Rehabilitation of Executive Function in Pediatric Traumatic Brain Injury (REPeaT): Outcomes of a pilot randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of Cogmed Working Memory Training (Cogmed) in improving working memory (WM) and decision making (DM) in childhood traumatic brain injury (TBI), and any associated increases in functional outcomes such as academic achievement in mathematics, behavior, social skills, and quality of life. METHOD: A randomized controlled trial of the Cogmed (RM version) intervention for children with TBI. A total of 69 children post-TBI were screened for WM impairments, of which 31 eligible participants (Mage: 10.6 years; male n = 21) were recruited and randomized to either the treatment group (Cogmed, n = 16) or the active-control group (Lexia Reading Core5, n = 15). Both groups completed computerized training for 5 weeks with clinician support via an online video platform. Immediately posttraining and at 6 months follow-up, primary (WM and DM) and secondary functional outcomes were assessed. RESULTS: Immediately postintervention, significant improvement was found in one primary outcome (WM verbal component) for the Cogmed group, but this was not maintained at the 6 months follow-up. No immediate improvements or maintenance gains (small effect sizes) in other primary outcomes of visuospatial WM or DM were reported in the Cogmed group. No other significant group differences were detected for other functional outcomes. CONCLUSIONS: Despite the limited benefits observed in this small randomized controlled trial, it will be beneficial to investigate Cogmed's efficacy in a case-series methodology, to further determine its effectiveness in a pediatric TBI population. Furthermore, a cautious approach in clinical implementation of Cogmed is advised. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The decision-making task: Development and evaluation in a paediatric traumatic brain injury population.

Assessment measures that quantify decision-making abilities in children and adolescents are limited. In the current study, a novel computerized Decision-Making Task (DMT), which identifies the process that is involved in decision-making, was developed based on an existing information-boards paradigm. The overall aim was to validate the DMT in a paediatric TBI population. This prospective study investigated the performance on the DMT for children post-TBI (n = 49; 7-15 years) compared to typically developing controls (n = 22; 7-15 years), and investigated the psychometric properties of the DMT by examining internal consistency-related reliability, convergent validity (measures of decision-making, working memory, functional outcomes, and behaviour), and divergent validity (vocabulary). Significant differences were detected for performance on the DMT between children post-TBI and the control group. Psychometric properties of the DMT were acceptable, with variable findings for convergent validity (working memory, functional outcomes, and behaviour). This is the first study to develop and investigate a novel computerised task to assess decision-making skills in a paediatric TBI population. Results cautiously suggest that the DMT is a valid and a reliable measure of decision-making in our clinical sample.

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.

Paediatric traumatic brain injury and the dysregulation profile: The mediating role of decision-making.

Decision-making is often impacted by paediatric traumatic brain injury (TBI). However, there are few tools available to assess these skills in children, with even less research on the consequences of decision-making deficits on dysregulation following TBI. This prospective preliminary study investigated whether decision-making mediated the effect of TBI on dysregulation in children. The performance of school-aged children aged between 7 and 15 years with TBI (n = 49) and that of typically developing controls (n = 22) was compared on The Decision-making Task, and on parent ratings of the dysregulation profile as characterized by the Child Behaviour Checklist-Dysregulation Profile. Relative to the Control group, the TBI group performed more poorly on the decision-making task, and parents of the TBI group rated their children to be more poorly on the dysregulation profile. Mediation analyses indicated that decision-making mediated the relationship between TBI and the dysregulation profile. Our preliminary findings suggest the need for further research in the area of decision-making, and its impact on dysregulated behaviours in children following TBI.

Long-Term Intellectual Function After Traumatic Brain Injury in Very Young Children.

OBJECTIVE: To investigate long-term intellectual function following a traumatic brain injury (TBI) in early childhood and to identify the contribution of injury and environment to outcome. PARTICIPANTS: Fifty children younger than 3 years with a diagnosis of accidental TBI were recruited through a pediatric hospital emergency department. Children with TBI were compared with a group (n = 33) of typically developing children (TDC) matched on demographics. DESIGN: Longitudinal, single-site, case-control study. MEASURES: Children completed intellectual assessments (IQ) at 4.5 to 5.5 years of age (average 3.5 years after TBI) and at 7.5 to 9 years of age (average 6.5 years after TBI). Information on injury and environmental predictors of outcome was collected. RESULTS: IQ scores for all groups were in the average range; however, children with TBI of any severity had lower scores than TDC at both time points. There was some suggestion of children with TBI achieving lower verbal IQ scores over time than TDC. IQ scores were predicted by family environment, not injury characteristics. CONCLUSIONS: A TBI in early childhood is associated with lower IQ scores that persist several years postinjury. Socioeconomic status is an influential factor on IQ at 6.5 years post-TBI.

Sleep Disturbances in Young Adults with Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life.

OBJECTIVE: This study assessed the consequences of childhood traumatic brain injury (TBI) on sleep, fatigue, depression, and quality of life (QoL) outcomes and explored the relationships between these variables at 20 years following childhood TBI. PARTICIPANTS: We followed up 54 young adults with mild, moderate, and severe TBI, and 13 typically developing control (TDC) participants, recruited at the time of TBI. METHODS: Sleep was assessed with the Pittsburgh Sleep Quality Index and actigraphy. RESULTS: At 20 years postinjury, results showed no significant difference between whole TBI group and TDC participants on subjective sleep quality; however, the moderate TBI group reported significantly poorer subjective sleep quality compared to those with severe TBI. Poorer subjective sleep was associated with increased symptoms of fatigue, depression, and poorer perceptions of General Health in the TBI group. Actigraphic sleep efficiency, fatigue, depression, and QoL outcomes were not significantly different between TBI and TDC or among TBI severity groups. CONCLUSIONS: These preliminary findings underscore associations between subjective sleep disturbance, fatigue, depression, and QoL in this TBI sample, and mostly comparable outcomes in sleep, fatigue, depression, and QoL between the TBI and TDC groups. Further research is required to clarify these findings.

Objective sleep outcomes 20 years after traumatic brain injury in childhood.

Purpose: To assess objective sleep outcomes and correlates in young adults with a history of childhood traumatic brain injury.Materials and methods: Participants included 45 young adults who sustained brain injury in childhood (mild = 12, moderate = 22, and severe = 11) and 13 typically developing control participants. Sleep was assessed with actigraphy and sleep diaries recorded over 14 consecutive days. Rates of good sleep (sleep efficiency ≥ 85%) and poor sleep (sleep efficiency < 85%) were also evaluated.Results: At 20-years postinjury, participants with traumatic brain injury and controls presented with similar outcomes across the objective sleep parameters (all p > 0.050) and rates of poor sleepers were also similar between these groups (p = 0.735): 67% and 77%, respectively. However, moderate and severe traumatic brain injury and female sex were associated with longer sleep duration.Conclusions: These findings provide preliminary insights into objective sleep outcome and associated factors in the very-long-term after childhood brain injuries. They also indicate the need to monitor sleep outcomes in young adults with and without traumatic brain injury.Implication for rehabilitationSustaining traumatic brain injury in childhood can impact on several functional domains including sleep.Sleep disturbances, particularly insomnia-related symptoms, are common in this population, with evidence of poor outcomes reported until adolescence postinjury, while outcomes beyond adolescence remain unexplored.In this first investigation of objective sleep outcomes in young adults with a history of childhood traumatic brain injury, we showed that insomnia-related symptoms are highly prevalent in both young adults with traumatic brain injury (67%) and healthy controls (77%).These findings suggest the need to routinely evaluate and treat sleep problem in young adults in general, irrespective of history of childhood traumatic brain injury.

Young adults' perspectives on health-related quality of life after paediatric traumatic brain injury: A prospective cohort study.

BACKGROUND: Quality of life (QoL) is commonly affected in children and families living with traumatic brain injury (TBI). Despite the established link between childhood TBI and reduced health-related QoL (HRQoL), there is a dearth of longitudinal, prospective research to determine the prevalence and predictors of impaired HRQoL in the very long term post-injury. OBJECTIVES: We evaluated HRQoL in young adult survivors of paediatric TBI at 15 years post-injury. We aimed to identify the prevalence of impaired HRQoL and the respective contribution of pre-injury, environmental, injury-related, cognitive and mood-based factors to various dimensions of HRQoL at 15 years post-injury. METHODS: This prospective study involved 52 young adult survivors of mild to severe TBI included from consecutive hospital admissions to the Royal Children's Hospital Melbourne, Australia between 1993 and 1997. Participants underwent neuropsychological evaluation and completed self-report measures of HRQoL, psychological functioning and social communication at 15 years post-injury. RESULTS: As compared with an age-matched Australian normative sample, the TBI group reported significantly poorer physical HRQoL at 15 years post-injury. Although group differences in other HRQoL domains did not reach statistical significance, 52% of the TBI group reported impaired functioning in at least one HRQoL domain. Contrary to expectations, HRQoL was not associated with injury severity, socioeconomic status, or pre-injury functioning. Instead, poorer HRQoL was linked to more severe depression symptoms, greater perceived social communication difficulty and reduced cognitive flexibility at 15 years post-injury. CONCLUSIONS: A substantial proportion of young adult survivors of childhood TBI experience poor HRQoL in at least one domain of functioning at 15 years post-injury. These findings suggest that, even in the very long term post-injury, the identification and treatment of modifiable risk factors has potential to improve very-long-term HRQoL outcomes in this vulnerable population.

Protocol for a prospective, longitudinal, cohort study of recovery pathways, acute biomarkers and cost for children with persistent postconcussion symptoms: the Take CARe Biomarkers study.

INTRODUCTION: The majority of children who sustain a concussion will recover quickly, but a significant minority will experience ongoing postconcussive symptoms, known as postconcussion syndrome (PCS). These symptoms include emotional, behavioural, cognitive and physical symptoms and can lead to considerable disability. The neurobiological underpinnings of PCS are poorly understood, limiting potential clinical interventions. As such, patients and families frequently re-present to clinical services, who are often ill equipped to address the multifactorial nature of PCS. This contributes to the high cost of concussion management and the disability of children experiencing PCS. The aims of the present study are: (1) to plot and contrast recovery pathways for children with concussion from time of injury to 3 months postinjury, (ii) evaluate the contribution of acute biomarkers (ie, blood, MRI) to delayed recovery postconcussion and (3) estimate financial costs of child concussion to patients attending the emergency department (ED) of a tertiary children's hospital and factors predicting high cost. METHODS AND ANALYSIS: Take C.A.Re is a prospective, longitudinal study at a tertiary children's hospital, recruiting and assessing 525 patients aged 5-<18 years (400 concussion, 125 orthopaedic injury) who present to the ED with a concussion and following them at 1-4 days, 2 weeks, 1 month and 3 months postinjury. Multiple domains are assessed: preinjury and postinjury, clinical, MRI, blood samples, neuropsychological, psychological and economic. PCS is defined as the presence of ≥2 symptoms on the Post Concussive Symptoms Inventory rated as worse compared with baseline 1 month postinjury. Main analyses comprise longitudinal Generalised Estimating Equation models and regression analyses of predictors of recovery and factors predicting high economic costs. ETHICS AND DISSEMINATION: Ethical approval has been obtained through the Royal Children's Hospital Melbourne Human Research Ethics Committee (33122). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media. TRIAL REGISTRATION NUMBER: ACTRN12615000316505; Results.

A Systematic Review of Sleep-Wake Disturbances in Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life.

OBJECTIVE: To systematically appraise the literature on the prevalence, types, and predictors of sleep-wake disturbances (SWD), and on the relationship between SWD, fatigue, depression, and quality of life in children and adolescents with traumatic brain injury (TBI). METHODS: MEDLINE, PubMed, PsychInfo, Web of Science, and EMBASE databases were searched, reference lists of retrieved articles were also searched for relevant articles, and study methods were evaluated for risk of bias. RESULTS: Of the 620 articles assessed, 16 met inclusion criteria. Sleep-wake disturbances were common in childhood TBI. The most common types of SWD reported were insomnia and excessive daytime sleepiness, with mild TBI participants showing a trend toward more sleep maintenance insomnia, while sleep-onset insomnia was typical in those with moderate-severe TBI. Predictors of SWD reported in studies involving mild TBI participants included TBI severity, male sex, preexisting SWD, high body weight, and depression; while injury severity and internalizing problems were associated with SWD in moderate-severe TBI participants. Sleep-wake disturbances were also associated with fatigue and poor quality of life following TBI. CONCLUSION: Sleep-wake disturbances are highly prevalent in childhood TBI, regardless of injury severity. Routine assessments of SWD in survivors of childhood TBI are recommended.

Outcomes of Subjective Sleep-Wake Disturbances Twenty Years after Traumatic Brain Injury in Childhood.

Sleep-wake disturbances (SWD) are frequent following traumatic brain injury (TBI) in childhood. However, outcomes of SWD following transition into young adulthood remain unknown. This study investigated prevalence and factors associated with subjective sleep quality, insomnia, and excessive daytime sleepiness in young adults with a history of childhood TBI. Participants included 54 young adults with mild (n = 14), moderate (n = 27), and severe (n = 13) TBI (age: mean = 27.7, SD = 3.3), and 13 typically developing controls (TDC) (age: mean = 25.9, SD = 2.2). SWD were assessed using the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Epworth Sleepiness Scale (ESS). Compared with TDC, young adults with TBI reported a trend toward poorer sleep quality (F[1, 63] = 3.85, p = 0.054, η2 = 0.06), with a higher risk in participants after moderate TBI (mean = 2.40, SD = 0.56) than after severe TBI (mean = 1.89, SD = 0.62: p = 0.015). However, the groups did not differ on symptoms of insomnia and excessive daytime sleepiness, and SWD were less frequent after severe TBI at 20 years post-injury. Poor sleep quality in young adults with TBI was associated with high levels of anxiety and pain, and pain was also associated with higher risk of insomnia and excessive daytime sleepiness. Our findings indicate that sustaining TBI in childhood can increase risk of SWD in young adulthood, particularly following moderate TBI. Routine assessments and treatment of SWD, as well as anxiety and pain in children with TBI, should therefore continue into adulthood.

Rehabilitation of Executive function in Paediatric Traumatic brain injury (REPeaT): protocol for a randomized controlled trial for treating working memory and decision-making.

BACKGROUND: Working memory allows us to hold information in an active state for short periods of time, and is essential in facilitating goal directed cognitive functioning. Difficulties in working memory and decision-making are common post childhood Traumatic Brain Injury (TBI). Despite this, there is a paucity of research pertaining to implementation and effectiveness of interventions to reduce these common difficulties which impact significantly on one's ability to function independently. One such intervention, Cogmed Working Memory Training Program, has shown success in improving working memory in other childhood clinical populations, but has received little evaluation in the TBI area. This study aims to evaluate whether Cogmed improves working memory and decision-making post childhood TBI and whether these benefits generalize to functional areas. METHODS: The study is a randomized controlled trial (RCT) of the Cogmed (RM version) intervention for children post-TBI. Children aged 7-15 years are initially screened for working memory impairments. Eligible participants are then randomized into either the treatment group (Cogmed) or the active-control group (Lexia Reading). Each group trains online for 50 min each day, 5 days per week, for 5 consecutive weeks. The online training is supported by online clinician meetings each week. Outcome neuropsychological and functional assessments are carried out immediately at the completion of the intervention and at 6 months follow-up. DISCUSSION: This study follows gold standard methodology in intervention research; uses a novel measure of decision-making; measures the effects of intervention on functional outcomes immediately and longer-term post intervention; uses online clinician support in order to allow more families easy access to the program; and promotes the use of technology to improve health services. If efficacious in improving working memory, decision-making, and functional outcomes, our team will then take a key role in implementing Cogmed into clinical care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000085370 . Trial Registration Date: 16/01/2017. Protocol Version/Date: HREC 35181G/18.08.2017. Study Status: Ongoing.

A Systematic Review of Interventions for Hot and Cold Executive Functions in Children and Adolescents With Acquired Brain Injury.

Objective: We investigated interventions, which aimed to improve cold and hot executive functions (EFs) in children and adolescents with a diagnosis of acquired brain injury (ABI). Methods: The following electronic databases were searched: Medline, CINAHL, PsycINFO, and Pubmed. The database filters limited the search to articles published between 1990 and July 2017 in English or Spanish, including children and adolescents. Articles were read and classified according to the levels of evidence of the Australian National Health and Medical Research Council and the Downs and Black checklist was used for Measuring Study Quality. Results: Thirty studies are reported in this systematic review. Level of evidence, quality of the studies, characteristics of the participants, interventions implemented, and outcomes are described. Conclusions: The study of rehabilitation for executive dysfunction in children with ABI is emerging. Although few high-quality intervention studies exist in this area, which limits conclusions regarding intervention efficacy, results of existing studies suggest that education for parents may be an important component of intervention. Moreover, caregiver involvement may improve the effectiveness of hot EFs rehabilitation interventions, while high intervention session frequency may be important in improving cold EFs. Positive behavior supports and specific training based on a cognitive model provided some promising findings, which require further evaluation.

Fatigue following Paediatric Acquired Brain Injury and its Impact on Functional Outcomes: A Systematic Review.

Fatigue is a commonly reported sequela following an acquired brain injury (ABI), and can have a negative impact on many areas of a child's life. However, there is minimal research that focuses on fatigue specifically, and so factors such as its occurrence, duration, and impact on functioning remain uncertain. This systematic review aims to provide a comprehensive summary of the research to date, bringing together a number of studies with a focus on paediatric ABI and fatigue. Terms were searched in relevant databases (PsycInfo, Medline, CINAHL), and articles were included or excluded based on specified criteria. Of the 1177 papers identified in the original search, a total of 9 papers met inclusion criteria, and were categorised as traumatic brain injury (TBI; n = 4), meningitis and meningococcal disease (n = 2), brain tumours (n = 2), and mixed ABI group (n = 1). Key findings suggest that fatigue is a problem encountered by a significant proportion of patients in all the studies reviewed, and often occurred regardless of the cause; fatigue was also associated with poor academic achievement, limited physical activity, and social and emotional problems. Injuries of greater severity were associated with higher levels of fatigue and worse outcomes. Several management options were suggested, though their efficacy was not reported. Future research is required with a suggested focus on using multiple time points to better understand the trajectories of fatigue following childhood ABI, and to build an evidence base to determine which management options are most suitable.

Feasibility and effectiveness of a parenting programme for Mexican parents of children with acquired brain injury-Case report.

BACKGROUND: Acquired brain injury (ABI) during childhood typically causes behaviour problems in the child and high levels of stress in the family. OBJECTIVES: (1) To investigate the feasibility and effectiveness of a parenting programme to: improve behaviour and self-regulation (SR) in Mexican children with ABI, enhance parenting skills, and decrease parental stress in parents of children with ABI; (2) to explore the impact of parent SR on child. METHODS: Case study design with four participants post-ABI, aged 7-12 years, recruited in Mexico City. A parenting programme (Signposts for Building Better Behaviour) was delivered and provided parents with strategies to manage child behaviour. Child behaviour, child self-regulation, parental stress and parenting practices were measured before, immediately post-intervention, and three months post-intervention. RESULTS: At immediate and three months post-intervention improvements in parenting skills, reduction in parental stress, and improvement in child behaviour were identified. CONCLUSIONS: The programme is feasible in a Mexican population and was effective in improving parenting skills and reducing stress in parents of children with ABI, as well as improving child behaviour and behavioural SR. These domains continue improving three months after the intervention. The improvements in challenging behaviour at home did not transfer to the school environment.

Brain volumetric correlates of inhibition and cognitive flexibility 16 years following childhood traumatic brain injury.

Executive functions (EFs), such as inhibition and cognitive flexibility, are essential for everyday functioning, including regulation of socially appropriate emotional responses. These skills develop during childhood and continue maturing into early adulthood. The current study aimed to investigate the very long-term impact of childhood traumatic brain injury (TBI) on inhibition and cognitive flexibility, and to examine whether global white matter is associated with these abilities. Twenty-eight young adult survivors of childhood TBI (mean age at 16-year follow-up = 21.67 years, SD = 2.70) and 16 typically developing controls (TDCs), group-matched for age, sex, and socioeconomic status, completed tests of inhibition and cognitive flexibility and underwent structural MRI. Survivors of childhood TBI did not significantly differ from TDCs on EF or white matter volume. However, the relationship between EF and white matter volume differed between survivors of TBI and TDCs. Survivors of TBI did not mimic the brain behavior relationship that characterized EF in TDCs. The inverse brain behavior relationship, exhibited by childhood TBI survivors, suggests disruptions in the whole brain underpinning EF following childhood TBI.

Managing challenging behaviour in preschool children post-traumatic brain injury with online clinician support: protocol for a pilot study.

BACKGROUND: Traumatic brain injury (TBI) in children is associated with a range of poor long-term outcomes, including behavioural disturbances. Parents can experience high levels of stress and injury-related burden, and evidence suggests that distressed parents are less likely to adopt positive parenting styles to manage their child's behaviour. The 'Signposts for Building Better Behaviour' program is a parenting programme that was originally developed to assist parents of children with an intellectual disability in managing their child's behaviour. More recently, it has been adapted to include a TBI module, to assist parents in managing post-TBI behaviour. However, geographical and financial barriers remain, preventing many parents from accessing the programme in the standard face-to-face modality. This project aims to investigate the feasibility and acceptability of the programme when delivered with clinician support via videoconferencing. METHODS/DESIGN: The sample for this feasibility study will be recruited from the Royal Children's Hospital, Melbourne, and the Victorian Paediatric Rehabilitation Service. Participants will be the parents of a child who sustained a TBI between the ages of 2.0 and 6.11, within the previous 2 years. The parents of 15 children will complete the programme, with clinician support via videoconferencing, while the parents of a further 15 children will form a treatment as usual wait-list control group. Parents complete questionnaires assessing their child's behaviour, as well as assessing their own mental health, sense of parenting competency, disciplinary style, and family functioning. These will be completed upon enrolment in the study regarding their child's pre-injury behaviour and then again pre-intervention, immediately post-intervention, and 4 months post-intervention. Parents who complete the intervention will also complete questionnaires assessing their satisfaction with the programme and its delivery. Information will be collected on the feasibility, clinical practicality, and acceptability of the programme when delivered through this medium. DISCUSSION: This study is the first to investigate the feasibility of delivering post-child TBI behavioural intervention via videoconferencing in Australia. Preliminary findings from this study may support the development of a larger randomised controlled trial. It is hoped that programme delivery through this medium would facilitate better access to the programme, enabling improved long-term outcomes for families. TRIAL REGISTRATION: ANZCTR, ACTRN12616001574437.

Trajectories and Risk Factors for Post-Traumatic Stress Symptoms following Pediatric Concussion.

A substantial minority of children experience post-traumatic stress symptoms (PTSS) following injury. Research indicates variation in the trajectory of PTSS following pediatric injury, but investigation of PTSS following concussion has assumed homogeneity. This study aimed to identify differential trajectories of PTSS following pediatric concussion and to investigate risk factors, including acute post-concussive symptoms (PCS), associated with these trajectories. A total of 120 children ages 8-18 years reported PTSS for 3 months following concussion diagnosis using the Child PTSD Symptom Scale, with a score of 16 or above indicating probable post-traumatic stress disorder diagnosis. Age, gender, injury mechanism, loss of consciousness, previous concussions, prior hospitalization, prior diagnosis of depression or anxiety, and acute PCS were assessed as risk factors. Data were analyzed using group-based trajectory modeling. Results revealed 16% of children had clinically significant PTSS 2 weeks post-concussion, declining to 10% at 1 month and 6% at 3 months post-injury. Group-based trajectory modeling identified three trajectories of PTSS post-concussion: "resilient" (70%); "recovering" (25%), in which children experienced elevated acute symptoms that declined over time; and "chronic symptomatology" (5%). Due to small size, the chronic group should be interpreted with caution. Higher acute PCS and prior diagnosis of depression or anxiety both significantly increased predicted probability of recovering trajectory group membership. These findings establish that most children are resilient to PTSS following concussion, but that PTSS do occur acutely in a substantial minority of children. The study indicates mental health factors, particularly PTSS, depression, and anxiety, should be considered integral to models of concussion management and treatment.

Validation of a Score to Determine Time to Postconcussive Recovery.

BACKGROUND: A reliable, developmentally appropriate and standardized method for assessing postconcussive symptoms (PCS) is essential to accurately determine recovery postconcussion and to effectively manage return to normal activities. The aim of this study was to develop an evidence-based, psychometrically validated approach to determining clinically useful cutoff scores by using a commonly administered PCS measure. METHODS: The current study was a prospective, longitudinal observational study conducted between July 2013 and November of 2015 at a statewide tertiary pediatric hospital. Participants were 120 children (5-18 years of age) presenting to the emergency department with a concussion within 48 hours of injury. PCS were assessed by using the Postconcussion Symptom Inventory (PCSI), acutely, 1 to 4 days postinjury and 2 weeks postinjury. Using comprehensive clinical assessment as gold standard, we assessed the clinical cutoff discrimination ability of PCSI at 2 weeks postinjury by using published approaches, and then varying each approach to optimize their discrimination ability. RESULTS: Existing and potential clinical cutoff scores were explored in predicting delayed recovery. Receiver operating characteristic curve results returned acceptable discrimination and sensitivity when PCSI items increased in severity from preinjury by 1 or more. Compared with a published cutoff score being 3+ items with increased severity, the current study suggests a more stringent cutoff requirement of 2+ is better able to accurately classify symptomatic children. CONCLUSIONS: This study provides the first validated index (2+ items, 1+ severity) of concussion recovery for children and youth. Further studies in more varied samples are needed to establish the effectiveness of this method.

Social dysfunction after pediatric traumatic brain injury: A translational perspective.

Social dysfunction is common after traumatic brain injury (TBI), contributing to reduced quality of life for survivors. Factors which influence the development or persistence of social deficits after injury remain poorly understood, particularly in the context of ongoing brain maturation during childhood and adolescence. Aberrant social interactions have recently been modeled in adult and juvenile rodents after experimental TBI, providing an opportunity to gain new insights into the underlying neurobiology of these behaviors. Here, we review our current understanding of social dysfunction in both humans and rodent models of TBI, with a focus on brain injuries acquired during early development. Modulators of social outcomes are discussed, including injury-related and environmental risk and resilience factors. Disruption of social brain network connectivity and aberrant neuroendocrine function are identified as potential mechanisms of social impairments after pediatric TBI. Throughout, we highlight the overlap and disparities between outcome measures and findings from clinical and experimental approaches, and explore the translational potential of future research to prevent or ameliorate social dysfunction after childhood TBI.