Owen Lloyd

Executive function in children and adolescents with unilateral cerebral palsy

The aim of this study was to compare executive function in children with left‐ and right‐sided unilateral cerebral palsy (CP) and typically developing children.

Predictors of child post-concussion symptoms at 6 and 18 months following mild traumatic brain injury

Background: A proportion of children will experience persistent post-concussion symptoms (PCS) following a mild traumatic brain injury (mTBI). As persistent PCS may be maintained by pathological and psychological factors, this study aimed to describe and evaluate potential pre- and post-injury parent and child predictors of persistent PCS. Methods: A total of 150 children with mTBI and their parents participated. Parents completed measures of their own distress and childrens PCS and health-related quality-of-life (HRQoL) at baseline (reflecting pre-injury function). These measures, as well as measures of childrens distress and cognitive function were administered at 6 and 18 months post-injury. Results: Childrens PCS at 6 months post-injury were predicted by both pre-injury parent distress and childrens pre-injury PCS. At 18 months post-injury, childrens PCS were predicted by higher levels of parent distress and child PCS at 6 months post-injury, as well as poorer post-injury cognitive functioning. Change in PCS between 6–18 months post-injury was predicted by parents pre-injury anxiety and childrens HRQoL. Conclusions: Children at risk of persistent PCS can be identified by higher levels of pre- and post-injury PCS, parent distress and poorer post-injury cognition. These factors should be addressed by interventions aimed at minimizing the occurrence and impact of child PCS.

Everyday psychological functioning in children with unilateral cerebral palsy: does executive functioning play a role?

To identify whether executive functioning mediates the effect of having unilateral cerebral palsy (CP) on executive functioning in everyday life, psychological functioning, and social functioning.

Mitii™ ABI: Study protocol of a randomised controlled trial of a web-based multi-modal training program for children and adolescents with an Acquired Brain Injury (ABI)

BackgroundAcquired brain injury (ABI) refers to multiple disabilities arising from damage to the brain acquired after birth. Children with an ABI may experience physical, cognitive, social and emotional-behavioural impairments which can impact their ability to participate in activities of daily living (ADL). Recent developments in technology have led to the emergence of internet-delivered therapy programs. “Move it to improve it” (Mitii™) is a web-based multi-modal therapy that comprises upper limb (UL) and cognitive training within the context of meaningful physical activity. The proposed study aims to compare the efficacy of Mitii™ to usual care to improve ADL motor and processing skills, gross motor capacity, UL and executive functioning in a randomised waitlist controlled trial.Methods/DesignSixty independently ambulant children (30 in each group) at least 12 months post ABI will be recruited to participate in this trial. Children will be matched in pairs at baseline and randomly allocated to receive either 20 weeks of Mitii™ training (30 min per day, six days a week, with a potential total dose of 60 h) immediately, or be waitlisted for 20 weeks. Outcomes will be assessed at baseline, immediately post-intervention and at 20 weeks post-intervention. The primary outcomes will be the Assessment of Motor and Process Skills and 30 s repetition maximum of functional strength exercises (sit-to-stand, step-ups and half kneel to stand). Measures of body structure and functions, activity, participation and quality of life will assess the efficacy of Mitii™ across all domains of the International Classification of Functioning, Disability and Health framework. A subset of children will undertake three tesla (3T) magnetic resonance imaging scans to evaluate functional neurovascular changes, structural imaging, diffusion imaging and resting state functional connectivity before and after intervention.DiscussionMitii™ provides an alternative approach to deliver intensive therapy for children with an ABI in the convenience of the home environment. If Mitii™ is found to be effective, it may offer an accessible and inexpensive intervention option to increase therapy dose.Trial RegistrationANZCTR12613000403730

Executive functioning in children with unilateral cerebral palsy: protocol for a cross-sectional study

Introduction Early brain injury, as found in children with unilateral cerebral palsy (CP), may cause deficits in higher-order cognitive tasks known as executive functions (EF). EF has been conceptualised as comprised of four distinct yet inter-related components: (1) attentional control, (2) cognitive flexibility, (3) goal setting and (4) information processing. The aim of this study was to examine EF in children with unilateral CP and compare their performance with a typically developing reference group (TDC). The potential laterality effects of unilateral CP on EF will be explored, as will the relationship between the cognitive measures of EF, behavioural manifestations of EF, psychological functioning and clinical features of unilateral CP. Methods and analysis This cross-sectional study aims to recruit a total of 42 children with unilateral CP (21 right unilateral CP and 21 left unilateral CP) and 21 TDC aged between 8 and 16 years. Clinical severity will be described for gross motor function and manual ability. Outcomes for cognitive EF measureswill include subtests from the Wechsler Intelligence Scale for Children—Fourth Edition, Delis-Kaplan Executive Function System, Rey Complex Figure Test and the Test of Everyday Attention for Children. Behavioural manifestations of EF will be assessed using the Behaviour Rating Inventory of Executive Function, Parent and Teacher versions. Psychological functioning will be examined using the Strengths and Difficulties Questionnaire. Between-groups differences will be examined in a series of one-way analyses of covariance and followed up using linear comparisons. An overall composite of cognitive EF measures will be created. Bivariate correlations between the EF composite and psychological measures will be calculated. Ethics and dissemination This protocol describes a study that, to our knowledge, is the first to examine multiple components of EF using a cohort of children with unilateral CP. Exploration of potential laterality effects of EF among children with a congenital, unilateral brain injury is also novel. Possible relationships between EF and psychological functioning will also be investigated. Ethics have been obtained through the University of Queensland School of Psychology Ethics Committee and the Queensland Childrens Health Services Human Research Ethics Committee. Results will be disseminated in peer reviewed publications and presentations at national and international conferences. This study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000263998).

Neurodevelopmental outcome following open heart surgery in infancy: 6-year follow-up

BACKGROUND Children undergoing open heart surgery are at risk of neurological injury. A cohort of 35 patients, who had undergone cardiac surgery during infancy, had a significant reduction in Bayley Scale of Infant Development scores at a 12-month assessment. This cohort has now reached an appropriate age to reassess developmental progress. METHODS Detailed psychometric testing was conducted on 20 children from the original cohort using the Weschler Preschool and Primary Scale of Intelligence, the Wide Range Assessment of Memory and Learning, and the Wechsler Individual Achievement Test. Parents completed the Connors Rating Scale, the Behaviour Rating Scale of Executive Functioning, and the Child Behaviour Checklist. RESULTS The mean age of the cohort at assessment was 6.6 (standard deviation 0.4) years. Mean scores on all tests of intelligence, memory, academic achievement, and executive function fell within the average range. Of the children, 20-35% were found to have significant difficulties across these areas. Mean scores in the areas of social, emotional, behavioural, and psychological functioning also fell within the average range. Of the children studied, 35% had clinically significant problems in these areas. There was only a weak association between the 12-month scores and the Full-Scale Intelligence Quotient at 6 years. CONCLUSION Detailed psychometric testing of these children suggests that they generally function in the average range; however, a significant proportion falls below age expectations in all the areas assessed. This highlights the importance of long-term follow-up with routine developmental screening to allow identification of a subgroup that may benefit from early educational and behavioural intervention.

Central nervous system stimulants for secondary attention deficit-hyperactivity disorder after paediatric traumatic brain injury: a rationale and protocol for single patient (n-of-1) multiple cross-over trials

BackgroundIt is estimated that 22,800 children were living with an Acquired Brain Injury (ABI) (0.6% of children aged under 15 years) in Australia during 2003. Many children after a traumatic brain injury will experience difficulties with attention and concentration; a condition termed secondary Attention Deficit-Hyperactivity Disorder. There is conflicting evidence on whether treatment with stimulant therapy with medications such as methylphenidate or dexamphetamine will improve the attention and behavior of children with this condition.Methods/DesignSingle patient trials (n-of-1s or SPTs) evaluate the effect of titrated doses of psychostimulants methylphenidate or dexamphetamine compared to placebo on attention and behavior, in children with TBI and secondary ADHD. The aggregation of multiple SPTs will produce a population estimate of the benefit. Forty-two children will be registered into the trial through rehabilitation services at three large children’s hospitals in Australia. Patients will complete up to 3 cycles of treatment. Each cycle is 2 weeks long comprising seven days each of treatment and placebo, with the first two days of each cycle considered a washout period and the data not analysed. The order of treatment and placebo is randomly allocated for each cycle. The Conners’ Parent Rating Scales long forms will be employed to measure change in attention-deficit/hyperactivity and related problems of the child, and the primary outcome measure is the Conners’ Global Index Parent Version. Secondary outcomes include the teacher and child (if aged > 12 years) Conners’ Rating Scales, the Behaviour Rating Inventory of Executive Function among other measures. This study will provide high-level evidence using a novel methodological approach to inform clinicians about the most appropriate treatment for individual children. Through aggregation of individual trials, a population estimate of treatment effect will be provided to guide clinical practice in the treatment of children with secondary ADHD after a traumatic brain injury.DiscussionThis study employs an innovative methodological approach on the effectiveness of CNS stimulants for secondary ADHD from a brain injury. The findings will both guide clinicians on treatment recommendations, and inform the concept and acceptance of SPTs in paediatric research.Trial registrationAustralian New Zealand Clinical Trials Registry. ACTRN12609000873224

Awareness deficits in children and adolescents after traumatic brain injury: a systematic review

Objectives:To systematically review empirical research on awareness deficits in children and adolescents following traumatic brain injury (TBI). Methods:PsycINFO, MEDLINE, Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Education Resources Information Centre), PsycBITE, and Web of Science were searched from inception to August 8, 2013, using key terms relating to awareness of deficits and brain injury in childhood/adolescence. Studies of children or adolescents with traumatic brain injury (TBI), systematic measurement of awareness of deficits, and reporting of quantitative data were included. Details of participants, methodology, and findings were summarized for each study, and methodological quality was rated. Results:Review of 12 eligible studies yielded mixed evidence concerning the presence of awareness deficits after childhood TBI. Awareness deficits were most evident both for memory and executive function impairments and for children and adolescents with severe TBI. Methodological variability, including sampling characteristics, objects of awareness, measurement issues, and approach to statistical analysis, contributed to the mixed findings. Conclusions:Further research focusing on factors contributing to awareness deficits following pediatric TBI, the course of recovery, and relation to functional outcomes is warranted.

Availability, spatial accessibility, utilisation and the role of telehealth for multi-disciplinary paediatric cerebral palsy services in Queensland:

Aims The purpose of this study was to understand the methods of current delivery of health care services to cerebral palsy (CP) patients in Queensland, Australia. The study also examines the current use of telehealth by clinicians and their perceptions about telehealth use. Methods Patient records during July 2013–July 2014 were accessed from the Queensland Paediatric Rehabilitation Service (QPRS) to collect information relating to the service delivery for CP patients. Analysis was carried out to examine the patient locations and travel distances using ArcMap geoprocessing software. In addition, 13 face-to-face semi structured interviews were conducted with clinicians from the QPRS and the Cerebral Palsy Health Service (CPHS) to understand the perceptions of clinicians relating to the current level of health care delivery. We also examined the clinicians’ current use of telehealth and their opinions about this method. Results Records of 329 paediatric CP patients were accessed and reviewed. The majority of patients (96%, n = 307) who attended the clinics at the Royal Childrens Hospital (RCH), Brisbane, were from remote, rural or regional areas of Queensland. Only 4% of patients (n = 13) were from major cities. During 12 months, patients had attended nine outreach programmes that were conducted by the QPRS and CPHS. The study found that non-local patients were required to travel an average distance of 836 km to access QPRS and CPHS services in Brisbane. The average distance for receiving a consultation at an outreach clinic was 173 km. Clinicians perceived that access to health care services to CP patients in Queensland is inadequate. Nearly all clinicians interviewed had some experience in using telehealth. They had high satisfaction levels with the method. Conclusions Traditional methods of delivering services to CP patients do not meet their needs. Clinicians have found telehealth is a feasible and satisfactory delivery method. However, the use of telehealth is still limited.

Randomized controlled trial of a web-based multi-modal therapy program for executive functioning in children and adolescents with unilateral cerebral palsy

Abstract Purpose state: Determine the efficacy of Move-it-to-improve-it (Mitii™), a multi-modal web-based program, in improving Executive Function (EF) in children with unilateral cerebral palsy (UCP). Method: Participants (n = 102) were matched in pairs then randomized to: intervention (Mitii™ for 20 weeks; n = 51; 26 males; mean age = 11 years 8 months (SD = 2 years 4 months); Full Scale IQ = 84.65 (SD = 15.19); 28 left UCP; GMFCS-E&R (I = 20, II = 31) or waitlist control (n = 50; 25 males; mean age = 11 years 10 months (SD = 2 years 5 months); Full Scale IQ = 80.75 (SD = 19.81); 20 left UCP; GMFCS-E&R (I = 25, II = 25). Mitii™ targeted working memory (WM), visual processing (VP), upper limb co-ordination and physical activity. EF capacity was assessed: attentional control (DSB; WISC-IV); cognitive flexibility (inhibition and number-letter sequencing DKEFS); goal setting (D-KEFs Tower Test); and information processing (WISC-IV Symbol Search and Coding). EF performance was assessed via parent report (BRIEF). Groups were compared at 20 weeks using linear regression (SPSS 21). Results: There were no significant between group differences in attentional control (DSB; p = 0.20;CI= −0.40,1.87); cognitive flexibility (Inhibition, p = 0.34; CI= −0.73,2.11; number/letter sequencing, p = 0.17; CI= −0.55,2.94); problem solving (Tower; p = 0.28; CI= −0.61,2.09), information processing (Symbol; p = 0.08; CI= −0.16, 2.75; Coding; p = 0.07; CI= −0.12,2.52) or EF performance (p = 0.13; CI= −10.04,1.38). Conclusion:In a large RCT, MitiiTM did not lead to significant improvements on measures of EF or parent ratings of EF performance in children with UCP. Implications for rehabilitation A large RCT of the multi-modal web based training; Move It to Improve It (MitiiTM) improves motor processing, visual perception, and physical capacity but does demonstrate statistically significant improvements or clinical significance in executive function in children with mild to moderate unilateral cerebral palsy (UCP). MitiiTM training completed by an intervention group was highly variable with few children reaching the target dosage of 60 h. Technical issues including server and internet connectively problems lead to disengagement with the program. Web-based training delivered in the home has the potential to increase therapy dose and accessibility, however, MitiiTM needs to be tailored to include tasks involving goal-setting, more complex problem solving using multi-dimensional strategies, mental flexibility, switching between two cognitively demanding tasks, and greater novelty in order to increase the cognitive component and challenge required to drive changes in EF.