OBJECTIVE To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury. DESIGN Retrospective ...analysis of a prospective observational study. SETTING Pediatric emergency department (ED) in a children's hospital. PARTICIPANTS Four hundred six children and adolescents aged 5 to 18 years. MAIN EXPOSURE Closed head trauma. MAIN OUTCOME MEASURES The Rivermead Post Concussion Symptoms Questionnaire administered 3 months after the injury. RESULTS Of the patients presenting to the ED with mild traumatic brain injury, 29.3% developed PCS. The most frequent PCS symptom was headache. Predictors of PCS, while controlling for other factors, were being of adolescent age, headache on presentation to the ED, and admission to the hospital. Patients who developed PCS missed a mean (SD) of 7.4 (13.9) days of school. CONCLUSIONS Adolescents who have headache on ED presentation and require hospital admission at the ED encounter are at elevated risk for PCS after mild traumatic brain injury. Interventions to identify this population and begin early treatment may improve outcomes and reduce the burden of disease.
Introduction
Pediatric brain tumor survivors (PBTS) experience psychosocial difficulties and poor quality of life (QOL). Family functioning may be adversely impacted by the stress of diagnosis and ...associated symptoms, which may, in turn, affect PBTS outcomes. The objective of this study was to complete a systematic review of family functioning and psychosocial outcomes in PBTS.
Methods
We conducted systematic searches of PubMed and PsychInfo. Full‐text articles (n = 324) were screened and 14 were included. A risk‐of‐bias assessment was conducted to evaluate the quality of study conclusions.
Results
Studies examined associations of family functioning with adaptive, social, emotional, and behavioral outcomes, and QOL. More adaptive family functioning (cohesiveness, effective communication, lower conflict) was associated with better PBTS outcomes. Studies were limited by heterogeneous/small samples and cross‐sectional designs.
Conclusions
Results provide preliminary support for the relationship between family functioning and psychosocial outcomes. Common outcome measures and prospective research designs can further advance understanding.
To describe the methodology and report primary outcomes of an exploratory randomized clinical trial (RCT) of aerobic training for management of prolonged symptoms after a mild traumatic brain injury ...(mTBI) in adolescents.
Outpatient research setting.
Thirty adolescents between the ages of 12 and 17 years who sustained a mTBI and had between 4 and 16 weeks of persistent symptoms.
Partially blinded, pilot RCT of subsymptom exacerbation aerobic training compared with a full-body stretching program.
The primary outcome was postinjury symptom improvement assessed by the adolescent's self-reported Post-Concussion Symptom Inventory (PCSI) repeated for at least 6 weeks of the intervention. Parent-reported PCSI and adherence are also described.
Twenty-two percent of eligible participants enrolled in the trial. Repeated-measures analysis of variance via mixed-models analysis demonstrated a significant group × time interaction with self-reported PCSI ratings, indicating a greater rate of improvement in the subsymptom exacerbation aerobic training group than in the full-body stretching group (F = 4.11, P = .044). Adherence to the home exercise programs was lower in the subsymptom exacerbation aerobic training group compared with the full-body stretching group (mean SD times per week = 4.42 1.95 vs 5.85 1.37, P < .0001) over the duration of the study.
Findings from this exploratory RCT suggest subsymptom exacerbation aerobic training is potentially beneficial for adolescents with persistent symptoms after an mTBI. These findings and other recent research support the potential benefit of active rehabilitation programs for adolescents with persistent symptoms after an mTBI. Larger replication studies are needed to verify findings and improve generalizability. Future work should focus on determining the optimal type, timing, and intensity of active rehabilitation programs and characteristics of individuals most likely to benefit.
IMPORTANCE: Pediatric traumatic brain injury (TBI) contributes to impairments in behavior and academic performance. However, the long-term effects of early childhood TBI on functioning across ...settings remain poorly understood. OBJECTIVE: To examine the long-term functional outcomes of early childhood TBI relative to early childhood orthopedic injuries (OIs). We also examine the moderating role of the social environment as defined by parent report and observational measures of family functioning, parenting practices, and home environment. DESIGN, SETTING, AND PARTICIPANTS: A prospective, longitudinal, observational cohort study conducted at each child’s home, school, and hospital, including 3 children’s hospitals and 1 general hospital in the Midwest. Patients were enrolled in the initial study between January 2003 and October 2006. Follow-ups were completed between January 2010 and April 2015. Fifty-eight children who sustained a TBI (67% of original enrolled cohort) and 72 children who sustained an OI (61% of the original enrolled cohort) were prospectively followed up from shortly after injury (between the ages of 3 and 7 years at enrollment) to an average of 6.7 years after injury, with assessments occurring at multiple points. MAIN OUTCOMES AND MEASURES: Long-term functional outcomes in everyday settings, as assessed through the Child and Adolescent Functional Assessment Scale (CAFAS). RESULTS: Of the 130 children included, the median age for those with OIs was 11.72 years and 11.97, 12.21, and 11.72 years for those with complicated mild, moderate, and severe TBIs, respectively. Children with moderate and severe TBI were rated as having more functional impairments in multiple domains than those with OIs (P < .05). Children with complicated mild TBI had greater impairments in school (odds ratio = 2.93; 95% CI = 1.10-7.82) and with thinking (odds ratio = 15.72; 95% CI = 3.31-74.73) than those with OIs. Functional impairments in children with TBI were more pronounced among children from families with higher levels of permissive (mean CAFAS of 49.71, 35.74, 58.14, and 16.16 for severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with significant difference between severe TBI and OI difference = 33.55; P < .001 and complicated mild TBI and OI difference = 41.98; P < .001) or authoritarian (mean CAFAS of 56.45, 41.80, 54.90, and 17.12 for severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with significant difference between severe TBI and OI difference = 39.33; P < .001, moderate TBI and OI difference = 24.68; P = .003, and complicated mild TBI and OI difference = 37.78; P < .001) parenting or with fewer home resources (mean CAFAS of 69.57, 47.45, 49.00, and 23.81 for severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with significant difference between severe TBI and OI difference = 45.77; P < .001, moderate TBI and OI difference = 23.64; P < .001, and complicated mild TBI and OI difference = 25.20; P < .001). CONCLUSIONS AND RELEVANCE: Even children with relatively mild early TBI experience long-term functional impairments, particularly in the context of less favorable home environments. These findings suggest that improving parenting skills and the quality of the home environment may promote functional recovery following early TBI.
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.
IMPORTANCE: Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency ...department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. OBJECTIVE: To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. EVIDENCE REVIEW: The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. FINDINGS: The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. CONCLUSIONS AND RELEVANCE: This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
Objective: This study sought to determine whether parenting styles predict long-term psychosocial outcomes after traumatic brain injury in young children.
Methods: The study involved a concurrent ...cohort, prospective design, with longitudinal assessments up to early adolescence. Participants included 126 children with moderate to severe traumatic brain injury or orthopedic injury, ages 3 to 6 years 11 months, recruited between 2003 and 2006. Parents rated children's pre-injury behavioral adjustment, social competence, and executive functioning shortly after injury, and again 6.8 years post injury. Parents also rated their parenting styles (permissive, authoritarian, authoritative) at both occasions.
Results: After controlling for pre-injury functioning, the groups differed significantly on all three outcomes (ΔR
2
0.07 to 0.13). Late but not early parenting styles predicted outcomes in all groups (ΔR
2
0.06 to 0.17): more permissive parenting predicted worse outcomes in all domains (β= −0.18, 0.20, 0.27); and more authoritative parenting predicted better social competence and executive functioning (β= −0.17, 0.46). Severe traumatic brain injury interacted with parenting style for several outcomes, with ineffective parenting exacerbating the negative sequelae.
Conclusions: Parenting style predicts children's long-term psychosocial functioning after early childhood injury, and may moderate the effects of early traumatic brain injury.
Implications for rehabilitation
Children with traumatic brain injury (especially those with severe injuries) are likely to require long-term monitoring and rehabilitation to address their psychosocial functioning.
Interventions that focus on parenting may be an important avenue for promoting better psychosocial outcomes among children with severe traumatic brain injury.
IMPORTANCE: In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened ...concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control’s (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. OBJECTIVE: To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. EVIDENCE REVIEW: Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. FINDINGS: Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. CONCLUSIONS AND RELEVANCE: This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.
Teen Online Problem Solving (TOPS) is an evidence-based teletherapy program designed to promote neurocognitive, behavioral, and psychosocial recovery following brain injury through family-centered ...training. To date, TOPS has been primarily administered by neuropsychologists and clinical psychologists. This clinical focus article discusses a quality improvement project to adapt the TOPS training and manual for use by speech-language pathologists (SLPs) and reports feedback from SLPs following TOPS training and after delivering the program with adolescents who experienced neurological insults.
SLPs were invited to participate in TOPS training. Trainees were asked to complete posttraining surveys, active therapist questionnaires, and follow-up surveys directed to SLPs who had completed the intervention with at least one patient.
To date, a total of 38 SLPs completed TOPS training, 13 have implemented TOPS with at least one adolescent. Eight SLPs and 16 psychologists/trainees responded to follow-up surveys to share their perspectives on the program. Perceptions of clinicians delivering the program did not differ significantly in most respects. SLPs rated the ease of understanding nonverbal communication higher than psychologists. Seven SLPs responded to an SLP-specific survey about their experiences administering TOPS, noting a range of advantages and some limitations in their open-ended responses.
Training SLPs to deliver TOPS has the potential to increase service provision to adolescents with acquired brain injury who have cognitive communication difficulties and their families.
https://doi.org/10.23641/asha.22357327.
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