Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than environmental factors as predictors of recovery. We addressed this concern using data collected during a prospective study of children with either TBI or orthopedic injuries (OI) and their families. Participants included 53 children with severe TBI, 56 with moderate TBI, and 80 with OI, all from 6 to 12 years of age at the time of injury. Measures of the preinjury family environment were collected shortly after the injury (baseline). Child cognitive and behavioral outcomes were assessed at baseline and at 6- and 12-month follow-ups. Individual growth curve analyses showed that measures of the preinjury family environment consistently predicted both the level of cognitive and behavioral functioning at 12 months postinjury and the rate of intraindividual change during the 12-month follow-up period, even after taking into account group membership and injury severity. In some cases, the preinjury family environment was a significant moderator of the effect of TBI, buffering its impact in high-functioning families and exacerbating it in low-functioning families. Thus, preinjury environmental factors predict recovery following TBI in children, even after accounting for injury-related variables. (JINS, 1997, 3, 617–630.)

This paper suggests there are, at present, four main kinds of cognitive rehabilitation programs for brain injured people. The first attempts to rehabilitate cognitive deficits through drills and exercises. The second uses theoretical models from cognitive psychology to identify deficits in order to remediate them. The third is primarily a patient-driven approach that uses a combination of learning theory, cognitive psychology, and neuropsychology to identify and remediate cognitive difficulties. The fourth is the holistic approach that has, as its basic philosophy, a belief that cognitive functions cannot be divorced from emotion, motivation, or other noncognitive functions, and consequently all aspects of functioning should be addressed in rehabilitation programs. Despite some overlap between these approaches, there are major differences. The two main arguments offered in this paper are (1) that the first two approaches do not lead to good clinical rehabilitation practice; and (2) that a synthesis of the second two approaches would result in the best cognitive rehabilitation model. (JINS, 1997, 3, 487–496.)

Meta-analysis was used to examine the performance of depressed and Alzheimer-type dementia (DAT) patients on standard and experimental clinical tests of cognitive function. Deficits were found for depression on almost every psychological test. Relative to nondepressed controls, the average deficit was 0.63 of a standard deviation, but the magnitude of the effect varied with the type of test. DAT patients performed worse than depressed patients, with an average effect size of 1.21 standard deviations, but the size of the effect depended on the clinical test. Effect sizes for the comparison between depressives and controls were significantly affected by age, treatment setting, ECT use, severity of depression, and the source of diagnostic criteria, but not by the type of depression. Effect sizes in the comparison of depressives to DAT patients were influenced by age, the severity of depression, and ECT. Depressives performed proportionately worse than controls on tasks with pleasant or neutral, compared with unpleasant content, on speeded compared with nonspeeded tasks, and on vigilance tasks. However, there were no differences in the magnitude of effect size for tests using recall compared with recognition, using categorical compared with noncategorical word lists, on story compared with word comprehension, and using verbal compared with visual material. Relative to DAT patients, depressives performed no better on recall compared to recognition tasks, or verbal compared to visual material. The findings of the review are not consistent with the hypothesis that depression is associated with deficits in effortful processing. A model of psychological deficit in depression as a deficit in speed or attention has more promise. (JINS, 1997, 3, 631–651.)

Barbara A. Wilson's article in this issue is a thoughtful and scholarly commentary on the present state of cognitive rehabilitation. Her review of the meaning of the term “rehabilitation,” and her reminder that we are better at treating disabilities than impairments after brain damage, set the background for her four major points. First, there are currently four basic approaches to cognitive rehabilitation. Second, two of these approaches are of little help to patients. Third, combining learning theory, cognitive psychology, and neuropsychology is helpful in dealing with the “everyday problems of brain-injured people.” Finally, this latter approach combined with the holistic approach is promising, especially given that patients' personality disturbances must be considered if neuropsychological rehabilitation is to be effective.

While readers may share my enthusiasm and gratitude for Prigatano's further explication of holistic rehabilitation, I would be disappointed if this were the only issue that remained highlighted in the debate. Other areas that I hope will promote further critical analysis are my arguments concerning the strengths and weaknesses of approaches to rehabilitation that differ according to whether impairments, disabilities, or handicaps are being treated. My critique of cognitive neuropsychological/theoretical approaches also deserves some reply.