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COGNITIVE REHABILITATION IN CHILDREN WITH ACQUIRED BRAIN INJURIES. Ingrid van ´t Hooft PhD Department of Women and Child Health Astrid Lindgren Children´s Hospital Karolinska University Hospital Karolinska Institutet NBCNS MÖTE SOLBACKA 2008.

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slide1

COGNITIVE REHABILITATION

IN CHILDREN WITH ACQUIRED BRAIN INJURIES

Ingrid van ´t Hooft PhDDepartment of Women and Child HealthAstrid Lindgren Children´s HospitalKarolinska University HospitalKarolinskaInstitutetNBCNS MÖTE SOLBACKA 2008

definitions
DEFINITIONS

Acquired Brain Injury

Injury to the brain occurring after the post neonatal period

Aetiology

Traumatic

Nontraumatic(malignancies,

high prevalence of cognitive sequelae
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)

cognitive dysfunctions after tbi
COGNITIVE DYSFUNCTIONS AFTER TBI

Slow processing speed

Attentional dysfunction

Memory dysfunction

Executive dysfunction

Behavioural dysfunction

neuropsychological assessment
NEUROPSYCHOLOGICAL ASSESSMENT

Neuropsychological tests, observations

interviews, ratingscales

cognitive rehabilitation
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

Reviews 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)

cognitive training in children with abi
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

slide9

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 ?
slide10

ATTENTION AND MEMORY TRAINING IN CHILDREN

AMAT-C (Hendriks 96) SMART –C (van´tHooft 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

””

slide11

Pilotprojectvan´t 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.

slide12

STUDY DESIGN RCT

Test 6 months follow up

Test

Test

17weeks of training

Rating

Rating

Rating

patient population
PATIENT POPULATION
  • Children from Neuropaediatric and Oncology Units at the Astrid Lindgren Children’s Hospital, Lunds University Hospital, Folke Bernadotte Hemmet, Uppsala.
  • Out of 53 eligible patients 40 parents gave their consent.

2 children relapsed into malignancy.

  • Age>9 years, ABI, 1-5 years since time of injury (TBI) or since end of treatment (malignancy), IQ>70, 20% 1 SD below the age appropriate average on neuropsychological tests
slide14

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

slide15

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**

slide16

TEST RESULTS TREATMENT GROUP CONTROL GROUP P-VALUE

DIGIT SPAN

15 WORDS RECALL

15 WORDS DELAYED

RCFT

BEHAVIOURAL MEMORY

<0.001**

0.39

0.02*

<0.001**

<0.001**

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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 studyvan´t Hooft I, Andersson K, Bergman B, Sejersen T, von Wendt L, Bartfai A.Brain Injury, 2003, 19(7), 511-518.

follow up after 6 months
FOLLOW UP AFTER 6 MONTHS
  • Evaluation of training effects 6 months after completed cognitive training
slide21

Sustained favorable effects of cognitive training

in children with acquired brain injuriesvan’t 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

<0.001**

0.04*

<0.002**

<0.001**

<0.001**

<0.001**

slide25

Measuring effects on behaviour after cognitive training in children with acquired brain injuriesvan’tHooft 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.

results
RESULTS

Teachers observed a significant change (p<.008) of school performance in the training group as compared to the controls direct after training

Parents showed the same trend

further studies
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

experiences recommendations
Experiences-recommendations

Involvingfamily

Involvingteacher

Transfer of exercises to daily life at home and at school

Support of the emotional and social aspects

slide29

Thanks for your attention

Thanks for your attention

BAD

GOOD

GOOD AND BAD BRAIN DRAWN BY KLARA 10 YEARS OF AGE