title: Impaired Visual Integration in Children with Traumatic Brain Injury: An Observational Study.
abstract: BACKGROUND
  Axonal injury after traumatic brain injury (TBI) may cause impaired sensory integration. We aim to determine the effects of childhood TBI on visual integration in relation to general neurocognitive functioning.
  
  
  METHODS
  We compared children aged 6-13 diagnosed with TBI (n = 103; M = 1.7 years post-injury) to children with traumatic control (TC) injury (n = 44). Three TBI severity groups were distinguished: mild TBI without risk factors for complicated TBI (mildRF- TBI, n = 22), mild TBI with ≥1 risk factor (mildRF+ TBI, n = 46) or moderate/severe TBI (n = 35). An experimental paradigm measured speed and accuracy of goal-directed behavior depending on: (1) visual identification; (2) visual localization; or (3) both, measuring visual integration. Group-differences on reaction time (RT) or accuracy were tracked down to task strategy, visual processing efficiency and extra-decisional processes (e.g. response execution) using diffusion model analysis. General neurocognitive functioning was measured by a Wechsler Intelligence Scale short form.
  
  
  RESULTS
  The TBI group had poorer accuracy of visual identification and visual integration than the TC group (Ps ≤ .03; ds ≤ -0.40). Analyses differentiating TBI severity revealed that visual identification accuracy was impaired in the moderate/severe TBI group (P = .05, d = -0.50) and that visual integration accuracy was impaired in the mildRF+ TBI group and moderate/severe TBI group (Ps < .02, ds ≤ -0.56). Diffusion model analyses tracked impaired visual integration accuracy down to lower visual integration efficiency in the mildRF+ TBI group and moderate/severe TBI group (Ps < .001, ds ≤ -0.73). Importantly, intelligence impairments observed in the TBI group (P = .009, d = -0.48) were statistically explained by visual integration efficiency (P = .002).
  
  
  CONCLUSIONS
  Children with mildRF+ TBI or moderate/severe TBI have impaired visual integration efficiency, which may contribute to poorer general neurocognitive functioning.
authors.affiliation: Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands.
authors.forename: Marsh
authors.initials: M
authors.lastname: Königs
authors.affiliation: Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands.|Department of Methods, VU University Amsterdam, Amsterdam, The Netherlands.|Institute of Psychology, Department of Methodology and Statistics, Leiden University, Leiden, The Netherlands.
authors.forename: Wouter D
authors.initials: WD
authors.lastname: Weeda
authors.affiliation: Pediatric Surgical Center of Amsterdam, Emma Children's Hospital Academic Medical Center and VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: L W Ernest
authors.initials: LW
authors.lastname: van Heurn
authors.affiliation: Department of Pediatric Neurology, VU University Medical Center, Amsterdam, The Netherlands.|Department of Pediatric Neurology, Maastricht University, Medical Center, Maastricht, The Netherlands.
authors.forename: R Jeroen
authors.initials: RJ
authors.lastname: Vermeulen
authors.affiliation: Trauma Unit, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: J Carel
authors.initials: JC
authors.lastname: Goslings
authors.affiliation: Department of Emergency Medicine, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Jan S K
authors.initials: JS
authors.lastname: Luitse
authors.affiliation: Department of Pediatric Neurology, Emma Children's Hospital Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: Bwee Tien
authors.initials: BT
authors.lastname: Poll-Thé
authors.affiliation: Merem Rehabilitation Center 'De Trappenberg', Huizen, The Netherlands.|Department of Rehabilitation, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Anita
authors.initials: A
authors.lastname: Beelen
authors.affiliation: Libra Rehabilitation Medicine and Audiology, 'Blixembosch', Eindhoven, The Netherlands.
authors.forename: Marleen
authors.initials: M
authors.lastname: van der Wees
authors.affiliation: Libra Rehabilitation Medicine and Audiology 'Leijpark', Tilburg, The Netherlands.
authors.forename: Rachèl J J K
authors.initials: RJ
authors.lastname: Kemps
authors.affiliation: Department of Pediatric Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Coriene E
authors.initials: CE
authors.lastname: Catsman-Berrevoets
authors.affiliation: Department of Clinical Neuropsychology, VU University Amsterdam, Amsterdam, The Netherlands.|Emma Children's Hospital Academic Medical Center, Amsterdam, the Netherlands.
authors.forename: Jaap
authors.initials: J
authors.lastname: Oosterlaan
mesh_terms: D000293:Adolescent; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D001930:Brain Injuries / Q000503:physiopathology; D003071:Cognition; D005500:Follow-Up Studies; D014796:Visual Perception