Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop.

OBJECTIVES: Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia. DESIGN: Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions. SETTING: A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus. SUBJECTS: Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium. CONCLUSIONS: These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.

Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation.

BACKGROUND: Inflammatory and endothelial activation responses during extracorporeal membrane oxygenation (ECMO) support in children are poorly understood. In this study, we aimed to determine if circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and with neurologic outcomes in children on ECMO. METHODS: We conducted a secondary analysis of a two-center prospective observational study of 99 neonatal and pediatric ECMO patients. Inflammatory (interferon gamma [IFNγ], interleukin-6 [IL-6], IL-1ß, tumor necrosis factor alpha [TNFα]), endothelial activation (E-selectin, P-selectin, intercellular adhesion molecule-3 [ICAM-3], thrombomodulin [TM]), and fibrinolytic markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1]) were measured in plasma on days 1, 2, 3, 5, 7, and every third day thereafter during the ECMO course. RESULTS: All ECMO day 1 inflammatory biomarkers were significantly elevated in children with abnormal vs. normal neuroimaging. ECMO day 1 and peak levels of IL-6 and PAI-1 were significantly elevated in children who died compared to those who survived to hospital discharge. Tested biomarkers showed no significant association with long-term neurobehavioral outcomes measured using the Vineland Adaptive Behavioral Scales, Second Edition. CONCLUSIONS: High levels of circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and abnormal neuroimaging in children on ECMO. IMPACT: The inflammatory, endothelial activation, and fibrinolytic profile of children on ECMO differs by primary indication for extracorporeal support. Proinflammatory biomarkers on ECMO day 1 are associated with abnormal neurologic imaging in children on ECMO in univariable but not multivariable models. In multivariable models, a pronounced proinflammatory and prothrombotic biomarker profile on ECMO day 1 and longitudinally was significantly associated with mortality. Further studies are needed to identify inflammatory, endothelial, and fibrinolytic profiles associated with increased risk for neurologic injury and mortality through potential mediation of bleeding and thrombosis.

Equivalency of In-Person Versus Remote Assessment: WISC-V and KTEA-3 Performance in Clinically Referred Children and Adolescents.

OBJECTIVE: Teletesting has the potential to reduce numerous barriers to patient care which have only become exacerbated during the COVID-19 pandemic. Although telehealth is commonly utilized throughout medicine and mental health practices, teletesting has remained limited within cognitive and academic evaluations. This may be largely due to concern for the validity of test administration via remote assessment. This cross-sectional study examined the equivalency of cognitive [Wechsler Intelligence Scales for Children - Fifth Edition (WISC-V)] and academic [Kaufman Test of Educational Achievement - Third Edition (KTEA-3)] subtests administered via either teletesting or traditional in-person testing within clinically referred youth. METHOD: Chart review using a retrospective, cross-sectional design included a total of 893 children and adolescents, ranging from 4 to 17 years (Mean age = 10.2 years, SD = 2.9 years) who were administered at least one subtest from the aforementioned cognitive or academic assessments. Of these, 285 received teletesting, with the remaining (n = 608) receiving in-person assessment. A total of seven subtests (five from the WISC-V and two from the KTEA-3) were examined. A series of inverse probability of exposure weighted (IPEW) linear regression models examined differences between groups for each of the seven subtests after adjustment for numerous demographic, diagnostic, and parent-reported symptom variables. RESULTS: Only two significant differences were found, such that WISC-V Visual Puzzles (p < .01) and KTEA-3 Math Concepts (p = .03) scores were slightly higher in the teletesting versus in-person groups. However, these differences were quite small in magnitude (WISC-V Visual Puzzles, d = .33, KTEA-3 Math Concepts, d = .18). CONCLUSIONS: Findings indicate equivalency across methods of service delivery without clinically meaningful differences in scores among referred pediatric patients.

Functional Gains in Children Receiving Inpatient Rehabilitation After Brain Tumor Resection.

OBJECTIVE: To examine whether children with brain tumors treated with resection benefit from inpatient rehabilitation and to explore what factors present at admission may predict better functional outcomes. DESIGN: Retrospective cohort design. SETTING: Pediatric inpatient rehabilitation unit. PARTICIPANTS: Forty patients (N=40; ages 3-21y; 42.5% female) admitted to the rehabilitation unit between 2003 and 2015 after brain tumor resection. INTERVENTIONS: Patients received multidisciplinary rehabilitation therapies as part of their admission to inpatient rehabilitation, including occupational, physical, and speech-language therapy. MAIN OUTCOME MEASURES: Functional outcomes included the FIM for Children (WeeFIM) at discharge and 3-month follow-up as well as WeeFIM efficiency. RESULTS: A repeated-measures analysis of variance using patient WeeFIM Developmental Functional Quotients (DFQs) at admission, discharge, and 3-month follow-up showed significant gains in total WeeFIM DFQ scores across time. Admission WeeFIM DFQ, time from surgery to admission, and age at admission provided the strongest model for predicting discharge and 3-month follow-up WeeFIM DFQ scores. Admission WeeFIM DFQ and time from surgery to admission provided the strongest model for predicting WeeFIM efficiency. Total Neurological Predictor Scale (NPS) at admission did not add predictive power to any of the 3 models over and above patient characteristics (admission WeeFIM DFQ, age at admission, time from surgery to admission). CONCLUSIONS: Patients admitted to inpatient rehabilitation after brain tumor resection made significant functional gains (as measured by the WeeFIM) during inpatient rehabilitation and continued to make significant gains 3 months after discharge. Age and timing of admission provided the strongest models for predicting patient outcomes. The NPS did not predict functional outcomes after rehabilitation when controlling for other variables known to influence rehabilitation outcomes.

The influence of comorbid asthma on the severity of symptoms in children with attention-deficit hyperactivity disorder.

OBJECTIVE: The current study examined the association between asthma and attention-deficit hyperactivity disorder (ADHD) symptoms in a clinical pediatric sample. METHODS: Demographic and neuropsychological data for children with a billing diagnosis of ADHD were extracted from a clinical database. Families completed standard rating scales. Seventy-one patients with a co-morbid asthma diagnosis were identified and matched by age to a group of 71 patients with only ADHD. RESULTS: Children with asthma and ADHD were more likely to display clinically elevated levels of hyperactivity, externalizing behaviors, anxiety, and hyperactive/impulsive behaviors compared to children with ADHD alone. Boys with asthma and ADHD had more symptoms than boys with only ADHD of somatization and emotional internalizing, while girls with asthma and ADHD had more symptoms of hyperactivity/impulsivity, conduct problems, anxiety, and emotional internalizing compared to girls with only ADHD. CONCLUSIONS: Findings suggest that in children with ADHD, co-morbid asthma is associated with increased behavioral and internalizing symptoms, with distinct gender differences present. Increased behavioral and internalizing symptoms seen in children with both asthma and ADHD may be due to the burden of their medical condition. No difference was found on cognitive variables, suggesting chronic hypoxia may be less influential in explaining these differences. Future research should determine the specific mechanisms of these differences.

Anesthesia and the developing brain: A way forward for laboratory and clinical research.

All commonly used general anesthetics have been shown to cause neurotoxicity in animal models, including nonhuman primates. Opinion, however, remains divided over how cumulative evidence from preclinical and human studies in this field should be interpreted and its translation to current practices in pediatric anesthesia and surgery. A group of international experts in laboratory and clinical sciences recently convened in Genoa, Italy, to evaluate the current state of both laboratory and clinical research and discuss future directions for basic, translational, and clinical studies in this field. This paper describes those discussions and conclusions. A central goal identified was the importance of continuing to pursue laboratory research efforts to better understand the biological pathways underlying anesthesia neurotoxicity. The distinction between basic and translational experimental designs in this field was highlighted, and it was acknowledged that it will be important for future animal research to try to causally link structural changes with long-term cognitive abnormalities. While inherent limitations will continue to affect the ability of even large observational cohorts to determine if anesthesia impacts neurodevelopment or behavioral outcomes, the importance of conducting further large well-designed cohort studies was also emphasized. Adequately powered cohorts could clarify which populations are at increased risk, provide information on environmental and healthcare-related risk modifiers, and guide future interventional trials. If anesthetics cause structural or functional adverse neurological effects in young children, alternative or mitigating strategies need to be considered. While protective or mitigating strategies have been repeatedly studied in animals, there are currently no human data to support alternative anesthetic strategies in clinical practice. Lastly, it was noted that there is still considerable debate over the clinical relevance of anesthesia neurotoxicity, and the need to evaluate the impact of other aspects of perioperative care on neurodevelopment must also be considered.

Time to Follow Commands and Duration of Posttraumatic Amnesia Predict GOS-E Peds Scores 1 to 2 Years After TBI in Children Requiring Inpatient Rehabilitation.

OBJECTIVE: To evaluate the utility of time to follow commands (TFC) in predicting functional outcome after pediatric traumatic brain injury (TBI), as assessed by an outcome measure sensitive to the range of outcomes observed after pediatric TBI, the Glasgow Outcome Scale-Extended, Pediatric Revision (GOS-E Peds). SETTING: Pediatric inpatient rehabilitation hospital and associated multidisciplinary brain injury follow-up clinic. PARTICIPANTS: Sixty-seven children with moderate-to-severe TBI (mean age at injury = 10.9 years; range, 3-18 years). DESIGN: Outcomes were scored retrospectively on the basis of documentation from an outpatient follow-up evaluation 1 to 2 years postinjury (days from injury to follow-up: mean = 518, SD = 137). Correlations between measures of severity and functional outcome were examined. Hierarchical logistic and linear regression analyses were performed to examine predictors of outcome. MAIN MEASURES: Earliest documented Glasgow Coma Scale (GCS), TFC, posttraumatic amnesia (PTA), total duration of impaired consciousness (TFC + PTA), and GOS-E Peds. RESULTS: For the logistic regression, TFC and TFC + PTA were significant predictors of outcome above and beyond GCS. For the linear analysis, PTA was also a significant predictor of functional outcome above and beyond GCS and TFC. The overall models were very comparable, with R values ranging from 0.31 to 0.36 for prediction of GOS-E Peds scores. CONCLUSION: Above and beyond the influence of GCS, TFC, PTA, and TFC + PTA are important predictors of later outcome after TBI.

Parent-rated emotional-behavioral and executive functioning in childhood epilepsy.

The present study examined clinical and demographic risk factors associated with parent-rated emotional-behavioral and executive functioning in children and adolescents with epilepsy. The medical records of 152 children and adolescents with epilepsy referred for neuropsychological evaluation were reviewed. Results indicated that the sample displayed significantly elevated symptoms across the emotional-behavioral and executive domains assessed. Executive functioning and behavioral symptoms had the highest rates of clinically elevated scores, with lowest rates of elevated scores in internalizing and externalizing emotional problems. Only 34% of those participants with clinically significant emotional-behavioral or executive functioning difficulties had a history of psychological or counseling services, highlighting the underserved mental health needs of this population. In regard to clinical factors, the majority of seizure-related variables were not associated with emotional-behavioral or executive functioning. However, the frequency of seizures (i.e., seizure status) was associated with behavioral regulation aspects of executive functioning, and the age at evaluation was associated with externalizing problems and behavioral symptoms. Family psychiatric history (with the exception of ADHD) was associated with all domains of executive and emotional-behavioral functioning. In summary, emotional-behavioral and executive functioning difficulties frequently co-occur with seizures in childhood epilepsy, with both seizure-related and demographic factors contributing to the presentation of such neurobehavioral comorbidities. The present findings provide treatment providers of childhood epilepsy with important information to assist in better identifying children and adolescents who may be at risk for neurobehavioral comorbidities and may benefit from intervention.

Neuromonitoring During Extracorporeal Membrane Oxygenation: A Systematic Review of the Literature.

OBJECTIVE: Neurologic injury remains a significant morbidity and risk factor for mortality in critically ill patients undergoing extracorporeal membrane oxygenation. Our goal was to systematically review the literature on the use of neuromonitoring methods during extracorporeal membrane oxygenation. DATA SOURCES: Electronic searches of PubMed, CINAHL, EMBASE, Web of Science, Cochrane, and Scopus were conducted in March 2014, using a combination of medical subject heading terms and text words to define concepts of extracorporeal life support, neurologic monitoring techniques, evaluation, and outcomes. STUDY SELECTION: Studies were selected based on inclusion and exclusion criteria defined a priori. DATA EXTRACTION: Two authors reviewed all citations independently. A standardized data extraction form was used to construct evidence tables by neuromonitoring method. Evidence was graded using the Oxford Evidence-Based Medicine scoring system. DATA SYNTHESIS: Of 3,459 unique citations, 39 studies met the inclusion criteria. Study designs were retrospective observational cohort studies (n = 20), prospective observational studies (n = 17), case-control studies (n = 2), and no interventional studies. Most studies evaluated newborns (n = 30). Extracorporeal membrane oxygenation neuromonitoring methods included neuroimaging (head ultrasound) (n = 12); intermittent, conventional, multichannel electroencephalography (n = 5); 1- to 2-channel amplitude-integrated electroencephalography (n = 2); Doppler ultrasound (n = 7); cerebral oximetry (n = 6); plasma brain injury biomarkers (n = 4); and other (n = 3). All evidence was graded 2B-4, with the majority of studies graded 3B (20/39 studies) and 4 (10/39 studies). Due to the heterogeneity of the studies included, aggregate analysis was not possible. CONCLUSIONS: Data supporting the use and effectiveness of current neuromonitoring methods are limited. Most studies have modest sample sizes, are observational in nature, and include patient populations that are of different ages and pathologies, with very limited data for pediatric and adult ages. Well-designed studies with adequate power and standardized short- and long-term outcomes are needed to develop guidelines for neuromonitoring and ultimately neuroprotection in patients on extracorporeal membrane oxygenation.

Prevalence and predictors of affective lability after paediatric traumatic brain injury.

OBJECTIVE: Paediatric severe traumatic brain injury (TBI) is associated with significant post-injury affective and behavioural problems. Few studies have examined the prevalence and characteristics of affective lability after paediatric TBI. METHODS: Ninety-seven children with severe TBI were evaluated 1 year post-injury for the presence of affective lability using the Children's Affective Lability Scale (CALS). Demographic, clinical and brain lesion characteristics were also assessed. RESULTS: Affective lability significantly increased after injury. Eighty-six children had a pre-injury CALS score of 1 SD or less from the group pre-injury mean (M = 8.11, SD = 9.31), of which 35 and 15 children had a 1 SD and 2 SD increase in their CALS score from pre- to post-injury, respectively. A variety of affective shifts manifested post-injury including anxiety, silliness, dysphoria and irritability. The most severe symptoms were irritability and unpredictable temper outbursts. Risk factors for affective lability included elevated pre-injury affective lability and psychosocial adversity as well as greater damage to the orbitofrontal cortex. Post-injury affective lability was most frequently associated with a post-injury diagnosis of attention-deficit hyperactivity disorder. CONCLUSIONS: Affective lability is common after paediatric TBI and frequently manifests as irritability and unpredictable outbursts. Early intervention is needed to improve psychiatric outcomes.

Functional outcomes in children with abusive head trauma receiving inpatient rehabilitation compared with children with nonabusive head trauma.

OBJECTIVE: To compare clinical features and functional outcomes of age- and sex-matched children with abusive and nonabusive head trauma receiving inpatient rehabilitation. STUDY DESIGN: Children with abusive head trauma (n = 28) and age- and sex-matched children with nonabusive head trauma (n = 20) admitted to an inpatient pediatric rehabilitation unit from 1995-2012 were studied. Acute hospitalization and inpatient rehabilitation records were retrospectively reviewed for pertinent clinical data: initial Glasgow Coma Scale score, signs of increased intracranial pressure, neuroimaging findings, and presence of associated injuries. Functional status at admission to and discharge from inpatient rehabilitation was assessed using the Functional Independence Measure for Children. Outcome at discharge and outpatient follow-up were described based on attainment of independent ambulation and expressive language. RESULTS: Children with abusive and nonabusive head trauma had similar levels of injury severity, although associated injuries were greater in those with abusive head trauma. Functional impairment upon admission to inpatient rehabilitation was comparable, and functional gains during inpatient rehabilitation were similar between groups. More children with nonabusive than with abusive head trauma attained independent ambulation and expressive language after discharge from rehabilitation; the difference was no longer significant when only children aged >12 months at injury were examined. There was variability in delay to obtain these skills and in the quality of gained skills in both groups. CONCLUSIONS: Despite more associated injuries, children with abusive head trauma make significant functional gains during inpatient rehabilitation, comparable with an age- and sex-matched sample with nonabusive head trauma. Key functional skills may be gained by children in both groups following discharge from inpatient rehabilitation.

Physical Abilities and Mobility Scale: reliability and validity in children receiving inpatient rehabilitation for acquired brain injury.

OBJECTIVE: To investigate the psychometric properties of the Physical Abilities and Mobility Scale (PAMS) in children receiving inpatient rehabilitation for acquired brain injury (ABI). DESIGN: Admission and discharge PAMS item and total scores were evaluated. The WeeFIM was used as the criterion standard. A case study was used to illustrate the complementary nature of the PAMS and WeeFIM. SETTING: A single, free-standing, academically affiliated pediatric rehabilitation hospital. PARTICIPANTS: Children (N=107) aged 2 through 18 years receiving inpatient rehabilitation for ABI between March 2009 and March 2012. Forty-two additional children treated during this time were excluded because of missing PAMS data. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Internal consistency was evaluated using Cronbach alpha. Interrater reliability was evaluated through overall agreement, Pearson correlations, and intraclass correlations. Construct validity was examined through exploratory factor analysis. Criterion validity was explored through correlations of PAMS overall and factor scores with WeeFIM total and subscale scores. Sensitivity to recovery was examined using paired t tests, examining differences between admission and discharge scores for each item and for the total score. RESULTS: Internal consistency and interrater reliability were high. Factor analysis revealed 2 factors: lower-level skills and higher-level mobility skills. Correlations with the WeeFIM ranged from moderate to very strong; total PAMS score most strongly correlated with the WeeFIM mobility subscore. Total PAMS score and each item score significantly increased between admission and discharge. CONCLUSIONS: The PAMS is a reliable and valid measure of progress during inpatient rehabilitation for children with ABI. By capturing fine-grain progress toward both lower-level and higher-level mobility skills, the PAMS complements the WeeFIM in assessing functional gains during the rehabilitation stay.

Examining acute rehabilitation outcomes for children with total functional dependence after traumatic brain injury: a pilot study.

OBJECTIVE: To examine in a pilot cohort factors associated with functional outcome at discharge and 3-month follow-up after discharge from inpatient rehabilitation in children with severe traumatic brain injury (TBI) who entered rehabilitation with the lowest level of functional skills. PARTICIPANTS: Thirty-nine children and adolescents (3-18 years old) who sustained a severe TBI and had the lowest possible rating at rehabilitation admission on the Functional Independence Measure for Children (total score = 18). METHODS: Retrospective review of data collected as part of routine clinical care. RESULTS: At discharge, 59% of the children were partially dependent for basic activities, while 41% remained dependent for basic activities. Initial Glasgow Coma Scale score, time to follow commands, and time from injury to rehabilitation admission were correlated with functional status at discharge. Time to follow commands and time from injury to rehabilitation admission were correlated with functional status at 3-month follow-up. Changes in functional status during the first few weeks of admission were associated with functional status at discharge and follow-up. CONCLUSIONS: Even children with the most severe brain injuries, who enter rehabilitation completely dependent for all daily activities, have the potential to make significant gains in functioning by discharge and in the following few months. Assessment of functional status early in the course of rehabilitation contributes to the ability to predict outcome from severe TBI.

Time to follow commands remains the most useful injury severity variable for predicting WeeFIM® scores 1 year after paediatric TBI.

OBJECTIVE: To investigate the relationship between injury severity variables, particularly time to follow commands (TFC) and long-term functional outcomes in paediatric traumatic brain injury (TBI). METHODS AND PROCEDURE: Participants included 40 children with moderate-to-severe TBI discharged from inpatient rehabilitation. Measures of severity were initial Glasgow Coma Scale score, TFC, duration of Post Traumatic Amnesia (PTA) and total duration of impaired consciousness (TFC + PTA). Functional outcome was measured by age-corrected Functional Independence Measure for Children (WeeFIM®) scores at 1-year after discharge. RESULTS: Correlations indicated that injury severity variables (TFC, PTA and TFC + PTA) were all associated with functional outcome. Regression analyses revealed that TFC and TFC + PTA similarly accounted for 49% or 47% of the variance, respectively, in total WeeFIM® score. Thirty-seven of 40 children had good outcome; of the three children with TFC >26 days, two had poor outcome. CONCLUSION: PTA and TFC + PTA do not provide a benefit over TFC alone for prediction of long-term outcome and TFC is identified earlier in the recovery course. TFC remains an important predictor of functional outcome 1-year after discharge from inpatient rehabilitation after paediatric TBI.

Cyclohexanone Exposure in Children on Extracorporeal Membrane Oxygenation Support.

The aim of this study was to determine if plasma cyclohexanone and metabolites are associated with clinical outcomes of children on extracorporeal membrane oxygenation (ECMO) support. We performed a secondary analysis of a prospective observational study of children on ECMO support at two academic centers between July 2010 and June 2015. We measured plasma cyclohexanone and metabolites on the first and last days of ECMO support. Unfavorable outcome was defined as in-hospital death or discharge Pediatric Cerebral Performance Category score > 2 or decline ≥ 1 from baseline. Among 90 children included, 49 (54%) had unfavorable outcome at discharge. Cyclohexanediol, a cyclohexanone metabolite, was detected in all samples and at both time points; concentrations on the first ECMO day were significantly higher in those with unfavorable versus favorable outcome at hospital discharge (median, 5.7 ng/µl; interquartile range [IQR], 3.3-10.6 ng/µl vs. median, 4.2 ng/µl; IQR, 1.7-7.3 ng/µl; p = 0.04). Twofold higher cyclohexanediol concentrations on the first ECMO day were associated with increased risk of unfavorable outcome at hospital discharge (multivariable-adjusted hazard ratio [HR], 1.24 [95% CI, 1.05-1.48]). Higher cyclohexanediol concentrations on the first ECMO day were not significantly associated with new abnormal neuroimaging or 1-year Vineland Adaptive Behavior Scales-II score < 85 or death among survivors.

Pediatric neuropsychological evaluation via telehealth: Novel models of care.

Objective: As the coronavirus pandemic extends across the globe, the impacts have been felt across domains of industry. Neuropsychology services are no exception. Methods for neuropsychological assessments, which typically require an in-person visit, must be modified in order to adhere to social distancing and isolation standards enacted in an effort to slow the pandemic. How can providers continue to meet the needs of patients referred for neuropsychology evaluations, while respecting federal and state guidelines for safety and ethical mandates? We offer a novel, tiered model of care, successfully implemented in response to mandated social distancing, in a large, pediatric neuropsychology program.Method: We describe the considerations and challenges to be addressed in transitioning a large neuropsychology department to a new model of care, including triaging referrals, developing -or rediscovering - types of services to meet the needs of a virtual patient population, and helping patients, parents, and providers to adjust to these new models.Conclusions: Lessons learned as a function of rapid changes in care models have implications for the field of neuropsychology as a whole as well as for future flexibility in meeting the needs of pediatric patients and their families.

Disruptive behaviour disorders and disruptive symptoms after severe paediatric traumatic brain injury.

OBJECTIVE: To determine pre-injury prevalence and post-injury incidence of DSM-III-R oppositional defiant disorder (ODD) and conduct disorder (CD), increase in disruptive symptoms after severe paediatric traumatic brain injury (TBI) and risk factors associated with development of these disturbances. METHODS: Ninety-four children were followed 1 one year after severe TBI. Assessments of pre-injury and 1-year psychiatric status were ascertained by parent report. The 1-year incidence of disruptive behaviour disorders/symptoms was the main outcome measure. RESULTS: The pre-injury prevalence of ODD and CD in the TBI sample was 6% and 8%, respectively, the prevalence of pre-injury CD being significantly higher than in a reference population. The incidence of new-onset ODD and CD 1-year post-injury was 9% and 8%, respectively, the incidence of new-onset CD being significantly higher than in a reference population. ODD symptoms and total number of disruptive symptoms increased significantly over the first post-injury year. Significant risk factors for disruptive disorders/symptoms included higher pre-injury psychosocial adversity, delinquency ratings and affective lability. CONCLUSIONS: Pre-injury conduct disorder is a significant risk factor for post-injury disruptive behaviours. New-onset CD and disruptive symptoms are consequences of TBI at 1-year post-injury. Risk factors for these post-injury disturbances are similar to risk factors in non-TBI populations.

Intensive care unit variables and outcome after pediatric traumatic brain injury: a retrospective study of survivors.

OBJECTIVE: Traumatic brain injury is a leading cause of death and disability in children. Hypotension has been associated with poor survival and outcome in children after traumatic brain injury, but the effect of acute hypertension is less certain. The objective was to obtain acute physiologic variables during the early hospitalization period in a cohort of children prospectively enrolled in another study. DESIGN: Retrospective chart reviews. SETTING: University-affiliated pediatric rehabilitation center. PATIENTS: Fifty-seven survivors, 5-17 yrs of age, admitted for rehabilitation between 1992 and 1995 after sustaining a traumatic brain injury. INTERVENTIONS: Standard of care. MEASUREMENTS AND MAIN RESULTS: Outcomes were assessed at 1 yr postinjury through cognitive testing of the child and parent interview of the child's global functional skills. Cognitive outcome was measured using the Performance IQ from the Wechsler Intelligence Scale for Children, Third Edition. Overall functional outcome was assessed using the Disability Rating Scale. CONCLUSIONS: This study suggests that early markers of secondary injury after moderate to severe traumatic brain injury in children may be predictive of long-term outcome. This study reinforces the need for longer term, systematic, and more precise measurements of outcomes in children with traumatic brain injury and prospective studies to examine the predictive value of acute management variables on multiple types of outcomes after traumatic brain injury in children.

Working memory performance following paediatric traumatic brain injury.

PRIMARY OBJECTIVE: The present study investigated working memory ability in children who sustained moderate-to-severe traumatic brain injuries in relation to pre-injury, injury-related and developmental factors. It was hypothesized that there would be a correlation between performance- and rater-based working memory measures; factors predictive of working memory impairment would include earlier age at injury, more severe injury, longer time since injury and poorer overall cognitive functioning; and working memory performance would be significantly impaired when compared to normative populations. METHODS AND PROCEDURES: Working memory was assessed in 62 children using a traditional performance measure (digit span backward) and parent report (Behaviour Rating Inventory of Executive Function (BRIEF)). MAIN OUTCOMES AND RESULTS: Contrary to prediction, there was no statistical association between performance- and rater-based measures of working memory. Regression analyses revealed injury severity, time-since-injury, overall cognitive ability and attention span were predictive of working memory performance. As a group, working memory was impaired relative to normative samples on both measures. CONCLUSIONS: Performance- and rater-based working memory measures, while not significantly correlated, are both sensitive to acquired cognitive dysfunction following paediatric traumatic brain injury. Demographic and clinical factors may be used to predict cognitive outcomes, educate caregivers and design clinical interventions.

Prevalence of aggressive behaviour after severe paediatric traumatic brain injury.

OBJECTIVE: The goals of this study were to explore the prevalence of aggressive behaviours after severe paediatric traumatic brain injury (TBI) and identify predictors of aggressive behaviours 1 year post-injury. METHODS: A cohort of 97 children aged 4-19 years at time of severe TBI (GCS 3-8) were prospectively followed for 1 year. Pre-injury psychiatric status was obtained retrospectively at enrolment and post-injury behavioural and functional concerns were assessed at 1 year. Aggression was measured with a modified version of the Overt Aggression Scale (OAS). RESULTS: Results revealed aggressive behaviour increased from pre-injury to post-injury. Pre-injury factors including aggression, attention problems and anxiety were associated with increased post-injury aggressive behaviour. Children with greater disability after injury were also at increased risk for aggressive behaviours. CONCLUSIONS: Aggression is a prevalent symptom after paediatric TBI and can significantly impede rehabilitation. Awareness of these predictors can aid in early identification of children at risk in order to help appropriately design rehabilitation programmes.