Maayke Hunfeld

251 General discussion association between PCPC and neuropsychological outcome on a large scale. In addition, it will create opportunities to develop interventions to improve outcome. In children with neurological injury caused by for example TBI, brain tumors or critical illness, there is growing evidence that cognitive rehabilitation and pharmacological interventions might influence outcome in a positive way. Pediatric brain tumor survivors might benefit from stimulant medications, which have been shown related to improvements in performance-based attention as well as improvements in academic competence (81, 82). In adolescents with severe TBI and prolonged disorders of consciousness, amantadine may promote functional recovery, although the drug’s mechanism of action is unclear (83). In addition, CogMed, a computerized intervention program targeting working memory, has been associated with improvements in visual working memory in survivors of pediatric cancer (84). Positive effects were also seen in children after neonatal extracorporeal membrane oxygenation (ECMO) therapy and/or survivors of congenital diaphragmatic hernia (at the age of 8-12 years), although this effect was temporary (85). There is some evidence that physical exercise programs have an effect on the brain structure, including increased white matter and hippocampal volume and increased cortical thickness in multiple brain regions in pediatric brain tumor survivors (86, 87). In children with mild TBI, reduction of post-concussive symptoms and faster reaction times after moderate exercise have been reported (88). Another promising technique to improve motor and cognitive functions is the use of virtual reality (VR) in neurorehabilitation. The therapy is provided through a computer-simulated environment where children interact with real-world-like objects and events through sight, sound, smell and touch (89). Recently, much attention has been paid to high-tech augmentative and alternative communication (AAC) systems, developed for patients with complex communication needs. AAC has been proven to improve communication in patients with communication impairments (90, 91). This includes unaided and aided communication systems. Examples of unaided systems are body signs and gestures. Aided communication systems involve external equipment. Picture boards are examples of low-tech AAC, while electronically powered devices include voice output and allow users to store and retrieve messages are examples of high-tech AAC. The use of high-tech AAC has significantly increased in recent years, primarily due to the accessibility through mobile phones and tablet touch-screen devices (92). For children with neurological deficits after OHCA the effect of such interventions has yet to be investigated. Collaboration between our institution with Delft University of Technology and Rijndam Rehabilitation Center would create a great opportunity to investigate intervention methods at the short term, such as AAC strategies, and at the long term, 8