Factors related to adverse long-term outcomes after mild traumatic brain injury in children: a scoping review.

OBJECTIVE: To identify demographic, premorbid and injury-related factors, or biomarkers associated with long-term (≥3 months) adverse outcomes in children after mild traumatic brain injury (mTBI). DESIGN: Scoping review of literature. PATIENTS: Children and adolescents with mTBI. RISK FACTORS: Any demographic, premorbid and injury-related factors, or biomarkers were included. We excluded genetic and treatment-related factors. MAIN OUTCOME MEASURES: Postconcussion syndrome (PCS), recovery. RESULTS: Seventy-three publications were included, reporting 12 long-term adverse outcomes, including PCS in 12 studies and recovery in 29 studies. Additional outcomes studied were symptom scores/severity (n=22), quality of life (n=9) and cognitive function (n=9). Forty-nine risk factors were identified across studies. Risk factors most often assessed were sex (n=28), followed by age (n=23), injury mechanism = (n=22) and prior mTBI (n=18). The influence of these and other risk factors on outcomes of mTBI were inconsistent across the reviewed literature. CONCLUSIONS: The most researched risk factors are sex, age and mechanism of injury, but their effects have been estimated inconsistently and did not show a clear pattern. The most studied outcomes are recovery patterns and symptom severity. However, these may not be the most important outcomes for clinicians and patients. Future primary studies in this area should focus on patient-important outcomes. Population-based prospective studies are needed that address prespecified hypotheses on the relationship of risk factors with given outcomes to enable reliable prediction of long-term adverse outcomes for childhood mTBI.

Acceptance and commitment therapy for young brain tumour survivors: study protocol for an acceptability and feasibility trial.

INTRODUCTION: Survivors of childhood brain tumours have the poorest health-related quality of life of all cancer survivors due to the multiple physical and psychological sequelae of brain tumours and their treatment. Remotely delivered acceptance and commitment therapy (ACT) may be a suitable and accessible psychological intervention to support young people who have survived brain tumours. This study aims to assess the feasibility and acceptability of remotely delivered ACT to improve quality of life among these young survivors. METHODS AND ANALYSIS: This study is a two-arm, parallel group, randomised controlled trial comparing ACT with waitlist control at 12-week follow-up as the primary endpoint. Seventy-two participants will be recruited, who are aged 11-24 and have completed brain tumour treatment. Participants will be randomised to receive 12 weeks of ACT either immediately or after a 12-week wait. The DNA-v model of ACT will be employed, which is a developmentally appropriate model for young people. Feasibility will be assessed using the proportion of those showing interest who consent to the trial and complete the intervention. Acceptability will be assessed using participant evaluations of the intervention, alongside qualitative interviews and treatment diaries analysed thematically. A range of clinical outcome measures will also assess physical and mental health, everyday functioning, quality of life and service usage at 12-week follow-up. The durability of treatment effects will be assessed by further follow-up assessments at 24 weeks, 36 weeks and 48 weeks. ETHICS AND DISSEMINATION: Ethical approval was given by East Midlands, Nottingham 1 Research Ethics Committee (Reference: 20/EM/0237). Study results will be disseminated in peer-reviewed journals, through public events and relevant third sector organisations. TRIAL REGISTRATION: ISRCTN10903290; NCT04722237.

Early Childhood General Anesthesia and Neurodevelopmental Outcomes in the Avon Longitudinal Study of Parents and Children Birth Cohort.

BACKGROUND: Most common anesthetic agents have been implicated in causing neurodegeneration in the developing animal brain, leading to warnings regarding their use in children. The hypothesis of this study was that exposure to general anesthesia and surgery before 4 yr would associate with adverse neurodevelopmental outcomes at age 7 to 16 yr. METHODS: This cohort study comprised 13,433 children enrolled in the Avon Longitudinal Study of Parents and Children, a prospective, population-based birth cohort born between 1991 and 1993 in southwest England. Children were grouped by none, single, or multiple exposures to general anesthesia and surgery by 4 yr. Motor, cognitive, linguistic, educational, social, and behavioral developmental outcomes were evaluated at 7 to 16 yr using school examination results, validated parent/teacher questionnaires, or clinic assessments. Continuous outcomes were z-scored. P-value thresholds were corrected using false discovery rate procedures. RESULTS: This study compared 46 neurodevelopmental outcomes in 13,433 children: 8.3% (1,110) exposed singly and 1.6% (212) exposed multiply to general anesthesia and surgery. Of these, the following reached predefined levels of statistical significance (corrected P < 0.00652): dynamic balance scores were 0.3 SD (95% CI, 0.1, 0.5; P < 0.001) lower in multiply exposed children; manual dexterity performance was 0.1 SD (95% CI, 0.0, 0.2; P = 0.006) lower in singly and 0.3 SD (95% CI, 0.1, 0.4; P < 0.001) lower in multiply exposed children; and social communication scores were 0.1 SD (95% CI, 0.0, 0.2; P = 0.001) and 0.4 SD (95% CI, 0.3, 0.5; P < 0.001) lower in singly and multiply exposed children, respectively. General anesthesia and surgery were not associated with impairments in the remaining neurodevelopmental measures including: general cognitive ability; attention; working memory; reading, spelling, verbal comprehension and expression; behavioral difficulties; or national English, mathematics, and science assessments (all ≤0.1 SD; corrected P ≥ 0.00652). CONCLUSIONS: Early childhood general anesthesia and surgery were not associated with a global picture of clinically and statistically significant neurodegenerative effects, providing reassurance about the neurotoxic potential of general anesthesia. Exposure to anesthesia and surgery was associated with significantly lower motor and social linguistic performance.

A randomized controlled trial of a manual-based psychosocial group intervention for young people with epilepsy [PIE].

We conducted an exploratory RCT to examine feasibility and preliminary efficacy for a manual-based psychosocial group intervention aimed at improving epilepsy knowledge, self-management skills, and quality of life in young people with epilepsy. METHOD: Eighty-three participants (33:50m/f; age range 12-17years) were randomized to either the treatment or control group in seven tertiary paediatric neuroscience centres in the UK, using a wait-list control design. Participants were excluded if they reported suicidal ideation and/or scored above the cut off on mental health screening measures, or if they had a learning disability or other neurological disorder. The intervention consisted of six weekly 2-hour sessions using guided discussion, group exercises and role-plays facilitated by an epilepsy nurse and a clinical psychologist. RESULTS: At three month follow up the treatment group (n=40) was compared with a wait-list control group (n=43) on a range of standardized measures. There was a significant increase in epilepsy knowledge in the treatment group (p=0.02). Participants receiving the intervention were also significantly more confident in speaking to others about their epilepsy (p=0.04). Quality of life measures did not show significant change. Participants reported the greatest value of attending the group was: Learning about their epilepsy (46%); Learning to cope with difficult feelings (29%); and Meeting others with epilepsy (22%). Caregiver and facilitator feedback was positive, and 92% of participants would recommend the group to others. CONCLUSION: This brief psychosocial group intervention was effective in increasing participants' knowledge of epilepsy and improved confidence in discussing their epilepsy with others. We discuss the qualitative feedback, feasibility, strengths and limitations of the PIE trial.

Errorless learning improves memory performance in children with acquired brain injury: a controlled comparison of standard and self-generation techniques.

The principle of errorless learning has proven efficacy in helping adults and older adults with acquired memory impairment learn novel information. However, surprisingly few studies have investigated its efficacy in children. The present study addresses this omission in the literature, investigating the effectiveness of two forms of errorless learning - the established method, in which the examiner provides responses during learning, and a self-generation method, in which learners produce their own responses - each relative to the standard baseline of trial-and-error learning, in young people with acquired brain injury (ABI, n = 15) and non-injured controls (n = 15). Participants learned different word lists in each condition and their memory was tested after distraction and, subsequently, after a 20-minute delay. Not surprisingly, controls performed better than the ABI group. However, while there was no effect of learning condition for controls, in the ABI group memory performance was significantly better under errorless conditions. In contrast to findings in the adult literature, there was no difference in the efficacy of the two errorless methods, suggesting that self-generation was no better than standard examiner-generation. This study extends upon previous research to provide the first demonstration of the effectiveness of errorless methods in a group of young people with ABI.

Patterns of attention and experiences of post-traumatic stress symptoms following childbirth: an experimental study.

Childbirth for some women can be experienced as a traumatic event whereby it is appraised as threatening to life and associated with feelings of fear, helplessness or horror. These women may develop symptoms consistent with post-traumatic stress disorder or its sub-clinical symptoms (post-traumatic stress, PTS). Cognitive processes such as attentional biases have been identified in individuals with PTS exposed to other traumatic events. This study used an experimental design (the modified Stroop task) to investigate the relationship between attentional biases and PTS symptoms in 50 women who experienced their labour and delivery as stressful and responded with fear, helplessness and horror. Attentional biases away from childbirth words were significantly associated with both symptoms of post-traumatic stress and more negative experiences of childbirth. A negative experience was also associated with more severe symptoms of PTS. Positive experiences were unassociated with attentional biases or symptoms. Post-traumatic stress responses, in this population, may be associated with avoidance, and through influencing cognitive processing, acting as a maintaining factor of distress.

Acquired microcephaly: causes, patterns, motor and IQ effects, and associated growth changes.

OBJECTIVES: The goals were to identify and to classify causes and growth patterns of acquired (or progressive) microcephaly and to look for hypothesized correlations between causes, growth patterns, and developmental quotient/IQ. METHODS: Fifty-one children (24 boys), 0.7 to 11.3 years of age, with early occipitofrontal circumference measurements above and later ones below the second percentile (SD: -2.03) were studied through retrospective note and growth chart review, with formal assessments of developmental quotient or IQ (n = 34). RESULTS: Causes were classifiable into 5 groups as follows: idiopathic, familial, syndromic, symptomatic, and mixed. Four patterns of head growth were identified, as follows: type A, initial decrease from the normal range to below the second percentile, followed by growth below and parallel to the second percentile; type B, continued decrease away from the second percentile; type C, decrease below the normal range, with partial later recovery; type D, insufficient data. For 12 children, there were accompanying decreases in weight percentiles and for 5 of these in height percentiles as well. Infants with lower head circumference z scores at the end of the study also had lower z scores for final weight and final length. There was no correlation between causal group and growth pattern. Developmental quotient/IQ values were mostly <100 and did not correlate with head circumference z score, cause, or pattern. CONCLUSIONS: The classification of causal groups and growth patterns should aid clinical management. Neither cause nor pattern predicted outcomes. The associations with poor weight gain and body growth deserve further study.

High frequency stimulation of the mamillothalamic tract for the treatment of resistant seizures associated with hypothalamic hamartoma.

We investigate the clinical outcome from stimulation of the mamillothalamic tract in two patients with intractable epilepsy secondary to hypothalamic hamartomas. One patient has a left-sided and the other a right-sided tumor. Both patients presented with a history of gelastic and complex partial seizures resistant to multiple antiepileptic drugs. Both patients underwent insertion of a single deep brain-stimulating electrode ipsilateral to the site of the tumor, lying adjacent to the mamillothalamic tract. Postoperatively they both had a significant reduction in seizure frequency, with one patient being seizure free for the last 10 months. An improvement in mood was reported by the patient's primary carers and demonstrated on quality of life questionnaires.

Posttraumatic stress symptoms following childbirth and mothers' perceptions of their infants.

Postpartum psychological distress can adversely affect the early mother-infant relationship; however, this has not been investigated in relation to posttraumatic stress disorder (PTSD) following childbirth. This article explores whether PTSD symptoms relating to labor and delivery are associated with mothers' early perceptions of their infant. Using labor and childbirth as the stressor criterion, 211 women were assessed at 6 weeks' postpartum for symptoms of intrusions, avoidance, and hyperarousal. Their perceptions of their infants, of mother-to-infant attachment, and infant behavioral characteristics also were evaluated. In sum, 3.8% of the women fulfilled full diagnostic criteria, and a further 21.3% reported clinically significant symptoms on at least one dimension of PTSD. Those meeting full or partial criteria perceived their attachment relationships to be significantly less optimal and reported more negative maternal representations in terms of their infants being less warm and more invasive. They also rated them as being temperamentally more difficult, prone to distress, and less easy to soothe. However, when the effects of depression were partialled, only the effect for perceived warmth remained. Posttraumatic stress symptoms relating to labor and delivery may adversely influence maternal perceptions of infants, with potentially adverse implications for the developing mother-infant relationship. The overlap with depressive symptoms requires further exploration.

The development of intellectual abilities in pediatric temporal lobe epilepsy.

PURPOSE: The aim of this study was to examine the impact of clinical variables, particularly age at onset of epilepsy, on intellectual function in a group of children with temporal lobe epilepsy (TLE). METHODS: We reviewed the preoperative neuropsychological test results of 79 children with unilateral TLE who subsequently underwent surgical resection. The impact of age at onset and duration of epilepsy, pathology type, and side of resection on full-scale intelligence quotient (IQ) scores was examined. RESULTS: Intellectual dysfunction (defined as IQ < 79) was present in 57% of children, and age at onset of epilepsy was the best predictor of intellectual function. Children with epilepsy onset in the first year of life had a particularly high incidence of intellectual impairment (82.4%). CONCLUSION: These data suggest a critical period during the first year of life for the subsequent development of intellectual abilities and highlight the importance of early treatment in this population.

A developmental framework for memory rehabilitation in children.

Memory difficulties in adults with acquired brain injuries have been reported in the literature for some time. In recent years, the consequences of memory difficulties from acquired and neurodevelopmental disorders in children have also been investigated. Initial studies have suggested that, like adults, children can experience severe and specific memory deficits. However, there are important developmental differences, both in terms of the nature of cognitive difficulties experienced, and the subsequent consequences for learning, educational attainment and everyday living. Despite the advances made in developmental memory studies, as yet, there appears to be scant literature to guide effective rehabilitation specifically targeted at children. As a starting point, it may be appropriate to consider adaptation of adult rehabilitation strategies to address memory problems in children. This paper describes some of the common principles and practices of adult rehabilitation strategies and then considers the validity of such strategies against developmental models of the memory system and child's learning environment. In particular, four important areas are highlighted: the development of normal memory functions in children, the range of cognitive deficits that can occur in a developing brain, the interaction of memory deficits with other immature cognitive skills and the context of the psycho-social environment in which rehabilitation may take place.

A new Stroop-like measure of inhibitory function development: typical developmental trends.

BACKGROUND: Difficulties with inhibition are increasingly regarded as central to pathological behavioural and learning disorders in childhood. However, few measures are available to assist in the assessment of young children's inhibitory competence. METHOD: A new, Stroop-like measure of inhibitory function is described which was designed to be appropriate for use with children from 3 years of age. One hundred and fifty-five school children aged between 3 and 16 years took part in a study to examine the developmental characteristics and behavioural correlates of task performance. RESULTS: The task appears to provide a robust measure of inhibitory function across the age range, 3 to 16 years. Furthermore, the animal-stroop task appears to identify those at risk of hyperactive symptomatology within a school-based sample. CONCLUSIONS: The clinical and developmental applications of this new measure are discussed.