A Systematic Review of Interventions for Hot and Cold Executive Functions in Children and Adolescents With Acquired Brain Injury

A Systematic Review of Interventions for Hot and Cold Executive Functions in Children and... Abstract Objective We investigated interventions, which aimed to improve cold and hot executive functions (EFs) in children and adolescents with a diagnosis of acquired brain injury (ABI). Methods The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between 1990 and July 2017 in English or Spanish, including children and adolescents. Articles were read and classified according to the levels of evidence of the Australian National Health and Medical Research Council and the Downs and Black checklist was used for Measuring Study Quality. Results Thirty studies are reported in this systematic review. Level of evidence, quality of the studies, characteristics of the participants, interventions implemented, and outcomes are described. Conclusions The study of rehabilitation for executive dysfunction in children with ABI is emerging. Although few high-quality intervention studies exist in this area, which limits conclusions regarding intervention efficacy, results of existing studies suggest that education for parents may be an important component of intervention. Moreover, caregiver involvement may improve the effectiveness of hot EFs rehabilitation interventions, while high intervention session frequency may be important in improving cold EFs. Positive behavior supports and specific training based on a cognitive model provided some promising findings, which require further evaluation. acquired brain injury, adolescents, children, executive functions, intervention, rehabilitation and systematic review Acquired brain injury (ABI) is a term that encompasses damage to the brain that occurs after birth Australian Institute of Health and Welfare (2007). ABIs have diverse causes including traumatic brain injury (TBI), cerebral vascular diseases, infections, brain tumors, vestibular dysfunction, and postsurgical complications (Ciuffreda & Kapoor, 2012). Children and adolescents with ABI usually present with deficits in several cognitive domains such as attention, processing speed, memory, language, and social problem-solving skills. In particular, executive functions (EFs) deficits are common and emerge with time postinjury as the child matures (Galvin, Lim, Steer, Edwards, & Lee, 2010; Kok et al., 2014). EFs refer to a group of cognitive skills required for purposeful goal-directed activity and can be divided into cold and hot domains (De Luca & Leventer (2008). Cold EF refers to purely cognitive EF, while hot EF refers to the affective aspects of these cognitive skills (Kerr & Zelazo, 2004). Cold EFs are more likely to be elicited by decontextualized problems such as manipulation of abstract concepts, numbers, or letters (Brock, Rimm-Kaufman, Nathanson, & Grimm, 2009; Hongwanishkul, Happaney, Lee, & Zelazo, 2005). Hot EFs refer to the socioemotional domain and are more likely to be evoked by motivationally and emotionally meaningful contexts (Brock et al., 2009; Hongwanishkul et al., 2005). The line between hot and cold EFs is blurred because both work together toward adaptive functions (Zelazo & Carlson, 2012). However, the degree to which tasks elicit hot or cold EFs differentiates tasks that aim to improve them (Hongwanishkul et al., 2005). Based on the description of De Luca and Leventer (2008), we considered behavior regulation, emotion regulation, affective decision making, social skills, and theory of mind hot EFs. Metacognition, cognitive flexibility, attention, inhibition, working memory planning, and problem-solving were considered cold EFs (De Luca & Leventer, 2008). The description of hot and cold EFs done by De Luca and Leventer (2008) was chosen because it includes social skills, which are usually impaired in children and adolescents with ABI (Beauchamp & Anderson 2010; Ryan et al., 2016). EFs are required in children’s daily activities. Children with deficits in cold EFs tend to forget instructions, misplace school supplies, have difficulties in concentrating during homework, make careless mistakes, and try a solution repeatedly even if it is not useful (Castellanos, Sonuga-Barke, Milham, & Tannock, 2006; Gioia, Kenworthy, & Isquith, 2010). Children with impairments in hot EFs are more likely to interrupt conversations, make risky decisions, present anger outbursts, and misinterpret others (Castellanos et al., 2006; Gioia et al., 2010; Zelazo & Carlson, 2012). Impairments in hot and cold EFs negatively impact children’s self-esteem, family functioning, social adaptation, and academic achievement (Brock et al., 2009; Yeates et al., 2004). The rehabilitation of specific cognitive processes is a path often used to improve a child’s EFs. This approach has strong support from cognitive models (Sohlberg & Mateer, 1987), which breakup cognitive processes into subcomponents or levels. The involvement of caregivers is a common practice in child rehabilitation. An example of this method is providing caregivers education about the ABI and associated behaviors to increase their knowledge and reduce stress (Bauml, Frobose, Kraemer, Rentrop, & Pitschel-Walz, 2006). Another example is acceptance and commitment therapy, which emphasizes acceptance rather than behavior change or elimination only (Morris, Johns, & Oliver, 2013). One more way to involve caregivers is by teaching them positive behavior supports (PBS) to improve their child’s behavior (Carr et al., 2002). Three main ideas support the inclusion of caregivers in a child's rehabilitation: (1) caregivers are aware of the behavioral changes presented after injury onset; (2) they are likely to be a stable resource throughout child’s life, and (3) EFs development can be affected by family factors (Catroppa et al., 2017; Lefley, 2009). Over recent years, systematic reviews of intervention programs in children and adolescents with ABI have been published, investigating technological interventions (de Kloet, Berger, Verhoeven, van Stein Callenfels, & Vlieland, 2012; Linden et al., 2016) and combining interventions for children with neurodevelopmental disorders and children with diagnosis of ABI (Robinson, Kaizar, Catroppa, Godfrey, & Yeates, 2014). To date, these interventions have failed to consider differences in hot and cold EF rehabilitation despite substantial evidence supporting the distinction between hot and cold EFs (Hongwanishkul et al., 2005; Rubia, 2011; Zelazo & Carlson, 2012). Research has typically studied EFs as a single domain and focused almost exclusively on cold EFs (Hongwanishkul et al., 2005; Zelazo & Carlson, 2012). The systematic study of interventions with an explicit deconstruction of EF into hot and cold is novel for a review and has the potential to advance knowledge in the field of rehabilitation of children with ABI. To our knowledge, this systematic review is the first in studying interventions that aimed to improve EFs distinguishing between its cold and hot components. We aimed to assess the quality of those studies and identify any interventions specific to hot and cold EF. Methods Selection of the Studies The systematic review was conducted following the PRISMA Statement (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2010). The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between January 1990 and July 2017 in English or Spanish, and included children and adolescents (age 0–18 years). The Medical Subject Headings (MeSH) or keywords were grouped as population, intervention and outcome. Online Supplementary Table S1 describes the keywords used for the search, and Online Supplementary Table S7 contains the PRISMA checklist. Requirements for Inclusion Abstracts were reviewed independently by two authors to determine eligibility for inclusion. Inclusion criteria were: (1) children and adolescents with ABI or families of children or adolescents with ABI; (2) participants of age 0–18 years. For papers that included children, adolescents, and adults, the majority of the participants had to be <18 years old for the study to be included; (3) at least two measurement points, before and after intervention; (4) any intervention or combination of interventions to improve EF and/or social skills and/or reduce disinhibited behavior; (5) the components of the intervention were described. Exclusion criteria were: (1) Review articles; (2) Participants with neurodevelopmental disorders, drug users, abusive head trauma, or diagnosis other than ABI; (3) Predominance of participants >18 years old; (4) Outcome other than EF, social skills, or behavior problems; and (5) Case studies. Abstracts were categorized as eligible, likely eligible, or ineligible. Reviewers agreed on 90% of the abstracts. For those where consensus was not initially achieved, full papers underwent review by two reviewers using a standard data collection form and then a decision was made. This electronic search generated 771 papers. Additionally, seven papers were identified from reference lists. A total of 554 papers were screened from which 30 papers met the inclusion criteria. From those 30 papers, 4 papers reported long-term outcomes of a previous study. In these cases, the original paper and the follow-up paper were treated as one with their previous results. Three papers (Kurowski et al., 2013; Tlustos et al., 2016; Wade, Stacin et al., 2014) reported different outcomes from the same study. Those papers were treated independently. We report 26 studies based on 30 papers. Figure 1 illustrates the selection process and results of the search. Figure 1. View largeDownload slide PRISMA flow diagram. Figure 1. View largeDownload slide PRISMA flow diagram. Classification of the Studies and Quality Grading All articles were read and classified by two reviewers according to the levels of evidence of the Australian National Health and Medical Research Council (ANHMRC; see Online Supplementary Table S2). After classifying the articles, quality was assessed by two authors using the Downs and Black checklist for Measuring Study Quality (DB; Downs & Black, 1998). The DB checklist consists of 27 items that assess the quality of reporting (10 items), external validity (3 items), internal validity (7 items), confounders (6 items), and power effect (1 item) (Downs & Black, 1998; see Online Supplementary Table S3). Effect sizes were not always reported in studies. Therefore, based on a previous systematic review (Knight, Scheinberg, and Harvey, 2013), we assigned a score of 1 to studies that reported effect sizes and 0 to studies that did not. A full description of the levels of Levels of evidence of the ANHMRC and DB checklist can be found in the Online Supplementary Tables S2 and S3. Data Synthesis The data were extracted from each study and entered into a code sheet, so relevant information could be processed by two reviewers (C.C. and E.C.). Description of the level of evidence and quality of the studies can be seen in the Online Supplementary Tables S2 and S3. A value indicating adherence to the 27 DB checklist criteria (yes/no at the item level, expressed as an aggregate adherence percentage) was calculated for each study. Participants’ characteristics are described in Table III. Studies were classified according to their main objective into interventions that aim to improve cold EFs (Table I), hot EFs (Table II), or both (Table III). Report of the effect sizes was often lacking and measures used were heterogeneous. For this reason, we followed the approach of a previous systematic review (Stinson, Wilson, Navreet, Yamada, & Holt, 2008) and reported the authors' main conclusions. Improvement was defined as p ≤ .05 reported by the authors. Authors divided cognitive processes into subcomponents to assess the treatment effectiveness. Online Supplementary Table S5 shows the measures used to assess cognitive processes and a list with the subtests used from each measure. The subcomponents reported by cognitive process and measures used varied among studies. Owing to the data heterogeneity, it was not possible to perform a meta-analysis. However, we reported the percentage of the studies targeting each cognitive process that found improvement in at least one measure (see Online Supplementary Table S6). Table I. Interventions That Aim to Improve Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 Note. ANHMRC = Australian National Health and Medical Research Council; EF = executive function; DB checklist = Downs and Black checklist; FTF = face-to-face—unable to determined or not reported..; SCT = Specific cognitive training. ANHMRC classifies case series, posttest, and pre–posttest as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table I. Interventions That Aim to Improve Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 Note. ANHMRC = Australian National Health and Medical Research Council; EF = executive function; DB checklist = Downs and Black checklist; FTF = face-to-face—unable to determined or not reported..; SCT = Specific cognitive training. ANHMRC classifies case series, posttest, and pre–posttest as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table II. Interventions That Aim to Improve Hot EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + Note. — Unable to determined or not reported; ACT = acceptance and commitment therapy; ANHMRC: Australian National Health and Medical Research Council; CAPS = counselor-assisted problem-solving; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist; EFs = executive functions; FPS = family problem-solving intervention; FTF = face-to-face; PBS = positive behavior supports; R = regulation; RCT = randomized control trial; signposts = signposts for building better behavior; SSTP = stepping stones triple P. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; SSTP = stepping stones triple P; TOPS = Teen online problem-solving; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table II. Interventions That Aim to Improve Hot EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + Note. — Unable to determined or not reported; ACT = acceptance and commitment therapy; ANHMRC: Australian National Health and Medical Research Council; CAPS = counselor-assisted problem-solving; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist; EFs = executive functions; FPS = family problem-solving intervention; FTF = face-to-face; PBS = positive behavior supports; R = regulation; RCT = randomized control trial; signposts = signposts for building better behavior; SSTP = stepping stones triple P. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; SSTP = stepping stones triple P; TOPS = Teen online problem-solving; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table III. Interventions That Aim to Improve Hot and Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 Note. —unable to determined or not reported; ANHMRC = Australian National Health and Medical Research Council; BrainSTARS = Brain Injury: strategies for teams and reeducation for students; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist EFs = executive functions; FTF = face-to-face; QOL = quality of life; R = regulation; RCT = randomized control trial; SCT = specific cognitive training. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table III. Interventions That Aim to Improve Hot and Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 Note. —unable to determined or not reported; ANHMRC = Australian National Health and Medical Research Council; BrainSTARS = Brain Injury: strategies for teams and reeducation for students; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist EFs = executive functions; FTF = face-to-face; QOL = quality of life; R = regulation; RCT = randomized control trial; SCT = specific cognitive training. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Results Level of Evidence and Quality of the Studies As can be seen on Tables I, II, and III, most of the evidence in the studies corresponded to a Level III-1, which is a randomized controlled trial (RCT) design without blinding arrangements (11 studies). Using nonrandomized methods or pseudo-randomized methods to assign participants to groups was common (five studies). Lack of a control group was a characteristic of the studies with a level of evidence IV (seven studies), while using a blind RCT resulted in a level of evidence II (three studies). On average, included studies met 72.3% of the DB checklist criteria for study quality. Most studies reported aims, outcomes measured, characteristics of the participants, primary results, and interventions. Adverse events or absence of adverse events and information regarding participants lost to follow-up were often not reported. On average, studies were 62.8% adherent to external validity criteria, 63.7% adherent to internal validity criteria, and 51.2% adherent to confounder criteria. Lower severity of injury, residing far from the hospital and non-White race were some of the characteristics of the nonparticipants. Eight studies in this systematic review allocated the control groups to waitlists, while only three studies allocated the control group to other types of treatment. Power analysis was conducted in 50% of the studies reviewed. Total 65.3% of the studies were conducted in English-speaking countries, and interventions were delivered in English. The search included papers in Spanish, but there were no studies published in Spanish or conducted with Hispanic participants. Furthermore, English not being the primary language was the main reason for participant exclusion in some studies. Participants Online Supplementary Table S4 illustrates participants' characteristics. Total 61.5% of the studies only included participants with TBI and were predominantly male in 57.6% of the studies. The majority of the studies included adolescents, while studies with children <12 years of age were scarce. Most studies did not have a determined period after injury as an inclusion criterion, and when reported, a wide range (3–24 months) was evident. Interventions for Cold EFs Cold EFs refer to skills within the cognitive domain. Cold EFs investigated by the studies reviewed included: attention, metacognition, problem-solving, and working memory. All of the interventions applied in these studies used a specific cognitive training approach (Table I). Interventions for Hot EFs Hot EFs refer to skills within the socioemotional domain. Hot EFs investigated by the studies in this systematic review included: behavior, emotion regulation, and social abilities. Additionally, these studies addressed family factors. Providing education about ABI and teaching parents PBS were the types of interventions used to improve hot EFs (Table II). Interventions for Both Hot and Cold EFs Table III describes the interventions in which the primary objective was to improve overall EFs. The types of interventions applied by these studies were ABI education, interactive video gaming, cognitive behavior therapy, and specific cognitive training. Outcomes Tables I, II, and III present the main outcomes of the studies indicating the functions that improved (+) and did not change (0) significantly according to the authors of the study. The most studied domains were attention and behavior regulation. Cold EF Outcomes Interventions that were effective in improving attention were short (6–17 weeks), intensive (1–2 weekly sessions along with homework), delivered as face-to-face sessions in a clinic, and were based on a cognitive model. Still, there was no clear difference between effective and noneffective interventions. Three studies measured working memory and reported improvement in at least one outcome. These interventions were short (length 5–12 weeks) and intensive (1–3 weekly sessions). Studies that aimed to improve metacognition were effective, those interventions were intensive (biweekly), delivered as face to face group sessions, and had strong theoretical support. There were two studies addressing problem-solving, only one of which was effective. The effective intervention was delivered using face-to-face group sessions and was based on a problem-solving model. One study found improvements in inhibition and no study reported improvements in planning. Two studies measured changes in cognitive flexibility and one of them found improvements. The effective intervention was delivered during a longer period of time (10 weeks) compared with the noneffective intervention (5 weeks). The duration of interventions that improved cold EFs ranged between 5 weeks and 6 months. Hot EF Outcomes Six studies measured functional domains related to social abilities and reported a few improvements. The domains reported were diverse. The interventions that improved behavior and emotion regulation provided parents with education about ABI and taught them PBS. Interventions that were effective in improving hot EFs lasted between 10 weeks and 8 months. Hot and Cold EF Outcomes The characteristics of the interventions that aimed to improve overall EFs were heterogeneous, and improvements were rarely seen, compared with interventions that targeted specific cold or hot EFs. Family Factor Outcomes The studies that taught parents PBS were effective in improving parenting practices. Improvements in parental distress were not presented in most of the studies. Family functioning presented mixed results. All the studies that targeted metacognition, working memory, and parenting practices found at least some improvement. Some improvement in emotional regulation, family functioning, behavior regulation, and attention were present in half or more of the studies targeting those outcomes. Effective results were limited in the studies that measure overall EFs, social abilities, parental stress, and planning. Discussion To our knowledge, this is the first systematic review that focuses on interventions aiming to improve hot and cold EFs of children and adolescents with ABI. Interventions from 26 studies were reviewed. The use of hot and cold EFs has several implications for knowledge in the field of rehabilitation of children with ABI. Owing to this framework, we were able to differentiate approaches used in rehabilitation. Improvement was defined as p ≤ .05 reported by the authors. Studies that targeted metacognition, working memory, and parenting practices found some improvement. Most interventions targeting emotional regulation (75%), behavior regulation (69.2%), and parenting practices (75%) found improvements by involving caregivers and teaching them PBS. Studies measuring overall EFs found less effective results (33.3%) than when treating specific EFs, such as attention (55.5%), inhibition (50%), social abilities (42.8%), cognitive flexibility (50%), and problem-solving (50%). Interventions aiming to reduce parental stress had limited improvements (25%). No studies measuring planning found improvements. Level of Evidence and Quality of the Studies The evidence that we have about the rehabilitation of hot and cold EFs is limited. However, the information provided in the studies was sufficient to assess the findings. In summary, the level of evidence and quality of the studies is still limited. Based on the results from the DB checklist, overall the percentage of adherence was 72.3% in reporting, 62.8% in external validity, 63.7% in internal validity, and 51.2% in confounders. Power analysis was reported in 50% of the studies. Control groups were generally allocated to waitlists, which has been associated with overestimation of the intervention effect (Patterson, Boyle, Kivlenieks, & Van Ameringen, 2016). Participants There was a predominance of male participants with TBI reported in the studies. This can be explained because of the high prevalence of child TBI in comparison with other types of ABI and there being more male participants in this clinical group (Thurman, 2016). Total 61.5% of the studies reported in this systematic review focused in studying participants with TBI. The absence of studies with young children is surprising considering that ABI is the leading cause of injury in children <5 years of age (Thurman, 2016). Taking into account that cognitive sequelae of brain injury in children become more evident over time (Anderson, Spencer-Smith, & Wood, 2011), it is expected that family and school staff’s concerns about children’s cognitive or behavioral deficits may become apparent when the requirements of the environment increase and when certain skills should come online. Participants included in the reviewed studies had a variety of injury and lesion types, making comparability across participants difficult. Each type of lesion has its own criteria to determine severity, and levels of severity are not comparable across lesions. The criteria used by Woods et al. (2014) to determine the level of severity, by combining neurological deficits and imaging results, seems like a useful alternative for ABI populations. A determined time after injury onset as an inclusion criterion is often missing. Spontaneous recovery of cognitive functions occurs up to ≥8 months after the onset of severe injuries (Chávez et al., 2016; Leon-Carrilo & Machuca-Murga, 2001) and therefore, spontaneous recovery can enhance the effectiveness of interventions, highlighting the importance of inclusion of control groups in trial designs for ABI. The studies included in this review describe injury-related variables; however, description of noninjury variables is often lacking. As EF development is influenced by the environment (Jansen et al., 2012; Meldrum, Verhoeven, Junger, van Aken, & Dekovic, 2016), noninjury variables should also be addressed (Catroppa et al., 2017). Cold EFs Cold EFs refer to skills within the cognitive domain. Attention is the most studied cold EF with 35% of the studies in this review focusing on this skill. In the studies reviewed, attention was usually deconstructed into the levels of attention reported by Sohlberg and Mateer (1987) and most commonly measured with the Test of Everyday Attention for Children (Manly et al., 2016). From the studies that measure attention 55.5% of them found some improvement. Interventions that aim to improve attention and working memory tend to combined weekly individual sessions with homework, while metacognition and problem-solving can be enhanced by face-to-face group sessions. Still, results show that there is no consensus on how cold EFs should be deconstructed and measured. Maintenance of improvements in cold EFs was often not assessed. Only two studies found maintenance of some improvement in attention at 6 months (van’t Hooft, et al., 2007) and 1.63 years (Kaldoja et al., 2015) after the intervention was completed. Interventions that aim to improve attention were greatly influenced by the attention treatment model of Sohlberg and Mateer (1987). This model has a specific process approach and considers five levels of attention: focused, sustained, selective, alternating, and divided. Tasks for each level of attention are applied based on its difficulty, going from basic to more complex tasks (Sohlberg & Mateer, 1987). The specific training approach was used by interventions that aim to improve Cold EFs. The theoretical support of the interventions that aim to improve metacognition included concepts from Clements and Natasi (1990), Ylvisaker and Feeney (2002), and Cole (2006). Based on those ideas, the interventions attempted to create real-life context, by teaching metacognitive skills and provide participants with the space to use them in the company of peers. To date, there is no precise pathway leading to the improvement of cold EFs. Nonetheless, effective treatments tend to focus on only one or two cold EFs, are short, intensive, and based on a cognitive model. This review adds to previous evidence (Bewick, Raymond, Malia, & Bennet, 1995), which supports the combination of specific cognitive training and metacognitive strategies to rehabilitate cold EFs. Theoretically, repetition in cognitive training activities appears to activate neural networks and seems to readjust the maladaptive networks presented after ABI onset (Galetto & Sacco, 2017). Enhancing metacognition within a context similar to real-life in combination with other cold EFs could be the key element to generalize cold EFs gains to new scenarios. Hot EFs Hot EFs refer to skills within the socioemotional domain. Challenging behavior is the most problematic consequence of brain injury according to family, teachers, and friends (Feeney, 2010). The impact that challenging behavior has on parents may explain why behavior regulation was targeted by 50% of the studies. The Child Behavior Checklist (Achenbach & Resco, 2001) was the questionnaire most often used to measure behavior regulation. Improvements were seen in 69.2% of the studies that targeted behavior regulation and can be achieved by providing parents with education about ABI and teaching them PBS. Maintenance of improvements in behavior regulation was reported at 6 months (Brown et al. 2014) and at 18 months (Woods, Catroppa, Godfrey, & Anderson 2014). By comparing the interventions, we can see that recovery of hot EFs seems to require more time in comparison to cold EFs. There is no agreement on how to deconstruct or measure social skills as a cognitive process; therefore, comparison among studies is not possible. The model from Beauchamp and Anderson (2010) describes the cognitive processes involve in social skills development, which can support the development of assessments tools and interventions for social skills. The concepts from Ylvisaker and Feeney (2009) strongly influenced the rehabilitation of hot EFs in children with ABI. They propose that the adults involve in the daily routines of the child should participate in the intervention (Ylvisaker & Feeney, 2009). The studies in this review taught parents PBS, which aim to improve behavior by applying educational methods to broaden behavior repertoire and redesign the context (Carr et al., 2002). Contexts impact EFs development (Zelazo, Qu, & Kesek, 2010) and children with ABI are especially vulnerable to adverse environments (Taylor et al., 2002). Their deficits on EFs can be exacerbated when they are surrounded by unfavorable family circumstances (Taylor et al., 2002). As a consequence, studies that aim to improve hot EFs involved parents, or the entire family, and measure family factors. Family Factors Results show that parenting practices can improve by teaching parents PBS. However, maintenance of improvements in parenting practices was reported only in one study (Brown et al. 2014). Studies included in this systematic review attempted to reduce parental stress by using mindfulness, acceptance commitment therapy, and stress management techniques with limited results that were not maintained over time (Woods, Catroppa, Godfrey, & Anderson 2014). Finally, the problem-solving model of D’Zurilla and Nezu (1999) was often used as part of the treatment to improve family functioning, and 60% of those studies found some improvement. Woods et al. (2014) and Kurowski et al., (2013) show that families' needs vary depending on the child’s cognitive impairment, age and severity of the injury. To date, we know that participants who present more impairment benefit the most (Chavez-Arana, 2018; Woods et al., 2014;). However, we cannot draw conclusions on how interventions can be adapted according to the child’s cognitive needs or age. Nonetheless, the single-case study methodology can add in this respect (Perdices & Tate, 2009). This review allowed us to acquire knowledge about the active ingredients in the rehabilitation of hot (PBS-parents) and cold (intensity) EFs. Still, we do not know if improvements found in the studies are transferable to other settings or maintained over time. Furthermore, we need consider that real-life contexts may be more challenging for the child because they require hot and cold EFs to work together toward adaptive function (Zelazo & Carlson, 2012). In addition, impairments in either hot or cold EFs can have secondary consequences to other aspects of EF (Blair & Diamond, 2008). Therefore, balance between cognition and emotion is required for self-regulation development (Blair & Diamond, 2008). Some of the interventions described are adaptations of interventions previously used in other populations, such as children with neurodevelopmental disorders or adults with ABI. For this reason, we suggest that adapting interventions from different populations can be beneficial for children and adolescents with ABI. Complete descriptions of the treatments and their theoretical base are often missing. The absence of complete descriptions limits the development of new interventions and replication studies, and therefore, hinders research in child neuropsychological rehabilitation. Future Directions Future studies are encouraged to use a stronger methodology to develop a stronger evidence base for the interventions. Outcomes reported by participants who are aware of their treatment allocation may differ from unaware participants (Hróbjartsson & Gøtzsche, 2001). We suggest that allocating control groups to another treatment can provide stronger evidence and control the effect caused by being treated by a health professional. Future studies are invited to study preschool children with ABI. Early brain injury has been associated with poor EFs in later stages of life (Anderson et al., 2011), which may be prevented or ameliorated by providing early interventions. Young children may benefit from interventions such as coordinative exercise, preventive educational–behavioral, and school-based programs, which have shown to be beneficial for healthy young children and young children requiring intensive care hospitalization (Chang, Tsai, Chen, & Hung, 2013; Diamond, Barnett, Thomas, & Munro, 2007; Melnyk, et al., 2004). Description of the reasons for attrition could assist in determining the generalizability of the results. We encourage future studies to include noninjury variables (e.g., parent mental health), evaluate whether improvements transfer to other settings, specify time since injury as an inclusion criterion, describe methods for determining injury severity, and outline the theoretical basis of the intervention. Adaptations of interventions that have been effective in improving EFs in different populations could benefit children and adolescents with ABI. Studies with participants with mild injury severity, participants who reside far from the hospital and non-Caucasian participants are required. These populations were underrepresented in existing research. In particular, there are no studies with the Hispanic population. Future studies could examine the feasibility and effectiveness of interventions in Spanish-speaking countries. Limitations The present study has several limitations. The way in which EFs are deconstructed and measured varied among studies; therefore, conclusions were drawn based on the qualitative synthesis of the studies. In addition, the keywords used in the search did not specify the variety of brain injuries. As a consequence, relevant studies may have been overlooked and not reported in this review. Another limitation of the study is that it was not possible to analyze the association between injury factors (severity, type, location), participant factors (age, preinjury deficits), and the effectiveness of the intervention. Owing to the absence of studies focusing on young children, conclusions in this systematic review may not apply to them. Another limitation is that we divided EFs into hot and cold based on the description from De Luca & Leventer (2008). However, hot or cold EFs are elicited depending on the context and they work together (Hongwanishkul, Happaney, Lee, & Zelazo, 2005). Most studies did not evaluate whether improvements are maintained over time; therefore, we know little about long-term outcomes. Clinical Recommendations Clinical recommendations resulting from this review should be considered with caution because of the limited quality of evidence included in this research synthesis. Further research is necessary to increase confidence in the generalizations that can be drawn from this body of research. We recommend that interventions provide ABI education to those close to or working with the child to maximize their understanding of the cognitive and behavioral consequences of ABI and how they may arise in everyday activities. For rehabilitation of hot EFs, we recommend active participation of parents by teaching them PBS to reduce or prevent behavior problems and improve parenting skills. For rehabilitation of Cold EFs, we endorse intensive rehabilitation, high frequency of sessions in combination with homework. 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A Systematic Review of Interventions for Hot and Cold Executive Functions in Children and Adolescents With Acquired Brain Injury

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© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Abstract

Abstract Objective We investigated interventions, which aimed to improve cold and hot executive functions (EFs) in children and adolescents with a diagnosis of acquired brain injury (ABI). Methods The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between 1990 and July 2017 in English or Spanish, including children and adolescents. Articles were read and classified according to the levels of evidence of the Australian National Health and Medical Research Council and the Downs and Black checklist was used for Measuring Study Quality. Results Thirty studies are reported in this systematic review. Level of evidence, quality of the studies, characteristics of the participants, interventions implemented, and outcomes are described. Conclusions The study of rehabilitation for executive dysfunction in children with ABI is emerging. Although few high-quality intervention studies exist in this area, which limits conclusions regarding intervention efficacy, results of existing studies suggest that education for parents may be an important component of intervention. Moreover, caregiver involvement may improve the effectiveness of hot EFs rehabilitation interventions, while high intervention session frequency may be important in improving cold EFs. Positive behavior supports and specific training based on a cognitive model provided some promising findings, which require further evaluation. acquired brain injury, adolescents, children, executive functions, intervention, rehabilitation and systematic review Acquired brain injury (ABI) is a term that encompasses damage to the brain that occurs after birth Australian Institute of Health and Welfare (2007). ABIs have diverse causes including traumatic brain injury (TBI), cerebral vascular diseases, infections, brain tumors, vestibular dysfunction, and postsurgical complications (Ciuffreda & Kapoor, 2012). Children and adolescents with ABI usually present with deficits in several cognitive domains such as attention, processing speed, memory, language, and social problem-solving skills. In particular, executive functions (EFs) deficits are common and emerge with time postinjury as the child matures (Galvin, Lim, Steer, Edwards, & Lee, 2010; Kok et al., 2014). EFs refer to a group of cognitive skills required for purposeful goal-directed activity and can be divided into cold and hot domains (De Luca & Leventer (2008). Cold EF refers to purely cognitive EF, while hot EF refers to the affective aspects of these cognitive skills (Kerr & Zelazo, 2004). Cold EFs are more likely to be elicited by decontextualized problems such as manipulation of abstract concepts, numbers, or letters (Brock, Rimm-Kaufman, Nathanson, & Grimm, 2009; Hongwanishkul, Happaney, Lee, & Zelazo, 2005). Hot EFs refer to the socioemotional domain and are more likely to be evoked by motivationally and emotionally meaningful contexts (Brock et al., 2009; Hongwanishkul et al., 2005). The line between hot and cold EFs is blurred because both work together toward adaptive functions (Zelazo & Carlson, 2012). However, the degree to which tasks elicit hot or cold EFs differentiates tasks that aim to improve them (Hongwanishkul et al., 2005). Based on the description of De Luca and Leventer (2008), we considered behavior regulation, emotion regulation, affective decision making, social skills, and theory of mind hot EFs. Metacognition, cognitive flexibility, attention, inhibition, working memory planning, and problem-solving were considered cold EFs (De Luca & Leventer, 2008). The description of hot and cold EFs done by De Luca and Leventer (2008) was chosen because it includes social skills, which are usually impaired in children and adolescents with ABI (Beauchamp & Anderson 2010; Ryan et al., 2016). EFs are required in children’s daily activities. Children with deficits in cold EFs tend to forget instructions, misplace school supplies, have difficulties in concentrating during homework, make careless mistakes, and try a solution repeatedly even if it is not useful (Castellanos, Sonuga-Barke, Milham, & Tannock, 2006; Gioia, Kenworthy, & Isquith, 2010). Children with impairments in hot EFs are more likely to interrupt conversations, make risky decisions, present anger outbursts, and misinterpret others (Castellanos et al., 2006; Gioia et al., 2010; Zelazo & Carlson, 2012). Impairments in hot and cold EFs negatively impact children’s self-esteem, family functioning, social adaptation, and academic achievement (Brock et al., 2009; Yeates et al., 2004). The rehabilitation of specific cognitive processes is a path often used to improve a child’s EFs. This approach has strong support from cognitive models (Sohlberg & Mateer, 1987), which breakup cognitive processes into subcomponents or levels. The involvement of caregivers is a common practice in child rehabilitation. An example of this method is providing caregivers education about the ABI and associated behaviors to increase their knowledge and reduce stress (Bauml, Frobose, Kraemer, Rentrop, & Pitschel-Walz, 2006). Another example is acceptance and commitment therapy, which emphasizes acceptance rather than behavior change or elimination only (Morris, Johns, & Oliver, 2013). One more way to involve caregivers is by teaching them positive behavior supports (PBS) to improve their child’s behavior (Carr et al., 2002). Three main ideas support the inclusion of caregivers in a child's rehabilitation: (1) caregivers are aware of the behavioral changes presented after injury onset; (2) they are likely to be a stable resource throughout child’s life, and (3) EFs development can be affected by family factors (Catroppa et al., 2017; Lefley, 2009). Over recent years, systematic reviews of intervention programs in children and adolescents with ABI have been published, investigating technological interventions (de Kloet, Berger, Verhoeven, van Stein Callenfels, & Vlieland, 2012; Linden et al., 2016) and combining interventions for children with neurodevelopmental disorders and children with diagnosis of ABI (Robinson, Kaizar, Catroppa, Godfrey, & Yeates, 2014). To date, these interventions have failed to consider differences in hot and cold EF rehabilitation despite substantial evidence supporting the distinction between hot and cold EFs (Hongwanishkul et al., 2005; Rubia, 2011; Zelazo & Carlson, 2012). Research has typically studied EFs as a single domain and focused almost exclusively on cold EFs (Hongwanishkul et al., 2005; Zelazo & Carlson, 2012). The systematic study of interventions with an explicit deconstruction of EF into hot and cold is novel for a review and has the potential to advance knowledge in the field of rehabilitation of children with ABI. To our knowledge, this systematic review is the first in studying interventions that aimed to improve EFs distinguishing between its cold and hot components. We aimed to assess the quality of those studies and identify any interventions specific to hot and cold EF. Methods Selection of the Studies The systematic review was conducted following the PRISMA Statement (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2010). The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between January 1990 and July 2017 in English or Spanish, and included children and adolescents (age 0–18 years). The Medical Subject Headings (MeSH) or keywords were grouped as population, intervention and outcome. Online Supplementary Table S1 describes the keywords used for the search, and Online Supplementary Table S7 contains the PRISMA checklist. Requirements for Inclusion Abstracts were reviewed independently by two authors to determine eligibility for inclusion. Inclusion criteria were: (1) children and adolescents with ABI or families of children or adolescents with ABI; (2) participants of age 0–18 years. For papers that included children, adolescents, and adults, the majority of the participants had to be <18 years old for the study to be included; (3) at least two measurement points, before and after intervention; (4) any intervention or combination of interventions to improve EF and/or social skills and/or reduce disinhibited behavior; (5) the components of the intervention were described. Exclusion criteria were: (1) Review articles; (2) Participants with neurodevelopmental disorders, drug users, abusive head trauma, or diagnosis other than ABI; (3) Predominance of participants >18 years old; (4) Outcome other than EF, social skills, or behavior problems; and (5) Case studies. Abstracts were categorized as eligible, likely eligible, or ineligible. Reviewers agreed on 90% of the abstracts. For those where consensus was not initially achieved, full papers underwent review by two reviewers using a standard data collection form and then a decision was made. This electronic search generated 771 papers. Additionally, seven papers were identified from reference lists. A total of 554 papers were screened from which 30 papers met the inclusion criteria. From those 30 papers, 4 papers reported long-term outcomes of a previous study. In these cases, the original paper and the follow-up paper were treated as one with their previous results. Three papers (Kurowski et al., 2013; Tlustos et al., 2016; Wade, Stacin et al., 2014) reported different outcomes from the same study. Those papers were treated independently. We report 26 studies based on 30 papers. Figure 1 illustrates the selection process and results of the search. Figure 1. View largeDownload slide PRISMA flow diagram. Figure 1. View largeDownload slide PRISMA flow diagram. Classification of the Studies and Quality Grading All articles were read and classified by two reviewers according to the levels of evidence of the Australian National Health and Medical Research Council (ANHMRC; see Online Supplementary Table S2). After classifying the articles, quality was assessed by two authors using the Downs and Black checklist for Measuring Study Quality (DB; Downs & Black, 1998). The DB checklist consists of 27 items that assess the quality of reporting (10 items), external validity (3 items), internal validity (7 items), confounders (6 items), and power effect (1 item) (Downs & Black, 1998; see Online Supplementary Table S3). Effect sizes were not always reported in studies. Therefore, based on a previous systematic review (Knight, Scheinberg, and Harvey, 2013), we assigned a score of 1 to studies that reported effect sizes and 0 to studies that did not. A full description of the levels of Levels of evidence of the ANHMRC and DB checklist can be found in the Online Supplementary Tables S2 and S3. Data Synthesis The data were extracted from each study and entered into a code sheet, so relevant information could be processed by two reviewers (C.C. and E.C.). Description of the level of evidence and quality of the studies can be seen in the Online Supplementary Tables S2 and S3. A value indicating adherence to the 27 DB checklist criteria (yes/no at the item level, expressed as an aggregate adherence percentage) was calculated for each study. Participants’ characteristics are described in Table III. Studies were classified according to their main objective into interventions that aim to improve cold EFs (Table I), hot EFs (Table II), or both (Table III). Report of the effect sizes was often lacking and measures used were heterogeneous. For this reason, we followed the approach of a previous systematic review (Stinson, Wilson, Navreet, Yamada, & Holt, 2008) and reported the authors' main conclusions. Improvement was defined as p ≤ .05 reported by the authors. Authors divided cognitive processes into subcomponents to assess the treatment effectiveness. Online Supplementary Table S5 shows the measures used to assess cognitive processes and a list with the subtests used from each measure. The subcomponents reported by cognitive process and measures used varied among studies. Owing to the data heterogeneity, it was not possible to perform a meta-analysis. However, we reported the percentage of the studies targeting each cognitive process that found improvement in at least one measure (see Online Supplementary Table S6). Table I. Interventions That Aim to Improve Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 Note. ANHMRC = Australian National Health and Medical Research Council; EF = executive function; DB checklist = Downs and Black checklist; FTF = face-to-face—unable to determined or not reported..; SCT = Specific cognitive training. ANHMRC classifies case series, posttest, and pre–posttest as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table I. Interventions That Aim to Improve Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Braga (2012) III-1 17 Metacognitive dimension program Metacognition and self-esteem SCT Group and individual, FTF 3 months (26) Twice a week (2 hr) Trained psychology students Metacognition + Self-esteem + Chan (2011) III-1 16 Problem-solving skills training program Problem-solving and metacognition SCT Group, FTF 7 weeks (14) Twice a week (3 hr) 0% Metacognition + Problem-solving + Eve (2016) IV 14 Cogmed Working memory SCT Individual, online 5–7 weeks (25) Weekly (30–40 min) Cogmed certified coach 22% Central executive and visuospatial sketchpad 0 Phonological loop + Galbiati (2009) III-2 16 Attention remediation training program Attention SCT Individual, FTF 6 months (104) Four times a week (45 min) 0% Attention + Kaldoja (2015) III-2 13 FORAMENRehab Attention SCT Individual, online 6 weeks (10) Twice a week (30–50 min) 0% Focused visual 0 Focus auditory 0 Sustained +* Complex — Tracking 0 Séguin (2017) II 21 Ready! Set? Let’s Train! Attention and metacognition SCT Individual, FTF 5 weeks (15) Three times a week (1 hr) Trained psychology students 10.5% Attention 0 Metacognition – Flexibility, working memory and inhibition + Sjö (2010) IV 10 Amat-C Attention and memory SCT Individual, FTF 6–9 months (100) Every weekday (30–45 min) Supervised trainer and teacher Attention — Memory — Thomas-Stonell (1994) III-1 13 TEACH-ware Attention, memory, and problem-solving SCT Individual, computer-based 8 weeks (—) Two times a week (1 hr) Language therapist 0% Attention 0 Memory + Problem-solving 0 van’t Hooft (2005), (2007) III-1 18 Amat-C Attention and memory SCT Children and coaches, FTF and home/school practice 17 weeks (17 and practice at home/school) Weekly sessions (—); Daily work (30 min) 10% Sustained attention + Selective attention +* Memory +/0 Note. ANHMRC = Australian National Health and Medical Research Council; EF = executive function; DB checklist = Downs and Black checklist; FTF = face-to-face—unable to determined or not reported..; SCT = Specific cognitive training. ANHMRC classifies case series, posttest, and pre–posttest as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table II. Interventions That Aim to Improve Hot EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + Note. — Unable to determined or not reported; ACT = acceptance and commitment therapy; ANHMRC: Australian National Health and Medical Research Council; CAPS = counselor-assisted problem-solving; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist; EFs = executive functions; FPS = family problem-solving intervention; FTF = face-to-face; PBS = positive behavior supports; R = regulation; RCT = randomized control trial; signposts = signposts for building better behavior; SSTP = stepping stones triple P. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; SSTP = stepping stones triple P; TOPS = Teen online problem-solving; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table II. Interventions That Aim to Improve Hot EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Brown (2014) II 22 SSTP combined with ACT Child behavior and emotion, parent’s psychological flexibility and experiential avoidance PBS and ACT Group and individual, FTF combined with telephone 10 weeks (8 group sessions, 3 phone calls) — (FTF 2 hr; phone calls 1.5 hr) Clinical psychologists certified in SSTP Post 16.66%; Follow-up 20%; Total: 36.66% Behavior R +* Emotion R + Parenting +* Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week (45–60 min) Therapist — Social abilities + Behavior R + Emotion R + Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week (at least 1 hr) Clinical psychologists 6% Social abilities +/0 Wade (2005) IV 18 FPS Cognition, coping, and family communication CBT Family, online — (8 core and 4 optional) — (videoconference 45–60 min; —) Research assistant and therapist 0% Social abilities 0 Emotion R 0 EFs 0 Family functioning 0 Wade (2006) III-1 21 FPS Behavior and social competence CBT Family, online — (8 core and 6 optional) Every 1 or 2 weeks (—) Psychologist and trained psych graduate 20% Social abilities 0 Behavior R 0/+ Wade (2006) III-1 20 FPS Problem-solving skills CBT Family, online 6 months (7 core and 4 optional) Every 1 or 2 weeks (75–100 min) Trained psych graduate 15.78% Behavior R + Parental stress 0 Wade (2008) III-1 20 TOPS EFs, language pragmatics, and social processing CBT and metacognitive training Family, online — (10 core and 4 optional) Every 1 or 2 weeks (—) Psych graduate 0% Behavior R 0 Emotion R + Parental stress 0 Family functioning + Wade (2011) III-1 18 TOPS Behavior and parent–teen conflicts CBT and metacognitive training Family, online 6 months (10 core, 4 optional) — — 20% Behavior R 0 Family conflict — Wade (2014, 2015) III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, 4 supplemental, 6 videoconference) — Trained psychologists Post: 12.30%; 18 months after baseline: 30.8% Behavior R and inhibition in older adolescents +, in younger adolescents 0. Wiseman-Hakes (1998) IV 11 Improving pragmatic skills Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social worker — Social sufficiency 0 Woods, Catroppa, Godfrey, & Anderson (2014) IV 14 Signpost Child behavior and parenting practices PBS and CBT Individual, telephone, combined with home practice 5 months (7 core and 2 supplemental) — Signpost certified psychologist — Behavior R +/0 Parenting + Parental stress 0 Woods, Catroppa, Godfrey, Anderson (2014) III-2 17 Signpost Child behavior, parenting practices, and family adaptation PBS and CBT Group, FTF or individual via telephone, combined with home practice 5 months (3 FTF or 8 phone calls) FTF sessions every 6 weeks (3 hr); telephone support biweekly (15–20 min) Signpost certified psychologist 0% Behavior R and parental stress children at risk +, children not at risk 0 Parenting + Note. — Unable to determined or not reported; ACT = acceptance and commitment therapy; ANHMRC: Australian National Health and Medical Research Council; CAPS = counselor-assisted problem-solving; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist; EFs = executive functions; FPS = family problem-solving intervention; FTF = face-to-face; PBS = positive behavior supports; R = regulation; RCT = randomized control trial; signposts = signposts for building better behavior; SSTP = stepping stones triple P. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; SSTP = stepping stones triple P; TOPS = Teen online problem-solving; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table III. Interventions That Aim to Improve Hot and Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 Note. —unable to determined or not reported; ANHMRC = Australian National Health and Medical Research Council; BrainSTARS = Brain Injury: strategies for teams and reeducation for students; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist EFs = executive functions; FTF = face-to-face; QOL = quality of life; R = regulation; RCT = randomized control trial; SCT = specific cognitive training. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Table III. Interventions That Aim to Improve Hot and Cold EFs First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 First author (year) Level of evidence ANHMRC DB checklist total score Name of intervention Target of the intervention Type of intervention Delivery mode Duration (# of sessions) Frequency (duration of each session) Providers skills Attrition Outcome Dise-Lewis (2009) IV 13 BrainSTARS Cognitive development Psycho-education Group, FTF and self-guided 4 months (3) Every 6 or 8 weeks (—) — — Behavior R 0 EFs 0 De Kloet (2012) IV 17 Therapy Wii Cognitive, social, physical activity and QOL Interactive video gaming Individual 12 weeks (2 FTF and practice at home) — (sessions 1 hr, home practice 2 hr a week) Occupational therapist, physical therapist and trained teachers 10% Attention +/0 Working memory + Social abilities +/0 Kurowski (2013), (2014) II 26 CAPS Problem solving, communication and self-regulation CBT Family, Online 6 months (7 core and 4 optional) Every 1 or 2 weeks (—) Psychologist 6-months: 5.97%; 18-months: 70.14% EFs in older teens +* EFs in younger teens 0 Treble-Barna (2015) III-2 16 AIM Attention and EFs SCT Individual, FTF combined with home online practice 10 weeks (10) Weekly sessions (60–90 min); homework two to four times per week (20–40 min) Trained psychologists 41% Inhibition 0 Flexibility 0 Planning 0 Behavior R +/0/0 Wade (2010) III-1 21 TOPS EFs CBT and metacognitive training Family, online — (10 core and 4 optional) — Psychologist and trained psych graduates 20% EFs severe TBI + EFs moderate TBI 0 EFS reported by parents 0 Note. —unable to determined or not reported; ANHMRC = Australian National Health and Medical Research Council; BrainSTARS = Brain Injury: strategies for teams and reeducation for students; CBT = cognitive behavior therapy; DB checklist = Downs and Black checklist EFs = executive functions; FTF = face-to-face; QOL = quality of life; R = regulation; RCT = randomized control trial; SCT = specific cognitive training. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; + Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process. Results Level of Evidence and Quality of the Studies As can be seen on Tables I, II, and III, most of the evidence in the studies corresponded to a Level III-1, which is a randomized controlled trial (RCT) design without blinding arrangements (11 studies). Using nonrandomized methods or pseudo-randomized methods to assign participants to groups was common (five studies). Lack of a control group was a characteristic of the studies with a level of evidence IV (seven studies), while using a blind RCT resulted in a level of evidence II (three studies). On average, included studies met 72.3% of the DB checklist criteria for study quality. Most studies reported aims, outcomes measured, characteristics of the participants, primary results, and interventions. Adverse events or absence of adverse events and information regarding participants lost to follow-up were often not reported. On average, studies were 62.8% adherent to external validity criteria, 63.7% adherent to internal validity criteria, and 51.2% adherent to confounder criteria. Lower severity of injury, residing far from the hospital and non-White race were some of the characteristics of the nonparticipants. Eight studies in this systematic review allocated the control groups to waitlists, while only three studies allocated the control group to other types of treatment. Power analysis was conducted in 50% of the studies reviewed. Total 65.3% of the studies were conducted in English-speaking countries, and interventions were delivered in English. The search included papers in Spanish, but there were no studies published in Spanish or conducted with Hispanic participants. Furthermore, English not being the primary language was the main reason for participant exclusion in some studies. Participants Online Supplementary Table S4 illustrates participants' characteristics. Total 61.5% of the studies only included participants with TBI and were predominantly male in 57.6% of the studies. The majority of the studies included adolescents, while studies with children <12 years of age were scarce. Most studies did not have a determined period after injury as an inclusion criterion, and when reported, a wide range (3–24 months) was evident. Interventions for Cold EFs Cold EFs refer to skills within the cognitive domain. Cold EFs investigated by the studies reviewed included: attention, metacognition, problem-solving, and working memory. All of the interventions applied in these studies used a specific cognitive training approach (Table I). Interventions for Hot EFs Hot EFs refer to skills within the socioemotional domain. Hot EFs investigated by the studies in this systematic review included: behavior, emotion regulation, and social abilities. Additionally, these studies addressed family factors. Providing education about ABI and teaching parents PBS were the types of interventions used to improve hot EFs (Table II). Interventions for Both Hot and Cold EFs Table III describes the interventions in which the primary objective was to improve overall EFs. The types of interventions applied by these studies were ABI education, interactive video gaming, cognitive behavior therapy, and specific cognitive training. Outcomes Tables I, II, and III present the main outcomes of the studies indicating the functions that improved (+) and did not change (0) significantly according to the authors of the study. The most studied domains were attention and behavior regulation. Cold EF Outcomes Interventions that were effective in improving attention were short (6–17 weeks), intensive (1–2 weekly sessions along with homework), delivered as face-to-face sessions in a clinic, and were based on a cognitive model. Still, there was no clear difference between effective and noneffective interventions. Three studies measured working memory and reported improvement in at least one outcome. These interventions were short (length 5–12 weeks) and intensive (1–3 weekly sessions). Studies that aimed to improve metacognition were effective, those interventions were intensive (biweekly), delivered as face to face group sessions, and had strong theoretical support. There were two studies addressing problem-solving, only one of which was effective. The effective intervention was delivered using face-to-face group sessions and was based on a problem-solving model. One study found improvements in inhibition and no study reported improvements in planning. Two studies measured changes in cognitive flexibility and one of them found improvements. The effective intervention was delivered during a longer period of time (10 weeks) compared with the noneffective intervention (5 weeks). The duration of interventions that improved cold EFs ranged between 5 weeks and 6 months. Hot EF Outcomes Six studies measured functional domains related to social abilities and reported a few improvements. The domains reported were diverse. The interventions that improved behavior and emotion regulation provided parents with education about ABI and taught them PBS. Interventions that were effective in improving hot EFs lasted between 10 weeks and 8 months. Hot and Cold EF Outcomes The characteristics of the interventions that aimed to improve overall EFs were heterogeneous, and improvements were rarely seen, compared with interventions that targeted specific cold or hot EFs. Family Factor Outcomes The studies that taught parents PBS were effective in improving parenting practices. Improvements in parental distress were not presented in most of the studies. Family functioning presented mixed results. All the studies that targeted metacognition, working memory, and parenting practices found at least some improvement. Some improvement in emotional regulation, family functioning, behavior regulation, and attention were present in half or more of the studies targeting those outcomes. Effective results were limited in the studies that measure overall EFs, social abilities, parental stress, and planning. Discussion To our knowledge, this is the first systematic review that focuses on interventions aiming to improve hot and cold EFs of children and adolescents with ABI. Interventions from 26 studies were reviewed. The use of hot and cold EFs has several implications for knowledge in the field of rehabilitation of children with ABI. Owing to this framework, we were able to differentiate approaches used in rehabilitation. Improvement was defined as p ≤ .05 reported by the authors. Studies that targeted metacognition, working memory, and parenting practices found some improvement. Most interventions targeting emotional regulation (75%), behavior regulation (69.2%), and parenting practices (75%) found improvements by involving caregivers and teaching them PBS. Studies measuring overall EFs found less effective results (33.3%) than when treating specific EFs, such as attention (55.5%), inhibition (50%), social abilities (42.8%), cognitive flexibility (50%), and problem-solving (50%). Interventions aiming to reduce parental stress had limited improvements (25%). No studies measuring planning found improvements. Level of Evidence and Quality of the Studies The evidence that we have about the rehabilitation of hot and cold EFs is limited. However, the information provided in the studies was sufficient to assess the findings. In summary, the level of evidence and quality of the studies is still limited. Based on the results from the DB checklist, overall the percentage of adherence was 72.3% in reporting, 62.8% in external validity, 63.7% in internal validity, and 51.2% in confounders. Power analysis was reported in 50% of the studies. Control groups were generally allocated to waitlists, which has been associated with overestimation of the intervention effect (Patterson, Boyle, Kivlenieks, & Van Ameringen, 2016). Participants There was a predominance of male participants with TBI reported in the studies. This can be explained because of the high prevalence of child TBI in comparison with other types of ABI and there being more male participants in this clinical group (Thurman, 2016). Total 61.5% of the studies reported in this systematic review focused in studying participants with TBI. The absence of studies with young children is surprising considering that ABI is the leading cause of injury in children <5 years of age (Thurman, 2016). Taking into account that cognitive sequelae of brain injury in children become more evident over time (Anderson, Spencer-Smith, & Wood, 2011), it is expected that family and school staff’s concerns about children’s cognitive or behavioral deficits may become apparent when the requirements of the environment increase and when certain skills should come online. Participants included in the reviewed studies had a variety of injury and lesion types, making comparability across participants difficult. Each type of lesion has its own criteria to determine severity, and levels of severity are not comparable across lesions. The criteria used by Woods et al. (2014) to determine the level of severity, by combining neurological deficits and imaging results, seems like a useful alternative for ABI populations. A determined time after injury onset as an inclusion criterion is often missing. Spontaneous recovery of cognitive functions occurs up to ≥8 months after the onset of severe injuries (Chávez et al., 2016; Leon-Carrilo & Machuca-Murga, 2001) and therefore, spontaneous recovery can enhance the effectiveness of interventions, highlighting the importance of inclusion of control groups in trial designs for ABI. The studies included in this review describe injury-related variables; however, description of noninjury variables is often lacking. As EF development is influenced by the environment (Jansen et al., 2012; Meldrum, Verhoeven, Junger, van Aken, & Dekovic, 2016), noninjury variables should also be addressed (Catroppa et al., 2017). Cold EFs Cold EFs refer to skills within the cognitive domain. Attention is the most studied cold EF with 35% of the studies in this review focusing on this skill. In the studies reviewed, attention was usually deconstructed into the levels of attention reported by Sohlberg and Mateer (1987) and most commonly measured with the Test of Everyday Attention for Children (Manly et al., 2016). From the studies that measure attention 55.5% of them found some improvement. Interventions that aim to improve attention and working memory tend to combined weekly individual sessions with homework, while metacognition and problem-solving can be enhanced by face-to-face group sessions. Still, results show that there is no consensus on how cold EFs should be deconstructed and measured. Maintenance of improvements in cold EFs was often not assessed. Only two studies found maintenance of some improvement in attention at 6 months (van’t Hooft, et al., 2007) and 1.63 years (Kaldoja et al., 2015) after the intervention was completed. Interventions that aim to improve attention were greatly influenced by the attention treatment model of Sohlberg and Mateer (1987). This model has a specific process approach and considers five levels of attention: focused, sustained, selective, alternating, and divided. Tasks for each level of attention are applied based on its difficulty, going from basic to more complex tasks (Sohlberg & Mateer, 1987). The specific training approach was used by interventions that aim to improve Cold EFs. The theoretical support of the interventions that aim to improve metacognition included concepts from Clements and Natasi (1990), Ylvisaker and Feeney (2002), and Cole (2006). Based on those ideas, the interventions attempted to create real-life context, by teaching metacognitive skills and provide participants with the space to use them in the company of peers. To date, there is no precise pathway leading to the improvement of cold EFs. Nonetheless, effective treatments tend to focus on only one or two cold EFs, are short, intensive, and based on a cognitive model. This review adds to previous evidence (Bewick, Raymond, Malia, & Bennet, 1995), which supports the combination of specific cognitive training and metacognitive strategies to rehabilitate cold EFs. Theoretically, repetition in cognitive training activities appears to activate neural networks and seems to readjust the maladaptive networks presented after ABI onset (Galetto & Sacco, 2017). Enhancing metacognition within a context similar to real-life in combination with other cold EFs could be the key element to generalize cold EFs gains to new scenarios. Hot EFs Hot EFs refer to skills within the socioemotional domain. Challenging behavior is the most problematic consequence of brain injury according to family, teachers, and friends (Feeney, 2010). The impact that challenging behavior has on parents may explain why behavior regulation was targeted by 50% of the studies. The Child Behavior Checklist (Achenbach & Resco, 2001) was the questionnaire most often used to measure behavior regulation. Improvements were seen in 69.2% of the studies that targeted behavior regulation and can be achieved by providing parents with education about ABI and teaching them PBS. Maintenance of improvements in behavior regulation was reported at 6 months (Brown et al. 2014) and at 18 months (Woods, Catroppa, Godfrey, & Anderson 2014). By comparing the interventions, we can see that recovery of hot EFs seems to require more time in comparison to cold EFs. There is no agreement on how to deconstruct or measure social skills as a cognitive process; therefore, comparison among studies is not possible. The model from Beauchamp and Anderson (2010) describes the cognitive processes involve in social skills development, which can support the development of assessments tools and interventions for social skills. The concepts from Ylvisaker and Feeney (2009) strongly influenced the rehabilitation of hot EFs in children with ABI. They propose that the adults involve in the daily routines of the child should participate in the intervention (Ylvisaker & Feeney, 2009). The studies in this review taught parents PBS, which aim to improve behavior by applying educational methods to broaden behavior repertoire and redesign the context (Carr et al., 2002). Contexts impact EFs development (Zelazo, Qu, & Kesek, 2010) and children with ABI are especially vulnerable to adverse environments (Taylor et al., 2002). Their deficits on EFs can be exacerbated when they are surrounded by unfavorable family circumstances (Taylor et al., 2002). As a consequence, studies that aim to improve hot EFs involved parents, or the entire family, and measure family factors. Family Factors Results show that parenting practices can improve by teaching parents PBS. However, maintenance of improvements in parenting practices was reported only in one study (Brown et al. 2014). Studies included in this systematic review attempted to reduce parental stress by using mindfulness, acceptance commitment therapy, and stress management techniques with limited results that were not maintained over time (Woods, Catroppa, Godfrey, & Anderson 2014). Finally, the problem-solving model of D’Zurilla and Nezu (1999) was often used as part of the treatment to improve family functioning, and 60% of those studies found some improvement. Woods et al. (2014) and Kurowski et al., (2013) show that families' needs vary depending on the child’s cognitive impairment, age and severity of the injury. To date, we know that participants who present more impairment benefit the most (Chavez-Arana, 2018; Woods et al., 2014;). However, we cannot draw conclusions on how interventions can be adapted according to the child’s cognitive needs or age. Nonetheless, the single-case study methodology can add in this respect (Perdices & Tate, 2009). This review allowed us to acquire knowledge about the active ingredients in the rehabilitation of hot (PBS-parents) and cold (intensity) EFs. Still, we do not know if improvements found in the studies are transferable to other settings or maintained over time. Furthermore, we need consider that real-life contexts may be more challenging for the child because they require hot and cold EFs to work together toward adaptive function (Zelazo & Carlson, 2012). In addition, impairments in either hot or cold EFs can have secondary consequences to other aspects of EF (Blair & Diamond, 2008). Therefore, balance between cognition and emotion is required for self-regulation development (Blair & Diamond, 2008). Some of the interventions described are adaptations of interventions previously used in other populations, such as children with neurodevelopmental disorders or adults with ABI. For this reason, we suggest that adapting interventions from different populations can be beneficial for children and adolescents with ABI. Complete descriptions of the treatments and their theoretical base are often missing. The absence of complete descriptions limits the development of new interventions and replication studies, and therefore, hinders research in child neuropsychological rehabilitation. Future Directions Future studies are encouraged to use a stronger methodology to develop a stronger evidence base for the interventions. Outcomes reported by participants who are aware of their treatment allocation may differ from unaware participants (Hróbjartsson & Gøtzsche, 2001). We suggest that allocating control groups to another treatment can provide stronger evidence and control the effect caused by being treated by a health professional. Future studies are invited to study preschool children with ABI. Early brain injury has been associated with poor EFs in later stages of life (Anderson et al., 2011), which may be prevented or ameliorated by providing early interventions. Young children may benefit from interventions such as coordinative exercise, preventive educational–behavioral, and school-based programs, which have shown to be beneficial for healthy young children and young children requiring intensive care hospitalization (Chang, Tsai, Chen, & Hung, 2013; Diamond, Barnett, Thomas, & Munro, 2007; Melnyk, et al., 2004). Description of the reasons for attrition could assist in determining the generalizability of the results. We encourage future studies to include noninjury variables (e.g., parent mental health), evaluate whether improvements transfer to other settings, specify time since injury as an inclusion criterion, describe methods for determining injury severity, and outline the theoretical basis of the intervention. Adaptations of interventions that have been effective in improving EFs in different populations could benefit children and adolescents with ABI. Studies with participants with mild injury severity, participants who reside far from the hospital and non-Caucasian participants are required. These populations were underrepresented in existing research. In particular, there are no studies with the Hispanic population. Future studies could examine the feasibility and effectiveness of interventions in Spanish-speaking countries. Limitations The present study has several limitations. The way in which EFs are deconstructed and measured varied among studies; therefore, conclusions were drawn based on the qualitative synthesis of the studies. In addition, the keywords used in the search did not specify the variety of brain injuries. As a consequence, relevant studies may have been overlooked and not reported in this review. Another limitation of the study is that it was not possible to analyze the association between injury factors (severity, type, location), participant factors (age, preinjury deficits), and the effectiveness of the intervention. Owing to the absence of studies focusing on young children, conclusions in this systematic review may not apply to them. Another limitation is that we divided EFs into hot and cold based on the description from De Luca & Leventer (2008). However, hot or cold EFs are elicited depending on the context and they work together (Hongwanishkul, Happaney, Lee, & Zelazo, 2005). Most studies did not evaluate whether improvements are maintained over time; therefore, we know little about long-term outcomes. Clinical Recommendations Clinical recommendations resulting from this review should be considered with caution because of the limited quality of evidence included in this research synthesis. Further research is necessary to increase confidence in the generalizations that can be drawn from this body of research. We recommend that interventions provide ABI education to those close to or working with the child to maximize their understanding of the cognitive and behavioral consequences of ABI and how they may arise in everyday activities. For rehabilitation of hot EFs, we recommend active participation of parents by teaching them PBS to reduce or prevent behavior problems and improve parenting skills. For rehabilitation of Cold EFs, we endorse intensive rehabilitation, high frequency of sessions in combination with homework. The evidence suggests that Cold EFs interventions can be developed based on a cognitive model. Supplementary Data Supplementary data can be found at: http://www.jpepsy.oxfordjournals.org/. Acknowledgments The authors would like to acknowledge Poh Chua from the library of Royal Children's Hospital for her valuable advice. Funding The study received support from The National Council for Science and Technology (CONACYT) and the Victorian Government Operational Infrastructure Scheme. The funding bodies did not play a role in the design of the study, collection, analysis, and interpretation of the data, or writing of the manuscript. All authors remain independent of all funding bodies described. Conflicts of interest: None declared. References Anderson V. , Spencer-Smith M. , Wood A. ( 2011 ). Do children really recover better? Neurobehavioural plasticity after early brain insult . Brain , 134(Pt 8) , 2197 – 2221 . Google Scholar CrossRef Search ADS Achenbach T. , Resco L. ( 2001 ). 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Journal of Pediatric PsychologyOxford University Press

Published: Sep 1, 2018

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