Metacognition refers to one’s ability to make online, in-the-moment judgments regarding their own cognitive performance, and has significant implications for one’s abilities to function in daily life. It has been documented that individuals with TBI often present with metacognitive deficits, and are slower than neurotypical peers in making such judgments. Preliminary attempts have been made to determine how neural contributions to metacognitive functioning differ after injury. Studies thus far have found unique roles of prefrontal gray matter volume and inter-network connectivity in metacognitive functioning after injury, but functional activation directly associated with metacognitive processing has yet to be investigated. This event-related functional magnetic resonance imaging (fMRI) study aimed to document differences in functional activation between adults with TBI and neurotypical peers when completing metacognitive confidence judgments.

16 adults with moderate to severe TBI and 10 healthy adults (HCs) completed a metacognitive task while in the fMRI scanner. All participants were exposed to target slides with polygons arranged in various positions, then asked to identify the target slide from a group including 3 other distractor slides. Following each response, participants provided a metacognitive retrospective confidence judgment (RCJ) by rating their confidence that the answer they provided was correct. Meta d', a signal-detection based metric of metacognitive accuracy, was calculated. FSL FEAT was used for processing and analysis of the imaging data. Contrasts were created to model activation that was greater when RCJs were made compared to target recognition, mixed effects modeling was then used to investigate group differences. Cluster based thresholding set to z>2.3, p<0.01 was used for multiple comparisons correction.

Healthy controls performed significantly better on the target identification task (p<0.01), and were faster at making RCJs (p=0.03). Individuals with TBI had greater meta d’ scores (p=0.03). Significant activation beyond what was present during target recognition (RCJ>recognition) was found in left supramarginal gyrus, left posterior cingulate, and left cerebellum when individuals with TBI made RCJs, while HCs showed significant activation in the left precuneus, and bilateral superior temporal gyri. Individuals with TBI demonstrated more activation in the lateral occipital cortex bilaterally and the left cerebellum than HCs when completing RCJs. HCs presented with more activation in the left supramarginal gyrus than the TBI group when making RCJs.

The areas of activation present in both the TBI and HC groups are consistent with previous imaging findings from studies of healthy samples. Interestingly, two structures previously implicated in self-directed cognition and consciousness, the posterior cingulate and precuneus, were differentially activated by the groups. The lack of a common network between the two groups suggests that survivors may rely on separate neural substrates to facilitate metacognition after injury. The TBI group was found to recruit more functional areas when completing the RCJs. These findings, paired with the behavioral data indicating metacognitive performance differences, suggests that neural recruitment may occur after injury to allow for survivors to engage in making metacognitive judgments. Future qualitative investigations of the metacognitive judgments are needed to determine the compensatory nature of this postinjury recruitment.

To investigate differences of the perceived unmet needs in a post-acute brain injury sample when referred to Resource Facilitation (RF) among various race/ethnic groups.

The methodology utilizied within this study consisted of a retrospective chart review, which was sourced from a clinical database serving chronic outpatients in the Midwest region. The main outcome measure was the Service of Unmet Needs & Service Use (SUNSU). The sample consisted of N = 455 subjects, which included a small sample size of Hispanics (N=7). Therefore, African American and Hispanic groups were combined for a total minority sample (N=84). Clinical disorders included within the study was an ABI from either stroke, anoxic injury, ruptured aneurysm, or tumor resection surgery. Eligibility criteria included participants’ admission into a RF program, a vocational goal, and a diagnosis of a moderate to severe TBI or other ABI. Lastly, key sociodemographic features included age, race, ethnicity, education, and sex.

Significant differences were found between ethnic groups (white non-Hispanics and minority group) in terms of years of education (p=<.01). White non-Hispanics had higher education (M=13.39, SD=2.23), reported significantly more rural addresses (40.2%, p=<.01), and had private insurance coverage more frequently than the minority group (33.7%, p=<.01). The full model was statistically significant, R2=.077 = F(4,450) = 9.387, p<.0001; adjusted R2 = .069. The addition of ethnicity led to a statistically significant increase in R2 of .019, F(1,450) =9.025, p<.0005.

Ethnicity was found to be a predictive factor for greater unmet needs even after controlling for insurance, employment status, and urbanicity. It is currently unknown RF’s success rate in providing culturally competent services to different racial/ethnic groups, which consider factors such as primary language spoken, immigration status, and additional ethnocultural factors that could deter accurate reporting of unmet needs by minoritized groups. Future studies should investigate barriers in referring and meeting eligibility for this program and analyze post-treatment data to determine if the impact of racial, geographic, and insurance disparities is mitigated with RF treatment.

Cognitive flexibility, typically measured using neuropsychological tasks of set-shifting, has been associated with mental and physical health, social relationships, resilience, and overall quality of life (Diamond, 2013; Chen et al., 2014; Davis et al., 2010; de Abreu et al., 2014; Genet et al., 2011). Previous research has found conflicting results regarding the relationship between set-shifting and various measures of functional outcomes in individuals with traumatic brain injury (Allanson et al., 2017). The present study examined the relationship between cognitive flexibility and adaptive functioning in individuals with acquired brain injuries (ABI).

Participants in this research are adults (n = 116) with severe, chronic ABI who completed a neuropsychological evaluation through Bancroft Neurorehab between 2012-2022. Participants ranged in age from 20.4 - 67.8 years (M = 45.8). Individuals included in data analysis completed Trails A and B, Wide Range Achievement Test, Fourth Edition (WRAT-4) Word Reading, and Texas Functional Living Scale (TFLS). Set-shifting ability was measured using Trails B and adaptive functioning was measured using the TFLS. Word reading ability, measured using the WRAT-4, was included as a covariate to account for the impact of word reading difficulties on Trails B performance.

A simple linear regression was conducted to examine if Trails B T-score (M = 24.7) and WRAT-4 Word Reading Standard Score (M = 87.8) predicted TFLS Total T-score (M = 35.8). The overall regression model was statistically significant (R2 = .351, F(2, 113) = 32.0, p < .001). It was found that lower performances on Trails B (ß = .272, p <.001) and WRAT-4 Word Reading (ß = .189, p <.001) both significantly predicted a lower TFLS Total T-score.

Set-shifting and word reading ability significantly predicted the overall adaptive functioning score on the TFLS which adds to a body of literature that suggests that the ability to think and behave flexibly affects functional aspects of everyday living. These findings are consistent with previous literature regarding the association between cognitive flexibility and adaptive functioning in the general population, and these results add to the growing body of research on cognitive flexibility in individuals with brain injury. Clinicians may use an individual’s set-shifting performance to estimate and further assess potential difficulties in completing activities of daily living. This information may assist in subsequent treatment planning and identifying treatment goals of cognitive rehabilitation consistent with rehabilitation psychology’s goals of increasing levels of adaptive functioning and quality of life (Division 22 of the American Psychological Association, n.d.). Future research may examine if certain domains of adaptive functioning are more or less affected by impairments in cognitive flexibility. Future research may also examine patterns of set-shifting performance, such as sequencing errors vs. set-loss errors, associated with specific areas of insult.

Modern perspectives of rehabilitation after traumatic brain injury (TBI) emphasize the importance of individualized holistic approaches (i.e., physical and psychological adjustment) and collaboration toward goals (e.g., among the survivor, rehabilitation professionals, family/friends, etc.). Recent research has sought to employ a holistic, value-based approach (via the Valued Living Questionnaire) to measuring goals and whether those with TBI are acting in accordance with them, and quality of life outcomes. However, no research has examined whether rehabilitation practices are consistent with survivor values using this framework. The aim of the current study was to investigate the impact of value-consistent rehabilitation practices on quality of life and psychological adjustment outcomes in those with TBI.

The current study included a sample of 73 adults with a history of TBI (M years since injury = 7.6, SD = 9.7) between the ages of 18 and 72 (Mage = 44.0 years, SD = 13.1; 73% female, 90.4% white) who had participated in outpatient rehabilitation. Individuals were recruited from brain injury support groups on Facebook and completed a series of surveys measuring TBI severity [Ohio State University Traumatic Brain Injury Identification Method-Short Form (OSU-TBI-ID)], value-consistent rehabilitation practices [modified Valued Living Questionnaire (VLQ)], life satisfaction [Life Satisfaction Questionnaire-9 (LiSat-9)], and psychological flexibility [Acceptance & Action Questionnaire - Acquired Brain Injury (AAQ-ABI)]. Discrepancy scores were calculated to compare perceived importance of and how helpful rehabilitation was for each VLQ domain. Bivariate Pearson correlations were conducted to investigate the relationships between value-consistent rehabilitation, life satisfaction, and psychological flexibility.

The VLQ domains with the greatest discrepancies were spirituality (-2.26), marriage/intimate relations (-2.06), and family relations (-2.02) such that rehabilitation helped less in these domains despite their importance. Greater levels of value-consistent rehabilitation were related to higher levels of life satisfaction overall (r = 0.40, p < 0.001) and lower levels of reactive avoidance of emotions related to one’s brain injury (r = -0.26, p = 0.03). In terms of specific domains of life satisfaction, greater value-consistent rehabilitation was related to higher levels of vocational (r= 0.44, p < .001), physical self-care (r = 0.28, p = 0.018), and friendship satisfaction (r= 0.41, p < .001).

Our findings suggest rehabilitation practices may not be acting proportionately with TBI survivor values. Moreover, our results suggest value-consistent rehabilitation is important for long term quality of life and psychological adjustment outcomes. Future work should seek to identify factors that optimize opportunity for individualized treatment.

Research indicates that Veterans with a history of traumatic brain injury (TBI) are at increased risk for dementia. Although the precise mechanisms underlying this relationship are poorly understood, remote TBI may exacerbate normal age-related changes to cerebral white matter (WM) and result in cognitive decline. However, Veterans commonly experience a constellation of mental (e.g., post-traumatic stress disorder [PTSD] and depression) and vascular (e.g., diabetes, hypertension, obesity) health conditions that have also been implicated in pathologic cerebral WM and cognitive aging trajectories. Therefore, the present study sought to (1) clarify the effects of remote TBI within the context of PTSD, depression, and vascular risk on WM micro- and macrostructure, and (2) explore if WM integrity is associated with cognition in a sample of Vietnam-Era Veterans.

The sample consisted of 195 male Veterans ages 60-80 (mean age=69.3) enrolled in the Department of Defense-Alzheimer’s Disease Neuroimaging Initiative (DoD-ADNI) study. 102 Veterans met criteria for TBI by sustaining a head-injury that resulted in a loss of consciousness, alteration of consciousness, or post-traumatic amnesia. Current and/or lifetime PTSD was designated by scores >30 on the Clinician-Administered PTSD Scale. The Geriatric Depression Scale was used as a continuous measure of depression. A vascular risk score (0-3) was calculated based on diabetes, hypertension, and obesity (BMI >30 kg/m2). An executive functioning composite was created by averaging sample-specific z-scores for Trail Making Tests (A and B), with higher scores indicating worse performance. Voxelwise analysis of WM microstructure (fractional anisotropy [FA]) was conducted with Tract-Based Spatial Statistics (TBSS), using non-parametric permutation testing with threshold-free cluster enhancement. SPM’s Lesion Segmentation Tool was used to investigate WM macrostructure (WM hyperintensity [WMH] volume). Lesion probability maps were masked to restrict WMH volume calculations to WM. Robust regression using M-estimation and predictive R2 calculated using 10-fold cross-validation examined WMH volume, predictor, and cognitive associations. Age was a covariate in all WM analyses, and education was a covariate in all cognitive analyses.

TBSS analysis revealed widespread, significant negative relationships between vascular risk and FA across numerous WM tracts (p’s<0.05). These associations remained significant after adjusting for TBI history, PTSD, and depression. TBSS identified significant positive relationships between executive functioning performance and FA across similar brain regions (p’s<0.05). Robust regressions revealed that vascular risk significantly predicted WMH volume (p=0.006; ß=0.161; R2=0.093), whereas TBI history, PTSD, and depression did not (p’s=0.107-0.166; ß's=-0.089-0.101). WMH volume significantly predicted executive functioning (p=0.002; ß=0.216; R2=0.105), whereas TBI history, PTSD, depression, and vascular risk did not (p’s=0.123-0.888; ß's=-0.012-0.125).

Our results suggest that vascular health, relative to remote TBI, PTSD, and depression, may be more robustly associated with cerebral WM micro- and macrostructure in older Veterans. Furthermore, poorer WM integrity is associated with poorer cognitive performance. These findings underscore the importance of vascular health interventions in preventing negative brain and cognitive aging outcomes in Veterans, independent of TBI history. Future studies might leverage other neuroimaging modalities (e.g., functional MRI) to further investigate the effects of vascular health on aging in Veterans with a history of TBI.

Social participation (SP) represents a key goal in TBI rehabilitation, as it allows the individual to return to active and purposeful roles in the community. However, studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were thus to 1) characterize a literature-based set of pre-injury, injury-related, and post-injury variables, as well as SP (measured with the MPAI-4 Participation scale) in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care and 2) assess the use of these variables to predict SP outcome after TBI for each rehabilitation pathway.

Participants (N = 372) were adults admitted between 2016 and 2020 to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a mild, moderate or severe TBI. The French-Canadian adaptation of the MPAI-4 questionnaire (Malec, 2005; Guerrette & McKerral, 2021; McKerral et al., 2014) presents three subscales (Abilities, Adjustment, Participation) and a total score, assessing functional and SP outcome after TBI. The MPAI-4 is completed for all individuals at admission and discharge in three major rehabilitation centers in the greater Montreal region. Independent variables consisted of sociodemographic and clinical characteristics collected from medical files and rehabilitation databases. Outcome measures consisted of a general SP level (MPAI-4 Participation subscale score at discharge from outpatient rehabilitation) and productivity status at discharge (productive if employed, child rearing, homemaker, student or volunteering; unproductive if unemployed or retired). Multiple and logistic regressions investigated the predictive value of each variable for SP outcome and productivity, separately for each rehabilitation pathway.

Samples’ sociodemographic and clinical characteristics differed between rehabilitation pathways. The inpatient-outpatient sample presented older age, lower productivity before TBI and poorer SP levels at admission and discharge from rehabilitation. However, both samples showed significant improvement on SP levels during rehabilitation. For the inpatient-outpatient rehabilitation path, general SP outcome was significantly predicted by three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake; R2 = 49%), whereas productivity status at discharge was significantly predicted by age at time of injury (R2 = 72%). For the outpatient rehabilitation path, general SP outcome was significantly predicted by five variables: premorbid hypertension, mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake (R2 = 47%), while productivity status at discharge was significantly predicted by age at time of injury and education years (R2 = 44%).

Different TBI rehabilitation care pathways showed distinct sample characteristics, as well as different premorbid and post-injury predictors of SP outcome and productivity. This highlights the importance of being aware of the potential limited generalizability of previously identified predictors when extrapolated to different clinical, rehabilitation and sociocultural contexts. The predictive models obtained could help clinicians identify more accurately patients at risk of showing poorer SP and productivity outcomes at end of rehabilitation, influence intervention approaches put forward with these individuals and set more appropriate goals and expectations.

Following a traumatic brain injury (TBI), the majority of patients report difficulties with prospective memory (PM). However, there is not always a significant relationship between subjective and objective PM measures. Several variables may influence the degree of severity of perceived difficulties, including the severity of the injury and psychoemotional status. The aim of this study was to determine whether the severity of the TBI and anxiety and depressive symptoms were related to objective and subjective difficulties of PM.

50 patients (mean age = 31,3 years old) with a TBI (20 mild and 30 moderate/severe) in the post-acute phase of recovery and 15 matched healthy control participants (mean age = 32,3 years old) were recruited. They completed inventories assessing the presence of anxiety (BAI) and depressive (BDI) symptoms and performed the Ecological test of prospective memory (TEMP), an objective measure of PM. The Comprehensive Assessment of PM (CAPM), a subjective measure of PM, was also filled out by participants and their relatives.

In patients with moderate/severe TBI, significant correlations were found between the CAPM and the BDI (r =.601, p<.001) and the BAI (r =.507, p=.004). A negative correlation was also observed between the relatives’ CAPM scores and the performance of the patients on the TEMP (r= -.374, p=.042). In patients with mild TBI, there was only a strong significant correlation between the CAPM and the BAI scores (r =.574, p=.008). However, no other correlation was significant between this group of patients and their relatives. Additionally, results on the TEMP were not significantly correlated with the CAMP completed by healthy control participants or their relatives. A linear regression conducted in the group of participants with TBI showed that BAI and BDI scores are the only significant predictors of the results on the CAPM (31% of the variance), while TBI severity is the only significant predictor of the results on the TEMP (37% of the variance).

The perception of PM difficulties in patients with a TBI does not seem to be related to their objective performance. Anxiety and depressive symptoms appear to influence their perception more than their objective performance. As suggested by their relatives, a decrease in self-awareness could explain the lack of relationship between subjective PM difficulties of patients with moderate/severe TBI and their objective performance. On the other hand, TBI severity is more strongly related to objective performance on PM tests. These results highlight the importance of using different measures to accurately assess PM and the various factors influencing this construct.

Metacognition is defined as the ability to observe, monitor, and make judgments about one’s own cognitive status. Judgments of learning (JOLs) and retrospective confidence judgments (RCJs) are two elements of metacognition related to memory, or metamemory. JOLs refer to one’s assumptions of their memory performance prior to completing a memory task, while RCJs describe one’s subjective assessment of their memory performance after they have completed the task. Traumatic brain injury (TBI) is known to negatively impact general metacognitive functioning. However, the nuanced effects of TBI on constituent metacognitive subprocesses like JOLs and RCJs remain unclear. This study aimed to characterize patterns of brain activity that occur when individuals with TBI render JOLs and RCJs during a meta-memory task. Differences between JOL- and RCJ-related patterns of activation were also explored.

20 participants with moderate-to-severe TBI completed a metacognition task while undergoing functional magnetic resonance imaging (fMRI). Participants were first exposed to target slides with a set of polygons placed in specific locations, then asked to identify the target slides within a set of distractors. Before identifying the target slides, participants rated how well they believed they would remember the polygons’ shape and location (JOL). After answering, they rated how confident they were that the answer they provided was correct (RCJ). First-level time series analyses of fMRI data were conducted for each participant using FSL FEAT. Higher-level random effects modeling was then performed to assess average activation across all participants. Finally, contrasts were applied to examine and compare JOL- and RCJ-specific patterns of activation.

JOLs were associated with activation of the left frontal gyri, bilateral anterior cingulate, left insula, and right putamen (p < 0.01). RCJs were associated with activation of the bilateral frontal gyri, bilateral posterior and anterior cingulate, left insula, right putamen, and left thalamus (p < 0.01). Compared to RCJs, JOLs demonstrated greater left insula activation (p < 0.01). Compared to JOLs, RCJs demonstrated greater activation of the left superior frontal gyrus, bilateral middle frontal gyrus, and bilateral anterior cingulate (p < 0.01).

The areas of activation found in this study were consistent with structures previously identified in the broader metacognition literature. Overall, RCJs produced activity in a greater number of regions that was more bilaterally distributed compared to JOLs. Moreover, several regions that were active during both metacognitive subprocesses tended to be even more active during RCJs. A hypothesis for this observation suggests that, unlike JOLs, the additional involvement of reflecting on one’s immediate memory of completing the task during RCJs may require greater recruitment of resources compared to JOLs. Importantly, these findings suggest that, while different metacognitive subprocesses may recruit similar brain circuitry, some subprocesses may require more potent and widespread activation of this circuitry than others. As such, subprocesses with greater activational needs and complexity, such as RCJs, may be more susceptible to damage caused by TBI. Future research should aim to compare patterns of activation associated with certain metacognitive subprocesses between survivors of TBI and healthy controls.

It has been well established that sustaining a head injury can result in cognitive impairments, but there is little research on the impact of head injuries within middle-aged and older adult samples. Given the two most common samples for head trauma research are athletes and military service members, most of this literature presents findings of individuals under 35 years old. It is important to study head injury outcomes in older samples because greater lengths of time may have passed since the injuries occurred, which may influence findings. Additionally, research indicates that head injuries can lead to measurable executive functioning difficulties - a cognitive domain previously established as susceptible to cognitive ageing-related decline. Therefore, the current investigation seeks to assess the connection between history of head injury and executive functioning performance in middle-aged and older adult participants.

The current study examined 1150 participants from the 2nd wave of the Midlife in the United States cohort (MIDUS) and 801 participants of the MIDUS refresher panel. As a part of the biomarkers study, participants indicated how many head injuries they experienced (up to three) along with whether they were hospitalized and the year the injury occurred. As a part of the cognitive study, participants completed a battery of measures that were combined into a single Z-scored executive functioning measure. Regression was used to evaluate the association between self-reported head trauma and executive functioning, controlling for age and gender. Post hoc analyses examined hospitalization and recency of head injury.

Of the 1951 included participants, 70.7% reported zero head injuries, 20.8% reported one head injury, 5.8% reported two head injuries, and 2.7% reported at least three head injuries. History of head trauma was not associated with lower levels of executive functioning (F[3,1945]=2.68, p=.38). Furthermore, executive functioning performance was not associated with hospitalization for head injury (b=-.04, p=.31) or recent head injuries (b=-.04, p=.70).

The current results do not provide evidence of decreased executive functioning performance linked to history of head injury in middle-aged and older adults. These findings are inconsistent with earlier literature suggesting that executive dysfunction is associated with prior head trauma. It is important to consider, however, that the operationalization of executive functioning as a cognitive domain is controversial and produces significant debate. Therefore, the present results solely indicate a lack of connection between previous head trauma and executive functioning, specifically as assessed by the current definition and measures. The present analyses were limited by the broad inclusion of all head injuries rather than a narrowed scope of specifically concussions or mild traumatic brain injuries. However, the study had the advantage of being adequately powered via a large sample size. The current results suggest that additional research is needed within middle-aged and older adult samples to investigate possible connections between head trauma and executive functioning performance using alternate definitions and assessments.

To characterize reasons for rehospitalization of Veterans and Service Members with mild, moderate, and severe traumatic brain injury (TBI) who received inpatient rehabilitation at a Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC) up to 10 years postinjury. TBI is a chronic condition, and a subset of TBI survivors experience rehospitalization after discharge from inpatient rehabilitation. Extant literature focuses primarily on persons with moderate-to-severe TBI and utilizes broad categories when determining readmission reasons. The present study aimed to delineate with greater specificity the reasons for rehospitalization up to 10 years postinjury across the TBI severity spectrum.

Participants were drawn from the VA TBI Model Systems multicenter longitudinal study for a cross-sectional analysis. Eligibility criteria included TBI diagnosis per case definition; age > 16 years at TBI; admitted for inpatient rehabilitation at one of the five VA PRCs; and informed consent by the participant or legally authorized representative. At follow up interviews 1, 2, 5, and 10 years post-TBI, participants were asked whether they were rehospitalized within the past year (up to five admissions). Rehospitalizations were classified according to the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project classification (18 categories). In the present analyses, TBI severity was classified by duration of posttraumatic amnesia (PTA; 0-1 days=mild, 2+ days=moderate-severe). Statistical analyses were conducted in SPSS.

Participants (N=1101; n=338 0-1 days PTA, n=513 2+ days PTA, n=250 no PTA data) ranged in age from 17 years to 91 years at the time of interview. Participants across all follow up timepoints reported 317 rehospitalizations in the past year. 19.45% of Year 1 participants, 24.37% of Year 2 participants, 16.19% of Year 5 participants, and 16.25% of Year 10 participants reported 1+ rehospitalizations in the past year. When controlling for age, participants with at least 2 days of PTA were more likely to be rehospitalized at least once compared to those with 0-1 days of PTA at Year 2 (OR=4.05, p<0.001) and Year 5 (OR=2.39, p=0.03) post-TBI. The three most common reasons for rehospitalization across all timepoints were injury and poisoning (17.3%), mental illness (16.7%), and diseases of the nervous system and sense organs (9.1%). Mental illness was the modal reason for rehospitalization at Years 2, 5, and 10, frequently due to substance- or alcohol-related disorders and suicide/intentional self-inflicted injury.

Compared to prior research, rates of rehospitalization were lower in this sample across follow-up time points. The inclusion of mild TBI in this analysis may partially explain the discrepancy. Importantly, two of the top three rehospitalization reasons are potentially preventable, and strategies to reduce risk of re-injury and minimize escalation of psychiatric distress should therefore be explored. Psychoeducation, supervision, and mental health support during the transition from hospital to community should be considered in order mitigate preventable causes of rehospitalization among long-term TBI survivors.

Poststroke depression is common in those with stroke and is associated with worse functional outcomes, recurrence of stroke, and increased mortality. Poststroke depression has been most commonly associated with lesions of the frontal lobe and anterior regions of the brain, in addition to lesions in subcortical structures. Yet, there is also evidence that indicates the presence of depressive symptoms in those with infratentorial (including brainstem, pontine, and cerebellar) stroke, which may be mediated by alternative pathophysiologic mechanisms. Patients undergoing acute inpatient stroke rehabilitation may present with depressive symptoms that go unassessed or untreated throughout their recovery, including those with infratentorial stroke. The current objective was to evaluate the degree of depressive symptoms in patients with infratentorial stroke compared to those with supratentorial stroke.

Participants were admitted to an acute inpatient rehabilitation unit for stroke rehabilitation. Participants were enrolled in an ongoing clinical trial. Participants with recent infratentorial stroke (N = 7; 4 female; Median age = 69 years; Median education = 16 years) were administered the Patient Health Questionnaire-9 (PHQ-9) to assess symptoms of depression. Severity of depressive symptoms (PHQ-9 total score) in participants with infratentorial stroke was compared to those with supratentorial stroke (N = 19; 10 female; Median age = 69 years; Median education = 15 years) through Mann-Whitney U tests.

Participants with infratentorial stroke endorsed similar levels of depression to those with supratentorial stroke. Participants with infratentorial stroke endorsed overall mild depressive symptoms (Mean PHQ-9 score = 7.29; Median = 7), similar to those with supratentorial stroke (Mean PHQ-9 score = 7.11; Median = 6). Significant differences in depressive symptoms were not observed between participants with infratentorial and supratentorial stroke (p = .785).

Patients with infratentorial and supratentorial stroke may experience a similar degree of poststroke depression. Despite differences in suspected pathophysiologic mechanisms, infratentorial and supratentorial stroke appear to influence depressive symptoms to a similar extent. While future analyses with larger sample sizes are indicated, the current study indicates that patients with infratentorial and supratentorial stroke should be evaluated for depressive symptoms during the acute phases of recovery to inform treatment and potentially improve outcomes.

Determine associations between cognitive outcomes in remote TBI (i.e., at least 6 months post injury), a blood marker of neural degeneration (i.e., Tau), and diffusion kurtosis imaging (DKI) measures (e.g., mean or radial kurtosis). Because DKI imaging is sensitive to the environmental complexity of the imaged area, we sought to investigate regions known to be associated with the cognitive and emotional sequalae of TBI, such as the anterior thalamic radiations, uncinate fasciculus, and the corpus callosum.

41 individuals with mild-to-moderate TBI and a mean age(SD) of 36.1(10.4) years underwent DKI, a blood draw, and neuropsychological assessments. 23 healthy controls (HC) with a mean age(SD) of 35.2(15.2) years underwent the blood draw and assessments, but no imaging. Higher diffusion kurtosis indicates more restricted diffusion, possibly due to greater complexity within the imaged region. Thus, in the context of TBI, DKI can be used as a proxy measurement for biological processes that alter the complexity of imaged environments, such as reactive gliosis. Some people show cognitive deficits long after TBI and this could be associated with increased inflammation and membrane protein aggregates in damaged brain regions. We used bivariate correlations and general linear models to investigate the association of mean kurtosis (MK) in long white matter tracts and Tau (total or phosphorylated) to color-word Stroop scores; a measure of fronto-subcortical function.

In patients with TBI, MK was significantly associated with serum total Tau (TTau) in the right (r=-0.396) and left (r=-0.555) uncinate fasciculus (UF), right (r=-0.402) and left (r=-0.504) anterior thalamic radiations (ATR), and the genu (r=-0.526) and body (r=-0.404) of the corpus callosum (CC). TTau had a significant association with word Stroop scores, F(1,63)=-2.546, p=0.013. However, there was no significant effect of group (i.e., TBI or HC), F(2,63)=-0.426, p=0.672, on cognitive performance. When models were implemented that included both TTau and MK in either the UF or ATR as explanatory variables to predict word Stroop scores, TTau levels and MK in the right UF explained a significant amount of the variance in Stroop performance, F(1,29)=2.215, p=0.025. Further, there was also a significant association between radial kurtosis in the right UF and Stroop word scores (r= 0.366).

Our results show that an indicator of biological complexity (DKI) in cognitively important brain regions is associated with cognitive performance and Tau in patients with remote mild-to-moderate TBI. The UF is a critical fronto-temporal/subcortical pathway that has previously been implicated in the manifestation of executive dysfunction and mood dysregulation in TBI. Tau is an important marker of neurodegeneration implicated in Alzheimer’s disease, Parkinson’s disease, and chronic traumatic encephalopathy (CTE), and DKI is potentially sensitive to markers of neurodegeneration. The association of Tau and DKI measures is novel and shows concordance between blood and brain imaging markers and cognitive performance in patients with mild to moderate TBI.

Alexithymia is characterized by difficulty identifying and describing one’s emotions. Alexithymia is more prevalent and severe after acquired brain injury (ABI; Fynn et al., 2021). Additionally, studies have shown frequent impairment of affect recognition after ABI (Neumann et. al, 2014). Research examining the relationship between the subjective experience of alexithymia and the objective ability to recognize emotion in others has been limited, especially among individuals with ABI. Some research indicates that alexithymia is more common following traumatic brain injury (TBI) than non-traumatic brain injury such as stroke; however, no previous research has examined the relationship between alexithymia and affect perception comparing adults with TBI and stroke. Accordingly, this study aimed to fill that gap.

Participants were 218 adults in three groups: healthy adults (HA; n = 99), TBI (n = 63), and stroke (n = 56).

Participants completed a neuropsychological battery that included the Toronto Alexithymia Scale-20 (TAS; Bagby et al., 1994), and a multicultural Face Emotion Perception Test (MFEPT). The MFEPT used images from the Montreal Set of Facial Displays of Emotion (Beaupre et al., 2000) to assess recognition accuracy for anger, sadness, fear, disgust, and neutral expressions. The Recognition Memory Test (RMT; Warrington, 1984) was included to account for variance in facial affect recognition associated with face recognition only.

Analysis of variance indicated a significant difference among the means on TAS (p < .001, n2 = .09. Tukey post hoc tests indicated lower TAS among HA than Stroke (d = -0.73, p = .001) and TBI (d = -0.56, p = .002) groups; however, TBI and Stroke did not differ significantly (d = -0.15, p = .667). Chi-square tests indicated that the percent of HA with clinically-elevated alexithymia (7.1%) was lower than Stroke (21.4%, p = .009) and TBI (25.8%, p = .001), who did not differ significantly (p = .610). Pearson correlations indicated medium inverse correlations between alexithymia and affect recognition for Stroke (r = -.39, p = .002) and TBI (r = -.36, p = .002). For HA, who showed low alexithymia, the relationship was not significant (r = -.15, p = .070). Examination of the TAS subscales indicated that TAS-Total correlations with MFEPT were driven primarily by Difficulty Identifying Feelings (DIF), as compared to Difficulty Describing Feelings or Externally-oriented Thinking. Partial correlations between TAS-DIF and MFEPT accounting for RMT remained significant for both TBI (rp = -.23, p = .036) and Stroke (rp = -.39 p = .002).

Consistent with prior research, alexithymia was more prevalent and severe among adults with TBI and stroke as compared to healthy adults. Adults with TBI and stroke showed similar levels of alexithymia, and the pattern of associations is consistent with the theory that alexithymia disrupts recognition of emotion displayed by others. This link may partly explain the robust findings of diminished and impaired social and interpersonal outcomes after ABI. Future research should test these links directly, to support the development of interventions to maximize social and interpersonal well-being after ABI.

Apathy, or loss of motivation and interest, is a common sequela of moderate to severe traumatic brain injury (msTBI) and has been associated with frontal lesions and with executive dysfunction in a sample an average of one year post injury (Andersson & Bergdalen, 2002). In older adults sustaining msTBI in particular, the appearance of apathy is more likely to be comorbid with depression when compared to injury in younger adults (Kant et al., 1998). However, studies have consistently shown an important dissociation between apathy and depression, despite overlapping symptoms, with apathy in particular associated with frontal lobe damage (Worthington & Wood, 2018). The present study holds two primary goals. First, to examine the relationship between current apathy ratings and cognition after controlling for ratings of depression and perceived changes in apathy, to account for the unique relationship of injury-related apathy on cognition. Second, to examine the potential variable role of APOE4 carrier status on depression and apathy ratings.

110 older adults with a lifetime history of msTBI (M=9.5 years post-injury) were included as part of a cross-sectional study. Apathy was measured using the Frontal Systems and Behaviors Scale (FrSBe) for both current apathy ratings and perceived change in apathy from pre- to post-injury. Depression was measured using the depression subscale of the Brief Symptom Inventory (BSI). Outcome measures included normed scores for learning (HVLT-R total recall), retention (HVLT-R percent retention), processing speed (Trails A), set-shifting and working memory (Trails B, Digit Span Backwards), and phonemic and category fluency (D-KEFS letter and category fluency). The main independent variable of interest was current apathy ratings. Depression and perceived apathy change were included as control variables for all analyses. Vif scores were calculated for all analyses to ensure that variables were not multicollinear. Finally, we ran an ANOVA to examine the relationship between apathy, depression, and APOE4 carrier status.

When controlling for depression and perceived changes in apathy, current apathy ratings were associated with poorer performance on learning (p=.04, n2=.04), processing speed (p=.001, n2=.10), set-shifting (p=.02, n2=.05), attention (p=.04, n2=.04), phonemic fluency (p=.001, n2=.09), category fluency (p=.001, n2=.10). Current apathy ratings were not associated with retention or working memory. Apathy was significantly associated with depression (p <.001), but was not associated with APOE4 carrier status or the interaction between depression and carrier status.

Despite overlap between depressive symptoms and apathy questionnaires (i.e., loss of interest/pleasure), by controlling for depressive symptoms and perceived changes following injury, we demonstrate the significant independent association of apathy and cognition in an older sample with chronic msTBI. Further, although previous work has shown strong associations between depression and APOE4 carrier status in chronic msTBI samples (Vervoordt et al., 2021), there was no significant relation with apathy directly in our sample, providing further evidence that these are neurobiologically distinct syndromes.

An acquired brain injury (ABI) is a neurological pathology that generates a physical injury in the brain. These include cerebrovascular accidents (CVA) and traumatic brain injuries (TBI). Brain injuries can cause cognitive, emotional, and social problems, which have the potential to severely alter a person’s independence and quality of life. Loneliness, thesubjective experience of social isolation, has been shown to be the best predictor of mental health problems and poorquality of life in patients with ABI. This study aimed to explore the relationship between cognitive, emotional, and social determinants and loneliness in Puerto Ricans with ABI in the chronic phase.

Cross-sectional, exploratory, and correlational methods were implemented. Assessments included the Frontal Systems Behavioral Scale - Spanish version (FrSBe-SP), Perth Emotional Reactivity Scale -Spanish version (PERS), Anticipated Stigma and Concealment (ASC), and the University of California Los Angeles - Loneliness Scale (UCLA-LS).

A total of seventeen participated (n=17). Twenty-nine percent of participants were female. Forty-seven percent had history of previous CVA and fifty-two percent had history of TBI. Correlational analyses suggest a positive and significant relationship between executive dysfunction (FrSBe-SP) and feelings of loneliness (UCLA-LS) (p=.601), as well as a positive and significant relationship between neuroticism-negative emotional reactivity (PERS) and feelings of loneliness (UCLA-LS) (p=.736). Correlational analysis suggests there is no significant relationship between anticipated stigma (ASC) and feelings of loneliness (UCLA-LS) (p=.282).

Our findings suggest that there is a significant relationship between cognitive determinants (executive functions) and emotional determinants (neuroticism) with feelings of loneliness in people with a history of ABI. These results support the connection between executive dysfunction, the tendency to experience negative emotions, and the subjective experience of loneliness, consistent with previous studies. However, our study did not find any significant relationship between interactional determinants, such as stigma and concealment, and loneliness. Understanding the role of cognition, emotions, and social variables in reported feelings of loneliness is important for clinical neuropsychological assessment and rehabilitation interventions.

Numerous survivors of Intimate Partner Violence (IPV) experience physical violence to the head and neck areas, placing them at high risk of sustaining a brain injury (BI). Studies report that the prevalence of traumatic BI among IPV survivors ranges from 35% to as much as 80%. IPV-related BIs can have debilitating long-term consequences on survivors’ quality of life and overall functioning. One important factor impacting quality of life following TBI is verbal memory abilities. Given the link between verbal memory abilities and functional status, identifying predictors of verbal memory performance has important implications for directing support and rehabilitative efforts for survivors of IPV-related BIs. The current aim of the study was to investigate predictors of verbal memory performance following TBI among survivors of IPV.

A modified HELPS Brain Injury (BI) screener was administered to women receiving services for IPV through community organizations and shelters in two urban, Midwestern cities. Women who screened positive for IPV-related BI (n=32) were invited to complete a comprehensive neuropsychological evaluation including the Rey Auditory Verbal Learning Test. The delayed recall score of the RAVLT was used as a measure of verbal memory performance. BI history and characteristics were based on survivors’ responses to the modified HELPS screener. Multiple regression was used to determine significant predictors of verbal performance with RAVLT-Delayed Recall scores serving as the criterion, and education, age, number of reported injuries, number of injuries that left participants feeling dazed/confused, following provider recommendations, and childhood history of injury all entered as predictors.

The model indicated that a large percentage of the variability (R2 = .378) in delayed recall performance could be attributed to the combination of predictors in the model (F (6, 25) = 2.828, p = .047). Examination of the regression coefficients indicated that only following provider recommendations (ß = .420, p = .019), and number of injuries that induced disorientation/confusion (ß = -.592, p = .004) were significantly related to delayed recall after controlling for all other variables in the model.

The results of this study suggest that injury severity and adhering to medical recommendations after IPV-related TBI play a significant role in predicting cognitive functioning. Consistent with existing literature, our findings show that injury characteristics of severity and repetition are closely associated with memory functioning. These findings have implications for guiding screening procedures that may be more sensitive to functional outcome in survivors of IPV who are at risk for BI. Furthermore, our findings highlight a need to increase awareness of IPV-related BI in medical professionals, and to support these front-line staff in providing medical care and psychoeducation about BI to IPV survivors.

Assessment of clinical, functional and psychological outcome after 6 months of moderate and severe TBI

Sixty consecutive participants aged 18 and above with moderate to severe TBI (GCS score of 3-12 at admission) attending the Outpatient Department of Neurosurgery Specialty, Post Graduate Institute of Medical Education and Research, Chandigarh, India were recruited. The exclusion criteria were any pre-existing major psychiatric disorders, intellectual disability, current or past history of substance abuse, degenerative and/or progressive condition, terminal illness and past history of TBI. Ethical clearance was obtained from Institute Ethics Committee. Written informed consent was obtained from all participants prior to inclusion in the study. Socio-demographic details (age, sex, marital status, family type, place of residence, education and occupation) and clinical details (mode of injury, injury severity, treatment, status on discharge, any previous co morbidities) were obtained from participant and hospital records. Functional outcome was assessed by Glasgow Outcome Scale and Barthel’s Index of Activities of Daily Living. Mini Mental State Examination (MMSE) was used to assess cognitive status. Hospital Anxiety and Depression Scale was used to assess symptoms of anxiety and depression.

Out of 60 patients, 40 had moderate head injury and 20 patients had suffered from severe head injury. There were 53 male (88.3%) and 7 (11.7%) female and the mean age was 34 years (SD=14.5). The mean duration of TBI was 11 months (SD=6.5). Fifty percent participants were married and majority was living in joint/extended families. Majorities were residing in rural localities 36 (60%). With regard to education level 11.7% were illiterate, 33% were educated up to 10th standard and 21.7% up to 12th standard. With regard to occupation, 11.7% were unemployed, 6.7% were housewives, 11.7% were students, 8.3% were retired and rest (61.6%) was engaged in varied occupations.

The most common mode of injury was road traffic accident (90%). Contusion was the most common CT abnormality noted (37 patients, 61.7%). Regarding treatment, 36 patients (60%) underwent surgical intervention and 24 (40%) were managed conservatively. With regard to surgical intervention, 28 (77.8 %) patients underwent decompressive hemicraniectomy and subsequent cranioplasty and rest 8 (22.2 %) underwent craniotomy and hematoma evacuation. As per Glasgow Outcome Scale, 50 (83%) had low disability and 10 (17%) had moderate to severe disability. The mean Barthel’s Index score was 19.6+1.07 (Range 15-20) which indicated that most of the patients had resumed independence in activities of daily living. Only 25% participants were observed to have cognitive impairment (MMSE). With regard to anxiety and depression 16.7% showed symptoms of anxiety whereas 30% showed symptoms of depression (HADS score >8).

After 6 months of TBI, most participants had resumed independence in activities of daily living but cognitive impairment is persistent in 25% and symptoms of depression in 30% participants.

Extant literature suggests significant heterogeneity in recovery trajectories after experiencing a moderate to severe traumatic brain injury (TBI) during childhood (Moran et al., 2016). The Cognitive and Linguistic Scale (CALS) is a promising non-norm-referenced measure designed for serial monitoring within an inpatient rehabilitation setting that may optimize prediction of acute recovery and long-term neuropsychological functioning. To date, the CALS has primarily been examined in the context of injury characteristics such as severity and etiology (e.g., Slomine et al., 2016), and it is unclear what non-injury factors may be relevant to consider. Using archival data gathered from an inpatient pediatric neurorehabilitation program, this study examined associations between the CALS and select sociodemographic factors to better inform the clinical utility of the measure.

Participants included 56 youth (46% BIPOC, 66% male) aged 2-17 years (M = 12.40, SD = 3.99) who were admitted for moderate to severe TBI to an inpatient rehabilitation program at a regional tertiary care children’s hospital. Data extracted from medical records included demographic information (i.e., age at injury, sex, ethnoracial identity, address, initial Glasgow Coma Scale (GCS) rating, CALS at admission, and full-scale IQ (FSIQ) at discharge. GCS was used as a proxy for injury severity. Residential addresses were geocoded and area-level median income was used as a proxy for familial socioeconomic status (SES). A multiple regression model was utilized to parse the individual contributions of demographic variables) on initial CALS performance while accounting for injury severity. Parallel regression models were used to determine whether patient characteristics moderate the association between initial CALS performance and cognitive functioning at discharge.

Preliminary analyses demonstrated that there were no significant associations between GCS and demographic variables, ps > .05. Patient age at injury was significantly associated with CALS total score at admission above and beyond injury severity and other demographic characteristics, t (31) = 2.55, p = .016, such that older age was associated with higher initial CALS scores. Results of moderator analyses between CALS and patient characteristics showed a significant main effect of injury severity, such that higher GCS was associated with higher FSIQ at discharge across models, ps < .05. No significant interactions were identified.

These findings provide additional evidence for the generalizability of the CALS and further characterize its associations with non-injury factors, which is important for better understanding aspects that contribute to recovery trajectories and outcomes after moderate to severe TBI. Given the longstanding challenges in regard to the validity of neuropsychological assessment for diverse groups, it is critical to explicitly examine cultural context when considering the clinical utility of a measure. A limitation of the current study is the utilization of broad demographic information due to limited availability of sociocultural data. Future research should examine more granular and culturally-specific variables that may impact CALS performance (e.g., educational attainment, linguistic considerations), beyond using broad-based demographic data as a proxy for sociocultural factors. Another important next step is to utilize serial administrations of the CALS to examine the impact of sociocultural factors on recovery trajectories following TBI.

Research has shown that a small, yet significant minority of individuals with traumatic brain injuries (TBI) experience psychotic symptoms post-TBI. TBI has also been associated with earlier onset schizophrenia in individuals with a genetic risk for psychosis.

The current case presents a 15-year-old female with pre-existing psychotic symptoms (auditory and visual hallucinations [AVH] and delusions) who stopped experiencing AVH a few weeks post-injury. The, at least temporary, cessation of her hallucinations raises several important questions about the neuroanatomy of pediatric psychosis and the impact of TBI on a potentially divergently developing brain.

Patient is a 15-year-old female who identifies as Hispanic (adopted, of Central American origin). Prior to her injury her developmental history was notable probable neglect prior to adoption, and her psychiatric history was notable for major depressive disorder, anxiety, chronic insomnia, and AVH. AVH were religious in nature and involved command hallucinations. AVH had been attributed to her chronic insomnia, per medical records. Participant was in a motorcycle accident with her caregiver and sustained a severe traumatic brain injury (GCS=3-8). Medical workup, including MRI, indicated a right basal ganglia hemorrhage, right thalamic hemorrhage, as well as injury of the brain stem at the pons, resulting in left-sided hemiparesis. She was ultimately diagnosed with traumatic right-sided intracerebral hemorrhage, traumatic subdural hematoma, traumatic hemorrhage of basal ganglia, traumatic encephalopathy, and a left homonymous hemianopia (left visual field cut) from her right temporal parietal injury. She received a neuropsychological evaluation 10 months post-TBI. Testing included: subtests of the WISC-V, measures of sustained attention and executive functioning, tasks of orientation and memory, and questionnaire measures assessing social-emotional, executive, and adaptive functioning. Parent and adolescent clinical interviews were conducted.

Results indicated appropriate orientation, broadly intact intelligence presumed consistent with premorbid functioning, average sustained attention, and deficits in aspects executive functioning, visual-motor processing speed, and fine motor skills. Although she performed well on objective measures of memory, she reported significant long term social memory loss (e.g., difficulties remembering friends and memories of emotional connectedness) during the clinical interview. Interview and questionnaire measures also indicated continued challenges with depression and anxiety, as well as post-traumatic personality changes, tics, and symptoms of trauma. Patient reported that her hallucinations, both visual and auditory, stopped early in her recovery post-TBI; patient’s premorbid delusions were still present post-TBI.

This case raises questions related to the impact of structural or axonal injury to regions or networks in the brain that may be associated with psychosis. It also adds to a minimal literature examining AVH in pediatric TBI. Using the current literature as a framework we will explore 1) the injury to this patient’s thalamus as it relates to both her emotional memory deficits as well as the interruption of her AVH hallucinations, and 2) the relationship between her visual field cut and the interruption of her visual hallucinations. Overall, this case study highlights the unique nature of the developing brain both in terms of the TBI and psychosis.

Executive function (EF) is a self-regulatory construct well-established as a predictor of long-term academic achievement and socioemotional functioning in children (Best et al., 2009; Diamond, 2013; Zelazo & Carlson, 2020). Traumatic brain injury (TBI) in childhood frequently results in EF deficits (Beauchamp & Anderson, 2013; Levin & Hanten, 2005). In comparison to adults (Okonkwo et al., 2013), there is an absence of viable blood biomarkers for pediatric TBI to assist in diagnosis and prognosis. Osteopontin (OPN), an inflammatory cytokine, has recently been identified as a putative pediatric TBI blood biomarker (Gao et al., 2020). However, more work is needed to establish OPN’s utility in predicting functional outcomes. Thus, the present study aimed to test relations between OPN measured during the first 72 hours of hospitalization and EF 6-12 months post injury among a sample of pediatric TBI patients.

Sample consisted of 38 children (age at injury = 4.60-16.67 years, M age = 10.61 years, 65.8% male, lowest Glasgow Coma Scale [GCS] score = 3-15, M gcs = 9.97) with TBI whose parents completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF-2; Gioia et al., 2015) 6-12 months post injury. Plasma OPN was measured at hospital admission, 24 hours after admission, 48 hours after admission, and 72 hours after admission. 7-scores for each BRIEF-2 clinical scale (Inhibit, Self-Monitor, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Task-Monitor, Organization of Materials) and composite index (Behavior Regulation Index, Emotion Regulation Index, Cognitive Regulation Index, Global Executive Composite) were used in analyses.

Correlation analyses revealed large positive associations (rs = .50-.73, ps = <.001.039) between 48-hour OPN and all BRIEF-2 scales/indices except Initiate. OPN at 24 hours positively correlated with Task-Monitor (r = .40, p = .037). Bivariate logistic regression analyses testing whether OPN predicted at least mildly elevated BRIEF-2 t-scores (>60) did not yield significant associations. Additional supplementary analyses testing whether alternative injury markers - glial fibrillary acidic protein (GFAP), ubiquitin C-terminal Hydrolase-L1 (UCH-L1), S100 calcium binding protein B (S100B) - measured at all time points as well as lowest GCS score correlated with EF revealed the following: admission S100B positively correlated with Inhibit (r = .34, p = .045), 48-hour UCH-L1 negatively correlated with Initiate (r = -.49, p = .041) and Cognitive Regulation Index (r = -.48, p = .044), and 72-hour UCH-L1 negatively correlated with Initiate (r = -.47, p = .048).

Findings showed higher OPN at 48 hours post admission was broadly related to worse parent-reported EF 6-12 months later, with 24-hour OPN also showing limited associations. Higher levels of alternative injury markers likewise showed limited associations with EF outcomes. Null logistic regression findings may be due to few participants having elevated BRIEF-2 scores. Disrupted EF development may be more noticeable after longer time periods as children age and self-regulatory demands increase. Overall, OPN was found to more consistently predict EF outcomes than GCS score and other injury markers. This could be because OPN is a marker of inflammation, which may be particularly predictive of TBI cognitive outcomes.