The past 50 years have been a period of exciting progress in neuropsychological research on traumatic brain injury (TBI). Neuropsychologists and neuropsychological testing have played a critical role in these advances. This study looks back at three major scientific advances in research on TBI that have been critical in pushing the field forward over the past several decades: The advent of modern neuroimaging; the recognition of the importance of non-injury factors in determining recovery from TBI; and the growth of cognitive rehabilitation. Thanks to these advances, we now have a better understanding of the pathophysiology of TBI and how recovery from the injury is also shaped by pre-injury, comorbid, and contextual factors, and we also have increasing evidence that active interventions, including cognitive rehabilitation, can help to promote better outcomes. The study also peers ahead to discern two important directions that seem destined to influence research on TBI over the next 50 years: the development of large, multi-site observational studies and randomized controlled trials, bolstered by international research consortia and the adoption of common data elements; and attempts to translate research into health care and health policy by the application of rigorous methods drawn from implementation science. Future research shaped by these trends should provide critical evidence regarding the outcomes of TBI and its treatment, and should help to disseminate and implement the knowledge gained from research to the betterment of the quality of life of persons with TBI. (JINS, 2017, 23, 806–817)

Objectives: Blast explosions are the most frequent mechanism of traumatic brain injury (TBI) in recent wars, but little is known about their long-term effects. Methods: Functional connectivity (FC) was measured in 17 veterans an average of 5.46 years after their most serious blast related TBI, and in 15 demographically similar veterans without TBI or blast exposure. Subcortical FC was measured in bilateral caudate, putamen, and globus pallidus. The default mode and fronto-parietal networks were also investigated. Results: In subcortical regions, between-groups t tests revealed altered FC from the right putamen and right globus pallidus. However, following analysis of covariance (ANCOVA) with age, depression (Center for Epidemiologic Studies Depression Scale), and posttraumatic stress disorder symptom (PTSD Checklist – Civilian version) measures, significant findings remained only for the right globus pallidus with anticorrelation in bilateral temporal occipital fusiform cortex, occipital fusiform gyrus, lingual gyrus, and cerebellum, as well as the right occipital pole. No group differences were found for the default mode network. Although reduced FC was found in the fronto-parietal network in the TBI group, between-group differences were nonsignificant after the ANCOVA. Conclusions: FC of the globus pallidus is altered years after exposure to blast related TBI. Future studies are necessary to explore the trajectory of changes in FC in subcortical regions after blast TBI, the effects of isolated versus repetitive blast-related TBI, and the relation to long-term outcomes in veterans. (JINS, 2016, 22, 631–642)

The present study compared executive dysfunction among children with attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (S-ADHD), pre-injury ADHD and children with TBI only (i.e., no ADHD). Youth aged 6–16 years admitted for TBI to five trauma centers were enrolled (n=177) and evaluated with a semi-structured psychiatric interview scheduled on three occasions (within 2 weeks of TBI, i.e., baseline assessment for pre-injury status; 6-months and 12-months post-TBI). This permitted the determination of 6- and 12-month post-injury classifications of membership in three mutually exclusive groups (S-ADHD; pre-injury ADHD; TBI-only). Several executive control measures were administered. Unremitted S-ADHD was present in 17/141 (12%) children at the 6-month assessment, and in 14/125 (11%) children at 12-months post-injury. The study found that children with S-ADHD exhibited deficient working memory, attention, and psychomotor speed as compared to children with pre-injury ADHD. Furthermore, the children with S-ADHD and the children with TBI-only were impaired compared to the children with pre-injury ADHD with regard to planning. No group differences related to response inhibition emerged. Age, but not injury severity, gender, or adaptive functioning was related to executive function outcome. Neuropsychological sequelae distinguish among children who develop S-ADHD following TBI and those with TBI only. Moreover, there appears to be a different pattern of executive control performance in those who develop S-ADHD than in children with pre-injury ADHD suggesting that differences exist in the underlying neural mechanisms that define each disorder, underscoring the need to identify targeted treatment interventions. (JINS, 2014, 20, 971–981)

Outcome of moderate to severe traumatic brain injury (TBI) includes impaired emotion regulation. Emotion regulation has been associated with amygdala and rostral anterior cingulate (rACC). However, functional connectivity between the two structures after injury has not been reported. A preliminary examination of functional connectivity of rACC and right amygdala was conducted in adolescents 2 to 3 years after moderate to severe TBI and in typically developing (TD) control adolescents, with the hypothesis that the TBI adolescents would demonstrate altered functional connectivity in the two regions. Functional connectivity was determined by correlating fluctuations in the blood oxygen level dependent (BOLD) signal of the rACC and right amygdala with that of other brain regions. In the TBI adolescents, the rACC was found to be significantly less functionally connected to medial prefrontal cortices and to right temporal regions near the amygdala (height threshold T = 2.5, cluster level p < .05, FDR corrected), while the right amygdala showed a trend in reduced functional connectivity with the rACC (height threshold T = 2.5, cluster level p = .06, FDR corrected). Data suggest disrupted functional connectivity in emotion regulation regions. Limitations include small sample sizes. Studies with larger sample sizes are necessary to characterize the persistent neural damage resulting from moderate to severe TBI during development. (JINS, 2013, 19, 1–14)

For this pilot study, we compared performance of 15 adolescents with moderate–severe traumatic brain injury (TBI) to that of 13 typically developing (TD) adolescents in predicting social actions and consequences for avatars in a virtual microworld environment faced with dilemmas involving legal or moral infractions. Performance was analyzed in relation to cortical thickness in brain regions implicated in social cognition. Groups did not differ in number of actions predicted nor in reasons cited for predictions when presented only the conflict situation. After viewing the entire scenario, including the choice made by the avatar, TD and TBI adolescents provided similar numbers of short-term consequences. However, TD adolescents provided significantly more long-term consequences (p = .010). Additionally, for the Overall qualitative score, TD adolescents’ responses were more likely to reflect the long-term impact of the decision made (p = .053). Groups differed in relation of the Overall measure to thickness of right medial prefrontal cortex/frontal pole and precuneus, with stronger relations for the TD group (p < .01). For long-term consequences, the relations to the posterior cingulate, superior medial frontal, and precentral regions, and to a lesser extent, the middle temporal region, were stronger for the TBI group (p < .01). (JINS, 2013, 19, 1–10.)

Explosive blast is a frequent cause of traumatic brain injury (TBI) among personnel deployed to Afghanistan and Iraq. Functional magnetic resonance imaging (fMRI) with an event-related stimulus-response compatibility task was used to compare 15 subjects with mild, chronic blast-related TBI with 15 subjects who had not experienced a TBI or blast exposure during deployment. Six TBI subjects reported multiple injuries. Relative to the control group, TBI subjects had slightly slower responses during fMRI and increased somatic complaints and symptoms of post-traumatic stress disorder (PTSD) and depression. A between-group analysis indicated greater activation during stimulus-response incompatibility in TBI subjects within the anterior cingulate gyrus, medial frontal cortex, and posterior cerebral areas involved in visual and visual-spatial functions. This activation pattern was more extensive after statistically controlling for reaction time and symptoms of PTSD and depression. There was also a negative relationship between symptoms of PTSD and activation within posterior brain regions. These results provide evidence for increased task-related activation following mild, blast-related TBI and additional changes associated with emotional symptoms. Limitations of this study include no matching for combat exposure and different recruitment strategies so that the control group was largely a community-based sample, while many TBI subjects were seeking services. (JINS, 2012, 18, 89–100)

There are very few studies investigating remediation of event-based prospective memory (EB-PM) impairments following traumatic brain injury (TBI). To address this, we used 2 levels of motivational enhancement (dollars vs. pennies) to improve EB-PM in children with moderate to severe TBI in the subacute recovery phase. Children with orthopedic injuries (OI; n = 61), moderate (n = 28), or severe (n = 30) TBI were compared. Significant effects included Group × Motivation Condition (F(2, 115) = 3.73, p < .03). The OI (p < .002) and moderate TBI (p < .03) groups performed significantly better under the high- versus low-incentive condition; however, the severe TBI group failed to demonstrate improvement (p = .38). EB-PM performance was better in adolescents compared to younger children (p < .02). These results suggest that EB-PM can be significantly improved in the subacute phase with this level of monetary incentives in children with moderate, but not severe, TBI. Other strategies to improve EB-PM in these children at a similar point in recovery remain to be identified and evaluated. (JINS, 2010, 16, 335–341.)

Arthur Benton, 97, died in Glenview, IL on December 27, 2006. He was born October 16, 1909 in New York City. He received his B.A. and M.A. degrees from Oberlin College, where Raymond Stetson was his mentor, and his Ph.D. in Psychology from Columbia University in 1935 under the mentorship of Carney Landis of the New York State Psychiatric Institute . Benton completed his training as a psychologist at the Payne Whitney Psychiatric Clinic of New York Hospital. Early in 1941, he volunteered for service in the United States Navy and was commissioned as a lieutenant in the medical department. His active duty lasted until 1945, followed by many years of service in the United States Navy Reserve, retiring at the rank of Captain. During his assignment at the San Diego Naval Hospital, Benton worked closely with neurologist Morris Bender and examined servicemen who had sustained penetrating brain wounds during combat. The experience of assessing servicemen with brain injury and Bender's influence led Benton to develop the Visual Retention Test, which still bears his name and continues to be widely used in clinical neuropsychological assessment.

To evaluate effects of unilateral frontal lesions on psychosocial and global outcome of traumatic brain injury (TBI) in children, Study 1 compared matched groups of 22 school aged children who had sustained TBI either with or without unilateral frontal lesions. Study 2 evaluated effects of unilateral extrafrontal lesions in 18 TBI patients as compared with 18 nonlesional TBI patients. Communication, Daily Living, and Socialization domains and the Maladaptive Behavior Scale of the Vineland Adaptive Behavior Scales (VABS) were used to assess psychosocial outcome, and the Glasgow Outcome Scale (GOS) measured global outcome. All patients underwent magnetic resonance imaging at least 3 months post injury. Children with frontal lesions had worse scores on the Daily Living and Socialization domains and a higher frequency of maladaptive behavior than those without frontal lesions, but there was no difference in cognitive function. Disability was twice as common in the frontal lesion group relative to children without frontal lesions. Volume of frontal lesion was related to the Socialization domain. Side of lesion had no effect, nor did presence of an extrafrontal lesion (Study 2). Unilateral frontal lesions adversely affect late psychosocial outcome of TBI in children. (JINS, 2004, 10, 305–316.)

This study evaluated the early cognitive and neurobehavioral outcomes of older adults with mild versus moderate traumatic brain injury (TBI). Thirty-five patients who were age 50 years and older and sustained mild or moderate TBI were prospectively recruited from acute care hospitals. Patients were administered cognitive and neurobehavioral measures up to 2 months post-injury. Demographically comparable control participants received the same measures. Patients and controls did not have previous histories of substance abuse, neuropsychiatric disturbance, dementia, or neurologic illness. Moderate TBI patients performed significantly poorer than mild TBI patients and controls on most cognitive measures, whereas the mild patients performed comparably to controls. In contrast, both mild and moderate patients exhibited significantly greater depression and anxiety/somatic concern than controls. The results indicate that the classification of TBI as mild versus moderate is prognostically meaningful as applied to older adults. The findings extend previous investigations in young adults by demonstrating a relatively good cognitive outcome on objective measures, but subjective complaints after a single, uncomplicated mild TBI in older persons. (JINS, 2001, 7, 373–383.)

The discourse of 91 children who had sustained severe (n = 68) or mild (n = 23) closed head injury (CHI) was examined at least three years postinjury. The groups' retellings of a narrative story were analyzed according to two domains, information and language. In comparison to the mild CHI group, the severe group produced stories characterized by reduced content and information, impaired organization, fewer words, and less complex sentences. The relationships between discourse production and the groups' performance on measures of language, executive function, memory, and processing speed were examined. Correlations were found between discourse production and general verbal ability including verbal fluency. Correlations were also found for discourse performance and executive function measures associated with problem solving and working memory. Site and extent of lesion were not useful in predicting discourse production. These findings indicate that children who sustain a severe closed head injury during early to middle childhood are at risk for persisting deficits in discourse processing and other cognitive abilities. (JINS, 2000, 6, 741–751)

To further investigate the usefulness of 3 purported measures of executive function (EF) in head injured children, we administered the Twenty Questions Test (TQT), Tower of London (TOL), and the Wisconsin Card Sorting Test (WCST) to 151 children who had sustained a closed head injury (CHI) of varying severity about 3 years earlier. In addition, we tested 89 normal controls. Fifty-seven of the patients were included in a longitudinal study that compared performance at 3 months and 36 months. All of the head injured children underwent magnetic resonance imaging for investigational purposes. Severity of CHI, as defined by the lowest Glasgow Coma Scale (GCS) score, affected performance on all 3 EF measures. Focal lesion volume incremented prediction of performance on TOL and WCST, but not TQT. Moderate intercorrelations of the test variables were obtained. Although all three EF measures depicted changes in performance over 3 years, a ceiling effect detracted from the sensitivity of the TOL to the impact of CHI on development. Implications of the findings for clinical applications are discussed. (JINS, 1997, 3, 598–607.)

Neuropsychological outcome was evaluated in a prospective, longitudinal follow-up study of children age 4 months to 7 years at injury with either mild-to-moderate (N = 35) or severe (N = 44) traumatic brain injury (TBI). Age-appropriate tests were administered at baseline, 6 months, 12 months, and 24 months after the injury. Performance was compared on (1) composite IQ and motor, (2) receptive and expressive language, and (3) Verbal and Perceptual–Performance IQ scores. In comparison to mild-to-moderate TBI, severe TBI in infants and preschoolers produced deficits in all areas. Interactions between task and severity of injury were obtained. Motor scores were lower than IQ scores, particularly after severe TBI. Both receptive and expressive scores were reduced following severe TBI. Expressive language scores were lower than receptive language scores for children sustaining mild-to-moderate TBI. While severe TBI lowered both Verbal and Perceptual– Performance IQ scores, Verbal IQ scores were significantly lower than Perceptual–Performance IQ scores after mild-to-moderate TBI. Mild injuries may produce subtle linguistic changes adversely impacting estimates of Verbal IQ and expressive language. Within the limited age range evaluated within this study, age at injury was unrelated to test scores: The impact of TBI was comparable in children ages 4 to 41 months versus 42 to 72 months at the time of injury. All neuropsychological scores improved significantly from baseline to the 6-month follow-up. However, no further change in scores was observed from 6 to 24 months after the injury. The persistent deficits and lack of catch-up over time suggest a reduction in the rate of acquisition of new skills after severe TBI. Methodological issues in longitudinal studies of young children were discussed. (JINS, 1997, 3, 581–591.)