Ingrid van ´t Hooft PhDIngrid van ´t Hooft PhD

Department of Women and Child HealthDepartment of Women and Child HealthAstrid Lindgren Children´s HospitalAstrid Lindgren Children´s Hospital

Karolinska University HospitalKarolinska University Hospital

Karolinska InstitutetKarolinska Institutet

NBCNS MÖTE SOLBACKA 2008NBCNS MÖTE SOLBACKA 2008

COGNITIVE REHABILITATION IN CHILDREN WITH ACQUIRED BRAIN INJURIES

NEUROPEDIATRIC REHABILITATION AT THE NEUROPEDIATRIC REHABILITATION AT THE ASTRID LINDGREN CHILDREN´S HOSPITALASTRID LINDGREN CHILDREN´S HOSPITAL

DEFINITIONSDEFINITIONS

Acquired Brain InjuryAcquired Brain Injury Injury to the brain occurring after the post Injury to the brain occurring after the post

neonatal periodneonatal period

AetiologyAetiology TraumaticTraumatic Nontraumatic (malignancies, Nontraumatic (malignancies,

HIGH PREVALENCE OF COGNITIVE SEQUELAEHIGH PREVALENCE OF COGNITIVE SEQUELAE

50% of children with severe to moderate TBI 50% of children with severe to moderate TBI ((Brown 1981, Klonoff 1995, Catroppa & Anderson 1999, Anderson et al. 2004)Brown 1981, Klonoff 1995, Catroppa & Anderson 1999, Anderson et al. 2004)

46% of children who suffered a stroke 46% of children who suffered a stroke ((Chapman 2003, Max et al. 2004)Chapman 2003, Max et al. 2004)

50% of children treated for brain malignancies 50% of children treated for brain malignancies (Fletcher & Copeland 1988, Armstrong & Horn 1995, Parker et al 1997, Mulhern et al 1998, Mulhern (Fletcher & Copeland 1988, Armstrong & Horn 1995, Parker et al 1997, Mulhern et al 1998, Mulhern 2005)2005)

COGNITIVE DYSFUNCTIONS AFTER TBICOGNITIVE DYSFUNCTIONS AFTER TBI

Slow processing speed Slow processing speed Attentional dysfunction Attentional dysfunction Memory dysfunction Memory dysfunction Executive dysfunctionExecutive dysfunction

Behavioural dysfunctionBehavioural dysfunction

NEUROPSYCHOLOGICAL ASSESSMENTNEUROPSYCHOLOGICAL ASSESSMENT

Neuropsychological tests, observationsNeuropsychological tests, observationsinterviews, ratingscalesinterviews, ratingscales

COGNITIVE REHABILITATIONCOGNITIVE REHABILITATION

Cognitive training is a theoretically based, specific and repeated Cognitive training is a theoretically based, specific and repeated training of impaired cognitive processes, with the aim to reduce training of impaired cognitive processes, with the aim to reduce behavioural changes due to CNS pathologybehavioural changes due to CNS pathology

Reviews of a large number of studies in adults with TBI provide support for the Reviews of a large number of studies in adults with TBI provide support for the effectiveness of cognitive rehabilitationeffectiveness of cognitive rehabilitation(Cappa 2003, Carney 2000 , Cicerone 2000, Cicerone et al. 2005)(Cappa 2003, Carney 2000 , Cicerone 2000, Cicerone et al. 2005)

COGNITIVE TRAINING IN CHILDRENCOGNITIVE TRAINING IN CHILDRENWITH ABIWITH ABI

PROCESS SPECIFIC TRAININGPROCESS SPECIFIC TRAININGABI ABI

Brett & Laatsch 1998, Franzen et al. 2005, Brett & Laatsch 1998, Franzen et al. 2005, Thomson & Kerns 2000Thomson & Kerns 2000

MALIGNANCIESMALIGNANCIES

::Butler & Copeland 1998Butler & Copeland 1998

COGNITIVECOGNITIVEREHABILITATION PROGRAMSREHABILITATION PROGRAMSABIABI

Light 1987, Ponsford 2001, Braga 2005Light 1987, Ponsford 2001, Braga 2005

MALIGNANCIESMALIGNANCIES

Hendriks 1996, Butler 2002Hendriks 1996, Butler 2002

Reviews : Limond &Leek 2005, Anderson & Reviews : Limond &Leek 2005, Anderson & Catroppa 2006, Laatsch et al. 2007Catroppa 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

 

””

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.

STUDY DESIGN RCT

Test 17 weeks of training Test Test 6 months follow up

Rating Rating Rating

PATIENT POPULATIONPATIENT POPULATION

Children from Neuropaediatric and Oncology Units at the Children from Neuropaediatric and Oncology Units at the Astrid Lindgren Children’s Hospital, Lunds University Astrid Lindgren Children’s Hospital, Lunds University Hospital, Folke Bernadotte Hemmet, Uppsala.Hospital, Folke Bernadotte Hemmet, Uppsala.

Out of 53 eligible patients 40 parents Out of 53 eligible patients 40 parents gavegave their consent. their consent.

2 children relapsed into malignancy.2 children relapsed into malignancy.

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

NEUROPSYCHOLOGICAL TEST BATTERY

Sustained attentionAuditory Reaction Time Tests Visual Reaction Time Test Gordon Diagnostic System

Selective attentionStroop Colour and Word Test Binary Choice Test Trail Making Test A, BCoding ( WISC III)

MemoryDigit Span Rey Auditory Verbal Learning Rey-Osterrieth Complex Figure Rivermead Behavioural Memory Test

TEST RESULTS TREATMENT GROUP CONTROL GROUP P VALUE

AUD RT

VISUAL RT

GORDON CORRECT

GORDON COMMISSIONS

BINARY CHOICE RT

BINARY CHOICE CORRECT

TMT A

TMT B

STROOP 1

STROOP 2

STROOP 3

CODING

0,38

0.52

0.01*

0.06

0.53

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*

<0.001**

<0.001**

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

Change of number of rec alled s egments on the RCFT af ter training

Median 25% -75%

Control group Treatment group-30

-20

-10

0

10

20

30

Num

ber o

f segm

ents

Figure 2.

Ch a n g e i n p e rfo rm a n ce o n T ra i l m a kin g T e st B a fte r tra i n i n g

M e d i a n 2 5 % -7 5 %

Co n tro l g ro u p T re a tm e n t g ro u p-5 0

-4 0

-3 0

-2 0

-1 0

0

1 0

2 0

3 0

4 0

5 0

Tim

e (S

ec.)

F i g u re 1 .

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 Beneficial effect from a cognitive training programme on children with acquired brain injuries demonstrated in a controlled studydemonstrated in a controlled studyvan´t Hooft I, Andersson K, Bergman B, Sejersen T, von Wendt L, Bartfai A.van´t Hooft I, Andersson K, Bergman B, Sejersen T, von Wendt L, Bartfai A. Brain Injury, 2003, 19(7), 511-518.Brain Injury, 2003, 19(7), 511-518.

FOLLOW UP AFTER 6 MONTHSFOLLOW UP AFTER 6 MONTHS

Evaluation of training Evaluation of training effects 6 months after effects 6 months after completed cognitive completed cognitive trainingtraining

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**

TEST RESULTS

Sustained favorable effects of cognitive trainingSustained favorable effects of cognitive training in children with acquired brain injuriesin children with acquired brain injuries

van’t Hooft I, Andersson K, Bergman B, Sejersen, von Wendt L, Bartfai A.van’t Hooft I, Andersson K, Bergman B, Sejersen, von Wendt L, Bartfai A.vol 22.2 NeuroRehabilitation 2007vol 22.2 NeuroRehabilitation 2007

Control group

Treatment group

Performance on the Digit Span Test

pre, post and post 6 months after training

Nu

mb

er

of

Dig

its

9.5

10.5

11.5

12.5

13.5

14.5

Pre Post Post 6 months

Figure 3.

Working memory pre, post and 6 months after training

Control group

Treatment group

Figure 2.

Before training 6 months after completed

IQ

94

96

98

100

102

104

106

108

Verbal Comprehension Factor Score (WISC-III by groups)

Control group

Treatment group

Figure 2

Before training 6 months after completed training

IQ

82

84

86

88

90

92

94

96

Freedom of distractibility factor score by goups

Measuring effects on behaviour after cognitive Measuring effects on behaviour after cognitive training in children with acquired brain injuriestraining in children with acquired brain injuries

van’t Hooft I, Brodin U, Sejersen T, von Wendt L, Bartfai A.van’t Hooft I, Brodin U, Sejersen T, von Wendt L, Bartfai A.Submitted Submitted 20082008

AimsAims:: Evaluating the effects of cognitive training on school Evaluating the effects of cognitive training on school performance, attention, executive functions and social performance, attention, executive functions and social behaviourbehaviour

MethodMethod: Ansula Behavioural Rating Scales : Ansula Behavioural Rating Scales (Levin 1992)(Levin 1992) as as rated by parents, teachers and children before, immediately after completed training and at the 6 months follow up.

RESULTSRESULTS

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 STUDIESFURTHER STUDIES

Smart training ……Smart training ……

Pilotstudie on 3 children with medulloblastomasPilotstudie on 3 children with medulloblastomas

Reducing the time to 10 weeks Reducing the time to 10 weeks

Combining the training with a parental Combining the training with a parental programme of 5x1hour sessionsprogramme of 5x1hour sessions

Experiences-Experiences-recommendationsrecommendations

Involving familyInvolving family Involving teacherInvolving teacher Transfer of exercises to daily life at home and Transfer of exercises to daily life at home and

at schoolat school Support of the emotional and social aspectsSupport of the emotional and social aspects

Thanks for your attention

GOOD AND BAD BRAIN DRAWN BY KLARA 10 YEARS OF AGE

Thanks for your attention

BADGOOD