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

NEUROPEDIATRIC REHABILITATION AT THE ASTRID LINDGREN CHILDREN´S HOSPITAL

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

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 Slow processing speed Attentional dysfunction Memory dysfunction Executive dysfunction Behavioural dysfunction

NEUROPSYCHOLOGICAL ASSESSMENT Neuropsychological tests, observations interviews, ratingscales

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

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 ?

Interactive training with a coach (parent or teacher) ATTENTION AND MEMORY TRAINING IN CHILDREN AMAT-C (Hendriks 96) SMART –C (van´t 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   ””

Pilotproject van´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.

STUDY DESIGN RCT Test 17 weeks of training Test Rating Rating Rating Test 6 months follow up Rating Rating Rating

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

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

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**

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*

Change of number of recalled segments on the RCF after training by groups

NO SIGNIFICANT DIFFERENCES WERE OBSERVED ON SIMPLE REACTION TIME TESTS 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 study van´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 Evaluation of training effects 6 months after completed cognitive training

Sustained favorable effects of cognitive training in children with acquired brain injuries van’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**

Working memory pre, post and 6 months after training

Verbal Comprehension Factor Score (WISC-III by groups)

Freedom of distractibility factor score by goups

Measuring effects on behaviour after cognitive training in children with acquired brain injuries van’t 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.

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

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