Exploring the association between cognitive activity and symptom resolution following concussion in adolescents aged 11-17 years.

OBJECTIVE: As opposed to postconcussion physical activity, the potential influence of cognitive activity on concussion recovery is not well characterised. This study evaluated the intensity and duration of daily cognitive activity reported by adolescents following concussion and examined the associations between these daily cognitive activities and postconcussion symptom duration. METHODS: This study prospectively enrolled adolescents aged 11-17 years with a physician-confirmed concussion diagnosis within 72 hours of injury from the emergency department and affiliated concussion clinics. Participants were followed daily until symptom resolution or a maximum of 45 days postinjury to record their daily cognitive activity (intensity and duration) and postconcussion symptom scores. RESULTS: Participants (n=83) sustained their concussion mostly during sports (84%), had a mean age of 14.2 years, and were primarily male (65%) and white (72%). Participants reported an average of 191 (SD=148), 166 (SD=151) and 38 (SD=61) minutes of low-intensity, moderate-intensity and high-intensity daily cognitive activity postconcussion while still being symptomatic. Every 10 standardised minutes per hour increase in moderate-intensity or high-intensity cognitive activities postconcussion was associated with a 22% greater rate of symptom resolution (adjusted hazard ratio (aHR) 1.22, 95% CI 1.01 to 1.47). Additionally, each extra day's delay in returning to school postconcussion was associated with an 8% lower rate of symptom resolution (aHR 0.92, 95% CI 0.85 to 0.99). CONCLUSION: In adolescents with concussion, more moderate-high intensity cognitive activity is associated with faster symptom resolution, and a delayed return to school is associated with slower symptom resolution. However, these relationships may be bidirectional and do not necessarily imply causality. Randomised controlled trials are needed to determine if exposure to early cognitive activity can promote concussion recovery in adolescents.

Bayley trajectories predict school readiness better than single assessments in formerly very preterm preschoolers.

BACKGROUND: Development of children born very preterm (VPT) is evaluated using the Bayley Scales of Infant Development. Early Bayley scores may not predict later outcomes. We studied whether VPT Bayley trajectories in the early years predicted school readiness better than single assessments. METHODS: We prospectively evaluated 53 VPT at 4-5 years using standardized measures of school readiness, including the domains of cognition, early mathematical and literacy abilities, and motor skills. Predictors were Bayley-III scores obtained 1-5 times/child between 6 and 35 months. Linear mixed models (LMM) with random effects extracted estimated random effect for slope (change in Bayley score/1 year) and fixed+random effect sum for the intercept (initial Bayley score) for each participant, to then evaluate 4-5-year outcomes prediction. RESULTS: Variability of individual trajectories prevailed across developmental domains. For the initial LMM, adding Bayley change to models with only initial score improved model fits for several Bayley-III domains. Models containing estimates for initial Bayley scores and Bayley change explained significantly more variability in school readiness scores (21-63%) than either variable alone. CONCLUSION: Neurodevelopmental follow-up of VPT is more relevant to school readiness when children are assessed multiple times in the first 3 years. Neonatal intervention research could use early trajectories rather than single timepoints as outcomes. IMPACT: This study is the first to examine individual Bayley scores and trajectories to predict school readiness of formerly preterm children at 4-5 years. Modeling demonstrated extreme variability of individual trajectories compared to the group's average trajectories. Models containing initial Bayley scores and Bayley change over time explained more variability in preschool readiness than either variable alone. Using the Bayley to predict future school readiness is enhanced by administration across multiple follow-up visits and inclusion of change across the first 3 years. Follow-up care models and clinical trial design for neonatal interventions may benefit from a trajectory-based approach to outcomes evaluation.

Development of the mentalizing network structures and theory of mind in extremely preterm youth.

Adolescents born preterm (<37 weeks of gestation) are at elevated risk for deficits in social cognition and peer relationships. Theory of Mind (ToM) is a complex form of social cognition important for regulating social interactions. ToM and the underlying mentalizing network continue to develop across adolescence. The present study recruited 48 adolescents (12-17 years old) who were either born extremely preterm (EPT; <28 weeks of gestation) or full-term (FT) at birth. Cortical thickness, gray matter volume and surface area were measured in four regions of the mentalizing network: the temporoparietal junction, anterior temporal cortex, posterior superior temporal sulcus and frontal pole (mBA10). We also assessed the adolescents' performance on a ToM task. Findings revealed both group differences and group-by-age interaction effects in the gray matter indices within the temporal lobe regions of the mentalizing network. The EPT group also performed significantly worse than the FT group on the ToM task. The cortical structural measures that discriminated the EPT and FT groups were not related to ToM performance. These results highlight altered developmental changes in brain regions underlying mentalizing functions in EPT adolescents relative to FT controls.

Online Problem Solving for Adolescent Brain Injury: A Randomized Trial of 2 Approaches.

OBJECTIVE: Adolescent traumatic brain injury (TBI) contributes to deficits in executive functioning and behavior, but few evidence-based treatments exist. We conducted a randomized clinical trial comparing Teen Online Problem Solving with Family (TOPS-Family) with Teen Online Problem Solving with Teen Only (TOPS-TO) or the access to Internet Resources Comparison (IRC) group. METHODS: Children, aged 11 to 18 years, who sustained a complicated mild-to-severe TBI in the previous 18 months were randomly assigned to the TOPS-Family (49), TOPS-TO (51), or IRC group (52). Parent and self-report measures of externalizing behaviors and executive functioning were completed before treatment and 6 months later. Treatment effects were examined using linear regression models, adjusting for baseline symptom levels. Age, maternal education, and family stresses were examined as moderators. RESULTS: The TOPS-Family group had lower levels of parent-reported executive dysfunction at follow-up than the TOPS-TO group, and differences between the TOPS-Family and IRC groups approached significance. Maternal education moderated improvements in parent-reported externalizing behaviors, with less educated parents in the TOPS-Family group reporting fewer symptoms. On the self-report Behavior Rating Inventory of Executive Functions, treatment efficacy varied with the level of parental stresses. The TOPS-Family group reported greater improvements at low stress levels, whereas the TOPS-TO group reported greater improvement at high-stress levels. The TOPS-TO group did not have significantly lower symptoms than the IRC group on any comparison. CONCLUSION: Findings support the efficacy of online family problem solving to address executive dysfunction and improve externalizing behaviors among youth with TBI from less advantaged households. Treatment with the teen alone may be indicated in high-stress families.

Investigating the Connection Between Traumatic Brain Injury and Posttraumatic Stress Symptoms in Adolescents.

OBJECTIVE: To identify potentially modifiable individual and social-environmental correlates of posttraumatic stress symptoms (PTSS) among adolescents hospitalized for traumatic brain injury (TBI). SETTING: Four pediatric hospitals and 1 general hospital in the United States. PARTICIPANTS: Children ages 11 to 18 years, hospitalized for moderate-severe TBI within the past 18 months. DESIGN: Retrospective cross-sectional analysis. MAIN MEASURES: The University of California at Los Angeles (UCLA) Post-traumatic Stress Disorder (PTSD) Reaction Index and the Youth Self-Report (YSR) PTSD subscale. RESULTS: Of 147 adolescents enrolled, 65 (44%) had severe TBI, with an average time since injury of 5.8 ± 4 months. Of the 104 who completed the UCLA-PTSD Reaction Index, 22 (21%) reported PTSS and 9 (8%) met clinical criteria for PTSD. Of the 143 who completed the YSR-PTSD subscale, 23 (16%) reported PTSS and 6 (4%) met clinical criteria for PTSD. In multivariable analyses, having a negative approach to problem solving and depressive symptoms were both associated (P < .001) with higher levels of PTSS based on the UCLA-PTSD Reaction Index (ß = 0.41 and ß = 0.33, respectively) and the YSR-PTSD subscale (ß = 0.33 and ß = 0.40, respectively). CONCLUSION: Targeting negative aspects of problem solving in youths after brain injury may mitigate PTSS.

Predictors of Long-Term Victimization After Early Pediatric Traumatic Brain Injury.

OBJECTIVE: Pediatric traumatic brain injuries (TBIs) adversely affect long-term functional and social outcomes. Limited research suggests children with TBI are more likely to be victimized by peers than noninjured children. Deficits in social information processing (SIP), cognitive ability, and executive functioning (EF) may contribute to increased victimization risk. This study examined rates of peer victimization/bullying in children with early TBI compared with children with orthopedic injuries (OIs) and the role of processing speed, executive function (EF), and SIP as mediators of the association of TBI and peer victimization. METHOD: Children ages 10 to 14 years who sustained a complicated mild/moderate or severe TBI (N = 58) or OI (N = 72) during early childhood (ages 3-7 yr) and their parents participated in a longitudinal prospective follow-up 6.8 years postinjury. SIP, EF and processing speed, and peer victimization were assessed. RESULTS: Parents of children with severe TBI reported greater rates of peer victimization than parents of children with OIs. Children with severe TBI demonstrated greater EF deficits than children with complicated mild/moderate TBI or OI and poorer processing speed than children with OI. No significant indirect relationships were found between groups and any outcome variables to indicate mediation. CONCLUSION: Based on parent report, children with severe TBI have higher risk of peer victimization than those with less severe injuries. In addition, children with severe TBI have more impaired EF and cognitive ability than counterparts with less severe TBI. Further research is needed to explore predictors of long-term victimization after early TBI to create interventions aimed at providing social, emotional, and behavioral skill building for victimized youth.

Determinants of Effective Caregiver Communication After Adolescent Traumatic Brain Injury.

OBJECTIVE: To characterize the effects of caregiver mental health and coping strategies on interactions with an injured adolescent acutely after traumatic brain injury (TBI). DESIGN: Multi-site, cross-sectional study. SETTING: Outpatient setting of 3 tertiary pediatric hospitals and 2 tertiary general medical centers. PARTICIPANTS: Adolescents (N = 125) aged 12-17 years, 1-6 months after being hospitalized with complicated mild to severe TBI. METHODS: Data were collected as part of a multi-site clinical trial of family problem-solving therapy after TBI. Multiple regression analyses were used to examine the relationship of caregiver and environmental characteristics to the dimensions of effective communication, warmth, and negativity during caregiver-adolescent problem-solving discussions. MAIN OUTCOMES MEASURES: Adolescent and caregiver interactions, as measured by the Iowa Family Interaction Rating Scales. RESULTS: Caregivers who utilized problem-focused coping strategies were rated as having higher levels of effective communication (P < .01), as were those with higher socioeconomic status (P < .01). Problem-focused coping style and higher socioeconomic status were also associated lower levels of negative interactions (P < .01 and P < .05, respectively). Female gender of the adolescent and fewer children in the home were associated with increased parental warmth during the interaction (P < .01 and P < .05, respectively). Neither adolescent TBI severity nor caregiver depression significantly influenced caregiver-teen interactions. CONCLUSIONS: Problem-focused coping strategies are associated with higher levels of effective communication and lower levels of caregiver negativity during the initial months after adolescent TBI, suggesting that effective caregiver coping may facilitate better caregiver-adolescent interactions after TBI.

Determinants of variability in motor performance in middle childhood: a cross-sectional study of balance and motor co-ordination skills.

BACKGROUND: Physical activity is a key component of exploration and development. Poor motor proficiency, by limiting participation in physical and social activities, can therefore contribute to poor psychological and social development. The current study examined the correlates of motor performance in a setting where no locally validated measures of motor skills previously existed. The development of an appropriate assessment schedule is important to avoid the potential misclassification of children's motor performance. METHODS: A cross-sectional study was conducted among a predominantly rural population. Boys (N = 148) and girls (N = 160) aged between 8 and 11 years were randomly selected from five schools within Kilifi District in Kenya. Four tests of static and dynamic balance and four tests of motor coordination and manual dexterity were developed through a 4-step systematic adaptation procedure. Independent samples t-tests, correlational, univariate and regression analyses were applied to examine associations between background variables and motor scores. RESULTS: The battery of tests demonstrated acceptable reliability and validity. Variability in motor performance was significantly associated with a number of background characteristics measured at the child, (gender, nutritional status and school exposure) household (household resources) and neighbourhood levels (area of residence). The strongest effect sizes were related to nutritional status and school exposure. CONCLUSIONS: The current study provides preliminary evidence of motor performance from a typically developing rural population within an age range that has not been previously studied. As well as being culturally appropriate, the developed tests were reliable, valid and sensitive to biological and environmental correlates. Further, the use of composite scores seems to strengthen the magnitude of differences seen among groups.

Outcomes of extremely low birth weight (<1 kg) and extremely low gestational age (<28 weeks) infants with bronchopulmonary dysplasia: effects of practice changes in 2000 to 2003.

OBJECTIVE: The goal was to evaluate whether changes in neonatal intensive care have improved outcomes for children with bronchopulmonary dysplasia (oxygen dependence at corrected age of 36 weeks). METHODS: We compared outcomes of extremely low birth weight (<1 kg) and extremely low gestational age (<28 weeks) infants with bronchopulmonary dysplasia between 2 periods (period I, 1996-1999: extremely low birth weight, n = 122; extremely low gestational age, n = 118; period II, 2000-2003: extremely low birth weight, n = 109; extremely low gestational age, n = 107). RESULTS: For both groups, significant practice changes between period I and period II included increased prenatal and decreased postnatal steroid therapy and increased surfactant therapy, indomethacin therapy, and patent ductus arteriosus ligation. Significant morbidity changes included decreased rates of severe cranial ultrasound abnormalities and increased rates of ventilator dependence. Rates of bronchopulmonary dysplasia did not change (52% vs 53%). Follow-up evaluation revealed significantly lower rates of neurosensory abnormalities during period II (extremely low birth weight: 29% vs 16%; extremely low gestational age: 31% vs 16%). There were no changes in rates of Mental Developmental Index scores of <70 (extremely low birth weight: 42% vs 42%; extremely low gestational age: 37% vs 45%) or overall developmental impairment (extremely low birth weight: 51% vs 49%; extremely low gestational age: 50% vs 51%). For the extremely low gestational age group, predictors of neurosensory abnormalities were severe cranial ultrasound abnormality and postnatal steroid therapy. Predictors of overall impairment included severe cranial ultrasound abnormalities, ventilator dependence, postnatal steroid therapy, and patent ductus arteriosus ligation. For the extremely low birth weight group, the only predictor of neurosensory abnormalities was severe cranial ultrasound abnormality. Predictors of overall impairment included multiple birth, ventilator dependence, and severe cranial ultrasound abnormalities. CONCLUSIONS: Neurosensory outcomes of infants with bronchopulmonary dysplasia improved during 2000 to 2003 but overall neurodevelopmental outcomes did not change.