2.0 CE Credits - Special Issue: Resilience (JINS 25:4, 2019): CE Bundle 2

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Educational Objectives
  1. List risk and protective factors related to cognitive outcomes amongst childhood brain tumor survivors and
  2. Discuss how aerobic exercise promotes recovery following acquired brain injury.
  3. Describe the prevalence of adaptive competence, or “resilience,” in a cohort of extremely preterm children compared to normal birth weight controls.
  4. Identify child and family characteristics associated with resilience in the preterm group.
  5. Explain what confabulations following brain injury is, and
  6. Discuss the possible causes for the why very few reports on children confabulating can be found.
  7. List the most common community neuropsychological rehabilitation goals of young people with Acquired Brain Injury (ABI)
  8. Describe the association between the types of rehabilitation goals a young person with ABI may have and their sex, age, injury type and time post-injury.

Course Information
Target Audience:Intermediate
Availability:Date Available: 2019-06-10
You may obtain CE for this JINS package at any time.
Offered for CEYes
CostMembers $10
Non-Members $15
Refund PolicyThis JINS package is not eligible for refunds
CE Credits2.0


Acquired brain injuries (ABI) involve damage to the brain that occurs after birth and is not due to congenital or genetic causes. ABI are prevalent throughout childhood and adolescence and arise from a range of causes, including traumatic brain injury (TBI) and non-traumatic insults such as stroke, brain tumors, infections, and hypoxia. The adverse effects of pediatric ABI have been extensively documented; regardless of etiology, they can affect multiple domains, including physical, cognitive, social, adaptive, and behavioral functioning. Impairments caused by ABI typically follow a dose–response relation, with more severe and diffuse injuries resulting in worse and more persistent negative outcomes, often leading to lifelong impairments and poor quality of life.

Most research on the consequences of ABI focuses on the difficulties and deficits that occur as a result of the injury. In this context, it is easy to forget that some children with ABI exhibit surprisingly rapid or good recovery, display positive outcomes, and return to, or even exceed, pre-injury levels of functioning. Indeed, some children with ABI are able to adapt to their symptoms and sequelae, compensate for any impairments, succeed in academic, social, and community settings, and experience good quality of life.

Accounts of good recovery after ABI are readily available. For example, a subgroup of children with severe TBI show no deficits in one or more domains of functioning (neuropsychological, behavioral, adaptive, academic) between 6 months and 4 years postinjury (Fay et al., 2009). At the milder end of the TBI spectrum, most children who sustain mild TBI or concussion display no postconcussive symptoms or neuropsychological difficulties within 1 month of their injuries (Beauchamp et al., 2018; Zemek et al., 2016). Other ABI populations also display instances of positive outcome. Adolescents born extremely premature, many of whom sustain perinatal brain injuries, perceive their health and well-being as similar to term-born peers (Hack et al., 2011). Similarly, young adult survivors of childhood brain cancers report unexpectedly good health-related quality of life, which may be attributable to better coping mechanisms and greater optimism (Stam et al., 2006).

Research focusing on positive outcomes after ABI is increasing and has the potential to provide critical information on the factors that are protective or predictive of preserved functioning, and conversely, on what markers may be useful in identifying children at-risk for poor outcome. Positive outcomes can be conceptualized in a variety of ways and using diverse methodologies. Many authors evoke the notion of resilience to explain seemingly contradictory associations between experienced hardship and favorable outcome. Resilience can be broadly defined as “the capacity of a dynamic system to adapt successfully to disturbances that threaten system function, viability, or development”; applied specifically to psychological disciplines, it usually refers to “positive adaptation in the context of risk or adversity” (Masten, 2014, pp. 9–10). For example, evidence suggests that certain aspects of resilience (Losoi et al., 2015; Tonks et al., 2011) and character strengths such as hope, zest, and courage (Hanks et al., 2014) are associated with better outcome after TBI.

Research focusing on healthy behaviors and quality of life and their determinants offers additional insights into what factors are associated with well-being after ABI such as stroke, brain tumors, and TBI (e.g., Di Battista et al., 2014; Gupta & Jalali, 2017; O’Keeffe et al., 2017). For example, health promotion and self-efficacy have been shown to be positively associated with health status, life satisfaction, and participation after TBI (Braden et al., 2012). Thus, healthy behaviors and quality of life, while often operationalized as indicators of poor outcome after ABI, can also be used to identify patients and families with good outcomes.

Collectively, descriptors referring to positive psychology, plasticity, reserve, resilience, character strengths, coping, healthy behaviors, and quality of life can be subsumed under the broader notion of “wellness,” defined by the World Health Organization as the absence of disease or infirmity in combination with a state of complete physical, mental, and social well-being (WHO, 1946). Wellness may thus be conceptualized as an umbrella term for a range of predictors, measures, and outcomes of optimal functioning and constitutes an interesting avenue for exploring “the other side of ABI.”

The aim of this special section of JINS is to showcase a collection of empirical articles that address notions of resilience and wellness after pediatric ABI. The articles concern a variety of etiologies of ABI, including TBI and concussion, neonatal stroke and hypoxic-ischemic encephalopathy, extremely low birthweight and prematurity, and brain tumor. They also represent a range of definitions and conceptualizations of resilience and wellness, and describe a variety of methodological approaches.

Several key distinctions are reflected in the articles. One is whether resilience and wellness are defined in terms of outcomes or in terms of characteristics that may predict outcomes. For example, Durish et al. examine psychological resilience as a predictor of concussion outcomes in adolescents, showing that it predicts postconcussive symptoms, as mediated by anxiety and depressive symptoms. Similarly, Donders et al. focus on cognitive reserve, as measured by maternal education, as a moderator and predictor of cognitive outcomes after TBI in children. In both of these studies, resilience is viewed as a personal characteristic that can affect outcomes.

By contrast, Taylor et al. define resilience in terms of positive academic and behavioral outcomes of children born preterm and extremely low birthweight. They show that resilience defined in this fashion is predicted by factors such as children’s cognitive functioning and learning, and more advantaged family environments. In a similar fashion, Beauchamp et al. examine wellness after pediatric concussion, with wellness defined in terms of multiple endpoints. They show that wellness can be predicted by children’s age and developmental history, as well as by injury mechanism and acute mental status. In these two studies, resilience and wellness are defined as outcomes in and of themselves, and the focus is on identifying the factors that help to predict them.

Another key distinction reflected in the papers is that resilience and wellness are very much in the eye of the beholder. That is, researchers and health-care providers may have different definitions of resilience and wellness than children with ABI or their parents. Williams et al. use a mixed methods approach to examine how parents of children with neonatal brain injury define resilience and show that qualitative and quantitative definitions are aligned but distinct. They also show that resilience in this population depends on close medical follow-up, early intervention, and intrinsic child and parent factors. McCarron et al. argue that resilience and wellness should be defined in terms of the goals of children with ABI if rehabilitation is to be truly patient centered. They show that the key goals for youth with ABI focus on activities and participation, body function, and environmental factors.

The papers also reflect a key distinction between resilience as defined by intrinsic versus extrinsic factors. Conklin et al. study aerobic fitness and motor proficiency as intrinsic characteristics that may promote better cognitive outcomes in children who are brain tumor survivors. Durish et al. and Donders et al. also treat resilience as an intrinsic characteristic, be it psychological resilience or cognitive reserve, respectively. In contrast, Taylor et al. and Williams et al. show how extrinsic factors, such as the family environment and the quality of health care, can promote resilience and wellness.

A final important distinction reflected by the papers is that resilience can be defined at different levels of analysis. Although resilience and wellness are defined in most cases at the level of children’s behavioral or psychological outcomes, they can also potentially be defined in terms of brain health. Conklin et al. use task-based functional magnetic resonance imaging to understand the neural substrates associated with better motor proficiency. Christensen et al. present a brief literature review to suggest that children’s developing brains may demonstrate a surprising resilience in response to ABI, evidenced by reduced vulnerability to confabulation. However, more work is needed to determine the underlying neural mechanisms that may protect against confabulation in younger brains.

The range of definitions and measures used in the studies in this special section reflects not only the breadth of concepts relevant to positive outcomes, but also the fact that applying positive perspectives to the study of ABI is a relatively new endeavor. Nonetheless, rehabilitation researchers are already exploring the efficacy of positive psychology, positive parenting interventions, and health and wellness programs for promoting optimal outcome in individuals with ABI (e.g., Andrewes et al., 2014; Antonini et al., 2012; Ashworth et al., 2015; Brenner et al., 2012). The conceptual boundaries between the constructs of positive psychology, plasticity, reserve, resilience, character strengths, coping, healthy behaviors, optimal outcome, quality of life, and wellness may well be somewhat blurry. Nevertheless, future research on who does well after pediatric ABI constitutes fertile ground for furthering the science of resilience and for developing interventions to promote wellness among children with ABI.

Individual Titles, Authors, and Articles:

Cognitive Performance, Aerobic Fitness, Motor Proficiency, and Brain Function Among Children Newly Diagnosed With Craniopharyngioma
  • Heather M. Conklin | Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Kirsten K. Ness | Department of Epidemiology/Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Jason M. Ashford | Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Matthew A. Scoggins | Division of Translational Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Robert J. Ogg | Division of Translational Imaging, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Yuanyuan Han | Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Yimei Li | Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Julie A. Bradley | Department of Radiation Oncology, University of Florida Health Proton Therapy Institute, Jacksonville, Florida
  • Frederick A. Boop | Department of Surgery, St. Jude Children’s Research Hospital, Memphis, Tennessee
  • Thomas E. Merchant | Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee


The authors do not have any conflicts of interest to disclose.


Craniopharyngioma survivors experience cognitive deficits that negatively impact quality of life. Aerobic fitness is associated with cognitive benefits in typically developing children and physical exercise promotes recovery following brain injury. Accordingly, we investigated cognitive and neural correlates of aerobic fitness in a sample of craniopharyngioma patients.


Patients treated for craniopharyngioma [N=104, 10.0±4.6 years, 48% male] participated in fitness, cognitive and fMRI (n=51) assessments following surgery but before proton radiation therapy.


Patients demonstrated impaired aerobic fitness [peak oxygen uptake (PKVO2)=23.9±7.1, 41% impaired (i.e., 1.5 SD<normative mean)], motor proficiency [Bruininks-Oseretsky (BOT2)=38.6±9.0, 28% impaired], and executive functions (e.g., WISC-IV Working Memory Index (WMI)=96.0±15.3, 11% impaired). PKVO2 correlated with better executive functions (e.g., WISC-IV WMI r=.27, p=.02) and academic performance (WJ-III Calculation r=.24, p=.04). BOT2 correlated with better attention (e.g., CPT-II omissions r=.26, p=.04) and executive functions (e.g., WISC-IV WMI r=.32, p=.01). Areas of robust neural activation during an n-back task included superior parietal lobule, dorsolateral prefrontal cortex, and middle and superior frontal gyri (p<.05, corrected). Higher network activation was associated with better working memory task performance and better BOT2 (p<.001).


Before adjuvant therapy, children with craniopharyngioma demonstrate significantly reduced aerobic fitness, motor proficiency, and working memory. Better aerobic fitness and motor proficiency are associated with better attention and executive functions, as well as greater activation of a well-established working memory network. These findings may help explain differential risk/resiliency with respect to acute cognitive changes that may portend cognitive late effects. (JINS, 2019, 25, 413–425)

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Resilience in Extremely Preterm/Extremely Low Birth Weight Kindergarten Children
  • H. Gerry Taylor | The Research Institute at Nationwide Children’s Hospital, Center for Biobehavioral Health, and Department of Pediatrics, The Ohio State University, Columbus, Ohio, Department of Pediatrics, Case Western Reserve University, and Rainbow Babies & Children’s Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio
  • Nori Minich | Department of Pediatrics, Case Western Reserve University, and Rainbow Babies & Children’s Hospital, University Hospitals Cleveland Medical Center, Cleveland, Ohio
  • Mark Schluchter | Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
  • Kimberly Andrews Espy | University of Texas at San Antonio, San Antonio, Texas
  • Nancy Klein | Department of Teacher Education, Cleveland State University, Cleveland, Ohio


The authors have no conflicts to declare.


Research on developmental outcomes of preterm birth has traditionally focused on adverse effects. This study investigated the prevalence and correlates of resilience in 146 extremely preterm/extremely low birth weight (EPT/ELBW) children (gestational age <28 weeks and/or birth weight <1000 g) attending kindergarten and 111 term-born normal birth weight (NBW) controls.

Methods: Adaptive competence (i.e., “resilience” in the EPT/ELBW group) was defined by scores within grade expectations on achievement tests and the absence of clinically elevated parent ratings of child behavior problems. The “adaptive” children who met these criteria were compared to the “maladaptive” children who did not on child and family characteristics. Additional analyses were conducted to assess the conjoint effects of group (ELBW vs. NBW) and family factors on adaptive competence.


A substantial minority of the EPT/ELBW group (45%) were competent compared to a majority of NBW controls (73%), odds ratio (95% confidence interval)=0.26 (0.15, 0.45), p<.001. Adaptive competence was associated with higher cognitive skills, more favorable ratings of behavior and learning not used to define adaptive competence, and more advantaged family environments in both groups, as well as with a lower rate of earlier neurodevelopmental impairment in the EPT/ELBW group. Higher socioeconomic status and more favorable proximal home environments were associated with competence independent of group, and group differences in competence persisted across the next two school years.


The findings document resilience in kindergarten children with extreme prematurity and highlight the role of environmental factors as potential influences on outcome. (JINS, 2019, 25, 362–374)

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Confabulation Resilience of the Developing Brain: A Brief Review
  • Julie Nyvang Christensen | Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Glostrup, Denmark
  • Thomas Alrik Sørensen | Aalborg University & Sino-Danish Center for Education and Research, Aalborg, Denmark


Neither of the authors has any potential conflicts of interest to report and neither has received financial support for this work.


To investigate a possible confabulation resilience of the developing brain.


We performed a literature search on confabulation in PubMed and identified all empirical studies of children and adolescents under the age of 18.


The analysis identified only three case studies of confabulation in children under the age of 18 of 286 empirical studies of confabulation. This reveals a striking discrepancy in the number of reported cases caused by brain injury between children and adults. We hypothesize that there may be a resilience toward confabulation in the developing brain and present three tentative explanations regarding the possible underlying mechanisms.


Additional awareness on the scarcity of reported cases of confabulation in children could lead to important insights on the nature of confabulation and greater understanding of the resilience and plasticity of the developing brain. (JINS, 2019, 25, 426–431)

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What do Kids with Acquired Brain Injury Want? Mapping Neuropsychological Rehabilitation Goals to the International Classification of Functioning, Disability and Health
  • Robyn Henrietta McCarron | The Cambridge Centre for Paediatric Neuropsychological Rehabilitation, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 8AH, UK, Department of Psychiatry, University of Cambridge, Cambridge, Cambridgeshire, CB2 0SZ, UK
  • Suzanna Watson | The Cambridge Centre for Paediatric Neuropsychological Rehabilitation, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 8AH, UK, Collaborations for Leadership in Applied Health Research and Care East of England Programme, National Institute of Health Research, Cambridge, Cambridgeshire, CB2 8AH, UK
  • Fergus Gracey | The Cambridge Centre for Paediatric Neuropsychological Rehabilitation, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, Cambridgeshire, CB2 8AH, UK, Collaborations for Leadership in Applied Health Research and Care East of England Programme, National Institute of Health Research, Cambridge, Cambridgeshire, CB2 8AH, UK, Department of Clinical Psychology, University of East Anglia, Norwich, Norfolk, NR4 7TJ, UK

E-mail address | robyn.dudley@cantab.net

S.W. holds a clinical management role overseeing the service within which the data were collected. The authors declare that there are no other conflicts of interest. There are no sources of financial support to declare for this paper.


To increase understanding of the community neuropsychological rehabilitation goals of young people with acquired brain injuries (ABIs).


Three hundred twenty-six neuropsychological rehabilitation goals were extracted from the clinical records of 98 young people with ABIs. The participants were 59% male, 2–19 years old, and 64% had a traumatic brain injury. Goals were coded using the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). Descriptive statistical analysis was performed to assess the distribution of goals across the ICF-CY. Chi-squared and Cramer’s V were used to identify demographic and injury-related associations of goal type.


The distribution of goals was 52% activities and participation (AP), 28% body functions (BF), 20% environmental factors (EF), and <1% body structures (BS). The number of EF goals increased with age at assessment (V = .14). Non-traumatic causes of ABIs were associated with more EF goals (V = .12). There was no association between sex or time post-injury and the distribution of goals across the ICF-CY.


Young people with ABIs have a wide range of community neuropsychological rehabilitation goals that require an individualized, context-sensitive, and interdisciplinary approach. Community neuropsychological rehabilitation services may wish to ensure they are resourced to focus intervention on AP, with increasing consideration for EF as a young person progresses through adolescence. The findings of this research support models of community neuropsychological rehabilitation that enable wellness by combining direct rehabilitative interventions with attention to social context and systemic working across agencies. (JINS, 2019, 25, 403–412)

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