Traumatic brain injury (TBI) is a leading cause of acquired disability in U.S. children,
with an estimated 700,000 cases every year, presenting in 75% of children with trauma and
accounting for 70% of deaths from childhood trauma. Childhood TBIs often result in
significant impairment in cognitive functions,1 particularly in core executive functions
(EFs) due to the vulnerability of the frontal lobes, especially after a moderate to
severe TBI. Core EF is composed of three skills: inhibitory control, working memory, and
cognitive flexibility. These skills are associated with impaired EF behaviors, increased
attention problems, and lower health-related quality-of-life (HRQOL). However,
evidence-based EF rehabilitation programs are lacking. Although a combination of diverse
cognitive interventions may improve children's EF, limited affordability, accessibility,
adherence, and generalizability hamper clinically adapting and implementing such
interventions in the rehabilitation setting. Virtual reality (VR) offers an exciting
alternative strategy for EF rehabilitation of childhood TBI due to its flexibility,
accessibility, and immersive experiences in three dimensions. These properties may
increase adherence to training and foster an enhanced transfer of learned EF skills to
untrained tasks in everyday life. Thus far, rigor-ous randomized clinical trials (RCTs)
have not been conducted to establish the efficacy of VR-based EF reha-bilitation for
childhood TBI.
The overall goal of the project is to assess the efficacy of a novel VR-based interactive
cognitive training (VICT) program for EF rehabilitation in children with TBI with the
following aims:
Aim 1. Examine VICT's efficacy in improving core and daily EF skills among children with
TBI.
Hypothesis 1.1: Children in the intervention group will show enhanced improvement over
controls in trained VR-based EF tasks and untrained NIH Toolbox tasks from baseline to
post-intervention and follow-up visits; Hypothesis 1.2: The intervention group will show
better reported daily EF than controls at the follow-up visit; Hypothesis 1.3: Children
in the intervention group will show faster improvement than controls in daily-reported EF
skills between post-intervention and follow-up visits.
Aim 2. Examine VICT's efficacy in reducing attentional problems among children with TBI.
Hypothesis 2.1: Children in the intervention group will show a greater reduction in
attentional problems as measured by testing on the Conners Continuous Performance Test
3rd Edition™ (Conners CPT 3TM) from baseline to the post-intervention and follow-up
visits than controls; Hypothesis 2.2: Children in the intervention group will show fewer
everyday attentional problems on the Be-havior Assessment System for Children 3rd Ed
(BASC-3) self- and parent-ratings of attention at the follow-up visit than controls;
Hypothesis 2.3: The direct effect of the VICT program in reducing attention problems will
be mediated by children's EF behaviors as measured by the Behavior Rating Inventory of
Executive Function, Second Edition (BRIEF2) at the follow-up visit.
Aim 3. Examine VICT's efficacy in improving HRQOL among children with TBI. Hypothesis
3.1: The intervention group will show higher levels of reported HRQOL than controls at
follow-up; Hypothesis 3.2: The direct effect of the VICT program on HRQOL at follow-up
will be mediated by children's EF skills and ratings of EF behaviors and attention at the
post-intervention and follow-up visits.