Sedation Research in Critically Ill Pediatric Patients: Proposals for Future Study Design From the Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research IV Workshop

OBJECTIVES

Sedation and analgesia for infants and children requiring mechanical ventilation in the PICU is uniquely challenging due to the wide spectrum of ages, developmental stages, and pathophysiological processes encountered. Studies evaluating the safety and efficacy of sedative and analgesic management in pediatric patients have used heterogeneous methodologies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) IV hosted a series of multidisciplinary meetings to establish consensus statements for future clinical study design and implementation as a guide for investigators studying PICU sedation and analgesia.

DESIGN

Twenty-five key elements framed as consensus statements were developed in five domains: study design, enrollment, protocol, outcomes and measurement instruments, and future directions.

SETTING

A virtual meeting was held on March 2-3, 2022, followed by an in-person meeting in Washington, DC, on June 15-16, 2022. Subsequent iterative online meetings were held to achieve consensus.

SUBJECTS

Fifty-one multidisciplinary, international participants from academia, industry, the U.S. Food and Drug Administration, and family members of PICU patients attended the virtual and in-person meetings. Participants were invited based on their background and experience.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Common themes throughout the SCEPTER IV consensus statements included using coordinated multidisciplinary and interprofessional teams to ensure culturally appropriate study design and diverse patient enrollment, obtaining input from PICU survivors and their families, engaging community members, and using developmentally appropriate and validated instruments for assessments of sedation, pain, iatrogenic withdrawal, and ICU delirium.

CONCLUSIONS

These SCEPTER IV consensus statements are comprehensive and may assist investigators in the design, enrollment, implementation, and dissemination of studies involving sedation and analgesia of PICU patients requiring mechanical ventilation. Implementation may strengthen the rigor and reproducibility of research studies on PICU sedation and analgesia and facilitate the synthesis of evidence across studies to improve the safety and quality of care for PICU patients.

Social adjustment in children diagnosed with sickle cell disease: A retrospective study

BACKGROUND

Children with sickle cell disease (SCD) are at risk for physical, psychological, and social adjustment challenges. This study sought to investigate social adjustment and related factors in children living with SCD.

METHODS

Data from 32 children (50% male, mean age = 10.32 years, SD = 3.27) were retrospectively collected from a neuropsychology clinic at a tertiary care pediatric hospital. Social adjustment was measured using the Behavior Assessment System for Children (BASC-3) parent-proxy, withdrawal subscale, and the Pediatric Quality of Life Inventory (PedsQL) Generic Module Social Functioning self- and parent-proxy subscales. Other measures captured executive functioning (i.e., Behavior Rating Inventory of Executive Function, Second Edition (BRIEF-2) Parent Form) and non-disease-related associations with social adjustment, including number of years in Canada and family functioning (i.e., PedsQL Family Impact Module).

RESULTS

Sixteen percent of patients reported elevated social adjustment difficulties. Multiple linear regression found better family functioning [B = .48, t = 2.65, p = .016], and higher executive functioning [B = -.43, t = -2.39, p = .028] were related to higher scores on the PedsQL parent-proxy ratings of social adjustment [F(4,18) = 5.88, p = .003]. Male sex [B = .54, t = 3.08, p = .005], and having lived more years in Canada [B = .55, t = 2.81, p = .009], were related to higher PedsQL self-reported social adjustment [F(4,23) = 3.75, p = .017]. The model examining the BASC-3 withdrawal subscale was not statistically significant [F(4,16) = 1.63, p = .22].

IMPLICATIONS

Social adjustment in children diagnosed with SCD warrants future research to understand the influence of executive function, and non-disease-related factors, particularly focusing on sociocultural factors.

Describing High School Stakeholders' Preferences for a Return-to-School Framework Following Concussion

BACKGROUND

Return to school supports are recommended to facilitate adolescents' re-entry to school following a concussion. However, little is known as to what school stakeholders prefer for a return-to-school process. This study sought to describe the preferences of high school students, parents, and educators for a Return-to-School Framework for adolescents following a concussion.

METHODS

We conducted qualitative semi-structured, 1-on-1 or group interviews with high school students (n = 6), parents (n = 5), and educators (n = 15) from Calgary, Canada. Interviews aimed to describe participants' preferences for a Return-to-School Framework for students following a concussion. Interviews were analyzed using conventional content analysis.

RESULTS

We organized the data into 4 main themes: (1) purpose of the Return-to-School Framework; (2) format and operation of the Return-to-School Framework; (3) communication about a student's concussion; and (4) necessity of concussion education for students and educators.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

A Return-to-School Framework following concussion should be developed in consultation with families, educators, and students and supports should be tailored to each student.

CONCLUSIONS

Participants preferred a standardized and consistent Return-to-School Framework including ongoing communication between stakeholders as well as feasible and individualized school supports.

"What If?": Caregivers' Experiences Following Early Childhood Concussion

OBJECTIVE

Little is known about the symptoms, signs, and management guidelines for children under the age of 6 years after they sustain a concussion. Caregivers of such young children may have unique concerns and encounter different challenges from those of school-age children given the distinctive developmental characteristics of the early childhood period. This study aimed to explore the experience of caregivers through semistructured interviews to inform clinical practice.

METHODS

Fifty caregivers of children aged 6 months to 5.99 years were interviewed 3 months postinjury for this qualitative study to document their experience in relation to their child's accident, recovery, and healthcare provisions.

RESULTS

Four main themes were identified: (1) visible changes associated with caregiver concerns, (2) a roller-coaster of emotions after the injury, (3) healthcare providers' role in addressing the need for reassurance, and (4) the need for better information after the injury.

CONCLUSION

The findings provide critical insight into the unique experiences and information needs of caregivers of young children who sustain concussion. The challenges identified can inform healthcare professionals regarding the needs of caregivers after early concussion and contribute to building a knowledge base for the development of age-appropriate anticipatory guidance for caregiver mental health and child recovery.

Academic Accommodations for Middle and High School Students Following a Concussion: Perspectives of Teachers and School Administrators

BACKGROUND

An estimated 1 in 5 adolescents have sustained a concussion in North America. Teachers and school administrators are responsible for implementing academic accommodations and other supports for optimal return to learn following a concussion. The primary objective of this study was to describe the prevalence and feasibility of providing academic accommodations to students following concussion from the perspectives of middle and high school teachers and school administrators.

METHODS

A cross-sectional survey was administered to teachers and school administrators (grades 7-12) across Canada online via REDCap. Participants were recruited via word-of-mouth and social media sampling. Survey responses were analyzed descriptively using proportions.

RESULTS

The survey was completed by 180 educators (138 teachers and 41 school administrators), of whom 86% had previously provided academic accommodations to students following concussion, and 96% agreed that students should have access to accommodations following concussion. Some accommodations (eg, breaks, extra time) were provided more often and were more feasible to provide than others (eg, no new learning, reduced bright light). Educators reported limited preparation time and limited school personnel support to assist students following concussion.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

The most feasible accommodations should be prioritized, ensuring students are supported within the school environment.

CONCLUSIONS

Teachers and school administrators confirmed the importance of providing accommodations to students following concussion.

Are Self-Reported and Parent-Reported Attention Problems and Hyperactivity Associated With Higher Rates of Concussion in Youth Ice Hockey Players?

OBJECTIVE

To examine the association between self-reported and parent-reported attention problems and hyperactivity and rates of injury and concussion in Canadian youth ice hockey players.

DESIGN

Secondary analyses of 2 prospective cohort studies.

SETTING

Canadian youth ice hockey teams.

PARTICIPANTS

Ice hockey players (ages 11-17 years) were recruited by team, over 4 seasons (2011-2016). A combined 1709 players contributing 1996 player-seasons were analyzed (257 players participated in more than one season).

ASSESSMENT OF RISK FACTORS

Data were collected from preseason baseline questionnaires, including child and parent proxy forms of the Behavior Assessment System for Children, second edition.

MAIN OUTCOME MEASURES

Injury and concussion rates and incidence rate ratios (IRR) comparing players with and without self-identified or parent-identified attention problems and hyperactivity, adjusted for covariates (ie, body checking policy, previous injury/concussion, and age) and a random effect for team, were estimated using multiple multilevel negative binomial regression.

RESULTS

When analyzed continuously, rates of concussion increased with higher self-reported and parent-reported measures of attention problems [IRR SELF = 1.025; 95% confidence interval (CI): 1.011-1.040; IRR PARENT = 1.032; 95% CI: 1.008-1.057]. Self-reported hyperactivity was significantly associated with concussion (IRR = 1.021; 95% CI: 1.007-1.035), but parent-reported hyperactivity was not (IRR = 1.005; 95% CI: 0.983-1.028). A T score ≥ 60 cutoff combining attention problems and hyperactivity scores (an estimate of probable attention-deficit hyperactivity disorder) was not significantly associated with rates of injury or concussion.

CONCLUSIONS

Attention problems and hyperactivity may place youth ice hockey players at increased risk of concussion and injury. Preseason assessments could identify players for targeted concussion education and risk reduction strategies.

Structural brain network lateralization across childhood and adolescence

Developmental lateralization of brain function is imperative for behavioral specialization, yet few studies have investigated differences between hemispheres in structural connectivity patterns, especially over the course of development. The present study compares the lateralization of structural connectivity patterns, or topology, across children, adolescents, and young adults. We applied a graph theory approach to quantify key topological metrics in each hemisphere including efficiency of information transfer between regions (global efficiency), clustering of connections between regions (clustering coefficient [CC]), presence of hub-nodes (betweenness centrality [BC]), and connectivity between nodes of high and low complexity (hierarchical complexity [HC]) and investigated changes in these metrics during development. Further, we investigated BC and CC in seven functionally defined networks. Our cross-sectional study consisted of 211 participants between the ages of 6 and 21 years with 93% being right-handed and 51% female. Global efficiency, HC, and CC demonstrated a leftward lateralization, compared to a rightward lateralization of BC. The sensorimotor, default mode, salience, and language networks showed a leftward asymmetry of CC. BC was only lateralized in the salience (right lateralized) and dorsal attention (left lateralized) networks. Only a small number of metrics were associated with age, suggesting that topological organization may stay relatively constant throughout school-age development, despite known underlying changes in white matter properties. Unlike many other imaging biomarkers of brain development, our study suggests topological lateralization is consistent across age, highlighting potential nonlinear mechanisms underlying developmental specialization.

Early analgesic administration and headache presence 7 days post-concussion in children

OBJECTIVE

This study investigates whether acute treatment with ibuprofen, acetaminophen, or both is associated with resolution of headache or reduction of headache pain at 7 days post-concussion in children and youth.

METHODS

A secondary analysis of the Predicting and Preventing Post-concussive Problems in Pediatrics (5P) prospective cohort study was conducted. Individuals aged 5-18 years with acute concussion presenting to nine Canadian pediatric emergency departments (ED) were enrolled from August 2013 to June 2015. The primary outcome was the presence of headache at 7 days, measured using the Post-Concussion Symptom Inventory. The association between acute administration of ibuprofen, acetaminophen, or both and headache presence at 7 days was investigated with propensity scores and adjusted multivariate regression models.

RESULTS

2277 (74.3%) of 3063 participants had headache upon ED presentation. Of these participants, 1543 (67.8%) received an analgesic medication before or during their ED visit [ibuprofen 754 (33.1%), acetaminophen 445 (19.5%), both 344 (15.1%); or no medication 734 (32.2%)]. Multivariate analysis pertained to 1707 participants with propensity scores based on personal characteristics and symptoms; 877 (51.4%) reported headache at 7 days post-concussion. No association emerged between treatment and presence of headache at 7 days [ibuprofen vs. untreated: (relative risk (RR) = 1.12 (95% CI 0.99,1.26); acetaminophen vs untreated RR = 1.02 (95% CI 0.87,1.22); both vs untreated RR = 1.02 (95% CI 0.86,1.18)].

CONCLUSIONS

Exposure to ibuprofen, acetaminophen, or both in the acute phase does not decrease the risk of headache at 7 days post-concussion. Non-opioid analgesics like ibuprofen or acetaminophen may be prescribed for short-term headache relief but clinicians need to be cautious with long-term medication overuse in those whose headache symptoms persist.

Multimodal magnetic resonance imaging of youth sport-related concussion reveals acute changes in the cerebellum, basal ganglia, and corpus callosum that resolve with recovery

Magnetic resonance imaging (MRI) can provide a number of measurements relevant to sport-related concussion (SRC) symptoms; however, most studies to date have used a single MRI modality and whole-brain exploratory analyses in attempts to localize concussion injury. This has resulted in highly variable findings across studies due to wide ranging symptomology, severity and nature of injury within studies. A multimodal MRI, symptom-guided region-of-interest (ROI) approach is likely to yield more consistent results. The functions of the cerebellum and basal ganglia transcend many common concussion symptoms, and thus these regions, plus the white matter tracts that connect or project from them, constitute plausible ROIs for MRI analysis. We performed diffusion tensor imaging (DTI), resting-state functional MRI, quantitative susceptibility mapping (QSM), and cerebral blood flow (CBF) imaging using arterial spin labeling (ASL), in youth aged 12-18 years following SRC, with a focus on the cerebellum, basal ganglia and white matter tracts. Compared to controls similar in age, sex and sport (N = 20), recent SRC youth (N = 29; MRI at 8 ± 3 days post injury) exhibited increased susceptibility in the cerebellum (p = 0.032), decreased functional connectivity between the caudate and each of the pallidum (p = 0.035) and thalamus (p = 0.021), and decreased diffusivity in the mid-posterior corpus callosum (p < 0.038); no changes were observed in recovered asymptomatic youth (N = 16; 41 ± 16 days post injury). For recent symptomatic-only SRC youth (N = 24), symptom severity was associated with increased susceptibility in the superior cerebellar peduncles (p = 0.011) and reduced activity in the cerebellum (p = 0.013). Fewer days between injury and MRI were associated with reduced cerebellar-parietal functional connectivity (p < 0.014), reduced activity of the pallidum (p = 0.002), increased CBF in the caudate (p = 0.005), and reduced diffusivity in the central corpus callosum (p < 0.05). Youth SRC is associated with acute cerebellar inflammation accompanied by reduced cerebellar activity and cerebellar-parietal connectivity, as well as structural changes of the middle regions of the corpus callosum accompanied by functional changes of the caudate, all of which resolve with recovery. Early MRI post-injury is important to establish objective MRI-based indicators for concussion diagnosis, recovery assessment and prediction of outcome.

Criterion validity of the brief test of adult cognition by telephone (BTACT) for mild traumatic brain injury

OBJECTIVES

There is a growing demand for remote assessment options for measuring cognition after mild traumatic brain injury (mTBI). The current study evaluated the criterion validity of the Brief Test of Adult Cognition by Telephone (BTACT) in distinguishing between adults with mTBI and trauma controls (TC) who sustained injuries not involving the head or neck.

METHODS

The BTACT was administered to the mTBI (n = 46) and TC (n = 35) groups at 1-2 weeks post-injury. Participants also completed the Rivermead Post Concussion Symptoms Questionnaire.

RESULTS

The BTACT global composite score did not significantly differ between the groups (t(79) = -1.04, p = 0.30); the effect size was small (d = 0.23). In receiver operating characteristic curve analyses, the BTACT demonstrated poor accuracy in differentiating between the groups (AUC = 0.567, SE = 0.065, 95% CI [0.44, 0.69]). The BTACT's ability to discriminate between mTBI and TCs did not improve after excluding mTBI participants (n = 15) who denied ongoing cognitive symptoms (AUC = 0.567, SE = 0.072, 95% CI [0.43, 0.71]).

CONCLUSIONS

The BTACT may lack sensitivity to subacute cognitive impairment attributable to mTBI (i.e., not explained by bodily pain, post-traumatic stress, and other nonspecific effects of injury).

Longitudinal trends in incidence and health care use for pediatric concussion in Alberta, Canada

BACKGROUND

We described longitudinal trends in the incidence of episodes of care (EOC) and follow-up care for pediatric concussion in relation to age, sex, rurality of patient residence, point of care, and area-based socioeconomic status (SES) in Alberta, Canada.

METHODS

A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age who received a diagnosis of concussion, other specified injuries of head, unspecified injury of head, or post-concussion syndrome between April 1, 2004 and March 31, 2018. Data were geospatially mapped.

RESULTS

Concussion EOCs increased 2.2-fold over the study period, follow-up visits 5.1-fold. Care was increasingly received in physician office (PO) settings. Concussion diagnoses in rural and remote areas occurred in emergency department (ED) settings more often than in metro centres or urban areas (76%/75% vs. 52%/60%). Proportion of concussion diagnoses was positively related to SES and age. Diagnosis and point of care varied geographically.

CONCLUSIONS

The shift in care to PO settings, increased incidence of all diagnoses, and the higher use of the ED by some segments of the population all have important implications for appropriate clinical management and the efficient provision of health care for pediatric concussion.

IMPACT

This is the first study to use EOC to describe longitudinal trends in incidence and follow-up care for pediatric concussion in relation to age, sex, rurality, point of care, and area-based SES. We report increased incidence of concussion in both emergency and outpatient settings and the proportion of diagnoses was positively related to SES and age. Patients increasingly received care for concussion in PO over time. Geospatial mapping indicated that the incidence of concussion and unspecified injury of head varied geographically and temporally. Results have important implications for appropriate clinical management and efficient provision of health care following pediatric concussion.

Self-perception and behavioural outcomes of early acquired brain injury

Acquired brain injury (ABI) occurs commonly in young children. Despite this, the psychosocial implications of ABI in young children are not established, with little understood about the impacts on self-perception and self-esteem. In this study we investigated self-perception, self-esteem and behaviour of children with early ABI. Children with an ABI (n = 47) before six years were compared to 17 typically developing controls (TDCs) matched on demographics. Children were aged 6-12 years and completed the Harter Self-Perception Profile. One parent completed the Child Behavior Checklist. No differences for self-perception and self-esteem were found between the groups. Parents of children with an early ABI reported more internalizing and externalizing behaviours. Children with more externalizing behaviour and social skill problems had more negative self-perceptions. Interaction effects were seen between socioeconomic status (SES) and child self-perception and behaviour. Specifically, children from families of higher SES had a more positive perception of their appearance and children from lower SES backgrounds had more externalizing behaviours and social problems. The study suggests that the relationship between ABI and self-perception and self-esteem is complicated and that children with behavioural problems have lowered feelings of competence. SES has an important role in self-perception and behavioural outcomes.

Examining Parent Adverse Childhood Experiences as a Distal Risk Factor in Pediatric Chronic Pain

OBJECTIVES

Adverse childhood experiences (ACEs; ie, exposure to abuse, neglect, household dysfunction in childhood) are associated with poor mental and physical health outcomes across the lifespan. Emerging research suggests parent ACEs also confer risk for poor child outcomes. The relation between parent ACEs and child pain in youth with chronic pain has not yet been examined. The aim of the current longitudinal study was to examine the associations among parent ACEs, parent health, and child pain, in a clinical sample of youth with chronic pain.

METHODS

In total, 192 youth (75.5% female, 10 to 18 y old) and one of their parents (92.2% female) were recruited from tertiary pediatric chronic pain clinics in Canada. At baseline, parents completed self-report measures of ACEs, chronic pain status, anxiety and depressive symptoms, and posttraumatic stress disorder symptoms. At a 3-month follow-up, youth completed self-report measures of pain intensity and pain interference.

RESULTS

Regression and mediation analyses revealed that parent ACEs significantly predicted parent chronic pain status and depressive symptoms, but not parent anxiety or posttraumatic stress disorder symptoms. Moreover, parent ACEs were not significantly related to youth pain, either directly or indirectly through parent health variables.

DISCUSSION

Findings suggest that an intergenerational cascade from parent ACEs to parent health to child pain was not present in the current sample. Further research that examines the role of parent ACEs in the development of child chronic pain, as well as other risk and resiliency factors that may mediate or moderate the association between parent ACEs and child chronic pain, is needed.

Diffusion MRI Microstructural Abnormalities at Term-Equivalent Age Are Associated with Neurodevelopmental Outcomes at 3 Years of Age in Very Preterm Infants

BACKGROUND AND PURPOSE

Microstructural white matter abnormalities on DTI using Tract-Based Spatial Statistics at term-equivalent age are associated with cognitive and motor outcomes at 2 years of age or younger. However, neurodevelopmental tests administered at such early time points are insufficiently predictive of mild-moderate motor and cognitive impairment at school age. Our objective was to evaluate the microstructural antecedents of cognitive and motor outcomes at 3 years' corrected age in a cohort of very preterm infants.

MATERIALS AND METHODS

We prospectively recruited 101 very preterm infants (<32 weeks' gestational age) and performed DTI at term-equivalent age. The Differential Ability Scales, 2nd ed, Verbal and Nonverbal subtests, and the Bayley Scales of Infant and Toddler Development, 3rd ed, Motor subtest, were administered at 3 years of age. We correlated DTI metrics from Tract-Based Spatial Statistics with the Bayley Scales of Infant and Toddler Development, 3rd ed, and the Differential Ability Scales, 2nd ed, scores with correction for multiple comparisons.

RESULTS

Of the 101 subjects, 84 had high-quality DTI data, and of these, 69 returned for developmental testing (82%). Their mean (SD) gestational age was 28.4 (2.5) weeks, and birth weight was 1121.4 (394.1) g. DTI metrics were significantly associated with Nonverbal Ability in the corpus callosum, posterior thalamic radiations, fornix, and inferior longitudinal fasciculus and with Motor scores in the corpus callosum, internal and external capsules, posterior thalamic radiations, superior and inferior longitudinal fasciculi, cerebral peduncles, and corticospinal tracts.

CONCLUSIONS

We identified widespread microstructural white matter abnormalities in very preterm infants at term that were significantly associated with cognitive and motor development at 3 years' corrected age.

Lifestyle and Early Achievement in Families (LEAF) study: Design of an ambidirectional cohort study of prenatal marijuana exposure and child development and behaviour

BACKGROUND

Marijuana is the most-used illicit substance during pregnancy in the USA, but only two cohort studies, begun over 30 years ago, were specifically established to assess the association of pregnancy use with childhood outcomes. They found use to be associated with specific deficits in executive function at 8+ years, but did not focus on these outcomes earlier in life when intervention may be more successful. Two general purpose cohorts found increased aggression in exposed female toddlers and increased behavioural problems and tic disorders in exposed school-age children.

OBJECTIVES

The Lifestyle and Early Achievement in Families (LEAF) study assesses the association of in utero marijuana exposure, documented prospectively by biomarker, self-report, and medical records, with executive function and aggression at age 3½-7 years.

METHODS

This ambidirectional cohort (historical cohort with continued follow-up) includes women enrolled in the Perinatal Research Repository during prenatal care at Ohio State University Wexner Medical Center and their children, recontacted 3½-7 years post-birth. Children complete 1-2 study visits including cognitive testing, behavioural observation, and maternal and teacher report of behaviour. Family and social environmental factors are assessed.

RESULTS

Child follow-up began in September 2016; visits continue through August 2020. There are 362 eligible children; 32% had mothers who used marijuana during pregnancy, 10% of mothers completed college, and 23% did not complete high school. Mean maternal age at study registration in pregnancy was 26.4 years, and 63% of mothers were African American. To date, 268 children have completed at least 1 study visit.

CONCLUSIONS

The LEAF Study will document the association of prenatal marijuana exposure with development and behaviour in the current era when marijuana is more potent than when previous cohorts were studied. The results may inform policy and interventions to counsel reproductive-aged women about the risks of use during pregnancy and guide prevention and treatment of adverse effects among children.

Changes in exertion-related symptoms in adults and youth who have sustained a sport-related concussion

OBJECTIVES

To identify the symptoms responsible for cessation of exercise testing and evaluate changes in post-concussion symptom scores on the Post-Concussion Symptom Scale (PCSS) from the Sport-Concussion Assessment Tool (SCAT5) immediately, 1-4h, and 6-12h following completion of the Buffalo Concussion Treadmill Test (BCTT) in youth and adults who have sustained a sport-related concussion.

DESIGN

Prospective case-series.

METHODS

Individuals who were diagnosed with a sport-related concussion and self-reported difficulties with exertion were referred to perform an exertional treadmill test. Individuals were recruited from a university sports medicine clinic. Change in PCSS symptom severity scores were operationally defined as a change ≥4 points.

RESULTS

Forty-five individuals aged 13-57 years consented to participate. A total of 14/24 (58.3%) female and 13/21 (61.9%) male participants reported an increase in symptom severity scores immediately following the BCTT. At 1-4h, 5/10 (50.0%) males and 5/14 (35.7%) females who completed the PCSS had elevated symptom severity scores compared to pre-exertion. Only 24.2% (3/17 males and 5/16 females) of participants completing the PCSS at 6-12h reported increased symptom severity scores.

CONCLUSION

Exertional testing is an important component of a multifaceted assessment following concussion; however, previous research evaluating symptom responses to exertion is limited. This study provides evidence to suggest individuals who experience an exacerbation of concussion-associated symptoms after exertion are likely to return to pre-exertion levels within the same day. Future research monitoring symptoms following exertion and throughout recovery should be performed in tandem with physiological measures to better understand the source of symptoms.

Objectively Diagnosed Diffuse White Matter Abnormality at Term Is an Independent Predictor of Cognitive and Language Outcomes in Infants Born Very Preterm

OBJECTIVE

To externally validate the independent value of objectively diagnosed diffuse white matter abnormality (DWMA; also known as diffuse excessive high signal intensity) volume to predict neurodevelopmental outcomes in very preterm infants (≤31 weeks of gestational age).

STUDY DESIGN

A prospective, multicenter, regional population-based cohort study in 98 very preterm infants without severe brain injury on magnetic resonance imaging (MRI). DWMA volume was diagnosed objectively on structural MRI at term-equivalent age using our published algorithm. Multivariable linear regression was used to assess the value of DWMA volume to predict cognitive and language scores on the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) at 2 years corrected age.

RESULTS

Of the infants who returned for follow-up (n = 74), the mean (SD) gestational age was 28.2 (2.4) weeks, and 42 (56.8%) were boys. In bivariable analyses, DWMA volume was a significant predictor of Bayley-III cognitive and language scores. In multivariable analyses, controlling for known predictors of Bayley-III scores (ie, socioeconomic status, gestational age, sex, and global brain abnormality score), DWMA volume remained a significant predictor of cognitive (P < .001) and language (P = .04) scores at 2 years. When dichotomized, objectively diagnosed severe DWMA was a significant predictor of cognitive and language impairments, whereas visual qualitative diagnosis of DWMA was a poor predictor.

CONCLUSIONS

In this multicenter, prospective cohort study, we externally validated our previous findings that objectively diagnosed DWMA is an independent predictor of cognitive and language development in very preterm infants. We also demonstrated again that visually-diagnosed DWMA is not predictive of neurodevelopmental outcomes.

A commentary for neuropsychologists on CDC's guideline on the diagnosis and management of mild traumatic brain injury among children

Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline.Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline.Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices.Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.

Post-acute white matter microstructure predicts post-acute and chronic post-concussive symptom severity following mild traumatic brain injury in children

INTRODUCTION

Mild traumatic brain injury (TBI) is a global public health concern that affects millions of children annually. Mild TBI tends to result in subtle and diffuse alterations in brain tissue, which challenges accurate clinical detection and prognostication. Diffusion tensor imaging (DTI) holds promise as a diagnostic and prognostic tool, but little research has examined DTI in post-acute mild TBI. The current study compared post-acute white matter microstructure in children with mild TBI versus those with mild orthopedic injury (OI), and examined whether post-acute DTI metrics can predict post-acute and chronic post-concussive symptoms (PCS).

MATERIALS AND METHODS

Children aged 8-16.99 years with mild TBI (n = 132) or OI (n = 69) were recruited at emergency department visits to two children's hospitals, during which parents rated children's pre-injury symptoms retrospectively. Children completed a post-acute (<2 weeks post-injury) assessment, which included a 3T MRI, and 3- and 6-month post-injury assessments. Parents and children rated PCS at each assessment. Mean diffusivity (MD) and fractional anisotropy (FA) were derived from diffusion-weighted MRI using Automatic Fiber Quantification software. Multiple multivariable linear and negative binomial regression models were used to test study aims, with False Discovery Rate (FDR) correction for multiple comparisons.

RESULTS

No significant group differences were found in any of the 20 white matter tracts after FDR correction. DTI metrics varied by age and sex, and site was a significant covariate. No interactions involving group, age, and sex were significant. DTI metrics in several tracts robustly predicted PCS ratings at 3- and 6-months post-injury, but only corpus callosum genu MD was significantly associated with post-acute PCS after FDR correction. Significant group by DTI metric interactions on chronic PCS ratings indicated that left cingulum hippocampus and thalamic radiation MD was positively associated with 3-month PCS in the OI group, but not in the mild TBI group.

CONCLUSIONS

Post-acute white matter microstructure did not differ for children with mild TBI versus OI after correcting for multiple comparisons, but was predictive of post-acute and chronic PCS in both injury groups. These findings support the potential prognostic utility of this advanced DTI technique.

Docosahexaenoic and Arachidonic Acid Supplementation of Toddlers Born Preterm Does Not Affect Short-Term Growth or Adiposity

BACKGROUND

Dietary DHA intake among US toddlers is low. Healthy physical growth is an important objective for the clinical care of children born preterm.

OBJECTIVES

The aim of the trial was to examine the effects of supplementing toddlers born preterm with DHA and arachidonic acid (AA) for 180 d on growth and adiposity.

METHODS

Omega Tots, a randomized placebo-controlled trial, was conducted between April 2012 and March 2017. Children born at <35 wk gestation who were 10-16 mo in corrected age were assigned to receive daily oral supplements of DHA and AA (200 mg each, "DHA + AA") or corn oil (placebo) for 180 d. Prespecified secondary outcomes included weight, length, head circumference, mid-upper arm circumference, triceps and subscapular skinfolds, BMI, and their respective z scores, and body fat percentage, which were measured at baseline and trial completion. Mixed-effects regression was used to compare the change in outcomes between the DHA + AA and placebo groups, controlling for baseline values.

RESULTS

Among 377 children included in the analysis (median corrected age = 15.7 mo, 48.3% female), 348 (92.3%) had growth or adiposity data at baseline and trial end. No statistically significant differences between the DHA + AA and placebo groups in growth or adiposity outcomes were observed. For instance, the change in weight-for-age z scores was 0.1 for the DHA + AA group and 0.0 for the placebo group (effect size = 0.01, P = 0.99). However, post-hoc subgroup analyses revealed a statistically significant interaction between treatment group and sex, suggesting somewhat slower linear growth for females assigned to the DHA + AA group compared with the placebo group.

CONCLUSIONS

Among toddlers born preterm, daily supplementation with DHA + AA for 180 d resulted in no short-term differences in growth or adiposity compared with placebo. If DHA supplementation is implemented after the first year of life, it can be expected to have no effect on short-term growth or adiposity. This trial is registered with clinicaltrials.gov as NCT02199808.

Parenting Behaviors after Moderate - Severe Traumatic Injury in Early Childhood

Purpose: Examine the impact of traumatic brain injury (TBI) on parenting behavior over time. Method: Included 206 children (3-7 years old) with moderate to severe TBI or orthopedic injury, using a prospective longitudinal cohort study design. Assessments completed at baseline, 6-months, 12-months, 18-months, 3.5 years, and 6.8 years after injury. Dependent variables included authoritative, permissive, and authoritarian parenting. Results: Injury characteristics had limited impact on parenting behaviors over time. Levels of authoritative parenting remained stable over time; however, levels of warmth and involvement declined over time for those with TBI. Levels of permissive and authoritarian parenting declined for all participants by 3.5 years post injury. SES and stressors impacted parenting behaviors. Conclusions: While there was limited effect of TBI on parenting behavior over time, it remains unclear how individuals respond to these parenting behaviors years after injury. Clinicians should monitor family and parenting behaviors to foster an environment to promote positive recovery.

The Association Between Moderate and Vigorous Physical Activity and Time to Medical Clearance to Return to Play Following Sport-Related Concussion in Youth Ice Hockey Players

Design: Prospective cohort study.

Background: The recommendations regarding the optimal amount and type of rest for promoting recovery following concussion are based on expert opinion rather than evidence-based guidelines due to current a lack of high-level studies. There is an evident need for more research into the parameters of rest and activity and its effects on recovery from concussion.

Objective: To evaluate the association between the amount of moderate and vigorous physical activity (MVPA) during the first 3 days following concussion diagnosis and time to medical clearance (days) to return to play in youth ice hockey players.

Methods: Thirty youth ice hockey players (12–17 years) that were diagnosed with a concussion sustained during ice hockey were recruited to participate. The exposure was the cumulative amount of MVPA (minutes), measured using a waist-worn Actigraph accelerometer. Participants were dichotomized into high (≥148.5) and low (<148.5) activity groups based on the median of cumulative time spent in MVPA over the first 3 days following injury diagnosis.

Results: Participants in both the low and high activity group reported to the clinic at a median time of 4 days post-injury (low activity IQR: 3–5 days; high activity IQR: 3–7 days). The low activity group completed a median time of 110.7 min (IQR: 76.2–131.0 min) in MVPA, whereas the high activity had a median of 217.2 min (IQR 184.2–265.2 min) in MVPA. Kaplan Meier survival curves with Log-rank tests of hypothesis revealed the high activity group took significantly more time to be medically cleared to return to play (p = 0.041) compared to the low activity group.

Conclusion: The results from this study suggest that more time in MVPA early in the recovery period may result in a greater time to medical clearance to return to full participation in ice hockey. Future research, using valid measures of activity, are required to better understand the relationship between early activity and recovery following concussion in youth.

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.

Natural Progression of Symptom Change and Recovery From Concussion in a Pediatric Population

IMPORTANCE

The natural progression of symptom change and recovery remains poorly defined in children after concussion.

OBJECTIVES

To describe the natural progression of symptom change by age group (5-7, 8-12, and 13-18 years) and sex, as well as to develop centile curves to inform families about children after injury recovery.

DESIGN, SETTING, AND PARTICIPANTS

Planned secondary analysis of a prospective multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics). The setting was 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network. Participants were aged 5 to 18 years with acute concussion, enrolled from August 1, 2013, to May 31, 2015, and data analyses were performed between January 2018 and March 2018.

EXPOSURES

Participants had a concussion consistent with the Zurich Consensus Statement on Concussion in Sport diagnostic criteria and 85% completeness of the Postconcussion Symptom Inventory (PCSI) at each time point.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom change, defined as current rating minus preinjury rating (delta score), at presentation and 1, 2, 4, 8, and 12 weeks after injury, measured using the PCSI. Symptoms were self-rated for ages 8 to 18 years and rated by the child and parent for ages 5 to 7 years. The secondary outcome was recovery, defined as no change in symptoms relative to current preinjury PCSI ratings (delta score = 0). Mixed-effects models incorporated the total score, adjusting for random effects (site and participant variability), fixed-effects indicators (age, sex, time, age by time interaction, and sex by time interaction), and variables associated with recovery. Recovery centile curves by age and sex were computed.

RESULTS

A total of 3063 children (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 60.7% male) completed the primary outcome; 2716 were included in the primary outcome analysis. For the group aged 5 to 7 years, symptom change primarily occurred the first week after injury; by 2 weeks, 75.6% of symptoms had improved (PCSI change between 0 and 2 weeks, -5.3; 95% CI, -5.5 to -5.0). For the groups aged 8 to 12 years and 13 to 18 years, symptom change was prominent the first 2 weeks but flattened between 2 and 4 weeks. By 4 weeks, 83.6% and 86.2% of symptoms, respectively, had improved for the groups aged 8 to 12 years (PCSI change between 0 and 4 weeks, -9.0; 95% CI, -9.6 to -8.4) and 13 to 18 years (PCSI change between 0 and 4 weeks, -28.6; 95% CI, -30.8 to -26.3). Sex by time interaction was significant only for the adolescent group (β = 0.32; 95% CI, 0.21-0.43; P < .001). Most adolescent girls had not recovered by week 12.

CONCLUSIONS AND RELEVANCE

Symptom improvement primarily occurs in the first 2 weeks after concussion in children and in the first 4 weeks after concussion in preadolescents and male adolescents. Female adolescents appear to have protracted recovery. The derived recovery curves may be useful for evidence-based anticipatory guidance.

Decomposing the within-person and between-person sources of variation in physical activity-cognition associations for low-active older adults

OBJECTIVES

To examine within-person and between-person sources of variation in the relationship between physical activity and cognition in older adults participating in a walking program. To explore whether demographic, health and fitness variables, and their interactions with activity, are significant predictors of cognition.

DESIGN

Brief longitudinal burst design.

PARTICIPANTS

118 participants (91 females, mean age = 72.81 + 5.24 years).

MAIN OUTCOME MEASURES

Cognition, self-reported moderate-to-vigorous walking and self-reported moderate-to-vigorous physical activity were assessed at baseline and 6, 9, 12 and 16 weeks follow-up. Attendance at weekly walks was also recorded.

RESULTS

Within-persons, changes in physical activity were related to select measures of executive functioning, with increased activity predictive of better cognition (three of four cognitive functions, p<.05). Between-persons, activity was also associated with cognition (two of four cognitive functions, p<.05). Younger age and higher education were related to better cognition. Interactions of demographic, health, and fitness variables with changes in within-person activity were generally non-significant.

CONCLUSION

The results highlight the importance of distinguishing within- from between-person effects in longitudinal analyses of the association between physical activity and cognition. This stringent within-person test of association underscores the potential value of simple physical activity interventions for improving cognitive function.

National Institute of Neurological Disorders and Stroke and Department of Defense Sport-Related Concussion Common Data Elements Version 1.0 Recommendations

Through a partnership with the National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health, and Department of Defense, the development of Sport-Related Concussion (SRC) Common Data Elements (CDEs) was initiated. The aim of this collaboration was to increase the efficiency and effectiveness of clinical research studies and clinical treatment outcomes, increase data quality, facilitate data sharing across studies, reduce study start-up time, more effectively aggregate information into metadata results, and educate new clinical investigators. The SRC CDE Working Group consisted of 32 worldwide experts in concussion from varied fields of related expertise divided into three Subgroups: Acute (<72 h post-concussion), Subacute (3 days-3 months post-concussion) and Persistent/Chronic (>3 months post-concussion). To develop CDEs, the Subgroups reviewed various domains, then selected from, refined, and added to existing CDEs, case report forms and field-tested data elements from national registries and funded research studies. Recommendations were posted to the NINDS CDE Website for Public Review from February 2017 to April 2017. Following an internal Working Group review of recommendations, along with consideration of comments received from the Public Review period, the first iteration (Version 1.0) of the NINDS SRC CDEs was completed in June 2017. The recommendations include Core and Supplemental-Highly Recommended CDEs for cognitive data elements and symptom checklists, as well as other outcomes and end-points (e.g., vestibular, oculomotor, balance, anxiety, depression), and sample case report forms (e.g., injury reporting, demographics, concussion history) for domains typically included in clinical research studies. The NINDS SRC CDEs and supporting documents are publicly available on the NINDS CDE website www.commondataelements.ninds.nih.gov . Widespread use of CDEs by researchers and clinicians will facilitate consistent SRC clinical research and trial design, data sharing, and metadata retrospective analysis.

Teen online problem solving for teens with traumatic brain injury: Rationale, methods, and preliminary feasibility of a teen only intervention

PURPOSE/OBJECTIVE

To describe the Teen Online Problem Solving-Teen Only (TOPS-TO) intervention relative to the original Teen Online Problem Solving-Family (TOPS-F) intervention, to describe a randomized controlled trial to assess intervention efficacy, and to report feasibility and acceptability of the TOPS-TO intervention. Research method and design: This is a multisite randomized controlled trial, including 152 teens (49 TOPS-F, 51 TOPS-TO, 52 IRC) between the ages of 11-18 who were hospitalized for a moderate to severe traumatic brain injury in the previous 18 months. Assessments were completed at baseline, 6-months post baseline, and 12-months post baseline. Data discussed include adherence and satisfaction data collected at the 6-month assessment (treatment completion) for TOPS-F and TOPS-TO.

RESULTS

Adherence measures (sessions completed, dropout rates, duration of treatment engagement, and rates of program completion) were similar across treatment groups. Overall, teen and parent reported satisfaction was high and similar across groups. Teens spent a similar amount of time on the TOPS website across groups, and parents in the TOPS-F spent more time on the TOPS website than those in the TOPS-TO group (p = .002). Parents in the TOPS-F group rated the TOPS website as more helpful than those in the TOPS-TO group (p = .05).

CONCLUSIONS/IMPLICATIONS

TOPS-TO intervention is a feasible and acceptable intervention approach. Parents may perceive greater benefit from the family based intervention. Further examination is required to understand the comparative efficacy in improving child and family outcomes, and who is likely to benefit from each approach. (PsycINFO Database Record

Processing speed in children treated for brain tumors: effects of radiation therapy and age

The current study examined processing speed in children two years post-treatment for brain tumors (BT) with radiation therapy (RT) compared to those treated with without RT. Participants included 59 children (4-17 years) with BT assessed as part of the Brain Radiation Investigative Study Consortium (BRISC). Processing speed was assessed at two time points: Time1 (3-9 months post-surgery) for 26 children who received whole brain or focal RT (RT group) and 33 treated without RT (no-RT group), and again two years later (Time2) for 42 participants (17 RT, 25 no-RT). Linear mixed effects (LME) regression analyses examined differences in cognitive and motor speed between groups and across visits, with age at Time1 (age1) treated as a moderating variable, and sex and primary tumor size as covariates. No effects for treatment group or visit were found for motor speed (Pegboard) or mean reaction time (Attention Network Task). On the Wechsler Processing Speed Index (PSI), the no-RT group performed better than the RT group, with a group-by-age interaction such that across visits, the difference between the no-RT and RT groups was larger among children who were older at initial treatment (≥10 years) than among those who were younger (<10 years). Cumulative brain injury earlier in life (tumor, surgery, plus RT) may result in greater impact on more complex tasks of cognitive efficiency. Children receiving RT showed reduced processing speed over time, with a larger group difference among those who were over 10 years at treatment.

Age- and sex-related effects in children with mild traumatic brain injury on diffusion magnetic resonance imaging properties: A comparison of voxelwise and tractography methods

Although there are several techniques to analyze diffusion-weighted imaging, any technique must be sufficiently sensitive to detect clinical abnormalities. This is especially critical in disorders like mild traumatic brain injury (mTBI), where pathology is likely to be subtle. mTBI represents a major public health concern, especially for youth under 15 years of age. However, the developmental period from birth to 18 years is also a time of tremendous brain changes. Therefore, it is important to establish the degree of age- and sex-related differences. Participants were children aged 8-15 years with mTBI or mild orthopedic injuries. Imaging was obtained within 10 days of injury. We performed tract-based spatial statistics (TBSS), deterministic tractography using Automated Fiber Quantification (AFQ), and probabilistic tractography using TRACULA (TRActs Constrained by UnderLying Anatomy) to evaluate whether any method provided improved sensitivity at identifying group, developmental, and/or sex-related differences. Although there were no group differences from any of the three analyses, many of the tracts, but not all, revealed increases of fractional anisotropy and decreases of axial, radial, and mean diffusivity with age. TBSS analyses resulted in age-related changes across all white matter tracts. AFQ and TRACULA revealed age-related changes within the corpus callosum, cingulum cingulate, corticospinal tract, inferior and superior longitudinal fasciculus, and uncinate fasciculus. The results are in many ways consistent across all three methods. However, results from the tractography methods provided improved sensitivity and better tract-specific results for identifying developmental and sex-related differences within the brain.

White matter microstructure predicts longitudinal social cognitive outcomes after paediatric traumatic brain injury: a diffusion tensor imaging study

BACKGROUND

Deficits in social cognition may be among the most profound and disabling sequelae of paediatric traumatic brain injury (TBI); however, the neuroanatomical correlates of longitudinal outcomes in this domain remain unexplored. This study aimed to characterize social cognitive outcomes longitudinally after paediatric TBI, and to evaluate the use of sub-acute diffusion tensor imaging (DTI) to predict these outcomes.

METHODS

The sample included 52 children with mild complex-severe TBI who were assessed on cognitive theory of mind (ToM), pragmatic language and affective ToM at 6- and 24-months post-injury. For comparison, 43 typically developing controls (TDCs) of similar age and sex were recruited. DTI data were acquired sub-acutely (mean = 5.5 weeks post-injury) in a subset of 65 children (TBI = 35; TDC = 30) to evaluate longitudinal prospective relationships between white matter microstructure assessed using Tract-Based Spatial Statistics and social cognitive outcomes.

RESULTS

Whole brain voxel-wise analysis revealed significantly higher mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) in the sub-acute TBI group compared with TDC, with differences observed predominantly in the splenium of the corpus callosum (sCC), sagittal stratum (SS), dorsal cingulum (DC), uncinate fasciculus (UF) and middle and superior cerebellar peduncles (MCP & SCP, respectively). Relative to TDCs, children with TBI showed poorer cognitive ToM, affective ToM and pragmatic language at 6-months post-insult, and those deficits were related to abnormal diffusivity of the sCC, SS, DC, UF, MCP and SCP. Moreover, children with TBI showed poorer affective ToM and pragmatic language at 24-months post-injury, and those outcomes were predicted by sub-acute alterations in diffusivity of the DC and MCP.

CONCLUSIONS

Abnormal microstructure within frontal-temporal, limbic and cerebro-cerebellar white matter may be a risk factor for long-term social difficulties observed in children with TBI. DTI may have potential to unlock early prognostic markers of long-term social outcomes.

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.

Uncovering the neuroanatomical correlates of cognitive, affective and conative theory of mind in paediatric traumatic brain injury: a neural systems perspective

Deficits in theory of mind (ToM) are common after neurological insult acquired in the first and second decade of life, however the contribution of large-scale neural networks to ToM deficits in children with brain injury is unclear. Using paediatric traumatic brain injury (TBI) as a model, this study investigated the sub-acute effect of paediatric traumatic brain injury on grey-matter volume of three large-scale, domain-general brain networks (the Default Mode Network, DMN; the Central Executive Network, CEN; and the Salience Network, SN), as well as two domain-specific neural networks implicated in social-affective processes (the Cerebro-Cerebellar Mentalizing Network, CCMN and the Mirror Neuron/Empathy Network, MNEN). We also evaluated prospective structure-function relationships between these large-scale neural networks and cognitive, affective and conative ToM. 3D T1- weighted magnetic resonance imaging sequences were acquired sub-acutely in 137 children [TBI: n = 103; typically developing (TD) children: n = 34]. All children were assessed on measures of ToM at 24-months post-injury. Children with severe TBI showed sub-acute volumetric reductions in the CCMN, SN, MNEN, CEN and DMN, as well as reduced grey-matter volumes of several hub regions of these neural networks. Volumetric reductions in the CCMN and several of its hub regions, including the cerebellum, predicted poorer cognitive ToM. In contrast, poorer affective and conative ToM were predicted by volumetric reductions in the SN and MNEN, respectively. Overall, results suggest that cognitive, affective and conative ToM may be prospectively predicted by individual differences in structure of different neural systems-the CCMN, SN and MNEN, respectively. The prospective relationship between cerebellar volume and cognitive ToM outcomes is a novel finding in our paediatric brain injury sample and suggests that the cerebellum may play a role in the neural networks important for ToM. These findings are discussed in relation to neurocognitive models of ToM. We conclude that detection of sub-acute volumetric abnormalities of large-scale neural networks and their hub regions may aid in the early identification of children at risk for chronic social-cognitive impairment.

Internet-based Interacting Together Everyday, Recovery After Childhood TBI (I-InTERACT): Protocol for a multi-site randomized controlled trial of an internet-based parenting intervention

Objectives

We discuss the rationale and description of the Internet-Based Interacting Together Everyday, Recovery After Childhood TBI (I-InTERACT), a telehealth intervention designed to promote positive parenting skills through live in-session skills practice and coaching. A second objective is to describe the protocol of a three-armed (Internet Resource Comparison, I-InTERACT, and I-InTERACT Express) multi-site randomized controlled trial (RCT) designed to examine intervention effectiveness.

Method

Participants included parents of children ages 3–9 who sustained a moderate or severe traumatic brain injury (TBI) any time since birth. Measures assessing parenting behaviors, parent–child interaction, parent/family factors, and child factors were collected prior to intervention, 3 months after enrollment and 6-months after enrollment.

Results

This protocol manuscript was submitted before the completion of data collection and prior to any data analysis. It is expected that the I-InTERACT and I-InTERACT Express interventions will be associated with an increase in positive parenting behaviors, and a decrease in negative parenting behaviors, parental distress, and child behavior problems. Finally it is expected that socioeconomic status, life stressors, and social resources will moderate treatment effects.

Conclusions

The study described in this protocol paper represents one of the first large multi-site RCTs of a parenting intervention designed to promote positive parenting skills in families with young children who sustained a TBI. We plan to disseminate findings to patients and families as well as clinical and research professionals, and begin to develop a research base for this telehealth intervention.

Reducing concussion symptoms among teenage youth: Evaluation of a mobile health app

OBJECTIVE

To evaluate whether a mobile health application that employs elements of social game design could compliment medical care for unresolved concussion symptoms.

DESIGN

Phase I and Phase II (open-label, non-randomized, ecological momentary assessment methodology).

SETTING

Outpatient concussion clinic.

PARTICIPANTS

Youth, aged 13-18 years, with concussion symptoms 3+ weeks after injury; Phase I: n = 20; Phase II: n = 19.

INTERVENTIONS

Participants received standard of care for concussion. The experimental group also used a mobile health application as a gamified symptoms journal.

OUTCOME MEASURES

Phase I: feasibility and satisfaction with intervention (7-point Likert scale, 1 high). Phase II: change in SCAT-3 concussion symptoms (primary), depression and optimism.

RESULTS

Phase 1: A plurality of participants completed the intervention (14 of 20) with high use (110 +/- 18% play) and satisfaction (median +/- interquartile range (IQR) = 2.0+/- 0.0). Phase II: Groups were equivalent on baseline symptoms, intervention duration, gender distribution, days since injury and medication prescription. Symptoms and optimism improved more for the experimental than for the active control cohort (U = 18.5, p = 0.028, effect size r = 0.50 and U = 18.5, p = 0.028, effect size r = 0.51, respectively).

CONCLUSIONS

Mobile apps incorporating social game mechanics and a heroic narrative may promote health management among teenagers with unresolved concussion symptoms.

Problem-Solving After Traumatic Brain Injury in Adolescence: Associations With Functional Outcomes

OBJECTIVE

To examine the association of problem-solving with functioning in youth with traumatic brain injury (TBI).

DESIGN

Cross-sectional evaluation of pretreatment data from a randomized controlled trial.

SETTING

Four children's hospitals and 1 general hospital, with level 1 trauma units.

PARTICIPANTS

Youth, ages 11 to 18 years, who sustained moderate or severe TBI in the last 18 months (N=153).

MAIN OUTCOME MEASURES

Problem-solving skills were assessed using the Social Problem-Solving Inventory (SPSI) and the Dodge Social Information Processing Short Stories. Everyday functioning was assessed based on a structured clinical interview using the Child and Adolescent Functional Assessment Scale (CAFAS) and via adolescent ratings on the Youth Self Report (YSR). Correlations and multiple regression analyses were used to examine associations among measures.

RESULTS

The TBI group endorsed lower levels of maladaptive problem-solving (negative problem orientation, careless/impulsive responding, and avoidant style) and lower levels of rational problem-solving, resulting in higher total problem-solving scores for the TBI group compared with a normative sample (P<.001). Dodge Social Information Processing Short Stories dimensions were correlated (r=.23-.37) with SPSI subscales in the anticipated direction. Although both maladaptive (P<.001) and adaptive (P=.006) problem-solving composites were associated with overall functioning on the CAFAS, only maladaptive problem-solving (P<.001) was related to the YSR total when outcomes were continuous. For the both CAFAS and YSR logistic models, maladaptive style was significantly associated with greater risk of impairment (P=.001).

CONCLUSIONS

Problem-solving after TBI differs from normative samples and is associated with functional impairments. The relation of problem-solving deficits after TBI with global functioning merits further investigation, with consideration of the potential effects of problem-solving interventions on functional outcomes.

Maternal and Paternal Distress and Coping Over Time Following Pediatric Traumatic Brain Injury

Objective

Examine differences in maternal and paternal coping and distress following traumatic brain injury (TBI) and orthopedic injuries (OI).

Method

Concurrent cohort/prospective design with five assessments between 1 and an average of 7 years after injury of children aged 3-6 years hospitalized for TBI ( n  = 87) or OI ( n  = 119). Mixed models analyses were used to examine hypotheses.

Results

Overall, fathers reported greater depression and general distress than mothers 18 months after injury, but not at long-term follow-up. Active and acceptance coping were unrelated to parental sex, injury factors, or time since injury. A group × rater × time interaction was noted for Denial coping. Following severe TBI, fathers reported greater denial at 18 months, whereas mothers reported greater denial at the long-term follow-up. Denial coping did not differ between mothers and fathers following OI and moderate TBI.

Conclusions

Parental response to early TBI is complex and may warrant clinical intervention even years after injury.

Association of Persistent Postconcussion Symptoms With Pediatric Quality of Life

IMPORTANCE

Persistent postconcussion symptoms (PPCS) pose long-term challenges and can negatively affect patients' health-related quality of life (HRQoL). To date, no large comprehensive study has addressed the association between PPCS and HRQoL.

OBJECTIVES

To determine the association between HRQoL and PPCS at 4 weeks after concussion and assess the degree of impairment of HRQoL in the subsequent 12 weeks.

DESIGN, SETTING, AND PARTICIPANTS

In a prospective, multicenter cohort study (Predicting Persistent Postconcussive Problems in Pediatrics [5P]) from August 14, 2013, to September 30, 2014, children aged 5 to 18 years who presented to the emergency department within 48 hours after head injury and were considered to have an acute concussion were enrolled across 9 pediatric emergency departments within the Pediatric Emergency Research Canada Network. Persistent postconcussion symptoms were defined as 3 or more persistent symptoms on the validated Post-Concussion Symptom Inventory at 4 weeks. Linear mixed effects random coefficients models evaluated the association between PPCS and HRQoL, adjusting for potential confounders including age, sex, prior concussions, migraine, anxiety, learning disability, depression, and sleep disorder.

MAIN OUTCOMES AND MEASURES

The primary outcome was HRQoL assessed with the validated Pediatric Quality of Life Inventory version 4.0 (PedsQL-4.0) at 4, 8, and 12 weeks after head injury.

RESULTS

Of 2006 children enrolled (median age, 11.8 years [interquartile range, 8.9-14.6 years]; 1241 boys and 765 girls), 1667 (83.1%) completed the PedsQL-4.0 at all 3 time points. Of these 1667 children, the 510 with PPCS (30.6%) had lower total PedsQL-4.0 scores (mean, 70.0) than did those without PPCS (mean, 80.3; mean difference, -10.3; 95% CI, -9.4 to -11.2). Patients with PPCS also had significantly lower physical, emotional, social, and school PedsQL-4.0 subscores at 4, 8, and 12 weeks. Patients with PPCS had lower HRQoL than published healthy norms at 4 weeks (mean difference, 13.89; 95% CI, 11.55-16.23), 8 weeks (mean difference, 11.63; 95% CI, 9.34-13.93), and 12 weeks (mean difference, 9.38; 95% CI, 7.01-11.75; P < .001). Patients who recovered from concussion also had lower HRQoL than norms at 4 weeks (mean difference, 3.56; 95% CI, 1.28-5.85) and 8 weeks (mean difference, 2.75; 95% CI, 0.48-5.02; P < .05). School functioning PedsQL-4.0 subscores were significantly lower for all children regardless of PPCS status at all time points.

CONCLUSIONS AND RELEVANCE

Children with PPCS have lower HRQoL compared with those who have recovered from concussion, yet deficits in HRQoL are pervasive across all domains and may persist for months even in children whose symptoms have resolved. Future interventional research should target the effect of concussion on HRQoL.

Children with Traumatic Brain Injury: Associations Between Parenting and Social Adjustment

Similarities and differences in parenting practices of children (Mage = 10; range 8-13 years) with traumatic brain injury (TBI) and socially-typical controls were examined. In addition, parenting practices were examined as moderators between injury group status (TBI or socially-typical) and social adjustment in the peer group. Mothers completed assessments of parenting practices; children's peers reported about children's social adjustment. The mothers of children with TBI reported significantly lower levels of nurturance and significantly higher levels of restrictiveness than mothers of socially-typical children. In addition, mothers' nurturance moderated the relation between injury group and peer rejection, such that children with TBI were more rejected by classmates compared to their socially-typical peers at low levels of maternal nurturance. The findings are interpreted as supporting the important role parents play in the development of children with a history of TBI, as well as the implications for family-level interventions.

Predictors of adaptive functioning and psychosocial adjustment in children with pediatric brain tumor: a report from the Brain Radiation Investigative Study Consortium

BACKGROUND

Children are at risk for psychosocial and adaptive morbidities following diagnosis of and treatment for a pediatric brain tumor. This study examined whether familial/demographic, developmental, diagnostic, or treatment-related variables best predict the acute psychosocial adjustment and adaptive functioning of children soon after an initial diagnosis.

PROCEDURE

Participants included 56 children (mean age = 10.72, SD = 4.02) newly diagnosed with a pediatric brain tumor. Parents completed background/demographic forms and completed ratings of children's behavioral and emotional symptoms, and adaptive behavior. Diagnostic and treatment-related information was abstracted from medical records.

RESULTS

Parent ratings of behavioral symptoms and adaptive functioning were within normative expectation, although rates of clinical impairment in adaptive functioning exceeded expected rates. A combination of familial/demographic and diagnostic variables were associated with acute functioning. In multiple regressions, tumor size best predicted adaptive functioning after initial diagnosis, whereas tumor location best predicted variance in behavioral symptoms.

CONCLUSIONS

Children may be more vulnerable to acute impairment in adaptive functioning following diagnosis of a pediatric brain tumor, but rates of behavioral symptoms were within expectation. Familial, sociodemographic, and diagnostic variables may help to identify those most at risk of impairment. Screening of these factors within tertiary care settings will be useful to identify those most in need of psychosocial care during the initial phases of treatment.

Neurodevelopmental outcome after cardiac surgery utilizing cardiopulmonary bypass in children

Introduction:

Modulating the stress response and perioperative factors can have a paramount impact on the neurodevelopmental outcome of infants who undergo cardiac surgery utilizing cardiopulmonary bypass.

Materials and Methods:

In this single center prospective follow-up study, we evaluated the impact of three different anesthetic techniques on the neurodevelopmental outcomes of 19 children who previously underwent congenital cardiac surgery within their 1^st year of life. Cases were done from May 2011 to December 2013. Children were assessed using the Stanford-Binet Intelligence Scales (5^th edition). Multiple regression analysis was used to test different parental and perioperative factors that could significantly predict the different neurodevelopmental outcomes in the entire cohort of patients.

Results:

When comparing the three groups regarding the major cognitive scores, a high-dose fentanyl (HDF) patients scored significantly higher than the low-dose fentanyl (LDF) + dexmedetomidine (DEX) (LDF + DEX) group in the quantitative reasoning scores (106 ± 22 vs. 82 ± 15 P = 0.046). The bispectral index (BIS) value at the end of surgery for the -LDF group was significantly higher than that in LDF + DEX group (P = 0.011). For the entire cohort, a strong correlation was seen between the standard verbal intelligence quotient (IQ) score and the baseline adrenocorticotropic hormone level, the interleukin-6 level at the end of surgery and the BIS value at the end of the procedure with an R² value of 0.67 and P < 0.04. There was an inverse correlation between the cardiac Intensive Care Unit length of stay and the full-scale IQ score (R = 0.4675 and P 0.027).

Conclusions:

Patients in the HDF group demonstrated overall higher neurodevelopmental scores, although it did not reach statistical significance except in fluid reasoning scores. Our results may point to a possible correlation between blunting the stress response and improvement of the neurodevelopmental outcome.

Pediatric stroke outcome measure: predictor of multiple impairments in childhood stroke

The ability to anticipate deficits would help with implementation of interventions for children affected by stroke. The pediatric stroke outcome measure (measure) measures neurological impairment after stroke, but there has been little research examining the relationship between the measure and functional outcomes. We hypothesized the Measure correlates with cognitive and behavioral outcomes. Thirty-six children with stroke were assessed with the Measure, and tested for cognitive ability, problem behavior, adaptive behavior, and social participation. We examined the correlation between the total Measure and outcomes and determined how subscale scores associated with outcomes. Higher total Measure scores correlated with poorer outcomes in cognitive ability, problem behaviors, adaptive behaviors, and social participation. Specific subscale scores correlated with poorer outcomes in multiple domains. The total Measure can be used to anticipate poor outcomes in multiple domains after stroke and can help the clinician in the treatment of children as they recover.

Temperament and social behavior in pediatric brain tumor survivors and comparison peers

OBJECTIVE

To examine the role of temperament (i.e., surgency/positive affect, negative affect, and effortful control) in the social behavior of pediatric brain tumor survivors and comparison classmates.

METHODS

Parent-, peer-, and self-report data were collected for 75 children after treatment for a brain tumor, and 67 comparison classmates. Tests of mediation and moderated mediation were run to examine whether effortful control accounted for group differences in social behavior and whether this indirect effect was moderated by surgency/positive or negative affectivity.

RESULTS

Peers described survivors as lower in Leadership-popularity and higher in Sensitivity-isolation and victimization than comparison classmates. Parent and self-report of surgency/positive affect revealed survivors were lower on this dimension. Survivors were rated by parents as demonstrating less effortful control. Effortful control did not consistently account for group differences in social behavior. There was limited evidence of moderated mediation.

CONCLUSIONS

Research on the implications of potential changes in temperament following treatment is warranted.

Sleep problems and their relationship to cognitive and behavioral outcomes in young children with traumatic brain injury

This study examined the effect of traumatic brain injury (TBI) in young children on sleep problems and the relationship of sleep problems to neuropsychological and psychosocial functioning. Participants were drawn from an ongoing longitudinal study of injury in young children recruited from 3 to 6 years of age. They constituted three groups: orthopedic injury (OI; n=92), complicated mild/moderate TBI (mTBI; n=55); and severe TBI (sTBI; n=20). Caregivers completed the Children's Sleep Habits Questionnaire (CSHQ), as well as ratings of behavioral adjustment, adaptive functioning, and everyday executive function at 1, 6, 12, and 18 months postinjury. Retrospective ratings of preinjury sleep and psychosocial functioning were obtained at the initial assessment. Children completed neuropsychological testing at all occasions. Children with complicated mTBI demonstrated more total sleep problems than children with OI at 6 months postinjury, but not at 12 or 18 months. Children with sTBI displayed more bedtime resistance and shorter sleep duration than those with complicated mTBI or OI at several occasions. Across groups, total sleep problems predicted more emotional and behavioral problems and worse everyday executive function as rated by parents across follow-up occasions. In contrast, sleep problems were generally not related to neuropsychological test performance. The results suggest that young children with TBI demonstrate more sleep problems than children with injuries not involving the head. Sleep problems, in turn, significantly increase the risk of poor psychosocial outcomes across time, but are not associated with worse neuropsychological test performance.

Maternal warm responsiveness and negativity following traumatic brain injury in young children

PURPOSE/OBJECTIVE

To understand how traumatic brain injury (TBI) affects maternal warm responsiveness and negativity over the first 12 months following injury.

METHOD/DESIGN

We used a concurrent cohort research design to examine dyadic interactions in young children with a TBI (n = 78) and a comparison group of young children with orthopedic injuries (OI; n = 112) and their families during the initial weeks following injury (i.e., baseline) and at two follow-up periods (approximately 6 and 12 months later). Trained raters coded videotaped interactions during a free play and structured teaching task for maternal warm responsiveness and negativity.

RESULTS

Mothers in the complicated mild/moderate TBI group, but not those in the severe TBI group, exhibited significantly lower levels of maternal warm responsiveness than mothers in the OI group. However, these differences were observed only at baseline during free play and only at baseline and 6 months postinjury during the structured teaching task, suggesting diminishing adverse effects of complicated mild/moderate TBI on parenting over time postinjury. Analysis failed to reveal group differences in maternal negativity at any of the assessments. Across groups, lower socioeconomic status (SES) was associated with lower levels of warm responsiveness and higher levels of negativity.

CONCLUSIONS/IMPLICATIONS

These findings, though preliminary, indicate possible alterations in mother-child interactions in the months following a TBI.

Susceptibility weighted imaging and its relationship to outcome after pediatric traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) sustained during childhood can cause difficulties in a wide range of physical, neurological, cognitive, social and functional domains. However, the ability of health professionals and researchers to accurately predict the outcome of pediatric TBI remains limited. The advent of advanced neuroimaging techniques shows some promise in improving outcome prediction, as they contribute to greater sensitivity in characterizing intracranial lesions underlying many cognitive and functional deficits. In this study, the relationship between lesions identified on susceptibility weighted imaging (SWI) and cognitive and functional outcomes was investigated following childhood TBI.

METHOD

Participants between 5 and 14 years of age with varying levels of TBI severity (mild, mild complicated, moderate, severe, n = 106) underwent susceptibility weighted scanning on average 1-month post-injury and completed an assessment of intellectual functioning, processing speed, and behavioral and adaptive skills 6-month post-injury.

RESULTS

More severe TBI was generally associated with poorer intellectual functioning, greater behavioral problems and lower adaptive functioning. Number and volume of SWI lesions were significantly correlated with clinical outcome variables including Glasgow Coma Score (GCS), surgical intervention, length of hospital stay and length of intubation, as well as with intellectual functioning. Together, SWI and GCS accounted for a significant, though small, proportion of the variance in intellectual quotient (IQ).

CONCLUSIONS

SWI is a sensitive technique for detecting brain lesions at all TBI severity levels and shows promise in contributing to prediction of cognitive outcomes in the initial stages post-injury.

Recommendations for the use of common outcome measures in pediatric traumatic brain injury research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroup's recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Abstract 2373: Childhood Stroke Impairs Functional Behavior

BACKGROUND: Stroke can affect children with long-term impairment of intellectual ability and increased risk of attention deficits and psychiatric disorders. Although limited studies in the literature suggest that stroke can chronically impair functional behavior and social adaptation, these functional outcomes have received little attention. We performed a pilot case-control study to examine the hypothesis that pediatric stroke impairs adaptive behavior, and we addressed the secondary hypotheses that stroke volume and location predict impaired functional behavior.

METHODS: Children ages 6-15 years who had neonatal or childhood onset arterial ischemic stroke were identified by chart review at the Nationwide Children’s (Columbus, OH, USA) and Royal Children’s Hospital (Melbourne, Australia). Subjects were included if they could complete the test battery. Age- and gender-matched children who had asthma were selected as controls. Stroke cases were assessed with the Pediatric Stroke Outcome Measure and had an MRI brain scan after the acute phase of stroke. Cases and controls underwent functional assessments at least one year after the incident stroke. The battery of tests and ratings included the Wechsler Abbreviated Scales of Intelligence, WISC-IV Processing Speed Index, Child Behavior Checklist, Adaptive Behavior Assessment System, and Child & Adolescent Scale of Participation. Infarct volumes were measured by manual segmentation.

RESULTS: The sample included 10 children with perinatal stroke, 26 with acquired childhood stroke, and 15 controls. Median age at assessment was 8.7 yrs (IQR 6.9-11.9) and median time after presentation was 5.1 yrs (IQR 2.8-7.4). The median PSOM for stroke cases was 1 (range 0-8.0) and for controls was 0 (range 0-1). Stroke was significantly associated with lower levels of multiple daily living skills (p range 0.001-0.025), functional academics (p=0.048), and self-care (p=0.020), as well as a trend toward impaired school participation (p=0.064), but was not associated with impaired intellectual functioning or behavioral adjustment. Larger Infarcts showed a trend association with higher PSOM total scores (p=0.091). Infarcts that involved both cortex and subcortical parenchyma were associated with poorer daily living skills (p range 0.005-0.052) and a trend toward impaired home community participation (p=0.079). Age of stroke onset was not associated with impairments.

Conclusions: Stroke causes deficits that may not be appreciated by standard IQ screening or report of overt behavior disorders. These deficits can affect daily living skills and result in impaired adaptive behavior. Strokes involving both cortex and subcortex, as a proxy for more extensive strokes, may be particularly associated with impaired adaptive behavior. These results are “best case” estimates because our study excluded mentally retarded or grossly impaired children.