National Institute on Aging's 50th anniversary: Advancing aging research and the health and well-being of older adults.

The National Institute on Aging (NIA), part of the National Institutes of Health (NIH), was founded in 1974 to support and conduct research on aging and the health and well-being of older adults. Fifty years ago, the concept of studying aging generated much skepticism. Early NIA-funded research findings helped establish the great value of aging research and provided the foundation for significant science advances that have improved our understanding of the aging process, diseases and conditions associated with aging, and the effects of health inequities, as well as the need to promote healthy aging lifestyles. Today, we celebrate the many important contributions to aging research made possible by NIA, as well as opportunities to continue to make meaningful progress. NIA emphasizes that the broad aging research community must continue to increase and expand our collective efforts to recruit and train a diverse next generation of aging researchers.

Readiness of emergency departments for pediatric patients and pediatric mortality: a systematic review.

BACKGROUND: Most children who need emergency care visit general emergency departments and urgent care centres; the weighted pediatric readiness score (WPRS) is currently used to evaluate emergency departments' readiness for pediatric patients. The aim of this study was to determine whether a higher WPRS was associated with decreased mortality and improved health care outcomes and utilization. METHODS: We conducted a systematic review of cohort and cross-sectional studies on emergency departments that care for children (age ≤ 21 yr). We searched MEDLINE (Ovid), Embase (Ovid), the Cochrane Library (Wiley), CINAHL (EBSCO), Global Health (Ovid) and Scopus from inception until July 29, 2022. Articles identified were screened for inclusion by 2 independent reviewers. The primary outcome was mortality, and the secondary outcomes were health care outcomes and utilization. We used the Newcastle-Ottawa Scale to assess for quality and bias of the included studies. The I 2 statistic was calculated to quantify study heterogeneity. RESULTS: We identified 1789 articles. Eight articles were included in the final analysis. Three studies showed an inverse association between highest WPRS quartile and pediatric mortality (pooled odds ratio [OR] 0.45, 95% confidence interval [CI] 0.26 to 0.78; I 2 = 89%, low certainty of evidence) in random-effects meta-analysis. Likewise, 1 study not included in the meta-analysis also reported an inverse association with a 1-point increase in WPRS (OR 0.93, 95% CI 0.88 to 0.98). One study reported that the highest WPRS quartile was associated with shorter length of stay in hospital (ß -0.36 days, 95% CI -0.61 to -0.10). Three studies concluded that the highest WPRS quartile was associated with fewer interfacility transfers. The certainty of evidence is low for mortality and moderate for the studied health care outcomes and utilization. INTERPRETATION: The data suggest a potential inverse association between the WPRS of emergency departments and mortality risk in children. More studies are needed to refute or confirm these findings. PROTOCOL REGISTRATION: PROSPERO-CRD42020191149.

Understanding and preference toward DOs and OMT before and after an osteopathic principles and practice fellow lecture series.

CONTEXT: One of the two major pathways to become a physician in the United States is the Doctor of Osteopathic Medicine (DO) degree. A major distinctive feature is often perceived as the addition of manual training in osteopathic manipulative treatment (OMT) in the DO education. However, the profession also has a distinct philosophy imbedded in the curriculum of all osteopathic medical schools. Many medical schools offer professional degrees with graduates who may choose to continue their education in medicine, such as the Master of Science in Biomedical Sciences (MSBS). At our institution, there is no formal exposure to the differences between osteopathic and allopathic medicine in the MSBS curriculum, and most of this understanding is gained through out-of-classroom conversations. During the SARS-CoV-2 pandemic, virtual learning prohibited the usual gathering and discourse that occurs when students are learning on campus. OBJECTIVES: The objective of this study is to create a curriculum in the form of a seminar series to assist premedical students in making an informed choice about which profession is the best fit for their own education and to gain an appreciation for osteopathic medicine. This appreciation could also aid in the future collaboration of premedical students with osteopathic providers, recommendations to patients, and potentially their own medical care. Questionnaires were utilized to determine if our osteopathic seminar series was effective at changing the preferences and understanding of MSBS students. We also sought to determine the effectiveness of virtual vs. in-person delivery of our curriculum. METHODS: A seminar series with pre-established objectives was developed and presented to MSBS students at an osteopathic institution during the Fall of 2020 and 2021. The 2020 seminar was delivered through a virtual conference platform, and the 2021 seminar was delivered in-person. An eight question pre-and postquestionnaire was given to participants to evaluate their preferences and understanding. Internal validity and differences between delivery formats were assessed. RESULTS: Both seminar series produced equally effective, significant changes in the preferences and perceptions of osteopathic medicine in both virtual and in-person delivery formats. Differences in pre-vs. post understanding across both seminar series were not consistently significant and were smaller than those observed in preferences and perceptions. Positive changes included an increased willingness to see a DO and to recommend a loved one see a DO as their personal physician. Preference changes between the in-person vs. virtual delivery platforms did not show significant differences; however, understanding did show some inconsistent differences. CONCLUSIONS: This study demonstrates the utility of a virtual or in-person seminar to improve the preferences and perceptions of the osteopathic profession in MSBS students. The seminar series was successful in its goal of offering formal exposure to the osteopathic profession. The improved preferences and perceptions will have potential substantial benefits to the field of osteopathic medicine in the future. Further research is warranted to determine the most effective way to increase understanding of the osteopathic profession.

Interpersonal attribution bias and social evaluation in adolescent eating disorders.

OBJECTIVE: Improved understanding of adolescent eating disorders (EDs), including identification and refinement of treatment and recovery targets, may help improve clinical outcomes. Interpersonal function is a proposed risk and maintenance factor that may be particularly relevant given the significance of adolescence for both psychosocial development and ED onset. This study examined self-referential thinking in adolescents with EDs compared to healthy adolescents. METHOD: Twenty-nine adolescents with EDs and 31 healthy controls completed a self-report measure of interpersonal attributions as well as a verbal appraisal task that required conducting direct and indirect evaluations about oneself and direct evaluations about others. RESULTS: The ED group had a more negative self-attribution bias than the control group (p = 0.006) even when controlling for depression severity. Additionally, the ED group exhibited less positive direct self (p < 0.001), direct social (p = 0.015), and social reflected self-appraisals (p = 0.011) than the healthy cohort. After including depression as a covariate in the verbal appraisal model, the model was no longer significant, suggesting group differences related to social appraisals may be mediated by depression. CONCLUSIONS: Adolescents with EDs have more negative interpersonal beliefs than comparison adolescents. Future studies are needed to determine how the constructs identified here relate to clinical course.

Qualitative patient experiences from the Self-Blame and Perspective-Taking Intervention for eating disorders.

BACKGROUND: Problems in social cognition and social support contribute to eating disorders (ED). Group therapy provides an ideal format to create an experiential learning environment focused on understanding social interactions. This pilot study examined the qualitative content of the participants' experiences in the Self-Blame and Perspective-Taking Intervention (SBPI) for ED. METHODS: The SBPI was a 4-week group therapy intervention involving art therapy and psychoeducation that focused on social behaviors in ED patients. Participants received surveys immediately after the intervention and at 1 to 4 weeks after the post-intervention. Thematic analyses of qualitative feedback were performed using Braun and Clarke's thematic analysis framework. RESULTS: Inductive analyses revealed three main themes: (1) Developing self-acceptance through emotional reflection, (2) Changing expectations with neurosocial knowledge, and (3) Bonding and vulnerability in social interactions; all concepts intentionally targeted by the SBPI. Participants varied in their support of a guideline to exclude personal discussion of ED-related cognitions and behaviors in the group. CONCLUSIONS: As a whole, patients valued the combination of psychosocial education with group experientials focused on social behavior. Positive feedback from the SBPI suggests that adjunctive treatments that target mental-wellness constructs indirectly related to ED pathology may be helpful by allowing patients to see themselves as separable from the illness. Trial registration ClinicalTrials.gov, NCT0487758. Registered 7 May 2021-Retrospectively registered. https://clinicaltrials.gov/ct2/show/NCT04877158 .

Adult patients with eating disorders frequently report challenges in developing and maintaining supportive social relationships. A group therapy intervention utilizing structured art tasks in conjunction with psychoeducation about interpersonal relationships was piloted in twenty-four women with eating disorders. Participants provided written feedback about their experiences in the intervention. These responses were coded by three raters to identify consistent themes related to those experiences. Participants reported benefits related to self-acceptance and emotional regulation, valued learning about their brain and behaviors, and appreciated peer interactions in this setting. In sum, this adjunctive and structured outpatient group targeting social interactions was acceptable to outpatients with eating disorders.

Pilot data from the Self-Blame and Perspective-Taking Intervention for eating disorders.

Eating disorders (EDs) are characterized by altered eating behaviors and valuation of self-image, as well as difficulty establishing supportive social relationships. This pilot study evaluated feasibility, acceptability, and clinical responses to a novel and brief group-therapy intervention for EDs, the Self-Blame and Perspective-Taking Intervention (SBPI). The SBPI consisted of four sessions of experiential art therapy activities in conjunction with psychoeducation targeting interpersonal attributions and mentalization. Twenty-four outpatient, treatment-seeking women with EDs participated in the SBPI, with 87.5% completing the intervention and 94% rating their participation positively. ED symptoms, depression, anxiety, self-attribution bias, and self-esteem were assessed before (T1) and after participation (N = 20 at T2; N = 18 at T3). Separate repeated measures MANOVAs were performed to assess these clinical and self-concept variables. Relative to baseline, participants demonstrated significant improvements in two all self-concept measures: self-attribution bias, trait self-esteem and state self-esteem at T2. ED, depression, and anxiety symptoms were significantly decreased at both T2 (1-4 weeks post) and T3 (3-5 months post). The SBPI altered self-concept targets acutely and led to sustained clinical improvements. Future work is needed to evaluate how self-concept and social constructs are related to clinical symptom expression in EDs.

NM GRADS: Lessons Learned from Implementing a School-Based Program for Young Parents Across New Mexico.

PURPOSE: The New Mexico Graduation Reality and Dual-role Skills (GRADS) program provides services for expectant and parenting students at high schools. The GRADS program has operated since 1989, serving more than 17,000 youth. This study summarizes the GRADS program model and program administrators' lessons learned from implementing this comprehensive, large-scale program. DESCRIPTION: The GRADS program is a multicomponent intervention that can include a classroom intervention, case management, linkages to child care and health care, and support for young fathers. The program aims to support expectant and parenting youth in finishing high school, delaying a repeat pregnancy, promoting health outcomes for their children, and preparing for college and career. This study presents program administrators' lessons learned to increase understanding of how to implement a statewide program to support expectant and parenting students. ASSESSMENT: During the 2010-2017 school years, the GRADS program operated in 26-31 sites each year, serving a total of 2691 parenting youth. Program administrators identified lessons learned from implementing the GRADS program during that period of expansion, including allowing variation across sites based on resources and needs, providing centralized implementation support, fostering buy-in from school and district leaders, and collecting consistent data to better understand participant outcomes. CONCLUSIONS: Although not based on a rigorous impact or implementation study, this article provides lessons learned from a statewide, school-based program that may be a promising way to serve a large number of expectant and parenting youth and help them overcome challenges for completing high school.

Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury.

OBJECTIVES: Vomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury. METHODS: This secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0-16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models. RESULTS: A total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7-3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5-7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9-3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors. CONCLUSIONS: Recurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.

Requirements for improving health and well-being of children with Prader-Willi syndrome and their families.

Prader-Willi syndrome (PWS) is a rare genetic condition with multi-system involvement. The literature was reviewed to describe neurodevelopment and the behavioural phenotype, endocrine and metabolic disorders and respiratory and sleep functioning. Implications for child and family quality of life were explored. Challenging behaviours contribute to poorer well-being and quality of life for both the child and caregiver. Recent evidence indicates healthy outcomes of weight and height can be achieved with growth hormone therapy and dietary restriction and should be the current target for all individuals with PWS. Gaps in the literature included therapies to manage challenging behaviours, as well as understanding the effects of growth hormone on respiratory and sleep function. New knowledge regarding the transition of children and families from schooling and paediatric health services to employment, accommodation and adult health services is also needed. Developing a national population-based registry could address these knowledge gaps and inform advocacy for support services that improve the well-being of individuals with PWS and their families.

Treatment Utilization and Medical Problems in a Community Sample of Adult Women With Anorexia Nervosa.

Anorexia nervosa (AN) has a prolonged course of illness, making both defining recovery and determining optimal outpatient treatments difficult. Here, we report the types of treatments utilized in a naturalistic sample of adult women with AN in Texas. Participants were recruited from earlier studies of women with AN (n = 28) and in weight recovery following AN (n = 18). Participants provided information about both their illness and treatments during their most severe period as well as during the 2-6 years following original assessments. Based upon their baseline and follow-up clinical status participants were classified as remaining ill (AN-CC, n = 17), newly in recovery (AN-CR, n = 11), and sustained weight-recovery (AN-WR, n = 18). Utilization of health care institutions and providers were compared across groups. There were no differences in groups related to symptoms or treatments utilized during the severe-period. During the follow-up period, intensive outpatient programs were utilized significantly more by the AN-CC group than the other groups, and dietitians were seen significantly less by the AN-WR group. Medical complications related to the ED were significantly more common in the AN-CC group. All groups maintained similar levels of contact with outpatient psychiatrists, therapists, and primary care physicians. Current treatments remain ineffective for a subset of AN participants. Future prospective studies assessing medical health and comorbidities in AN may provide additional insights into disease severity and predictors of clinical outcome.

Mentalization and the left inferior frontal gyrus and insula.

OBJECTIVE: To determine if an interpersonal attribution bias associated with self-perception, the externalizing bias, was related to neural activations during mentalization. METHODS: A functional magnetic resonance imaging task involving verbal appraisals measured neural activations when thinking about oneself and others in 59 adults, including healthy women as well as women with and recovered from anorexia nervosa. Whole-brain regressions correlated brain function during mentalization with the externalizing bias measured using the Internal, Personal, and Situational Attributions Questionnaire. RESULTS: Women with anorexia nervosa had a lower externalizing bias, demonstrating a tendency to self-attribute more negative than positive social interactions, unlike the other groups. The externalizing bias was correlated with activation of the left inferior frontal gyrus and posterior insula, when comparing thinking about others evaluating oneself with direct self-evaluation. DISCUSSION: Externalizing biases may provide an office-based assay reflecting neurocognitive disturbances in social self-perception that are common during anorexia nervosa.

Pilot investigation into the sickness response to influenza vaccination in adults: Effect of depression and anxiety.

OBJECTIVE: To determine whether depressed or anxious patients experience greater affective change than mentally healthy individuals following influenza vaccination. METHODS: Participants (n=112) completed the Positive and Negative Affect Schedule (PANAS) before influenza vaccination and 1-2days post-vaccination (M=32.3h). Pre- and post-vaccination PANAS scores were compared using two-tailed, paired-samples t-tests. Change in positive affect between participants with depression or anxiety and those without was compared using two-way ANOVA. Follow up positive affect was further examined using multiple linear regression. RESULTS: Positive affect decreased following vaccination (M=2.18, 95% CI [1.07, 3.29], t(111)=3.89, p<0.001) for all participants and was more pronounced for those with anxiety or depression (F(1, 110)=7.51, p=0.009). Similarly, predicted follow up affect score was higher for those without a mental health conditions (ß=3.67, 95% CI [1.18, 6.16], t(103)=2.92, p=0.004). CONCLUSIONS: These data suggest that influenza vaccine has a greater effect on affect in patients with depression and anxiety than in mentally healthy individuals. This effect was focused on positive affect, suggesting that influenza vaccine induced inflammation may be best suited to examine alterations in positive affect and positive valence systems.

Neuropsychological and Cognitive Correlates of Recovery in Anorexia Nervosa.

OBJECTIVE: To identify clinical or cognitive measures either predictive of illness trajectory or altered with sustained weight recovery in adult women with anorexia nervosa. METHODS: Participants were recruited from prior studies of women with anorexia nervosa (AN-C) and in weight-recovery following anorexia nervosa (AN-WR). Participants completed a neuropsychological battery at baseline and clinical assessments at both baseline and follow-up. Groups based on clinical outcome (continued eating disorder, AN-CC; newly in recovery, AN-CR; sustained weight-recovery, AN-WR) were compared by using one-way ANOVAs with Bonferroni-corrected post hoc comparisons. RESULTS: Women with continued eating disorder had poorer neuropsychological function and self-competence at baseline than AN-CR. AN-CR showed changes in depression and externalizing bias, a measure of self-related attributions. AN-WR differed from both AN-CC and AN-CR at baseline in externalizing bias, but only from AN-CC at outcome. DISCUSSION: Neuropsychological function when recently ill may be a prognostic factor, while externalizing bias may provide a clinical target for recovery. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

In God we trust? Neural measures reveal lower social conformity among non-religious individuals.

Even in predominantly religious societies, there are substantial individual differences in religious commitment. Why is this? One possibility is that differences in social conformity (i.e. the tendency to think and behave as others do) underlie inclination towards religiosity. However, the link between religiosity and conformity has not yet been directly examined. In this study, we tested the notion that non-religious individuals show dampened social conformity, using both self-reported and neural (EEG-based ERPs) measures of sensitivity to others' influence. Non-religious vs religious undergraduate subjects completed an experimental task that assessed levels of conformity in a domain unrelated to religion (i.e. in judgments of facial attractiveness). Findings showed that, although both groups yielded to conformity pressures at the self-report level, non-religious individuals did not yield to such pressures in their neural responses. These findings highlight a novel link between religiosity and social conformity, and hold implications for prominent theories about the psychological functions of religion.

Neural activations are related to body-shape, anxiety, and outcomes in adolescent anorexia nervosa.

Anorexia nervosa (AN) is an illness that frequently begins during adolescence and involves weight loss. Two groups of adolescent girls (AN-A, weight-recovered following AN) and (HC-A, healthy comparison) completed a functional magnetic resonance imaging task involving social evaluations, allowing comparison of neural activations during self-evaluations, friend-evaluations, and perspective-taking self-evaluations. Although the two groups were not different in their whole-brain activations, anxiety and body shape concerns were correlated with neural activity in a priori regions of interest. A cluster in medial prefrontal cortex and the dorsal anterior cingulate correlated with the body shape questionnaire; subjects with more body shape concerns used this area less during self than friend evaluations. A cluster in medial prefrontal cortex and the cingulate also correlated with anxiety such that more anxiety was associated with engagement when disagreeing rather than agreeing with social terms during self-evaluations. This data suggests that differences in the utilization of frontal brain regions during social evaluations may contribute to both anxiety and body shape concerns in adolescents with AN. Clinical follow-up was obtained, allowing exploration of whether brain function early in course of disease relates to illness trajectory. The adolescents successful in recovery used the posterior cingulate and precuneus more for friend than self evaluations than the adolescents that remained ill, suggesting that neural differences related to social evaluations may provide clinical predictive value. Utilization of both MPFC and the precuneus during social and self evaluations may be a key biological component for achieving sustained weight-recovery in adolescents with AN.

Beauty is in the belief of the beholder: cognitive influences on the neural response to facial attractiveness.

Judgments of facial attractiveness are central to decision-making in various domains, but little is known about the extent to which they are malleable. In this study, we used EEG/ERP methods to examine two novel influences on neural and subjective responses to facial attractiveness: an observer's expectation and repetition. In each trial of our task, participants viewed either an ordinary or attractive face. To alter expectations, the faces were preceded by a peer-rating that ostensibly reflected the overall attractiveness value assigned to that face by other individuals. To examine the impact of repetition, trials were presented twice throughout the experimental session. Results showed that participants' expectations about a person's attractiveness level powerfully altered both the neural response (i.e. the late positive potential; LPP) and self-reported attractiveness ratings. Intriguingly, repetition enhanced both the LPP and self-reported attractiveness as well. Exploratory analyses further suggested that both observer expectation and repetition modulated early neural responses (i.e. the early posterior negativity; EPN) elicited by facial attractiveness. Collectively, these results highlight novel influences on a core social judgment that underlies individuals' affective lives.

Barricades and brickwalls--a qualitative study exploring perceptions of medication use and deprescribing in long-term care.

BACKGROUND: The co-administration of multiple drugs (polypharmacy) is the single most common cause of adverse drug events in the older population, and residents of long-term care facilities (LTCFs) are at particularly high risk of medication harm. 'Deprescribing'--the withdrawal of an inappropriate medication with goal of managing polypharmacy and improving outcomes--may improve the quality of life of LTCF residents. The RELEASE study sought to explore perceptions of medication use and the concept of deprescribing in LTCFs. METHODS: Focus groups and interviews were conducted with General Practitioners (GPs), pharmacists, nursing staff, residents and their relatives within three LTCFs in the Illawarra-Shoalhaven region of NSW, Australia. Audiotapes were transcribed verbatim and, using the Integrative Model of Behaviour Prediction as a framework, thematic analysis of transcripts was conducted using QSR NVivo 10. RESULTS: Participants acknowledged the burden of too many medications (time to administer, physical discomfort, cost), yet displayed passivity towards medication reduction. Residents and relatives lacked understanding of medicine indications or potential harms. Willingness to initiate and accept medication change was dependent on the GP, who emerged as a central trusted figure. GPs preferred 'the path of least resistance', signalling systems barriers (poor uniformity of LTCF medical records, limited trained LTCF personnel); time constraints (resident consultations, follow-up with specialists and family); and the organisation of care (collaborating with LTCF staff, pharmacists and prescribing specialists) as obstacles to deprescribing. CONCLUSIONS: Targeted engagement is required to raise awareness of the risks of polypharmacy in LTCFs and encourage acceptance of deprescribing amongst residents and their relatives. GPs are integral to the success of deprescribing initiatives within this sector.

A Balanced Protocol for Return to School for Children and Youth Following Concussive Injury.

BACKGROUND: Few protocols exist for returning children/youth to school after concussion. Childhood concussion can significantly affect school performance, which is vital to social development, academic learning, and preparation for future roles. The goal of this knowledge translation research was to develop evidence based materials to inform physicians about pediatric concussion. METHODS: The Return to School (RTS) concussion protocol was developed following the National Institute for Health and Care Excellence procedures. RESULTS: Based on a scoping review, and stakeholder opinions, an RTS protocol was developed for children/youth. This unique protocol focuses on school adaptation in 4 main areas: (a) timetable/attendance, (b) curriculum, (c) environmental modifications, and (d) activity modifications. CONCLUSION: A balance of cognitive rest and timely return to school need to be considered for returning any student to school after a concussion. Implementation of these new recommendations may be an important tool in prevention of prolonged absence from school and academic failure while supporting brain recovery.

Post-concussion return to play and return to school guidelines for children and youth: a scoping methodology.

PURPOSE: The objective of this study was to identify and describe management strategies to ensure safe return to activity (RTA) and return to school (RTS) of children with mild traumatic brain injury (MTBI) and determine whether they are evidence-based. METHODS: A scoping methodology was conducted using research published between 1990 and 2013, gray literature and clinical expertise. Once the data had been charted, an expert panel of physicians and clinicians was consulted to inform and validate study findings. An analytical and thematic framework was used to examine the study findings. RESULTS: A total of 400 potentially relevant published articles, 100 websites and 24 iPad Applications were found. Ten articles and three web-based resources met inclusion criteria and were included in the final review. Nine articles recommended a more conservative approach to RTA, as well as identified a step-wise or severity-oriented approach. General recommendations were also found regarding safe RTS. One study recommended a stepwise RTS protocol for children. CONCLUSIONS: This scoping methodology determined that the most comprehensive guidelines for management are focused on adults. Evidence concerning prolonged recovery patterns in children and the impact of concussion on the developing brain suggests that pediatric-specific guidelines are needed for RTA and RTS after MTBI/concussion. IMPLICATIONS FOR REHABILITATION: Although concussion in children is an increasing concern, it has been determined that the most comprehensive guidelines for management are focused on adults. These guidelines are primarily consensus-based and are not proven fact through quality research. Evidence concerning prolonged recovery patterns in youth and the impact of concussion on the developing brain suggest that pediatric guidelines should be more conservative than for adults. Therefore, pediatric-specific guidelines need to be developed for return to activity and return to school after MTBI/concussion.

Development of a conservative protocol to return children and youth to activity following concussive injury.

BACKGROUND: Consensus-based guidelines exist for adult athletes returning to play after concussion, but there are no protocols developed specifically for children. The goal of this knowledge translation research was to develop evidence-based materials to inform physicians about pediatric concussion. METHODS: A pediatric concussion protocol was developed based on the National Institute for Health and Care Excellence procedures. RESULTS: This return to activity protocol was developed to guide management when children/youth sustain a concussion. The protocol incorporated 3 main themes: (a) a protocol must include return to all activity, including sport and school; (b) existing consensus-based adult protocols are not appropriate for children; and (c) a more conservative protocol is needed. After pilot testing, the developed protocol is being used across Ontario. CONCLUSION: Implementation of these new pediatric recommendations is an important addition to prevention of subsequent concussions during vulnerable recovery periods, with potential to facilitate recovery by preventing prolonged symptomatology, and secondary sequelae.