Predictors of outcome following acquired brain injury in children

Factors influencing recovery in a pediatric sample with disorders of consciousness: insights from an observational study

OBJECTIVE

To estimate rates and time to reach emergence of consciousness from vegetative state/unresponsive wakefulness syndrome (VS/UWS), and explore factors associated with improved recovery in children and adolescents with disorders of consciousness (DoC) following severe traumatic and non-traumatic brain injury.

METHODS

Analytical, retrospective, cohort study. Clinical records of consecutively referred patients admitted in VS/UWS to a neurological rehabilitation institute in Argentina, between 2005 and 2021 were reviewed. Seventy children and adolescents were included in the analysis. A specialized 12-week rehabilitation program was administered, and emergence was defined by scores ≥44 points on the Western Neuro Sensory Stimulation Profile (WNSSP), sustained for at least 3 weeks on consecutive weekly evaluations.

RESULTS

Emergence from VS/UWS to consciousness occurred within 5.4 (SD 2.6) weeks in almost one-third of patients. Multivariate Cox regression analysis showed emergence was significantly lower in patients with hypoxic ischemic encephalopathy compared to patients with other non-traumatic etiologies [HRadj 0.23 (95% CI 0.06-0.89); p = 0.03)].

CONCLUSIONS

Our findings reinforce growing evidence on the impact of etiology on DoC recovery in pediatric populations, ultimately influencing treatment and family-related decisions in child neurorehabilitation.

Nurse Practitioners in a Canadian Pediatric Rehabilitation Hospital: A Description of Roles and Scope of Practice

The nurse practitioner role is strongly suited to meet the needs of children with complex developmental conditions in pediatric rehabilitation settings as they have a unique combination of clinical expertise. To meet the increasing demands in a large Canadian pediatric rehabilitation hospital, the NP role was implemented in several clinical program settings to improve access to care. This paper describes the contributions of NPs to nine specialized inpatient and outpatient programs in NP-led, collaborative NP and physician or interagency care team models of practice. The initial challenges of role implementation and implications for NP practice, research and leadership are discussed.

Pediatric acquired brain injury resources for educators: a multi-year scan of Canadian-relevant internet resources

BACKGROUND

Acquired Brain Injury (ABI) is the leading cause of death and disability in children, yet educators report a lack of knowledge about ABI and supporting students with ABI. With no formal learning about ABI, education professionals may turn to the internet for information.

OBJECTIVES

To find online resources about supporting students with ABI, in any format, available freely and publicly, aimed toward elementary educators and that could be applied in a Canadian context.

METHODS

We performed an environmental scan using keyword Google searches, key websites, and expert recommendations. The search was performed twice: 2018 and 2021.

RESULTS

96 resources were included after screening. The resources were published by organizations in the United States (n = 57), Canada (n = 19), United Kingdom (n = 16), Australia (n = 3) and New Zealand (n = 1). Traumatic brain injury and concussion were the most commonly addressed type of ABI, and Short Fact/Information sheets were the most common resource format. Between 2018 and 2021, 13 previously included resource links were no longer accessible.

CONCLUSIONS

This scan suggests that there are many online resources available to educators in a variety of formats, and that information online can be transient. Future studies should evaluate the accuracy and quality of the resources available.

Ableism among children and youth with acquired brain injury and their caregivers: a systematic review

PURPOSE

Children and youth with acquired brain injury (ABI) experience persistent discrimination and ableism. The purpose of this systematic review was to understand the experiences and impact of ableism among children and youth with ABI.

METHOD

Six international databases were systematically searched for articles from 2002-2022. Studies were screened independently by four researchers who performed the data extraction. Study quality was appraised using the Standard quality assessment criteria for evaluating primary research.

RESULTS

Of the 2085 studies identified in the search, 15 met the inclusion criteria, which involved 1442 children and youth with brain injuries or caregivers representing them. Studies in the review showed the following key trends: (1) incidence of ableism among children and youth with ABI; (2) experiences of ableism at the individual and institutional levels, (3) impact of ableism (i.e., mental health, social relationships, quality of life) and (4) coping strategies (i.e., resources, supports).

CONCLUSIONS

Our findings reveal the alarming incidence of ableism among youth with ABI. Therefore, there is a critical need for more research to explore youth's lived experiences of ableism, especially from their perspectives along with the co-development of solutions to help enhance their social inclusion and well-being.

The role of the Neuropsychologist across the stages of recovery from acquired brain injury: a summary from the pediatric rehabilitation Neuropsychology collaborative

Neuropsychologists working in a pediatric neurorehabilitation setting provide care for children and adolescents with acquired brain injuries (ABI) and play a vital role on the interdisciplinary treatment team. This role draws on influences from the field of clinical neuropsychology and its pediatric subspecialty, as well as rehabilitation psychology. This combination of specialties is uniquely suited for working with ABI across the continuum of recovery. ABI recovery often involves a changing picture that spans across stages of recovery (e.g., disorders of consciousness, confusional state, acute cognitive impairment), where each stage presents with distinctive characteristics that warrant a specific evidence-based approach. Assessment and intervention are used reciprocally to inform diagnostics, treatment, and academic planning, and to support patient and family adjustment. Neuropsychologists work with the interdisciplinary teams to collect and integrate data related to brain injury recovery and use this data for treatment planning and clinical decision making. These approaches must often be adapted and adjusted in real time as patients recover, demanding a dynamic expertise that is currently not supported through formal training curriculum or practice guidelines. This paper outlines the roles and responsibilities of pediatric rehabilitation neuropsychologists across the stages of ABI recovery with the goal of increasing awareness in order to continue to develop and formalize this role.

The Concussion Challenge Assessment: Development and reliability of a novel gross motor assessment tool for paediatric concussion

Aims

The aim of this study was to develop a gross motor performance clinical assessment tool, the Concussion Challenge Assessment (CCA), for paediatric concussion populations.

Methods

An expert panel evaluated tasks from the Acquired Brain Injury Challenge Assessment to determine relevant tasks for a paediatric concussion population. These tasks were administered to a convenience sample of 854 healthy youth. An analysis of the response options for each task, considering task difficulty, was performed. The test-retest reliability of each task was considered to finalise the tool.

Results

The Acquired Brain Injury Challenge Assessment was reduced to six tasks (three coordination, two speed and agility, and one strength) to create the CCA. Population-specific 4-point response options were generated, which, upon examination of task difficulty, were revised as 5-point response sets to better capture performance differences. The test-retest reliability results led to acceptance of all six: three performance tasks and three exertion tasks.

Conclusion

This development of the CCA is an important step in creating a gross motor performance assessment tool that can assist in the determination of when youth are able to safely return to activity following a concussion.

Gross motor change after inpatient rehabilitation for children with acquired brain injury: A 10-year retrospective review

AIM

To estimate gross motor change in inpatient school-aged children with subacute acquired brain injury (ABI), identify factors associated with gross motor change, and describe inpatient physiotherapy focus.

METHOD

This retrospective chart review involved inpatient children (5-18 years) with subacute ABI who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T scores were calculated. Regression analyses examined factors predicting gross motor change. GAS goal areas were analysed to determine physiotherapy focus.

RESULTS

Of the 546 charts screened, 266 (118 female) met study criteria. The GMFM-88 was generally administered first, followed by other measures. GMFM-88 (n = 202), Community Balance and Mobility Scale (n = 89), and Six-Minute Walk Test (6MWT) (n = 98) mean change scores were 18.03% (SD 19.34), 17.85% (SD 10.77), and 142.3 m (SD 101.8) respectively. The mean GAS T score was 55.06 (SD 11.50). Lower baseline scores and increased time between assessments were most predictive of greater GMFM-88 change (r ≥ 0.40). Twenty-five percent of GAS goals were ambulation-based.

INTERPRETATION

Appropriate outcome measure selection is integral to detecting gross motor change in pediatric inpatient ABI rehabilitation. Mean change score estimates can be used to compare standard inpatient rehabilitation with new treatment approaches.

Rehabilitation after paediatric acquired brain injury: Longitudinal change in content and effect on recovery

AIM

To describe cross-sectional and longitudinal variation in neurorehabilitation content provided to young people after severe paediatric acquired brain injury (pABI) and to relate this to observed functional recovery.

METHOD

This was an observational study in a cohort of admissions to a residential neurorehabilitation centre. Recovery was described using the Pediatric Evaluation of Disability - Computer Adaptive Testing instrument. Rehabilitation content was measured using the recently described Paediatric Rehabilitation Ingredients Measure (PRISM) and examined using multidimensional scaling.

RESULTS

The PRISM reveals wide variation in rehabilitation content between and during admissions primarily reflecting proportions of child active practice, child emotional support, and other management of body structure and function. Rehabilitation content is predicted by pre-admission recovery, suggesting therapist decisions in designing rehabilitation programmes are shaped by their initial expectations of recovery. However, significant correlations persist between plausibly-related aspects of delivered therapy and observed post-admission recovery after adjusting for such effects.

INTERPRETATION

The PRISM approach to the analysis of rehabilitation content shows promise in that it demonstrates significant correlations between plausibly-related aspects of delivered therapy and observed recovery that have been hard to identify with other approaches. However, rigorous, causal analysis will be required to truly understand the contributions of rehabilitation to recovery after pABI.

WHAT THIS PAPER ADDS

Rehabilitation content varies widely between, and during, admissions for neurorehabilitation after paediatric acquire brain injury. Strong correlations are seen between plausibly-related aspects of rehabilitation content and observed recovery, though careful interpretation is necessary.

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

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

A systematic review and quantitative synthesis of the long-term psychiatric sequelae of pediatric autoimmune encephalitis

BACKGROUND

Long-term neuropsychiatric sequelae of autoimmune encephalitis (AE) remain understudied, particularly in pediatric-onset AE. We aimed to synthesize the published data on ongoing psychiatric symptoms in pediatric-onset AE.

METHODS

The Pubmed, PyscINFO, Web of Science databases were searched from their inception years to August 23, 2021, and 29 studies were identified and analyzed. We also performed a quantitative synthesis of available patient data from the 29 studies combined with a cohort of anti-NMDA receptor (NMDAR) AE from our institution to examine the associations between acute treatment course and long-term psychiatric outcome.

RESULTS

At long-term follow up, 52.4% of the cases with pediatric-onset AE had any persistent symptom and 36.0% had at least one psychiatric symptom. Pooled data found that 36.3% of pediatric-onset anti-NMDAR AE had ongoing psychiatric symptoms. Using a univariate logistic regression analysis, we found that abnormal initial EEG, use of certain immunotherapies, and persistent cognitive impairments were associated with ongoing psychiatric symptoms.

LIMITATIONS

Limitations of the existing literature included a significant paucity of outcomes measured using consistent, objective methods. Limitations of the systematic review included the wide variability among the studies reviewed, which rendered a meta-analysis impossible and beyond the scope of the paper.

CONCLUSION

Chronic psychiatric and behavioral problems remain present in one-third of children months to years after onset of AE. Larger scaled prospective observational studies with a consistent standardized battery of testing are needed to examine impact of specific clinical features and immunotherapies on long-term mental health outcomes.

Associations between Electroencephalographic Variables, Early Post-Traumatic Seizure Risk, and Outcomes following Pediatric Severe Traumatic Brain Injury

Early post-traumatic seizures (PTS) are associated with worse outcomes in children with traumatic brain injury (TBI). Our aim was to identify the association between continuous electroencephalogram (cEEG) characteristics and early PTS risk following pediatric severe TBI. We also evaluated the relationship between cEEG background features and outcomes. A single-center retrospective cohort study was performed on children between 0 and 18 years of age admitted to the pediatric intensive care unit from 2016 to 2019 with severe TBI and cEEG monitoring within 7 days of injury. Raw cEEG tracings were reviewed by an epileptologist in accordance with American Clinical Neurophysiology Society (ACNS) Critical Care EEG terminology. Univariate comparisons were made between children with and without early PTS, as well as between those with and without varying cEEG background features. Eighteen children (31%) of the 59 included had early PTS. Interictal abnormalities, inclusive of sporadic spikes and sharp waves, rhythmic delta activity, or lateralized periodic discharges (LPDs) were more common among children with seizures (100 vs. 22%; p < 0.01). LPDs were also more common in the seizure group (44 vs. 2%; p < 0.01). Background discontinuity was associated with worse Glasgow Outcome Scale—Extended Pediatric Version (GOS-E Peds) scores at discharge and 3-, 6-, and 12-month post-discharge (p < 0.01). Lack of reactivity was also associated with worse GOS-E Peds scores at 3-, 6-, and 12-month post-discharge (p < 0.01). Interictal abnormalities and LPDs were each associated with early PTS following pediatric severe TBI. Larger studies should evaluate if high-risk patients would benefit from prolonged cEEG monitoring and/or more aggressive anti-seizure prophylaxis. Discontinuity and lack of variability were associated with worse outcomes. Future studies should attempt to clarify their role as potential early markers of prognosis.

Factors Influencing Functional Recovery during Rehabilitation after Severe Acquired Brain Injuries: A Retrospective Analysis

Severe acquired brain injuries (sABI) represent one of the main causes of disability and limitation in social life participation that need an intensive rehabilitation approach. The purpose of this study was to identify a possible correlation between different supposed conditioning factors and the efficiency of rehabilitation interventions. In this retrospective study, data were processed regarding 44 patients admitted to a neurorehabilitation department after sABI. A significant correlation with the efficiency of the rehabilitation intervention (expressed as the variation of the Barthel score between discharge and admittance in relation to the duration of the rehabilitative hospitalization) was found for both the etiology of the brain injury (p = 0.023), the precocity of the rehabilitation treatment (p = 0.0475), the presence of a tracheal cannula (p = 0.0084) and forms of nutrition other than oral (p < 0.0001). The results of this study suggest that improving the management of the respiratory system, swallowing and nutritional aspects, and favoring an early and personalized rehabilitation treatment, can help to optimize the overall care of patients suffering from sABI, thus allowing a reduction in complications, improvement in functional recovery and ensuring a better management of economic, social and health resources.

A Population-Based Study of the Incidence, Medical Care, and Medical Expenditures for Pediatric Traumatic Brain Injury

BACKGROUND

Traumatic brain injury (TBI) is one of the leading causes of pediatric trauma morbidity and mortality around the world. However, limited research exists regarding disparities in the incidence of TBI and medical care seeking behaviors and medical expenditures for TBI, particularly using population-based and nationally-representative data.

MATERIALS AND METHODS

The present study used the Medical Expenditure Panel Survey (MEPS) Panels 9-19 (2004-2015) to provide nationally-representative estimates for the civilian, non-institutionalized U.S.

POPULATION

We examined differences in TBI incidence and associated medical care seeking behaviors and expenditures in relation to individual and family sociodemographic characteristics.

RESULTS

From a total of 50,563 children in the MEPS Panels 9-19, we identified 449 children with TBI. For 82% of these children, medical treatment was sought. The estimated annual total expenditure associated with pediatric TBIs nationally was approximately $667 million, with mean expenditures per TBI being $1,532 and family out of pocket expenditures accounting for 8.3% of total expenditures. Race/ethnicity was the only significant factor associated with both medical care seeking behavior and total expenditures.

CONCLUSIONS

The present study is among the first to compare pediatric TBI-related medical expenditures among different sociodemographic groups in the U.S. Our findings can inform future intervention research and policy-making from the perspectives of both epidemiological and behavioral sciences.

Understanding the Needs of Ontario Educators in Supporting Students With Acquired Brain Injury in the Classroom

BACKGROUND

When a child sustains an acquired brain injury (ABI), the impact extends to significant environments in their life, including school. Educator knowledge of ABI can influence a child's success with academic and social reintegration. An assessment of educator ABI knowledge was conducted to determine what information they require to support school reintegration.

METHODS

A mixed-methods approach included a sampling of educators in a needs assessment survey and workshop. The survey determined levels of educator knowledge regarding ABI in the classroom, and the workshop scoped educator views in the development of a user-driven ABI learning program to enrich their expertise.

RESULTS

Our sample reported being somewhat knowledgeable about ABI and the impact on students. There were no differences based on respondents' educational role. Teachers reported having minimal and inadequate supports for students following ABI during school transitions, feeling unprepared to assist students during these transitions, and that families also appeared unprepared for school reintegration following ABI. The workshop identified the need for a 2-part educational course.

CONCLUSIONS

Supportive school environments are essential for the reintegration of students following ABI. This study identified educators' needs for ABI knowledge and resources to support their existing expertise.

Pediatric traumatic brain injury and abusive head trauma

Childhood traumatic brain injury (TBI) commonly occurs during brain development and can have direct, immediately observable neurologic, cognitive, and behavioral consequences. However, it can also disrupt subsequent brain development, and long-term outcomes are a combination of preinjury development and abilities, consequences of brain injury, as well as delayed impaired development of skills that were immature at the time of injury. There is a growing number of studies on mild TBI/sport-related concussions, describing initial symptoms and their evolution over time and providing guidelines for effective management of symptoms and return to activity/school/sports. Mild TBI usually does not lead to long-term cognitive or academic consequences, despite reports of behavioral/psychologic issues postinjury. Regarding moderate to severe TBI, injury to the brain is more severe, with evidence of a number of detrimental consequences in various domains. Patients can display neurologic impairments (e.g., motor deficits, signs of cerebellar disorder, posttraumatic epilepsy), medical problems (e.g., endocrine pituitary deficits, sleep-wake abnormalities), or sensory deficits (e.g., visual, olfactory deficits). The most commonly reported deficits are in the cognitive-behavioral field, which tend to be significantly disabling in the long-term, impacting the development of autonomy, socialization and academic achievement, participation, quality of life, and later, independence and ability to enter the workforce (e.g., intellectual deficits, slow processing speed, attention, memory, executive functions deficits, impulsivity, intolerance to frustration). A number of factors influence outcomes following pediatric TBI, including preinjury stage of development and abilities, brain injury severity, age at injury (with younger age at injury most often associated with worse outcomes), and a number of family/environment factors (e.g., parental education and occupation, family functioning, parenting style, warmth and responsiveness, access to rehabilitation and care). Interventions should identify and target these specific factors, given their major role in postinjury outcomes. Abusive head trauma (AHT) occurs in very young children (most often <6 months) and is a form of severe TBI, usually associated with delay before appropriate care is sought. Outcomes are systematically worse following AHT than following accidental TBI, even when controlling for age at injury and injury severity. Children with moderate to severe TBI and AHT usually require specific, coordinated, multidisciplinary, and long-term rehabilitation interventions and school adaptations, until transition to adult services. Interventions should be patient- and family-centered, focusing on specific goals, comprising education about TBI, and promoting optimal parenting, communication, and collaborative problem-solving.

Transitions to Outpatient Care After Traumatic Brain Injury for Hispanic Children

BACKGROUND AND OBJECTIVES

Rehabilitation after a child's traumatic brain injury (TBI) occurs in hospital, community, and school settings, requiring coordination of care and advocacy by parents. Our objective was to explore Hispanic parents' experiences during child's transitions of care after TBI.

METHODS

We conducted this qualitative study using semistructured interviews. We used a convenient sample of Hispanic parents of children hospitalized for a TBI in a single level I trauma center. Thematic content analysis using iterative deductive coding and triangulation with clinical data was conducted to identify barriers and facilitators for transitions of care.

RESULTS

Fifteen mothers, mostly from rural areas and with limited English proficiency, participated in the study. Obtaining outpatient rehabilitation was difficult. Barriers included lack of therapists and clinical providers close to home, worsened by insufficient transportation and other support resources; poor understanding of child's illness and treatments; and suboptimal communication with clinicians and school administrators. Facilitators included interpreter use, availability of Spanish written information, and receipt of inpatient rehabilitation. Parents of patients discharged to inpatient rehabilitation reported that observing therapies, receiving school discharge plans by hospital-teachers, and coordination of care were facilitators to access outpatient treatments and to support school return. Parents of children discharged from the hospital from acute care reported need of legal services to obtain school services.

CONCLUSIONS

Hispanic parents, especially those with limited English proficiency, can face significant challenges accessing TBI outpatient rehabilitation and school resources for their children. Although barriers are multifactorial, efforts to improve communication, parent's TBI education, and care coordination during transitions of care may facilitate a child's reintegration to the community and school.

The Information Gap for Children and Young People with Acquired Brain Injury

Statement of Purpose: This study explored the information requirements of children/youth with an acquired brain injury.Methods: An online survey (n = 16), focus group (n = 5) and in-depth semi-structured interviews (n = 3) elicited the views of 24 children/youth with ABI. A priori thematic coding was used to analyze the data.Results: Five themes emerged: stage and age, school, friendship and peers, delivery methods and information content. The desired information changes over time depending on age and time since the injury. Children/youth want their friends and teachers to access information on brain injury. Children/youth want information delivered through a range of channels, including videos (featuring genuine case studies), apps and board games. Children/youth wanted information specific to their injury, information on brain injury more generally, and practical strategies for overcoming problems.Conclusions: Children/youth with ABI were able to express views about their information needs, which change over time and include a range of channels.

The presence of high level physical difficulties in children and young people with severe acquired brain injuries who regain independent mobility

Background/Aims

Children and young people with acquired brain injuries take part in less physical activity than age-matched peers. A possible cause of this is reduced high level motor proficiency. This study aimed to determine whether children and young people who regain independent mobility following a severe acquired brain injury continue to experience high-level physical difficulties.

Methods

A retrospective review of routinely collected Bruininks-Oseretsky Test of Motor Proficiency 2 assessments was performed. Descriptive data analysis of motor proficiency results, both overall and within the different subsections, was conducted.

Results

Out of 26 participants (5–17 years) with severe traumatic and non-traumatic acquired brain injury, 22 scored below or well below average in overall motor composite score. The mean standard scores across all participants in three of the subsections were below average: manual coordination 35.9; body coordination 37.1; and strength and agility 37.9. The only subsection that produced scores within the average for participants' ages was fine motor control (mean 41.8).

Conclusions

Children and young people demonstrate reduced motor proficiency following acquired brain injury despite regaining functionally independent mobility. Those not participating in physical activities should be screened for high level motor difficulties that may impact on their participation.

Factors Associated With Gains in Performance During Rehabilitation After Pediatric Brain Injury: Growth Curve Analysis

OBJECTIVE

Predicting recovery of functional performance within pediatric rehabilitation after brain injury is important for health professionals and families, but information regarding factors associated with change in functional skills ("what the child can do") and functional independence ("what the child does") is limited. The aim of the study was to examine change in functional skills and independence over time in children with moderate-severe brain injury during prolonged inpatient rehabilitation.

DESIGN

This study used a retrospective cohort design. Longitudinal data from 139 children (age 1.6-20.6 yrs), hospitalized for 115.4 ± 72 days, were examined. Growth curve analysis was used to examine factors associated with change in the Pediatric Evaluation of Disability Inventory (functional skills and caregiver assistance, ie, functional independence) in mobility and self-care. Typical estimates for change per hospitalization day were obtained.

RESULTS

Traumatic brain injury and older age at injury, but not sex, were associated with faster recovery. Length of stay was associated with rate of change in functional skills but not in functional independence, suggesting that improvement in functional independence during rehabilitation may be associated with other factors.

CONCLUSIONS

Identifying the factors associated with individual profiles of functional improvement can provide valuable information for clinicians and decision-makers to optimize performance after prolonged inpatient rehabilitation.

Severe acquired brain injury aetiologies, early clinical factors, and rehabilitation outcomes: a retrospective study on pediatric patients in rehabilitation

Objective: Studies on pediatric severe acquired brain injury (sABI) outcomes focused mostly on single etiologies, not clarifying the independent role of clinical factors, and scantly explored inter-dependence between variables. We assessed associations of clinical factors at admission with essential outcomes, controlling for inter-dependence and sABI etiology. Methods: We reviewed the clinical records of 280 patients with traumatic and 292 with non-traumatic sABI, discharged from intensive care to pediatric neurological rehabilitation. We analyzed the distribution of clinical factors based on sABI etiology; conducted a factor analysis of variables; built multivariate models evaluating the associations of variables with death, persistent vegetative states, duration of coma, GOS outcome, length of stay. Results: We described the study sample. Factor analysis of inter-dependence between GCS, time before rehabilitation, dysautonomia, device use, produced the indicators "injury severity" and "neurological dysfunction", independent from sABI etiology, age, sex, and admittance GOS. Multivariate analyzes showed that: coma duration, GOS outcome, and length of stay, which may depend on rehabilitation courses, were directly associated with injury severity, neurological dysfunction, and patients' age; death and persistent vegetative states were also associated with etiology. Conclusion: Future studies should analyze larger cohorts and investigate mechanisms linking specific etiologies and patients' age with outcomes.

Using child- and family-centred goal setting as an outcome measure in residential rehabilitation for children and youth with acquired brain injuries: The challenge of predicting expected levels of achievement

PURPOSE

Collaborative, child- and family-centred goal setting is essential in paediatric, acquired brain injury (ABI) rehabilitation. This study aims to understand which goals children and families prioritize and how accurately therapists predict expected levels of achievement for these goals.

METHODS

Routinely collected Goal Attainment Scale-Light data from 122 children with severe ABI receiving residential rehabilitation were retrospectively analysed. Goals were mapped onto the International Classification of Functioning, Disability and Health. Descriptive analysis of accuracy of therapists' prediction of goal achievement was conducted.

RESULTS

Eight-hundred sixty goals were set: 82% in activities and participation domains, most commonly mobility, self-care, and communication chapters. Forty-six per cent of therapist-set expected levels of achievement for these goals were met at the expected level, and 24% were exceeded. Chapters with the highest prediction accuracy included two environmental chapters and one body structure and function. Accurate prediction of activity and participation goals varied (35% in general tasks and demands to 58.8% in major life areas).

CONCLUSIONS

Children and families prioritize mobility, self-care, and communication during ABI residential rehabilitation. Setting expected outcomes for these goals is challenging, as demonstrated by the variety in accurate prediction rates between and within chapters. Families need to be aware of this uncertainty during goal-setting discussions.

Assessing psychosocial functioning following childhood acquired brain injury: The Sydney Psychosocial Reintegration Scale for Children

OBJECTIVE

The Sydney Psychosocial Reintegration Scale for Children (SPRS-C) assesses psychosocial functioning in children with acquired brain injury (ABI). This article aims to: (1) describe normative data for the parent-rated SPRS-C and, (2) evaluate the discriminant validity of the SPRS-C.

METHODS

For Aim 1, participants were parents of typically developing children (TDC) aged 5-14 years (N = 200). For Aim 2, participants with ABI were aged 5-14 years (n = 26). A matched group of TDC was sampled from the larger normative sample to serve as a control group (n = 26).

RESULTS

For Aim 1, SPRS-C scores across the 10 age-bands were in the higher ranges. Correlation coefficients of SPRS-C total score with child's age and parent occupational skill level were not statistically significant. For Aim 2, SPRS-C scores for the ABI group were significantly lower than the control group.

CONCLUSIONS

These data provide a guide for clinical interpretation of the SPRS-C for measuring psychosocial functioning in children with ABI.

Children and youth with non-traumatic brain injury: a population based perspective

BACKGROUND

Children and youth with non-traumatic brain injury (nTBI) are often overlooked in regard to the need for post-injury health services. This study provided population-based data on their burden on healthcare services, including data by subtypes of nTBI, to provide the foundation for future research to inform resource allocation and healthcare planning for this population.

METHODS

A retrospective cohort study design was used. Children and youth with nTBI in population-based healthcare data were identified using International Classification of Diseases Version 10 codes. The rate of nTBI episodes of care, demographic and clinical characteristics, and discharge destinations from acute care and by type of nTBI were identified.

RESULTS

The rate of pediatric nTBI episodes of care was 82.3 per 100,000 (N = 17,977); the average stay in acute care was 13.4 days (SD = 25.6 days) and 35% were in intensive care units. Approximately 15% were transferred to another inpatient setting and 6% died in acute care. By subtypes of nTBI, the highest rates were among those with a diagnosis of toxic effect of substances (22.7 per 100,000), brain tumours (18.4 per 100,000), and meningitis (15.4 per 100,000). Clinical characteristics and discharge destinations from the acute care setting varied by subtype of nTBI; the proportion of patients that spent at least one day in intensive care units and the proportion discharged home ranged from 25.9% to 58.2% and from 50.6% to 76.4%, respectively.

CONCLUSIONS

Children and youth with nTBI currently put an increased demand on the healthcare system. Active surveillance of and in-depth research on nTBI, including subtypes of nTBI, is needed to ensure that timely, appropriate, and targeted care is available for this pediatric population.

Variation in Anticonvulsant Selection and Electroencephalographic Monitoring Following Severe Traumatic Brain Injury in Children-Understanding Resource Availability in Sites Participating in a Comparative Effectiveness Study

OBJECTIVES

Early posttraumatic seizures may contribute to worsened outcomes after traumatic brain injury. Evidence to guide the evaluation and management of early posttraumatic seizures in children is limited. We undertook a survey of current practices of continuous electroencephalographic monitoring, seizure prophylaxis, and the management of early posttraumatic seizures to provide essential information for trial design and the development of posttraumatic seizure management pathways.

DESIGN

Surveys were sent to site principal investigators at all 43 sites participating in the Approaches and Decisions in Acute Pediatric TBI trial at the time of the survey. Surveys consisted of 12 questions addressing strategies to 1) implement continuous electroencephalographic monitoring, 2) posttraumatic seizure prophylaxis, 3) treat acute posttraumatic seizures, 4) treat status epilepticus and refractory status epilepticus, and 5) monitor antiseizure drug levels.

SETTING

Institutions comprised a mixture of free-standing children's hospitals and university medical centers across the United States and Europe.

SUBJECTS

Site principal investigators of the Approaches and Decisions in Acute Pediatric TBI trial.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Continuous electroencephalographic monitoring was available in the PICU in the overwhelming majority of clinical sites (98%); however, the plans to operationalize such monitoring for children varied considerably. A similar majority of sites report that administration of prophylactic antiseizure medications is anticipated in children (93%); yet, a minority reports that a specified protocol for treatment of posttraumatic seizures is in place (43%). Reported medication choices varied substantially between sites, but the majority of sites reported pentobarbital for refractory status epilepticus (81%). The presence of treatment protocols for seizure prophylaxis, early posttraumatic seizures, posttraumatic status epilepticus, and refractory status epilepticus was associated with decreased reported medications (all p < 0.05).

CONCLUSIONS

This study reports the current management practices for early posttraumatic seizures in select academic centers after pediatric severe traumatic brain injury. The substantial variation in continuous electroencephalographic monitoring implementation, choice of seizure prophylaxis medications, and management of early posttraumatic seizures across institutions was reported, signifying the areas of clinical uncertainty that will help provide focused design of clinical trials. Although sites with treatment protocols reported a decreased number of medications for the scenarios described, completion of the Approaches and Decisions in Acute Pediatric TBI trial will be able to determine if these protocols lead to decreased variability in medication administration in children at the clinical sites.

Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma

Studies about long-term outcome following abusive head trauma (AHT) are scarce. The aims of this study were to report long-term neurological, cognitive, behavioral and academic outcomes, ongoing treatments and/or rehabilitation, several years after AHT diagnosis, and factors associated with outcome. In this retrospective study, all patients admitted to a single rehabilitation unit following AHT between 1996 and 2005, with subsequent follow-up exceeding 3 years, were included. Medical files were reviewed and a medical interview was performed with parents on the phone when possible. The primary outcome measure was the Glasgow Outcome Scale (GOS). Forty-seven children (out of 66) met the inclusion criteria (mean age at injury 5.7 months; SD=3.2). After a median length of follow-up of 8 years (range 3.7-12), only seven children (15%) had "good outcome" (normal life - GOS I) and 19 children (40%) presented with severe neurological impairment (GOS III and IV). Children sustained epilepsy (38%), motor deficits (45%), visual deficit (45%), sleep disorders (17%), language abnormalities (49%), attention deficits (79%) and behavioral disorders (53%). Most children (83%) had ongoing rehabilitation. Only 30% followed a normal curriculum, whereas 30% required special education services. Children with better overall outcome (GOS I and II) had significantly higher educated mothers than those with worse outcomes (GOS III and IV): graduation from high school 59% and 21% respectively (p=0.006). This study highlights the high rate of severe sequelae and health care needs several years post-AHT, and emphasizes the need for extended follow-up of medical, cognitive and academic outcomes.

A Systematic Review of Hospital-to-School Reintegration Interventions for Children and Youth with Acquired Brain Injury

OBJECTIVES

We reviewed the literature on interventions that aimed to improve hospital-to-school reintegration for children and youth with acquired brain injury (ABI). ABI is the leading cause of disability among children and youth. A successful hospital-to-school reintegration process is essential to the rehabilitative process. However, little is known about the effective components of of such interventions.

METHODS AND FINDINGS

Our research team conducted a systematic review, completing comprehensive searches of seven databases and selected reference lists for relevant articles published in a peer-reviewed journal between 1989 and June 2014. We selected articles for inclusion that report on studies involving: a clinical population with ABI; sample had an average age of 20 years or younger; an intentional structured intervention affecting hospital-to-school transitions or related components; an experimental design; and a statistically evaluated health outcome. Two independent reviewers applied our inclusion criteria, extracted data, and rated study quality. A meta-analysis was not feasible due to the heterogeneity of the studies reported. Of the 6933 articles identified in our initial search, 17 articles (reporting on 350 preadolescents and adolescents, aged 4-19, (average age 11.5 years, SD: 2.21) met our inclusion criteria. They reported on interventions varying in number of sessions (one to 119) and session length (20 minutes to 4 hours). The majority of interventions involved multiple one-to-one sessions conducted by a trained clinician or educator, homework activities, and parental involvement. The interventions were delivered through different settings and media, including hospitals, schools, and online. Although outcomes varied (with effect sizes ranging from small to large), 14 of the articles reported at least one significant improvement in cognitive, social, psychological, or behavioral functioning or knowledge of ABI.

CONCLUSIONS

Cognitive, behavioral, and problem-solving interventions have the potential to improve school reintegration for youth with ABI. However, more comprehensive interventions are needed to help link rehabilitation clinicians, educators, adolescents, and families.

Long-term outcome of abusive head trauma

Abusive head trauma is a severe inflicted traumatic brain injury, occurring under the age of 2 years, defined by an acute brain injury (mostly subdural or subarachnoidal haemorrhage), where no history or no compatible history with the clinical presentation is given. The mortality rate is estimated at 20-25% and outcome is extremely poor. High rates of impairments are reported in a number of domains, such as delayed psychomotor development; motor deficits (spastic hemiplegia or quadriplegia in 15-64%); epilepsy, often intractable (11-32%); microcephaly with corticosubcortical atrophy (61-100%); visual impairment (18-48%); language disorders (37-64%), and cognitive, behavioral and sleep disorders, including intellectual deficits, agitation, aggression, tantrums, attention deficits, memory, inhibition or initiation deficits (23-59%). Those combined deficits have obvious consequences on academic achievement, with high rates of special education in the long term. Factors associated with worse outcome include demographic factors (lower parental socioeconomic status), initial severe presentation (e.g., presence of a coma, seizures, extent of retinal hemorrhages, presence of an associated cranial fracture, extent of brain lesions, cerebral oedema and atrophy). Given the high risk of severe outcome, long-term comprehensive follow-up should be systematically performed to monitor development, detect any problem and implement timely adequate rehabilitation interventions, special education and/or support when necessary. Interventions should focus on children as well as families, providing help in dealing with the child's impairment and support with psychosocial issues. Unfortunately, follow-up of children with abusive head trauma has repeatedly been reported to be challenging, with very high attrition rates.

Comparison of subgroups based on hemorrhagic lesions between SWI and FLAIR in pediatric traumatic brain injury

PURPOSE

The purpose of this study was to investigate efficient ways to diagnose and predict clinical outcomes for childhood traumatic brain injury.

METHODS

Hemorrhagic signal intensities in nine brain regions were observed using axial fluid-attenuated inversion recovery (FLAIR) and susceptibility-weighted imaging (SWI). After having divided the subjects into mild presentation (GCS 14-15) and moderate-to-severe presentation groups (GCS ≤13), we divided the patients into three subgroups: Subgroup I, hemorrhagic foci observed only on SWI and not on FLAIR; Subgroup II, hemorrhagic foci observed on both SWI and FLAIR in the same brain regions; and Subgroup III, any cases with additional foci on SWI in other brain regions. We investigated the clinical course and compared lesion numbers and distributions of hemorrhagic lesions on SWI among the subgroups.

RESULTS

Three clinical variables (hospitalization period in intensive care unit, total days of hospitalization, and outcome based on Pediatric Cerebral Performance Category Scale score) showed significant relevance to the three subgroups. Subgroup I showed the fewest lesions followed by Subgroups II and III, respectively. In all three subgroups, lesions were most abundant in cortical regions. Lesion in the thalamus, basal ganglia, corpus callosum, and brainstem was least in Subgroup I and gradually increased in Subgroups II and III. Such distinction was more significant in the moderate-to-severe group when compared with the mild group.

CONCLUSIONS

In cases of pediatric traumatic brain injury, categorizing patients into one of the above three subgroups based on hemorrhagic lesions on SWI and FLAIR is a promising method for predicting patient's clinical outcome.

Developmental expression of N-methyl-D-aspartate (NMDA) receptor subunits in human white and gray matter: potential mechanism of increased vulnerability in the immature brain

The pathophysiology of perinatal brain injury is multifactorial and involves hypoxia-ischemia (HI) and inflammation. N-methyl-d-aspartate receptors (NMDAR) are present on neurons and glia in immature rodents, and NMDAR antagonists are protective in HI models. To enhance clinical translation of rodent data, we examined protein expression of 6 NMDAR subunits in postmortem human brains without injury from 20 postconceptional weeks through adulthood and in cases of periventricular leukomalacia (PVL). We hypothesized that the developing brain is intrinsically vulnerable to excitotoxicity via maturation-specific NMDAR levels and subunit composition. In normal white matter, NR1 and NR2B levels were highest in the preterm period compared with adult. In gray matter, NR2A and NR3A expression were highest near term. NR2A was significantly elevated in PVL white matter, with reduced NR1 and NR3A in gray matter compared with uninjured controls. These data suggest increased NMDAR-mediated vulnerability during early brain development due to an overall upregulation of individual receptors subunits, in particular, the presence of highly calcium permeable NR2B-containing and magnesium-insensitive NR3A NMDARs. These data improve understanding of molecular diversity and heterogeneity of NMDAR subunit expression in human brain development and supports an intrinsic prenatal vulnerability to glutamate-mediated injury; validating NMDAR subunit-specific targeted therapies for PVL.

Quality-of-life, mood and executive functioning after childhood craniopharyngioma treated with surgery and proton beam therapy

PRIMARY OBJECTIVE

Childhood craniopharyngioma, a benign tumour with a good survival rate, is associated with important neurocognitive and psychological morbidity, reducing quality-of-life (QoL).

METHOD

This retrospective study analysed QoL, mood disorders, everyday executive functioning and disease's impact on family life in 29 patients (mean age at diagnosis 7 years 10 months (SD = 4.1); mean follow-up period 6 years 2 months (SD = 4.5)) treated for childhood craniopharyngioma by surgery combined with radiotherapy using proton beam. Assessment included a semi-structured interview and standardized scales evaluating self-report of QoL (Kidscreen 52) and depression (MDI-C) and proxy-reports of QoL (Kidscreen 52), executive functioning (BRIEF) and disease's impact (Hoare and Russel Questionnaire).

RESULTS

Twenty-three families answered the questionnaires completely. Overall QoL self-report was within the normal range. QoL proxy-report was lower than self-report. Eleven patients reported depression; 24-38% had dysexecutive symptoms. A majority of families felt 'very concerned' by the disease. Depression and low parental educational level were associated with lower QoL and higher levels of executive dysfunction.

CONCLUSION

Given the high morbidity of childhood craniopharyngioma, screening for psychosocial outcome, cognitive functioning, including executive functions, mood and QoL should be systematic and specific interventions should be developed and implemented.

Predictors of change in participation rates following acquired brain injury: results of a longitudinal study

AIM

The purpose of this study was (1) to examine the changes in participation rates over 1 year among children and adolescents after acquired brain injury and (2) to explore the effect of child and family factors on these changes.

METHOD

The participation levels of 136 children and young people (88 males; 48 females; age range 4y 11mo-17y 6mo; mean age 11y 6mo) after acquired brain injury (3≤ Glasgow Coma Scale score ≤15; mean 12.8) were assessed three times: at their return to school, and at 8 and 12 months after returning to school. The Children's Assessment of Participation and Enjoyment measured the participants' diversity and intensity of participation in out-of-school activities. At baseline, information on general family functioning and medical and demographic information was collected as possible predictors. Mixed-effect model analyses of participation scores were performed while controlling for child's age at injury.

RESULTS

The severity of the injury explained rates of change across time for participation intensity in recreational, physical, and social activities. Household income influenced changes in the intensity of recreational activities, whereas family functioning predicted changes in the diversity of skill-based activities.

INTERPRETATION

Participation is a relevant outcome of recovery that needs to be assessed and monitored post brain injury. Special attention can be directed to severity of injury and family functioning when developing intervention plans.

Adaptive ability, behavior and quality of life pre and posttraumatic brain injury in childhood

CONTEXT

Traumatic brain injury (TBI) is a common, acquired childhood disability, which has been shown to have a significant impact on children's cognitive and educational function. While behavioral problems are also noted, there is ongoing debate about the contribution of preinjury factors in this domain. Few studies have attempted to measure the impact of these preinjury functions on postinjury behavior.

OBJECTIVE

To compare pre and postinjury adaptive ability, behavior, executive function and quality of life (QOL) and to identify factors that contribute to outcomes in these domains including injury severity, socio-demographic and preinjury characteristics.

DESIGN

Consecutive recruitments to a prospective, longitudinal study, utilizing a between factor design, with injury severity as the independent variable.

PARTICIPANTS AND METHODS

Children admitted to hospital with a diagnosis of TBI aged between 6 and 14 years (n = 205) were divided according to injury severity (mild, moderate and severe). Adaptive behavior (Vineland Adaptive Behavior Scales), child behavior (Child Behavior Checklist), everyday executive functions (Behavior Rating Inventory of Executive Function) and QOL (Child Health Questionnaire) assessed at 6 months post-TBI.

RESULTS AND CONCLUSIONS

Severity by time interactions were identified across a range of outcome domains demonstrating that more severe injury is associated with a decrease in functional ability at 6 months post-TBI. This effect was most pronounced for everyday executive skills, social function and internalizing aspects of child behavior. Preinjury function was a consistent predictor of postinjury status. Injury severity contributed little to the prediction of functional outcomes once preinjury functioning was accounted for in the model. Age at injury and family cohesion were relevant to specific outcome domains only. Socio-economic status did not contribute significantly to outcome at 6 months. Preinjury functioning as reported by parents in the acute phase may be a useful predictive tool for identifying children who may be at risk of functioning difficulties 6 months post-TBI.

Community integration following severe childhood traumatic brain injury

PURPOSE OF REVIEW

Severe childhood traumatic brain injury (TBI) is the leading cause of death and acquired disability in children, causing impairments in children's sensory-motor, cognitive and behavioural functioning, with devastating consequences on community integration. Community integration is the ultimate goal of rehabilitation; it is a complex outcome, with many variables contributing to it.

RECENT FINDINGS

Community integration and quality of life (QOL) are lower in children who sustained severe TBI at a younger age. Further, a wide range of injury-related, demographic and postinjury factors influence outcomes, and should serve as targets for specific interventions. An increasing number of interventions targeting cognitive, behavioural or family-related issues have been developed, with promising results.

SUMMARY

Children should benefit from early integrated patient and family-centred specific care, and receive long-term follow-up until early adulthood, with regular assessments, enabling detection and treatment of any emerging problem, and to ensure the acquisition of independent living skills and stable vocational outcome when this is possible. So far, few well conducted intervention studies are available, but their number is increasing with positive results on the trained skills. Well designed studies using large samples and looking at generalization of the skills in everyday life are needed.

Survival and long-term health and cognitive outcomes after low-grade glioma

Long-term morbidity for children with low-grade glioma (LGG) requires exposure-specific characterization. Overall survival (OS) and progression-free survival (PFS) were estimated for 361 children diagnosed with LGG between 1985 and 2007 at a single institution. Five-year survivors (n = 240) received risk-based clinical assessment. Cumulative incidence of late effects 15 years from diagnosis were estimated. Risk factors for adverse health were identified using Fine and Gray's approach to Cox's proportional hazards model, accounting for death as a competing risk. OS at 15 years was 86% (95% confidence interval [CI] 82%-90%), and PFS was 55% (95% CI 51%-58%). Among the 240 5-year survivors, the 5-, 10-, and 15-year cumulative incidence of adverse outcomes included blindness: 10%, 13%, and 18%, respectively; hearing loss: 8%, 14%, and 22%; obesity/overweight: 18%, 35%, and 53%; hyperinsulinism: 1%, 5%, and 24%; growth hormone deficiency: 13%, 27%, and 29%;thyroid hormone deficiency: 16%, 28%, and 33%; and adrenocorticotropic hormone (ACTH) deficiency: 12%, 22%, and 26%. Multivariable models demonstrated radiation therapy to be a significant independent predictor of hearing loss, growth hormone deficiency, abnormal thyroid function, and ACTH deficiency. Diencephalic location was a statistically significant independent risk factor for blindness, growth hormone deficiency, abnormal thyroid function, and ACTH deficiency. Among the 182 5-year survivors assessed for intellectual function, 34% had an intelligence quotient (IQ) below average (<85), associated with younger age at diagnosis, epilepsy, and shunt placement. Survivors of childhood LGG experience substantial long-term adverse effects that continue to increase well beyond the 5-year survival time point.

Neuropsychological features and risk factors in children with Sturge-Weber syndrome: four case reports

Sturge-Weber Syndrome (SWS) is a rare neurocutaneous disorder involving facial capillary malformation (port-wine birthmark) and vascular malformation of the brain that is frequently associated with epilepsy, stroke-like episodes, cognitive deficits, motor impairment, and/or visual field cut. The four cases presented here (ages 8-9, two females) illustrate the broad range of physiologic involvement and associated neuropsychological functioning in SWS, and argue against the idea of a "typical" SWS neuropsychological presentation. Rather, we highlight a preliminary collection of disease status/severity factors thought to impact neuropsychological presentation in SWS, including degree of cortical involvement (unilateral versus bilateral; posterior only versus posterior/anterior), age at time of seizure onset, extent of seizure control, history of stroke-like episodes, and magnitude of neurologic decline/deficit. We discuss the need for broad-based assessment in this medical population, as various impairment combinations (e.g., perceptual, language, executive) create unique presentations as well as the need for individualized intervention.

Health-related quality of life after pediatric trauma

PURPOSE OF REVIEW

Pediatric injury results in significant preventable morbidity and functional limitations, with long-term impact on the quality of life of children and their families. The purpose of this review is to outline recent research in health-related quality of life (HRQOL) in pediatric trauma, with an emphasis on identification of predictors of outcome that will impact interventions and allocation of resources to optimize recovery.

RECENT FINDINGS

Studies of HRQOL in pediatric trauma use a variety of generic measurement tools that have now been validated in this patient population. Most children experience rapid recovery of physical and psychological functioning after injury, but children with traumatic brain injury continue to demonstrate long-term impairments. Decrease in HRQOL of children after trauma contributes to increase in caregiver stress and family burden of injury. There is increasing recognition of post-traumatic stress disorder (PTSD) in pediatric trauma, correlating with and impacting HRQOL.

SUMMARY

Evaluation of HRQOL in children after trauma should become incorporated into standards of care, with development of family-centered interventions and evidence-based allocation of resources for high-risk children and families to optimize long-term outcomes.