Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players.

OBJECTIVE: To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion. DESIGN: Prospective cohort study, Safe to Play (2013-2018). SETTING: Youth hockey leagues in Alberta and British Columbia, Canada. PARTICIPANTS: Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions. INDEPENDENT VARIABLES: Psychosocial variables. MAIN OUTCOME MEASURES: Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit. RESULTS: Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery. CONCLUSIONS: Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

Perceptions of Symptom Duration are Associated With Emotional Distress and Functioning in Adolescents With Protracted Concussion Recovery.

Adolescents with persisting post-concussive symptoms often report high levels of emotional distress, which can impact their daily functioning. The associations between modifiable factors, such as perceptions of recovery, and emotional distress have not been investigated in this age group. OBJECTIVE: To evaluate perceptions about recovery duration (e.g., "my symptoms will last a long time", "my symptoms will be permanent rather than temporary") and its associations with emotional distress and functioning in children and adolescents with a slower post-concussive recovery. METHODS: Participants (N = 49, 69% girls, 11-17 years old, M = 15.8 years old, SD = 1.8) were recruited from a concussion clinic on average 7.7 months after injury (SD = 2.5). Measures included the Illness Perception Questionnaire Revised (perceived duration of symptoms only) to evaluate recovery expectations, the Health and Behavior Inventory (self and parent reports) to evaluate current post-concussive symptoms (cognitive and somatic symptoms), the emotional distress subscale of the Strengths and Difficulties Questionnaire (SDQ-self-report), and the emotional functioning subscale of the Pediatric Quality of Life Questionnaire (PedsQL-self-report). RESULTS: Regression analyses (linear models with all covariates entered at once) suggested that greater expectations for symptom persistence were significantly associated with higher emotional distress on both SDQ and PedsQL subscales, after controlling for post-concussive symptom severity and other confounds. Emotional distress/functioning was not associated with perceptions of symptom duration reported by parents, severity of post-concussive symptoms (self- and parent reports), age, number of concussions, time since injury, or a history of mental health concern or diagnosis (parent-reported). CONCLUSIONS: This study suggests that pessimistic attitudes for recovery duration may be more strongly associated with emotional distress than current post-concussive symptom severity or a history of mental health concern or diagnosis.

Demographic and Clinical Presentations of Youth using Enhanced Mental Health Services in Six Indigenous Communities from the ACCESS Open Minds Network.

OBJECTIVE: In many Indigenous communities, youth mental health services are inadequate. Six Indigenous communities participating in the ACCESS Open Minds (AOM) network implemented strategies to transform their youth mental health services. This report documents the demographic and clinical presentations of youth accessing AOM services at these Indigenous sites. METHODS: Four First Nations and two Inuit communities contributed to this study. Youth presenting for mental health services responded to a customized sociodemographic questionnaire and presenting concerns checklist, and scales assessing distress, self-rated health and mental health, and suicidal thoughts and behaviors. RESULTS: Combined data from the First Nations sites indicated that youth across the range of 11-29 years accessed services. More girls/women than boys/men accessed services; 17% identified as LBGTQ+. Most (83%) youth indicated having access to at least one reliable adult and getting along well with the people living with them. Twenty-five percent of youth reported difficulty meeting basic expenses. Kessler (K10) distress scores indicated that half likely had a moderate mental health problem and a fourth had severe problems. Fifty-five percent of youth rated their mental health as fair or poor, while 50% reported suicidal thoughts in the last month. Anxiety, stress, depression and sleep issues were the most common presenting problems. Fifty-one percent of youth either accessed services themselves or were referred by family members. AOM was the first mental health service accessed that year for 68% of youth. CONCLUSIONS: This report is the first to present a demographic and clinical portrait of youth presenting at mental health services in multiple Indigenous settings in Canada. It illustrates the acceptability and feasibility of transforming youth mental health services using core principles tailored to meet communities' unique needs, resources, and cultures, and evaluating these using a common protocol. Data obtained can be valuable in evaluating services and guiding future service design. Trial registration name and number at Clinicaltrials.gov: ACCESS Open Minds/ACCESS Esprits ouverts, ISRCTN23349893.

How Perceptions Impact Recovery from Concussion in Childhood and Adolescence: a Systematic Review.

Perceptions about the causes and consequences of concussion, and individual representations and interpretations of these factors, can influence the post-concussive recovery process. The goal of this project was to synthesize evidence on perceptions related to concussions as experienced by children, adolescents, and parents, and to evaluate how these perceptions impact post-concussive recovery in physical, behavioural, cognitive, and psychological domains. We undertook a systematic review based on the Cochrane Handbook, conducting a comprehensive search of six databases and Google Scholar. Duplicate, independent screening was employed and the quality of studies was assessed using the Mixed Methods Appraisal Tool (MMAT). A total of 1552 unique records were identified, and six records (5 scientific articles and 1 thesis, published between 1990 and 2018; N = 26 to 412, age range from 2 to 18 years) were included. Perceptions about concussions were assessed differently between studies, with a range in types of measures and respondents. Some evidence suggested that perceptions could negatively impact concussion recovery, mostly post-concussive symptoms. However, results were not consistent between studies and the methodological quality was variable (and often low). There is limited evidence of the impact of perceptions of children, adolescents, and their parents on concussion recovery. Priorities for future research investigating concussion recovery should include recruiting representative samples, accounting for potential confounders, and measuring perceptions in children, adolescents and parents using validated measures. Higher quality studies are needed to better understand the role of perceptions in concussion recovery and to inform clinical care.

Microstructure of the Corpus Callosum Long after Pediatric Concussion.

OBJECTIVE: The long-term effects of pediatric concussion on white matter microstructure are poorly understood. This study investigated long-term changes in white matter diffusion properties of the corpus callosum in youth several years after concussion. METHODS: Participants were 8-19 years old with a history of concussion (n = 36) or orthopedic injury (OI) (n = 21). Mean time since injury for the sample was 2.6 years (SD = 1.6). Participants underwent diffusion magnetic resonance imaging, completed cognitive testing, and rated their post-concussion symptoms. Measures of diffusivity (fractional anisotropy, mean, axial, and radial diffusivity) were extracted from white matter tracts in the genu, body, and splenium regions of the corpus callosum. The genu and splenium tracts were further subdivided into 21 equally spaced regions along the tract and diffusion values were extracted from each of these smaller regions. RESULTS: White matter tracts in the genu, body, and splenium did not differ in diffusivity properties between youth with a history of concussion and those with a history of OI. No significant group differences were found in subdivisions of the genu and splenium after correcting for multiple comparisons. Diffusion metrics did not significantly correlate with symptom reports or cognitive performance. CONCLUSIONS: These findings suggest that at approximately 2.5 years post-injury, youth with prior concussion do not have differences in their corpus callosum microstructure compared to youth with OI. Although these results are promising from the perspective of long-term recovery, further research utilizing longitudinal study designs is needed to confirm the long-term effects of pediatric concussion on white matter microstructure.

A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Insomnia in Adolescents With Persistent Postconcussion Symptoms.

OBJECTIVE: Cognitive-behavioral therapy for insomnia (CBT-I) is an effective insomnia treatment but has yet to be applied to adolescents with sleep disruption following concussion. This pilot study evaluated CBT-I to improve insomnia in adolescents with protracted concussion recovery. SETTING: Tertiary pediatric hospital. PARTICIPANTS: Participants (N = 24) were 12 to 18 years old (M = 15.0, SD = 1.4), 15.1 weeks (SD = 9.2) postinjury, and presenting with sleep disruption and persistent postconcussion symptoms. DESIGN: A single-blind, parallel-group randomized controlled trial (RCT) design comparing 6 weeks of CBT-I and a treatment-as-usual control group. Outcomes were measured before treatment, at treatment completion, and 4 weeks after completion. MAIN MEASURES: Primary outcome was Insomnia Severity Index. Secondary outcomes included Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep Scale, 7-night sleep diary, PROMIS Depression, PROMIS Anxiety, and Health and Behavior Inventory. RESULTS: Adolescents who received CBT-I demonstrated large and clinically significant improvements in insomnia ratings at posttreatment that were maintained at follow-up. They also reported improved sleep quality, fewer dysfunctional beliefs about sleep, better sleep efficiency, shorter sleep-onset latency, and longer sleep time compared with those with treatment as usual. There was also a modest reduction in postconcussion symptoms. CONCLUSION: In this pilot RCT, 6 weeks of CBT-I produced significant improvement in sleep in adolescents with persistent postconcussion symptoms. A larger trial is warranted.

Headache long after pediatric concussion: presence, intensity, interference, and association with cognition.

Objective: Document headache presence, intensity, and interference after concussion(s), as well as examine its association with cognition.Participants: Participants 8-19 years of age were assessed on average 34 months (SD = 21.5) after an orthopedic injury (OI, n = 29), single concussion (n = 21), or multiple concussions (n = 15).Measures: Headache intensity was rated using the Headache Rating Scale and headache interference was rated using the Post-Concussion Symptom Inventory (PCSI). Cognition was rated using the PCSI and measured using CNS Vital Signs.Results: Type of injury did not differ significantly in headache presence or intensity. However, there was a dose-response relationship found for children's ratings of headache interference, which was rated highest among children with multiple concussions, intermediate among those with single concussion, and lowest among children with OI. Both headache intensity and interference ratings correlated significantly with self and parent ratings of cognition on the PCSI, but not with cognitive test performance.Conclusions: Youth with single or multiple concussions report greater headache interference - but not higher headache intensity - compared to youth without concussion. Although higher headache intensity and interference were associated with more self-reported cognitive symptoms, headaches did not correlate with cognitive test performance.

Functional magnetic resonance imaging study of working memory several years after pediatric concussion.

PRIMARY OBJECTIVE: The neurophysiological effects of pediatric concussion several years after injury remain inadequately characterized. The objective of this study was to determine if a history of concussion was associated with BOLD response differences during an n-back working memory task in youth. RESEARCH DESIGN: Observational, cross-sectional. METHODS AND PROCEDURES: Participants include 52 children and adolescents (M = 15.1 years, 95%CI = 14.4-15.8, range = 9-19) with past concussion (n = 33) or orthopedic injury (OI; n = 19). Mean time since injury was 2.5 years (95%CI = 2.0-3.0). Measures included postconcussion symptom ratings, neuropsychological testing, and blood-oxygen-dependent-level (BOLD) functional magnetic resonance imaging (fMRI) during an n-back working memory task. MAIN OUTCOMES AND RESULTS: Groups did not differ on accuracy or speed during the three n-back conditions. They also did not differ in BOLD signal change for the 1- vs. 0-back or 2- vs. 0-back contrasts (controlling for task performance). CONCLUSIONS: This study does not support group differences in BOLD response during an n-back working memory task in youth who are on average 2.5 years post-concussion. The findings are encouraging from the perspective of understanding recovery after pediatric concussion.

Cerebral blood flow in children and adolescents several years after concussion.

OBJECTIVES: The long-term effects of concussion in youth remain poorly understood. The objective of this study was to determine the association between history of concussion and cerebral blood flow (CBF) in youth. METHODS: A total of 53 children and adolescents with a history of concussion (n = 37) or orthopaedic injury (OI; n = 16) were considered. Measures included pseudo-continuous arterial spin labelling magnetic resonance imaging to quantify CBF, post-concussion symptoms, psychological symptoms, and cognitive testing. RESULTS: Participants (mean age: 14.4 years, 95% CI = 13.8-15.4, range = 8-19) were on average 2.7 years (95% CI = 2.2-3.1) post-injury. Youth with a history of concussion had higher parent-reported physical, cognitive, anxiety, and depression symptoms than children with OI, but the groups did not differ on self-reported symptoms (post-concussive or psychological) or cognitive testing. Global CBF did not differ between groups. Regional CBF analyses suggested that youth with a history of concussion had hypoperfusion in posterior and inferior regions and hyperperfusion in anterior/frontal/temporal regions as compared to those with OI. However, neither global nor regional CBF were significantly associated with demographics, pre-injury functioning, number of concussions, time since injury, post-concussive symptoms, psychological symptoms, or cognitive abilities. CONCLUSIONS: Youth with a history of concussion demonstrate differences in regional CBF (not global CBF), but without clear clinical expression.

Predictors of Long-Term Psychosocial Functioning and Health-Related Quality of Life in Children and Adolescents With Prior Concussions.

OBJECTIVES: Individual differences in long-term psychosocial functioning after concussions in children and adolescents are poorly understood. The aim of the study was to investigate potential predictors of long-term psychosocial functioning and health-related quality of life in youth after prior concussion. METHODS: Participants (N=75; mean age=14.3 years old; 52% girls) with one prior concussion (n=24), multiple prior concussions (n=24), or a prior orthopedic injury and no concussion (n=27) were seen on average 2.7 years after their most recent injury. Psychosocial functioning was assessed using the self-report versions of the Behavior Assessment System for Children (BASC-2; Anxiety and Depression scales only), the Strengths and Difficulties Questionnaire, and the Pediatric Quality of Life Inventory TM 4.0. Pre-existing conditions (attention problems, learning difficulties, mood concerns, anxiety concerns, and migraines) were reported by parents using a checklist and examined as predictors of long-term functioning. Other potential predictors included age at testing, sex, time between most recent injury and testing, and number of prior concussions. RESULTS: The groups did not differ significantly on long-term psychosocial functioning. Moreover, only pre-existing mood concerns or attention problems significantly predicted psychosocial adjustment. CONCLUSIONS: Children's functioning before a concussion is critical to understanding outcome. Pre-injury attention and mood concerns should be assessed in clinical settings to prevent and treat long-term psychosocial problems after concussion. (JINS, 2018, 24, 540-548).

Complex effects of dyslexia risk factors account for ADHD traits: evidence from two independent samples.

BACKGROUND: Developmental dyslexia (DD) and attention deficit/hyperactivity disorder (ADHD) are among the most common neurodevelopmental disorders, whose etiology involves multiple risk factors. DD and ADHD co-occur in the same individuals much more often than would be expected by chance. Several studies have found significant bivariate heritability, and specific genes associated with either DD or ADHD have been investigated for association in the other disorder. Moreover, there are likely to be gene-by-gene and gene-by-environment interaction effects (G × G and G × E, respectively) underlying the comorbidity between DD and ADHD. We investigated the pleiotropic effects of 19 SNPs spanning five DD genes (DYX1C1, DCDC2, KIAA0319, ROBO1, and GRIN2B) and seven DD environmental factors (smoke, miscarriage, birth weight, breastfeeding, parental age, socioeconomic status, and parental education) for main, either (a) genetic or (b) environmental, (c) G × G, and (d) G × E upon inattention and hyperactivity/impulsivity. We then attempted replication of these findings in an independent twin cohort. METHODS: Marker-trait association was analyzed by implementing the Quantitative Transmission Disequilibrium Test (QTDT). Environmental associations were tested by partial correlations. G × G were investigated by a general linear model equation and a family-based association test. G × E were analyzed through a general test for G × E in sib pair-based association analysis of quantitative traits. RESULTS: DCDC2-rs793862 was associated with hyperactivity/impulsivity via G × G (KIAA0319) and G × E (miscarriage). Smoke was significantly correlated with hyperactivity/impulsivity. We replicated the DCDC2 × KIAA0319 interaction upon hyperactivity/impulsivity in the twin cohort. CONCLUSIONS: DD genetic (DCDC2) and environmental factors (smoke and miscarriage) underlie ADHD traits supporting a potential pleiotropic effect.

Is Computerized Cognitive Testing Useful in Children and Adolescents with Moderate-to-Severe Traumatic Brain Injury?

OBJECTIVES: Children and adolescents with moderate-to-severe traumatic brain injury (TBI) present with short and long-term neuropsychological deficits following their injury. The aim of this study was to investigate the utility of a brief computerized test battery for evaluating cognitive functioning sub-acutely following a TBI. METHODS: Participants (n=33) sustained a moderate-to-severe TBI, were between 8 and 18 years old, and were assessed using CNS Vital Signs (CNSVS) within 6 months post-injury (median=0.6 month). Participants with TBI were matched to 33 healthy controls based on age, sex, and handedness to compare their cognitive functioning on the CNSVS battery. RESULTS: Children and adolescents with moderate-to-severe TBI had significantly lower scores and large effect sizes on Reaction Time, Complex Attention, and Cognitive Flexibility domains, as well as medium effect sizes on two Visual Memory test scores and one Psychomotor Speed test score. A significantly higher percentage of participants with TBI had cognitive impairment on Reaction Time domain score compared to the control group. Finally, CNSVS domain scores correctly categorized 76% of participants as either group with TBI or control group. CONCLUSIONS: CNSVS may be a useful tool for screening cognitive abilities in children and adolescents who are early in their recovery from a moderate-to-severe TBI, particularly when a rapid screening evaluation can help guide management, interventions, and track recovery. (JINS, 2017, 23, 304-313).

Phenotypic and genetic associations between reading and attention-deficit/hyperactivity disorder dimensions in adolescence.

Multiple studies have shown that reading abilities and attention-deficit/hyperactivity disorder symptoms, mainly inattention symptoms, are phenotypically and genetically associated during childhood. However, few studies have looked at these associations during adolescence to investigate possible developmental changes. The aim of the study is to examine the genetic and environmental etiology of the associations between inattention and hyperactivity reported by parents, and reading accuracy, reading speed, and word reading in a population-based twin sample (Quebec Newborn Twin Study). Participants were between 14 and 15 years of age at the time of testing (N = 668-837). Phenotypic results showed that when nonverbal and verbal abilities were controlled, inattention, but not hyperactivity/impulsivity, was a modest and significant predictor of reading accuracy, reading speed, and word reading. The associations between inattention and all reading abilities were partly explained by genetic and unique environmental factors. However, the genetic correlations were no longer significant after controlling for verbal abilities. In midadolescence, inattention is the attention-deficit/hyperactivity disorder dimension associated with reading abilities, but they could also share genetic factors with general verbal skills.

Phenotypic and genetic associations between reading comprehension, decoding skills, and ADHD dimensions: evidence from two population-based studies.

BACKGROUND: The phenotypic and genetic associations between decoding skills and ADHD dimensions have been documented but less is known about the association with reading comprehension. The aim of the study is to document the phenotypic and genetic associations between reading comprehension and ADHD dimensions of inattention and hyperactivity/impulsivity in early schooling and compare them to those with decoding skills. METHODS: Data were collected in two population-based samples of twins (Quebec Newborn Twin Study - QNTS) and singletons (Quebec Longitudinal Study of Child Development - QLSCD) totaling ≈ 2300 children. Reading was assessed with normed measures in second or third grade. Teachers assessed ADHD dimensions in kindergarten and first grade. RESULTS: Both decoding and reading comprehension were correlated with ADHD dimensions in a similar way: associations with inattention remained after controlling for the other ADHD dimension, behavior disorder symptoms and nonverbal abilities, whereas associations with hyperactivity/impulsivity did not. Genetic modeling showed that decoding and comprehension largely shared the same genetic etiology at this age and that their associations with inattention were mostly explained by shared genetic influences. CONCLUSION: Both reading comprehension and decoding are uniquely associated with inattention through a shared genetic etiology.

The diagnosis of ADHD in children and adolescents with epilepsy: a scoping review.

Attention-deficit hyperactivity disorder (ADHD) is often diagnosed in children and adolescents with epilepsy, but clear clinical guidelines on how to make this diagnosis are still lacking. Without these guidelines, there is no consensus between specialists on how to proceed when assessing children with epilepsy for ADHD, which can negatively impact the quality of care being offered to this population. As a first step toward gaining more specific clinical guidelines, this scoping review was aimed at documenting the tools and procedures used to diagnose ADHD in children and adolescents with epilepsy over time and at determining whether the diagnoses were made in accordance with clinical guidelines and recommendations. The literature search was conducted using PsycINFO, PubMed, and CINAHL. Studies were included if conducted with children and adolescents aged between 4 and 18 years with epilepsy being evaluated for ADHD. Studies were clustered according to their publication date and the reported diagnostic procedures were identified. Forty-nine out of 3854 records were included. Results highlight discrepancies between how ADHD was diagnosed in reviewed studies and clinical guidelines or recommendations. Indeed, most studies did not use a multi-method and multi-informant approach when diagnosing ADHD in children with epilepsy, with no improvement over time. Future studies aimed at diagnosing ADHD in children and adolescents should ensure that they are following clinical guidelines and recommendations, in addition to adapting their diagnostic procedures to the presence of any neurological comorbidities, such as epilepsy.

Psychopathology and mind wandering in young university students.

Mind wandering has often been studied in relation to psychopathology. However, debates remain as to whether sluggish cognitive tempo, recently termed cognitive disengagement syndrome (CDS), and ADHD symptoms could be unique predictors of mind wandering. Therefore, this study was aimed at documenting the associations between CDS, ADHD symptoms and mind wandering while controlling for age, sex, internalized symptoms, and sleep. A sample consisting of university students (N = 60; aged between 17 and 32 years; 65% female) completed measures of CDS, ADHD symptoms, internalized functioning and insomnia. Mind wandering was also assessed using the 5-item Mind Wandering Questionnaire (MWQ) and thought sampling during a reading task. Multiple regression analyses show that while younger age and inattention were significant predictors of greater levels of self-reported mind wandering on the MWQ, sex, CDS, hyperactivity/impulsivity, internalized symptoms, and sleep were not. In addition, no variables were able to significantly predict spontaneous and deliberate mind wandering as assessed by thought sampling. These findings raise important questions regarding the equivalence between measures of state-level and trait-level mind wandering. The associations between ADHD, CDS and mind wandering in young adults are still unclear, but our findings highlight critical methodological considerations for future studies that might further our understanding of the relationship between task-unrelated thought and psychopathology.

Psychoeducational Interventions and Postconcussive Recovery in Children and Adolescents: A Rapid Systematic Review.

OBJECTIVE: The purpose of this rapid systematic review was to identify and synthesize results of empirical studies that have examined psychoeducational interventions provided to children and adolescents aged 5-19 recovering from a concussion and their families. METHODS: This study followed the PRISMA guidelines adjusted for a rapid systematic review. We searched three databases (EMBASE, PsycInfo and MEDLINE) with key terms for concussion (or mild traumatic brain injury - mTBI), the intervention (psychoeducation, instructions, and reassurance) and the target population (children and adolescents aged 5 to 19). Our search strategy generated 2225 unique records and seven were included. We performed a quality appraisal on the included studies using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Results indicated that psychoeducational interventions had satisfactory feasibility results. Caregivers generally found the intervention to be useful to determine return to play (n=2) and understand consequences following a concussion (n=1). However, results from studies on post-concussive symptom improvement (n=4) and post-intervention concussion knowledge (n=2) showed variability and mixed findings. Methodological quality was low for most studies. CONCLUSIONS: This present review shows that there are very few published studies on psychoeducational interventions offered to children, adolescents, and families for the post-concussion management. Current evidence suggests that those interventions are useful in guiding caregivers during their child's recovery. However, the impact of psychoeducational interventions on post-concussive recovery seems to be less clear.

Parental Knowledge, Self-confidence, and Usability Evaluation of a Web-Based Infographic for Pediatric Concussion: Multimethod Study.

BACKGROUND: Concussions, which are known as mild traumatic brain injuries, are complex injuries caused by direct or indirect blows to the head and are increasingly being recognized as a significant public health concern for children and their families. Previous research has identified few studies examining the efficacy of educational interventions on parental concussion knowledge. The aim of this research was to actively work together with children who have experienced a concussion and their parents to develop, refine, and evaluate the usability of a web-based infographic for pediatric concussion. OBJECTIVE: The objective of this study was to report on the usability of the infographic, parental knowledge, and self-confidence in pediatric concussion knowledge before and after exposure to the infographic. METHODS: A multiphase, multimethod research design using patient engagement techniques was used to develop a web-based infographic. For this phase of the research (usability, knowledge, and confidence evaluation), parents who could communicate in English were recruited via social media platforms and invited to complete web-based questionnaires. Electronic preintervention and postintervention questionnaires were administered to parents to assess changes to concussion knowledge and confidence after viewing the infographic. A usability questionnaire with 11 items was also completed. RESULTS: A web-based, infographic was developed. The infographic is intended for parents and children and incorporates information that parents and children identified as both wants and needs about concussion alongside the best available research evidence on pediatric concussion. A total of 31 surveys were completed by parents. The mean scores for each item on the usability surveys ranged from 8.03 (SD 1.70) to 9.26 (SD 1.09) on a 10-point Likert scale, indicating that the usability components of the infographic were largely positive. There was no statistically significant difference between preintervention and postintervention knowledge scores (Z=-0.593; P=.55; both preintervention and postintervention knowledge scores had a median of 9 out of 10). In contrast, there was a statistically significant difference between preintervention (mean 3.9/5, SD 0.56) and postintervention (mean 4.4/5, SD 0.44) confidence in knowledge scores (t30=-5.083; P<.001). CONCLUSIONS: Our results demonstrate that parents positively rated a web-based, infographic for pediatric concussion. In addition, although there was no statistically significant difference overall in parents' knowledge scores before and after viewing the infographic, their confidence in their knowledge did significantly increase. These results suggest that using a web-based infographic as a knowledge translation intervention may be useful in increasing parents' confidence in managing their child's concussion.

"You Can't Fix Your Brain": Exploring concussion experiences of children and parents.

PURPOSE: To explore the experiences, information needs and preferences of children who have had a concussion and their parents who have cared for them. DESIGN: Qualitative description. METHODS: Semi-structured qualitative interviews were conducted via Zoom with children who have had a concussion between ages 5 and 16 years and parents who have cared for a child with a concussion. Interviews were audio-recorded and transcribed. RESULTS: Fourteen interviews were conducted with children and parents who have experiences with concussion. Four major themes were identified: (1) mechanism of injury and concussion symptoms experienced by children, (2) parent concerns, emotions, and health care experience with child's concussion, (3) concussions affect more than just your head and, (4) health information seeking, and preferences of parents and children related to concussion. Children and their parents have unique experiences, information needs and preferences regarding concussion. PRACTICE IMPLICATIONS: This information offers valuable insights about developing resources about childhood concussion that parents and children will find useful and relevant. This research has direct relevance to healthcare professionals who may encounter children with concussion in their daily practice so they can ensure the needs of children and families are being met. Our findings will be used to create the content for an innovative knowledge translation tool about pediatric concussion.

Community Social Paediatrics Approach, an Innovative Healthcare Intervention: Implementation Fidelity in Atlantic Canada.

The Community Social Paediatrics approach (CSPA) is a comprehensive and personalized approach to care that is becoming more widely used throughout Canada. However, data on its implementation fidelity remain scarce. The purpose of this research was to assess the implementation fidelity of a CSPA established in 2017 in Canada. Data were collected through focus group interviews with the CSPA team using an implementation fidelity grid based on the Dr. Julien Foundation standard accreditation criteria. Results showed that on one hand, administrative and financial management and governance were among those domains with lower ratings. On the other hand, assessment/orientation and follow-up/support had high levels of fidelity of implementation. This research helps to better understand which factors are contributing to varying levels of fidelity of implementation. To reach an increased level of fidelity of implementation, it is recommended that adequate resources be in place.