Objective: Traumatic brain injury (TBI) sustained in childhood is associated with poor social outcomes. This study investigated the role of theory of mind (ToM) as a mediator of the relation between TBI and peer rejection/victimization and reciprocated friendships, as well as the moderating effect of parental nurturance on those relationships. Method: Participants were children of 8–13 years old (M = 10.45, SD = 1.47), including 13 with severe TBI, 39 with complicated mild/moderate TBI, and 32 children with orthopedic injuries. Data on peer rejection/victimization and friendship were collected in school classrooms using the Extended Class Play and friendship nominations. Parents rated parental nurturance using the Child-Rearing Practices Report. Finally, ToM was measured based on children’s average performance across three tasks measuring different aspects of ToM. Results: Severe TBI was associated with poorer ToM, greater peer rejection/victimization, and fewer reciprocated friendships. ToM mediated the relation between severe TBI and peer rejection/victimization (i.e., severe TBI predicted poorer ToM, which in turn predicted greater rejection/victimization). Parental nurturance significantly moderated this relation, such that the mediating effect of ToM was significant only at low and average levels of parental nurturance, for both severe and complicated mild/moderate TBI groups. Neither the mediating effect of ToM nor the moderating effect of parental nurturance was significant for reciprocated friendships. Conclusion: High parental nurturance may mitigate the negative effects of ToM deficits on risk of peer rejection/victimization among children with TBI. Interventions designed to increase parental nurturance or ToM may promote better social outcomes among children with TBI.

Objectives: Fluency is a major problem for individuals with neurodevelopmental disorders, including fluency deficits for academic skills. The aim of this study was to determine neurocognitive predictors of academic fluency within and across domains of reading, writing, and math, in children and adults, with and without spina bifida. In addition to group differences, we expected some neurocognitive predictors (reaction time, inattention) to have similar effects for each academic fluency outcome, and others (dexterity, vocabulary, nonverbal reasoning) to have differential effects across outcomes. Methods: Neurocognitive predictors were reaction time, inattention, dexterity, vocabulary, and nonverbal reasoning; other factors included group (individuals with spina bifida, n=180; and without, n=81), age, and demographic and untimed academic content skill covariates. Univariate and multivariate regressions evaluated hypotheses. Results: Univariate regressions were significant and robust (R2=.78, .70, .73, for reading, writing, and math fluency, respectively), with consistent effects of covariates, age, reaction time, and vocabulary; group and group moderation showed small effect sizes (<2%). Multivariate contrasts showed differential prediction across academic fluency outcomes for reaction time and vocabulary. Conclusions: The novelty of the present work is determining neurocognitive predictors for an important outcome (academic fluency), within and across fluency domains, across population (spina bifida versus typical), over a large developmental span, in the context of well-known covariates. Results offer insight into similarities and differences regarding prediction of different domains of academic fluency, with implications for addressing academic weakness in spina bifida, and for evaluating similar questions in other neurodevelopmental disorders. (JINS, 2019, 25, 249–265)

Objectives: The current study examines whether psychosocial outcomes following pediatric traumatic brain injury (TBI) vary as a function of children’s rejection sensitivity (RS), defined as their disposition to be hypersensitive to cues of rejection from peers. Methods: Children ages 8–13 with a history of severe TBI (STBI, n=16), complicated mild/moderate TBI (n=35), or orthopedic injury (OI, n=49) completed measures assessing self-esteem and RS on average 3.28 years post-injury (SD=1.33, range=1.25–6.34). Parents reported on their child’s emotional and behavioral functioning and social participation. Results: Regression analyses found moderation of group differences by RS for three outcomes: social participation, self-perceptions of social acceptance, and externalizing behavior problems. Conditional effects at varying levels of RS indicated that externalizing problems and social participation were significantly worse for children with STBI at high levels of RS, compared to children with OI. Social participation for the STBI group remained significantly lower than the OI group at mean levels of RS, but not at low levels of RS. At high levels of RS, self-perceptions of social acceptance were lower for children with moderate TBI compared to OI, but group differences were not significant at mean or low levels of RS. No evidence of moderation was found for global self-worth, self-perceptions of physical appearance or athletic ability, or internalizing problems. Conclusions: The findings highlight the salient nature of social outcomes in the context of varying levels of RS. These findings may have implications for the design of interventions to improve social outcomes following TBI. (JINS, 2017, 23, 451–459)

Objectives: This study examined whether children with distinct brain disorders show different profiles of strengths and weaknesses in executive functions, and differ from children without brain disorder. Methods: Participants were children with traumatic brain injury (N=82; 8–13 years of age), arterial ischemic stroke (N=36; 6–16 years of age), and brain tumor (N=74; 9–18 years of age), each with a corresponding matched comparison group consisting of children with orthopedic injury (N=61), asthma (N=15), and classmates without medical illness (N=68), respectively. Shifting, inhibition, and working memory were assessed, respectively, using three Test of Everyday Attention: Children’s Version (TEA-Ch) subtests: Creature Counting, Walk-Don’t-Walk, and Code Transmission. Comparison groups did not differ in TEA-Ch performance and were merged into a single control group. Profile analysis was used to examine group differences in TEA-Ch subtest scaled scores after controlling for maternal education and age. Results: As a whole, children with brain disorder performed more poorly than controls on measures of executive function. Relative to controls, the three brain injury groups showed significantly different profiles of executive functions. Importantly, post hoc tests revealed that performance on TEA-Ch subtests differed among the brain disorder groups. Conclusions: Results suggest that different childhood brain disorders result in distinct patterns of executive function deficits that differ from children without brain disorder. Implications for clinical practice and future research are discussed. (JINS, 2017, 23, 529–538)

As survival rates for childhood acute lymphoblastic leukemia have increased, concerns over improved quality-of-life have also increased. Although 3-10% of children may experience acute transient neurotoxicity during induction chemotherapy, they are felt to be at low risk for late sequelae. We report three previously healthy boys with newly-diagnosed acute lymphoblastic leukemia who presented with obtundation and severe seizures during late induction with a standard four drug chemotherapy regimen. While all three are disease-free survivors, they unexpectedly have persistent and medically intractable partial complex seizures, broad-based neuropsychological impairment and striking neuroimaging abnormalities. These findings suggest that children with leukemia who develop an acute encephalopathy during induction chemotherapy are at risk for long-term neurological and neuropsychological sequelae, despite the cessation of further potentially neurotoxic therapy.

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)

There is increasing need for early, pro-active programs that can delay dementia diagnosis and enhance well-being of individuals with mild cognitive impairment (MCI) and their care-partners (i.e., care-dyads). This randomized controlled trial evaluated the efficacy of a combined cognitive rehabilitation and multi-family group treatment (CR-MFG) that was designed to facilitate adoption of newly learned cognitive strategies into the care-dyads everyday lives. Analyzed data included 23 care-dyads who participated in CR-MFG treatment and 23 care-dyads in standard care (SC). The 3-month intervention consisted of individual joining sessions, an educational workshop, and 20/twice weekly multifamily memory strategy training and problem-solving sessions. Everyday functioning, memory, and psychological functioning (i.e., quality-of-life, depression, coping) were assessed. The CR-MFG intervention was associated with significant post-test group differences and improved post-test performances by the MCI participants on performance-based measures of everyday functioning and neuropsychological tests of memory. There was also some suggestion that CR-MFG care-partners perceived positive change in the everyday functioning of the MCI participants. In contrast, no post-test group differences were found for either care-dyad member on the self-report psychological measures; care-partners in the treatment group did self-report improved coping behaviors at post-test. These 3-month results are preliminary but suggestive that CR-MFG may produce modest, practical everyday functional benefits for persons with MCI. (JINS, 2014, 20, 1–12)

This study examined differences in friendship quality between children with traumatic brain injury (TBI) and orthopedic injury (OI) and behavioral outcomes for children from both groups. Participants were 41 children with TBI and 43 children with OI (M age=10.4). Data were collected using peer- and teacher-reported measures of participants’ social adjustment and parent-reported measures of children’s post-injury behaviors. Participants and their mutually nominated best friends also completed a measure of the quality of their friendships. Children with TBI reported significantly more support and satisfaction in their friendships than children with OI. Children with TBI and their mutual best friend were more similar in their reports of friendship quality compared to children with OI and their mutual best friends. Additionally, for children with TBI who were rejected by peers, friendship support buffered against maladaptive psychosocial outcomes, and predicted skills related to social competence. Friendship satisfaction was related to higher teacher ratings of social skills for the TBI group only. Positive and supportive friendships play an important role for children with TBI, especially for those not accepted by peers. Such friendships may protect children with TBI who are rejected against maladaptive psychosocial outcomes, and promote skills related to social competence. (JINS, 2014, 21, 1–10)

Covert orienting is related to the integrity of the midbrain, but the specificity of the relation is unclear. We compared covert orienting in three etiologies of congenital hydrocephalus (aqueductal stenosis [AS], Dandy-Walker malformation [DWM], and spina bifida myelomeningocele [SBM]—with and without tectal beaking) to explore the effects of midbrain and posterior fossa malformations. We hypothesized a stepwise order of group performance reflecting the degree of midbrain tectum dysmorphology. Performance on an exogenously cued covert orienting task was compared using repeated measures analysis of covariance, controlling for age. Individuals with SBM and tectal beaking demonstrated the greatest disengagement cost in the vertical plane, whereas individuals with AS performed as well as a typically developing (TD) group. Individuals with SBM but no tectal beaking and individuals with DWM showed greater disengagement costs in the vertical plane relative to the TD group, but better performance relative to the group with SBM and tectal beaking. Individuals with AS, DWM, and SBM and tectal beaking demonstrated poorer inhibition of return than TD individuals. Impairments in attentional disengagement in SBM are not attributable to the general effects of hydrocephalus, but are instead associated with specific midbrain anomalies that are part of the Chiari II malformation. (JINS, 2014, 20, 1–10)

Social communication involves influencing what other people think and feel about themselves. We use the term conative theory of mind (ToM) to refer to communicative interactions involving one person trying to influence the mental and emotional state of another, paradigmatic examples of which are irony and empathy. This study reports how children with traumatic brain injury (TBI) understand ironic criticism and empathic praise, on a task requiring them to identify speaker belief and intention for direct conative speech acts involving literal truth, and indirect speech acts involving either ironic criticism or empathic praise. Participants were 71 children in the chronic state of a single TBI and 57 age- and gender-matched children with orthopedic injuries (OI). Group differences emerged on indirect speech acts involving conation (i.e., irony and empathy), but not on structurally and linguistically identical direct speech acts, suggesting specific deficits in this aspect of social cognition in school-age children with TBI. Deficits in children with mild-moderate TBI were less widespread and more selective than those of children with more severe injuries. Deficits in understanding the social, conative function of indirect speech acts like irony and empathy have widespread and deep implications for social function in children with TBI. (JINS, 2013, 19, 1–11)

This study examined peer relationships in children with traumatic brain injury (TBI) relative to children with orthopedic injuries (OI), and explored whether differences in peer relationships correlated with white matter volumes. Classroom procedures were used to elicit peer perceptions of social behavior, acceptance, and friendships for eighty-seven 8- to 13-year-old children, 15 with severe TBI, 40 with complicated mild/moderate TBI, and 32 with OI. Magnetic resonance imaging (MRI) and voxel-based morphometry (VBM) were used to investigate volumetric correlates of peer relationship measures. Children with severe TBI were rated higher in rejection-victimization than children with OI, and were less likely than children with OI to have a mutual friendship in their classroom (47% vs. 88%). Children with TBI without a mutual friend were rated lower than those with a mutual friend on sociability-popularity and prosocial behavior and higher on rejection-victimization, and had lower peer acceptance ratings. Mutual friendship ratings were related to white matter volumes in several posterior brain regions, but not to overall brain atrophy. Severe TBI in children is associated with detrimental peer relationships that are related to focal volumetric reductions in white matter within regions of the brain involved in social information-processing. (JINS, 2013, 19, 1–10)

We compared neuropsychological profiles in children with shunted hydrocephalus secondary to aqueductal stenosis (AS), a rare form of congenital hydrocephalus, and spina bifida myelomeningocele (SBM), a common form of congenital hydrocephalus. Participants were 180 children with shunted hydrocephalus grouped according to etiology: SBM (n = 151), AS (n = 29), and typically developing (TD; n = 60) individuals. The group with AS performed below the TD group on all tasks except for reading, and their overall performance was higher than the group with SBM, who had the lowest performance in the sample. Both clinical groups significantly differed from the TD group on tasks of spatial function, concept formation, motor function, and memory. Performance of the subgroup of AS children with normal cerebellum status approximated that of the TD group, while those with cerebellar anomalies performed lower than others with AS. Cerebellar abnormalities (present in the whole SBM group and in a subset of the AD group) are associated with more compromise of cognitive as well as motor function. (JINS, 2012, 18, 1–10)

Facial emotion expresses feelings, but is also a vehicle for social communication. Using five basic emotions (happiness, sadness, fear, disgust, and anger) in a comprehension paradigm, we studied how facial expression reflects inner feelings (emotional expression) but may be socially modulated to communicate a different emotion from the inner feeling (emotive communication, a form of affective theory of mind). Participants were 8- to 12-year-old children with TBI (n = 78) and peers with orthopedic injuries (n = 56). Children with mild–moderate or severe TBI performed more poorly than the OI group, and chose less cognitively sophisticated strategies for emotive communication. Compared to the OI and mild–moderate TBI groups, children with severe TBI had more deficits in anger, fear, and sadness; neutralized emotions less often; produced socially inappropriate responses; and failed to differentiate the core emotional dimension of arousal. Children with TBI have difficulty understanding the dual role of facial emotions in expressing feelings and communicating socially relevant but deceptive emotions, and these difficulties likely contribute to their social problems. (JINS, 2013, 18, 1–10)

Theory of mind (ToM) involves thinking about mental states and intentions to understand what other people know and to predict how they will act. We studied ToM in children with traumatic brain injury (TBI) and age- and gender-matched children with orthopedic injuries (OI), using a new three-frame Jack and Jill cartoon task that measures intentional thinking separate from contingent task demands. In the key ToM trials, which required intentional thinking, Jack switched a black ball from one hat to another of a different color, but Jill did not witness the switch; in the otherwise identical non-ToM trials, the switch was witnessed. Overall accuracy was higher in children with OI than in those with TBI. Children with severe TBI showed a larger decline in accuracy on ToM trials, suggesting a specific deficit in ToM among children with severe TBI. Accuracy was significantly higher on trials following errors than on trials following correct responses, suggesting that all groups monitored performance and responded to errors with increased vigilance. TBI is associated with poorer intentional processing in school-age children and adolescents relative to peers with OI; furthermore, children with TBI are challenged specifically by intentional demands, especially when their injury is severe. (JINS, 2012, 19, 1–9)