J Head Trauma Rehabil c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Cognitive Intervention for Attention and Executive Function Impairments in Children With Traumatic Brain Injury: A Pilot Study Amery Treble-Barna, PhD; McKay Moore Sohlberg, PhD; Beth E. Harn, PhD; Shari L. Wade, PhD Objective: To test the effectiveness of the Attention Improvement and Management (AIM) program, a cognitive intervention for improving impairments in attention and executive functions (EFs) after pediatric traumatic brain injury (TBI). Setting: Tertiary care children’s hospital. Participants: A total of 13 children with complicated mildto-severe TBI (average of 5 years postinjury) and 11 healthy comparison children aged 9 to 15 years completed the study. Design: Open-label pilot study with a nontreated control group. Main Measures: Subtests from the Test of Everyday Attention-for Children (TEA-Ch) and the Delis–Kaplan Executive Function System (D-KEFS), the self- and parent-report from the Behavior Rating Inventory of Executive Function (BRIEF), and the Goal Attainment Scale (GAS). Results: Relative to the healthy comparison group, children with TBI demonstrated significant improvement postintervention on a neuropsychological measure of sustained attention, as well as on parent-reported EFs. The majority of families also reported expected or more-than-expected personalized goal attainment. Conclusions: The study provides preliminary evidence for the effectiveness of AIM in improving parent-reported EFs and personalized real-world goal attainment in children with TBI. Key words: child, cognitive remediation, cognitive rehabilitation, executive function, pilot projects, traumatic brain injury
Author Affiliations: Department of Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Treble-Barna); Communication Disorders and Sciences, University of Oregon, Eugene, Oregon (Dr Sohlberg); Department of Special Education and Clinical Sciences, University of Oregon, Eugene, Oregon (Dr Harn); Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Wade). The authors would like to recognize the contributions of Jason Prideaux, Jennifer Taylor, Holly MacPherson, Stacey Raj, and Julia Smith. This project was supported in part by grants from the Department of Education’s National Institute on Disability and Rehabilitation Research (Center on Interventions for Children and Youth with Traumatic Brain Injury; Grant number H133B090010-10) and the Ohio Department of Public Safety Emergency Medical Services Program. This material does not necessarily represent the policy of these agencies, nor is the material necessarily endorsed by the Federal Government. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.headtraumahab.com). The authors declare no conflicts of interest. Corresponding Author: Amery Treble-Barna, PhD, Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 ([email protected]). DOI: 10.1097/HTR.0000000000000200
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EDIATRIC TRAUMATIC BRAIN INJURY (TBI) is the most common source of acquired morbidity and mortality in children.1 Among the most disruptive and persistent symptoms post-TBI are changes in attention and executive functions (EFs).2 These cognitive deficits are evident in about 50% of cases, and can persist for several years postinjury and into adulthood.3,4 Deficits in attention and EFs are associated with reduced functioning in academic, social, and behavioral domains and ultimately have been linked with poorer educational and vocational outcomes.5,6 Despite the prevalence and impact of attention and EF impairments after pediatric TBI, there are limited evidence-based cognitive interventions available for this population.7–9 Attention is considered a strong modulator of cognition and encompasses the processes that allow a sustained and selective focus on environmental stimuli.10,11 Executive functions are the abilities that permit allocation or control of attentional resources, including skills such as working memory, inhibition, interference control, cognitive flexibility, reasoning, problem solving, and planning.12–14 The brain networks that subserve 1
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JOURNAL OF HEAD TRAUMA REHABILITATION
these systems are highly distributed and integrated, making them particularly susceptible to disruption in TBI and accounting, in part, for the pervasive nature of these impairments.15 In addition, the nature of attention and EF impairments after pediatric TBI is heterogeneous, in part because highly individualized injuries are imposed on a uniquely developing system. Cognitive impairment profiles include a unique combination of specific types of attention and EF deficits with the additional population characteristic of variability in performance across tasks and over time. This variability necessitates developing treatments that can address a wide range of impairment profiles. THE TREATMENT EVIDENCE IN ACQUIRED PEDIATRIC BRAIN INJURY Recent studies of cognitive interventions for attention and EF impairments in children with acquired brain injury have evaluated a combination of drill-based attention training and metacognitive strategy instruction. Attention training drills are grounded in the emerging literature supporting experience-dependent plasticity16–19 and are mostly based on the adult brain injury rehabilitation literature that has produced practice guidelines supporting this intervention.20,21 A critical issue with this intervention approach is equivocal evidence for generalization or “transfer” of gains from cognitive training to nontrained tasks, including everyday, “real-world” activities, in pediatric brain injury or other childhood conditions.15,22–24 Metacognitive strategy training involves instruction in behaviors that facilitate efficient allocation of cognitive resources and enhance self-regulation. Metacognitive strategy training can be used to promote generalizability of cognitive interventions to everyday tasks through a context-sensitive approach in which participants and clinicians identify specific daily challenges, then strategize, test, and problem-solve potential solutions involving evidence-based metacognitive concepts.22,23 Initial studies of metacognitive strategy training in children with developmental attention deficits (eg, attention-deficit/hyperactivity disorder [ADHD]) suggest promise for transfer of strategy training to improvements on real-world tasks.25,26 The integration of attention drills and metacognitive training may optimize the potential for generalization of treatment gains to attentionally demanding real-world activities. van’t Hooft et al27,28 conducted a randomized trial of attention drills and strategy instruction in 38 children (ages 9–17 years) with acquired brain injury 1 to 5 years postinjury or treatment for malignancy. Treated children demonstrated significantly greater improvement than nontreated children postintervention and at 6-month follow-up on measures of sustained and selective attention, learning and recall, and verbal reasoning, but
not simple reaction time or general intelligence. Butler et al29 conducted a multicenter, randomized clinical trial of their Cognitive Remediation Program (CRP) for survivors (ages 6–17 years) of cancer involving the central nervous system or treatment to the central nervous system who were at least 1 year posttreatment. Treated children demonstrated significantly greater improvements relative to nontreated children in academic achievement and parent-reported attention, but not in focused attention, working memory, vigilance, or self-esteem. Galbiati and colleagues30 reported the effectiveness of a computerized attention intervention combined with metacognitive strategy instruction with 65 children with severe TBI within the first year postinjury (ages 6–18 years; 25 as nontreated controls). Treated children showed significantly greater improvements than nontreated children from baseline to 1-year follow-up on a computerized attention task and parent-reported adaptive functioning, but not on a measure of intelligence, possibly suggesting specificity of treatment effects. Participation in these interventions requires significant time and effort on the part of families, often resulting in high participant attrition rates.27,31 This has led several investigators to examine feasibility issues when implementing drill-based training integrated with strategy instruction. van’t Hooft and Norberg32 conducted a pilot study with 3 children (ages 9–14 years) with histories of medulloblastoma to examine the feasibility of a condensed version of their training program with an additional structured parent coaching component. Although each family completed the intervention, the authors noted that the condensed intervention was more stressful for parents than the longer intervention because of increased weekly time commitment. Sjo¨ and colleagues33 evaluated the feasibility of providing cognitive intervention within the school setting with 7 children with acquired brain injury (ages 8–16 years). Authors reported successful integration of the intervention into the children’s regular school schedule and increased child motivation. Finally, Luton et al31 used an abbreviated version of Butler and colleagues’29 CRP with 18 children with various neurological conditions (ages 6– 15 years). The abbreviated CRP had a 100% intervention completion rate compared with 60% in Butler’s study. Feasibility continues to be a significant challenge for cognitive interventions, necessitating the continued exploration of delivery methods aimed at reducing child and family burden and increasing motivation and completion rates. THE ATTENTION IMPROVEMENT AND MANAGEMENT PROGRAM The Attention Improvement and Management (AIM) program is a cognitive intervention that combines computerized attention tasks and instruction in
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Cognitive Intervention for Attention and EF Impairments in Children With TBI metacognitive strategies that extends previous interventions by targeting the specific attention and executive function impairment profile of each child. In addition, it is delivered through a combination of home-based practice sessions and face-to-face clinical sessions, with the goal of promoting feasibility of the intervention by reducing the number of times families would need to come to the clinic. Program delivery via computer allows tracking of performance and motivation over time. After each attention exercise, participants rate their level of effort and motivation, which encourages self-monitoring and allows the clinician to examine the potential influence of affective states on task performance. A recent descriptive article34 evaluated clinical decision making in the implementation of AIM with 11 children with TBI (ages 13–16 years). The previous article identified and described the clinical decisions and behaviors critical to implementing computerized drillbased and strategy training programs to distinguish therapy components that seem to be critical to this rehabilitation approach; the previous article did not examine intervention effectiveness. The present pilot study examined intervention effectiveness of the AIM program with the inclusion of an age- and sex-matched healthy comparison (HC) group who did not complete AIM to control for practice effects on outcome measures. We examined the effectiveness of AIM in improving attention and EFs from pre- to posttreatment in children with chronic TBI as measured by neuropsychological tests, parent and child reports of EFs, and participant-reported goal attainment. METHODS Participants Participants included children with a history of TBI and HC children recruited from Cincinnati Children’s Hospital Medical Center (CCHMC). Children aged 9 to 18 years with complicated mild-to-severe TBI (GCS [Glasgow Coma Scale]35 score of ≤ 12 or a GCS of 13–15 accompanied by abnormalities on imaging) were recruited from the CCHMC Trauma Registry, ongoing study participants, and hospital clinicians that identified potentially eligible participants. To minimize potential adherence problems, only participants who resided in the home for the duration of the study were included. To increase the likelihood that children with TBI would benefit from treatment, we recruited children with evidence of real-world attention difficulties on the basis of attention impairments on the Vanderbilt ADHD Diagnostic Parent Rating Scale, Attention Subscale36 (endorsed at least 4 of 9 attention items, with a frequency score of 2 or 3). Additional eligibility criteria for the TBI group included time since injury of at least 1 year to ensure relatively complete neural recovery, and con-
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venient access to a computer. A comparison cohort of children aged 9 to 18 years and matched with the TBI group on age and sex was recruited through CCHMC, allowing us to control for practice effects and determine whether changes associated with AIM are reliable. Exclusionary criteria for the HC group included a diagnosis of ADHD or attention impairments on the Vanderbilt ADHD Diagnostic Parent Rating Scale, Attention Subscale (endorsed at least 4 of 9 attention items, with a frequency score of 2 or 3). Exclusionary criteria for both controls and children with TBI included a diagnosis of intellectual disability (before the injury for the TBI group) or inability to operate a computer. Participants were consented in accordance with the Institutional Review Board. A total of 22 children with TBI and 11 HC children were enrolled. Nine participants with TBI dropped out before study completion (41%). Study completers were younger than noncompleters by 2.2 years, t(20) = 2.25, P = .040, but there were no significant differences in sex, ethnicity, handedness, or GCS between completers and noncompleters (all P > .05). The first 7 participants to complete AIM from the present study were also included in the previously published descriptive article examining the clinical implementation of AIM, which was published before completing recruitment for the present pilot study.34 The remaining 4 participants in the previous article were recruited from a university speech and language clinic serving children with recent concussions. Those participants were not included in the present study because we wanted to examine treatment effectiveness in the chronic phase of injury when neural recovery is complete. There were no significant differences between participants described in the previous article and new participants in time since injury, sex, ethnicity, or GCS (all P > .05); however, the 7 participants who were included in the previous article were on average significantly older than the newer participants, t(11) = −2.77, P = .018. Participants who completed the study ranged in age from 9 and 15 years (mean = 13.1; standard deviation [SD] = 2.2). There were no significant differences between the TBI and HC groups in age, sex, ethnicity, or handedness (all P > .05; see Table 1). Of the 13 participants with TBI who completed the study, 5 had complicated mild injuries, two had moderate injuries, and 6 had severe brain injuries. Participants with TBI were an average of 5 years postinjury (mean = 5.2; SD = 2.7; range = 1.1–9.1). See Supplemental Table 1 (http://links.lww.com/JHTR/A154) for characteristics of the participants with TBI. Intervention The AIM program is a cognitive intervention program combining computerized attention tasks and www.headtraumarehab.com
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JOURNAL OF HEAD TRAUMA REHABILITATION
Table 1
Participant characteristics TBI n = 13
Age at pretest—mean 13.11 (2.4) (SD), y Sex—male, % 27 Ethnicity—nonwhite, % 9 Handedness—right, % 82
Healthy comparison n = 11
P
13.37 (2.1)
.781
38 15 77
.289 .424 .370
Abbreviations: SD, standard deviation; TBI, traumatic brain injury.
metacognitive strategy instruction. The tasks are divided into the following attention and EF domains: sustained attention, alternating attention, selective attention, working memory, and interference control tasks. The metacognitive strategies were drawn from the literature and organized into 11 categories37 : breathing, eye closing, mental imagery, repeating/clarifying instructions, predicting task difficulty, taking a break, internal self-talk, external self-talk, rewarding self, reviewing progress, and goal setting. The participants practiced the selected strategies in conjunction with their attention exercises and set generalization goals consistent with their goal attainment scaling (GAS; described in detail below) for how they intended to apply the strategies to real-world tasks. The AIM program was designed to facilitate home practice with its capacity to capture and send performance data remotely via the Internet. The AIM program was designed as a 10-week program administered in weekly face-to-face meetings between the child and the research clinician. During the initial intake meeting with the child, the computer program guides the clinician through an intake procedure to select attention training tasks and metacognitive strategies tailored to the needs of the child on the basis of test scores, parent and child ratings, and child input. Clinician ratings integrating these data were used by the AIM program to generate an initial menu of drills and strategies for each child that is updated during training on the basis of the child’s performance and progress. The attention drills were selected on the basis of the child’s neuropsychological impairment profile, whereas the metacognitive strategies were selected in part on the basis of the child and parent ratings of strengths and current strategy use. After the initial intake, each subsequent session included the following components: (1) review of home practice sessions and metacognitive strategy use; (2) completion of individualized selection of attention training tasks under clinician observation; and (3) review of homework for the next session, including a discussion of how participants might apply metacogni-
tive strategies to real-world tasks at home or in the classroom. Participants were asked to complete 2 to 4 practice sessions per week, and, when feasible, treatment was extended by 1 week for each week that participants did not complete at least 2 home practice sessions. Home practice sessions were tracked and reviewed by clinicians via a USB drive designed to record and electronically send participant practice data to the clinician’s computer. Study clinicians participated in a 2-day training conducted by the second author. All clinicians had at least 1 year of experience working with individuals with TBI and comprised psychology graduate students (n = 4), one bachelor’s level clinician, and a senior psychologist. To ensure consistency across clinicians, the second author led weekly phone meetings to discuss participants’ performance and progress, as well as intervention modifications. Data from the in-office visits were recorded and provided an ongoing record of treatment content. Fidelity was also supported through review of detailed therapist logs documenting procedures and clinical progress. Procedure All participants completed a battery of neuropsychological tests and parent- and self-report questionnaires at two time points, a mean of 18 weeks apart (SD = 5.7; range = 9.9–32.7). Only children in the TBI group completed the AIM program between pre- and posttesting. Outcome measures Neuropsychological tests The following instruments were administered pre- and posttest to evaluate changes in attention and EF skills. All of the instruments have evidence of reliability and validity for children with TBI. The Test of Everyday Attention for Children (TEA-Ch).38 Several subtests from the TEA-Ch were administered to assess aspects of attention and EF. Total Correct scaled scores from the Score! (sustained attention), Walk/Don’t Walk (inhibition), and Code Transmission (sustained attention) subtests, and the Attention scaled score from the Sky Search (selective attention) subtest were examined. Delis–Kaplan Executive Function System (D-KEFS).39 Several subtests from the D-KEFS were administered to assess aspects of EFs. The Number-Letter Switching score from The Trail Making Test (TMT; cognitive flexibility), Inhibition/Switching score from the ColorWord Interference Test (CWIT; verbal inhibition), and the Total Achievement Score from the Tower Test (TT; planning and reasoning, impulsivity) were examined.
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Cognitive Intervention for Attention and EF Impairments in Children With TBI Parent- and child-report measures The Behavior Rating Inventory of Executive Function (BRIEF).40 The BRIEF is a self- and parent-report measure of everyday behaviors associated with EFs that are often impaired after TBI. To reduce the number of statistical tests, we focused on the primary index scores, the Behavioral Regulation Index and the Metacognition Index, as well as the Global Executive Composite (GEC) score. Only children who were in the 11 to 18-year-old age range completed the BRIEF self-report. Goal Attainment Scale (GAS).41 Goal Attainment Scaling is a criterion-referenced measure of an individual’s goal achievement that uses a collaborative process involving an interview between the clinician, participant, and parent. Summary outcomes are quantified across participants who are receiving the same intervention but targeting different goals.42,43 The GAS provides (1) a person-centered approach that emphasizes collaborative goal setting, with the establishment of goals and levels of progress that are meaningful to the participant; and (2) scores that can be used to assess the effectiveness of an intervention on the basis of personally relevant goals.44,45 In line with previous research, personally relevant goals and current levels of performance were delineated through an interview with the participant and parent using the GAS 5-point scale (−2 to +2); performance at baseline is always rated as −1. After the AIM intervention, participants and parents collaboratively rated the child’s level of goal attainment. The desired level of goal attainment that could reasonably be expected after the intervention period or expected level of outcome receives a 0 rating. Ratings of +1 and +2 correspond to somewhat more than expected and much more than expected, respectively, whereas −1 (representing baseline level of functioning) and −2 correspond to somewhat less than expected and much less than expected, respectively. Although participants discussed with clinicians throughout treatment how they might apply their metacognitive strategies to the functional goal domain listed in their GAS, goals were not specifically trained as part of the AIM intervention. Therefore, improvement in GAS scores represents an ecological measure of generalization of treatment gains to real-world activities that are meaningful to participants and their families.
Satisfaction survey Participants and their parents were each asked to complete a satisfaction survey written by the authors to qualitatively assess families’ experiences with the AIM program. The survey included several open-ended questions as well as questions and statements for which respondents were asked to respond on a scale from 1 to 10 (eg,
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1 = not at all; 10 = completely/extremely) or a 4-point Likert scale from “strongly disagree” to “strongly agree.” Data analysis Because our primary goal in this pilot study was to examine intervention effectiveness, we employed a Per Protocol analytic strategy in which all participants who completed the intervention (TBI group only) and pre- and posttest assessments according to our protocol were included in subsequent analyses.46 We used a mixed-model analytical approach with group as a between-subject variable and time (pretest and posttest) as a within-subject variable. Utilizing this analytical approach, a significant group × time interaction would provide evidence for differential change in scores in the TBI group relative to the HC group that could be attributable to treatment effectiveness rather than practice effects. Although this analytical approach is relatively conservative, we view this as a strength of the study in the context of a nascent literature composed of relatively liberal analytic approaches. Effect sizes were computed by standardizing all continuous outcome variables (mean = 0; SD = 1) and obtaining parameter estimates on the basis of the final mixed model for each dependent variable. The resulting coefficients are akin to standardized mean differences (eg, d).47 We used conventional definitions of effect size for mean differences to characterize the magnitude of parameter estimates and any interactions involving them (ie, 0.2 is small, 0.5 is medium, and 0.8 is large). Because of the exploratory nature of this study, we maintained alpha values at P < .05 for all significance tests. RESULTS Feasibility As noted earlier, 9 of the 22 participants with TBI (41%) dropped out of the study before completion. Of the participants who dropped out, 4 completed no intervention sessions, 3 completed a single intervention session, and 2 dropped out after 2 and 4 sessions, respectively. Reasons cited for discontinuation included health or family factors (n = 1); too time-consuming (n = 2); dissatisfaction with the program or clinician (n = 3); or the family was lost to follow-up (n = 3). Treatment dosage for participants who completed the study varied. The number of in-clinic 60- to 90-minute sessions ranged from 10 to 13 (more clinic sessions were added for participants who had not completed at least 2 home practice sessions when feasible), and the number of self-initiated 20- to 40-minute home practice sessions ranged from 8 to 44 (mean = 21.07; SD = 9.9). Because of the small sample size, we did not examine associations between treatment dosage and outcome. www.headtraumarehab.com
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Satisfaction survey data were available for 8 children who completed AIM and 7 of their parents. As reported in Supplemental Table 2 (http://links.lww.com/JHTR/ A155), responses were generally positive from both children and parents. On average, children and parents reported noticing changes in participants’ attention after completing AIM and reported that the program was helpful and enjoyable. A minority of children and parents reported that the program was too long or too short or that the attention tasks were boring. Interestingly, approximately 50% of children reported that the attention tasks were too easy, too hard, or too confusing. Only 50% of children reported they would participate in the program again compared with 86% of parents. All children and parents reported that participants had a strategy for paying attention and that they would recommend the program to other families. All parents and all but 1 child reported that they were doing better in school after completing AIM. Neuropsychological test performance Pre- and posttest means and SDs for each group are reported in Table 2, along with results of t tests for pretest group differences and the mixed-model group × time interaction and their respective effect sizes. The TBI group showed significantly poorer performance at pretest relative to the HC group on the TEA-Ch Code Transmission subtest, with a large effect size. Group differences at pretest for the remaining TEA-Ch subtests did not reach statistical significance and effect sizes were small. Group differences at pretest for the 3 D-KEFS subtests did not reach statistical significance in our small sample; however, group differences were in the expected direction and effect sizes were medium. Mixed-model analyses revealed a significant group × time interaction for the TEA-Ch Code Transmission subtest, with a large effect size. As illustrated in Figure 1, simple main effects revealed that the TBI group’s scores improved significantly from pre- to posttest, t(19) = −2.15, P = .045, effect size = −0.62, whereas the scores of the HC group who did not receive the AIM intervention showed a nonsignificant decline, t(19) = 1.64, P = .118, effect size = 0.45. The group × time interactions for the other neuropsychological test measures were not statistically significant, and effect sizes were small to medium in magnitude. After removing the nonsignificant interaction from the models, the only significant main effect was for the effect of time on D-KEFS TT, F(1, 19) = 4.87, P = .040, effect size = 0.45, suggesting practice effects across groups on this measure. Parent- and child-report measures of EF Pre- and posttest means and SDs for each group are also reported in Supplemental Table 2, along with results
of t tests for pretest group differences and the mixedmodel group × time interaction and their respective effect sizes. The TBI group showed significantly more parent- and child-reported behaviors associated with executive dysfunction at pretest relative to the HC group on all 3 examined BRIEF scores, all with large effect sizes. Mixed-model analyses revealed significant group × time interactions for all 3 parent-reported BRIEF scores examining behavioral regulation, metacognition, and global EF, with medium to large effect sizes. As illustrated in Figure 2, simple main effects revealed that the TBI group’s scores improved significantly from pre- to posttest (BRI: t(19) = 4.13, P < .001, effect size = 0.86; MI: t(19) = 4.60, P < .001, effect size = 0.52; GEC: t(19) = 4.90, P < .001, effect size = 0.66), whereas the scores of the HC group who did not receive the AIM intervention remained relatively unchanged, (BRI: t(19) = −1.20, P = .244, effect size = −0.24; MI: t(19) = −1.37, P = .185, effect size = −0.15; GEC: t(19) = −1.14, P = .268, effect size = −0.15). The group × time interactions for all 3 child-reported BRIEF scores were not statistically significant, and effect sizes were small in magnitude. After removing the nonsignificant interactions from the child-report BRIEF models, there were significant main effects of group on each measure (BRI: F(1, 14) = 5.84, P = .030, effect size = −1.01; MI: F(1, 14) = 11.99, P = .004, effect size = −1.32; GEC: F(1, 14) = 9.19, P = .009, effect size = −1.21), indicating poorer self-reported executive functioning in the TBI group across time. Goal attainment Supplemental Table 3 (http://links.lww.com/JHTR/ A156) presents each participant’s GAS goal, baseline goal attainment, final session goal attainment, and the metacognitive strategies participants reported using to work toward their goals. GAS scores and/or details of specific goals were unavailable for 3 participants because of inadequate documentation. Most participant goals related to school performance or completion of tasks at home (eg, homework and chores). After completion of the AIM intervention, parents and participants were interviewed to determine the goal attainment level achieved. Each participant’s GAS contained 5 levels of a quantifiable goal that was important to the participant, and that the family and clinician believed was related to attention or EFs. The 5 levels were nonoverlapping and designed to be roughly equidistant. After completion of the AIM intervention, parents and participants were interviewed to determine the goal attainment level achieved. Across the 13 participants, 1 reported improvement as much more than expected, 7 reported improvement as somewhat greater than expected, 2 reported expected progress, and 3 reported no
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45.27 (6.7) 47.55 (7.9) 46.55 (7.6) 44.56 (12.7) 44.67 (12.4) 44.22 (13.3)
64.38 (8.8) 72.08 (8.9) 70.31 (7.6)
60.40 (11.9) 63.50 (7.6) 63.30 (9.8)
.388 .343 .256 .014 .062 .061 .256
Cognitive Intervention for Attention and Executive Function Impairments in Children With Traumatic Brain Injury: A Pilot Study Amery Treble-Barna, PhD; McKay Moore Sohlberg, PhD; Beth E. Harn, PhD; Shari L. Wade, PhD Objective: To test the effectiveness of the Attention Improvement and Management (AIM) program, a cognitive intervention for improving impairments in attention and executive functions (EFs) after pediatric traumatic brain injury (TBI). Setting: Tertiary care children’s hospital. Participants: A total of 13 children with complicated mildto-severe TBI (average of 5 years postinjury) and 11 healthy comparison children aged 9 to 15 years completed the study. Design: Open-label pilot study with a nontreated control group. Main Measures: Subtests from the Test of Everyday Attention-for Children (TEA-Ch) and the Delis–Kaplan Executive Function System (D-KEFS), the self- and parent-report from the Behavior Rating Inventory of Executive Function (BRIEF), and the Goal Attainment Scale (GAS). Results: Relative to the healthy comparison group, children with TBI demonstrated significant improvement postintervention on a neuropsychological measure of sustained attention, as well as on parent-reported EFs. The majority of families also reported expected or more-than-expected personalized goal attainment. Conclusions: The study provides preliminary evidence for the effectiveness of AIM in improving parent-reported EFs and personalized real-world goal attainment in children with TBI. Key words: child, cognitive remediation, cognitive rehabilitation, executive function, pilot projects, traumatic brain injury
Author Affiliations: Department of Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Treble-Barna); Communication Disorders and Sciences, University of Oregon, Eugene, Oregon (Dr Sohlberg); Department of Special Education and Clinical Sciences, University of Oregon, Eugene, Oregon (Dr Harn); Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio (Dr Wade). The authors would like to recognize the contributions of Jason Prideaux, Jennifer Taylor, Holly MacPherson, Stacey Raj, and Julia Smith. This project was supported in part by grants from the Department of Education’s National Institute on Disability and Rehabilitation Research (Center on Interventions for Children and Youth with Traumatic Brain Injury; Grant number H133B090010-10) and the Ohio Department of Public Safety Emergency Medical Services Program. This material does not necessarily represent the policy of these agencies, nor is the material necessarily endorsed by the Federal Government. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.headtraumahab.com). The authors declare no conflicts of interest. Corresponding Author: Amery Treble-Barna, PhD, Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 ([email protected]). DOI: 10.1097/HTR.0000000000000200
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EDIATRIC TRAUMATIC BRAIN INJURY (TBI) is the most common source of acquired morbidity and mortality in children.1 Among the most disruptive and persistent symptoms post-TBI are changes in attention and executive functions (EFs).2 These cognitive deficits are evident in about 50% of cases, and can persist for several years postinjury and into adulthood.3,4 Deficits in attention and EFs are associated with reduced functioning in academic, social, and behavioral domains and ultimately have been linked with poorer educational and vocational outcomes.5,6 Despite the prevalence and impact of attention and EF impairments after pediatric TBI, there are limited evidence-based cognitive interventions available for this population.7–9 Attention is considered a strong modulator of cognition and encompasses the processes that allow a sustained and selective focus on environmental stimuli.10,11 Executive functions are the abilities that permit allocation or control of attentional resources, including skills such as working memory, inhibition, interference control, cognitive flexibility, reasoning, problem solving, and planning.12–14 The brain networks that subserve 1
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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these systems are highly distributed and integrated, making them particularly susceptible to disruption in TBI and accounting, in part, for the pervasive nature of these impairments.15 In addition, the nature of attention and EF impairments after pediatric TBI is heterogeneous, in part because highly individualized injuries are imposed on a uniquely developing system. Cognitive impairment profiles include a unique combination of specific types of attention and EF deficits with the additional population characteristic of variability in performance across tasks and over time. This variability necessitates developing treatments that can address a wide range of impairment profiles. THE TREATMENT EVIDENCE IN ACQUIRED PEDIATRIC BRAIN INJURY Recent studies of cognitive interventions for attention and EF impairments in children with acquired brain injury have evaluated a combination of drill-based attention training and metacognitive strategy instruction. Attention training drills are grounded in the emerging literature supporting experience-dependent plasticity16–19 and are mostly based on the adult brain injury rehabilitation literature that has produced practice guidelines supporting this intervention.20,21 A critical issue with this intervention approach is equivocal evidence for generalization or “transfer” of gains from cognitive training to nontrained tasks, including everyday, “real-world” activities, in pediatric brain injury or other childhood conditions.15,22–24 Metacognitive strategy training involves instruction in behaviors that facilitate efficient allocation of cognitive resources and enhance self-regulation. Metacognitive strategy training can be used to promote generalizability of cognitive interventions to everyday tasks through a context-sensitive approach in which participants and clinicians identify specific daily challenges, then strategize, test, and problem-solve potential solutions involving evidence-based metacognitive concepts.22,23 Initial studies of metacognitive strategy training in children with developmental attention deficits (eg, attention-deficit/hyperactivity disorder [ADHD]) suggest promise for transfer of strategy training to improvements on real-world tasks.25,26 The integration of attention drills and metacognitive training may optimize the potential for generalization of treatment gains to attentionally demanding real-world activities. van’t Hooft et al27,28 conducted a randomized trial of attention drills and strategy instruction in 38 children (ages 9–17 years) with acquired brain injury 1 to 5 years postinjury or treatment for malignancy. Treated children demonstrated significantly greater improvement than nontreated children postintervention and at 6-month follow-up on measures of sustained and selective attention, learning and recall, and verbal reasoning, but
not simple reaction time or general intelligence. Butler et al29 conducted a multicenter, randomized clinical trial of their Cognitive Remediation Program (CRP) for survivors (ages 6–17 years) of cancer involving the central nervous system or treatment to the central nervous system who were at least 1 year posttreatment. Treated children demonstrated significantly greater improvements relative to nontreated children in academic achievement and parent-reported attention, but not in focused attention, working memory, vigilance, or self-esteem. Galbiati and colleagues30 reported the effectiveness of a computerized attention intervention combined with metacognitive strategy instruction with 65 children with severe TBI within the first year postinjury (ages 6–18 years; 25 as nontreated controls). Treated children showed significantly greater improvements than nontreated children from baseline to 1-year follow-up on a computerized attention task and parent-reported adaptive functioning, but not on a measure of intelligence, possibly suggesting specificity of treatment effects. Participation in these interventions requires significant time and effort on the part of families, often resulting in high participant attrition rates.27,31 This has led several investigators to examine feasibility issues when implementing drill-based training integrated with strategy instruction. van’t Hooft and Norberg32 conducted a pilot study with 3 children (ages 9–14 years) with histories of medulloblastoma to examine the feasibility of a condensed version of their training program with an additional structured parent coaching component. Although each family completed the intervention, the authors noted that the condensed intervention was more stressful for parents than the longer intervention because of increased weekly time commitment. Sjo¨ and colleagues33 evaluated the feasibility of providing cognitive intervention within the school setting with 7 children with acquired brain injury (ages 8–16 years). Authors reported successful integration of the intervention into the children’s regular school schedule and increased child motivation. Finally, Luton et al31 used an abbreviated version of Butler and colleagues’29 CRP with 18 children with various neurological conditions (ages 6– 15 years). The abbreviated CRP had a 100% intervention completion rate compared with 60% in Butler’s study. Feasibility continues to be a significant challenge for cognitive interventions, necessitating the continued exploration of delivery methods aimed at reducing child and family burden and increasing motivation and completion rates. THE ATTENTION IMPROVEMENT AND MANAGEMENT PROGRAM The Attention Improvement and Management (AIM) program is a cognitive intervention that combines computerized attention tasks and instruction in
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Cognitive Intervention for Attention and EF Impairments in Children With TBI metacognitive strategies that extends previous interventions by targeting the specific attention and executive function impairment profile of each child. In addition, it is delivered through a combination of home-based practice sessions and face-to-face clinical sessions, with the goal of promoting feasibility of the intervention by reducing the number of times families would need to come to the clinic. Program delivery via computer allows tracking of performance and motivation over time. After each attention exercise, participants rate their level of effort and motivation, which encourages self-monitoring and allows the clinician to examine the potential influence of affective states on task performance. A recent descriptive article34 evaluated clinical decision making in the implementation of AIM with 11 children with TBI (ages 13–16 years). The previous article identified and described the clinical decisions and behaviors critical to implementing computerized drillbased and strategy training programs to distinguish therapy components that seem to be critical to this rehabilitation approach; the previous article did not examine intervention effectiveness. The present pilot study examined intervention effectiveness of the AIM program with the inclusion of an age- and sex-matched healthy comparison (HC) group who did not complete AIM to control for practice effects on outcome measures. We examined the effectiveness of AIM in improving attention and EFs from pre- to posttreatment in children with chronic TBI as measured by neuropsychological tests, parent and child reports of EFs, and participant-reported goal attainment. METHODS Participants Participants included children with a history of TBI and HC children recruited from Cincinnati Children’s Hospital Medical Center (CCHMC). Children aged 9 to 18 years with complicated mild-to-severe TBI (GCS [Glasgow Coma Scale]35 score of ≤ 12 or a GCS of 13–15 accompanied by abnormalities on imaging) were recruited from the CCHMC Trauma Registry, ongoing study participants, and hospital clinicians that identified potentially eligible participants. To minimize potential adherence problems, only participants who resided in the home for the duration of the study were included. To increase the likelihood that children with TBI would benefit from treatment, we recruited children with evidence of real-world attention difficulties on the basis of attention impairments on the Vanderbilt ADHD Diagnostic Parent Rating Scale, Attention Subscale36 (endorsed at least 4 of 9 attention items, with a frequency score of 2 or 3). Additional eligibility criteria for the TBI group included time since injury of at least 1 year to ensure relatively complete neural recovery, and con-
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venient access to a computer. A comparison cohort of children aged 9 to 18 years and matched with the TBI group on age and sex was recruited through CCHMC, allowing us to control for practice effects and determine whether changes associated with AIM are reliable. Exclusionary criteria for the HC group included a diagnosis of ADHD or attention impairments on the Vanderbilt ADHD Diagnostic Parent Rating Scale, Attention Subscale (endorsed at least 4 of 9 attention items, with a frequency score of 2 or 3). Exclusionary criteria for both controls and children with TBI included a diagnosis of intellectual disability (before the injury for the TBI group) or inability to operate a computer. Participants were consented in accordance with the Institutional Review Board. A total of 22 children with TBI and 11 HC children were enrolled. Nine participants with TBI dropped out before study completion (41%). Study completers were younger than noncompleters by 2.2 years, t(20) = 2.25, P = .040, but there were no significant differences in sex, ethnicity, handedness, or GCS between completers and noncompleters (all P > .05). The first 7 participants to complete AIM from the present study were also included in the previously published descriptive article examining the clinical implementation of AIM, which was published before completing recruitment for the present pilot study.34 The remaining 4 participants in the previous article were recruited from a university speech and language clinic serving children with recent concussions. Those participants were not included in the present study because we wanted to examine treatment effectiveness in the chronic phase of injury when neural recovery is complete. There were no significant differences between participants described in the previous article and new participants in time since injury, sex, ethnicity, or GCS (all P > .05); however, the 7 participants who were included in the previous article were on average significantly older than the newer participants, t(11) = −2.77, P = .018. Participants who completed the study ranged in age from 9 and 15 years (mean = 13.1; standard deviation [SD] = 2.2). There were no significant differences between the TBI and HC groups in age, sex, ethnicity, or handedness (all P > .05; see Table 1). Of the 13 participants with TBI who completed the study, 5 had complicated mild injuries, two had moderate injuries, and 6 had severe brain injuries. Participants with TBI were an average of 5 years postinjury (mean = 5.2; SD = 2.7; range = 1.1–9.1). See Supplemental Table 1 (http://links.lww.com/JHTR/A154) for characteristics of the participants with TBI. Intervention The AIM program is a cognitive intervention program combining computerized attention tasks and www.headtraumarehab.com
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Table 1
Participant characteristics TBI n = 13
Age at pretest—mean 13.11 (2.4) (SD), y Sex—male, % 27 Ethnicity—nonwhite, % 9 Handedness—right, % 82
Healthy comparison n = 11
P
13.37 (2.1)
.781
38 15 77
.289 .424 .370
Abbreviations: SD, standard deviation; TBI, traumatic brain injury.
metacognitive strategy instruction. The tasks are divided into the following attention and EF domains: sustained attention, alternating attention, selective attention, working memory, and interference control tasks. The metacognitive strategies were drawn from the literature and organized into 11 categories37 : breathing, eye closing, mental imagery, repeating/clarifying instructions, predicting task difficulty, taking a break, internal self-talk, external self-talk, rewarding self, reviewing progress, and goal setting. The participants practiced the selected strategies in conjunction with their attention exercises and set generalization goals consistent with their goal attainment scaling (GAS; described in detail below) for how they intended to apply the strategies to real-world tasks. The AIM program was designed to facilitate home practice with its capacity to capture and send performance data remotely via the Internet. The AIM program was designed as a 10-week program administered in weekly face-to-face meetings between the child and the research clinician. During the initial intake meeting with the child, the computer program guides the clinician through an intake procedure to select attention training tasks and metacognitive strategies tailored to the needs of the child on the basis of test scores, parent and child ratings, and child input. Clinician ratings integrating these data were used by the AIM program to generate an initial menu of drills and strategies for each child that is updated during training on the basis of the child’s performance and progress. The attention drills were selected on the basis of the child’s neuropsychological impairment profile, whereas the metacognitive strategies were selected in part on the basis of the child and parent ratings of strengths and current strategy use. After the initial intake, each subsequent session included the following components: (1) review of home practice sessions and metacognitive strategy use; (2) completion of individualized selection of attention training tasks under clinician observation; and (3) review of homework for the next session, including a discussion of how participants might apply metacogni-
tive strategies to real-world tasks at home or in the classroom. Participants were asked to complete 2 to 4 practice sessions per week, and, when feasible, treatment was extended by 1 week for each week that participants did not complete at least 2 home practice sessions. Home practice sessions were tracked and reviewed by clinicians via a USB drive designed to record and electronically send participant practice data to the clinician’s computer. Study clinicians participated in a 2-day training conducted by the second author. All clinicians had at least 1 year of experience working with individuals with TBI and comprised psychology graduate students (n = 4), one bachelor’s level clinician, and a senior psychologist. To ensure consistency across clinicians, the second author led weekly phone meetings to discuss participants’ performance and progress, as well as intervention modifications. Data from the in-office visits were recorded and provided an ongoing record of treatment content. Fidelity was also supported through review of detailed therapist logs documenting procedures and clinical progress. Procedure All participants completed a battery of neuropsychological tests and parent- and self-report questionnaires at two time points, a mean of 18 weeks apart (SD = 5.7; range = 9.9–32.7). Only children in the TBI group completed the AIM program between pre- and posttesting. Outcome measures Neuropsychological tests The following instruments were administered pre- and posttest to evaluate changes in attention and EF skills. All of the instruments have evidence of reliability and validity for children with TBI. The Test of Everyday Attention for Children (TEA-Ch).38 Several subtests from the TEA-Ch were administered to assess aspects of attention and EF. Total Correct scaled scores from the Score! (sustained attention), Walk/Don’t Walk (inhibition), and Code Transmission (sustained attention) subtests, and the Attention scaled score from the Sky Search (selective attention) subtest were examined. Delis–Kaplan Executive Function System (D-KEFS).39 Several subtests from the D-KEFS were administered to assess aspects of EFs. The Number-Letter Switching score from The Trail Making Test (TMT; cognitive flexibility), Inhibition/Switching score from the ColorWord Interference Test (CWIT; verbal inhibition), and the Total Achievement Score from the Tower Test (TT; planning and reasoning, impulsivity) were examined.
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Cognitive Intervention for Attention and EF Impairments in Children With TBI Parent- and child-report measures The Behavior Rating Inventory of Executive Function (BRIEF).40 The BRIEF is a self- and parent-report measure of everyday behaviors associated with EFs that are often impaired after TBI. To reduce the number of statistical tests, we focused on the primary index scores, the Behavioral Regulation Index and the Metacognition Index, as well as the Global Executive Composite (GEC) score. Only children who were in the 11 to 18-year-old age range completed the BRIEF self-report. Goal Attainment Scale (GAS).41 Goal Attainment Scaling is a criterion-referenced measure of an individual’s goal achievement that uses a collaborative process involving an interview between the clinician, participant, and parent. Summary outcomes are quantified across participants who are receiving the same intervention but targeting different goals.42,43 The GAS provides (1) a person-centered approach that emphasizes collaborative goal setting, with the establishment of goals and levels of progress that are meaningful to the participant; and (2) scores that can be used to assess the effectiveness of an intervention on the basis of personally relevant goals.44,45 In line with previous research, personally relevant goals and current levels of performance were delineated through an interview with the participant and parent using the GAS 5-point scale (−2 to +2); performance at baseline is always rated as −1. After the AIM intervention, participants and parents collaboratively rated the child’s level of goal attainment. The desired level of goal attainment that could reasonably be expected after the intervention period or expected level of outcome receives a 0 rating. Ratings of +1 and +2 correspond to somewhat more than expected and much more than expected, respectively, whereas −1 (representing baseline level of functioning) and −2 correspond to somewhat less than expected and much less than expected, respectively. Although participants discussed with clinicians throughout treatment how they might apply their metacognitive strategies to the functional goal domain listed in their GAS, goals were not specifically trained as part of the AIM intervention. Therefore, improvement in GAS scores represents an ecological measure of generalization of treatment gains to real-world activities that are meaningful to participants and their families.
Satisfaction survey Participants and their parents were each asked to complete a satisfaction survey written by the authors to qualitatively assess families’ experiences with the AIM program. The survey included several open-ended questions as well as questions and statements for which respondents were asked to respond on a scale from 1 to 10 (eg,
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1 = not at all; 10 = completely/extremely) or a 4-point Likert scale from “strongly disagree” to “strongly agree.” Data analysis Because our primary goal in this pilot study was to examine intervention effectiveness, we employed a Per Protocol analytic strategy in which all participants who completed the intervention (TBI group only) and pre- and posttest assessments according to our protocol were included in subsequent analyses.46 We used a mixed-model analytical approach with group as a between-subject variable and time (pretest and posttest) as a within-subject variable. Utilizing this analytical approach, a significant group × time interaction would provide evidence for differential change in scores in the TBI group relative to the HC group that could be attributable to treatment effectiveness rather than practice effects. Although this analytical approach is relatively conservative, we view this as a strength of the study in the context of a nascent literature composed of relatively liberal analytic approaches. Effect sizes were computed by standardizing all continuous outcome variables (mean = 0; SD = 1) and obtaining parameter estimates on the basis of the final mixed model for each dependent variable. The resulting coefficients are akin to standardized mean differences (eg, d).47 We used conventional definitions of effect size for mean differences to characterize the magnitude of parameter estimates and any interactions involving them (ie, 0.2 is small, 0.5 is medium, and 0.8 is large). Because of the exploratory nature of this study, we maintained alpha values at P < .05 for all significance tests. RESULTS Feasibility As noted earlier, 9 of the 22 participants with TBI (41%) dropped out of the study before completion. Of the participants who dropped out, 4 completed no intervention sessions, 3 completed a single intervention session, and 2 dropped out after 2 and 4 sessions, respectively. Reasons cited for discontinuation included health or family factors (n = 1); too time-consuming (n = 2); dissatisfaction with the program or clinician (n = 3); or the family was lost to follow-up (n = 3). Treatment dosage for participants who completed the study varied. The number of in-clinic 60- to 90-minute sessions ranged from 10 to 13 (more clinic sessions were added for participants who had not completed at least 2 home practice sessions when feasible), and the number of self-initiated 20- to 40-minute home practice sessions ranged from 8 to 44 (mean = 21.07; SD = 9.9). Because of the small sample size, we did not examine associations between treatment dosage and outcome. www.headtraumarehab.com
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Satisfaction survey data were available for 8 children who completed AIM and 7 of their parents. As reported in Supplemental Table 2 (http://links.lww.com/JHTR/ A155), responses were generally positive from both children and parents. On average, children and parents reported noticing changes in participants’ attention after completing AIM and reported that the program was helpful and enjoyable. A minority of children and parents reported that the program was too long or too short or that the attention tasks were boring. Interestingly, approximately 50% of children reported that the attention tasks were too easy, too hard, or too confusing. Only 50% of children reported they would participate in the program again compared with 86% of parents. All children and parents reported that participants had a strategy for paying attention and that they would recommend the program to other families. All parents and all but 1 child reported that they were doing better in school after completing AIM. Neuropsychological test performance Pre- and posttest means and SDs for each group are reported in Table 2, along with results of t tests for pretest group differences and the mixed-model group × time interaction and their respective effect sizes. The TBI group showed significantly poorer performance at pretest relative to the HC group on the TEA-Ch Code Transmission subtest, with a large effect size. Group differences at pretest for the remaining TEA-Ch subtests did not reach statistical significance and effect sizes were small. Group differences at pretest for the 3 D-KEFS subtests did not reach statistical significance in our small sample; however, group differences were in the expected direction and effect sizes were medium. Mixed-model analyses revealed a significant group × time interaction for the TEA-Ch Code Transmission subtest, with a large effect size. As illustrated in Figure 1, simple main effects revealed that the TBI group’s scores improved significantly from pre- to posttest, t(19) = −2.15, P = .045, effect size = −0.62, whereas the scores of the HC group who did not receive the AIM intervention showed a nonsignificant decline, t(19) = 1.64, P = .118, effect size = 0.45. The group × time interactions for the other neuropsychological test measures were not statistically significant, and effect sizes were small to medium in magnitude. After removing the nonsignificant interaction from the models, the only significant main effect was for the effect of time on D-KEFS TT, F(1, 19) = 4.87, P = .040, effect size = 0.45, suggesting practice effects across groups on this measure. Parent- and child-report measures of EF Pre- and posttest means and SDs for each group are also reported in Supplemental Table 2, along with results
of t tests for pretest group differences and the mixedmodel group × time interaction and their respective effect sizes. The TBI group showed significantly more parent- and child-reported behaviors associated with executive dysfunction at pretest relative to the HC group on all 3 examined BRIEF scores, all with large effect sizes. Mixed-model analyses revealed significant group × time interactions for all 3 parent-reported BRIEF scores examining behavioral regulation, metacognition, and global EF, with medium to large effect sizes. As illustrated in Figure 2, simple main effects revealed that the TBI group’s scores improved significantly from pre- to posttest (BRI: t(19) = 4.13, P < .001, effect size = 0.86; MI: t(19) = 4.60, P < .001, effect size = 0.52; GEC: t(19) = 4.90, P < .001, effect size = 0.66), whereas the scores of the HC group who did not receive the AIM intervention remained relatively unchanged, (BRI: t(19) = −1.20, P = .244, effect size = −0.24; MI: t(19) = −1.37, P = .185, effect size = −0.15; GEC: t(19) = −1.14, P = .268, effect size = −0.15). The group × time interactions for all 3 child-reported BRIEF scores were not statistically significant, and effect sizes were small in magnitude. After removing the nonsignificant interactions from the child-report BRIEF models, there were significant main effects of group on each measure (BRI: F(1, 14) = 5.84, P = .030, effect size = −1.01; MI: F(1, 14) = 11.99, P = .004, effect size = −1.32; GEC: F(1, 14) = 9.19, P = .009, effect size = −1.21), indicating poorer self-reported executive functioning in the TBI group across time. Goal attainment Supplemental Table 3 (http://links.lww.com/JHTR/ A156) presents each participant’s GAS goal, baseline goal attainment, final session goal attainment, and the metacognitive strategies participants reported using to work toward their goals. GAS scores and/or details of specific goals were unavailable for 3 participants because of inadequate documentation. Most participant goals related to school performance or completion of tasks at home (eg, homework and chores). After completion of the AIM intervention, parents and participants were interviewed to determine the goal attainment level achieved. Each participant’s GAS contained 5 levels of a quantifiable goal that was important to the participant, and that the family and clinician believed was related to attention or EFs. The 5 levels were nonoverlapping and designed to be roughly equidistant. After completion of the AIM intervention, parents and participants were interviewed to determine the goal attainment level achieved. Across the 13 participants, 1 reported improvement as much more than expected, 7 reported improvement as somewhat greater than expected, 2 reported expected progress, and 3 reported no
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45.27 (6.7) 47.55 (7.9) 46.55 (7.6) 44.56 (12.7) 44.67 (12.4) 44.22 (13.3)
64.38 (8.8) 72.08 (8.9) 70.31 (7.6)
60.40 (11.9) 63.50 (7.6) 63.30 (9.8)
.388 .343 .256 .014 .062 .061 .256
