Further recommendations of the International Paediatric Brain Injury Society (IPBIS) for the post-acute rehabilitation of children with acquired brain injury.

BACKGROUND: Paediatric acquired brain injury is a life-long condition which impacts on all facets of the individual's lived experience. The existing evidence base continues to expand and new fields of enquiry are established as clinicians and researchers uncover the extent of these impacts. PRIMARY OBJECTIVE: To add to recommendations described in the International Paediatric Brain Injury Society's 2016 paper on post-acute care for children with acquired brain injury and highlight new areas of enquiry. REVIEW OF INFORMATION: Recommendations were made based on the opinions of a group of experienced international clinicians and researchers who are current or past members of the board of directors of the International Paediatric Brain Injury Society. The importance of each recommendation was agreed upon by means of group consensus. OUTCOMES: This update gives new consideration to areas of study including injuries which occur in pre-school children, young people in the military, medical referral, young offenders and the use of technology in rehabilitation.

Post-Concussive Symptoms in Preschool Children up to Three Months Post-Injury.

BACKGROUND AND AIMS: Post-concussive symptoms (PCS) are central to the assessment and management of mild traumatic brain injury (mTBI); however, this remains poorly understood in children aged ≤5 years. The study aimed to explore individual PCS, pattern of parents' PCS report over time, proportion of symptomatic children, and variables associated with parents' report of PCS in their preschool child after a mTBI. METHODS: Children aged 2-5 years with either a mTBI (n=13) or limb injury (n=6) were recruited from the emergency department (ED). Parent ratings of child PCS were assessed at ED presentation, at one month, and at three months post-injury. Injury (e.g. injury group, pain), child (e.g. pre-existing behavior, symptoms), and parent (e.g. parental stress, education) characteristics were considered when investigating variables that may be relevant to parent report of PCS. RESULTS: The number of total, physical, and sleep PCS were significantly higher after mTBI, with a significant decrease in physical and sleep PCS over time. The proportion of symptomatic children was comparable between injury groups at each time point. Acute pain and pre-injury symptoms were significantly associated with parents' acute PCS report in the mTBI group. Further research is needed on variables that may be relevant to parents' PCS report at follow-up. CONCLUSION: Preliminary findings suggest a general trauma response after a mTBI or limb injury, but acute physical and sleep PCS may help differentiate the injury groups. Injury and premorbid child variables may be relevant to parents' report of acute PCS in their child. Additional research is needed to investigate PCS in preschoolers and variables that may predict parents' PCS report.

Behaviour outcomes three months after mild TBI in preschool children.

This study examined parents' report of behaviour in preschoolers after a mild traumatic brain injury (mTBI), compared the proportion of preschoolers with elevated behaviour ratings between the mTBI and limb injury (LI) groups, and explored injury, premorbid child, and parent variables that may be associated with parents' report of behaviour at three months post-injury. Children aged 2-5 years with a mTBI (n = 13) or mild LI (n = 6) were recruited from the emergency department. Behaviour was assessed using the Child Behaviour Checklist. Preliminary findings showed that post-injury behaviour ratings remained in the normal range. The mTBI group had higher scores than the LI group at three months post-injury in terms of sleep; however, this may have been pre-existing. Two children with mTBI received borderline-clinically significant ratings on diagnostic-level anxiety problems at the three-month follow-up, while none of the limb-injured controls obtained elevated behaviour ratings. Parent-rated post-injury behaviour was significantly associated with premorbid child functioning and parental stress, which needs to be explored in greater detail using larger preschool mTBI samples.

The Australian and New Zealand brain injury lifespan cohort protocol: Leveraging common data elements to characterise longitudinal outcome and recovery.

INTRODUCTION: Cognitive, behavioural, academic, mental health and social impairments are common following paediatric traumatic brain injury (TBI). However, studies are often reliant on small samples of children drawn from narrow age bands, and employ highly variable methodologies, which make it challenging to generalise existing research findings and understand the lifetime history of TBI. METHOD AND ANALYSIS: This study will synthesise common data sets from national (Victoria, New South Wales, Queensland) and international (New Zealand) collaborators, such that common data elements from multiple cohorts recruited from these four sites will be extracted and harmonised. Participant-level harmonised data will then be pooled to create a single integrated data set of participants including common cognitive, social, academic and mental health outcome variables. The large sample size (n=1816), consisting of participants with mild, moderate and severe TBI, will provide statistical power to answer important questions that cannot be addressed by small, individual cohorts. Complex statistical modelling, such as generalised estimation equation, multilevel and latent growth models, will be conducted. ETHICS AND DISSEMINATION: Ethics approval was granted by the Human Research Ethics Committee (HREC) of the Royal Children's Hospital (RCH), Melbourne (HREC Reference Number 2019.168). The approved study protocol will be used for all study-related procedures. Findings will be translated into clinical practice, inform policy decisions, guide the appropriate allocation of limited healthcare resources and support the implementation of individualised care.

Improving subacute management of post concussion symptoms: a pilot study of the Melbourne Paediatric Concussion Scale parent report.

Aim: To pilot a modification of the Post Concussion Symptom Inventory, the Melbourne Paediatric Concussion Scale (MPCS) and examine its clinical utility. Materials & methods: A total of 40 families of concussed children, aged 8-18 years, were recruited from the emergency department. Parent responses to the MPCS in the emergency department and 2-weeks post injury determined child symptomatic status. Association between MPCS symptom endorsement and symptomatic group status was examined. Results: All additional MPCS items were endorsed by at least 25% of the parents of symptomatic children at 2 weeks. MPCS items were classified into nine symptom domains, with most falling in mood, neurological, autonomic and vestibular domains. Conclusion: The additional items and domain classifications in the MPCS have the potential to improve subacute diagnostic precision, monitoring of clinical recovery and identification of appropriate interventions post pediatric concussion.

Post-concussive Signs and Symptoms in Preschool Children: A Systematic Review.

Mild traumatic brain injury (mTBI) is common in children aged < 5 years, however, less is known about their experience of post-concussive signs and symptoms. This systematic review aims to identify post-concussive signs and symptoms experienced by preschool children up to 12 months post-injury, and to review the methods used to report this data. Relevant findings, including rates, progression, and possible predictors of post-concussive signs and symptoms were also identified. Databases (Ovid MEDLINE, EMBASE, PsycInfo, PubMed, Scopus) and reference lists were searched for relevant articles, which were screened based on specified criteria. Eleven articles met the inclusion criteria, being original studies published in English and presenting data on post-concussive signs and symptoms specific to preschool children with mTBI. Most reviewed studies investigated acute presentations of mTBI, and identified that preschool children demonstrate post-concussive symptoms (PCS) similar to other age groups. Post-traumatic amnesia duration of approximately one day was reported in preschool children following mTBI, as were changes in mood and behavior during the recovery period. Parents were the main informants, with data obtained through either interview or questionnaire. Review findings highlight the lack of empirical data regarding the presentation and progression of PCS in preschoolers following mTBI and evidence on how to best manage this group during recovery.

Protocol for a randomised clinical trial of multimodal postconcussion symptom treatment and recovery: the Concussion Essentials study.

INTRODUCTION: While most children recover from a concussion shortly after injury, approximately 30% experience persistent postconcussive symptoms (pPCS) beyond 1-month postinjury. Existing research into the treatment of pPCS have evaluated unimodal approaches, despite evidence suggesting that pPCS likely represent an interaction across various symptom clusters. The primary aim of this study is to evaluate the effectiveness of a multimodal, symptom-tailored intervention to accelerate symptom recovery and increase the proportion of children with resolved symptoms at 3 months postconcussion. METHODS AND ANALYSIS: In this open-label, assessor-blinded, randomised clinical trial, children with concussion aged 8-18 years will be recruited from The Royal Children's Hospital (The RCH) emergency department, or referred by a clinician, within 17 days of initial injury. Based on parent ratings of their child's PCS at ~10 days postinjury, symptomatic children (≥2 symptoms at least 1-point above those endorsed preinjury) will undergo a baseline assessment at 3 weeks postinjury and randomised into either Concussion Essentials (CE, n=108), a multimodal, interdisciplinary delivered, symptom-tailored treatment involving physiotherapy, psychology and education, or usual care (UC, n=108) study arms. CE participants will receive 1 hour of intervention each week, for up to 8 weeks or until pPCS resolve. A postprogramme assessment will be conducted at 3 months postinjury for all participants. Effectiveness of the CE intervention will be determined by the proportion of participants for whom pPCS have resolved at the postprogramme assessment (primary outcome) relative to the UC group. Secondary outcome analyses will examine whether children receiving CE are more likely to demonstrate resolution of pPCS, earlier return to normal activity, higher quality of life and a lower rate of utilisation of health services, compared with the UC group. ETHICS AND DISSEMINATION: Ethics were approved by The RCH Human Research Ethics Committee (HREC: 37100). Parent, and for mature minors, participant consent, will be obtained prior to commencement of the trial. Study results will be disseminated at international conferences and international peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12617000418370; pre-results.

Child concussion recognition and recovery: a community delivered, evidenced-based solution.

Pediatric concussion is a growing health concern. Concussion is generally poorly understood within the community. Many parents are unaware of the signs and varying symptoms of concussion. Despite the existence of concussion management and return to play guidelines, few parents are aware of how to manage their child's recovery and return to activities. Digital health technology can improve the way this information is communicated to the community. A multidisciplinary team of pediatric concussion researchers and clinicians translated evidence-based, gold-standard guidelines and tools into a smartphone application with recognition and recovery components. HeadCheck is a community facing digital health application developed in Australia (not associated with HeadCheck Health) for management of concussion in children aged 5-18 years. The application consists of (I) a sideline concussion check and (II) symptom monitoring and symptom-targeted psychoeducation to assist the parent manage their child's safe return to school, exercise and sport. The application was tested with target end users as part of the development process. HeadCheck provides an accessible platform for disseminating best practice evidence. It provides feedback to help recognize a concussion and symptoms of more serious injuries and assists parents guide their child's recovery.

Concussive Symptoms Following Pediatric Mild Traumatic Brain Injury.

OBJECTIVES: To determine the proportion of children with postconcussive symptoms (PCSs) and to explore the influence of noninjury and injury factors on parents' PCS report at 3 months postinjury. DESIGN: A cross-sectional analysis of the 3-month postinjury data from a larger, prospective, longitudinal study. METHODS: Parents and their child aged 2 to 12 years who presented at the emergency department with either a mild traumatic brain injury (mTBI) or a superficial injury to the head (SIH) were recruited. Parents reported their child's symptoms at the time of injury and at 3 months postinjury. Child, family/parent, and injury characteristics were considered as potential predictors. Logistic regression was conducted to determine which factors increase the likelihood of parents' PCS report. RESULTS: At 3 months postinjury, 30% and 13% of children in the mTBI and SIH groups exhibited 1 or more symptoms, respectively. On the other hand, 18% (mTBI) and 8% (SIH) continued to have ongoing problems when 2 or more symptoms were considered at follow-up. The final model, which included child's sex, injury group, number of symptoms at the time of injury, and parental stress, had a significant predictive utility in determining parents' report of 1 or more symptoms at follow-up. Only parental stress continued to be a significant predictor when considering 2 or more symptoms at 3 months postinjury. CONCLUSIONS: Children with mTBI have worse outcomes than children with SIH at follow-up, with parents more likely to report 1 or more ongoing symptoms if their children had an mTBI. Postinjury assessment of parental stress and ongoing symptom monitoring in young children with mTBI will allow for timely provision of support for the family.

Impact of childhood traumatic brain injury on educational outcomes and adult standard of living.

Background: There is a limited literature investigating the long-term impact of traumatic brain injury sustained in childhood that compares injury severity with educational attainment, employment, material standard of living, or receipt of government benefits in adulthood.Method: A total of 161 participants who sustained an injury prior to age 18 years, aged between 18 and 30 years, and averaged 13.7 years postinjury. Injuries were mild traumatic brain injury (n = 57), moderate-severe traumatic brain injury (n = 62), and orthopedic injury control group (n = 42).Results: Using a semi-structured interview, with the exception of employment outcomes, adult survivors of childhood traumatic brain injury had poorer outcomes across all domains assessed relative to the other injury control group, with moderate to severe traumatic brain injury having worse outcomes than those with mild traumatic brain injury.Conclusions: Overall, the findings indicate that there is a greater need to consider the long-term impact of traumatic brain injury sustained in childhood, with injury severity impacting several psychosocial domains in adulthood, including education, material standard of living, and benefit recipiency.Implications for rehabilitationAdult outcomes of childhood are influenced by initial injury severity, with those with mild traumatic brain injury having predominantly good outcomes, while those with moderate/severe traumatic brain injury having poorer outcomes in all areas of adult functioning evaluated.Childhood traumatic brain injury is associated with reduced educational attainment in adolescence and adulthood.A young person with traumatic brain injury requires support within the education system to improve educational attainment.A history of traumatic brain injury in childhood is associated with a reduced standard of living in adulthood.Adults with a history of moderate/severe traumatic brain injury in childhood are more likely to be recipients of government benefits in adulthood, and rehabilitation input may be needed to assist individuals with traumatic brain injury to maintain employment and reduce benefit use.

The prevalence of traumatic brain injury, comorbid anxiety and other psychiatric disorders in an outpatient child and adolescent mental health service.

Background: A history of traumatic brain injury (TBI) is prevalent in children and adolescents within the health system, which may be accompanied with higher rates of poor mental health outcomes including anxiety and other psychiatric disorders.Aims: To explore rates of TBI and associated anxiety and other psychiatric diagnoses in children and adolescents aged 5-18 years within the mental health system.Methods: Participants were recruited from an outpatient mental health service in Canterbury, New Zealand. The Ohio State University TBI Identification method was utilised to ascertain TBI history. Anxiety and other diagnoses were identified by a mental health file review.Results: Over 28% of children in this study reported a history of TBI, the majority of which were mild. Review of mental health files revealed no significant differences between participants with and without TBI for anxiety and psychiatric diagnoses.Conclusions: A proportionately high number of children and adolescents within the mental health system reported a previous TBI. However, anxiety and other psychiatric problems were not over-represented in this group. Further research is essential for examining the characteristics of children and adolescents with TBI within the mental health system, particularly those with more severe injuries, who may present a subgroup.

Impact of mild traumatic brain injury understanding on intended help-seeking behaviour.

Children do not always receive adequate medical attention following a mild traumatic brain injury (mTBI), despite the necessity of this treatment. Adult mTBI knowledge may be one factor that affects if a child receives medical attention, but little is known about association between mTBI knowledge and help-seeking behaviour. Participants were 212 females and 58 males, including 84 parents, with a mean age of 35.57 years (standard deviation = 10.96). A questionnaire evaluated participants' understanding of mTBI and vignettes to evaluate behavioural intentions regarding help-seeking behaviour after an mTBI. Only 40.0% of participants were able to recall an adequate number of mTBI symptoms (5+). Surprisingly, mTBI history was not associated with better mTBI knowledge, t(df, 268) = 1.29, p = .20. Similarly, knowing a close friend or family member with mTBI was not associated with higher mTBI knowledge, t(df = 268) = .81, p = .4. Further, neither mTBI symptom knowledge nor vignette child age (young = 5 years, older = 15 years) significantly predicted participants' cited intentions to perform help-seeking behaviour. Consistent with the existing research, the current study demonstrates a continued lack of mTBI knowledge in the general population. However, this may not be a factor that influences an adult's decision to take a child to hospital following mTBI. Future research should investigate the association between help-seeking intentions and actual behaviour in relation to paediatric mTBI.

Postconcussive Symptoms Following Mild TBI and Extracranial Injury: What Are the Contributing Factors?

OBJECTIVES: Whether mild traumatic brain injury (mTBI) sustained by children results in persistent or recurrent symptoms, over and above those experienced by children who solely sustain mild extracranial injuries, remains debated. The current prospective longitudinal case-controlled study aimed to examine the relative influence of injury and noninjury factors on symptoms in preschool and primary school-aged children who sustained an mTBI or mild extracranial injury at least 8 month earlier. METHODS: Participants were 64 parents of children (31 mTBI, 33 trauma controls) who sustained injury between ages 2 and 12, whose postconcussive symptoms across the first 3-month postinjury have been previously described. The current study assessed postconcussive symptoms at 8 or more months postinjury (M = 24.3, SD = 8.4) and examined a range of injury and noninjury predictive factors. RESULTS: At or beyond 8-month postinjury, symptom numbers in the mTBI group were comparable with those of the group who sustained mild extracranial injury. Educational attainment of parents (below or above high-school attainment level) was the only predictor of symptoms at follow-up, with preexisting learning difficulties approaching significance as a predictor. CONCLUSIONS: While our earlier study found that mTBI was associated with symptoms at 3-month postinjury, follow-up at more than 8 months showed mTBI no longer predicted symptom reporting. While mTBI contributes significantly to the presence of symptoms in the first few months postinjury, researchers and healthcare practitioners in this field need to consider the potential impact of noninjury factors on persistent or recurrent symptoms after mTBI.

An International Exploration of the Effect of Media Portrayals of Postconcussion Management on Concussion Identification in the General Public.

BACKGROUND: Concussion portrayal in media broadcasts of sporting events may contribute to lack of public understanding regarding concussion. METHODS: In total, 828 participants from Australia, New Zealand, and the United Kingdom completed a questionnaire assessing concussion knowledge. Participants were randomly assigned to either receive sports return-to-play (RTP) guideline information (RTP group) or not (no-RTP group). Participants viewed 12 short clips from televised rugby games and indicated whether they believed the player in each clip had sustained a concussion. Participants were then informed whether the player was removed, returned, or stayed in the game and again asked whether they thought a concussion had occurred. RESULTS: Probability of reporting a likely concussion over all videos was 65.6%. When told a player's possible concussion was managed by removal from the game, participants were more likely to change their response from "no" (no concussion) to "yes" (concussion) than from "yes" to "no." When told the player stayed or returned to the game, participants were more likely to change their response from "yes" (concussion) to "no" (no concussion) than from "no" to "yes." There was no significant main effect for RTP guideline manipulation or interaction effect with RTP information. CONCLUSION: Additional player's injury management information influenced participants' judgments of concussion occurrence. Results show that information provided via sports media broadcasts influenced viewers' perceptions of concussion and appropriate concussion management.

Testing a new interpersonal model of disordered eating between Australian and East-Asian women: The relationships between theory of mind, maladaptive schemas, and appearance-based rejection sensitivity.

The current study tested a new interpersonal model of disordered eating behaviours, whereby maladaptive schemas and theory of mind decoding (ToM-decoding) were related with disordered eating attitudes (body dissatisfaction) and behaviours (binging/purging and food restriction) through the mediating variable appearance-based rejection-sensitivity. A secondary aim was to test whether this model differed between two cultural groups: Caucasian Australian women (N = 197, ages ranging 17-43, M = 19.25, SD = 3.10), and Asian women living in East-Asia (N = 195, ages ranging 18-40, M = 28.60, SD = 5.15). Participants completed an online survey assessing the variables of interest. While the model showed acceptable fit for both groups, invariance testing demonstrated that the model worked differently in each group. Appearance-based rejection-sensitivity mediated the effect of maladaptive schemas on body dissatisfaction and disordered eating in both groups, but only mediated the effect of ToM-decoding on body dissatisfaction in the East-Asian group. Overall, the significant indirect pathways were greater in strength and number for the Caucasian-Australian group. These findings indicate that while the relationships between maladaptive schemas, appearance-based rejection-sensitivity, and disordered eating attitudes and behaviours are present in both cultures, ToM-decoding may only play a role for East-Asian participants.

The long-term effects of childhood traumatic brain injury on adulthood relationship quality.

PRIMARY OBJECTIVE: To investigated the long-term effect of childhood Traumatic Brain Injury (TBI) on adulthood Relationship Quality (RQ), examining injury severity, age of injury, and markers of prefrontal cortex (PFC) functioning, apathy, disinhibition, and executive dysfunction. RESEARCH DESIGN: Longitudinal, between-subjects, cross-sectional design using retrospective and current data. METHODS AND PROCEDURES: Participants (N = 169; 61 mild TBI (mTBI); 65 moderate to severe TBI (MSTBI); 43 orthopaedic injury (OI); Injury age: 1-17 years; Testing age: 18-31 years) completed a structured interview regarding their injury, demographic characteristics and RQ, the National Adults Reading Test, and Frontal Systems Behaviour Scale. Data were analyzed using IBM SPSS 25. MAIN OUTCOMES AND RESULTS: Adults who had experienced childhood TBI had significantly poorer RQ than adults who had experienced childhood OI. Severity of TBI did not impact adulthood RQ. Earlier age of injury predicted reduced adulthood RQ in the MSTBI group. Greater PFC dysfunction predicted poorer RQ in adults with a history of childhood TBI. While elevated levels of apathy, disinhibition, and executive dysfunction were associated with poorer RQ, no individual marker had predictive value. CONCLUSION: Experiencing a childhood TBI can have a long-term negative influence on adulthood RQ. Such RQ deficits can underpin reduced life satisfaction and increased health issues.

Misconceptions about traumatic brain injury among educators: has anything changed over the last 20 years?

PURPOSE: To examine educational professionals' knowledge and understanding of childhood brain injury. MATERIALS AND METHODS: Educational professionals from all schools in the state of Victoria, Australia, were invited to participate in an online cross-sectional survey consisting of 20 questions assessing knowledge of concussion and 30 questions examining knowledge of traumatic brain injury (n = 364). RESULTS: On average, participants correctly answered 16/20 (80%) questions about concussion and 24.3/30 (81%) about traumatic brain injuries. Participants who had previously taught a child with a brain injury demonstrated greater knowledge of traumatic brain injury, but not concussion, than those who had not. There were no differences in knowledge of concussion or brain injury between participants who had and had not attended a briefing session about concussion. Misconceptions displayed by educators predominantly related to the ongoing effects and impact of both concussion and traumatic brain injury, including effects on emotion, cognition, and social behaviour, as well as the increased risk of multiple injuries following an initial brain injury. When participants' responses to the brain injury questionnaire were compared with results reported by Farmer and Johnson-Gerard in 1997 using the same questionnaire, many of the same misconceptions were evident in the two samples of educational professionals. CONCLUSIONS: Although educators demonstrated reasonable understanding of concussion and brain injury, some gaps in knowledge were apparent. Providing educational professionals with further training and professional development regarding childhood brain injuries would enhance their preparedness to manage students with these injuries in the school environment. Implications for Rehabilitation Mild to moderate brain injuries are relatively common among school-aged children, and educators may be required to manage and support students with these injuries in the school environment. This study shows that educators generally have a good understanding of the symptoms and immediate effects of brain injuries, but have gaps in knowledge regarding the potential socioemotional, behavioural, and cognitive difficulties and vulnerabilities to multiple injuries that may be present during recovery. Pre-service training and professional development may increase educators' understanding and capacity to accommodate the needs of students with brain injuries.

A comparison of emergency department medical records to parental self-reporting of traumatic brain injury symptoms.

AIM: Studies have shown Emergency Department (ED) recording of traumatic brain injury (TBI) cases to be poor. METHODS: Parents of children aged 2-12 who attended an ED with injury to the head completed a concussion checklist which was compared with medical records. RESULTS: ED medical records commonly used head injury (HI), concussion, minor-HI and mild-HI without distinction between TBI and superficial HI. Recalled symptoms included vomiting, blurred vision and headaches versus headaches, fatigue and feeling sick from parents who reported more concussive symptoms. More cases of TBI were identifiable from parental recall compared with medical records, which recorded fewer symptoms for diagnosis, prognosis and statistical reporting of TBI. CONCLUSION: Clear guidelines need to be implemented to improve retrospective diagnosis for incidence gathering and future clinical use.

A systematic review and meta-analysis of educational interventions for children and adolescents with acquired brain injury.

BACKGROUND: Children with brain injuries face significant challenges in their recovery. One of the greatest is transitioning from hospital/home to school where they face issues such as reintegration, lack of understanding and catching up with missed work. Many children struggle with their altered circumstances and require additional supports to meet the academic demands of systems which are ill equipped to teach them. OBJECTIVE: To summarise the best available evidence for the use of educational interventions to improve academic attainment in childhood survivors of acquired brain injury (ABI). METHODS: Six electronic databases (Cinahl, Embase, Medline, PsycINFO, Pubmed, & Web of Science) were systematically searched for randomised controlled trials published between 1980 and 2017. Two authors independently reviewed these studies and extracted data on type of intervention, characteristics of participants, outcome measures, findings and recommendations. The Cochrane Collaboration's Risk of Bias tool was used to assess systematic error in the included studies. RESULTS: Four studies met the inclusion criteria (n = 296 children and adolescents). Three studies (n = 287) were included in meta-analysis for the primary outcome which showed no statistically significant difference between the intervention and control conditions on academic attainment (SMD 1.31, 95% CI -0.06 to 2.68, p = 0.06). No statistically significant differences were found which favoured the intervention for the secondary outcomes of attention, internalising or externalising behavior. All effect sizes were considered as small. CONCLUSIONS: This review suggests that no currently effective educational interventions exist for children with ABI. Greater efforts are required to produce effective and rigorously tested interventions to improve outcomes for these children.