Mary Ann Roberts

Cognitive outcome in children and adolescents following severe traumatic brain injury: influence of psychosocial, psychiatric, and injury-related variables

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than psychiatric or psychosocial factors as correlates of cognitive outcomes. We addressed this concern by recruiting a consecutive series (N = 24) of children age 5 through 14 years who suffered a severe TBI, a matched group who sustained a mild TBI, and a second matched group who sustained an orthopedic injury. Standardized intellectual, memory, psychiatric, family functioning, family psychiatric history, neurological, and neuroimaging assessments were conducted at an average of 2 years following injury. Severe TBI, when compared to mild TBI and orthopedic injury, was associated with significant decrements in intellectual and memory function. A principal components analysis of independent variables that showed significant (p < .05) bivariate correlations with the outcome measures yielded a neuropsychiatric factor encompassing severity of TBI indices and postinjury psychiatric disorders and a psychosocial disadvantage factor. Both factors were independently and significantly related to intellectual and memory function outcome. Postinjury psychiatric disorders added significantly to severity indices and family functioning and family psychiatric history added significantly to socioeconomic status in explaining several specific cognitive outcomes. These results may help to define subgroups of children who will require more intensive services following their injuries.

External validation of oppositional disorder and attention deficit disorder with hyperactivity.

Validity of the distinction between oppositional disorder (OD) and attention deficit disorder with hyperactivity (ADDH) was examined in a sample of 6- to 12-year-old boys with behavior problems. Problem identification, cognitive/attentional, family context, and behavioral symptom differences were examined among nine boys with OD only, 20 with ADDH, 40 with comorbid OD and ADDH, and 28 with neither disruptive behavior disorder. Systematic comparisons of groups including and excluding the OD and ADDH diagnoses were undertaken to determine the existence of pure OD and pure ADDH disorder effects. The most consistent result was the lack of evidence for either pure OD or pure ADDH effects. Most of the significant findings reflected differences between the nondisruptive (neither) and comorbid groups. The results support the importance of comorbidity, but they provide little support for disorder-specific distinctions between oppositional and attention deficit disorders.

A behavioral observation method for differentiating hyperactive and aggressive boys

This study employed a playroom observation technique to examine the behavioral differences between hyperactive and aggressive boys. Subjects were clinic-referred boys assigned to Hyperactive, Aggressive, or Hyperactive plus Aggressive goups on the basis of behavior checklists and ratings of psychiatric chart information. While significant discrimination was obtained in all three settings (free play, restricted play, and restricted academic), behavioral differences among the subject groups were most pronounced during the restricted academic period. Discriminant function analysis for the restricted academic period resulted in accurate classification of 86% of the subjects as hyperactive, aggressive, or hyperactive plus aggressive. The present findings suggest that children with externalizing disorders can be distinguished in light of their observed clinic behavior in the restricted academic setting.

A preliminary validation of subtypes of DSM-IV Attention-Deficit/Hyperactivity Disorder

Preliminary validity of DSM-IV ADHD was examined in a sample of 6- to 12-year-old boys with behavior problems. Problem identification, extent of impairment, cognitive/attentional, family context, and behavioral symptom differences were examined among 28 boys with ADHD, inattentive type; 9 with ADHD, hyperactive-impulsive type; 59 with ADHD, combined type; and 18 with no ADHD diagnosis. Some evidence for validity of ADHD was suggested, especially for the inattentive and combined subtypes, and on measures of impairment, mother-, father-, and teacher-rated disruptive symptoms, and observed playroom behavior. Few differences were obtained on measures of family context and age-corrected indices of cognitive/attentional functioning. Supplementary analyses of the boys with ADHD, combined type, subgrouped on the presence or absence of oppositional and conduct disorders, highlight the role of such diagnostic comorbidity in some of the dysfunctions attributed to ADHD.

Differentiating Practice Effects and Statistical Regression on the Conners Hyperkinesis Index

The Conners Abbreviated Parent-Teacher Questionnaire or Hyperkinesis Index (HI), a set of l0 checklist items from the Conners Parent and Teacher Rating Scales, is a widely used instrument to diagnose and monitor the treatment of hyperactive children. The scale appears to fulfill necessary criteria for such a diagnostic instrument: it is easily administered; it differentiates normal and hyperative children; and it shows high test-retest reliability. Further, it differentiates between active and placebo drug treatment, as well as different dosage levels of stimulant medication (Goyette, Conners, & Ulrich, 1978). In a study of methylphenidate treatment with hyperactive children, Werry and Sprague (1974) noted a significant drop in both the Conners teacher and parent scores between the first rating and the second through fifth ratings. They labeled this phenomenon a practice effect and proposed that investigators using the Conners administer the scale once prior to treatment in order to wash out this effect. While a definition of practice effect was not provided by the authors, from their discussion of the topic one could infer that the practice effect is a property of the Conners scale itself and that the drop in scores from first to subsequent administrations should occur for all factors on the Conners. Since Werry and Spragues article, other investigators have cautioned against a single administration of the Conners and have attempted to compensate for practice

Neurobehavioural dysfunction following mild traumatic brain injury in childhood: A case report with positive findings on positron emission tomography (PET)

The present case study describes the neurobehavioural, neurodiagnostic, and positron emission tomography (PET) scan findings in a child who sustained a whiplash-type injury in a motor vehicle accident. Although neck and back pain were reported immediately, neurobehavioural symptoms, such as staring spells, gradually increased in frequency over a 2-year period following the accident. At 4 years after the accident the patients symptoms persisted, as reported by teachers and parents, and more extensive diagnostic work-up was initiated. Standard EEG was normal while two ambulatory EEGs were abnormal and interpreted as epileptiform. A PET scan showed evidence of marked hypometabolism in both temporal lobes. Neuropsychological findings were consistent with PET findings and reflected verbal and visual memory deficits in the context of high average intelligence. Treatment with carbamazepine, verapamil, and fluoxetine greatly improved the patients symptoms. The present case illustrates an example of a poor outcome in a paediatric case of mild traumatic brain injury, the importance of PET in demonstrating definitive evidence of brain dysfunction, and the childs positive response to anticonvulsant medication.

Cognitive remediation in pediatric traumatic brain injury

Abstract Robinsons (1970) elaborative encoding technique (PQRST) was implemented as the active cognitive intervention strategy to address verbal memory deficits in 2 fourth-grade boys following mild or moderate traumatic brain injury (TBI). A metacognitive reading comprehension technique (Smith & Dauer, 1984) was also implemented for comparison purposes. Single-case methodology was employed using a counter-balanced crossover of the two intervention strategies controlling for the effects of attention. The performance of both boys was significantly better during strategy training with the PQRST technique and approached the performance level of the normal comparison subject. In contrast, the performance of both subjects with TBI remained at, or returned to, baseline levels during the metacognitive intervention. These findings suggest that Robinsons cognitive remediation intervention holds promise in addressing memory and reading comprehension deficits following pediatrie traumatic brain injury. Future rese...

Episodic symptoms in dysfunctioning children and adolescents following mild and severe traumatic brain injury

The present investigation examines the phenomenology of episodic symptoms in dysfunctioning children and adolescents following mild (n = 25) or severe (n = 25) traumatic brain injury (TBI). TBI patients in both groups commonly endorsed symptoms such as staring spells, memory gaps, and temper outbursts. Anticonvulsant response in the 27 patients treated, reflected moderate to substantial improvement in 92%. A dose-response relationship between injury severity and number of episodic symptoms was not observed; however, patients in the severe TBI sample did produce significantly more defective performances on a dichotic word-listening task (DWLT) and lower IQ values. Defective DWLT performance was also significantly associated with greater number of episodic symptoms endorsed, but only in the mild TBI sample. Parallels with epilepsy spectrum disorder and clinical implications for paediatric TBI are discussed.

Functional neuro-imaging and post-traumatic olfactory impairment

Objective: To evaluate via a research literature survey the anterior neurological significance of decreased olfactory functioning following traumatic brain injuries. Materials and Methods: A computer literature review was performed to locate all functional neuro-imaging studies on patients with post-traumatic anosmia and other olfactory deficits. Results: A convergence of findings from nine functional neuro-imaging studies indicating evidence for reduced metabolic activity at rest or relative hypo-perfusion during olfactory activations. Hypo-activation of the prefrontal regions was apparent in all nine post-traumatic samples, with three samples yielding evidence of reduced activity in the temporal regions as well. Conclusions: The practical ramifications include the reasonable hypothesis that a total anosmic head trauma patient likely has frontal lobe involvement.

Comparing the external validity of the DSM-1V and Two-Factor models of childhood behavior problems:

This study of 132 clinic-referred 6to 12-year old boys with behavior problems examined the concurrent external validity of dimensions of the DSM-IV and Two-Factor diagnostic models. Both models used parent responses to the same DSM structured interview, focusing the study on conceptual differences between the models. Age at evaluation accounted for major variation and was held constant in all analyses. Both models, in both twoand three-dimension versions, had considerable external validity. The Two-Factor inattention-overactivity (10) dimension predicted more external variables than the DSM-IV inattention (IN) dimension. DSM oppositional/conduct (OD/CD) accounted for some variation that is usually misattributed to DSM-IV hyperactivity-impulsivity (HI). In hierarchical analyses, the 10 and AG dimensions of the Two-Factor model predicted more variation in more dependent variables than did the IN and HI dimensions of the DSM model of ADHD. However, when the often-ignored third dimension (OD/CD) was included, the complete three-dimension DSM-IV model accounted for more variation in more dependent variables than did the Two-Factor model. When the excluded third dimension (HI) was added to the Two-Factor model, the two three-dimension models were essentially equal in external validity.