Transcript Cognitive Rehabilitation in children with acquired brain

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
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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)
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46% of children who suffered a stroke
(Chapman 2003, Max et al. 2004)
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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

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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
ABI
Light 1987, Ponsford 2001, Braga 2005
MALIGNANCIES
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)
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
Rating
17 weeks of training
Test
Rating
Test 6 months follow up
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.
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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
AUD RT
TREATMENT GROUP
CONTROL GROUP
P VALUE
0,38
0.52
VISUAL RT
GORDON CORRECT
GORDON COMMISSIONS
BINARY CHOICE RT
BINARY CHOICE CORRECT
0.01*
0.06
0.53
0.002**
TMT A
TMT B
0.006**
STROOP 1
0.02*
STROOP 2
0.08
STROOP 3
0.27
CODING
0.002**
TEST RESULTS
TREATMENT GROUP
DIGIT SPAN
CONTROL GROUP
P-VALUE
<0.001**
15 WORDS RECALL
0.39
15 WORDS DELAYED
0.02*
RCFT
<0.001**
BEHAVIOURAL MEMORY
<0.001**
Change of number of recalled segments on the
RCF after training by groups
Figure 2. Change of number of recalled segments on the RCFT after training
30
20
10
0
Number of segments
-10
-20
Median
25%-75%
-30
Control group
Treatment group
Figure 1.
50
Change in performance on Trail making Test B after training
40
30
20
10
0
Time (Sec.)
-10
-20
-30
-40
Median
25%-75%
-50
Control group
Treatment group

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
<0.001**
GORDON COMMISSIONS
0.04*
BINARY CORRECT
<0.002**
15 WORDS RECALL
<0.001**
REY COMPLEX FIGURE
<0.001**
BEHAVIOURAL MEMORY
<0.001**
Working memory pre, post and 6 months after training
Figure 3.
Performance on the Digit Span Test
pre, post and post 6 months after training
14.5
Number of Digits
13.5
12.5
11.5
10.5
Control group
Treatment group
9.5
Pre
Post
Post 6 months
Verbal Comprehension Factor Score (WISC-III by groups)
Figure 2.
108
106
104
IQ
102
100
98
96
Control group
94
Treatment group
Before training
6 months after completed
Freedom of distractibility factor score by goups
Figure 2
96
94
92
IQ
90
88
86
84
Control group
82
Treatment group
Bef ore training
6 months af ter completed training
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
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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
Experiencesrecommendations
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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
BAD
GOOD
GOOD AND BAD BRAIN DRAWN BY KLARA
10 YEARS OF AGE