Concussion Symptom Treatment and Education Program: A Feasibility Study.

OBJECTIVE: To evaluate the feasibility and potential benefits of a manualized, brief cognitive-behavioral therapy-based intervention program for children and adolescents with persistent postconcussive symptoms. SETTING: Two outpatient pediatric concussion programs in the United States. PARTICIPANTS: Patients aged 8 to 17 years who sustained concussions between 2 and 12 months prior to enrollment. DESIGN: Pre-/postretrospective study. MAIN MEASURES: SCAT-3; HBI; PedsQL 4.0 Generic Core Scales; and RCADS. RESULTS: Thirty children and adolescents completed the treatment program. Self- and parent-reported postconcussive symptoms, quality of life, and internalizing symptoms significantly improved with treatment. Mixed-effects models revealed a significant decline in self-reported postconcussive symptoms across treatment sessions, a = -2.07, SE = 0.25, P < .001. The largest change occurred between sessions 2 and 3, following the session focusing on concussion psychoeducation and sleep hygiene (estimated mean change between sessions 2 and 3 = -4.72, P < .0001). CONCLUSIONS: Our findings indicate that a 6-session manualized cognitive behavioral intervention is feasible to initiate in an outpatient clinic 1 to 12 months following a pediatric mild traumatic brain injury. With a manualized format, clinicians at most levels of training should be able to implement this treatment manual and flexibly adapt as needed when working with children and adolescents who are experiencing delayed symptom recovery following concussion.

A Longitudinal Investigation of Symptom Recovery following Concussion in Youth Soccer.

OBJECTIVE: To prospectively evaluate symptom outcomes after youth soccer-related concussion. STUDY DESIGN: Using a prospective cohort design, we enrolled male and female competitive soccer players age 8-17 years into 3 groups: concussed (n = 23), matched control (n = 23), and orthopedic injury (n = 24). Postconcussive symptoms were monitored serially via both athlete and parent report at days 1-2, 4, 7, 10, 30, and 90. RESULTS: Repeated-measures analyses revealed a significant time by group interaction (F [12, 402] = 19.91, P < .001). In the initial days postinjury, the concussed group reported greater symptoms than the comparison groups, with more symptoms reported by athletes on average than parents. By 10 days, concussed athletes did not differ from the matched controls by either rater's report, but they did differ from the orthopedic injury group by parent report. At 30 days, no differences were apparent among groups. At 30 days, 100% of concussed youth and 91% of parents rated symptoms as back to preinjury levels using reliable change indices. At 30 days, 86% of athletes had been cleared to return to full game play. CONCLUSIONS: The natural clinical history of concussion symptoms in youth competitive soccer players was similar to that seen in older athletes, with resolution in days to a few weeks. Additional study will be required to investigate which factors best predict symptom outcomes for individual athletes and how symptom report relates to performance-based outcome measures and underlying neurophysiologic recovery.

The Multiple Deficit Model: Progress, Problems, and Prospects.

The multiple deficit model (MDM) was proposed because the prevailing single-deficit model provided an inadequate account of atypical neuropsychological development. Across methods and levels of analysis, there has been support for the two fundamental tenets of the MDM, that multiple predictors contribute probabilistically to neurodevelopmental disorders and shared risk factors contribute to comorbidity. Diagnostically, the multiplicity of factors means that no single cognitive deficit or combination of deficits can be used to rule in or out most neurodevelopmental disorders. Challenges for the MDM are that the theory is difficult to falsify and that current cross-sectional studies cannot establish causality. Prospects for further development of the MDM include incorporating an explicit focus on promotive and protective factors and pursuing mechanistic connections between multiple factors across levels of analysis.

Literacy acquisition influences children's rapid automatized naming.

Previous research has established that learning to read improves children's performance on reading-related phonological tasks, including phoneme awareness (PA) and nonword repetition. Few studies have investigated whether literacy acquisition also promotes children's rapid automatized naming (RAN). We tested the hypothesis that literacy acquisition should influence RAN in an international, longitudinal population sample of twins. Cross-lagged path models evaluated the relationships among literacy, PA, and RAN across four time points from pre-kindergarten through grade 4. Consistent with previous research, literacy showed bidirectional relationships with reading-related oral language skills. We found novel evidence for an effect of earlier literacy on later RAN, which was most evident in children at early phases of literacy development. In contrast, the influence of earlier RAN on later literacy was predominant among older children. These findings imply that the association between these two related skills is moderated by development. Implications for models of reading development and for dyslexia research are discussed.

Featured Article: Interpersonal Stressors and Resources as Predictors of Adolescent Adjustment Following Traumatic Brain Injury.

Objective: The present study sought to examine adolescents' perceptions of their interpersonal stressors and resources across parent, sibling, friend, and school relationships, and the longitudinal associations with self-reported adjustment after traumatic brain injury (TBI) over a 12-month period. Methods: We examined the main effects of stressors and resources on internalizing and externalizing symptoms in 152 adolescents who had sustained complicated mild-to-severe TBI. We also investigated the conjoint effects of stressors and resources and the moderating effects of TBI severity with stressors and resources on outcomes. Results: High stressors consistently predicted worse adjustment. High resources were generally only associated with fewer internalizing symptoms. Main effects were qualified by interactions between school stressors and resources in predicting externalizing symptoms and between friend stressors and resources in predicting internalizing and externalizing symptoms. For school stressors, the effects of resources on externalizing symptoms functioned as a buffer. In comparison, the buffering effects of friend resources on internalizing and externalizing symptoms disappeared at moderate-to-high levels of friend stress. Moderating effects of TBI severity were also observed, such that as family resources increased, only adolescents with complicated mild-to-moderate TBI, but not those with severe TBI, experienced decreases in internalizing and eternalizing symptoms. Conclusion: Interpersonal stressors and social support have important implications for adolescent adjustment after TBI. Adolescents with low levels of school resources, with high levels of friend stress, and who sustain severe TBI are at greatest risk for difficulties with adjustment.

Explaining the sex difference in dyslexia.

BACKGROUND: Males are diagnosed with dyslexia more frequently than females, even in epidemiological samples. This may be explained by greater variance in males' reading performance. METHODS: We expand on previous research by rigorously testing the variance difference theory, and testing for mediation of the sex difference by cognitive correlates. We developed an analytic framework that can be applied to group differences in any psychiatric disorder. RESULTS: Males' overrepresentation in the low performance tail of the reading distribution was accounted for by mean and variance differences across sex. There was no sex difference at the high performance tail. Processing speed (PS) and inhibitory control partially mediated the sex difference. Verbal reasoning emerged as a strength in males. CONCLUSIONS: Our results complement a previous finding that PS partially mediates the sex difference in symptoms of attention deficit/hyperactivity disorder (ADHD), and helps explain the sex difference in both dyslexia and ADHD and their comorbidity.

A Pilot Study Investigating Neuropsychological Consultation as an Intervention for Persistent Postconcussive Symptoms in a Pediatric Sample.

OBJECTIVE: To examine the efficacy of a one-time neuropsychological consultation as an intervention for youth with persistent postconcussive symptoms following mild traumatic brain injury. STUDY DESIGN: Using a prospective interrupted time series design, we enrolled 80 patients aged 8-17 years referred consecutively for clinical neuropsychological consultation. Patients needed to have sustained injury between 2 and 12 months prior to enrollment. Parent and child postconcussive symptom ratings were used as the primary outcome measures and were collected at 6 time points, 3 before the neuropsychological consultation and 3 after. Repeated measure ANOVA was used to estimate the magnitude of change in symptom ratings before and after the neuropsychological intervention. RESULTS: The decrease in symptoms for the week prior to consultation was nonsignificant by both child (P = .63) and parent (P = .19) report. In contrast, for both reporters, the decrease in symptoms at 1 week and 3 months postconsultation was significant (P < .0001). The difference in reported change was also significant when comparing the week before the intervention to the 3 months after (child: P < .0001; parent: P = .0009). CONCLUSIONS: Postconcussive symptoms decreased significantly following the neuropsychological consultation. The primary limitation of the study is that it lacked randomization and a control group. The results warrant further research into the benefits of neuropsychological consultation after mild traumatic brain injury and provide justification for clinical providers to consider referring to neuropsychologists in the face of persistent postconcussive symptoms.

Preinjury Emotional-Behavioral Functioning of Children With Lingering Problems After Mild Traumatic Brain Injury.

This study aimed to characterize preinjury emotional-behavioral functioning in pediatric patients with lingering problems after mild traumatic brain injury (TBI). The clinical case series design included 278 patients 8-17 years old. Parents retrospectively rated children's preinjury emotional-behavioral functioning on a broadband questionnaire. The rate of clinically significant preinjury anxiety was elevated compared with national norms. The number of previous TBIs was associated with clinically significant preinjury externalizing problems, suggesting a link between externalizing disorders and mild TBI exposure. Premorbid emotional-behavioral difficulties may play an important role in the establishment or maintenance of lingering symptoms after pediatric mild TBI.

Developmental dyslexia.

This review uses a levels-of-analysis framework to summarize the current understanding of developmental dyslexia's etiology, brain bases, neuropsychology, and social context. Dyslexia is caused by multiple genetic and environmental risk factors as well as their interplay. Several candidate genes have been identified in the past decade. At the brain level, dyslexia is associated with aberrant structure and function, particularly in left hemisphere reading/language networks. The neurocognitive influences on dyslexia are also multifactorial and involve phonological processing deficits as well as weaknesses in other oral language skills and processing speed. We address contextual issues such as how dyslexia manifests across languages and social classes as well as what treatments are best supported. Throughout the review, we highlight exciting new research that cuts across levels of analysis. Such work promises eventually to provide a comprehensive explanation of the disorder as well as its prevention and remediation.

Longitudinal Stability of Phonological and Surface Subtypes of Developmental Dyslexia.

Limited evidence supports the external validity of the distinction between developmental phonological and surface dyslexia. We previously identified children age 8 to 13 meeting criteria for these subtypes (Peterson, Pennington, & Olson, 2013), and now report on their reading and related skills approximately 5 years later. Longitudinal stability of subtype membership was fair and appeared stronger for phonological than surface dyslexia. Phonological dyslexia was associated with a pronounced phonological awareness deficit, but subgroups otherwise had similar cognitive profiles. Subtype did not inform prognosis. Results provide modest evidence for the validity of the distinction, although not for its clinical utility.

Statistical Learning, Letter Reversals, and Reading.

Reversal errors play a prominent role in theories of reading disability. We examined reversal errors in the writing of letters by 5-6-year-old children. Of the 130 children, 92 had a history of difficulty in producing speech sounds, a risk factor for reading problems. Children were more likely to reverse letter forms that face left, such as 〈d〉 and 〈J〉, than forms that face right, such as 〈b〉 and 〈C〉. We propose that this asymmetry reflects statistical learning: Children implicitly learn that the right-facing pattern is more typical of Latin letters. The degree of asymmetry that a child showed was not related to the child's reading skill at Time 2, 2 ¾ years later. Although children who went on to become poorer readers made more errors in the letter writing task than children who went on to become better readers, they were no more likely to make reversal errors.

Cognitive disengagement syndrome in pediatric spina bifida.

The primary aim of this study was to characterize Cognitive Disengagement Syndrome (CDS) symptomatology in youth with spina bifida (SB). One hundred and sixty-nine patients aged 5-19 years old were drawn from clinical cases seen through a multidisciplinary outpatient SB clinic at a children's hospital between 2017 and 2019. Parent-reported CDS and inattention were measured using Penny's Sluggish Cognitive Tempo Scale and the Vanderbilt ADHD Rating Scale. Self-reported internalizing symptoms were measured with the 25-item Revised Children's Anxiety and Depression Scale (RCADS-25). We replicated Penny's proposed 3-factor structure of CDS with slow, sleepy, and daydreamer components. The slow component of CDS overlapped heavily with inattention, while the sleepy and daydreamer components were distinct from inattention and internalizing symptoms. Eighteen percent (22 of 122) of the full sample met criteria for elevated CDS, and 39% (9 of 22) of those patients did not meet criteria for elevated inattention. Diagnosis of myelomeningocele and presence of a shunt were associated with greater CDS symptoms. CDS can be measured reliably in youth with SB and can be discriminated from inattention and internalizing symptoms in this population. ADHD rating scale measures fail to identify a substantial portion of the SB population with attention-related challenges. Standard screening for CDS symptoms in SB clinics may be important to help identify clinically impairing symptoms and design targeted treatment plans.

Quality of Life in Youth Soccer Players After Mild Traumatic Brain Injury.

CONTEXT: Pediatric mild traumatic brain injuries (mTBIs) represent an evolving field of interest in youth athletics. Although most players recover within 4 weeks, some have symptoms that last longer. Little is known about youth health-related quality of life (HRQoL) after mTBI. OBJECTIVES: To characterize youth HRQoL after soccer-related mTBI and to identify predictors of individual differences in HRQoL recovery. DESIGN: Prospective cohort study. SETTING: Youth soccer. PARTICIPANTS: Soccer players, aged 8 to 17 years, who sustained an mTBI (n = 23) or orthopaedic injury (OI, n = 24) or remained uninjured (n = 23) during a single season. MAIN OUTCOME MEASURE(S): We assessed HRQoL via the Pediatric Quality of Life Inventory, version 4.0, and postconcussive symptoms via the Health and Behavior Index. Serial assessments occurred at 24 to 48 hours, 7 days, 30 days, and 90 days postinjury via telephone interview. RESULTS: At 7 days postinjury, the mTBI and OI groups had poorer total HRQoL (F2,67 = 11.35, P < .001) than the uninjured control group. At 7 days, the mTBI group had the poorest psychosocial HRQoL, whereas the OI group had the poorest physical HRQoL. Differences between the mTBI and uninjured control groups resolved by 30 days. Within the mTBI group, players with significant postconcussive symptoms at 7 days had poorer total (F1,21 = 23.071, P ≤ .001; F1,21 = 5.798, P = .028), psychosocial (F1,21 = 16.488, P = < .001; F1,21 = 5.050, P = .039), and physical (F1,21 = 21.671, P = < .001; F1,21 = 5.119, P = .038) HRQoL at 7 and 30 days, respectively, than players with minimal symptoms; these differences resolved by 90 days. CONCLUSIONS: As a group, youth soccer players who sustained mTBI had transient impairments in HRQoL that resolved by 30 days. A subset of players with significant postconcussive symptoms at 7 days postinjury had poorer HRQoL for at least 30 days postinjury than those whose postconcussive symptoms had resolved within a week of injury. This suggests ongoing recovery in this subset at 30 days and the potential utility of HRQoL as a measure of recovery.

Caregiver report of social-emotional functioning in infants and young children after inflicted traumatic brain injury.

Social-emotional difficulties are common sequelae of traumatic brain injury (TBI). Children who have experienced inflicted TBI (iTBI) may be at increased risk for social-emotional problems due to the risk factors associated with both early neurologic injury and with child maltreatment. We characterized the associations among injury severity, caregiver type (i.e., biological parents, non-kinship, kinship), and child social-emotional functioning in 41 infants and young children who had sustained iTBI and were seen in a large, regional children's hospital. This study was a retrospective analysis, utilizing data collected from the medical record as part of routine clinical care. Social-emotional functioning was assessed with the Bayley Scales of Infant and Toddler Development-Third Edition. Children with more severe injuries were rated as having worse social-emotional functioning. Caregiver type was associated with child social-emotional scores, above and beyond injury and demographic predictors. Biological parents were more likely to report better social-emotional skills than non-kinship caregivers, with the pattern of results suggesting that rater bias plays a role in this difference. In order to ensure that children are accurately identified for supports, these relationships should be considered when interpreting caregiver report of social-emotional skills.

Developmental dyslexia.

Dyslexia is a neurodevelopmental disorder that is characterised by slow and inaccurate word recognition. Dyslexia has been reported in every culture studied, and mounting evidence draws attention to cross-linguistic similarity in its neurobiological and neurocognitive bases. Much progress has been made across research specialties spanning the behavioural, neuropsychological, neurobiological, and causal levels of analysis in the past 5 years. From a neuropsychological perspective, the phonological theory remains the most compelling, although phonological problems also interact with other cognitive risk factors. Work confirms that, neurobiologically, dyslexia is characterised by dysfunction of the normal left hemisphere language network and also implicates abnormal white matter development. Studies accounting for reading experience demonstrate that many recorded neural differences show causes rather than effects of dyslexia. Six predisposing candidate genes have been identified, and evidence shows gene by environment interaction.

Behavioral and cognitive predictors of educational outcomes in pediatric traumatic brain injury.

Research reveals mixed results regarding the utility of standardized cognitive and academic tests to predict educational outcomes in youth following a traumatic brain injury (TBI). Yet, deficits in everyday school-based outcomes are prevalent after pediatric TBI. The current study used path modeling to test the hypothesis that parent ratings of adolescents' daily behaviors associated with executive functioning (EF) would predict long-term functional educational outcomes following pediatric TBI, even when injury severity and patient demographics were included in the model. Furthermore, we contrasted the predictive strength of the EF behavioral ratings with that of a common measure of verbal memory. A total of 132 adolescents who were hospitalized for moderate to severe TBI were recruited to participate in a randomized clinical intervention trial. EF ratings and verbal memory were measured within 6 months of the injury; functional educational outcomes were measured 12 months later. EF ratings and verbal memory added to injury severity in predicting educational competence post injury but did not predict post-injury initiation of special education. The results demonstrated that measurement of EF behaviors is an important research and clinical tool for prediction of functional outcomes in pediatric TBI.

Adolescents' internalizing problems following traumatic brain injury are related to parents' psychiatric symptoms.

BACKGROUND: A small body of previous research has demonstrated that pediatric traumatic brain injury (TBI) increases risk for internalizing problems, but findings have varied regarding their predictors and correlates. METHODS: We examined the level and correlates of internalizing symptoms in 130 teens who had sustained a complicated mild to severe TBI within the past 1 to 6 months. Internalizing problems were measured via both maternal- and paternal-report Child Behavior Checklist. We also measured family functioning, parent psychiatric symptoms, and postinjury teen neurocognitive function. RESULTS: Mean parental ratings of internalizing problems were within the normal range. Depending on informant, 22% to 26% of the sample demonstrated clinically elevated internalizing problems. In multiple and binary logistic regression models, only parent psychiatric symptoms consistently provided unique prediction of teen internalizing symptoms. For maternal but not paternal report, female gender was associated with greater internalizing problems. CONCLUSION: Parent and teen emotional problems are associated following adolescent TBI. Possible reasons for this relationship, including the effects of TBI on the family unit, are discussed.

Processing Speed is Related to the General Psychopathology Factor in Youth.

The relationship between the p factor and cognition in youth has largely focused on general cognition (IQ) and executive functions (EF). Another cognitive construct, processing speed (PS), is dissociable from IQ and EF, but has received less research attention despite being related to many different mental health symptoms. The present sample included 795 youth, ages 11-16 from the Colorado Learning Disabilities Research Center (CLDRC) sample. Confirmatory factor analyses tested multiple p factor models, with the primary model being a second-order, multi-reporter p factor. We then tested the correlation between the p factor and a latent PS factor. There was a significant, negative correlation between the p factor and PS (r(87) = -0.42, p < .001), indicating that slower processing speed is associated with higher general mental health symptoms. This association is stronger than previously reported associations with IQ or EF. This finding was robust across models that used different raters (youth and caregiver) and modeling approaches (second-order vs. bifactor). Our findings indicate that PS is related to general psychopathology symptoms. This research points to processing speed as an important transdiagnostic construct that warrants further exploration across development.

Sequencing Deficits and Phonological Speech Errors, But Not Articulation Errors, Predict Later Literacy Skills.

PURPOSE: Speech sound disorder (SSD) in conjunction with a language disorder has been associated with poor literacy acquisition; however, no study has evaluated whether articulation, phonological, or sequencing skills are differentially related to reading skills. Therefore, this study examined the relationship between speech error types at ages 5-6 years and literacy at ages 7-9 years. Phonological errors were hypothesized to predict phonological awareness (PA) and literacy even while accounting for other speech error types and language skills. METHOD: One hundred twenty-three children, 86 with a history of speech impairment, completed a battery of speech, language, and literacy tests at ages 5-6 years and again at ages 7-9 years. Speech production at ages 5-6 years was analyzed, and indices of articulation errors, phonological errors, and sequencing deficits were obtained. The relationships of these error types to concurrent language and preliteracy skills and to later literacy outcomes were assessed. RESULTS: As expected, phonological, but not articulation, errors at ages 5-6 years predicted concurrent PA and letter knowledge, as well as literacy at ages 7-9 years, even while accounting for language skills. Surprisingly, of all the error types, sequencing deficits showed the strongest relationship with PA (ages 5-6 years) and literacy (ages 7-9 years). CONCLUSIONS: These results suggest that some components of SSD uniquely predict preliteracy and literacy skills, even when controlling for language ability. Future investigations should examine further the association between sequencing deficits and literacy skills, test whether observed relationships hold at younger ages, and evaluate the efficacy of integrating literacy interventions into speech therapy to reduce later reading difficulties. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19624020.

Child, Parent, and Family Adjustment for Patients Followed in a Multidisciplinary Spina Bifida Clinic.

Objectives: To characterize child, parent, and family adjustment for patients followed in a multidisciplinary spina bifida (SB) clinic. Methods: Participants were drawn from clinical cases seen through a multidisciplinary outpatient SB clinic at a children's hospital between 2017 and 2019. Participants included 209 youth under 19 years old who were diagnosed with SB and their parents. Self-reported internalizing symptoms were measured in youth in grade 3 through 12 using the 25-item Revised Children's Anxiety and Depression Scale-25 (RCADS-25). Self- and parent-reported quality of life and family functioning were obtained using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and Family Impact Modules. Results: A total of 45.7% of children and adolescents reported at-risk psychosocial functioning on the PedsQL. In contrast, only 5% of patients reported clinically elevated internalizing symptoms on the RCADS. Parents' quality of life and family functioning in the study were higher than in most studies of parents of children with other chronic health conditions, children with attention deficit-hyperactivity disorder, and healthy control samples. Conclusion: Our findings indicate that children and adolescents with SB are at risk for poor health-related quality of life (HRQOL); however, poorer HRQOL may not necessarily be associated with more severe psychiatric symptoms in this population. Examining resilience factors that may help to buffer against challenges to HRQOL will be important in informing future interventions.