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A Pilot Study of the Neuropsychological Benefits of Computerized Cognitive Rehabilitation in Ugandan Children With HIV

OBJECTIVE Because antiretroviral treatment (ART) fails to improve neurocognitive impairment in children with HIV, we completed a pilot study evaluating the feasibility and cognitive benefit of computerized cognitive rehabilitation therapy (CCRT) in Ugandan children with HIV. METHOD Sixty Ugandan children with HIV (23 on ART) were randomly assigned to 10 sessions of Captains Log CCRT (Sandford, 2007) training configured for attention and memory skills or no intervention. Kaufman Assessment Battery for Children (2nd ed., KABC-2; Kaufman & Kaufman, 2004) performance at baseline indicated pervasive neurocognitive impairment. Cognitive ability was assessed before and after training using the Cogstate computerized neuropsychological test (Darby, Maruff, Collie, & McStephen, 2002). Viral load along with CD4 and CD8 absolute and activation levels also were measured posttest. RESULTS CCRT was well received with a 95% adherence rate to scheduled training sessions. CCRT intervention children showed greater improvement on a Cogstate card detection task of simple attention (p = .02), and speed of correct moves on a Groton Maze Learning Task (p < .001). These analyses were completed using an analysis of covariance model that adjusted Cogstate performance for the childs age, standardized weight for age, gender, socioeconomic status, school grade level, and baseline KABC-2 performance. ART treatment was not related to Cogstate performance or improvement as a result of CCRT. CD4 and CD8 activation levels were correlated with Cogstate improvement specifically for the CCRT group. CONCLUSIONS CCRT was feasible with our study population and improved maze learning and attention on a detection task. This supports previous findings by our group with cerebral malaria survivors (Bangirana, Giordani, et al., 2009).

Immediate neuropsychological and behavioral benefits of computerized cognitive rehabilitation in Ugandan pediatric cerebral malaria survivors.

Objective: Our earlier studies on Ugandan children surviving cerebral malaria showed cognitive deficits mainly in attention and memory. We now present the first study in sub-Saharan Africa to investigate the feasibility and potential benefits of computerized cognitive rehabilitation training on neuropsychological and behavioral functioning of children surviving cerebral malaria. Methods: A randomized trial in which 65 children admitted 45 months earlier with cerebral malaria were recruited at Mulago Hospital, Kampala, Uganda. For 8 weeks, 32 of the children received weekly training sessions using Captains Log cognitive training software and the other 33 were assigned to a nontreatment condition. Pre- and postintervention assessments were completed using CogState, a computerized neuropsychological battery, measuring visuomotor processing speed, working memory, learning, attention and psychomotor speed and the Child Behavior Checklist measuring internalizing problems, externalizing problems, and total problems. Results: Preintervention scores were similar between both groups. Treatment effects were observed on visuospatial processing speed [group effect (standard error) 0.14 (0.03); p < .001], on a working memory and learning task [0.08 (0.02); p < .001], psychomotor speed [0.14 (0.07); p = .04], and on internalizing problems [−3.80 (1.56); p = .02] after controlling for age, sex, school grade, quality of the home environment, and weight for age z scores. Similar treatment effects were observed when no adjustments for the above covariates were made. Conclusions: Computerized cognitive training long after the cerebral malaria episode has immediate benefit on some neuropsychological and behavioral functions in African children. The long-term benefit of this intervention needs to be investigated.

Estimation after adaptive allocation

Abstract In recent years a vast number of adaptive designs have been proposed, often in the context of clinical trials or industrial applications. The adjective adaptive refers to the feature that, in such designs, the current allocation may depend on data already collected. When analyzing such designs, proving consistency and asymptotic normality of estimators is of fundamental importance. For some designs, this has not yet been done. When it has, the proofs have been tailored to the particular design being analyzed, often utilizing martingale arguments. In this paper independence properties of the allocated sequence are proved and then used to provide a simple method for proving consistency and asymptotic normality of estimators for a wide class of designs.

Elder Abuse in Long-Term Care: Types, Patterns, and Risk Factors

The authors investigated types and patterns of elder abuse by paid caregivers in long-term care and assessed the role of several risk factors for different abuses and for multiple abuse types. The results are based on a 2005 random-digit-dial survey of relatives of persons in long-term care. We computed occurrence rates and conditional occurrence rates for each of six abuse types: physical, caretaking, verbal, emotional, neglect, and material. Among older adults who have experienced at least one type of abuse, more than half (51.4%) have experienced another type of abuse. Physical functioning problems, activities of daily living limitations, and behavioral problems are significant risk factors for at least three types of abuse and are significant for multiple abuse types. The findings have implications for those monitoring the well-being of older adults in long-term care as well as those responsible for developing public health interventions.

A year-long caregiver training program improves cognition in preschool Ugandan children with human immunodeficiency virus.

OBJECTIVE To evaluate mediational intervention for sensitizing caregivers (MISC). MISC biweekly caregiver training significantly enhanced child development compared with biweekly training on health and nutrition (active control) and to evaluate whether MISC training improved the emotional well-being of the caregivers compared with controls. STUDY DESIGN Sixty of 120 rural Ugandan preschool child/caregiver dyads with HIV were assigned by randomized clusters to biweekly MISC training, alternating between home and clinic for 1 year. Control dyads received a health and nutrition curriculum. Children were evaluated at baseline, 6 months, and 1 year with the Mullen Early Learning Scales and the Color-Object Association Test for memory. Caldwell Home Observation for Measurement of the Environment and videotaped child/caregiver MISC interactions also were evaluated. Caregivers were evaluated for depression and anxiety with the Hopkins Symptoms Checklist. RESULTS Between-group repeated-measures ANCOVA comparisons were made with age, sex, CD4 levels, viral load, material socioeconomic status, physical development, and highly active anti-retroviral therapy treatment status as covariates. The children given MISC had significantly greater gains compared with controls on the Mullen Visual Reception scale (visual-spatial memory) and on Color-Object Association Test memory. MISC caregivers significantly improved on Caldwell Home Observation for Measurement of the Environment scale and total frequency of MISC videotaped interactions. MISC caregivers also were less depressed. Mortality was less for children given MISC compared with controls during the training year. CONCLUSIONS MISC was effective in teaching Ugandan caregivers to enhance their childrens cognitive development through practical and sustainable techniques applied during daily interactions in the home.

A Year-Long Caregiver Training Program to Improve Neurocognition in Preschool Ugandan HIV-Exposed Children

Objective: Mediational intervention for sensitizing caregivers (MISC) is a structured program enabling caregivers to enhance their child’s cognitive and emotional development through daily interactions. The principal aim was to evaluate if a year-long MISC caregiver training program produced greater improvement in child cognitive and emotional development compared with a control program. Methods: One hundred and nineteen uninfected HIV-exposed preschool children and their caregivers were randomly assigned to 1 of 2 treatment arms: biweekly MISC training alternating between home and clinic for 1 year or a health and nutrition curriculum. All children were evaluated at baseline, 6 months, and 1 year with the Mullen Early Learning Scales, Color-Object Association Test for memory, and Achenbach Child Behavior Checklist for psychiatric symptoms. Caregivers were evaluated on the same schedule with the Hopkins Symptoms Checklist-25 for depression and anxiety. Results: The treatment arms were compared using repeated-measures analysis of covariance with child age, gender, weight, socioeconomic status, caregiving quality, caregiver anxiety, and caregiver education as covariates. The MISC children had significantly greater gains compared to controls on the Mullen Receptive and Expressive Language development, and on the Mullen composite score of cognitive ability. Color-Object Association Test total memory for MISC children was marginally better than controls. No Achenbach Child Behavior Checklist differences between the groups were noted. Caldwell Home Observation for Measurement of the Environment scores and observed mediational interaction scores from videotapes measuring caregiving quality also improved significantly more for the MISC group. Conclusions: The MISC enhanced cognitive performance, especially in language development. These benefits were possibly mediated by improved caregiving and positive emotional benefit to the caregiver.

Developmental outcomes in Malawian children with retinopathy‐positive cerebral malaria

Objective  To assess children with retinopathy‐positive cerebral malaria (CM) for neurocognitive sequelae.

Neuropsychological Effects of Konzo: A Neuromotor Disease Associated With Poorly Processed Cassava

BACKGROUND: Konzo is an irreversible upper-motor neuron disorder affecting children dependent on bitter cassava for food. Although the neuroepidemiology of konzo is well characterized, we report the first neuropsychological findings. METHOD: Children with konzo in the Democratic Republic of Congo (mean age 8.7 years) were compared with children without konzo (mean age 9.1 years) on the Kaufman Assessment Battery for Children, second edition (KABC-II), and the Bruininks-Oseretsky Test of Motor Proficiency, second edition (BOT-2). Both groups were also compared with normative KABC measures from earlier studies in a nearby nonkonzo region. RESULTS: Using a Kruskal-Wallis test, children with konzo did worse on the KABC-II simultaneous processing (visual-spatial analysis) (K [1] = 8.78, P = .003) and mental processing index (MPI) (K [1] = 4.56, P = .03) than children without konzo. Both konzo and nonkonzo groups had poorer KABC sequential processing (memory) and MPI relative to the normative group from a nonkonzo region (K [2] = 75.55, P < .001). Children with konzo were lower on BOT-2 total (K [1] = 83.26, P < .001). KABC-II MPI and BOT-2 total were predictive of konzo status in a binary logistic regression model: odds ratio = 1.41, P < .013; 95% confidence interval 1.13–1.69. CONCLUSIONS: Motor proficiency is dramatically affected, and both children with and without konzo have impaired neurocognition compared with control children from a nonoutbreak area. This may evidence a subclinical neurocognitive form of the disease, extending the human burden of konzo with dramatic public health implications.

Cognition, behaviour and academic skills after cognitive rehabilitation in Ugandan children surviving severe malaria: a randomised trial

BackgroundInfection with severe malaria in African children is associated with not only a high mortality but also a high risk of cognitive deficits. There is evidence that interventions done a few years after the illness are effective but nothing is known about those done immediately after the illness. We designed a study in which children who had suffered from severe malaria three months earlier were enrolled into a cognitive intervention program and assessed for the immediate benefit in cognitive, academic and behavioral outcomes.MethodsThis parallel group randomised study was carried out in Kampala City, Uganda between February 2008 and October 2010. Sixty-one Ugandan children aged 5 to 12 years with severe malaria were assessed for cognition (using the Kaufman Assessment Battery for Children, second edition and the Test of Variables of Attention), academic skills (Wide Range Achievement Test, third edition) and psychopathologic behaviour (Child Behaviour Checklist) three months after an episode of severe malaria. Twenty-eight were randomised to sixteen sessions of computerised cognitive rehabilitation training lasting eight weeks and 33 to a non-treatment group. Post-intervention assessments were done a month after conclusion of the intervention. Analysis of covariance was used to detect any differences between the two groups after post-intervention assessment, adjusting for age, sex, weight for age z score, quality of the home environment, time between admission and post-intervention testing and pre-intervention score. The primary outcome was improvement in attention scores for the intervention group. This trial is registered with Current Controlled Trials, number ISRCTN53183087.ResultsSignificant intervention effects were observed in the intervention group for learning mean score (SE), [93.89 (4.00) vs 106.38 (4.32), P = 0.04] but for working memory the intervention group performed poorly [27.42 (0.66) vs 25.34 (0.73), P = 0.04]. No effect was observed in the other cognitive outcomes or in any of the academic or behavioural measures.ConclusionsIn this pilot study, our computerised cognitive training program three months after severe malaria had an immediate effect on cognitive outcomes but did not affect academic skills or behaviour. Larger trials with follow-up after a few years are needed to investigate whether the observed benefits are sustained.Trial registrationISRCTN: ISRCTN53183087

The Effect of Care Setting on Elder Abuse: Results from a Michigan Survey

This study compares abuse rates for elders age 60 and older in three care settings: nursing home, paid home care, and assisted living. The results are based on a 2005 random-digit dial survey of relatives of, or those responsible for, a person in long-term care. Nursing homes have the highest rates of all types of abuse, although paid home care has a relatively high rate of verbal abuse and assisted living has an unexpected high rate of neglect. Even when adjusting for health conditions, care setting is a significant factor in both caretaking and neglect abuses. Moving from paid home care to nursing homes is shown to more than triple the odds of neglect. Furthermore, when computing abuse rates by care setting for persons with specified health conditions, nursing homes no longer have the highest abuse rates.