Psychiatric disorders after pediatric traumatic brain injury: a prospective, longitudinal, controlled study

Puberty, brain network connectivity and neuropsychiatric outcomes following pediatric traumatic brain injury in females: A research protocol

BACKGROUND

Examining the role of sex on recovery from pediatric TBI (pTBI) is a complex task, specifically when referring to injuries occurring during critical developmental and maturation periods. The effect of sex hormones on neurological and neuropsychiatric outcomes has been studied among adult TBI females, but not in children. During development, puberty is considered a key milestone accompanied by changes in physical growth, neuronal maturation, sex hormones, and psychological symptoms. Following pTBI, such changes might have a significant effect on brain re-organization and on long-term neuropsychiatric outcomes. While hormonal dysfunction is a common consequence following pTBI, only few studies have systematically evaluated hormonal changes following pTBI.

AIMS

To describe a multimodal protocol aimed to examine the effect of puberty on brain connectivity and long-term neuropsychiatric outcomes following TBI in female girls and adolescents.

METHODS

A case-control longitudinal prospective design will be used. 120 female participants aged 9 to 16 years (N = 60 per group) will be recruited. In the acute phase (T0-1 month), participants will undergo an MRI protocol for brain connectivity, as well as a clinical evaluation for puberty stage and hormonal levels. In the chronic phase (T1-18-24 months), participants will complete a neuropsychiatric assessment in addition to the MRI and puberty evaluations. Hormonal levels will be monitored at T0 and T1. A moderation-mediation model will be used to examine the moderating effects of puberty on the association between pTBI and neuropsychiatric symptoms in female girls and adolescents, through the mediating effect of brain network connectivity.

SIGNIFICANCE

This study will highlight sex-specific factors related to outcomes among females following pTBI and enhance our understanding of the unique challenges they face. Such information has a substantial potential to guide future directions for research, policy and practice.

Association of neurostructural biomarkers with secondary attention-deficit/hyperactivity disorder (ADHD) symptom severity in children with traumatic brain injury: a prospective cohort study

BACKGROUND

Despite a well-established link between childhood traumatic brain injury (TBI) and elevated secondary attention-deficit/hyperactivity disorder (s-ADHD) symptomology, the neurostructural correlates of these symptoms are largely unknown. Based on the influential 'triple-network model' of ADHD, this prospective longitudinal investigation aimed to (i) assess the effect of childhood TBI on brain morphometry of higher-order cognitive networks proposed to play a key role in ADHD pathophysiology, including the default-mode network (DMN), salience network (SN) and central executive network (CEN); and (ii) assess the independent prognostic value of DMN, SN and CEN morphometry in predicting s-ADHD symptom severity after childhood TBI.

METHODS

The study sample comprised 155 participants, including 112 children with medically confirmed mild-severe TBI ascertained from consecutive hospital admissions, and 43 typically developing (TD) children matched for age, sex and socio-economic status. High-resolution structural brain magnetic resonance imaging (MRI) sequences were acquired sub-acutely in a subset of 103 children with TBI and 34 TD children. Parents completed well-validated measures of ADHD symptom severity at 12-months post injury.

RESULTS

Relative to TD children and those with milder levels of TBI severity (mild, complicated mild, moderate), children with severe TBI showed altered brain morphometry within large-scale, higher-order cognitive networks, including significantly diminished grey matter volumes within the DMN, SN and CEN. When compared with the TD group, the TBI group showed significantly higher ADHD symptomatology and higher rates of clinically elevated symptoms. In multivariable models adjusted for other well-established risk factors, altered DMN morphometry independently predicted higher s-ADHD symptomatology at 12-months post-injury, whilst SN and CEN morphometry were not significant independent predictors.

CONCLUSIONS

Our prospective study findings suggest that neurostructural alterations within higher-order cognitive circuitry may represent a prospective risk factor for s-ADHD symptomatology at 12-months post-injury in children with TBI. High-resolution structural brain MRI has potential to provide early prognostic biomarkers that may help early identification of high-risk children with TBI who are likely to benefit from early surveillance and preventive measures to optimise long-term neuropsychiatric outcomes.

Health-Related Quality of Life after Pediatric Traumatic Brain Injury: A Qualitative Comparison of Perspectives of Children and Adolescents after TBI and a Comparison Group without a History of TBI

BACKGROUND

The assessment of the impact of pediatric traumatic brain injury (TBI) on the health-related quality of life (HRQoL) of the children and adolescents affected can be ameliorated by a disease-specific instrument. Such an instrument does not yet exist. This qualitative study investigates how children and adolescents after TBI subjectively perceive their HRQoL and whether and how this differs from the perspective of individuals without a history of TBI.

METHODS

Eight problem-centered interviews were conducted with 11 children and adolescents around four years after mild TBI and with eight children and adolescents around three years after moderate to severe TBI. Nine problem-centered interviews were conducted with 25 participants without a history of TBI. The interviews were recorded and transcribed verbatim. The statements were assigned to inductively and deductively derived categories relevant to the HRQoL of children and adolescents after TBI and compared with those of individuals without a history of TBI.

RESULTS

The HRQoL of children and adolescents after TBI tended to display both structural and content-related differences, independently of TBI severity, on several HRQoL dimensions, in contrast to the comparison group. For example, participants after TBI reported a broader range of negative emotions (such as worry, sadness, shame, and guilt), permanent physical impairments, felt that they were treated differently from others, and perceived cognitive limitations.

CONCLUSIONS

The results of this qualitative study identified HRQoL dimensions that are relevant to children and adolescents after TBI and underlined the need for the development of a disease-specific instrument.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Novel Psychiatric Disorder 6 Months After Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

To investigate the factors predictive of novel psychiatric disorders in the interval 0-6 months following traumatic brain injury (TBI).

METHODS

Children ages 5-14 years consecutively hospitalized for mild to severe TBI at five hospitals were recruited. Participants were evaluated at baseline (soon after injury) for pre-injury characteristics including psychiatric disorders, socioeconomic status (SES), psychosocial adversity, family function, family psychiatric history, and adaptive function. In addition to the psychosocial variables, injury severity and lesion location detected with acquisition of a research MRI were measured to develop a biopsychosocial predictive model for development of novel psychiatric disorders. Psychiatric outcome, including occurrence of a novel psychiatric disorder, was assessed 6 months after the injury.

RESULTS

The recruited sample numbered 177 children, and 141 children (80%) returned for the six-month assessment. Of the 141 children, 58 (41%) developed a novel psychiatric disorder. In univariable analyses, novel psychiatric disorder was significantly associated with lower SES, higher psychosocial adversity, and lesions in frontal lobe locations, such as frontal white matter, superior frontal gyrus, inferior frontal gyrus, and orbital gyrus. Multivariable analyses found that novel psychiatric disorder was independently and significantly associated with frontal-lobe white matter, superior frontal gyrus, and orbital gyrus lesions.

CONCLUSION

The results demonstrate that occurrence of novel psychiatric disorders following pediatric TBI requiring hospitalization is common and has identifiable psychosocial and specific biological predictors. However, only the lesion predictors were independently related to this adverse psychiatric outcome.

Mood Disorders in Young People With Acquired Brain Injury: An Integrated Model

Purpose/Objective

Young people with paediatric acquired brain injury (pABI) are twice as likely to develop a mood disorder as their peers, frequently have significant unmet socio-emotional needs, and are at over double the risk of going on to use adult mental health services. Recent years have seen significant advances in the development of interventions for young people with mood disorders. However, evidence-based approaches to mood disorders in pABI are lacking and surprisingly little work has evaluated clinical and neuro-developmental models of mood disorders in this population.

Method

We review the literature regarding key mechanisms hypothesised to account for the increased vulnerability to mood disorders in pABI: First, we summarise the direct neurocognitive consequences of pABI, considering the key areas of the brain implicated in vulnerability to mood disorders within a neurodevelopmental framework. Second, we outline five key factors that contribute to the heightened prevalence of mood disorders in young people following ABI. Finally, we synthesise these, integrating neuro-cognitive, developmental and systemic factors to guide clinical formulation.

Results and Implications

We present a framework that synthesises the key mechanisms identified in our review, namely the direct effects of pABI, neurocognitive and neuroendocrine factors implicated in mood and anxiety disorders, maladaptive neuroplasticity and trauma, structural and systemic factors, and psychological adjustment and developmental context. This framework is the first attempt to provide integrated guidance on the multiple factors that contribute to elevated life-long risk of mood disorders following pABI.

Risk factors for development of long-term mood and anxiety disorder after pediatric traumatic brain injury: a population-based, birth cohort analysis

OBJECTIVES

The objective of this study was to identify characteristics associated with an increased risk of anxiety and mood disorder prior to 25 years of age, in children who sustained a traumatic brain injury (TBI) prior to age 10.

METHODS

This population-based study identified 562 TBI cases from a 1976-1982 birth cohort in Olmsted County, Minnesota. TBI cases were manually confirmed and classified by injury severity. Separate Cox proportional hazards regression models were fit to estimate the association of TBI and secondary non-TBI related characteristics with the risk of a subsequent clinically determined anxiety or mood disorder. Multivariable-adjusted population attributable risk (PAR) estimates were calculated for TBI characteristics.

RESULTS

Older age at initial TBI and extracranial injury at time of initial TBI were significantly associated with an increased risk of anxiety (adjusted HR [95% CI]: 1.33 [1.16, 1.52] per 1-year increase and 2.41 [1.26, 4.59]), respectively. Older age at initial TBI was significantly associated with an increased risk of a mood disorder (adjusted HR 1.17 [1.08-1.27]).

CONCLUSION

In individuals sustaining a TBI prior to age 10, age at injury greater than 5 years old was the largest contributor to development of a mood or anxiety disorder.

Novel Oppositional Defiant Disorder 12 Months After Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

The investigators examined the factors predictive of novel oppositional defiant disorder in the 6-12 months following traumatic brain injury (TBI).

METHODS

Children ages 5-14 years old who experienced a TBI were recruited from consecutive admissions to five hospitals. Participants were evaluated soon after injury (baseline) for preinjury characteristics, including psychiatric disorders, adaptive function, family function, psychosocial adversity, family psychiatric history, socioeconomic status, and injury severity, to develop a biopsychosocial predictive model for development of novel oppositional defiant disorder. MRI analyses were conducted to examine potential brain lesions. Psychiatric outcome, including that of novel oppositional defiant disorder, was assessed 12 months after injury.

RESULTS

Although 177 children were recruited for the study, 120 children without preinjury oppositional defiant disorder, conduct disorder, or disruptive behavior disorder not otherwise specified (DBD NOS) returned for the 12-month assessment. Of these 120 children, seven (5.8%) exhibited novel oppositional defiant disorder, and none developed conduct disorder or DBD NOS in the 6-12 months postinjury. Novel oppositional defiant disorder was significantly associated with lower socioeconomic status, higher psychosocial adversity, and lower preinjury adaptive functioning.

CONCLUSIONS

These results demonstrate that novel oppositional defiant disorder following TBI selectively and negatively affects an identifiable group of children. Both proximal (preinjury adaptive function) and distal (socioeconomic status and psychosocial adversity) psychosocial variables significantly increase risk for this outcome.

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.

Global and domain-specific self-esteem after pediatric traumatic brain injury: Contribution of injury characteristics and parent mental health

This prospective, longitudinal case-control study examined global and domain-specific aspects of self-esteem 6-months following pediatric traumatic brain injury (TBI) and evaluated the contribution of injury-related factors and parent mental health to child self-esteem. Participants included 103 children with mild-severe TBI representing consecutive admissions to the emergency department of the Royal Children's Hospital, Melbourne, Australia. Forty-three age-and-sex matched typically developing controls were recruited for comparison. Information regarding injury characteristics including age at injury and clinical indicators of TBI severity were collected for participants at recruitment, with research magnetic resonance imaging conducted 2-8 weeks later. At 6 months post-injury, children rated their global and domain-specific self-esteem (Harter Self-Perception Profile for Children), and ratings of parent mental health were collected (General Health Questionnaire). Self-esteem for behavioural and academic domains was significantly poorer for children with TBI relative to TD children. In the TBI group, higher child-rated scores of global and domain-specific aspects of self-esteem were associated with more severe TBI, presence of frontal neuropathology, younger age at injury, and lower parental symptoms of anxiety/insomnia. Given the psychological status of parents represents a potentially modifiable risk factor, it may form the target of clinical interventions designed to bolster child self-esteem following pediatric TBI.

Novel Oppositional Defiant Disorder 6 Months After Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

The investigators aimed to assess predictive factors of novel oppositional defiant disorder (ODD) among children and adolescents in the first 6 months following traumatic brain injury (TBI).

METHODS

Children ages 5-14 years who experienced a TBI were recruited from consecutive admissions to five hospitals. Testing of a biopsychosocial model that may elucidate the development of novel ODD included assessment soon after injury (baseline) of preinjury characteristics, including psychiatric disorders, adaptive function, family function, psychosocial adversity, family psychiatric history, socioeconomic status, injury severity, and postinjury processing speed (which may be a proxy for brain injury). MRI analyses were also conducted to examine potential brain lesions. Psychiatric outcome, including that of novel ODD, was assessed 6 months after the injury.

RESULTS

A total of 177 children and adolescents were recruited for the study, and 134 who were without preinjury ODD, conduct disorder, or disruptive behavior disorder not otherwise specified (DBD NOS) returned for the 6-month assessment. Of those who returned 6 months postinjury, 11 (8.2%) developed novel ODD, and none developed novel conduct disorder or DBD NOS. Novel ODD was significantly associated with socioeconomic status, preinjury family functioning, psychosocial adversity, and processing speed.

CONCLUSIONS

These findings show that an important minority of children with TBI developed ODD. Psychosocial and injury-related variables, including socioeconomic status, lower family function, psychosocial adversity, and processing speed, significantly increase risk for this outcome.

Psychological Interventions for Individuals With Acquired Brain Injury, Cerebral Palsy, and Spina Bifida: A Scoping Review

BACKGROUND

With current medical advancements, more adolescents with neurodevelopmental disorders are transitioning from child- to adult-centred health care services. Therefore, there is an increasing demand for transitional services to help navigate this transition. Health care transitions can be further complicated by mental health challenges prevalent among individuals with cerebral palsy (CP), spina bifida (SB), and childhood onset acquired brain injury (ABI). Offering evidence-based psychological interventions for these populations may improve overall outcomes during transition period(s) and beyond. The objective of this scoping review is to identify key characteristics of psychological interventions being used to treat the mental health challenges of adolescents and adults with CP, SB, and childhood onset ABI.

METHODS

Methodological frameworks by Arksey and O'Malley, and Levac and colleagues were used to explore studies published between 2009 and 2019. Included studies were required to be written in English and report on a psychological intervention(s) administered to individuals at least 12 years of age with a diagnosis of CP, SB, or childhood onset ABI. All study designs were included.

RESULTS

A total of 11 studies were identified. Of these, eight reported psychological interventions for childhood onset ABI, while three reported on CP. No studies reporting on SB were identified. Commonly used interventions included acceptance and commitment therapy (ACT), psychotherapy, and cognitive behavioral therapy (CBT).

CONCLUSIONS

There are a limited number of studies investigating psychological interventions for individuals with childhood onset ABI and CP, and none for individuals with SB. Further research into effective psychological interventions for these populations will improve mental health outcomes and transitional services.

Traumatic Brain Injury in Children and Adolescents: Psychiatric Disorders 24 Years Later

OBJECTIVE

The investigators aimed to extend findings regarding predictive factors of psychiatric outcomes among children and adolescents with traumatic brain injury (TBI) from 2 to 24 years postinjury.

METHODS

Youths aged 6-14 years who were hospitalized following TBI from 1992 to 1994 were assessed at baseline for TBI severity and for preinjury psychiatric, adaptive, and behavioral functioning; family functioning; family psychiatric history; socioeconomic status; and intelligence within weeks of injury. Predictors of psychiatric outcomes following pediatric TBI at 3, 6, 12, and 24 months postinjury have previously been reported. In this study, repeat psychiatric assessments were completed at 24 years postinjury with the same cohort, now adults aged 29-39 years, with the outcome measure being presence of a psychiatric disorder not present before the TBI ("novel psychiatric disorder").

RESULTS

Fifty participants with pediatric TBI were initially enrolled, and the long-term outcome analyses focused on data from 45 individuals. Novel psychiatric disorder was present in 24 out of 45 (53%) participants. Presence of a current novel psychiatric disorder was independently predicted by the presence of a preinjury lifetime psychiatric disorder and by severity of TBI.

CONCLUSIONS

Long-term psychiatric outcome (mean=23.92 years [SD=2.17]) in children and adolescents hospitalized for TBI can be predicted at the point of the initial hospitalization encounter by the presence of a preinjury psychiatric disorder and by greater injury severity.

Diffusion Tensor Imaging Correlates of Resilience Following Adolescent Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is associated with considerable mortality and morbidity in adolescents, but positive outcomes are possible. Resilience is the concept that some individuals flourish despite significant adversity.

OBJECTIVE

To determine if there is a relationship between resilience-promoting factors that are known to promote resilience and white matter (WM) microstructure 1 year after complicated mild TBI or moderate or severe TBI that is sustained by adolescents.

METHOD

We examined the relationship between performance on a self-report measure of resilience-promoting factors and WM integrity assessed by diffusion tensor imaging in a group of adolescents who had sustained either a TBI (n = 38) or an orthopedic injury (OI) (n = 23).

RESULTS

Immediately following injury, the individuals with TBI and the OI controls had comparable levels of resilience-promoting factors; however, at 1 year post injury, the TBI group endorsed fewer resilience-promoting factors and exhibited WM disruption compared with the OI controls. The individuals with TBI who had more resilience-promoting factors at 1 year post injury exhibited increased WM integrity, but the OI controls did not. Findings were particularly strong for the following structures: anterior corona radiata, anterior limb of the internal capsule, and genu of the corpus callosum-structures that are implicated in social cognition and are frequently disrupted after TBI. Relationships were notable for caregiver and community-level resilience-promoting factors.

CONCLUSION

The current findings are some of the first to indicate neurobiological evidence of previously noted buffering effects of resilience-promoting factors in individuals with TBI.

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.

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.

White Matter Disruption in Pediatric Traumatic Brain Injury: Results From ENIGMA Pediatric Moderate to Severe Traumatic Brain Injury

OBJECTIVE

Our study addressed aims (1) to test the hypothesis that moderate-severe traumatic brain injury (TBI) in pediatric patients is associated with widespread white matter (WM) disruption, (2) to test the hypothesis that age and sex affect WM organization after injury, and (3) to examine associations between WM organization and neurobehavioral outcomes.

METHODS

Data from 10 previously enrolled, existing cohorts recruited from local hospitals and clinics were shared with the Enhancing NeuroImaging Genetics Through Meta-Analysis (ENIGMA) Pediatric Moderate/Severe TBI (msTBI) working group. We conducted a coordinated analysis of diffusion MRI (dMRI) data using the ENIGMA dMRI processing pipeline.

RESULTS

Five hundred seven children and adolescents (244 with complicated msTBI and 263 controls) were included. Patients were clustered into 3 postinjury intervals: acute/subacute, <2 months; postacute, 2 to 6 months; and chronic, ≥6 months. Outcomes were dMRI metrics and postinjury behavioral problems as indexed by the Child Behavior Checklist. Our analyses revealed altered WM diffusion metrics across multiple tracts and all postinjury intervals (effect sizes range d = -0.5 to -1.3). Injury severity is a significant contributor to the extent of WM alterations but explained less variance in dMRI measures with increasing time after injury. We observed a sex-by-group interaction: female patients with TBI had significantly lower fractional anisotropy in the uncinate fasciculus than controls (β = 0.043), which coincided with more parent-reported behavioral problems (β = -0.0027).

CONCLUSIONS

WM disruption after msTBI is widespread, persistent, and influenced by demographic and clinical variables. Future work will test techniques for harmonizing neurocognitive data, enabling more advanced analyses to identify symptom clusters and clinically meaningful patient subtypes.

Long-Term Psychiatric Outcomes in Adults with History of Pediatric Traumatic Brain Injury

The objective of the study was to compare psychiatric outcomes in adults with and without history of pediatric traumatic brain injury (TBI). Youth ages 6 to 14 years hospitalized for TBI from 1992 to 1994 were assessed at baseline and at 3, 6, 12, and 24 months post-injury. In the current study, psychiatric assessments were repeated at 24 years post-injury with the same cohort, now adults ages 29 to 39 years. A control group of healthy adults also was recruited for one-time cross-sectional assessments. Outcome measures included: 1) presence of a psychiatric disorder since the 24-month assessment not present before the TBI ("novel psychiatric disorder," NPD), or in the control group, the presence of a psychiatric disorder that developed after the mean age of injury of the TBI group plus 2 years; and 2) Time-to-Event for onset of an NPD during the same time periods. In the TBI group, NPDs were significantly more common, and presence of a current NPD was significantly predicted by presence of a pre-injury lifetime psychiatric disorder and by abnormal day-of-injury computed tomography (CT) scan. Compared with controls, the TBI group also had significantly shorter Time-to-Event for onset of any NPD. These findings demonstrate that long-term psychiatric outcomes in adults previously hospitalized for pediatric TBI are significantly worse when compared with adult controls without history of pediatric TBI, both in terms of prevalence and earlier onset of NPD. Further, in the TBI group, long-term NPD outcome is predicted independently by presence of pre-injury psychiatric disorder and abnormal day-of-injury CT scan.

The ENIGMA sports injury working group:- an international collaboration to further our understanding of sport-related brain injury

Sport-related brain injury is very common, and the potential long-term effects include a wide range of neurological and psychiatric symptoms, and potentially neurodegeneration. Around the globe, researchers are conducting neuroimaging studies on primarily homogenous samples of athletes. However, neuroimaging studies are expensive and time consuming, and thus current findings from studies of sport-related brain injury are often limited by small sample sizes. Further, current studies apply a variety of neuroimaging techniques and analysis tools which limit comparability among studies. The ENIGMA Sports Injury working group aims to provide a platform for data sharing and collaborative data analysis thereby leveraging existing data and expertise. By harmonizing data from a large number of studies from around the globe, we will work towards reproducibility of previously published findings and towards addressing important research questions with regard to diagnosis, prognosis, and efficacy of treatment for sport-related brain injury. Moreover, the ENIGMA Sports Injury working group is committed to providing recommendations for future prospective data acquisition to enhance data quality and scientific rigor.

Challenges and opportunities for neuroimaging in young patients with traumatic brain injury: a coordinated effort towards advancing discovery from the ENIGMA pediatric moderate/severe TBI group

Traumatic brain injury (TBI) is a major cause of death and disability in children in both developed and developing nations. Children and adolescents suffer from TBI at a higher rate than the general population, and specific developmental issues require a unique context since findings from adult research do not necessarily directly translate to children. Findings in pediatric cohorts tend to lag behind those in adult samples. This may be due, in part, both to the smaller number of investigators engaged in research with this population and may also be related to changes in safety laws and clinical practice that have altered length of hospital stays, treatment, and access to this population. The ENIGMA (Enhancing NeuroImaging Genetics through Meta-Analysis) Pediatric Moderate/Severe TBI (msTBI) group aims to advance research in this area through global collaborative meta-analysis of neuroimaging data. In this paper, we discuss important challenges in pediatric TBI research and opportunities that we believe the ENIGMA Pediatric msTBI group can provide to address them. With the paucity of research studies examining neuroimaging biomarkers in pediatric patients with TBI and the challenges of recruiting large numbers of participants, collaborating to improve statistical power and to address technical challenges like lesions will significantly advance the field. We conclude with recommendations for future research in this field of study.

Caregiver and Child Behavioral Health Service Utilization Following Pediatric Traumatic Brain Injury

Given sparse literature examining receipt of behavioral health service in children and caregivers following traumatic brain injury (TBI), we sought to identify predictors of unmet need. We performed an individual participant data meta-analysis using generalized linear mixed-effect models to examine predictors of behavioral health service use and unmet need. We included 572 children, ages 3 to 18, who were hospitalized overnight following complicated mild to severe TBI between 2002 and 2015. Caregivers completed ratings of depression and distress, child behavior problems, family functioning, and behavioral health service utilization. For children, unmet behavioral health service need was defined as an elevation on one or more child behavior problem scales without receipt of behavioral health services. For caregivers, unmet need was defined as an elevation on either a depression or distress scale without behavioral health service utilization. Among those with behavioral health needs, rates of unmet need were high for both children (77.8%) and caregivers (71.4%). Poorer family functioning was related to more unmet need in children (F(1, 497) = 6.57, p = 0.01; OR = 1.8) and caregivers (F(1, 492) = 17.54, p < 0.001; OR = 2.7). Children with unmarried caregivers also had more unmet behavioral health service need than those with married caregivers (F(1, 497) = 12.14, p < 0.001; OR = 2.2). In conclusion, unmet needs are common after pediatric TBI and relate to family factors. The findings underscore the importance of monitoring service needs following pediatric TBI and point to disparities in service use.

Detecting mental health problems after paediatric acquired brain injury: A pilot Rasch analysis of the strengths and difficulties questionnaire

The parent-reported Strengths and Difficulties Questionnaire (SDQ-P) is commonly used to assess for mental health problems, but its psychometric properties have not been studied in the paediatric Acquired Brain Injury (ABI) population. This study investigated the properties of the SDQ-P and its subscales in this population using Rasch analysis. One hundred and forty-three SDQ-Ps and 123 Impact Supplements were analyzed. Sixty-nine percent of SDQ-Ps were completed by female carers, 59% of young people were male, and 58% had Traumatic Brain Injury (TBI). In this population the SDQ-P Total Difficulties Scale and the Conduct Problems subscale showed questionable construct validity. The individual subscales and Impact Supplement did not meet the criteria for reliability. Two items had disordered thresholds. The individual subscales showed mistargeting and 13-24% person misfit. Two items were significantly underdiscriminating. There was differential item functioning with age and time post-injury, and local dependence between subscale items. The Total Difficulties scale was multidimensional. The most easily endorsed items were in keeping with common symptoms of brain injury. These findings suggest the SDQ-P in its current form may not be a reliable and valid assessment measure for mental health difficulties in the paediatric ABI population and requires further investigation.

Concussion Management for Children Has Changed: New Pediatric Protocols Using the Latest Evidence

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild's 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

Sleep disturbances and internalizing behavior problems following pediatric traumatic injury

OBJECTIVE

This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury.

METHOD

Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes.

RESULTS

Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury.

CONCLUSIONS

Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record

Recovery Trajectories of Child and Family Outcomes Following Online Family Problem-Solving Therapy for Children and Adolescents after Traumatic Brain Injury

OBJECTIVES

We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time.

METHODS

We examined data from 359 children with complicated mild to severe TBI, aged 5-18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent-child conflict).

RESULTS

We found a main effect for measure for both child and family outcomes [F(3, 731) = 7.35, p < .001; F(3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [t(731) = -5.15, p < .001, and t(731) = -3.90, p = .002, respectively, for child outcomes; t(532) = -4.81, p < .001, and t(532) = -3.80, p < .001, respectively, for family outcomes].

CONCLUSIONS

The results suggest limited differences in the measures' responsiveness to treatment while highlighting OFPST's utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.

Decompressive craniectomy for severe traumatic brain injury in children: analysis of long-term neuropsychological impairment and review of the literature

OBJECTIVE

The effectiveness of decompressive craniectomy (DC) in the context of neurocritical care in adult patients has been recently under debate. The aim of our study was to evaluate the impact of decompressive craniectomy in severe traumatic brain injury (TBI) in children, focusing on short and long-term neurological and neuropsychological outcomes.

METHODS

Retrospective review of the medical records of children admitted at a level I trauma center, between January 2012 and December 2015, submitted to DC due to severe TBI. Additionally, an extensive review of literature on this subject was carried out.

RESULTS

Sixteen patients underwent DC for TBI at our institution during the evaluated period. 62.5% were males and the mean age was 12 years. Road traffic accident (RTA) was the main mechanism of trauma (62.5%). Average Glasgow Coma Scale (GCS) at admission was 5.2, whereas 75% of the patients presented with pathological pupillary reaction. Initial computed tomography (CT) showed skull fractures in 62.5% and acute subdural hemorrhage (ASH) in 56.3% of the patients. The mean intracranial pressure (ICP) was 27.2 mmHg prior to surgery, and the mean time window between admission and DC was 36.3 h. Unilateral DC was performed in 68.8% of the cases. The average Glasgow Outcome Scale (GOS) at 6-month follow-up was 3.7, whereas 70% of the survivors presented good recovery (GOS 4-5). Abnormal pupillary reaction at hospital admission increased 3-fold the risk of long-term neuropsychological disturbances. Follow-up evaluation revealed cognitive abnormality in 55.6% of the patients. The overall mortality at 6-month follow-up was 37.5%.

CONCLUSION

The present study indicates towards a potential benefit of DC in children with severe TBI; nevertheless, our data demonstrated a high incidence of neuropsychological impairment in the long-term follow-up. Psychological and cognitive assessment should be computed in prognosis evaluation in future prospective studies.

Paediatric goal management training in patients with acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Compromised integrity of the brain due to paediatric acquired brain injury (pABI) has been associated with cognitive impairment, particularly executive dysfunction, in addition to somatic and emotional symptoms and reduced everyday function. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with ABI. The purpose of the present study is to determine the efficacy of a recently developed paediatric version of GMT (pGMT) for children and adolescents with ABI and reported executive dysfunction.

METHODS AND ANALYSIS

This study protocol describes a parallel randomised controlled trial including allocation concealment and assessor blinding. Eighty survivors after pABI, aged 10-17 years at the time of intervention, will be recruited. Participants will be randomly allocated to either pGMT (n=40) or a psychoeducative control intervention (n=40; paediatric Brain Health Workshop). Both interventions consist of seven group sessions for participants and parents, followed by external cueing and telephone counselling. The study also includes involvement of teachers. Assessments will be performed at baseline, immediately postintervention and at 6 months' follow-up. Primary outcome measure will be changes in daily life EF as reported by parents (The Behavior Rating Inventory of Executive Function). Secondary outcomes include other assessments of EF (neuropsychological tests and questionnaires). Furthermore, we aim to assess generalisation effects of pGMT on other cognitive functions, as well as emotional, behavioural, adaptive and family function, academic performance, fatigue and quality of life.

ETHICS AND DISSEMINATION

Results from this study will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals, in addition to presentations at scientific conferences. The study will be conducted in accordance with the Helsinki declaration and the Ethical Research Involving Children (ChildWatch International and Unicef). In accordance to Good Clinical Practice our study includes safety and quality monitoring guarantees in compliance with research ethics and safety. The trial will be reported in accordance with the Consolidated Standards of Reporting Trials 2010 statement and Standard Protocol Items for Reporting in Trials recommendations, in addition to being registered at ClinicalTrials.gov. The study has been approved by the Regional Committees for Medical and Health Research Ethics Norway (2017/772).

TRIAL REGISTRATION NUMBER

NCT03215342.

Anxiety Disorders in Adults With Childhood Traumatic Brain Injury: Evidence of Difficulties More Than 10 Years Postinjury

OBJECTIVE

To explore long-term psychiatric outcomes in individuals with a history of childhood traumatic brain injury (TBI) or orthopedic injury (OI).

SETTING

Hospital emergency department, medical admission records and outpatient settings.

PARTICIPANTS

There were 95 males (M = 22.78 years, SD = 3.44 years) and 74 females (M = 22.27 years, SD = 3.09 years), 65 with mild TBI (M = 23.25 years, SD = 3.58 years), 61 with moderate-severe TBI (M = 22.34 years, SD = 2.79 years), and 43 with OI (M = 21.81 years, SD = 3.36 years).

DESIGN

Longitudinal, between-subjects, cross-sectional design using retrospective and current data.

MAIN MEASURES

Semistructured interview to obtain psychiatric diagnoses and background information, and medical records for identification of TBI.

RESULTS

Group with moderate-severe TBI presented with significantly higher rates of any anxiety disorder (χ2 = 6.81, P = .03) and comorbid anxiety disorder (χ2 = 6.12, P < .05). Group with overall TBI presented with significantly higher rates of any anxiety disorder (χ1 = 5.36, P = .02), panic attacks (χ1 = 4.43, P = .04), specific phobias (χ1 = 4.17, P = .04), and depression (χ1 = 3.98, P < .05). Prediction analysis revealed a statistically significant model (χ7 = 41.84, P < .001) explaining 23% to 37% of the variance in having any anxiety disorder, with significant predictors being group (TBI) and gender (female).

CONCLUSIONS

Children who have sustained a TBI may be vulnerable to persistent anxiety, panic attacks, specific phobias, and depression, even 13 years after the injury event.

Systematic review protocol for facilitators and barriers to integrating health services for traumatic brain injury and mental health or addictions

INTRODUCTION

In the most populous province of Canada, one in five adults and one in six students report a lifetime history of traumatic brain injury (TBI). These individuals were also more likely to report elevated psychological distress and use illicit substances compared with those without TBI. The need for integrated health services has been recognised globally, yet efforts to develop more comprehensive and effective care for TBI and mental health and/or addictions (MHA) continue to be challenged by the siloing of the two systems. This protocol is for a systematic review that describes the current types of integrated care for TBI and MHA and identifies the barriers and facilitators to integrating healthcare for these populations.

METHODS AND ANALYSIS

This review will systematically search MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Central Register of Controlled Trials, Sociological Abstracts, and Dissertations & Theses Global. References of eligible articles will also be searched for additional relevant studies. The search strategy will include the use of text words and subject headings relevant to the concepts 'TBI,' 'substance abuse, gambling, or mental health,' 'integrated healthcare,' 'barriers and facilitators,' and 'healthcare access.' Two reviewers will independently screen all articles based on predetermined inclusion and exclusion criteria and perform quality assessment on eligible studies. A narrative synthesis will be conducted using the data abstracted by the two reviewers.

ETHICS AND DISSEMINATION

Findings from the systematic review will be published in peer-reviewed journals, presented at scientific meetings, and summarised for key stakeholders in the field of TBI and/or MHA. This protocol will form a systematic review that holds the potential to impact policy and planning in the development of integrated person-centred care for TBI and MHA and addresses a recognised gap in TBI care.

TRIAL REGISTRATION NUMBER

CRD42018108343.

What do Kids with Acquired Brain Injury Want? Mapping Neuropsychological Rehabilitation Goals to the International Classification of Functioning, Disability and Health

OBJECTIVE

To increase understanding of the community neuropsychological rehabilitation goals of young people with acquired brain injuries (ABIs).

METHOD

Three hundred twenty-six neuropsychological rehabilitation goals were extracted from the clinical records of 98 young people with ABIs. The participants were 59% male, 2-19 years old, and 64% had a traumatic brain injury. Goals were coded using the International Classification of Functioning, Disability and Health: Children and Youth Version (ICF-CY). Descriptive statistical analysis was performed to assess the distribution of goals across the ICF-CY. Chi-squared and Cramer's V were used to identify demographic and injury-related associations of goal type.

RESULTS

The distribution of goals was 52% activities and participation (AP), 28% body functions (BF), 20% environmental factors (EF), and &lt;1% body structures (BS). The number of EF goals increased with age at assessment (V = .14). Non-traumatic causes of ABIs were associated with more EF goals (V = .12). There was no association between sex or time post-injury and the distribution of goals across the ICF-CY.

CONCLUSIONS

Young people with ABIs have a wide range of community neuropsychological rehabilitation goals that require an individualized, context-sensitive, and interdisciplinary approach. Community neuropsychological rehabilitation services may wish to ensure they are resourced to focus intervention on AP, with increasing consideration for EF as a young person progresses through adolescence. The findings of this research support models of community neuropsychological rehabilitation that enable wellness by combining direct rehabilitative interventions with attention to social context and systemic working across agencies. (JINS, 2019, 25, 403-412).

Behavioral Health Service Utilization and Unmet Need After Traumatic Brain Injury in Childhood

OBJECTIVE

The need for behavioral health services, service utilization, and predictors of utilization was examined in children with moderate-to-severe traumatic brain injury (TBI) relative to a comparison group of children with orthopedic injury (OI) 6.8 years after injury.

METHODS

A total of 130 children hospitalized for moderate-to-severe TBI (16 severe and 42 moderate) or OI (72) between the ages of 3 and 7 years, who were enrolled at the time of injury at 3 tertiary care children's hospital and one general hospital in Ohio, and completed a long-term follow-up 6.8 years after injury were included in analyses.

RESULTS

Adolescents with TBI (moderate [38%] and severe [69%]) had significantly greater rates of need than those with OI (17%). Behavioral health services were utilized by 10% of the sample with no injury group differences (OI: 6%; moderate: 17%; severe: 13%). Early treatment and white race were associated with less service utilization; 77% had an unmet need, with no injury group differences (OI: 75%; moderate: 75%; severe: 82%). Rate of unmet need was greater among white than non-white children.

CONCLUSION

Children who sustain a TBI in early childhood experience persistent and clinically significant impairments even years after injury. Rates of unmet need were high for all injury groups. Findings underscore the importance of long-term monitoring to identify developing needs and prevent significant complications/deficits.

Examination of Injury, Host, and Social-Environmental Moderators of Online Family Problem Solving Treatment Efficacy for Pediatric Traumatic Brain Injury Using an Individual Participant Data Meta-Analytic Approach

A series of five randomized controlled clinical trials (RCTs) conducted between 2002 and 2015 support the potential efficacy of online family problem-solving treatment (OFPST) in improving both child and parent/family outcomes after pediatric traumatic brain injury (TBI). However, small sample sizes and heterogeneity across individual studies have precluded examination of potentially important moderators. We jointly analyzed individual participant data (IPD) from these five RCTs, involving 359 children and adolescents between the ages of 5 and 18 years, to confirm the role of previously identified moderators (child's age and pre-treatment symptom levels, parental education) and to examine other potential moderators (race, sex, IQ), using IPD meta-analysis. This reanalysis revealed statistically strong evidence that parental education, child age at baseline, IQ, sex, and parental depression level pre-treatment moderated the effect of OFPST on various outcomes. In particular, children of parents with a less than high school education exhibited fewer internalizing problems and better social competence. Children injured at an older age exhibited fewer externalizing behaviors and less executive dysfunction following OFPST. Child IQ moderated the effect of OFPST on social competence, with significantly better competence for children with lower IQ who received OFPST. Lower levels of parental depression followed OFPST among subgroups with lower IQ, boys, and higher parental depression scores at baseline. Our findings indicate that the optimal application of OFPST is likely to involve older children, those with lower IQ scores, or those from families with lower socioeconomic status (SES).

Comparative effectiveness of family problem-solving therapy (F-PST) for adolescents after traumatic brain injury: Protocol for a randomized, multicenter, clinical trial

Introduction

The objective of this manuscript is to describe the methodology that will be used to test the comparative effectiveness, feasibility, and acceptability of three formats of family problem solving therapy (F-PST) for improving functional outcomes of complicated mild to severe adolescent TBI.

Methods

Three-arm comparative effectiveness, randomized clinical trial (RCT) design. We describe the protocol of a three-arm RCT comparing the effectiveness of three modalities of F-PST to reduce executive dysfunction and behavior problems following TBI in adolescence. The RCT will compare the relative effectiveness among face-to-face; online and self-directed; and therapist-supported online modes of treatment.

Ethics and dissemination

It is anticipated that findings from this work will inform future clinical care practices, with implications for treatment of other patient populations of youth with psychological symptoms arising from neurological conditions. Institutional review board approval will be obtained from all sites prior to commencement of the study.

Secondary Attention-Deficit/Hyperactivity Disorder in Children and Adolescents 5 to 10 Years After Traumatic Brain Injury

IMPORTANCE

After traumatic brain injury (TBI), children often experience impairment when faced with tasks and situations of increasing complexity. Studies have failed to consider the potential for attention problems to develop many years after TBI or factors that may predict the development of secondary attention-deficit/hyperactivity disorder (SADHD). Understanding these patterns will aid in timely identification of clinically significant problems and appropriate initiation of treatment with the hope of limiting additional functional impairment.

OBJECTIVE

To examine the development of SADHD during the 5 to 10 years after TBI and individual (sex, age at injury, and injury characteristics) and environmental (socioeconomic status and family functioning) factors that may be associated with SADHD.

DESIGN, SETTING, AND PARTICIPANTS

Concurrent cohort/prospective study of children aged 3 to 7 years hospitalized overnight for TBI or orthopedic injury (OI; used as control group) who were screened at 3 tertiary care children's hospitals and 1 general hospital in Ohio from January 2003 to June 2008. Parents completed assessments at baseline (0-3 months), 6 months, 12 months, 18 months, 3.4 years, and 6.8 years after injury. A total of 187 children and adolescents were included in the analyses: 81 in the TBI group and 106 in the OI group.

MAIN OUTCOMES AND MEASURES

Diagnosis of SADHD was the primary outcome. Assessments were all completed by parents. Secondary ADHD was defined as an elevated T score on the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale of the parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or current treatment with stimulant medication not present at the baseline assessment. The Family Assessment Device-Global Functioning measurement was used to assess family functioning; scores ranged from 1 to 4, with greater scores indicating poorer family functioning.

RESULTS

The analyzed sample included 187 children with no preinjury ADHD. Mean (SD) age was 5.1 (1.1) years; 108 (57.8%) were male, and 50 (26.7%) were of nonwhite race/ethnicity. Of the 187 children, 48 (25.7%) met our definition of SADHD. Severe TBI (hazard ratio [HR], 3.62; 95% CI, 1.59-8.26) was associated with SADHD compared with the OI group. Higher levels of maternal education (HR, 0.33; 95% CI, 0.17-0.62) were associated with a lower risk of SADHD. Family dysfunction was associated with increased risk of SADHD within the TBI group (HR, 4.24; 95% CI, 1.91-9.43), with minimal association within the OI group (HR, 1.32; 95% CI, 0.36-4.91).

CONCLUSIONS AND RELEVANCE

Early childhood TBI was associated with increased risk for SADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with 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.

Psychological outcome after severe traumatic brain injury in adolescents and young adults: The chronic phase

OBJECTIVES

Young individuals surviving severe traumatic brain injury (TBI) frequently experience a wide range of cognitive, emotional and behavioural consequences. This cross-sectional follow-up study investigated psychological outcome of young survivors in the chronic phase, and whether psychological outcome was associated with improvement of functional abilities during sub-acute admission.

METHODS

Patients, who acquired a severe TBI during adolescence or early adulthood (n = 36) and received early intensive rehabilitation, were contacted for follow-up assessment concerning psychological outcome and completed the Adult Self Report 18-59 (ASR18-59). Demographic data, functional outcomes and severity measures were obtained from the local database.

RESULTS

The participants had a mean age of 24.1 years (SD = 4.1) at follow-up, and the mean time since injury was 72.1 months (SD = 44.2). Results showed significantly higher scores compared with the normative reference population in relation to the subscales withdrawal/isolation (p = 0.013), attention problems (p = 0.008) and intrusive behaviour (p = 0.046). Pearson correlation analyses showed that young survivors experiencing more functional improvement during inpatient rehabilitation had fewer psychological problems during the chronic phase in the subscales: withdrawal/isolation, rule breaking, intrusive behaviour and total problems.

CONCLUSION

Young patients reported psychological problems in several areas during the chronic phase of injury, which may hinder complete reintegration and participation in society. Larger functional improvement during sub-acute rehabilitation seemed to be associated with less psychological problems in the chronic phase.

Psychosocial and Executive Function Recovery Trajectories One Year after Pediatric Traumatic Brain Injury: The Influence of Age and Injury Severity

Time since traumatic brain injury (TBI) and developmental stage at injury may affect the trajectory of outcomes associated with adjustment and school success. We prospectively enrolled a cohort of 519 children with either TBI or orthopedic injury (OI) age 2.5-15 years to examine children's psychosocial and executive function outcomes at 3- and 12-months post-injury. Outcome measures included the Child Behavior Checklist (CBCL), Strengths and Difficulties Questionnaire (SDQ), and Behavior Rating Inventory of Executive Function (BRIEF) ratings. Controlling for pre-injury ratings and using the OI group as the reference, children with TBI, regardless of age or injury severity, had affective, anxiety, and attention-deficit/hyperactivity disorder (ADHD) problems on the CBCL. Symptom trajectories differed both by injury severity and age at injury. Children with mild and complicated mild TBI had a decreasing anxiety trajectory, whereas children with severe TBI had increasing symptoms. Children 6-11 years of age had high ADHD and affective scores; however, the youngest children had increasing symptoms over time. On the SDQ, peer relationships and prosocial behaviors were not significantly affected by TBI but were associated with family environment. Children with severe TBI had the worst executive function scores; however, mild and complicated mild/moderate TBI groups had clinically important working memory deficits. Hispanic ethnicity and strong social capital were positively associated with multiple outcomes. Children's recovery trajectories differed by injury severity, time since injury, and developmental stage when injured. Schools need to reassess children's skills over time as new problems in behavior and learning may emerge.

Internalizing disorders in adults with a history of childhood traumatic brain injury

INTRODUCTION

While the presence of externalizing behavioral problems following traumatic brain injury (TBI) has been well established in the literature, less is known regarding internalizing disorders, and more specifically anxiety disorders, in such a population. This study explored the presence, rate, and incidence of internalizing behavior problems, including anxiety, depression, somatic complaints, avoidant personality symptomatology, and overall internalizing behavior problems in university students aged 18-25 years.

METHOD

A convenience sample of 247 university students (197 non-TBI, 47 mild TBI, 2 moderate TBI, 1 severe TBI) aged 18-25 years was utilized. Participants completed a self-report measure on behavioral functioning, the Adult Self Report (ASR), to identify internalizing behaviors, and a questionnaire to identify TBI history.

RESULTS

Raw scores of behavior indicated that participants with a history of childhood TBI reported significantly higher levels of withdrawal, somatic complaints, and internalizing behavioral problems than the non-TBI participants. When analyzing standardized T-scores for borderline and clinically elevated ASR syndromes and Diagnostic and Statistical Manual of Mental Disorders (DSM)-oriented scales, individuals in the TBI group were significantly more likely to have higher rates of borderline anxiety, somatic complaints, avoidant personality problems, and overall internalizing disorders, and clinically elevated somatic complaints. Adults with a history of childhood TBI were also significantly more likely to report at least 1 or more DSM disorders.

CONCLUSION

These results clearly suggest that individuals with a childhood history of TBI are at a heightened risk for a range of internalizing disorders in early adulthood, which is particularly troubling in a university sample pursuing tertiary education.

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.

Psychiatric outcomes after pediatric sports-related concussion

OBJECT

The objectives of this study were twofold: (1) to examine the prevalence of emotional symptoms among children and adolescents with a sports-related concussion (SRC) who were referred to a multidisciplinary pediatric concussion program and (2) to examine the prevalence, clinical features, risk factors, and management of postinjury psychiatric outcomes among those in this clinical population.

METHODS

The authors conducted a retrospective chart review of all patients with SRC referred to a multidisciplinary pediatric concussion program between September 2013 and October 2014. Clinical assessments carried out by a single neurosurgeon included clinical history, physical examination, and Post-Concussion Symptom Scale (PCSS) scoring. Postinjury psychiatric outcomes were defined as a subjective worsening of symptoms of a preinjury psychiatric disorder or new and isolated suicidal ideation or diagnosis of a novel psychiatric disorder (NPD). An NPD was defined as a newly diagnosed psychiatric disorder that occurred in a patient with or without a lifetime preinjury psychiatric disorder after a concussion. Clinical resources, therapeutic interventions, and clinical and return-to-play outcomes are summarized.

RESULTS

One hundred seventy-four patients (mean age 14.2 years, 61.5% male) were included in the study. At least 1 emotional symptom was reported in 49.4% of the patients, and the median emotional PCSS subscore was 4 (interquartile range 1-8) among those who reported at least 1 emotional symptom. Overall, 20 (11.5%) of the patients met the study criteria for a postinjury psychiatric outcome, including 14 patients with an NPD, 2 patients with isolated suicidal ideation, and 4 patients with worsening symptoms of a preinjury psychiatric disorder. Female sex, a higher initial PCSS score, a higher emotional PCSS subscore, presence of a preinjury psychiatric history, and presence of a family history of psychiatric illness were significantly associated with postinjury psychiatric outcomes. Interventions for patients with postinjury psychiatric outcomes included pharmacological therapy alone in 2 patients (10%), cognitive behavioral therapy alone in 4 (20%), multimodal therapy in 9 (45%), and no treatment in 5 (25%). Overall, 5 (25%) of the patients with postinjury psychiatric disorders were medically cleared to return to full sports participation, whereas 5 (25%) were lost to follow-up and 9 (45%) remained in treatment by the multidisciplinary concussion program at the end of the study period. One patient who was asymptomatic at the time of initial consultation committed suicide.

CONCLUSIONS

Emotional symptoms were commonly reported among pediatric patients with SRC referred to a multidisciplinary pediatric concussion program. In some cases, these symptoms contributed to the development of an NPD, isolated suicidal ideation, and worsening symptoms of a preexisting psychiatric disorder. Future research is needed to clarify the prevalence, pathophysiology, risk factors, and evidence-based management of postinjury psychiatric outcomes after pediatric SRC. Successful management of these patients requires prompt recognition and multidisciplinary care by experts with clinical training and experience in concussion and psychiatry.

Neuropsychological outcome and diffusion tensor imaging in complicated versus uncomplicated mild traumatic brain injury

This study examined whether intracranial neuroimaging abnormalities in those with mild traumatic brain injury (MTBI) (i.e., “complicated” MTBIs) are associated with worse subacute outcomes as measured by cognitive testing, symptom ratings, and/or diffusion tensor imaging (DTI). We hypothesized that (i) as a group, participants with complicated MTBIs would report greater symptoms and have worse neurocognitive outcomes than those with uncomplicated MTBI, and (ii) as a group, participants with complicated MTBIs would show more Diffusion Tensor Imaging (DTI) abnormalities. Participants were 62 adults with MTBIs (31 complicated and 31 uncomplicated) who completed neurocognitive testing, symptom ratings, and DTI on a 3T MRI scanner approximately 6-8 weeks post injury. There were no statistically significant differences between groups on symptom ratings or on a broad range of neuropsychological tests. When comparing the groups using tract-based spatial statistics for DTI, no significant difference was found for axial diffusivity or mean diffusivity. However, several brain regions demonstrated increased radial diffusivity (purported to measure myelin integrity), and decreased fractional anisotropy in the complicated group compared with the uncomplicated group. Finally, when we extended the DTI analysis, using a multivariate atlas based approach, to 32 orthopedic trauma controls (TC), the findings did not reveal significantly more areas of abnormal DTI signal in the complicated vs. uncomplicated groups, although both MTBI groups had a greater number of areas with increased radial diffusivity compared with the trauma controls. This study illustrates that macrostructural neuroimaging changes following MTBI are associated with measurable changes in DTI signal. Of note, however, the division of MTBI into complicated and uncomplicated subtypes did not predict worse clinical outcome at 6-8 weeks post injury.

Determinants of Effective Caregiver Communication After Adolescent Traumatic Brain Injury

OBJECTIVE

To characterize the effects of caregiver mental health and coping strategies on interactions with an injured adolescent acutely after traumatic brain injury (TBI).

DESIGN

Multi-site, cross-sectional study.

SETTING

Outpatient setting of 3 tertiary pediatric hospitals and 2 tertiary general medical centers.

PARTICIPANTS

Adolescents (N = 125) aged 12-17 years, 1-6 months after being hospitalized with complicated mild to severe TBI.

METHODS

Data were collected as part of a multi-site clinical trial of family problem-solving therapy after TBI. Multiple regression analyses were used to examine the relationship of caregiver and environmental characteristics to the dimensions of effective communication, warmth, and negativity during caregiver-adolescent problem-solving discussions.

MAIN OUTCOMES MEASURES

Adolescent and caregiver interactions, as measured by the Iowa Family Interaction Rating Scales.

RESULTS

Caregivers who utilized problem-focused coping strategies were rated as having higher levels of effective communication (P < .01), as were those with higher socioeconomic status (P < .01). Problem-focused coping style and higher socioeconomic status were also associated lower levels of negative interactions (P < .01 and P < .05, respectively). Female gender of the adolescent and fewer children in the home were associated with increased parental warmth during the interaction (P < .01 and P < .05, respectively). Neither adolescent TBI severity nor caregiver depression significantly influenced caregiver-teen interactions.

CONCLUSIONS

Problem-focused coping strategies are associated with higher levels of effective communication and lower levels of caregiver negativity during the initial months after adolescent TBI, suggesting that effective caregiver coping may facilitate better caregiver-adolescent interactions after TBI.

Online problem-solving therapy after traumatic brain injury: a randomized controlled trial

BACKGROUND

Pediatric traumatic brain injury (TBI) contributes to impairments in functioning in everyday settings. Evidence suggests that online family problem-solving therapy (FPST) may be effective in reducing adolescent behavioral morbidity. This article examines the efficacy of Counselor-Assisted Problem Solving (CAPS), a form of online FPST in improving long-term functional outcomes of adolescents with TBI relative to Internet resources only.

METHODS

Children, aged 12 to 17 years, who were hospitalized in the previous 7 months for TBI were enrolled in a multisite, assessor-blinded randomized controlled trial. Consented participants were randomly assigned to CAPS or an Internet resource comparison (IRC) condition. Outcomes were assessed at baseline and at follow-ups 6, 12, and 18 months postbaseline. The Child and Functional Assessment Scale and the Iowa Family Interaction Rating Scale (IFIRS) served as primary outcomes of child and family functioning respectively.

RESULTS

For the Child and Functional Assessment Scale total, we found a significant group × time interaction, with less impaired functioning for the CAPS group than for the IRC group at the final follow-up. Parent education moderated the efficacy of CAPS on overall rates of impairment and school/work functioning, with the advantage of CAPS over IRC evident at the final follow-up only for participants with less-educated parents. Neither group differences nor group × time interactions were found for the IFIRS.

CONCLUSIONS

Relatively brief, online treatment shortly after injury may result in long-term improvements in child functioning, particularly among families of lower socioeconomic status. Clinical implementation of CAPS during the initial months postinjury should be considered.

Psychiatric disorders in children and adolescents 24 months after mild traumatic brain injury

This study aimed to better understand the occurrence of novel psychiatric disorders (NPDs) in children with mild traumatic brain injury (mTBI) in relation to preinjury variables, injury-related variables, and concurrent neurocognitive outcome. Eighty-seven children aged 5-14 years who had experienced mTBI were studied from consecutive hospital admissions with semistructured psychiatric interviews soon after injury (baseline). Fifty-four children were reassessed 24 months postinjury. Standardized instruments were used to evaluate injury severity, lesion characteristics, preinjury variables (lifetime psychiatric disorder, family psychiatric history, family function, socioeconomic status, psychosocial adversity, adaptive function, and academic function), and finally, postinjury neurocognitive and adaptive function. At 24 months postinjury, NPDs had occurred in 17 of 54 (31%) participants. NPD at 24 months was related to frontal white matter lesions and was associated with estimated preinjury reading, preinjury adaptive function, and concurrent deficits in reading, processing speed, and adaptive function. These findings extend earlier reports that the psychiatric morbidity after mTBI in children is more common than previously thought, and moreover, it is linked to preinjury individual variables and injury characteristics and is associated with postinjury adaptive and neurocognitive functioning.

Improving child and parenting outcomes following paediatric acquired brain injury: a randomised controlled trial of Stepping Stones Triple P plus Acceptance and Commitment Therapy

BACKGROUND

Persistent behavioural difficulties are common following paediatric acquired brain injury (ABI). Parents and families also experience heightened stress, psychological symptoms and burden, and there is evidence of a reciprocal relationship between parent and child functioning, which may be mediated by the adoption of maladaptive parenting practices. Despite this, there is currently a paucity of research in family interventions in this population. The aim of this study was to determine the efficacy of Stepping Stones Triple P: Positive Parenting Program (SSTP), with an Acceptance and Commitment Therapy (ACT) workshop, in improving child outcomes and parenting practices following paediatric ABI.

METHODS

Fifty-nine parents of children (mean age 7 years, SD 3 years, 1 month; 35 males, 24 females) with ABI (Traumatic injuries 58%, Tumour 17%, Encephalitis or meningitis 15%, Cardiovascular accident 7%, Hypoxia 3%) who were evidencing at least mild behaviour problems were randomly assigned to treatment or care-as-usual conditions over 10 weeks. Mixed-model repeated-measures linear regression analyses were conducted to compare conditions from pre- to postintervention on child behavioural and emotional functioning (Eyberg Child Behavior Inventory, Strengths and Difficulties Questionnaire) and dysfunctional parenting style (Parenting Scale). Assessment of maintenance of change was conducted at a 6-month follow-up. The trial was registered on Australian New Zealand Clinical Trials Registry (ID: ACTRN12610001051033, www.anzctr.org.au).

RESULTS

Significant time-by-condition interactions were identified on number and intensity of child behaviour problems, child emotional symptoms and parenting laxness and overreactivity, indicating significant improvements in the treatment condition, with medium-to-large effect sizes. Most improvements were maintained at 6 months.

CONCLUSIONS

Group parenting interventions incorporating Triple P and ACT may be efficacious in improving child and parenting outcomes following paediatric ABI.

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

PURPOSE

The objective of this study was to identify and describe management strategies to ensure safe return to activity (RTA) and return to school (RTS) of children with mild traumatic brain injury (MTBI) and determine whether they are evidence-based.

METHODS

A scoping methodology was conducted using research published between 1990 and 2013, gray literature and clinical expertise. Once the data had been charted, an expert panel of physicians and clinicians was consulted to inform and validate study findings. An analytical and thematic framework was used to examine the study findings.

RESULTS

A total of 400 potentially relevant published articles, 100 websites and 24 iPad Applications were found. Ten articles and three web-based resources met inclusion criteria and were included in the final review. Nine articles recommended a more conservative approach to RTA, as well as identified a step-wise or severity-oriented approach. General recommendations were also found regarding safe RTS. One study recommended a stepwise RTS protocol for children.

CONCLUSIONS

This scoping methodology determined that the most comprehensive guidelines for management are focused on adults. Evidence concerning prolonged recovery patterns in children and the impact of concussion on the developing brain suggests that pediatric-specific guidelines are needed for RTA and RTS after MTBI/concussion.

IMPLICATIONS FOR REHABILITATION

Although concussion in children is an increasing concern, it has been determined that the most comprehensive guidelines for management are focused on adults. These guidelines are primarily consensus-based and are not proven fact through quality research. Evidence concerning prolonged recovery patterns in youth and the impact of concussion on the developing brain suggest that pediatric guidelines should be more conservative than for adults. Therefore, pediatric-specific guidelines need to be developed for return to activity and return to school after MTBI/concussion.