Lifetime and novel psychiatric disorders after pediatric traumatic brain injury

Psychological Predictors of Mental Health Difficulties after Pediatric Concussion

Children often experience mental health difficulties after a concussion. Yet, the extent to which a concussion precipitates or exacerbates mental health difficulties remains unclear. This study aimed to examine psychological predictors of mental health difficulties after pediatric concussion. Children (aged 5 to <18 years, M=11.7, SD=3.3) with concussion were recruited in a single-site longitudinal prospective cohort study conducted at a tertiary children's hospital (n=115, 73.9% male). The primary outcomes included internalizing (anxious, depressed, withdrawn behaviors), externalizing (risk-taking, aggression, attention difficulties), and total mental health problems, as measured by the Child Behavior Checklist at two weeks (acute) and three months (post-acute) after concussion. Predictors included parents' retrospective reports of premorbid concussive symptoms (Post-Concussion Symptom Inventory; PCSI), the child and their family's psychiatric history, child-rated perfectionism (Adaptive-Maladaptive Perfectionism Scale), and child-rated resilience (Youth Resilience Measure). Higher premorbid PCSI ratings consistently predicted acute and post-acute mental health difficulties. This relationship was significantly moderated by child psychiatric history. Furthermore, pre-injury learning difficulties, child psychiatric diagnoses, family psychiatric history, lower resilience, previous concussions, female sex, and older age at injury were associated with greater mental health difficulties after concussion. Pre-injury factors accounted for 23.4-39.9% of acute mental health outcomes, and 32.3-37.8% of post-acute mental health outcomes. When acute mental health was factored into the model, a total of 47.0%-68.8% of variance was explained by the model. Overall, in this sample of children, several pre-injury demographic and psychological factors were observed to predict mental health difficulties after a concussion. These findings need to be validated in future research involving larger, multi-site studies that include a broader cohort of children after concussion.

Temporal shifts to the gut microbiome associated with cognitive dysfunction following high-fat diet consumption in a juvenile model of traumatic brain injury

The gut-brain axis interconnects the central nervous system (CNS) and the commensal bacteria of the gastrointestinal tract. The composition of the diet consumed by the host influences the richness of the microbial populations. Traumatic brain injury (TBI) produces profound neurocognitive damage, but it is unknown how diet influences the microbiome following TBI. The present work investigates the impact of a chow diet versus a 60% fat diet (HFD) on fecal microbiome populations in juvenile rats following TBI. Twenty-day-old male rats were placed on one of two diets for 9 days before sustaining either a Sham or TBI via the Closed Head Injury Model of Engineered Rotational Acceleration (CHIMERA). Fecal samples were collected at both 1- and 9-days postinjury. Animals were cognitively assessed in the novel object recognition tests at 8 days postinjury. Fecal microbiota DNA was isolated and sequenced. Twenty days of HFD feeding did not alter body weight, but fat mass was elevated in HFD compared with Chow rats. TBI animals had a greater percentage of entries to the novel object quadrant than Sham counterparts, P < 0.05. The Firmicutes/Bacteroidetes ratio was significantly higher in TBI than in the Sham, P < 0.05. Microbiota of the Firmicutes lineage exhibited perturbations by both injury and diet that were sustained at both time points. Linear regression analyses were performed to associate bacteria with metabolic and neurocognitive endpoints. For example, counts of Lachnospiraceae were negatively associated with percent entries into the novel object quadrant. Taken together, these data suggest that both diet and injury produce robust shifts in microbiota, which may have long-term implications for chronic health.NEW & NOTEWORTHY Traumatic brain injury (TBI) produces memory and learning difficulties. Diet profoundly influences the populations of gut microbiota. Following traumatic brain injury in a pediatric model consuming either a healthy or high-fat diet (HFD), significant shifts in bacterial populations occur, of which, some are associated with diet, whereas others are associated with neurocognitive performance. More work is needed to determine whether these microbes can therapeutically improve learning following trauma to the brain.

Exploring caregiver and participant experiences of the Program for the Education and Enrichment of Relational Skills (PEERS®) for youth with acquired brain injury and cerebral palsy

PURPOSE

This study explored the experience of adolescents with brain injuries and their caregivers who participated in the Program for the Education and Enrichment of Relational Skills (PEERS®) in Australia.

MATERIALS AND METHODS

Twenty-seven adolescents and 31 caregivers, who completed the PEERS® intervention as part of an RCT, contributed to focus groups following the 14-week program. Semi-structed interviews guided focus groups. An interpretive description methodology was used to understand participants' experiences in the program and suggestions for improvements.

RESULTS

Thematic analysis led to the development of five themes. "Challenging families and meeting expectations" explored the challenge and worth of participating. "Learnt new skills" highlighted skills and strategies gained and methods used to achieve these. "Connecting, belonging and understanding that's our normal" represented the value placed on the group experience. "Confidence in knowing and doing" reflected the changes in everyday social experiences and "Where to from here?" provided many suggestions for adaptation to improve practice.

CONCLUSION

After taking part in the PEERS® social skills group intervention, most adolescents with brain injury and their caregivers perceived improvement in their social participation and had suggestions for improving the group experience. Some adolescents didn't enjoy the program.IMPLICATIONS FOR REHABILITATIONOffering adolescents with brain injury and their caregivers the opportunity to participate in a group social skills intervention is an important part of paediatric rehabilitation.Participants of group social skills interventions are likely to perceive improvements in their everyday social functioning following completion.Considering strategies to enhance engagement in the group is expected to be important for outcomes.Participants of group social skills programs may need additional support and adjustments to balance the demands of the intervention with other everyday family and school tasks and requirements.

Consciousness Recovery in Traumatic Brain Injury: A Systematic Review Comparing Modafinil and Amantadine

OBJECTIVES

Acute traumatic brain injury is one of the most common causes of death and disability. Reduction in the level of consciousness is a significant complication that can impact morbidity. Glasgow Coma Scale (GCS) is the most widely used method of assessing the level of consciousness. Neurostimulants such as amantadine and modafinil are common pharmacologic agents that increase GCS in patients with brain trauma. This study aimed to compare the effectiveness of these 2 drugs.

METHODS

This systematic review obtained articles from Google Scholar, PubMed, Scopus, Embase, and MEDLINE databases. Extensive searches were conducted separately by 4 individuals in 3 stages. Ultimately, 16 clinical trials, cohort studies, case reports, and case series articles were obtained after reading the title, abstract, and full text and considering the exclusion criteria. The data of the final article were entered into the analysis table. This study was registered with PROSPERO (registration number CRD42022334409) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Amantadine seems to be associated with a higher overall response rate. In contrast, modafinil is associated with the most remarkable change in GCS score during treatment. However, the number of clinical trials with high quality and sample size has not been satisfactory to compare the effectiveness of these 2 drugs and their potential side effects.

CONCLUSIONS

The authors recommend additional double-blind clinical trials are needed to be conducted with a larger sample size, comparing amantadine with modafinil to delineate the efficacy and adverse effects, both short and long term.

High-Fat Diet Exacerbates Stress Responsivity in Juvenile Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the leading causes of death for children in the United States. Juveniles are more likely to sustain TBIs than most other age groups, and TBI has been shown to result in increased anxiety and stress behaviors. In addition, the hypothalamic-pituitary-adrenal (HPA) axis has previously been shown to become dysregulated after a TBI. Further, many children consume diets high in saturated fats and refined sugars, which are also connected to alterations in HPA axis function and behavior disorders. The goal of the current study was to identify a potential relationship between high-fat diet (HFD) consumption and TBI on HPA axis function in juvenile rats. In the present study, male juvenile Long-Evans rats were fed either a combination of an HFD with a high-fructose corn syrup solution or a standard chow diet. On post-natal Day 30, subjects sustained either a sham TBI or a TBI via the Closed-Head Injury Model of Engineered Rotational Acceleration (CHIMERA). Subjects participated in a trial of the open field test (OFT) following injury. In addition, some rats performed in an acute restraint stress test. All subjects were euthanized 7 days post-injury. Brain and blood plasma samples were collected for use in real-time polymerase chain reaction (RT-PCR), immunohistochemistry, and corticosterone or adrenocorticotropic hormone (ACTH) assays. Immediately following TBI, injured juveniles had increased time to righting and walking, with HFD-fed TBI rats having increased time to walking over Chow-fed TBI rats. HFD-fed TBI rats had a reduced number of entries to the center of the OFT, in addition to reduced time spent in the center compared with HFD Sham controls and Chow TBI rats. During the acute restraint stress test, HFD-fed TBI rats had elevated pre-stress ACTH and corticosterone and post-stress ACTH levels. Pre-stress ACTH levels were significantly elevated in HFD TBI compared with Chow TBI. Further, pre-stress ACTH:corticosterone ratios were elevated in HFD TBI compared with Chow TBI. cFos immunoreactivity in the paraventricular nucleus (PVN) of the hypothalamus following the acute restraint stress test was elevated in HFD-fed TBI rats. HFD TBI rats had greater activation of cFos in the PVN compared with Chow TBI. In addition, RT-PCR showed significantly reduced expression of relevant HPA axis genes, NR3C1, NR3C2, and CRHR2, in the hypothalamus of TBI subjects compared with Sham subjects. Further, AVP and CRHR2 in the hypothalamus were significantly reduced in HFD TBI compared with Chow TBI. These results offer evidence that TBI paired with high-fat diet consumption can cause HPA axis dysfunction, resulting in more anxiety-like behaviors.

Association between pediatric TBI and mental health and substance use disorders: A scoping review

BACKGROUND

The relationship between pediatric Traumatic Brain Injury (TBI) and long-term mental health and substance use disorders is not well known, resulting in inadequate prevention and management strategies. The aim of this scoping review is to review the evidence on pediatric TBI and the development of mental health disorders and substance use later in life and to identify gaps in the literature to inform future research.

METHODS

We searched multiple databases for original articles published between September 2002 and September 2022 on TBI-related mental health and/or substance use disorders in children and youth. Two independent reviewers performed the screening using Arksey and O'Malley and Levac et al.'s scoping review framework.

RESULTS

A total of six papers are included in this scoping review. Studies included are comprised of cross-sectional and prospective longitudinal cohort studies.

DISCUSSION

A correlation between pediatric TBI and development of certain mental health disorders and substance use is suggested, although much of the current evidence is mixed and does not account for confounding variables. Future studies should aim to closely examine these links and identify modifiers that can influence these relationships.

Association between mild traumatic brain injury, brain structure, and mental health outcomes in the Adolescent Brain Cognitive Development Study

BACKGROUND

Children that experience a mild traumatic brain injury (mTBI) are at an increased risk of neural alterations that can deteriorate mental health. We test the hypothesis that mTBI is associated with psychopathology and that structural brain metrics (e.g., volume, area) meaningfully mediate the relation in an adolescent population.

METHODS

We analyzed behavioral and brain MRI data from 11,876 children who participated in the Adolescent Brain Cognitive Development (ABCD) Study. Mixed-effects models were used to examine the longitudinal association between mTBI and mental health outcomes. Bayesian methods were used to investigate brain regions that are intermediate between mTBI and symptoms of poor mental health.

RESULTS

There were 199 children with mTBI and 527 with possible mTBI across the three ABCD Study visits. There was a 7% (IRR = 1.07, 95% CI: 1.01, 1.13) and 15% (IRR = 1.16, 95% CI: 1.05, 1.26) increased risk of emotional or behavioral problems in children that experienced possible mTBI or mTBI, respectively. Possible mTBI was associated with a 17% (IRR: 1.17, 95% CI: 0.99, 1.40) increased risk of experiencing distress following a psychotic-like experience. We did not find any brain regions that meaningfully mediated the relationship between mTBI and mental health outcomes. Analysis of volumetric measures found that approximately 2% to 5% of the total effect of mTBI on mental health outcomes operated through total cortical volume. Image intensity measure analyses determined that approximately 2% to 5% of the total effect was mediated through the left-hemisphere of the dorsolateral prefrontal cortex.

CONCLUSION

Results indicate an increased risk of emotional and behavioral problems in children that experienced possible mTBI or mTBI. Mediation analyses did not elucidate the mechanisms underlying the association between mTBI and mental health outcomes.

The process of identity change following ABI from the perspectives of adolescents and their mothers: A relational grounded theory approach

This study explored the process of identity adjustment following adolescent brain injury, within the systemic context of the parent-adolescent dyad. Six young people with an ABI (mean age 16.5 years, range 15-18 years; TBI: n = 3) were individually interviewed, and six respective mothers (mean age 45 years, range 37-50 years). A novel relational qualitative grounded theory approach was used, with analyses of dyads linked in an attempt to capture the shared process of adaptation post-injury for young people and their parents. Shared themes emerged for adolescents and mothers regarding "continuity and change" and "acknowledging or rejecting" experiences of change post injury. Adolescents experienced change as an, at times, distressing sense of being "not normal". While mothers turned towards their child, working hard to try to "fix everything", adolescents sought continuity of identity in the context of peer relationships, withdrawing socially to avoid feeling abnormal, reframing or finding new relationships. Some mothers sought to fill social losses through family or disability-specific activity. This study provides a relational understanding of the process of identity adjustment post adolescent BI. Future research and clinical practice should recognize the significant work of mothers, and significance of social relationships to adolescents' emerging post-injury identity.

Traumatic Brain Injury Characteristics Predictive of Subsequent Sleep-Wake Disturbances in Pediatric Patients

Simple Summary

Traumatic brain injury is a leading cause of death and disabilities in children and adolescents. Poor sleep after brain injury can slow recovery and worsen outcomes. We investigated clinical sleep problems following pediatric brain injury. We examined characteristics of the injury and details about the patients that may be risk factors for developing sleep problems. The number of patients that developed problems with their sleep after a brain injury was similar between genders. The probability of insomnia increased with increasing patient age. The probability of ‘difficulty sleeping’ was highest in 7–9 year-old brain-injured patients. Older patients had a shorter time between brain injury and sleep problems compared to younger patients. Patients with severe brain injury had the shortest time between brain injury and development of sleep problems, whereas patients with mild or moderate brain injury had comparable times between brain injury and the onset of poor sleep. Multiple characteristics of brain injury and patient details were identified as risk factors for developing sleep problems following a brain injury in children. Untreated sleep problems after a brain injury can worsen symptoms, lengthen hospital stays, and delay return to school. Identifying risk factors could improve the diagnosis, management, and treatment of sleep problems in survivors of pediatric brain injury.

Abstract

The objective of this study was to determine the prevalence of sleep-wake disturbances (SWD) following pediatric traumatic brain injury (TBI), and to examine characteristics of TBI and patient demographics that might be predictive of subsequent SWD development. This single-institution retrospective study included patients diagnosed with a TBI during 2008–2019 who also had a subsequent diagnosis of an SWD. Data were collected using ICD-9/10 codes for 207 patients and included the following: age at initial TBI, gender, TBI severity, number of TBIs diagnosed prior to SWD diagnosis, type of SWD, and time from initial TBI to SWD diagnosis. Multinomial logit and negative-binomial models were fit to investigate whether the multiple types of SWD and the time to onset of SWD following TBI could be predicted by patient variables. Distributions of SWD diagnosed after TBI were similar between genders. The probability of insomnia increased with increasing patient age. The probability of ‘difficulty sleeping’ was highest in 7–9 year-old TBI patients. Older TBI patients had shorter time to SWD onset than younger patients. Patients with severe TBI had the shortest time to SWD onset, whereas patients with mild or moderate TBI had comparable times to SWD onset. Multiple TBI characteristics and patient demographics were predictive of a subsequent SWD diagnosis in the pediatric population. This is an important step toward increasing education among providers, parents, and patients about the risk of developing SWD following TBI.

Examining the role of neuropsychology in community-based pediatric mental health care

Numerous investigations have demonstrated a link between neuropsychological functioning and mental health. Children with a history of neurological compromise are more vulnerable to mental illness and there is a growing literature indicating that neurocognitive functioning predicts psychosocial outcomes in adulthood. However, not much is known about how neuropsychological information is utilized in community-based mental health care. Thus, we examined what neuropsychological information is available to pediatric centers and how neuropsychological functioning relates to treatment outcomes in these settings. Two content analyses were conducted to identify mental health indicators across different intake sources and these results were compared to a structured intake. Further, a series of standardized neurocognitive and neuroemotional measures were completed and these indices were correlated with treatment outcomes. Qualitative results confirmed that neuropsychological factors are often overlooked when utilizing current approaches and that observable symptoms are a primary focus of treatment. Additionally, neurocognitive deficits were associated with self-reported interpersonal difficulties and caregivers' reports of externalizing; however, only caregiver-reported externalizing challenges correlated with treatment outcomes. Importantly, neurocognitive challenges were associated with long-term treatment responses, suggesting that these factors may be an important therapeutic target. Collectively, these findings indicate a need to incorporate neuropsychological factors in pediatric mental health treatment.

Pediatric traumatic brain injury and a subsequent transient immune challenge independently influenced chronic outcomes in male mice

Traumatic brain injury (TBI) is a major contributor to death and disability worldwide. Children are at particularly high risk of both sustaining a TBI and experiencing serious long-term consequences, such as cognitive deficits, mental health problems and post-traumatic epilepsy. Severe TBI patients are highly susceptible to nosocomial infections, which are mostly acquired within the first week of hospitalization post-TBI. Yet the potential chronic impact of such acute infections following pediatric TBI remains unclear. In this study, we hypothesized that a peripheral immune challenge, such as lipopolysaccharide (LPS)-mimicking a hospital-acquired infection-would worsen inflammatory, neurobehavioral, and seizure outcomes after experimental pediatric TBI. To test this, three-week old male C57Bl/6J mice received a moderate controlled cortical impact or sham surgery, followed by 1 mg/kg i.p. LPS (or 0.9% saline vehicle) at 4 days TBI. Mice were randomized to four groups; sham-saline, sham-LPS, TBI-saline or TBI-LPS (n = 15/group). Reduced general activity and increased anxiety-like behavior were observed within 24 h in LPS-treated mice, indicating a transient sickness response. LPS-treated mice also exhibited a reduction in body weights, which persisted chronically. From 2 months post-injury, mice underwent a battery of tests for sensorimotor, cognitive, and psychosocial behaviors. TBI resulted in hyperactivity and spatial memory deficits, independent of LPS; whereas LPS resulted in subtle deficits in spatial memory retention. At 5 months post-injury, video-electroencephalographic recordings were obtained to evaluate both spontaneous seizure activity as well as the evoked seizure response to pentylenetetrazol (PTZ). TBI increased susceptibility to PTZ-evoked seizures; whereas LPS appeared to increase the incidence of spontaneous seizures. Post-mortem analyses found that TBI, but not LPS, resulted in robust glial reactivity and loss of cortical volume. A TBI × LPS interaction in hippocampal volume suggested that TBI-LPS mice had a subtle increase in ipsilateral hippocampus tissue loss; however, this was not reflected in neuronal cell counts. Both TBI and LPS independently had modest effects on chronic hippocampal gene expression. Together, contrary to our hypothesis, we observed minimal synergy between TBI and LPS. Instead, pediatric TBI and a subsequent transient immune challenge independently influenced chronic outcomes. These findings have implications for future preclinical modeling as well as acute post-injury patient management.

Adverse childhood experiences and traumatic brain injury among adolescents: findings from the 2016-2018 National Survey of Children's Health

Exposure to adverse childhood experiences (ACEs) is a significant public health issue for youth. However, traumatic brain injury (TBI) has been almost entirely overlooked in the ACEs and health outcomes literature, which has largely focused on the significant mental and behavioral health impact of ACEs. The goal the current study is to examine the association between ACEs and TBI among a nationally representative sample of adolescents in the United States and the extent to which ADHD and conduct problems inform this association. To assess this relationship, we use a sample of 42,204 adolescents (ages 12-17 years) in the United States whose caregivers were surveyed during the three most recent cohorts (2016-2018) of the National Survey of Children's Health (NSCH). The results revealed a dose-response relationship between ACEs and TBI, even after accounting for an array of confounding variables. Findings also indicated that associations were of a greater magnitude among youth who are not sports-involved. Supplemental mediation analyses showed that ADHD and conduct problems attenuated associations between ACE exposure and TBI, but only in the absence of youth sports involvement. Given that both ACEs and TBI carry long-term consequences for health and well-being, the findings from this study draw attention to the need for early intervention and prevention programming (e.g. home visiting) that can reduce the prevalence of ACEs and a history of TBI among adolescents.

Brain-Derived Neurotrophic Factor Val66Met and Behavioral Adjustment after Early Childhood Traumatic Brain Injury

The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on behavioral adjustment in children with traumatic brain injury (TBI) relative to children with orthopedic injury (OI). Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Parents completed the Child Behavior Checklist (CBCL) at the immediate post-acute period, 6, 12, and 18 months after injury, and an average of 3.5 and 7 years after injury. Longitudinal mixed models examined the BDNF Val66Met allele status (Met carriers vs. Val/Val homozygotes) × injury group (TBI vs. OI) interaction in association with behavioral adjustment. After adjusting for continental ancestry, socioeconomic status, time post-injury, and pre-injury functioning, the allele status × injury group interaction was statistically significant for Internalizing, Externalizing, and Total Behavior problems. Post hoc within-group analysis suggested a consistent trend of poorer behavioral adjustment in Met carriers relative to Val/Val homozygotes in the TBI group; in contrast, the opposite trend was observed in the OI group. These within-group differences, however, did not reach statistical significance. The results support a differential effect of the BDNF Val66Met polymorphism on behavioral adjustment in children with early TBI relative to OI, and suggest that the Met allele associated with reduced activity-dependent secretion of BDNF may impart risk for poorer long-term behavioral adjustment in children with TBI.

Effective connectivity in the default mode network after paediatric traumatic brain injury

Children who experience a traumatic brain injury (TBI) are at elevated risk for a range of negative cognitive and neuropsychological outcomes. Identifying which children are at greatest risk for negative outcomes can be difficult due to the heterogeneity of TBI. To address this barrier, the current study applied a novel method of characterizing brain connectivity networks, Bayesian multi-subject vector autoregressive modelling (BVAR-connect), which used white matter integrity as priors to evaluate effective connectivity-the time-dependent relationship in functional magnetic resonance imaging (fMRI) activity between two brain regions-within the default mode network (DMN). In a prospective longitudinal study, children ages 8-15 years with mild to severe TBI underwent diffusion tensor imaging and resting state fMRI 7 weeks after injury; post-concussion and anxiety symptoms were assessed 7 months after injury. The goals of this study were to (1) characterize differences in positive effective connectivity of resting-state DMN circuitry between healthy controls and children with TBI, (2) determine if severity of TBI was associated with differences in DMN connectivity and (3) evaluate whether patterns of DMN effective connectivity predicted persistent post-concussion symptoms and anxiety. Healthy controls had unique positive connectivity that mostly emerged from the inferior temporal lobes. In contrast, children with TBI had unique effective connectivity among orbitofrontal and parietal regions. These positive orbitofrontal-parietal DMN effective connectivity patterns also differed by TBI severity and were associated with persisting behavioural outcomes. Effective connectivity may be a sensitive neuroimaging marker of TBI severity as well as a predictor of chronic post-concussion symptoms and anxiety.

A Systematic Scoping Review of New Attention Problems Following Traumatic Brain Injury in Children

Objective: To summarize existing knowledge about the characteristics of attention problems secondary to traumatic brain injuries (TBI) of all severities in children.

Methods: Computerized databases PubMed and PsychINFO and gray literature sources were used to identify relevant studies. Search terms were selected to identify original research examining new ADHD diagnosis or attention problems after TBI in children. Studies were included if they investigated any severity of TBI, assessed attention or ADHD after brain injury, investigated children as a primary or sub-analysis, and controlled for or excluded participants with preinjury ADHD or attention problems.

Results: Thirty-nine studies were included in the review. Studies examined the prevalence of and risk factors for new attention problems and ADHD following TBI in children as well as behavioral and neuropsychological factors associated with these attention problems. Studies report a wide range of prevalence rates of new ADHD diagnosis or attention problems after TBI. Evidence indicates that more severe injury, injury in early childhood, or preinjury adaptive functioning problems, increases the risk for new ADHD and attention problems after TBI and both sexes appear to be equally vulnerable. Further, literature suggests that cases of new ADHD often co-occurs with neuropsychiatric impairment in other domains. Identified gaps in our understanding of new attention problems and ADHD include if mild TBI, the most common type of injury, increases risk and what brain abnormalities are associated with the emergence of these problems.

Conclusion: This scoping review describes existing studies of new attention problems and ADHD following TBI in children and highlights important risk factors and comorbidities. Important future research directions are identified that will inform the extent of this outcome across TBI severities, its neural basis and points of intervention to minimize its impact.

Association of Attention-Deficit/Hyperactivity Disorder Diagnoses With Pediatric Traumatic Brain Injury: A Meta-analysis

IMPORTANCE

There are conflicting accounts about the risk for attention-deficit/hyperactivity disorder (ADHD) following traumatic brain injury (TBI), possibly owing to variations between studies in acute TBI severity or when ADHD was assessed postinjury. Analysis of these variations may aid in identifying the risk.

OBJECTIVE

To conduct a meta-analysis of studies assessing ADHD diagnoses in children between ages 4 and 18 years following concussions and mild, moderate, or severe TBI.

DATA SOURCES

PubMed, PsycInfo, and Cochrane Central Register of Controlled Trials (1981-December 19, 2019) were searched including the terms traumatic brain injury, brain injuries, closed head injury, blunt head trauma, concussion, attention deficit disorders, ADHD, and ADD in combination with childhood, adolescence, pediatric, infant, child, young adult, or teen.

STUDY SELECTION

Limited to English-language publications in peer-reviewed journals and patient age (4-18 years). Differences about inclusion were resolved through consensus of 3 authors.

DATA EXTRACTION AND SYNTHESIS

MOOSE guidelines for abstracting and assessing data quality and validity were used. Odds ratios with 95% credible intervals (CrIs) are reported.

MAIN OUTCOMES AND MEASURES

The planned study outcome was rate of ADHD diagnoses.

RESULTS

A total of 12 374 unique patients with TBI of all severity levels and 43 491 unique controls were included in the 24 studies in this review (predominantly male: TBI, 61.8%; noninjury control, 60.9%; other injury control, 66.1%). The rate of pre-TBI ADHD diagnoses was 16.0% (95% CrI, 11.3%-21.7%), which was significantly greater than the 10.8% (95% CrI, 10.2%-11.4%) incidence of ADHD in the general pediatric population. Compared with children without injuries, the odds for ADHD were not significantly increased following concussion (≤1 year: OR, 0.32; 95% CrI, 0.05-1.13), mild TBI (≤1 year: OR, 0.56; 0.16-1.43; >1 year: OR, 1.07; 95% CrI, 0.35-2.48), and moderate TBI (≤1 year: OR, 1.28; 95% CrI, 0.35-3.34; >1 year: OR, 3.67; 95% CrI, 0.83-10.56). The odds for ADHD also were not significantly increased compared with children with other injuries following mild TBI (≤1 year: OR, 1.07; 95% CrI, 0.33-2.47; >1 year: OR, 1.18; 95% CrI, 0.32-3.12) and moderate TBI (≤1 year: OR, 2.34; 95% CrI, 0.78-5.47; >1 year: OR, 3.78; 95% CrI, 0.93-10.33). In contrast, the odds for ADHD following severe TBI were increased at both time points following TBI compared with children with other injuries (≤1 year: OR, 4.81; 95% CrI, 1.66-11.03; >1 year: OR, 6.70; 95% CrI, 2.02-16.82) and noninjured controls (≤1 year: OR, 2.62; 95% CrI, 0.76-6.64; >1 year: OR, 6.25; 95% CrI, 2.06-15.06), as well as those with mild TBI (≤1 year OR, 5.69; 1.46-15.67: >1 year OR, 6.65; 2.14-16.44). Of 5920 children with severe TBI, 35.5% (95% CrI, 20.6%-53.2%) had ADHD more than 1 year postinjury.

CONCLUSIONS AND RELEVANCE

This study noted a significant association between TBI severity and ADHD diagnosis. In children with severe but not mild and moderate TBI, there was an association with an increase in risk for ADHD. The high rate of preinjury ADHD in children with TBI suggests that clinicians should carefully review functioning before a TBI before initiating treatment.

Behavior Problems Following Childhood TBI: The Role of Sex, Age, and Time Since Injury

OBJECTIVE

To examine the frequency of behavioral problems after childhood traumatic brain injury (TBI) and their associations with injury severity, sex, and social environmental factors.

SETTING

Children's hospitals in the Midwestern/Western United States.

PARTICIPANTS

381 boys and 210 girls with moderate (n = 359) and severe (n = 227) TBI, with an average age at injury of 11.7 years (range 0.3-18) who were injured ≤3 years ago.

DESIGN

Secondary data analysis of a multistudy cohort.

MAIN MEASURES

Child Behavior Checklist (CBCL) administered pretreatment.

RESULTS

Thirty-seven percent had borderline/clinical elevations on the CBCL Total Problem Scale, with comparable rates of Internalizing and Externalizing problems (33% and 31%, respectively). Less parental education was associated with higher rates of internalizing, externalizing, and total problems. Time since injury had a linear association with internalizing symptoms, with greater symptoms at longer postinjury intervals. Younger boys had significantly higher levels of oppositional defiant symptoms than girls, whereas older girls had significantly greater attention-deficit hyperactivity disorder symptoms than boys.

CONCLUSIONS

Pediatric TBI is associated with high rates of behavior problems, with lower socioeconomic status predicting substantially elevated risk. Associations of higher levels of internalizing symptoms with greater time since injury highlight the importance of tracking children over time.

From Early Childhood to Adolescence: Lessons About Traumatic Brain Injury From the Ohio Head Injury Outcomes Study

OBJECTIVE

The Ohio Head Injury Outcomes study was a 12-year longitudinal study of early childhood traumatic brain injury (TBI). This article reviewed the findings pertaining to caregiver and family functioning and child cognition, behavior, social competence, emotional functioning, and academics. We further considered individual and social-environmental influences on recovery and interventions.

SETTING

Recruitment was completed at 3 children's hospitals and 1 general hospital.

PARTICIPANTS

Children aged 3 to 7 years at the time of injury with complicated mild to moderate and severe TBI or orthopedic injury requiring hospitalization were included.

DESIGN

A concurrent cohort/prospective research design was used. A baseline assessment was completed shortly after the injury. Follow-up assessments were completed at 6, 12, and 18 months and at an average of 38 and 82 months postinjury.

MAIN MEASURES

At baseline, parents/guardians completed retrospective ratings of their child's behavioral, emotional, and social functioning preinjury. At the subsequent assessments, ratings reflected current functioning. Information about current family and caregiver functioning was collected at each time point and cognitive testing was completed at selected time points.

RESULTS AND CONCLUSIONS

Recovery after TBI is complex, varies over time, and involves injury-related and premorbid influences, cognition, genetics, and caregiver and family functioning. A sizable number of children with TBI have persisting unmet clinical needs.

Impact of Secondary ADHD on Long-Term Outcomes After Early Childhood Traumatic Brain Injury

OBJECTIVE

To examine the impact of secondary attention-deficit/hyperactivity disorder (SADHD) on long-term global and executive functioning in adolescents after traumatic brain injury (TBI).

SETTING

Three tertiary cared children's hospitals and 1 general hospital.

PARTICIPANTS

One hundred twenty children (TBI: n = 54; orthopedic injury: n = 66) without preinjury ADHD evaluated approximately 6.8 years postinjury.

DESIGN

Cross-sectional data analysis from a prospective, longitudinal study.

MAIN MEASURES

Outcomes included functional impairment (Child and Adolescent Functional Assessment Scale) and executive functioning (Behavior Rating Inventory of Executive Function [BRIEF]).

RESULTS

SADHD moderated the association of injury type with the BRIEF-Behavioral Regulation Index (F1,113 = 4.42, P = .04) and the Child and Adolescent Functional Assessment Scale (F1,112 = 8.95, P = .003). TBI was only associated with poorer outcomes in the context of SADHD. SADHD was also associated with poorer outcomes on the BRIEF-Global Executive Composite (F1,113 = 52.92, P < .0001) and BRIEF-Metacognitive Index scores (F1,113 = 48.64, P < .0001) across groups. Adolescents with TBI had greater BRIEF-Global Executive Composite scores than those with orthopedic injury (F1,113 = 5.00, P = .03).

CONCLUSIONS

Although SADHD was associated with poorer functioning across groups, its adverse effects on behavioral regulation and overall functioning were amplified following TBI. TBI + SADHD may confer an elevated risk for significant impairments in early adolescence.

As Time Goes by: Understanding Child and Family Factors Shaping Behavioral Outcomes After Traumatic Brain Injury

Objective: To model pre-injury child and family factors associated with the trajectory of internalizing and externalizing behavior problems across the first 3 years in children with pediatric traumatic brain injury (TBI) relative to children with orthopedic injuries (OI). Parent-reported emotional symptoms and conduct problems were expected to have unique and shared predictors. We hypothesized that TBI, female sex, greater pre-injury executive dysfunction, adjustment problems, lower income, and family dysfunction would be associated with less favorable outcomes. Methods: In a prospective longitudinal cohort study, we examined the level of behavior problems at 12 months after injury and rate of change from pre-injury to 12 months and from 12 to 36 months in children ages 4-15 years with mild to severe TBI relative to children with OI. A structural equation model framework incorporated injury characteristics, child demographic variables, as well as pre-injury child reserve and family attributes. Internalizing and externalizing behavior problems were indexed using the parent-rated Emotional Symptoms and Conduct Problems scales from the Strengths and Difficulties questionnaire. Results: The analysis cohort of 534 children [64% boys, M (SD) 8.8 (4.3) years of age] included 395 with mild to severe TBI and 139 with OI. Behavior ratings were higher after TBI than OI but did not differ by TBI severity. TBI, higher pre-injury executive dysfunction, and lower income predicted the level and trajectory of both Emotional Symptoms and Conduct Problems at 12 months. Female sex and poorer family functioning were vulnerability factors associated with greater increase and change in Emotional Symptoms by 12 months after injury; unique predictors of Conduct Problems included younger age and prior emotional/behavioral problems. Across the long-term follow-up from 12 to 36 months, Emotional Symptoms increased significantly and Conduct Problems stabilized. TBI was not a significant predictor of change during the chronic stage of recovery. Conclusions: After TBI, Emotional Symptoms and Conduct Problem scores were elevated, had different trajectories of change, increased or stayed elevated from 12 to 36 months after TBI, and did not return to pre-injury levels across the 3 year follow-up. These findings highlight the importance of addressing behavioral problems after TBI across an extended time frame.

Mental health after paediatric concussion: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis sought to rigorously examine mental health outcomes following paediatric concussion. To date, heterogeneous findings and methodologies have limited clinicians' and researchers' ability to meaningfully synthesise existing literature. In this context, there is a need to clarify mental health outcomes in a homogeneous sample, controlling for key methodological differences and applying a consistent definition of concussion across studies.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched Medline, Embase, PsycINFO, CINAHL, SportDiscus, Scopus and PubMed.

ELIGIBILITY

Peer-reviewed studies published between 1980 and June 2020 that prospectively examined mental health outcomes after paediatric concussion, defined as per the Berlin Consensus Statement on Concussion in Sport.

RESULTS

Sixty-nine articles characterising 60 unique samples met inclusion criteria, representing 89 114 children with concussion. Forty articles (33 studies) contributed to a random effects meta-analysis of internalising (withdrawal, anxiety, depression, post-traumatic stress), externalising (conduct problems, aggression, attention, hyperactivity) and total mental health difficulties across three time points post-injury (acute, persisting and chronic). Overall, children with concussion (n=6819) experienced significantly higher levels of internalising (g=0.41-0.46), externalising (g=0.25-0.46) and overall mental health difficulties compared with controls (g=0.18-0.49; n=56 271), with effects decreasing over time.

SUMMARY/CONCLUSIONS

Our review highlights that mental health is central to concussion recovery. Assessment, prevention and intervention of mental health status should be integrated into standard follow-up procedures. Further research is needed to clarify the mechanisms underlying observed relationships between mental health, post-concussion symptoms and other psychosocial factors. Results suggest that concussion may both precipitate and exacerbate mental health difficulties, thus impacting delayed recovery and psychosocial outcomes.

Longitudinal Growth Curve Trajectories of Family Dynamics after Pediatric Traumatic Brain Injury in Mexico

Pediatric traumatic brain injury (TBI) represents a serious public health concern. Family members are often caregivers for children with TBI, which can result in a significant strain on familial relationships. Research is needed to examine aspects of family functioning in the context of recovery post-TBI, especially in Latin America, where cultural norms may reinforce caregiving by family members, but where resources for these caregivers may be scarce. This study examined caregiver-reported family satisfaction, communication, cohesion, and flexibility at three time points in the year post-injury for 46 families of a child with TBI in comparison to healthy control families. Families experiencing pediatric TBI were recruited from a large hospital in Guadalajara, Mexico, while healthy controls were recruited from a local educational center. Results from multilevel growth curve models demonstrated that caregivers of children with a TBI reported significantly worse family functioning than controls at each assessment. Families experiencing pediatric TBI were unable to attain the level of functioning of controls during the time span studied, suggesting that these families are likely to experience long-term disruptions in family functioning. The current study highlights the need for family-level intervention programs to target functioning for families affected by pediatric TBI who are at risk for difficulties within a rehabilitation context.

Effects of Web-Based Parent Training on Caregiver Functioning Following Pediatric Traumatic Brain Injury: A Randomized Control Trial

OBJECTIVE

To examine the effects of a Web-based parenting intervention (I-InTERACT), and an abbreviated version (Express), on caregiver depression, psychological distress, parenting stress, and parenting efficacy following pediatric traumatic brain injury (TBI).

SETTING

Four children's hospitals and 1 general hospital in the United States.

PARTICIPANTS

148 caregivers of 113 children aged 3 to 9 years with a moderate to severe TBI.

DESIGN

Multicenter randomized controlled trial. Participants were randomly assigned to I-InTERACT, Express, or an active control condition. Caregiver data were collected at baseline and postintervention (6 months later).

INTERVENTION

I-InTERACT (10-14 sessions) and Express (7 sessions) combine live coaching of parenting skills and positive parenting strategies.

MAIN MEASURES

Center for Epidemiologic Studies Depression Scale (CES-D); Global Severity Index of the Symptom Checklist-90-R (GSI), Parenting Stress Index (PSI), and Caregiver Self-Efficacy Scale (CSES).

RESULTS

Analyses revealed no main effects of treatment on caregiver distress (GSI), parenting stress (PSI), or parenting efficacy (CSES). However, analyses examining baseline severity as a moderator found that caregivers with elevated levels of depression in I-InTERACT experienced significantly greater reductions in CES-D scores compared with caregivers in the active control condition.

CONCLUSIONS

I-InTERACT reduced caregiver depression but no other facets of caregiver psychological functioning. Modifications to the treatment content may be necessary to reduce parenting stress and improve caregiver efficacy.

Lifelong consequences of brain injuries during development: From risk to resilience

Traumatic brain injuries in children represent a major public health issue and even relatively mild injuries can have lifelong consequences. However, the outcomes from these injuries are highly heterogeneous, with most individuals recovering fully, but a substantial subset experiencing prolonged or permanent disabilities across a number of domains. Moreover, brain injuries predispose individuals to other kinds of neuropsychiatric and somatic illnesses. Critically, the severity of the injury only partially predicts subsequent outcomes, thus other factors must be involved. In this review, we discuss the psychological, social, neuroendocrine, and autonomic processes that are disrupted following traumatic brain injury during development, and consider the mechanisms the mediate risk or resilience after traumatic brain injury in this vulnerable population.

The 100 most cited papers about pediatric traumatic brain injury: a bibliometric analysis

BACKGROUND

The high incidence of traumatic brain injury (TBI) in children, combined with the challenges in diagnosis and treatment options, the difficulty of predicting the outcome of each case, and also the wide variety of possibly lifelong complications, has led to an extraordinary number of published papers regarding this topic. This bibliometric analysis is aimed at identifying and reviewing the 100 most cited papers in the most challenging and trending aspects of pediatric traumatic brain injury.

METHODS

A search was performed using the Web of Science database in October 2018. Results were organized by citation number, and the 100 most cited papers were further reviewed and analyzed.

RESULTS

Our search resulted in 2754 published papers from 1975 until October 2018, of which 1783 (64.74%) had been published in the last decade (2010-2018). The 100 most cited papers about traumatic brain injury in children have an average citation of 140.59 and have been published in 44 different journals. Four hundred thirty-five authors have contributed to these prominent articles, most of them from the USA.

CONCLUSIONS

By reviewing those highly cited papers, we sought to offer significant help not only for studying this challenging field but also for designing new studies.

Influence of Methylphenidate on Long-Term Neuropsychological and Everyday Executive Functioning After Traumatic Brain Injury in Children with Secondary Attention Problems

OBJECTIVE

To investigate the effects of methylphenidate on long-term executive and neuropsychological functioning in children with attention problems following TBI, as well as the relationship between methylphenidate associated changes in lab-based neuropsychological measures of attentional control, processing speed, and executive functioning and parent- or self-report measures of everyday executive functioning.

METHOD

26 children aged 6-17 years, who were hospitalized for moderate-to-severe blunt head trauma 6 or more months previously, were recruited from a large children's hospital medical center. Participants were randomized into a double-masked, placebo-controlled cross-over clinical trial. Participants completed a comprehensive neuropsychological battery and parent- and self-report ratings of everyday executive functioning at baseline, and at 4 weeks and 8 weeks following upward titration of medication to an optimal dose or while administered a placebo.

RESULTS

Methylphenidate was associated with significant improvements in processing speed, sustained attention, and both lab-based and everyday executive functioning. Significant treatment-by-period interactions were found on a task of sustained attention. Participants who were randomized to the methylphenidate condition for the first treatment period demonstrated random or erratic responding, with slower and more variable response times when given placebo during the second period.

CONCLUSION

Results indicate that methylphenidate treatment is associated with positive outcomes in processing speed, sustained attention, and both lab-based and everyday measures of executive functioning compared to placebo group. Additionally, results suggest sustained attention worsens when discontinuing medication. (JINS, 2019, 25, 740-749).

Online Family Problem Solving for Pediatric Traumatic Brain Injury: Influences of Parental Marital Status and Participation on Adolescent Outcomes

OBJECTIVE

To examine the moderating effects of parent marital status and participation on efficacy of an online family problem-solving intervention for pediatric traumatic brain injury (TBI).

METHODS

Participants were 132 adolescents (12-17 years) who had sustained a recent (<6 months) TBI and their parents. Participants were randomly assigned to the intervention (Counselor-Assisted Problem Solving, CAPS) or an Internet resource comparison (IRC) condition. CAPS was designed to support families in the initial phase following TBI, by teaching problem-solving skills and addressing common challenges. To examine the moderating effect of parent marital status, participants were divided into 4 groups (ie, CAPS married household, CAPS unmarried household, IRC married household, and IRC unmarried household). Family income and caregiver education were controlled in analyses.

RESULTS

Parent marital status moderated treatment effects on adolescent externalizing behavior problems. Adolescents from married households in CAPS displayed fewer behavior problems at 6 and 18 months postbaseline compared with adolescents from unmarried households in CAPS. Among married CAPS families, there were no differences in outcomes among families where 1 or 2 parents actively participated.

CONCLUSIONS

Web-based interventions for pediatric TBI, such as CAPS, are a viable option for some although not all families. Further research is needed to investigate factors that influence efficacy to match families to the most beneficial treatments.

Randomized Controlled Trial of an Online Problem-Solving Intervention Following Adolescent Traumatic Brain Injury: Family Outcomes

OBJECTIVE

To examine parent and family outcomes of a randomized controlled trial (RCT) comparing Teen Online Problem-Solving with Family (TOPS-F), Teen Online Problem-Solving-Teen Only (TOPS-TO), or access to Internet resources alone (Internet resource comparison [IRC]).

DESIGN

Three-arm RCT.

SETTING

Four children's hospitals and 1 general medical center in Ohio and Colorado.

PARTICIPANTS

Children and adolescents (N=152), 11-18 years old, hospitalized for complicated mild to severe traumatic brain injury in the previous 18 months.

INTERVENTIONS

Intervention groups: TOPS-F, TOPS-TO, and IRC.

MAIN OUTCOME MEASURE

Parental depression (CES-D), parental psychological distress (SCL-90-GSI), family functioning (FAD-GF), cohesiveness (PARQ), and conflict (IBQ) were assessed pre- and post-treatment. Treatment effects and the moderating effect of the number of parents in the home (single vs 2-parent families).

RESULTS

Number of parents moderated treatment effects with effects ranging from trending to statistically significant for depression, family functioning, cohesion, and conflict. Among single parents, TOPS-TO reported better family functioning than TOPS-F and greater cohesion and less conflict than IRC. Among 2-parent families, TOPS-F reported less depression than IRC and less depression and greater cohesion than TOPS-TO. The effect of family composition was also noted within TOPS-TO and TOPS-F. In TOPS-F, 2-parent families reported less depression than single-parent families. In TOPS-TO single parents reported greater cohesion and better family functioning than 2-parent families.

CONCLUSIONS

Findings support the TOPS intervention improves family outcomes, with differential effects noted for single vs 2-parent households. The TOPS-TO format appeared more beneficial for single-parent households, while TOPS-F was more beneficial for 2-parent households, highlighting the importance of considering family composition when determining the best treatment modality.

Polygenic Risk and Neural Substrates of Attention-Deficit/Hyperactivity Disorder Symptoms in Youths With a History of Mild Traumatic Brain Injury

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a major sequela of traumatic brain injury (TBI) in youths. The objective of this study was to examine whether ADHD symptoms are differentially associated with genetic risk and brain structure in youths with and without a history of TBI.

METHODS

Medical history, ADHD symptoms, genetic data, and neuroimaging data were obtained from a community sample of youths. ADHD symptom severity was compared between those with and without TBI (TBI n = 418, no TBI n = 3193). The relationship of TBI history, genetic vulnerability, brain structure, and ADHD symptoms was examined by assessing 1) ADHD polygenic score (discovery sample ADHD n = 19,099, control sample n = 34,194), 2) basal ganglia volumes, and 3) fractional anisotropy in the corpus callosum and corona radiata.

RESULTS

Youths with TBI reported greater ADHD symptom severity compared with those without TBI. Polygenic score was positively associated with ADHD symptoms in youths without TBI but not in youths with TBI. The negative association between the caudate volume and ADHD symptoms was not moderated by a history of TBI. However, the relationship between ADHD symptoms and structure of the genu of the corpus callosum was negative in youths with TBI and positive in youths without TBI.

CONCLUSIONS

The identification of distinct ADHD etiology in youths with TBI provides neurobiological insight into the clinical heterogeneity in the disorder. Results indicate that genetic predisposition to ADHD does not increase the risk for ADHD symptoms associated with TBI. ADHD symptoms associated with TBI may be a result of a mechanical insult rather than neurodevelopmental factors.

Prevalence of Parent-Reported Traumatic Brain Injury in Children and Associated Health Conditions

IMPORTANCE

Traumatic brain injury (TBI) in children results in a high number of emergency department visits and risk for long-term adverse effects.

OBJECTIVES

To estimate lifetime prevalence of TBI in a nationally representative sample of US children and describe the association between TBI and other childhood health conditions.

DESIGN, SETTING, AND PARTICIPANTS

Data were analyzed from the 2011-2012 National Survey of Children's Health, a cross-sectional telephone survey of US households with a response rate of 23%. Traumatic brain injury prevalence estimates were stratified by sociodemographic characteristics. The likelihood of reporting specific health conditions was compared between children with and without TBI. Age-adjusted prevalence estimates were computed for each state. Associations between TBI prevalence, insurance type, and parent rating of insurance adequacy were examined. Data analysis was conducted from February 1, 2016, through November 1, 2017.

MAIN OUTCOMES AND MEASURES

Lifetime estimate of TBI in children, associated childhood health conditions, and parent report of health insurance type and adequacy.

RESULTS

The lifetime estimate of parent-reported TBI among children was 2.5% (95% CI, 2.3%-2.7%), representing over 1.8 million children nationally. Children with a lifetime history of TBI were more likely to have a variety of health conditions compared with those without a TBI history. Those with the highest prevalence included learning disorders (21.4%; 95% CI, 18.1%-25.2%); attention-deficit/hyperactivity disorder (20.5%; 95% CI, 17.4%-24.0%); speech/language problems (18.6%; 95% CI, 15.8%-21.7%); developmental delay (15.3%; 95% CI, 12.9%-18.1%); bone, joint, or muscle problems (14.2%; 95% CI, 11.6%-17.2%); and anxiety problems (13.2%; 95% CI, 11.0%-16.0%). States with a higher prevalence of childhood TBI were more likely to have a higher proportion of children with private health insurance and higher parent report of adequate insurance. Examples of states with higher prevalence of TBI and higher proportion of private insurance included Maine, Vermont, Pennsylvania, Washington, Montana, Wyoming North Dakota, South Dakota, and Colorado.

CONCLUSIONS AND RELEVANCE

A large number of US children have experienced a TBI during childhood. Higher TBI prevalence in states with greater levels of private insurance and insurance adequacy may suggest an underrecognition of TBI among children with less access to care. For more comprehensive monitoring, health care professionals should be aware of the increased risk of associated health conditions among children with TBI.

Parent and child ratings of child behaviour following mild traumatic brain injury

BACKGROUND

Mild traumatic brain injury (mTBI) in children is most commonly associated with parent-reported child behaviour problems. The extent to which parent and child ratings align is unknown.

OBJECTIVES

To examine differences in child behaviour and patterns of recovery over the first 12 months following mTBI based on parent and child self-report.

METHODS

Ninety-nine children (8-15 years) with mTBI and one of their parents completed the Behavioural Assessment Scale for Children - version 2 to assess child hyperactivity, anxiety and depression at baseline, 1, 6 and 12 months post-injury. Differences between ratings from parents and children were evaluated using Bland-Altman limits of agreement analyses. Child recovery over time was examined using mixed models repeated measures analyses.

RESULTS

Parent and child ratings for child hyperactivity, anxiety and depression differed significantly at baseline and these differences remained constant at each follow-up. Parents tended to report more child hyperactivity, anxiety and depression. Over time, parents and children reported fewer child hyperactivity and anxiety problems.

CONCLUSIONS

Parents and children have poor agreement in ratings of child behaviour yet there is general agreement in patterns of recovery in the year following mTBI. Findings show the importance of considering both parent and self-report of child behaviour.

Neurosensory Deficits Vary as a Function of Point of Care in Pediatric Mild Traumatic Brain Injury

Neurosensory abnormalities are frequently observed following pediatric mild traumatic brain injury (pmTBI) and may underlie the expression of several common concussion symptoms and delay recovery. Importantly, active evaluation of neurosensory functioning more closely approximates real-world (e.g., physical and academic) environments that provoke symptom worsening. The current study determined whether symptom provocation (i.e., during neurosensory examination) improved classification accuracy relative to pre-examination symptom levels and whether symptoms varied as a function of point of care. Eighty-one pmTBI were recruited from the pediatric emergency department (PED; n = 40) or outpatient concussion clinic (n = 41), along with matched (age, sex, and education) healthy controls (HC; n = 40). All participants completed a brief (∼ 12 min) standardized neurosensory examination and clinical questionnaires. The magnitude of symptom provocation upon neurosensory examination was significantly higher for concussion clinic than for PED patients. Symptom provocation significantly improved diagnostic classification accuracy relative to pre-examination symptom levels, although the magnitude of improvement was modest, and was greater in the concussion clinic. In contrast, PED patients exhibited worse performance on measures of balance, vision, and oculomotor functioning than the concussion clinic patients, with no differences observed between both samples and HC. Despite modest sample sizes, current findings suggest that point of care represents a critical but highly under-studied variable that may influence outcomes following pmTBI. Studies that rely on recruitment from a single point of care may not generalize to the entire pmTBI population in terms of how neurosensory deficits affect recovery.

Neuroimaging of the Injured Pediatric Brain: Methods and New Lessons

Traumatic brain injury (TBI) is a significant public health problem in the United States, especially for children and adolescents. Current epidemiological data estimate over 600,000 patients younger than 20 years are treated for TBI in emergency rooms annually. While many patients experience a full recovery, for others there can be long-lasting cognitive, neurological, psychological, and behavioral disruptions. TBI in youth can disrupt ongoing brain development and create added family stress during a formative period. The neuroimaging methods used to assess brain injury improve each year, providing researchers a more detailed characterization of the injury and recovery process. In this review, we cover current imaging methods used to quantify brain disruption post-injury, including structural magnetic resonance imaging (MRI), diffusion MRI, functional MRI, resting state fMRI, and magnetic resonance spectroscopy (MRS), with brief coverage of other methods, including electroencephalography (EEG), single-photon emission computed tomography (SPECT), and positron emission tomography (PET). We include studies focusing on pediatric moderate-severe TBI from 2 months post-injury and beyond. While the morbidity of pediatric TBI is considerable, continuing advances in imaging methods have the potential to identify new treatment targets that can lead to significant improvements in outcome.

Parent-Reported Mild Head Injury History in Children: Long-Term Effects on Attention-Deficit Hyperactivity Disorder

Objective. Consequences of mild head injury for behavioral adjustment have not been well researched, and little is known about the long-term effects of mild head injury for attention-deficit hyperactivity disorder (ADHD). Methods. In this longitudinal study of 418 children in Jintan City, China, parents reported children's history of head injury at age 6 years, and the Child Behavior Checklist was used to measure child iDSM-IV-oriented ADHD at ages 6 (Wave I) and 12 years (Wave II). Regression models were used to calculate the long-term (Wave II) effect of mild head injury on diagnosed ADHD, while controlling for diagnosed ADHD in Wave I. Results. Fifty-seven children (13.6%) had a single injury and 42 (10.0%) had multiple injuries before the age of 6 years. The long-term effect of multiple mild injury on ADHD at age 12 years was significant (R2 = 0.103, P < .05), even after controlling for ADHD at age 6 years. Conclusions. Multiple, but not single, mild head injuries before the age of 6 years had a significant long-term effect on ADHD. Thus, injuries traditionally overlooked and underreported still pose significant risks to children's long-term behavioral development.

Recovery Trajectories of Executive Functioning After Pediatric TBI: A Latent Class Growth Modeling Analysis

OBJECTIVE

To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across recovery trajectories using latent class growth modeling (LCGM).

METHOD

A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups.

RESULTS

Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories.

CONCLUSION

The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries.

Traumatic Brain Injury, Sleep Disorders, and Psychiatric Disorders: An Underrecognized Relationship

Traumatic brain injury (TBI) is commonplace among pediatric patients and has a complex, but intimate relationship with psychiatric disease and disordered sleep. Understanding the factors that influence the risk for the development of TBI in pediatrics is a critical component of beginning to address the consequences of TBI. Features that may increase risk for experiencing TBI sometimes overlap with factors that influence the development of post-concussive syndrome (PCS) and recovery course. Post-concussive syndrome includes physical, psychological, cognitive and sleep-wake dysfunction. The comorbid presence of sleep-wake dysfunction and psychiatric symptoms can lead to a more protracted recovery and deleterious outcomes. Therefore, a multidisciplinary evaluation following TBI is necessary. Treatment is generally symptom specific and mainly based on adult studies. Further research is necessary to enhance diagnostic and therapeutic approaches, as well as improve the understanding of contributing pathophysiology for the shared development of psychiatric disease and sleep-wake dysfunction following TBI.

Results from a randomized trial evaluating a hospital-school transition support model for students hospitalized with traumatic brain injury

OBJECTIVE

To evaluate the utility of the STEP model, a systematic hospital-school transition protocol for children hospitalized for TBI.

SETTING

Five children's hospitals in Colorado, Ohio, and Oregon.

PARTICIPANTS

Hundred families of children with mild, complicated mild, moderate, or severe TBI.

DESIGN

Randomized controlled trial (RCT); participants were randomized while hospitalized to the STEP (a standardized hospital-school transition protocol for children treated for TBI) or usual care condition.

MAIN MEASURES

Questionnaire about child's special education eligibility status, support services, and academic accommodations; Achenbach Child Behaviour Checklist (CBCL); Behaviour Rating Inventory of Executive Function (BRIEF); Child and Adolescent Scale of Participation (CASP); Child and Adolescent Scales of Environment (CASE) Results: There were no significant effects, indicating that STEP participants did not differ from usual care participants on any study outcome at one month post-discharge or at one-year follow-up.

CONCLUSION

The lack of significant findings in this study does not imply that effective hospital-to-school transition programming is unnecessary. Rather, the findings raise important questions regarding timing and dosage/intensity of intervention, appropriate measurement of outcomes, and fidelity of programme delivery. The study highlights difficulties involved in the conduct of community-based RCTs in the paediatric TBI population.

Use of Mental Health Services by Adolescents After Traumatic Brain Injury: A Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mental health problems are common after pediatric traumatic brain injury (TBI). Many patients in need of mental health services do not receive them, but studies have not consistently used prospective and objective methods or followed samples for more than 1 year.

OBJECTIVE

To examine adolescents' use of mental health services after TBI.

DESIGN

Secondary analysis from multicenter prospective randomized controlled trial.

SETTING

Five level 1 U.S. trauma centers.

PARTICIPANTS

Adolescents aged 12-17 years with moderate-to-severe TBI were recruited for a randomized clinical trial (n = 132 at baseline, 124 at 6 months, 113 at 12 months, and 101 at 18 months).

METHODS

Participants were randomly assigned to counselor-assisted problem-solving or Internet resource comparison. Follow-up assessments were completed at 6, 12, and 18 months after baseline. Generalized estimating equations with a logit link were used to examine use of mental health services. Treatment group and participant impairment were examined as predictors of use.

MAIN OUTCOME MEASUREMENTS

Mental health care use was measured with the Service Assessment for Children and Adolescents; daily functioning and clinical outcome with the Child and Adolescent Functional Assessment Scale; behavioral and emotional functioning with the Child Behavior Checklist; and executive dysfunction with the Behavior Rating Inventory of Executive Function.

RESULTS

Use of mental health services ranged from 22% to 31% in the 2 years post-TBI. Participants with impairments were about 3 times more likely than those without impairments to receive services (odds ratio 4.61; 95% confidence interval 2.61-8.14; P < .001). However, 50%-68% of patients identified as impaired had unmet mental health care needs.

CONCLUSIONS

Less than one half of adolescents with behavioral health needs after TBI received mental health services. Future studies are needed to examine barriers associated with seeking services after TBI and psychoeducation as preventive care for this population.

LEVEL OF EVIDENCE

II.

The Neuropsychology of Traumatic Brain Injury: Looking Back, Peering Ahead

The past 50 years have been a period of exciting progress in neuropsychological research on traumatic brain injury (TBI). Neuropsychologists and neuropsychological testing have played a critical role in these advances. This study looks back at three major scientific advances in research on TBI that have been critical in pushing the field forward over the past several decades: The advent of modern neuroimaging; the recognition of the importance of non-injury factors in determining recovery from TBI; and the growth of cognitive rehabilitation. Thanks to these advances, we now have a better understanding of the pathophysiology of TBI and how recovery from the injury is also shaped by pre-injury, comorbid, and contextual factors, and we also have increasing evidence that active interventions, including cognitive rehabilitation, can help to promote better outcomes. The study also peers ahead to discern two important directions that seem destined to influence research on TBI over the next 50 years: the development of large, multi-site observational studies and randomized controlled trials, bolstered by international research consortia and the adoption of common data elements; and attempts to translate research into health care and health policy by the application of rigorous methods drawn from implementation science. Future research shaped by these trends should provide critical evidence regarding the outcomes of TBI and its treatment, and should help to disseminate and implement the knowledge gained from research to the betterment of the quality of life of persons with TBI. (JINS, 2017, 23, 806-817).

Observed parent behaviors as time-varying moderators of problem behaviors following traumatic brain injury in young children

Parent behaviors moderate the adverse consequences of pediatric traumatic brain injury (TBI); however, it is unknown how these moderating effects change over time. This study examined the moderating effect of observed parent behaviors over time since injury on the relation between TBI and behavioral outcomes. Participants included children, ages 3-7 years, hospitalized for moderate (n = 52) or severe (n = 20) TBI or orthopedic injury (OI; n = 95). Parent-child dyads were videotaped during structured task and free play conditions, and parents completed child behavior ratings. Linear mixed models using a lagged, time-varying moderator analysis examined the relationship of observed parent behaviors at the baseline, 6-month, and 12-month assessments to child behavior problems at 6 months, 12 months, and 18 months postinjury, after controlling for preinjury levels of child behavior problems. The effect of TBI on behavior was exacerbated by less favorable parent behaviors, and buffered by more favorable parent behaviors, in children with severe TBI over the first 12 months postinjury. By 18 months postinjury, however, the moderating effect of parent behaviors diminished, such that children with severe TBI showed more behavior problems relative to children with moderate TBI or OI regardless of parent behaviors or in response to parent behaviors that were initially protective. The results suggest that the moderating effects of the family environment are complex and likely vary in relation to both recovery and developmental factors, with potentially important implications for targets and timing of intervention. (PsycINFO Database Record

Do Children Who Sustain Traumatic Brain Injury in Early Childhood Need and Receive Academic Services 7 Years After Injury?

OBJECTIVE

To examine the prevalence of academic need, academic service utilization, and unmet need as well as factors associated with academic service utilization 6.8 years after traumatic brain injury (TBI) in early childhood.

METHODS

Fifty-eight (16 severe, 14 moderate, 28 complicated mild) children with TBI and 72 children with orthopedic injury (OI) completed the long-term follow-up 6.8 years after injury in early childhood (ages 3-7 years). Injury group differences in rates of need for academic services, academic service utilization, and unmet need as well as factors associated with service utilization and unmet need were examined.

RESULTS

Students with moderate and severe TBI had significantly greater rates of need than those with OI. A greater proportion of the severe TBI sample was receiving academic services at long-term follow-up than the OI and complicated mild groups however, among those with an identified need, injury group did not affect academic service utilization. Below average IQ/achievement scores was the only area of need predictive of academic service utilization. Rates of unmet need were high and similar across injury groups (46.2%-63.6%).

CONCLUSION

The need for academic services among patients who sustained a TBI during early childhood remains high 6.8 years post injury. Findings underscore the importance of continued monitoring of behaviors and academic performance in students with a history of early childhood TBI. This may be especially true among children with less severe injuries who are at risk for being underserved.

A Systematic Review of Psychiatric, Psychological, and Behavioural Outcomes following Mild Traumatic Brain Injury in Children and Adolescents

BACKGROUND

Evidence regarding longer-term psychiatric, psychological, and behavioural outcomes (for example, anxiety, mood disorders, depression, and attention disorders) following mild traumatic brain injury (mTBI) in children and adolescents has not been previously synthesized.

OBJECTIVE

To conduct a systematic review of the available evidence examining psychiatric, psychological, and behavioural outcomes following mTBI in children and adolescents.

MATERIALS AND METHODS

Nine electronic databases were systematically searched from 1980 to August 2014. Studies selected met the following criteria: original data; study design was a randomized controlled trial, quasi-experimental design, cohort or historical cohort study, case-control study, or cross-sectional study; exposure included mTBI (including concussion); population included children and adolescents (<19 years) at the time of mTBI, as well as a comparison group (for example, healthy children, children with orthopaedic injuries); and included psychiatric, psychological, or behavioural outcomes (for example, anxiety, mood disorders, depression, attention disorders). Two authors independently assessed the quality and level of evidence with the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine (OCEBM) model, respectively, for each manuscript.

RESULTS

Of 9472 studies identified in the initial search, 30 were included and scored. Heterogeneity in methodology and injury definition precluded meta-analyses. The median methodological quality for all 30 studies, based on the DB criteria, was 15/33 (range 6 to 19). The highest level of evidence demonstrated by all reviewed studies was level 2b based on OCEBM criteria, with the majority (28/30 studies) classified at this level. Based on the literature included in this systematic review, psychological and psychiatric problems in children with a history of mTBI were found to be more prevalent when mTBI is associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not involving the head).

CONCLUSIONS

Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the acute and subacute period following an mTBI in children and adolescents.