1. 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

2. NEUROPEDIATRIC REHABILITATION AT THE ASTRID LINDGREN CHILDREN´S HOSPITAL

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

4. 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)

5. COGNITIVE DYSFUNCTIONS AFTER TBI
Slow processing speed
Attentional dysfunction
Memory dysfunction
Executive dysfunction
Behavioural dysfunction

6. NEUROPSYCHOLOGICAL ASSESSMENT
Neuropsychological tests, observations
interviews, ratingscales

7. 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)

8. 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

9. 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 ?

10. 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 ””

11. Pilotproject van´t Hooft I, Andersson K, Sejersen T, Bartfai A, von Wendt L. Acta Paediatrica, 2003, 92; children (9-16 years of age) with TBI trained 30 min per day during 20 weeks.

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

13. 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

14. 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

15. 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**

16. 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*

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

19. 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),

20. FOLLOW UP AFTER 6 MONTHS
Evaluation of training effects 6 months after completed cognitive training

21. 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**

22. Working memory pre, post and 6 months after training

23. Verbal Comprehension Factor Score (WISC-III by groups)

24. Freedom of distractibility factor score by goups

25. 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.

26. 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

27. 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

28. Experiences-recommendations
Involving family
Involving teacher
Transfer of exercises to daily life at home and at school
Support of the emotional and social aspects

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