive functioning in Sturge-Weber Syndrome

The present study examined the intellectual and adaptive functioning in a sample of children and young adults with Sturge-Weber Syndrome (SWS). A total of 80 research participants from a SWS study database underwent full neurological evaluation as part of their participation or concurrent medical care. Twenty-nine of the participants received neuropsychological evaluations. Analyses indicated no significant demographic or neurological differences between those who did and did not receive neuropsychological evaluations. Overall, the neuropsychological evaluation sample displayed significantly lower functioning relative to published normative data across domains of intellectual and adaptive functioning. Thirty-two percent of the sample displayed impaired performance (standard score ≤ 75) in intellectual functioning and 58% displayed impaired performance in adaptive functioning. Hemiparesis status independently predicted overall adaptive functioning while seizure frequency independently predicted overall intellectual functioning. Younger participants displayed significantly higher (more intact) ratings in adaptive functioning compared to older participants, specifically in overall adaptive functioning, motor skills, and community living skills. A composite measure of neurological status (SWS-NRS) incorporating seizure and hemiparesis status effectively distinguished between individuals with impaired or nonimpaired adaptive and intellectual functioning and showed promise as a screening method for identifying individuals with more involved intellectual and/or adaptive needs.

Failure to maintain set as a predictor of childhood depression within a children's psychiatric inpatient sample

Despite a wealth of studies in adults and adolescents, only a handful of studies have examined executive function in childhood depression. This study utilized retrospective chart review of a childrens psychiatric inpatient program to evaluate executive function via Wisconsin Card Sorting Test (WCST) in 33 children (6-12 years old) with a depressive disorder and 61 age/sex-matched children without a depressive disorder referred for neuropsychological evaluation. WCST categories, perseverative errors, and failure to maintain set errors were examined as potential predictors of depressive disorder diagnosis and self-reported depressive symptoms. After controlling for age, length of hospital stay, and ADHD, failure to maintain set significantly predicted depressive disorder diagnosis. Failure to maintain set was also significantly associated with self-reported depressive symptoms. Current findings provide preliminary evidence to suggest that failure to maintain set may reflect a core deficit of childhood depression. While findings are preliminary, this may have important implications for the diagnosis and treatment of childhood depression.

The role of inhibitory control in the hospitalization of children with severe psychiatric disorders

Objective: Inhibitory control is a heterogeneous domain involving multiple inhibitory processes at levels of behavior, attention/cognition, and emotion/motivation. Prior studies have identified an underlying role of inhibitory control in the manifestation of childhood-onset psychiatric symptoms. This study investigated the inhibitory control abilities of children within a severe, childhood psychiatric sample. Method: A medical chart review was conducted for 100 children who received a neuropsychological evaluation during a children’s psychiatric inpatient program hospitalization from 2010 to 2014. Three measures neurocognitive of inhibitory control, Stroop Color–Word Score, CPT-II Commission Errors, and WCST Failure to Maintain Set were used in the present study. The presence of externalizing behaviors at hospital admission was classified as poor behavioral/self-control. Results: Forty-eight percent of the sample displayed evidence of inhibitory control impairment on neurocognitive measures, with 40% displaying response inhibition impairment and only 5–7% displaying interference control impairment. Similarly elevated rates of impairment were found in those children without attention deficit hyperactivity disorder (ADHD). Depressive disorders were associated with interference control, while ADHD was associated with interference control and response inhibition. Receiver Operating Characteristic analysis found that response inhibition predicted a prolonged hospitalization in an older males subgroup but not in the younger males or females subgroups. Conclusions: Current findings suggest that inhibitory control impairments are highly prevalent in the children’s psychiatric inpatient setting and associated with specific psychiatric disorders, although the influence of these impairments on subsequent outcome may be limited to a select portion of children. These findings highlight the importance of neuropsychological evaluation and management in childhood psychiatric disorders.

Neurocognitive Phenotypes in Severe Childhood Psychiatric Disorders.

Abstract This study investigated the presence of potential neurocognitive phenotypes within a severe childhood psychiatric sample. A medical chart review was conducted for 106 children who received a neuropsychological evaluation during children’s psychiatric inpatient program hospitalization. A hierarchical cluster analysis was conducted to identify distinct clinical clusters based on neurocognitive measures. Cluster analysis identified four distinct clusters, subsequently labeled neurocognitive phenotypes: “intact cognition” (27%), “global dysfunction” (20%), “organization/planning” (21%), and “inhibition-memory” (32%). Significant differences were identified in history of legal involvement and antipsychotic medications at hospital admission. Differences between none-minimal and moderate-high neurocognitive dysfunction were identified in age, amount of diagnoses and antipsychotic medications at admission, and hospital length of stay. Current findings provide preliminary evidence of underlying neurocognitive phenotypes within severe childhood psychiatric disorders. Findings highlight the importance of neuropsychological evaluation in the treatment of childhood psychiatric disorders.

Use of a Cumulative Risk Scale to Predict Poor Intellectual and Academic Outcomes in Childhood Epilepsy

Discrete risk factors for poor outcomes in childhood epilepsy have been identified, but it is unclear whether the combined effect of several risk factors better predicts outcome. The Epilepsy Cumulative Risk Scale was developed to quantify cumulative risk for poor outcomes in childhood epilepsy. Participants included 156 clinic-referred children with epilepsy. The Epilepsy Cumulative Risk Scale was developed using variables previously associated with functional outcomes. Scale utility was examined through its association with intellectual and academic functioning. All Epilepsy Cumulative Risk Scale variables were significantly associated with functioning. The Total Score (ie, cumulative effect) was most strongly correlated with cognition and academic skills. A Total Score ≥ 5 had the best sensitivity and specificity for differentiating those at high risk for poor outcomes. The Epilepsy Cumulative Risk Scale shows promise as a practical, data-driven tool for quantification of cumulative risk for poor outcomes in childhood epilepsy and may be helpful in detecting those needing referral for additional services.