Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms.

OBJECTIVE: To introduce a set of revised guidelines for the management of mild traumatic brain injury (mTBI) and persistent symptoms following concussive injuries. QUALITY OF EVIDENCE: The Guidelines for Mild Traumatic Brain Injury and Persistent Symptoms were made available in March 2011 based on literature and information up to 2008. A search for new clinical practice guidelines addressing mTBI and a systematic review of the literature evaluating treatment of persistent symptoms was conducted. Healthcare professionals representing a range of disciplines from Canada and abroad attended a consensus conference to revise the original guidelines in light of new evidence. MAIN MESSAGE: A modified Delphi process was used to create 96 recommendations addressing the diagnosis and management of mTBI and persistent symptoms, including post-traumatic headache, sleep disturbances, mental health disorders, cognitive difficulties, vestibular and vision dysfunction, fatigue and return to activity/work/school. Numerous resources, tools and treatment algorithms were also included to aid implementation of the recommendations. CONCLUSION: The revised clinical practice guideline reflects the most current evidence and is recommended for use by clinicians who provide care to people who experience PPCS following mTBI.

Teachers' Responses to Child Maltreatment.

Purpose: Teachers play an important role in detecting and reporting child maltreatment by virtue of their extensive contact with children. Current research, while limited, shows a tendency among teachers to under-detect and under-report various forms of child abuse and neglect. Methods: Using data from a pilot evaluation of child maltreatment training for teachers, we examined teachers' self-reported behaviours for different forms of maltreatment. Participants included 45 experienced teachers from a large urban centre in the province of Ontario (Canada) who rated their likelihood of, and rationale for, detecting and reporting maltreatment based on four case vignettes. Results: Accuracy rates for detection and reporting were highest for sexual abuse (95% and 93%), followed by neglect (87% and 75%), emotional abuse (86% and 70%), and physical abuse (58% and 27%). Differences in detection and reporting rates were only significant between physical abuse and other maltreatment types (sexual abuse and neglect for detection; sexual abuse, neglect, and emotional abuse for reporting), with accurate detection and reporting rates being significantly lower for physical abuse. Teachers stated that the physical abuse vignette lacked convincing evidence of child maltreatment. Further, many teachers indicated that additional information was needed to determine whether the vignette represented physical abuse and, as such, was reportable. Conclusion: Our findings suggest the need for more targeted interventions to improve teachers' decision-making with potential child maltreatment scenarios, especially for physical abuse, so that children who are experiencing maltreatment may be more accurately detected and reported to child protection.

Meta-Analysis on Interventions for Children Exposed to Intimate Partner Violence.

Several reviews have been conducted on children's outcomes following exposure to intimate partner violence (IPV), but there remain inconsistent findings. We conducted a meta-analysis on child emotional and behavioral outcomes of IPV exposure interventions, based on published reviews that included a child component. We also explored relative effect sizes by examining moderators of the effect sizes across studies. This meta-analysis included 21 evaluation studies across 12 published reviews, which were located using a multiple database systematic search of English publications between 2000 and 2019. Studies were required to evaluate IPV interventions that included children, to gather quantitative pre- and post-intervention data on child outcomes, to use standardized instruments, and to present data in a format that could be used in a meta-analysis. Results indicated an overall pre- to post-intervention medium effect size (d = 0.49), with effect sizes ranging from small to large depending on the specific outcome. Improvements at follow-up were maintained for internalizing behaviors but decreased for trauma-related symptoms and social, externalizing, and total behaviors. However, externalizing and total behavior outcomes still had significant effect sizes in the small-to-medium range (d = 0.36 and 0.44). There were greater intervention effects when treatment was not exclusively trauma-specific. It appears that IPV exposure interventions are generally effective for improving children's emotional and behavioral well-being, although interventions would benefit from greater tailoring to children's specific needs. Interventions may also benefit from incorporating various content areas (both trauma-specific and non-trauma-specific) and from greater focus on ensuring the maintenance of treatment gains.

Trauma-symptom profiles of adolescents in child welfare.

In the province of Ontario (Canada), over 28,900 adolescents are investigated by child welfare agencies each year because of suspected maltreatment. Exposure to childhood maltreatment represents a major threat to the psychological well-being of young people, particularly in terms of trauma-related stress. The present study investigated trauma symptom profiles among 479 adolescents (13-17 years) involved with the Canadian child welfare system between 2003 and 2010. Latent profile analysis identified three profiles using self-report data from the Trauma Symptom Checklist for Children. Most adolescents (59%, n=281) were classified into the profile depicting minimal trauma-related symptoms, 30% (n=144) were characterized by moderate trauma-related symptoms, and 11% (n=54) were in the profile reflecting severe trauma-related symptoms. Several variables predicted profile membership. Greater severity of sexual abuse and female sex were associated with a greater likelihood of belonging to the severe trauma symptom profile than both the moderate and the minimal trauma symptom profiles. In addition, having society ward status (compared to crown ward) was related to an increased likelihood of belonging to both the severe and moderate symptom profiles relative to the minimal symptom profile. This study provides some insight into the typologies of trauma experienced among child-welfare-involved adolescents and the set of factors which relate to the specific profiles. Findings are important for informing psychological assessment practices, as well as tailored interventions, for adolescents in the child welfare system.

The Canadian Safe Driving Study-Phase I pilot: Examining potential logistical barriers to the full cohort study.

Multiple organizations and task forces have called for a reliable and valid method to identify older drivers who are medically unfit to drive. The development of a clinical decision rule for this type of screening requires data from a longitudinal prospective cohort of older drivers. The aim of this article is to identify potential design, sampling and data collection barriers to such studies based on an analysis of the Canadian Safe Driving Study-phase I pilot (Candrive I). A convenience sample of 100 active older drivers aged 70 years or more was recruited through the aid of a seniors' organization, 94 of whom completed the full study (retention rate 94%). Data were collected over the course of 1 year on various driving behaviours, as well as on cognitive, physical and mental functioning. Driving patterns were recorded using driving diaries, logs and electronic devices. Driving records from the Ministry of Transportation of Ontario (MTO) were obtained for the 3-year period preceding the study initiation and up to 1 year following study completion. An increased burden of illness was observed as the number of medical diagnoses and medication use increased over the study period. Study participants were involved in a total of five motor vehicle collisions identified through MTO records, which was comparable to the Ontario annual collision rate of 4.1% for drivers aged 75 years or older. In sum, many of the relevant logistical and practical barriers to studying a large sample of older drivers longitudinally have been shown to be addressable, supporting the feasibility of completing a large prospective cohort study of older drivers.

The impact of subclinical sleep problems on self-reported driving patterns and perceived driving abilities in a cohort of active older drivers.

The present study sought to investigate the influence of subclinical sleep disturbances on driving practices and driver perceptions in a large cohort of healthy older drivers. Participants from the Candrive II prospective cohort study were investigated. Self-reported measures of sleep problems were used to determine the influence of sleep disturbance on self-reported driving practices and perceived driving abilities, as measured by the Situational Driving Frequency, Situational Driving Avoidance, and Perceived Driving Abilities scales. Hierarchical regression analyses were used to estimate whether mild self-reported sleep problems were predictive of driving restrictions and perceived abilities, while controlling for a variety of health-related factors and demographic variables known to mediate sleep problems or to impact driving. Cross-sectional analysis of baseline data from the Candrive II study suggests that subclinical sleep problems do not significantly influence self-reported driving patterns or perceived driving abilities in older drivers once control variables are considered. The relationship between sleep problems, driving frequency, avoidance and perceived abilities is better explained by mediating demographic, health, and cognitive factors. Further research examining sleep disturbances and driving should include objective measures of driving practices (exposure, patterns) and outcomes (crashes, violations) and should take in consideration the severity of sleep problems.

The relationship between cognitive performance, perceptions of driving comfort and abilities, and self-reported driving restrictions among healthy older drivers.

The objective of the present study was to examine the relationship between cognitive performance, driver perceptions and self-reported driving restrictions. A cross-sectional analysis was conducted on baseline data from Candrive II, a five-year prospective cohort study of 928 older drivers aged 70-94 years from seven cities. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) as well as the Trail Making Test, parts A and B. Driver perceptions were assessed using the Day and Night Driving Comfort Scales and the Perceived Driving Abilities scale, while driving practices were captured by the Situational Driving Frequency and Avoidance scales, as well as the Driving Habits and Intentions Questionnaire. The baseline data indicates this cohort is largely a cognitively intact group. Univariate regression analysis showed that longer Trails A and B completion times were significantly, but only modestly associated with reduced driving frequency and perceived driving abilities and comfort, as well as a significant tendency to avoid more difficult driving situations (all p<.05). Most of these associations persisted after adjusting for age and sex, as well as indicators of health, vision, mood and physical functioning. Exceptions were Trails A and B completion times and situational driving frequency, as well as time to complete Trails B and current driving restrictions. After adjusting for the confounding factors, the total MoCA score was not associated with any of the driving measure scores while the number of errors on Trails A was significantly associated only with situational driving frequency and number of errors on Trails B was significantly associated only with situational driving avoidance. Prospective follow-up will permit examination of whether baseline cognition or changes in cognition are associated with changes in driver perceptions, actual driving restrictions and on-road driving outcomes (e.g., crashes, violations) over time.

Determining the validity of the AMA guide: A historical cohort analysis of the assessment of driving related skills and crash rate among older drivers.

BACKGROUND: Chronic health conditions associated with ageing can lead to changes in driving ability. The Canadian Driving Research Initiative for Vehicular Safety in the Elderly (Candrive II) is a 5-year prospective study funded by the Canadian Institutes of Health Research aiming to develop an in-office screening tool that will help clinicians identify potentially at-risk older drivers. Currently, no tools exist to directly predict the risk of motor vehicle collision (MVC) in this population. The American Medical Association (AMA), in collaboration with the National Highway Traffic Safety Association, has designed an opinion-based guide for assessing medical fitness to drive in older adults and recommends that physicians use the Assessment of Driving Related Skills (ADReS) as a test battery to measure vision, cognition and motor/somatosensory functions related to driving. The ADReS consists of the Snellen visual acuity test, visual fields by confrontation test, Trail Making Test part B, clock drawing test, Rapid Pace Walk, and manual tests of range of motion and motor strength. We used baseline data from the Candrive/Ozcandrive common cohort of older drivers to evaluate the validity of the ADReS subtests. We hypothesized that participants who crashed in the 2 years before the baseline assessment would have poorer scores on the ADReS subtests than participants who had not crashed. METHODS: In the Candrive/Ozcandrive study, 1230 participants aged 70 years or older were recruited from 7 Canadian cities, 1 Australian city and 1 New Zealand city, all of whom completed a comprehensive clinical assessment at study entry. The assessment included all tests selected as part of the ADReS. For this historical cohort study, data on all crashes (at-fault and non-at-fault) that occurred within 2 years preceding the baseline assessment were obtained from the respective licensing jurisdictions. Those who crashed were compared to those who had not crashed on their ADReS subtest scores using Pearson's chi-squared test and Student's t-test. RESULTS: Sixty-three of the 1230 participants (5.1%) were involved in an MVC within the 2 years preceding the baseline assessment. Contrary to our hypothesis, there were no statistically significant associations between abnormal performance on the tests constituting the ADReS and history of crash in the previous 2 years (p>0.01). DISCUSSION: We found that a history of crash in the previous 2 years was not associated with abnormalities on the subtests comprising the ADReS. This suggests the need for prospective analyses of risk factors over time to establish sensitive, valid predictors of crash that can be incorporated in clinical practice guidelines.