Journal of Pediatric Psychology, 43(8), 2018, 928–942

doi: 10.1093/jpepsy/jsy013
Advance Access Publication Date: 21 March 2018
Systematic Review

A Systematic Review of Interventions for Hot

and Cold Executive Functions in Children and
Adolescents With Acquired Brain Injury
Clara Chavez-Arana,1,2,3 MS, Cathy Catroppa,1,2 PHD, Edmundo

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Carranza-Esca rcega,4 BSC, Celia Godfrey,1 DPSYCH, Guillermina
n
Ya llez,3 PHD, Bele
~ez-Te n Prieto-Corona,3 PHD, Miguel A. de Leo n,5 MS,
and Vicki Anderson,1,2 PHD
1
Child Neuropsychology, Murdoch Children’s Research Institute, 2University of Melbourne, 3FES Iztacala,
Universidad Nacional Autonoma de Mexico, 4Universidad del Valle de Mexico, and 5Iskalti Centro de Atencion y
Educacion Psicologica
All correspondence concerning this article should be addressed to Clara Chavez-Arana, Convento de San Diego 3,
Colonia Santa Monica, Tlalnepantla de Baz, Estado de Mexico C.P.54050, Mexico. E-mail: clara.chavezarana@gmail.com
Received September 15, 2017; revisions received February 21, 2018; accepted February 23, 2018

Abstract
Objective We investigated interventions, which aimed to improve cold and hot executive
functions (EFs) in children and adolescents with a diagnosis of acquired brain injury (ABI).
Methods The following electronic databases were searched: Medline, CINAHL, PsycINFO, and
Pubmed. The database filters limited the search to articles published between 1990 and July 2017
in English or Spanish, including children and adolescents. Articles were read and classified accord-
ing to the levels of evidence of the Australian National Health and Medical Research Council and
the Downs and Black checklist was used for Measuring Study Quality. Results Thirty studies are
reported in this systematic review. Level of evidence, quality of the studies, characteristics of the
participants, interventions implemented, and outcomes are described. Conclusions The study
of rehabilitation for executive dysfunction in children with ABI is emerging. Although few high-
quality intervention studies exist in this area, which limits conclusions regarding intervention effi-
cacy, results of existing studies suggest that education for parents may be an important component
of intervention. Moreover, caregiver involvement may improve the effectiveness of hot EFs rehabili-
tation interventions, while high intervention session frequency may be important in improving cold
EFs. Positive behavior supports and specific training based on a cognitive model provided some
promising findings, which require further evaluation.

Key words: acquired brain injury; adolescents; children; executive functions; intervention;
rehabilitation and systematic review.

Acquired brain injury (ABI) is a term that encom- Children and adolescents with ABI usually present with
passes damage to the brain that occurs after birth deficits in several cognitive domains such as attention,
Australian Institute of Health and Welfare (2007). processing speed, memory, language, and social
ABIs have diverse causes including traumatic brain problem-solving skills. In particular, executive func-
injury (TBI), cerebral vascular diseases, infections, tions (EFs) deficits are common and emerge with time
brain tumors, vestibular dysfunction, and postsurgi- postinjury as the child matures (Galvin, Lim, Steer,
cal complications (Ciuffreda & Kapoor, 2012). Edwards, & Lee, 2010; Kok et al., 2014).

C The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
V
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 928
Interventions for Hot and Cold Executive Functions 929

EFs refer to a group of cognitive skills required for commitment therapy, which emphasizes acceptance
purposeful goal-directed activity and can be divided rather than behavior change or elimination only
into cold and hot domains (De Luca & Leventer (Morris, Johns, & Oliver, 2013). One more way to in-
(2008). Cold EF refers to purely cognitive EF, while volve caregivers is by teaching them positive behavior
hot EF refers to the affective aspects of these cognitive supports (PBS) to improve their child’s behavior (Carr
skills (Kerr & Zelazo, 2004). Cold EFs are more likely et al., 2002). Three main ideas support the inclusion
to be elicited by decontextualized problems such as of caregivers in a child’s rehabilitation: (1) caregivers
manipulation of abstract concepts, numbers, or letters are aware of the behavioral changes presented after in-
(Brock, Rimm-Kaufman, Nathanson, & Grimm, jury onset; (2) they are likely to be a stable resource
2009; Hongwanishkul, Happaney, Lee, & Zelazo, throughout child’s life, and (3) EFs development can
2005). Hot EFs refer to the socioemotional domain be affected by family factors (Catroppa et al., 2017;
and are more likely to be evoked by motivationally Lefley, 2009).

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and emotionally meaningful contexts (Brock et al., Over recent years, systematic reviews of interven-
2009; Hongwanishkul et al., 2005). The line between tion programs in children and adolescents with ABI
hot and cold EFs is blurred because both work to- have been published, investigating technological inter-
gether toward adaptive functions (Zelazo & Carlson, ventions (de Kloet, Berger, Verhoeven, van Stein
2012). However, the degree to which tasks elicit hot Callenfels, & Vlieland, 2012; Linden et al., 2016) and
or cold EFs differentiates tasks that aim to improve combining interventions for children with neurodeve-
them (Hongwanishkul et al., 2005). Based on the de-
lopmental disorders and children with diagnosis of
scription of De Luca and Leventer (2008), we consid-
ABI (Robinson, Kaizar, Catroppa, Godfrey, & Yeates,
ered behavior regulation, emotion regulation, affective
2014). To date, these interventions have failed to con-
decision making, social skills, and theory of mind hot
sider differences in hot and cold EF rehabilitation de-
EFs. Metacognition, cognitive flexibility, attention, in-
spite substantial evidence supporting the distinction
hibition, working memory planning, and problem-
between hot and cold EFs (Hongwanishkul et al.,
solving were considered cold EFs (De Luca &
2005; Rubia, 2011; Zelazo & Carlson, 2012).
Leventer, 2008). The description of hot and cold EFs
done by De Luca and Leventer (2008) was chosen be- Research has typically studied EFs as a single domain
cause it includes social skills, which are usually im- and focused almost exclusively on cold EFs
paired in children and adolescents with ABI (Hongwanishkul et al., 2005; Zelazo & Carlson,
(Beauchamp & Anderson 2010; Ryan et al., 2016). 2012). The systematic study of interventions with an
EFs are required in children’s daily activities. explicit deconstruction of EF into hot and cold is novel
Children with deficits in cold EFs tend to forget for a review and has the potential to advance knowl-
instructions, misplace school supplies, have difficulties edge in the field of rehabilitation of children with ABI.
in concentrating during homework, make careless mis- To our knowledge, this systematic review is the first in
takes, and try a solution repeatedly even if it is not studying interventions that aimed to improve EFs dis-
useful (Castellanos, Sonuga-Barke, Milham, & tinguishing between its cold and hot components. We
Tannock, 2006; Gioia, Kenworthy, & Isquith, 2010). aimed to assess the quality of those studies and iden-
Children with impairments in hot EFs are more likely tify any interventions specific to hot and cold EF.
to interrupt conversations, make risky decisions, pre-
sent anger outbursts, and misinterpret others Methods
(Castellanos et al., 2006; Gioia et al., 2010; Zelazo &
Carlson, 2012). Impairments in hot and cold EFs neg- Selection of the Studies
atively impact children’s self-esteem, family function- The systematic review was conducted following the
ing, social adaptation, and academic achievement PRISMA Statement (Moher, Liberati, Tetzlaff,
(Brock et al., 2009; Yeates et al., 2004). Altman, & PRISMA Group, 2010). The following
The rehabilitation of specific cognitive processes is electronic databases were searched: Medline,
a path often used to improve a child’s EFs. This ap- CINAHL, PsycINFO, and Pubmed. The database fil-
proach has strong support from cognitive models ters limited the search to articles published between
(Sohlberg & Mateer, 1987), which breakup cognitive January 1990 and July 2017 in English or Spanish,
processes into subcomponents or levels. The involve- and included children and adolescents (age 0–18
ment of caregivers is a common practice in child reha- years). The Medical Subject Headings (MeSH) or key-
bilitation. An example of this method is providing words were grouped as population, intervention and
caregivers education about the ABI and associated outcome. Online Supplementary Table S1 describes
behaviors to increase their knowledge and reduce the keywords used for the search, and Online
stress (Bauml, Frobose, Kraemer, Rentrop, & Pitschel- Supplementary Table S7 contains the PRISMA
Walz, 2006). Another example is acceptance and checklist.
930 Chavez-Arana et al.

Records idenfied through Addional records idenfied

Idenficaon
database searching through other sources
(n = 771) (n = 7)

Records aer duplicates removed

(n = 554)
Screening

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Records screened Records excluded
(n = 554) (n = 476)

Full-text arcles assessed Full-text arcles excluded,

for eligibility with reasons
Eligibility

(n = 56) (n = 26)
Included

Studies included in
qualitave synthesis
(n = 30)

Figure 1. PRISMA flow diagram.

Requirements for Inclusion achieved, full papers underwent review by two

Abstracts were reviewed independently by two reviewers using a standard data collection form and
authors to determine eligibility for inclusion. Inclusion then a decision was made. This electronic search gen-
criteria were: (1) children and adolescents with ABI or erated 771 papers. Additionally, seven papers were
families of children or adolescents with ABI; (2) par- identified from reference lists. A total of 554 papers
ticipants of age 0–18 years. For papers that included were screened from which 30 papers met the inclusion
children, adolescents, and adults, the majority of the criteria. From those 30 papers, 4 papers reported
participants had to be <18 years old for the study to long-term outcomes of a previous study. In these
be included; (3) at least two measurement points, be- cases, the original paper and the follow-up paper were
fore and after intervention; (4) any intervention or treated as one with their previous results. Three papers
combination of interventions to improve EF and/or so- (Kurowski et al., 2013; Tlustos et al., 2016; Wade,
cial skills and/or reduce disinhibited behavior; (5) the Stacin et al., 2014) reported different outcomes from
components of the intervention were described. the same study. Those papers were treated indepen-
Exclusion criteria were: (1) Review articles; (2) dently. We report 26 studies based on 30 papers.
Participants with neurodevelopmental disorders, drug Figure 1 illustrates the selection process and results of
users, abusive head trauma, or diagnosis other than the search.
ABI; (3) Predominance of participants >18 years old;
(4) Outcome other than EF, social skills, or behavior Classification of the Studies and Quality Grading
problems; and (5) Case studies. All articles were read and classified by two reviewers
Abstracts were categorized as eligible, likely eligi- according to the levels of evidence of the Australian
ble, or ineligible. Reviewers agreed on 90% of the National Health and Medical Research Council
abstracts. For those where consensus was not initially (ANHMRC; see Online Supplementary Table S2).
Interventions for Hot and Cold Executive Functions 931

After classifying the articles, quality was assessed by methods to assign participants to groups was common
two authors using the Downs and Black checklist for (five studies). Lack of a control group was a character-
Measuring Study Quality (DB; Downs & Black, istic of the studies with a level of evidence IV (seven
1998). The DB checklist consists of 27 items that as- studies), while using a blind RCT resulted in a level of
sess the quality of reporting (10 items), external valid- evidence II (three studies). On average, included stud-
ity (3 items), internal validity (7 items), confounders ies met 72.3% of the DB checklist criteria for study
(6 items), and power effect (1 item) (Downs & Black, quality. Most studies reported aims, outcomes mea-
1998; see Online Supplementary Table S3). Effect sured, characteristics of the participants, primary
sizes were not always reported in studies. Therefore, results, and interventions. Adverse events or absence
based on a previous systematic review (Knight, of adverse events and information regarding partici-
Scheinberg, and Harvey, 2013), we assigned a score of pants lost to follow-up were often not reported. On
1 to studies that reported effect sizes and 0 to studies average, studies were 62.8% adherent to external va-

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that did not. A full description of the levels of Levels lidity criteria, 63.7% adherent to internal validity cri-
of evidence of the ANHMRC and DB checklist can be teria, and 51.2% adherent to confounder criteria.
found in the Online Supplementary Tables S2 and S3. Lower severity of injury, residing far from the hospital
and non-White race were some of the characteristics
Data Synthesis of the nonparticipants. Eight studies in this systematic
The data were extracted from each study and entered review allocated the control groups to waitlists, while
into a code sheet, so relevant information could be only three studies allocated the control group to other
processed by two reviewers (C.C. and E.C.). types of treatment. Power analysis was conducted in
Description of the level of evidence and quality of the 50% of the studies reviewed. Total 65.3% of the stud-
studies can be seen in the Online Supplementary ies were conducted in English-speaking countries, and
Tables S2 and S3. A value indicating adherence to the interventions were delivered in English. The search in-
27 DB checklist criteria (yes/no at the item level, cluded papers in Spanish, but there were no studies
expressed as an aggregate adherence percentage) was published in Spanish or conducted with Hispanic par-
calculated for each study. Participants’ characteristics ticipants. Furthermore, English not being the primary
are described in Table III. Studies were classified language was the main reason for participant exclu-
according to their main objective into interventions sion in some studies.
that aim to improve cold EFs (Table I), hot EFs
(Table II), or both (Table III). Report of the effect sizes Participants
was often lacking and measures used were heteroge- Online Supplementary Table S4 illustrates partici-
neous. For this reason, we followed the approach of a pants’ characteristics. Total 61.5% of the studies only
previous systematic review (Stinson, Wilson, Navreet, included participants with TBI and were predomi-
Yamada, & Holt, 2008) and reported the authors’ nantly male in 57.6% of the studies. The majority of
main conclusions. Improvement was defined as the studies included adolescents, while studies with
p  .05 reported by the authors. Authors divided cog- children <12 years of age were scarce. Most studies
nitive processes into subcomponents to assess the did not have a determined period after injury as an
treatment effectiveness. Online Supplementary Table inclusion criterion, and when reported, a wide range
S5 shows the measures used to assess cognitive pro- (3–24 months) was evident.
cesses and a list with the subtests used from each mea-
sure. The subcomponents reported by cognitive Interventions for Cold EFs
process and measures used varied among studies. Cold EFs refer to skills within the cognitive domain.
Owing to the data heterogeneity, it was not possible Cold EFs investigated by the studies reviewed in-
to perform a meta-analysis. However, we reported the cluded: attention, metacognition, problem-solving,
percentage of the studies targeting each cognitive pro- and working memory. All of the interventions applied
cess that found improvement in at least one measure in these studies used a specific cognitive training ap-
(see Online Supplementary Table S6). proach (Table I).

Interventions for Hot EFs

Results Hot EFs refer to skills within the socioemotional do-
Level of Evidence and Quality of the Studies main. Hot EFs investigated by the studies in this sys-
As can be seen on Tables I, II, and III, most of the evi- tematic review included: behavior, emotion
dence in the studies corresponded to a Level III-1, regulation, and social abilities. Additionally, these
which is a randomized controlled trial (RCT) design studies addressed family factors. Providing education
without blinding arrangements (11 studies). Using about ABI and teaching parents PBS were the types of
nonrandomized methods or pseudo-randomized interventions used to improve hot EFs (Table II).
Table I. Interventions That Aim to Improve Cold EFs
932

First author Level of DB checklist total Name of Target of the Type of Delivery mode Duration Frequency Providers Attrition Outcome
(year) evidence score intervention intervention intervention (# of sessions) (duration of skills
ANHMRC each session)

Braga (2012) III-1 17 Metacognitive di- Metacognition SCT Group and indi- 3 months (26) Twice a week Trained psy- Metacognition þ
mension and self- vidual, FTF (2 hr) chology Self-esteem þ
program esteem students
Chan (2011) III-1 16 Problem-solving Problem-solving SCT Group, FTF 7 weeks (14) Twice a week 0% Metacognition þ
skills training and (3 hr) Problem-solving þ
program metacognition
Eve (2016) IV 14 Cogmed Working SCT Individual, 5–7 weeks (25) Weekly Cogmed cer- 22% Central executive
memory online (30–40 min) tified and visuospatial
coach sketchpad 0
Phonological
loop þ
Galbiati III-2 16 Attention remedia- Attention SCT Individual, FTF 6 months (104) Four times a 0% Attention þ
(2009) tion training week
program (45 min)
Kaldoja III-2 13 FORAMENRehab Attention SCT Individual, 6 weeks (10) Twice a week 0% Focused visual 0
(2015) online (30–50 min) Focus auditory
0 Sustained þ*
Complex —
Tracking 0
Seguin (2017) II 21 Ready! Set? Let’s Attention and SCT Individual, FTF 5 weeks (15) Three times a Trained psy- 10.5% Attention 0
Train! metacognition week (1 hr) chology Metacognition –
students Flexibility,
working memory
and inhibition þ
Sjö (2010) IV 10 Amat-C Attention and SCT Individual, FTF 6–9 months Every week- Supervised Attention —
memory (100) day (30–45 trainer Memory —
min) and
teacher
Thomas- III-1 13 TEACH-ware Attention, mem- SCT Individual, com- 8 weeks (—) Two times a Language 0% Attention 0
Stonell ory, and prob- puter-based week (1 hr) therapist Memory þ
(1994) lem-solving Problem-solving 0
van’t Hooft III-1 18 Amat-C Attention and SCT Children and 17 weeks Weekly 10% Sustained
(2005), memory coaches, FTF (17 and sessions (—); attention þ
(2007) and home/ practice at Daily work Selective
school home/school) (30 min) attention þ*
practice Memory þ/0

Note. ANHMRC ¼ Australian National Health and Medical Research Council; EF ¼ executive function; DB checklist ¼ Downs and Black checklist; FTF ¼ face-to-face—unable to determined or not reported..; SCT ¼ Specific
cognitive training. ANHMRC classifies case series, posttest, and pre–posttest as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2; pseudo-RCTs
are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow-up; þ Indicates significant improvement in at least one outcome;
0 indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process.
Chavez-Arana et al.

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Table II. Interventions That Aim to Improve Hot EFs

First author Level of evi- DB Name of Target of the Type of Delivery mode Duration Frequency (dura- Providers skills Attrition Outcome
(year) dence checklist intervention intervention intervention (# of sessions) tion of each
ANHMRC total score session)

Brown (2014) II 22 SSTP combined Child behavior and PBS and ACT Group and individ- 10 weeks (8 group — (FTF 2 hr; phone Clinical psycholo- Post 16.66%; Behavior R þ*
with ACT emotion, ual, FTF com- sessions, 3 phone calls 1.5 hr) gists certified in Follow-up 20%; Emotion R þ
parent’s psycho- bined with calls) SSTP Total: 36.66% Parenting þ*
logical flexibility telephone
and experiential
avoidance
Pastore (2011) III-2 17 CBT Child behavior CBT Individual 4–8 months (—) 2–3 each week Therapist — Social
(45–60 min) abilities þ Behavior
Rþ
Emotion R þ
Tlustos (2016) III-1 17 CAPS Social competence CBT Family, online 6 months (—) 1–2 each week Clinical 6% Social
(at least 1 hr) psychologists abilities þ/0
Wade (2005) IV 18 FPS Cognition, coping, CBT Family, online — (8 core and 4 — (videoconference Research assistant 0% Social
and family optional) 45–60 min; —) and therapist abilities 0
communication Emotion R 0
EFs 0
Interventions for Hot and Cold Executive Functions

Family
functioning 0
Wade (2006) III-1 21 FPS Behavior and social CBT Family, online — (8 core and 6 Every 1 or 2 weeks Psychologist and 20% Social abilities 0
competence optional) (—) trained psych Behavior R 0/þ
graduate
Wade (2006) III-1 20 FPS Problem-solving CBT Family, online 6 months (7 core Every 1 or 2 weeks Trained psych 15.78% Behavior R þ
skills and 4 optional) (75–100 min) graduate Parental
stress 0
Wade (2008) III-1 20 TOPS EFs, language prag- CBT and meta- Family, online — (10 core and 4 Every 1 or 2 weeks Psych graduate 0% Behavior R 0
matics, and so- cognitive optional) (—) Emotion R þ
cial processing training Parental
stress 0 Family
functioning þ
Wade (2011) III-1 18 TOPS Behavior and par- CBT and meta- Family, online 6 months — — 20% Behavior R 0
ent–teen cognitive (10 core, 4 Family
conflicts training optional) conflict —
Wade (2014, III-1 20 CAPS Behavior CBT Family, online 6 months (8 core, — Trained Post: 12.30%; Behavior R and in-
2015) 4 supplemental, psychologists 18 months after hibition in
6 videoconference) baseline: 30.8% older
adolescents þ,
in younger adoles-
cents 0.
Wiseman- IV 11 Improving prag- Pragmatic skills Group, FTF 6 weeks (24) 4 each week (4 hr) Trained social — Social
Hakes matic skills worker sufficiency 0
(1998)
Woods, IV 14 Signpost Child behavior and PBS and CBT Individual, tele- 5 months (7 core and — Signpost certified — Behavior R þ/0
Catroppa, parenting phone, combined 2 supplemental) psychologist Parenting þ
Godfrey, & practices with home Parental
Anderson practice stress 0
(2014)

(continued)
933

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 934 Chavez-Arana et al.

pseudo-RCTs are Level III-1; SSTP ¼ stepping stones triple P; TOPS ¼ Teen online problem-solving; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains at follow
DB checklist ¼ Downs and Black checklist; EFs ¼ executive functions; FPS ¼ family problem-solving intervention; FTF ¼ face-to-face; PBS ¼ positive behavior supports; R ¼ regulation; RCT ¼ randomized control trial; signposts ¼ signposts for build-
Note. — Unable to determined or not reported; ACT ¼ acceptance and commitment therapy; ANHMRC: Australian National Health and Medical Research Council; CAPS ¼ counselor-assisted problem-solving; CBT ¼ cognitive behavior therapy;

ing better behavior; SSTP ¼ stepping stones triple P. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent controls are considered Level III-2;
Behavior R and pa-
rental stress chil-
Interventions for Both Hot and Cold EFs

risk þ, children
Outcome Table III describes the interventions in which the pri-

not at risk 0
Parenting þ
mary objective was to improve overall EFs. The types

dren at
of interventions applied by these studies were ABI edu-
cation, interactive video gaming, cognitive behavior
therapy, and specific cognitive training.
Attrition

Outcomes
Tables I, II, and III present the main outcomes of the

up; þ Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the same cognitive process.
0%

studies indicating the functions that improved (þ) and

did not change (0) significantly according to the
Providers skills

Signpost certified

authors of the study. The most studied domains were

psychologist

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attention and behavior regulation.

Cold EF Outcomes
Interventions that were effective in improving atten-
Frequency (dura-

FTF sessions every

tion were short (6–17 weeks), intensive (1–2 weekly

6 weeks (3 hr);
telephone sup-
port biweekly
tion of each

(15–20 min)
session)

sessions along with homework), delivered as face-to-

face sessions in a clinic, and were based on a cognitive
model. Still, there was no clear difference between ef-
fective and noneffective interventions. Three studies
measured working memory and reported improve-
Group, FTF or indi- 5 months (3 FTF or
(# of sessions)

8 phone calls)

ment in at least one outcome. These interventions

Duration

were short (length 5–12 weeks) and intensive (1–3

weekly sessions). Studies that aimed to improve meta-
cognition were effective, those interventions were in-
tensive (biweekly), delivered as face to face group
phone, combined
vidual via tele-
Delivery mode

sessions, and had strong theoretical support. There

with home

were two studies addressing problem-solving, only

practice

one of which was effective. The effective intervention

was delivered using face-to-face group sessions and
was based on a problem-solving model. One study
intervention

found improvements in inhibition and no study

PBS and CBT
Type of

reported improvements in planning. Two studies mea-

sured changes in cognitive flexibility and one of them
found improvements. The effective intervention was
parenting practi-

delivered during a longer period of time (10 weeks)

ces, and family
Target of the
intervention

Child behavior,

compared with the noneffective intervention

adaptation

(5 weeks). The duration of interventions that im-

proved cold EFs ranged between 5 weeks and
6 months.
intervention
Name of

Hot EF Outcomes
Six studies measured functional domains related to so-
Signpost

cial abilities and reported a few improvements. The

domains reported were diverse. The interventions that
total score
checklist

improved behavior and emotion regulation provided

DB

17

parents with education about ABI and taught them

PBS. Interventions that were effective in improving
hot EFs lasted between 10 weeks and 8 months.
Level of evi-

ANHMRC
dence

III-2
Table II. Continued

Hot and Cold EF Outcomes

The characteristics of the interventions that aimed to
improve overall EFs were heterogeneous, and
Catroppa,

Anderson

improvements were rarely seen, compared with inter-

First author

Godfrey,

(2014)

ventions that targeted specific cold or hot EFs.

Woods,
(year)
Table III. Interventions That Aim to Improve Hot and Cold EFs

First author Level of DB Name of Target of the Type of Delivery mode Duration Frequency Providers skills Attrition Outcome
(year) evidence checklist intervention intervention intervention (# of sessions) (duration of
ANHMRC total score each session)

Dise-Lewis IV 13 BrainSTARS Cognitive Psycho- Group, FTF 4 months (3) Every 6 or — — Behavior R 0
(2009) development education and self- 8 weeks (—) EFs 0
guided
De Kloet IV 17 Therapy Wii Cognitive, so- Interactive Individual 12 weeks (2 — (sessions 1 Occupational 10% Attention þ/0
(2012) cial, physical video gaming FTF and prac- hr, home therapist, Working
activity and tice at home) practice 2 hr physical memory þ
QOL a week) therapist and Social abilities
trained þ/0
teachers
Kurowski II 26 CAPS Problem solv- CBT Family, 6 months (7 Every 1 or 2 Psychologist 6-months: EFs in older
(2013), ing, commu- Online core and 4 weeks (—) 5.97%; teens þ*
(2014) nication and optional) 18-months: EFs in younger
self- 70.14% teens 0
Interventions for Hot and Cold Executive Functions

regulation
Treble- III-2 16 AIM Attention and SCT Individual, 10 weeks (10) Weekly sessions Trained 41% Inhibition 0
Barna EFs FTF com- (60–90 min); psychologists Flexibility 0
(2015) bined with homework two Planning 0
home online to four times Behavior R
practice per week þ/0/0
(20–40 min)
Wade III-1 21 TOPS EFs CBT and meta- Family, online — (10 core and — Psychologist 20% EFs severe
(2010) cognitive 4 optional) and trained TBI þ
training psych EFs moderate
graduates TBI 0
EFS reported by
parents 0

Note. —unable to determined or not reported; ANHMRC ¼ Australian National Health and Medical Research Council; BrainSTARS ¼ Brain Injury: strategies for teams and reeducation for students;
CBT ¼ cognitive behavior therapy; DB checklist ¼ Downs and Black checklist EFs ¼ executive functions; FTF ¼ face-to-face; QOL ¼ quality of life; R ¼ regulation; RCT ¼ randomized control trial;
SCT ¼ specific cognitive training. ANHMRC classifies case series, posttest, and pre–post-test as Level IV; comparative studies without controls are Level III-3; comparative studies with concurrent con-
trols are considered Level III-2; pseudo-RCTs are Level III-1; RCTs are Level II and systematic reviews of RCT are Level I. The total score from the DB checklist is reported. * Indicates changes maintains
at follow-up; þ Indicates significant improvement in at least one outcome; 0 Indicates no significant change; / was used in the outcome column when different results were found across measures of the
same cognitive process.
935

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936 Chavez-Arana et al.

Family Factor Outcomes because of the high prevalence of child TBI in compar-
The studies that taught parents PBS were effective in ison with other types of ABI and there being more
improving parenting practices. Improvements in pa- male participants in this clinical group (Thurman,
rental distress were not presented in most of the stud- 2016). Total 61.5% of the studies reported in this sys-
ies. Family functioning presented mixed results. tematic review focused in studying participants with
All the studies that targeted metacognition, work- TBI. The absence of studies with young children is sur-
ing memory, and parenting practices found at least prising considering that ABI is the leading cause of in-
some improvement. Some improvement in emotional jury in children <5 years of age (Thurman, 2016).
regulation, family functioning, behavior regulation, Taking into account that cognitive sequelae of brain
and attention were present in half or more of the stud- injury in children become more evident over time
ies targeting those outcomes. Effective results were (Anderson, Spencer-Smith, & Wood, 2011), it is
limited in the studies that measure overall EFs, social expected that family and school staff’s concerns about
abilities, parental stress, and planning.

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children’s cognitive or behavioral deficits may become
apparent when the requirements of the environment
Discussion increase and when certain skills should come online.
Participants included in the reviewed studies had a
To our knowledge, this is the first systematic review
variety of injury and lesion types, making comparabil-
that focuses on interventions aiming to improve hot
ity across participants difficult. Each type of lesion has
and cold EFs of children and adolescents with ABI.
its own criteria to determine severity, and levels of se-
Interventions from 26 studies were reviewed. The use
verity are not comparable across lesions. The criteria
of hot and cold EFs has several implications for
used by Woods et al. (2014) to determine the level of
knowledge in the field of rehabilitation of children
severity, by combining neurological deficits and imag-
with ABI. Owing to this framework, we were able to
ing results, seems like a useful alternative for ABI pop-
differentiate approaches used in rehabilitation.
ulations. A determined time after injury onset as an
Improvement was defined as p  .05 reported by the
inclusion criterion is often missing. Spontaneous re-
authors. Studies that targeted metacognition, working
memory, and parenting practices found some im- covery of cognitive functions occurs up to 8 months
provement. Most interventions targeting emotional after the onset of severe injuries (Chavez et al., 2016;
regulation (75%), behavior regulation (69.2%), and Leon-Carrilo & Machuca-Murga, 2001) and there-
parenting practices (75%) found improvements by in- fore, spontaneous recovery can enhance the effective-
volving caregivers and teaching them PBS. Studies ness of interventions, highlighting the importance of
measuring overall EFs found less effective results inclusion of control groups in trial designs for ABI.
(33.3%) than when treating specific EFs, such as at- The studies included in this review describe injury-
tention (55.5%), inhibition (50%), social abilities related variables; however, description of noninjury
(42.8%), cognitive flexibility (50%), and problem- variables is often lacking. As EF development is influ-
solving (50%). Interventions aiming to reduce paren- enced by the environment (Jansen et al., 2012;
tal stress had limited improvements (25%). No studies Meldrum, Verhoeven, Junger, van Aken, & Dekovic,
measuring planning found improvements. 2016), noninjury variables should also be addressed
(Catroppa et al., 2017).
Level of Evidence and Quality of the Studies
The evidence that we have about the rehabilitation of Cold EFs
hot and cold EFs is limited. However, the information Cold EFs refer to skills within the cognitive domain.
provided in the studies was sufficient to assess the Attention is the most studied cold EF with 35% of the
findings. In summary, the level of evidence and quality studies in this review focusing on this skill. In the stud-
of the studies is still limited. Based on the results from ies reviewed, attention was usually deconstructed into
the DB checklist, overall the percentage of adherence the levels of attention reported by Sohlberg and
was 72.3% in reporting, 62.8% in external validity, Mateer (1987) and most commonly measured with
63.7% in internal validity, and 51.2% in confounders. the Test of Everyday Attention for Children (Manly
Power analysis was reported in 50% of the studies. et al., 2016). From the studies that measure attention
Control groups were generally allocated to waitlists, 55.5% of them found some improvement.
which has been associated with overestimation of the Interventions that aim to improve attention and work-
intervention effect (Patterson, Boyle, Kivlenieks, & ing memory tend to combined weekly individual ses-
Van Ameringen, 2016). sions with homework, while metacognition and
problem-solving can be enhanced by face-to-face
Participants group sessions. Still, results show that there is no con-
There was a predominance of male participants with sensus on how cold EFs should be deconstructed and
TBI reported in the studies. This can be explained measured. Maintenance of improvements in cold EFs
Interventions for Hot and Cold Executive Functions 937

was often not assessed. Only two studies found main- how to deconstruct or measure social skills as a cogni-
tenance of some improvement in attention at 6 months tive process; therefore, comparison among studies is
(van’t Hooft, et al., 2007) and 1.63 years (Kaldoja not possible. The model from Beauchamp and
et al., 2015) after the intervention was completed. Anderson (2010) describes the cognitive processes in-
Interventions that aim to improve attention were volve in social skills development, which can support
greatly influenced by the attention treatment model of the development of assessments tools and interven-
Sohlberg and Mateer (1987). This model has a specific tions for social skills.
process approach and considers five levels of atten- The concepts from Ylvisaker and Feeney (2009)
tion: focused, sustained, selective, alternating, and di- strongly influenced the rehabilitation of hot EFs in
vided. Tasks for each level of attention are applied children with ABI. They propose that the adults in-
based on its difficulty, going from basic to more com- volve in the daily routines of the child should partici-
plex tasks (Sohlberg & Mateer, 1987). The specific pate in the intervention (Ylvisaker & Feeney, 2009).

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training approach was used by interventions that aim The studies in this review taught parents PBS, which
to improve Cold EFs. The theoretical support of the aim to improve behavior by applying educational
interventions that aim to improve metacognition in- methods to broaden behavior repertoire and redesign
cluded concepts from Clements and Natasi (1990), the context (Carr et al., 2002). Contexts impact EFs
Ylvisaker and Feeney (2002), and Cole (2006). Based development (Zelazo, Qu, & Kesek, 2010) and chil-
on those ideas, the interventions attempted to create dren with ABI are especially vulnerable to adverse
real-life context, by teaching metacognitive skills and environments (Taylor et al., 2002). Their deficits on
provide participants with the space to use them in the EFs can be exacerbated when they are surrounded by
company of peers. unfavorable family circumstances (Taylor et al.,
To date, there is no precise pathway leading to the 2002). As a consequence, studies that aim to improve
improvement of cold EFs. Nonetheless, effective treat- hot EFs involved parents, or the entire family, and
ments tend to focus on only one or two cold EFs, are measure family factors.
short, intensive, and based on a cognitive model. This
review adds to previous evidence (Bewick, Raymond, Family Factors
Malia, & Bennet, 1995), which supports the combina- Results show that parenting practices can improve by
tion of specific cognitive training and metacognitive teaching parents PBS. However, maintenance of
strategies to rehabilitate cold EFs. Theoretically, repe- improvements in parenting practices was reported
tition in cognitive training activities appears to acti- only in one study (Brown et al. 2014). Studies included
vate neural networks and seems to readjust the in this systematic review attempted to reduce parental
maladaptive networks presented after ABI onset stress by using mindfulness, acceptance commitment
(Galetto & Sacco, 2017). Enhancing metacognition therapy, and stress management techniques with lim-
within a context similar to real-life in combination ited results that were not maintained over time
with other cold EFs could be the key element to gener- (Woods, Catroppa, Godfrey, & Anderson 2014).
alize cold EFs gains to new scenarios. Finally, the problem-solving model of D’Zurilla and
Nezu (1999) was often used as part of the treatment
Hot EFs to improve family functioning, and 60% of those stud-
Hot EFs refer to skills within the socioemotional do- ies found some improvement.
main. Challenging behavior is the most problematic Woods et al. (2014) and Kurowski et al., (2013)
consequence of brain injury according to family, show that families’ needs vary depending on the
teachers, and friends (Feeney, 2010). The impact that child’s cognitive impairment, age and severity of the
challenging behavior has on parents may explain why injury. To date, we know that participants who pre-
behavior regulation was targeted by 50% of the stud- sent more impairment benefit the most (Chavez-
ies. The Child Behavior Checklist (Achenbach & Arana, 2018; Woods et al., 2014;). However, we can-
Resco, 2001) was the questionnaire most often used to not draw conclusions on how interventions can be
measure behavior regulation. Improvements were seen adapted according to the child’s cognitive needs or
in 69.2% of the studies that targeted behavior regula- age. Nonetheless, the single-case study methodology
tion and can be achieved by providing parents with ed- can add in this respect (Perdices & Tate, 2009).
ucation about ABI and teaching them PBS. This review allowed us to acquire knowledge about
Maintenance of improvements in behavior regulation the active ingredients in the rehabilitation of hot (PBS-
was reported at 6 months (Brown et al. 2014) and at parents) and cold (intensity) EFs. Still, we do not
18 months (Woods, Catroppa, Godfrey, & Anderson know if improvements found in the studies are trans-
2014). By comparing the interventions, we can see ferable to other settings or maintained over time.
that recovery of hot EFs seems to require more time in Furthermore, we need consider that real-life contexts
comparison to cold EFs. There is no agreement on may be more challenging for the child because they
938 Chavez-Arana et al.

require hot and cold EFs to work together toward Hispanic population. Future studies could examine
adaptive function (Zelazo & Carlson, 2012). In addi- the feasibility and effectiveness of interventions in
tion, impairments in either hot or cold EFs can have Spanish-speaking countries.
secondary consequences to other aspects of EF (Blair
& Diamond, 2008). Therefore, balance between cog- Limitations
nition and emotion is required for self-regulation de- The present study has several limitations. The way in
velopment (Blair & Diamond, 2008). which EFs are deconstructed and measured varied
Some of the interventions described are adaptations among studies; therefore, conclusions were drawn
of interventions previously used in other populations, based on the qualitative synthesis of the studies. In ad-
such as children with neurodevelopmental disorders dition, the keywords used in the search did not specify
or adults with ABI. For this reason, we suggest that the variety of brain injuries. As a consequence, rele-
adapting interventions from different populations can vant studies may have been overlooked and not

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be beneficial for children and adolescents with ABI. reported in this review. Another limitation of the
Complete descriptions of the treatments and their the- study is that it was not possible to analyze the associa-
oretical base are often missing. The absence of com- tion between injury factors (severity, type, location),
plete descriptions limits the development of new participant factors (age, preinjury deficits), and the ef-
interventions and replication studies, and therefore, fectiveness of the intervention. Owing to the absence
hinders research in child neuropsychological of studies focusing on young children, conclusions in
rehabilitation. this systematic review may not apply to them. Another
limitation is that we divided EFs into hot and cold
Future Directions based on the description from De Luca & Leventer
Future studies are encouraged to use a stronger meth- (2008). However, hot or cold EFs are elicited depend-
odology to develop a stronger evidence base for the ing on the context and they work together
interventions. Outcomes reported by participants who (Hongwanishkul, Happaney, Lee, & Zelazo, 2005).
are aware of their treatment allocation may differ Most studies did not evaluate whether improvements
from unaware participants (Hr objartsson & are maintained over time; therefore, we know little
Gøtzsche, 2001). We suggest that allocating control about long-term outcomes.
groups to another treatment can provide stronger evi-
dence and control the effect caused by being treated Clinical Recommendations
by a health professional. Future studies are invited to Clinical recommendations resulting from this review
study preschool children with ABI. Early brain injury should be considered with caution because of the lim-
has been associated with poor EFs in later stages of ited quality of evidence included in this research syn-
life (Anderson et al., 2011), which may be prevented thesis. Further research is necessary to increase
or ameliorated by providing early interventions. confidence in the generalizations that can be drawn
Young children may benefit from interventions such from this body of research. We recommend that inter-
as coordinative exercise, preventive educational–be- ventions provide ABI education to those close to or
havioral, and school-based programs, which have working with the child to maximize their understand-
shown to be beneficial for healthy young children and ing of the cognitive and behavioral consequences of
young children requiring intensive care hospitalization ABI and how they may arise in everyday activities. For
(Chang, Tsai, Chen, & Hung, 2013; Diamond, rehabilitation of hot EFs, we recommend active partic-
Barnett, Thomas, & Munro, 2007; Melnyk, et al., ipation of parents by teaching them PBS to reduce or
2004). Description of the reasons for attrition could prevent behavior problems and improve parenting
assist in determining the generalizability of the results. skills. For rehabilitation of Cold EFs, we endorse in-
We encourage future studies to include noninjury vari- tensive rehabilitation, high frequency of sessions in
ables (e.g., parent mental health), evaluate whether combination with homework. The evidence suggests
improvements transfer to other settings, specify time that Cold EFs interventions can be developed based on
since injury as an inclusion criterion, describe methods a cognitive model.
for determining injury severity, and outline the theo-
retical basis of the intervention. Adaptations of inter- Supplementary Data
ventions that have been effective in improving EFs in
Supplementary data can be found at: http://www.jpepsy.
different populations could benefit children and ado-
oxfordjournals.org/.
lescents with ABI. Studies with participants with mild
injury severity, participants who reside far from the
hospital and non-Caucasian participants are required. Acknowledgments
These populations were underrepresented in existing The authors would like to acknowledge Poh Chua from the
research. In particular, there are no studies with the library of Royal Children’s Hospital for her valuable advice.
Interventions for Hot and Cold Executive Functions 939

Funding Castellanos, F. X., Sonuga-Barke, E. J., Milham, M. P., &

The study received support from The National Council for Tannock, R. (2006). Characterizing cognition in ADHD:
Science and Technology (CONACYT) and the Victorian Beyond executive dysfunction. Trends in Cognitive
Government Operational Infrastructure Scheme. The fund- Sciences, 10, 117–123.
ing bodies did not play a role in the design of the study, col- Catroppa, C., Hearps, S., Crossley, L., Yeates, K. O.,
lection, analysis, and interpretation of the data, or writing of Beauchamp, M. H., Fusella, J., & Anderson, V. (2017).
the manuscript. All authors remain independent of all fund- Social and behavioral outcomes following traumatic brain
ing bodies described. injury. Journal of Neurotrauma, 34, 1439–1447.
Chan, D. Y. K., & Fong, K. N. K. (2011). The effects of prob-
Conflicts of interest: None declared. lem-solving skills training based on metacognitive princi-
ples for children with acquired brain injury attending
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