Performance monitoring in children following traumatic brain injury Tisha J. Ornstein, 1 Harvey S. Levin, 3 Shirley Chen, 2 Gerri Hanten, 3 Linda Ewing-Cobbs, 4 Maureen Dennis, 5 Marcia Barnes, 6 Jeffrey E. Max, 7 Gordon D. Logan, 8 and Russell Schachar 2 1 Department of Psychology, Ryerson University, Toronto, Ontario Canada; 2 Department of Psychiatry, Hospital for Sick Children, Toronto, Ontario, Canada; 3 Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA; 4 University of Texas Health Center, Houston, TX, USA; 5 Department of Psychology, Hospital for Sick Children, Toronto, Ontario, Canada; 6 University of Guelph, Guelph, Ontario, Canada; 7 Department of Psychiatry, University of California, San Diego and Children’s Hospital and Health Center, San Diego, CA, USA; 8 Department of Psychology, Vanderbilt University, Nashville, TN, USA Background: Executive control deficits are common sequelae of childhood traumatic brain injury (TBI). The goal of the current study was to assess a specific executive control function, performance monitoring, in children following TBI. Methods: Thirty-one children with mild–moderate TBI, 18 with severe TBI, and 37 control children without TBI, of comparable age and sex, performed the stop signal task, a speeded choice reaction time task. On occasion, they were presented with a signal to stop their responses. Performance monitoring was defined as the extent of slowing in go-task reaction time following failure to stop responses. Results: The TBI group as a whole demonstrated less post-error slowing than did controls. This finding suggested impaired error monitoring performance. In addition, time since injury and socioeconomic status predicted less slowing after stopped responses. Conclusions: We suggest that alterations in performance monitoring expressed as the inability to notice, regulate and adjust behavior to changing situations are an effect of TBI in children. Keywords: Performance monitoring, traumatic brain injury, children, head injury, neuropsychology, pediatrics. Traumatic brain injury (TBI) affects nearly half a million children each year (Langlois, Rutland- Brown, & Thomas, 2005) and is the leading cause of death disability among children and adolescents. TBI is commonly caused by pedestrian or bicycle- associated collisions, or motor vehicle accidents (Middleton, 2001). About 85% of all injuries are considered mild (see for review Yeates, 2000). TBI in children frequently produces impairment of execu- tive control processes (Kaufman, Fletcher, Levin, Miner, & Ewing-Cobbs, 1993; Levin et al., 1994, 1996; Kelly & Eyre, 1999; Dennis, Guger, Ronca- din, Barnes, & Schachar, 2001; Christ, White, Brunstrom, & Abrams, 2003) that are mediated by frontal-subcortical pathways (Alexander, Delong, & Strick, 1986). The impact on executive control processes has been attributed to the vulnerability of prefrontal cortex to focal lesions and the relatively late maturation of this region. (Proficient executive control performance relies on the integrity of the frontal lobes, which serve to organize and regulate behavior through the mediation of the so-called ‘executive functions,’ a term that refers to a range of processes that ‘enable a person to engage success- fully in independent, purposive, self-serving behavior’) (see Lezak, 1995, p. 42). A core executive control system function is the ability to monitor and regulate behavior, which involves identification of and adjustment to errors in performance (Rabbitt & Rodgers, 1977; Logan, 1985). Deficient performance monitoring can result in post-error slowing that is often construed as a behavioral adaptation to a changing environ- ment or to the detection and correction of an error. Hence, performance monitoring is considered an ‘adaptive’ process – once error detection has occurred, behavioral adjustments or remedial action can take place that result in fewer errors and enhanced task performance (Holroyd & Coles, 2002). Impaired performance monitoring has been iden- tified in various neurologic and psychiatric popula- tions with presumed dysfunction of the frontostriatal circuits (see for review, Ullsperger, 2006). In addi- tion, several studies have shown that adults with frontal lobe lesions exhibit a pattern suggestive of deficient performance monitoring; these subjects make errors and are unconcerned by the conse- quences of their behaviors, including the lack of goal attainment (Rylander, 1947; Tow & Whitty, 1953; Eslinger & Damasio, 1985). However, there has been little systematic investigation of performance monitoring in children. Krusch et al. (1996) reported that normal children tend to slow following errors made in speeded choice reaction time tasks. Wiersema, van der Meere, and Roeyers (2007) used an event-related potentials paradigm to demonstrate that, like adults, children exhibit error awareness and adjustment of response strategies, despite showing signs of a less Conflict of interest statement: No conflicts declared. Journal of Child Psychology and Psychiatry 50:4 (2009), pp 506–513 doi:10.1111/j.1469-7610.2008.01997.x Ó 2008 The Authors Journal compilation Ó 2008 Association for Child and Adolescent Mental Health. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA