Ingrid van

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Ingrid van t Hooft PhDDepartment of
Women and Child HealthAstrid Lindgren Childrens
HospitalKarolinska University HospitalKarolinsk
a InstitutetNBCNS MÖTE SOLBACKA 2008
COGNITIVE REHABILITATION IN CHILDREN
WITH ACQUIRED BRAIN INJURIES
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NEUROPEDIATRIC REHABILITATION AT THE ASTRID
LINDGREN CHILDRENS HOSPITAL
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DEFINITIONS

• Acquired Brain Injury
• Injury to the brain occurring after the post
  neonatal period
• Aetiology
• Traumatic
• Nontraumatic (malignancies,

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HIGH PREVALENCE OF COGNITIVE SEQUELAE

• 50 of children with severe to moderate TBI
• (Brown 1981, Klonoff 1995, Catroppa Anderson
  1999, Anderson et al. 2004)
• 46 of children who suffered a stroke
• (Chapman 2003, Max et al. 2004)
• 50 of children treated for brain malignancies
• (Fletcher Copeland 1988, Armstrong Horn
  1995, Parker et al 1997, Mulhern et al 1998,
  Mulhern 2005)

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COGNITIVE DYSFUNCTIONS AFTER TBI

• Slow processing speed
• Attentional dysfunction
• Memory dysfunction
• Executive dysfunction
• Behavioural dysfunction

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NEUROPSYCHOLOGICAL ASSESSMENT

Neuropsychological tests, observations interviews,
ratingscales
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COGNITIVE REHABILITATION
Cognitive training is a theoretically based,
specific and repeated training of impaired
cognitive processes, with the aim to reduce
behavioural changes due to CNS pathology Re
views of a large number of studies in adults with
TBI provide support for the effectiveness of
cognitive rehabilitation (Cappa 2003, Carney 2000
, Cicerone 2000, Cicerone et al. 2005)
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COGNITIVE TRAINING IN CHILDRENWITH ABI

• PROCESS SPECIFIC TRAINING
• ABI
• Brett Laatsch 1998, Franzen et al. 2005,
• Thomson Kerns 2000
• MALIGNANCIES
• Butler Copeland 1998
• COGNITIVE
• REHABILITATION PROGRAMS
• ABI
• Light 1987, Ponsford 2001, Braga 2005
• MALIGNANCIES
• Hendriks 1996, Butler 2002
• Reviews Limond Leek 2005, Anderson
  Catroppa 2006, Laatsch et al. 2007

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• QUESTIONS
• Can we influence cognitive dysfunctions with
  cognitive rehabilitation after ABI in children ?
• How is the effect of cognitive rehabilitation
  over time?
• Does cognitive rehabilitation have an effect on
  behaviour and school achievement ?

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ATTENTION AND MEMORY TRAINING IN CHILDREN AMAT-C
(Hendriks 96) SMART C (vant Hooft et al.
2003, 2005, 2007)

• Interactive training with a coach (parent or
  teacher)
• Specific exercises in attention and memory
  techniques
• Strategy training, insight and awareness
• 30 min/day during 17 weeks
• 1x/week feedback and support at the hospital

 

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Pilotprojectvant Hooft I, Andersson K,
Sejersen T, Bartfai A, von Wendt L. Acta
Paediatrica, 2003, 92 935-940.3 children (9-16
years of age) with TBI trained 30 min per day
during 20 weeks.
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STUDY DESIGN RCT

Test 6 months follow up
Test
Test
17 weeks of training
Rating
Rating
Rating





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PATIENT POPULATION

• Children from Neuropaediatric and Oncology Units
  at the Astrid Lindgren Childrens Hospital, Lunds
  University Hospital, Folke Bernadotte Hemmet,
  Uppsala.
• Out of 53 eligible patients 40 parents gave their
  consent.
• 2 children relapsed into malignancy.
• Agegt9 years, ABI, 1-5 years since time of injury
  (TBI) or since end of treatment (malignancy),
  IQgt70, 20 1 SD below the age appropriate average
  on neuropsychological tests

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NEUROPSYCHOLOGICAL TEST BATTERY Sustained
attention Auditory Reaction Time Tests Visual
Reaction Time Test Gordon Diagnostic
System Selective attention Stroop Colour and
Word Test Binary Choice Test Trail Making Test
A, B Coding ( WISC III) Memory Digit Span Rey
Auditory Verbal Learning Rey-Osterrieth Complex
Figure Rivermead Behavioural Memory Test
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TEST RESULTS TREATMENT GROUP
CONTROL GROUP P VALUE
0,38
AUD RT VISUAL RT GORDON CORRECT GORDON
COMMISSIONS
0.52
0.01
0.06
0.53
BINARY CHOICE RT BINARY CHOICE CORRECT TMT
A TMT B STROOP 1 STROOP 2 STROOP 3 CODING
0.002
0.006
0.02
0.08
0.27
0.002
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TEST RESULTS TREATMENT GROUP CONTROL
GROUP P-VALUE
DIGIT SPAN 15 WORDS RECALL 15 WORDS
DELAYED RCFT BEHAVIOURAL MEMORY
lt0.001 0.39 0.02 lt0.001 lt0.001
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Change of number of recalled segments on the RCF
after training by groups
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(No Transcript)
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• SIGNIFICANT IMPROVEMENTS WAS SHOWN ON MORE
  COMPLEX NEUROPSYCHOLOGICAL TESTS
• NO SIGNIFICANT DIFFERENCES WERE OBSERVED ON
  SIMPLE REACTION TIME TESTS
• Beneficial effect from a cognitive training
  programme on children with acquired brain
  injuries demonstrated in a controlled studyvant
  Hooft I, Andersson K, Bergman B, Sejersen T, von
  Wendt L, Bartfai A. Brain Injury, 2003, 19(7),
  511-518.

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FOLLOW UP AFTER 6 MONTHS

• Evaluation of training effects 6 months after
  completed cognitive training

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Sustained favorable effects of cognitive training
in children with acquired brain injuriesvant
Hooft I, Andersson K, Bergman B, Sejersen, von
Wendt L, Bartfai A.vol 22.2 NeuroRehabilitation
2007
TEST RESULTS
P-VALUE
GORDON CORRECT GORDON COMMISSIONS BINARY
CORRECT 15 WORDS RECALL REY COMPLEX
FIGURE BEHAVIOURAL MEMORY
lt0.001 0.04 lt0.002 lt0.001 lt0.001 lt0
.001
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Working memory pre, post and 6 months after
training
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Verbal Comprehension Factor Score (WISC-III by
groups)
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Freedom of distractibility factor score
by goups
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Measuring effects on behaviour after cognitive
training in children with acquired brain
injuriesvant Hooft I, Brodin U, Sejersen T, von
Wendt L, Bartfai A.Submitted 2008

• Aims Evaluating the effects of cognitive
  training on school performance, attention,
  executive functions and social behaviour
• Method Ansula Behavioural Rating Scales (Levin
  1992) as rated by parents, teachers and children
  before, immediately after completed training and
  at the 6 months follow up.

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RESULTS

• Teachers observed a significant change (plt.008)
  of school performance in the training group as
  compared to the controls direct after training
• Parents showed the same trend

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FURTHER STUDIES

• Smart training
• Pilotstudie on 3 children with medulloblastomas
• Reducing the time to 10 weeks
• Combining the training with a parental programme
  of 5x1hour sessions

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Experiences-recommendations

• Involving family
• Involving teacher
• Transfer of exercises to daily life at home and
  at school
• Support of the emotional and social aspects

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Thanks for your attention
Thanks for your attention
BAD
GOOD
GOOD AND BAD BRAIN DRAWN BY KLARA 10 YEARS OF AGE