Rehabilitation and ongoing support after pediatric TBI: twenty years of progress

Predicting and improving outcome in severe pediatric traumatic brain injury

INTRODUCTION

Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments.

AREAS COVERED

The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions.

EXPERT OPINION

There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.

Dry needling effects on motor impairments in a patient with traumatic brain injury: A case study

BACKGROUND

Motor impairments are common consequences of traumatic brain injury (TBI). It affects the individuals' participation in activities of daily living (ADLs). Dry needling treatment (DNT) uses a specialized needle to alter cortical activity. This case study aims to examine the effects of DNT on spasticity, balance, gait, and self-independence in a single patient with TBI.

CASE DESCRIPTION

A twenty-six-year-old male with a history of TBI, resulting in muscle weakness on the right side of the body, spasticity, distributed balance, and difficulties with independent gait participated in this study. The Berg balance scale (BBS), 6-min walk test (6MWT), Modified Ashworth Scale (MAS), and Functional Independence Measure (FIM) were used to evaluate balance, gait, spasticity, and functional performance, respectively.

OUTCOME

After 36 DNT sessions extended over 12 weeks, the patient demonstrated improvements in spasticity, balance, gait, and functional capacity both immediately after the intervention and at the 4-week follow-up.

CONCLUSION

This case study demonstrates that DNT is considered a novel intervention for treating spasticity and improving balance, gait, and functional capacity post-TBI. Further research is recommended to verify these findings.

Strategies supporting parent-delivered rehabilitation exercises to improve motor function after paediatric traumatic brain injury: A systematic review

AIM

To identify and analyse ways in which parents are supported to deliver rehabilitation exercises to their child after traumatic brain injury (TBI), conceptualized as strategies.

METHOD

A systematic search was completed using seven online databases and three grey literature databases, from inception to November 2021. The included studies focused on physical rehabilitation in children after TBI with the involvement of parents as hands-on deliverers or facilitators of rehabilitation (e.g. supervising the exercise). Intervention descriptions were reviewed to identify strategies; this was followed by fine-grained analysis using the Behaviour Change Wheel to identify intervention components. Risk of bias was analysed using the revised Cochrane Risk-of-Bias Tool for Randomized Trials or the Risk Of Bias In Non-randomized Studies - of Interventions.

RESULTS

Six interventions including 211 participants and one trial protocol met the inclusion criteria. All studies included a proportion of children diagnosed with TBI and four studies included mixed samples of acquired brain injury or cerebral palsy. All interventions included elements of goal setting and instruction.

INTERPRETATION

Interventions focus heavily on the initiation of physical rehabilitation, but focus less on the longer-term maintenance of rehabilitation delivery. Further research should integrate perspectives from parents to inform the development of new interventions.

WHAT THIS PAPER ADDS

Parents need support to deliver or supervise rehabilitation exercises. The interventions identified in this review supported goal setting, action planning, and learning rehabilitation exercises. Interventions focused primarily on the initiation of exercises but less on maintenance. Rehabilitation is complex and new approaches are needed to better support parents.

Cognitive Orientation to daily Occupational Performance to improve occupational performance goals for children with executive function deficits after acquired brain injury

AIM

To determine the effectiveness of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach in improving the occupational performance goals of children and young people with executive function deficits after acquired brain injury (ABI) (e.g. etiologies such as stroke, encephalitis, brain tumor, and traumatic brain injury).

METHOD

A replicated single-case experimental study using a randomized multiple baseline design across participants and goals was used. Three clusters of four participants (12 participants, nine males and three females, aged 8-16 years) were included. The intervention consisted of 14 individual CO-OP sessions. Each participant chose four goals; three goals were trained during the intervention sessions and a fourth goal served as the control. The Goal Attainment Scale (GAS) was used as a repeated measure to determine goal achievement while the Canadian Occupational Performance Measure (COPM) was used to identify the perceived goal achievement of children, young people, and their parents.

RESULTS

For 26 of the 35 trained goals, the intervention led to statistically significant improvements in the GAS. Perceived occupational performance and satisfaction improved significantly for the trained goals (30 out of 35 goals for the COPM performance and satisfaction of participants; 26 out 31 goals for the COPM performance of parents; 24 out of 31 goals for the COPM satisfaction of parents) and were maintained at the follow-up. Almost all COPM control goal results were significant, but these changes were not supported by the GAS measures or the statistical analysis.

INTERPRETATION

The generally positive results of this study provide evidence of the benefits of using the CO-OP approach with this population.

Predictors of neurocognitive outcome in pediatric ischemic and hemorrhagic stroke

This clinical study examined the impact of eight predictors (age at stroke, stroke type, lesion size, lesion location, time since stroke, neurologic severity, seizures post-stroke, and socioeconomic status) on neurocognitive functioning following pediatric stroke. Youth with a history of pediatric ischemic or hemorrhagic stroke (n = 92, ages six to 25) underwent neuropsychological testing and caregivers completed parent-report questionnaires. Hospital records were accessed for medical history. Spline regressions, likelihood ratios, one-way analysis of variance, Welch's t-tests, and simple linear regressions examined associations between predictors and neuropsychological outcome measures. Large lesions and lower socioeconomic status were associated with worse neurocognitive outcomes across most neurocognitive domains. Ischemic stroke was associated with worse outcome in attention and executive functioning compared to hemorrhagic stroke. Participants with seizures had more severe executive functioning impairments than participants without seizures. Youth with cortical-subcortical lesions scored lower on a few measures than youth with cortical or subcortical lesions. Neurologic severity predicted scores on few measures. No differences were found based on time since stroke, lesion laterality, or supra- versus infratentorial lesion. In conclusion, lesion size and socioeconomic status predict neurocognitive outcome following pediatric stroke. An improved understanding of predictors is valuable to clinicians who have responsibilities related to neuropsychological assessment and treatments for this population. Findings should inform clinical practice through enhanced appraisals of prognosis and the use of a biopsychosocial approach when conceptualizing neurocognitive outcome and setting up support services aimed at fostering optimal development for youth with stroke.

Family involvement in rehabilitation programmes for children and adolescents with acquired brain injury: A scoping literature review

Paediatric acquired brain injury (ABI) can adversely impact families, and it is widely accepted that families should be involved in the rehabilitation of children/adolescents with ABI. However, there is limited guidance about how to best involve families in paediatric ABI rehabilitation. Several programmes involving the families of children/adolescents with ABI have been developed, but there are no published reviews outlining their characteristics. This scoping literature review aimed to synthesize information about these programmes and develop an understanding of how families are involved in them. Four databases were systematically searched to identify sources of evidence that described programmes in paediatric ABI rehabilitation that involve family members. One hundred and eight sources of evidence describing 42 programmes were included. Programmes were categorized as: service coordination (n = 11), psychosocial (n = 17), support groups (n = 4), training/instruction (n = 9), and education (n = 1). Families' involvement in these programmes varied across programme development, delivery, and evaluation stages. The findings of this scoping literature review outline how families can be involved in paediatric ABI rehabilitation. While this review outlines many approaches to supporting families, it also highlights the need for models of family-centred care to better articulate how clinicians and services can involve families in paediatric ABI rehabilitation.

The growing gap: A study of sleep, encoding, and consolidation of new words in chronic traumatic brain injury

Word learning is an iterative and dynamic process supported by multiple neural and cognitive systems. Converging evidence from behavioral, cellular, and systems neuroscience highlights sleep as an important support for memory and word learning over time. In many lab-based word learning experiments, participants encode and subsequently retrieve newly learned words in a single session. These designs are inadequate to capture the full dynamic word learning process, making them less ecologically valid. Single timepoint studies also limit investigation of the role of behavioral and lifestyle factors, like sleep, in supporting word learning over time. Adults with a history of traumatic brain injury (TBI), who commonly exhibit deficits in the memory systems that support word learning and report concomitant sleep disturbance, provide a unique opportunity to examine the link between memory, sleep, and word learning. Here we examined word learning over time and the influence of sleep on short- and long-term word recall in 50 adults with chronic moderate-severe TBI and 50 demographically matched neurotypical peers. We used a randomized within-participant crossover design to assess immediate encoding of new words and the consolidation of those words over time across intervals that did or did not involve sleep. Participants completed this study over the course of two weeks in their own homes to capture the iterative, dynamic process of real-world word learning. We also measured sleep in free living conditions using actigraphy throughout the experiment. Participants with TBI exhibited a word learning deficit that began at encoding and persisted across time. Critically, this deficit grew over the course of the week. The performance gap between groups was larger at the 1-week post-test than the immediate post-test, suggesting deficits in both encoding and consolidation of new words in individuals with TBI. Participants with and without TBI remembered more words when they slept after learning. Ecologically valid research designs that examine the relationship between memory, sleep, and word learning over time promise to advance mechanistic accounts of word learning and improve the long-term retention of new words in individuals with and without brain injury.

School-based interventions for children and adolescents following traumatic brain injury: A systematic review

BACKGROUND

Childhood traumatic brain injury (TBI) can result in impairments in learning, cognition, and behaviour; all of which can adversely influence educational outcomes. Schools can play a crucial role in rehabilitation, therefore it is important that evidence-based supports are available in these settings.

OBJECTIVE

The aim of this systematic review was to evaluate the effectiveness of school-based supports and interventions available following childhood TBI.

METHODS

A comprehensive search strategy involved eight research databases, grey literature, and backward reference searching.

RESULTS

The search identified 19 studies, reporting on sixteen distinct interventions, which used a variety of person-centred and systemic approaches, and typically contained multiple components, including: psychoeducation, behavioural scripts, and attention training. While offering some indication for future directions in intervention, the evidence base for individual interventions was typically limited, and does not take account of cost or issues in sustainability.

CONCLUSION

While there appears to be great potential to support students who may otherwise not gain access to services, there is insufficient evidence to guide widespread policy or practice change without further research. Greater collaboration between researchers, clinical practitioners, and educators is necessary to ensure that all interventions developed are robustly evaluated and disseminated.

Word Learning as a Window to Memory and Rehabilitation Outcomes in Traumatic Brain Injury

PURPOSE

The purpose of this viewpoint is to advocate for increased study of word learning abilities and word learning interventions in traumatic brain injury (TBI).

METHOD

We describe the word learning process and the unique opportunities afforded by studying each component and stage. Building on discussions at the 2022 International Cognitive-Communication Disorders Conference, we describe how word learning may underlie a variety of functional outcomes after TBI, making it a promising target for rehabilitation. Finally, we discuss principles that may guide study in this critical area to advance outcomes after TBI for children and adults.

RESULTS

Word learning is a dynamic and iterative process taking place over time and in multiple stages. Thus, studying word learning affords the opportunity to parse the relative contributions of multiple memory systems to different phases and components of the process. However, single-timepoint designs are insufficient to capture the full word learning process, which occurs over time and across contexts. Word learning also presents an opportunity to assess the contributions of behavioral and lifestyle factors (e.g., sleep and exercise) to different memory phases. Understanding these interactions could drive clinical interventions aimed at improving memory through manipulable external behaviors.

CONCLUSIONS

Word learning is key to success in functional spheres across the life span. The importance of words to daily life remains after TBI, even as the memory systems that support word learning are disrupted. The empirical study of word learning and rehabilitation of word learning deficits in TBI presents a promising new direction in understanding the breadth of neurogenic cognitive-communication disorders and an opportunity to explore a potential driver of functional outcome and impactful rehabilitation target.

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 clinical utility of the Children's Communication Checklist-2 in children with early childhood traumatic brain injury

ObjectivePediatric traumatic brain injury (TBI) is associated with long-term cognitive and behavioral deficits. Social communication impairments are common and impact functional outcomes, such as social engagement and academic performance. There are many barriers to identifying social communication deficits following TBI, including the absence of a standardized parent-reported communication measure for use in this population. The Children's Communication Checklist-Second Edition (CCC-2) has demonstrated utility in identifying communication deficits in diagnoses other than TBI. This study investigated the clinical utility of the CCC-2's social communication scales in children with TBI. Method: 203 children who sustained TBI or orthopedic injuries between the ages of 36 and 83 months were recruited as part of a larger, longitudinal study. We analyzed social communication subscale scores from the CCC-2 an average of 3.5 years postinjury. We used binary logistic regression analyses to examine the measure's accuracy in classifying children with and without social communication deficits on other measures of pragmatic language and social competence. Correlation analyses and linear mixed models were used to examine the construct validity of the CCC-2. Results: The CCC-2 was able to accurately classify those with and without pragmatic language impairments on the Comprehensive Assessment of Spoken Language 92% of the time (sensitivity = 55%) and 96% of the time on the Home and Community Social Behavior scale (sensitivity = 72%). The CCC-2 demonstrated strong correlations with and predictive validity for measures of social communication and competence. Conclusions: The findings offer support for the clinical utility of the CCC-2 in the pediatric TBI population.

Reflections on the physical, executive developmental and systems applied framework in child neuropsychological rehabilitation

This paper describes the influence of the Physical, Executive, Developmental and Systems (PEDS) framework on the delivery of community-based child neuropsychological rehabilitation and how it has been enhanced by the proliferation of neuroscientific, neuropsychological and psychosocial research and evidence-base in childhood brain injury and rehabilitation over the past decade. The paper signposts to some of the key models, theories and concepts currently shaping service delivery. Application of the PEDS framework in a clinical case is described.

The influence of methylphenidate on sustained attention in paediatric acquired brain injury: a meta-analytical review

Impairment in sustained attention is a common consequence of childhood Acquired Brain Injury (ABI). Whilst methylphenidate provides promise in enhancing "attention" as a unitary construct, little work has explored its effectiveness upon individual attentional domains. The current systematic review and meta-analysis evaluates the utility of methylphenidate on sustained attentional performance across childhood ABI groups. Five databases (PsycINFO, MEDLINE, Embase, Scopus & Cochrane Library) were searched for relevant articles from their inception to March 2022. A purpose-developed evaluation tool was used to assess each study's research quality (QuEST:MAP). Nine of the 1600 identified articles were included within this review (n = 259). Meta-analytical findings reported an overall significant benefit of methylphenidate on sustained attention in childhood ABI (g = -0.33, 95% CI: -0.62 to -0.04). Associated summary effect sizes were relatively small, particularly when adjusting for outlier cases. Subgroup analyses identified a significantly greater benefit of methylphenidate in clinical subgroups with comorbid ADHD diagnoses (p < .01). The current evidence base is characterized by small-scale clinical trials with variable research quality and low generalizability. Further robust research is needed to quantify methylphenidate utility upon individual attentional domains in larger and more representative ABI samples.

A new model to guide identity-focused multidisciplinary rehabilitation for children and young people following acquired brain injury: I-FoRM

A complexity of biological, psychological, environmental and systemic factors influences a child's adaption after acquired brain injury (ABI), all of which transform as the child matures. Multidisciplinary rehabilitation teams are challenged by balancing family system needs and the child's needs, whilst promoting the child's functional skills in difficult or unappealing tasks. This paper presents the conceptual basis for a model for use in childhood ABI neurorehabilitation to address these challenges. A non-systematic narrative review of literature pertinent to integrated neurorehabilitation of pediatric ABI was conducted. Contemporary models of adult and pediatric psychosocial adaptation involving identity following ABI were reviewed. Key findings were then synthesized with models of pediatric resilience and self-concept development. The resulting model describes a cyclical adaptation process whereby the child learns experientially about their self and their world after ABI. Processes of identity development play a central role - particularly emotive processes of self-evaluation - by influencing the child's motivation for participation, tolerance for challenge, self-regulation and emerging self-awareness. The model directs clinicians to use the psychosocial processes of identity development to enhance the child's willingness and capacity to engage in the daily challenges of rehabilitation. Further systematic development and evaluation of the model is needed.

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

Purpose/Objective

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

Method

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

Results and Implications

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

The Value of Patient Registries to Advance Basic and Translational Research in the Area of Traumatic Brain Injury

The number of individuals affected by traumatic brain injury (TBI) is growing globally. TBIs may cause a range of physical, cognitive, and psychiatric deficits that can negatively impact employment, academic attainment, community independence, and interpersonal relationships. Although there has been a significant decrease in the number of injury related deaths over the past several decades, there has been no corresponding reduction in injury related disability over the same time period. We propose that patient registries with large, representative samples and rich multidimensional and longitudinal data have tremendous value in advancing basic and translational research and in capturing, characterizing, and predicting individual differences in deficit profile and outcomes. Patient registries, together with recent theoretical and methodological advances in analytic approaches and neuroscience, provide powerful tools for brain injury research and for leveraging the heterogeneity that has traditionally been cited as a barrier inhibiting progress in treatment research and clinical practice. We report on our experiences, and challenges, in developing and maintaining our own patient registry. We conclude by pointing to some future opportunities for discovery that are afforded by a registry model.

Care Coordination for Children with Special Health Care Needs: A Scoping Review to Inform Strategies for Students with Traumatic Brain Injuries

BACKGROUND

Chronic and complex medical issues, including traumatic brain injuries (TBIs), have significant educational implications. The purpose of this study was to identify and summarize the literature on care coordination strategies among health care professionals, educators, and caregivers for children with special health care needs (CSHCN). Clarifying factors that influence care coordination for CSHCN can inform future studies on care coordination for students with TBI. Improved understanding of these factors may lead to better communication, reduction of unmet needs, more efficient service access, and improved long-term outcomes for children.

METHODS

A scoping review was conducted, guided by PRISMA-ScR methodology. Five databases (CINAHL, PSYCINFO, EMBASE, ERIC, PubMed) were searched to identify relevant studies that focused on care coordination and educational settings.

RESULTS

Twelve articles met inclusion criteria. Care coordination interventions for CSHCN used in educational settings focused on relationship-building strategies, clear procedures and roles, and education of members of the school community.

CONCLUSIONS

Findings highlight strategies to coordinate care for CSHCN and factors that may moderate effects of these interventions. Key stakeholders should now study these strategies specifically in children with TBI.

Rehabilitation of executive function in chronic paediatric brain injury: a randomized controlled trial

BACKGROUND

Impaired executive functions (EFs, i.e., purposeful, goal-directed behaviour) cause significant disability after paediatric acquired brain injury (pABI) warranting efficient interventions. Goal Management Training (GMT) is a metacognitive protocol proven effective for executive dysfunction in adults. This pre-registered, blinded, parallel-randomized controlled trial evaluated efficacy of a paediatric adaptation (pGMT) compared to a psychoeducative control (paediatric Brain Health Workshop, pBHW) to improve EF.

METHODS

Children aged 10 to 17 years with pABI (e.g., traumatic brain injury, brain tumour), ≥ 1 year post-onset or ended treatment, with parent-reported EF complaints were eligible. Participants were randomized (computer-algorithm) to either group-based pGMT (n = 38) or pBHW (n = 38). The active control was tailored to keep non-specific factors constant. Thus, both treatments comprised of 7 sessions at hospitals over 3 consecutive weeks, followed by 4 weeks of telephone counselling of participants, parents, and teachers. Parent-reported daily life EF, assessed by the questionnaire Behavior Rating Inventory of Executive Function (BRIEF; Behavioral Regulation Index (BRI) and Metacognition Index (MI)), were co-primary outcomes 6 months post-intervention. Secondary outcomes included neuropsychological tests and a complex naturalistic task (Children's Cooking Task).

RESULTS

Seventy-three participants (96%) completed allocated interventions and 71 (93%) attended the 6-month follow-up. The results demonstrated no significant difference in effectiveness for the two interventions on parent-reported EF: For BRIEFBRI, mean (SD) raw score for pGMT was 42.7 (8.8) and 38.3 (9.3) for pBHW. Estimated difference was - 2.3 (95% CI - 5.1 to 0.6). For BRIEFMI, the corresponding results were 80.9 (20.4) for GMT and 75.5 (19.3) for pBHW. Estimated difference was - 1.4 (95% CI -8.5 to 5.8). In performance-based tests, pGMT was associated with improved inhibition and executive attention, while pBHW was associated with fewer errors in the naturalistic task.

CONCLUSIONS

In pABI, metacognitive training (pGMT) did not demonstrate additional effectiveness on parent-reported daily life EF at 6-month follow-up, when compared to a psychoeducative control. Both interventions were well-tolerated and demonstrated distinct improvements at different EF assessment levels. To conclude on pGMT efficacy, larger studies are needed, including further investigation of appropriate assessment levels and possible differences in effect related to treatment duration, developmental factors, and injury characteristics.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT0321534211, 11 July 2017.

Exploring the use of the Cognitive Orientation to daily Occupational Performance approach (CO-OP) with children with executive functions deficits after severe acquired brain injury: A single case experimental design study

Children with acquired brain injury (ABI) often have cognitive and behavioral impairments that affect participation in everyday activities. Among them, executive function (EF) deficits are frequent. Cognitive Orientation to Daily Occupational Performance (CO-OP) is an individualized treatment that teaches cognitive strategies necessary to support successful performance. Few studies have examined the effectiveness of CO-OP in children with EF deficits after ABI.

OBJECTIVES

to assess whether the use of CO-OP could be of interest in children with EF deficits after ABI, to improve their occupational performance, their executive functioning in everyday life and their cognitive processes constituting EF.

METHODS

This was a single case experimental study with multiple baselines across individuals and behaviors. We included 2 children at least 6 months after severe ABI. The children received 14 individual sessions of the CO-OP intervention. Each child set 3 goals by using the Canadian Occupational Performance Measure; 2 goals were trained and the third was a control goal. The achievement of the goals was measured by using repeated measures of Goal Attainment Scales (GASs). Ecological assessments of EF included the Children's Cooking Task and parent and teacher ratings of the Behavior Rating Inventory of Executive Function (BRIEF) questionnaire.

RESULTS

both children improved their performance on both trained goals (and, to a lesser extent, on untrained goals). We found significant improvement on tests of EF and on the BRIEF questionnaire, reflecting executive functioning in everyday life, at home and at school.

CONCLUSIONS

these results are encouraging and suggest the feasibility and effectiveness of CO-OP for children with EF deficits after ABI. They should be replicated in a larger number of cases.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04718688).

Return to School Following TBI: Educational Services Received 1 Year After Injury

BACKGROUND

Many children who experience a traumatic brain injury (TBI) return to school without receiving needed support services.

OBJECTIVE

To identify services received and predictors of formal special education services (ie, Individualized Education Plan [IEP]) for students with TBI 1 year after returning to school.

SETTING AND PARTICIPANTS

A total of 74 students with TBI recruited from children's hospitals in Colorado, Ohio, and Oregon.

DESIGN

Secondary analysis of previously reported randomized control trials with surveys completed by caregivers when students returned to school (T1) and 1 year later (T2). This study reports data collected at T2.

RESULTS

While 45% of students with TBI reported an IEP 1 year after returning to school, nearly 50% of students received informal or no services. Male students, those who sustained a severe TBI, and students whose parents reported domain-specific concerns were more likely to receive special education services at 1 year. In a multivariate model, sex remained the only significant predictor of IEP services at T2.

CONCLUSIONS

Females and students with less severe or less visible deficits were less likely to receive special education services. While transition services may help students obtain special education for the first year after TBI, identifying students with TBI who have subtle or later-developing deficits remains a challenge.

Disability and the COVID-19 Pandemic: A Survey of Individuals With Traumatic Brain Injury

Objectives

To identify the consequences of the coronavirus 2019 (COVID-19) pandemic for individuals with traumatic brain injury (TBI), with particular attention to unique effects for individuals with chronic disability.

Design

Individuals with and without a history of TBI completed a web-based survey.

Setting

Participants were recruited from the Vanderbilt Brain Injury Patient Registry in Nashville, TN, and completed the survey from their homes between May and June 2020, during social distancing related to the COVID-19 pandemic.

Participants

Participants (N=47) in the chronic phase of moderate-severe TBI (>6mo postinjury) and 51 noninjured comparison (NC) peers completed the survey.

Interventions

Not applicable.

Main Outcome Measures

Participants, or respondents, answered a mix of multiple choice and free text questions about how the COVID-19 pandemic has affected their work, education, medical care, social communication, sources of information and decision making, and mental and physical well-being. Individuals with TBI also answered questions about how TBI has affected their experiences of the pandemic.

Results

As a group, respondents with TBI reported less pandemic-related behavior change (eg, daily habits, virtual social visits, and masking) than NC peers. Both NCs and respondents with TBI identified health care providers as trusted sources of public health information. One-third of individuals with TBI indicated that brain injury has made coping with the pandemic more difficult, and respondents identified mental health challenges and social isolation as key barriers.

Conclusions

These results suggest that health care providers should look for ways to provide tailored education and reduce social isolation for individuals with disability during the ongoing COVID-19 pandemic. We discuss several direct suggestions from participant responses.

The student journey: Living and learning following traumatic brain injury

Primary objective: In this research we set out to gain further understanding of the experiences of students participating in secondary and tertiary education following TBI: exploring academic and non-academic factors, as well as changes in experiences over time.Methods and procedures: A longitudinal, qualitative investigation was completed. 12 students (17-32 years) completed up to three in-depth interviews over a period of 4-15 months, capturing atotal of 30 time points. Data were analyzed using grounded theory methods.Main outcomes and results: Students' participation experiences were unique and varied with different timelines and outcomes, however they shared many similar critical points. We interpreted their experiences as a student journey traveling through four significant landscapes, "Choosing to study", "Studying", "Deciding what to do", "Making the next step." Journeys involved complex processes of living and learning. Moving along the pathway was not always smooth or straightforward.Conclusions: Students' experiences of returning to study following TBI can be interpreted as a complex journey of living and learning. Four important stages of the journey provide clinicians and educators with landscape features that can provide a structure for exploring supports to address both academic and non-academic factors to assist students in their study journey.

Delineating the Nature and Correlates of Social Dysfunction after Childhood Traumatic Brain Injury Using Common Data Elements: Evidence from an International Multi-Cohort Study

Although childhood traumatic brain injury (TBI) has been linked to heightened risk of impaired social skills and behavior, current evidence is weakened by small studies of variable methodological quality. To address these weaknesses, this international multi-cohort study involved synthesis of data from two large observational cohort studies of complicated mild-severe child TBI in Australia and North America. Both studies adopted a unified approach to data collection and coding procedures, providing the opportunity to merge datasets from multiple, well-characterized cohorts for which gold standard measures of social outcomes were collected during the chronic recovery phase. The study involved 218 children, including 33 children with severe TBI, 83 children with complicated mild-moderate TBI, 59 children with orthopedic injury, and 43 age- and sex-matched typically developing control children. All injured children were recruited from academic children's hospitals and underwent direct cognitive assessments including measures of theory of mind (ToM) at least 1-year post- injury. Parents rated their child's social adjustment using standardized measures of social skills, communication and behavior. Results showed a brain-injury specific effect on ToM abilities, such that children with both complicated mild to moderate and severe TBI displayed significantly poorer ToM than children without TBI. In mediator models, poorer ToM predicted poorer parent-rated self-direction and social skills, as well as more frequent behavioral symptoms. The ToM mediated the effect of severe TBI on parent ratings of communication and social skills, as well as on overall behavior symptoms. The findings suggest that deficits in ToM are evident across the spectrum of TBI severity and represent one mechanism linking severe child TBI to long-term social adjustment difficulties. The findings underscore the value of large-scale data harmonization projects to increase the quality of evidence regarding the outcomes of TBI. Clinical and scientific implications are discussed.

Long term effects of early childhood traumatic brain injury on narrative discourse gist and psychosocial functioning

Purpose: To examine the long-term consequences of early childhood traumatic brain injury (TBI), approximately 6.8 years post-injury, on cognitive communication competency within a complex interplay of individual, contextual, and psychosocial factors. Additionally, we were interested in looking at the association of communication competence with social competence and overall functioning.Methods: 64 children with orthopedic injury, 40 children with moderate traumatic brain injury, and 14 children with severe traumatic brain injury who were between 3 years and 6 years 11 months at injury completed a narrative discourse task and clinical measures in a single visit at a longer term follow up in early adolescence, an average of 6.8 years post injury. Analyses of covariance were conducted to compare groups on the discourse task, and hierarchical linear regressions were conducted to examine the association of discourse measures with clinical measures of cognitive and psychosocial functioning.Results: Children with severe traumatic brain injury performed worse than children with moderate traumatic brain injury and orthopedic injury on all discourse indices and clinical measures. Injury severity, pragmatic skills, and socioeconomic status were associated with discourse gist. Discourse gist was the most sensitive measure of communication competence, and it was significantly associated with psychosocial outcomes independent of group.Conclusion: Children who sustain a severe traumatic brain injury in early childhood are at risk for long-term cognitive communication impairments that may be related to a complex interplay of injury, individual, and social factors.Implications for rehabilitationThe assessment and treatment of cognitive communication impairments after traumatic brain injury are complex and require consideration of individual, contextual, and psychosocial factors.Discourse, in general, and gist reasoning specifically, is a sensitive measure for detecting cognitive communication competence several years after pediatric traumatic brain injury.Treatments to address gist reasoning deficits may support improvements in global and social functioning.

Association of Insurance Status With Treatment and Outcomes in Pediatric Patients With Severe Traumatic Brain Injury

OBJECTIVE

To determine whether a health insurance disparity exists among pediatric patients with severe traumatic brain injury using the National Trauma Data Bank.

DESIGN

Retrospective cohort study.

SETTING

National Trauma Data Bank, a dataset containing more than 800 trauma centers in the United States.

PATIENTS

Pediatric patients (< 18 yr old) with a severe isolated traumatic brain injury were identified in the National Trauma Database (years 2007-2016). Isolated traumatic brain injury was defined as patients with a head Abbreviated Injury Scale score of 3+ and excluded those with another regional Abbreviated Injury Scale of 3+.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Procedure codes were used to identify four primary treatment approaches combined into two classifications: craniotomy/craniectomy and external ventricular draining/intracranial pressure monitoring. Diagnostic criteria and procedure codes were used to identify condition at admission, including hypotension, Glasgow Coma Scale, mechanism and intent of injury, and Injury Severity Score. Children were propensity score matched using condition at admission and other characteristics to estimate multivariable logistic regression models to assess the associations among insurance status, treatment, and outcomes. Among the 12,449 identified patients, 91.0% (n = 11,326) had insurance and 9.0% (n = 1,123) were uninsured. Uninsured patients had worse condition at admission with higher rates of hypotension and higher Injury Severity Score, when compared with publicly and privately insured patients. After propensity score matching, having insurance was associated with a 32% (p = 0.001) and 54% (p < 0.001) increase in the odds of cranial procedures and monitor placement, respectively. Insurance coverage was associated with 25% lower odds of inpatient mortality (p < 0.001).

CONCLUSIONS

Compared with insured pediatric patients with a traumatic brain injury, uninsured patients were in worse condition at admission and received fewer interventional procedures with a greater odds of inpatient mortality. Equalizing outcomes for uninsured children following traumatic brain injury requires a greater understanding of the factors that lead to worse condition at admission and policies to address treatment disparities if causality can be identified.

Preliminary Efficacy of Online Traumatic Brain Injury Professional Development for Educators: An Exploratory Randomized Clinical Trial

OBJECTIVE

To examine the efficacy of an online traumatic brain injury (TBI) professional development intervention, In the Classroom After Concussion: Best Practices for Student Success.

DESIGN

A randomized controlled trial with a sample of 100 general educators, who were randomly assigned to the In the Classroom Web site (treatment group) or the LEARNet Web site (control group). Participants completed the pretest, accessed the In the Classroom or LEARNet site and the posttest and completed follow-up assessments 60 days after posttest.

MEASURES

(1) Knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized self-efficacy measure.

RESULTS

On the posttest assessment, In the Classroom educators showed significantly greater gains in knowledge (P < .0001, d = 1.36 [large effect]), TBI knowledge application (P = .0261, d = 0.46), and general self-efficacy (P = .0106, d = 0.39) than the LEARNet controls. In the Classroom educators maintained significant gains in knowledge (P = .001, d = 0.82) and general self-efficacy (P = .018, d = 0.38) but not in TBI knowledge application (P = .921, d = 0.02).

CONCLUSION

Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Management of Spasticity After Traumatic Brain Injury in Children

Traumatic brain injury is a common cause of disability worldwide. In fact, trauma is the second most common cause of death and disability, still today. Traumatic brain injury affects nearly 475 000 children in the United States alone. Globally it is estimated that nearly 2 million people are affected by traumatic brain injuries every year. The mechanism of injury differs between countries in the developing world, where low velocity injuries and interpersonal violence dominates, and high-income countries where high velocity injuries are more common. Traumatic brain injury is not only associated with acute problems, but patients can suffer from longstanding consequences such as seizures, spasticity, cognitive and social issues, often long after the acute injury has resolved. Spasticity is common after traumatic brain injury in children and up to 38% of patients may develop spasticity in the first 12 months after cerebral injury from stroke or trauma. Management of spasticity in children after traumatic brain injury is often overlooked as there are more pressing issues to attend to in the early phase after injury. By the time the spasticity becomes a priority, often it is too late to make meaningful improvements without reverting to major corrective surgical techniques. There is also very little written on the topic of spasticity management after traumatic brain injury, especially in children. Most of the information we have is derived from stroke research. The focus of management strategies are largely medication use, physical therapy, and other physical rehabilitative strategies, with surgical management techniques used for long-term refractory cases only. With this manuscript, the authors aim to review our current understanding of the pathophysiology and management options, as well as prevention, of spasticity after traumatic brain injury in children.

The feasibility and acceptability of goal management training of executive functions in children with spina bifida and acquired brain injury

Executive dysfunction causes significant real-life disability for children with spina bifida (SB) and acquired brain injury (ABI), and efficient interventions are needed. Goal Management Training (GMT) is a cognitive rehabilitation intervention for improving executive function (EF) that has received empirical support in studies of adults with SB and ABI. The purpose of this study was to determine the feasibility and acceptability of a newly developed pediatric GMT protocol (pGMT). Thirteen children (7 boys, 10-16 years) with SB (n = 4), traumatic brain injury (n = 8), and encephalitis (n = 1) were included, based upon the presence of EF problems as described by parents. The participants received 21 h of pGMT, using inpatient intervention periods, followed by 4 h of pGMT outpatient guidance over 8 weeks. Notably, pGMT was found to be both feasible and acceptable, with satisfactory compliance for the children, parents and teachers, in addition to being considered acceptable by all participants. Furthermore, a reliable change in daily life EF was reported by the parents for 2 children. And, some children obtained scores below clinical cut-off on a measure of parent reported real-life EF after intervention. Hence, findings suggest that a randomized controlled trial of pGMT, with a larger sample size, should be conducted.

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

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

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT03215342.

Treatment of severe traumatic brain injury in German pediatric intensive care units-a survey of current practice

PURPOSE

German pediatric guidelines for severe traumatic brain injury (TBI) management expired in 2011. Thus, divergent evidence-based institutional protocols are predominantly being followed. We performed a survey of current Pediatric Intensive Care Unit (PICU) management of isolated severe TBI in Germany to reveal potential varying practices.

METHODS

Seventy German PICUs were invited to join an anonymous online survey from February to May 2017. Twenty-nine participants (41.4%) successfully completed the survey (17 university hospitals and 12 district hospitals). The majority of items were polar (yes/no) or scaled (e.g., never - always). Main topics were imaging, neurosurgery, neuromonitoring, adjuvant therapy, and medication. Severity of TBI was defined via Glasgow Coma Scale.

RESULTS

The majority of respondents (93.1%) had internal TBI standards, and patients were mainly administered to interdisciplinary trauma units. The use of advanced neuromonitoring techniques, intracranial hypertension management, and drug treatment differed between PICUs. Routine administration of hypertonic saline in TBI-associated cerebral edema was performed by 3.4%, while it was never an option for 31.0% of the participants. Prophylactic anticonvulsive therapy was restrictively performed. If indicated, the main anticonvulsive drugs used were phenobarbital and levetiracetam. Neuroendocrine follow-up was recommended/performed by 58.6% of the PICUs.

CONCLUSIONS

This survey provides an overview of the current PICU practices of isolated severe TBI management in Germany and demonstrates a wide instrumental and therapeutical range, revealing an unmet need for the revised national guideline and further (international) clinical trials for the treatment of severe TBI in pediatrics.

A quasi-experimental study examining the effects of online traumatic brain injury professional development on educator knowledge, application, and efficacy in a practitioner setting

Background: Each year ∼700 000 U.S. children ages 0-19 years sustain a traumatic brain injury. Children who experience brain injury are at risk for impairments in executive function, processing speed, cognition, memory, attention, and behavior which can lead to school failure. However, few teachers or other educational professionals receive training on effectively working with students who have traumatic brain injury (TBI). The purpose of this study was to examine the efficacy of an online traumatic brain injury professional development intervention, In the Classroom after Concussion: Best Practices for Student Success.Methods: This quasi-experimental study examined the effects of online traumatic brain injury professional development (In the Classroom after Concussion: Best Practices for Student Success) on educator knowledge, knowledge application, and self-efficacy in a practitioner setting with a sample of 81 educators from all professional backgrounds. Participants completed the pretest, accessed the In the Classroom training and posttest, and completed follow-up assessments 30 days after the posttest. Measures: (1) knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized measure of educator self-efficacy.Results: On the posttest assessment, educators showed significant gains in knowledge (p = 0.001, r = 0.62), knowledge application (p = 0.001, r = 0.63), and self-efficacy (p = 0.008, r = 0.29). At 30-day follow up, educators maintained significant gains in knowledge (p = 0.001, r = 0.62) and self-efficacy (p value = 0.008, r = 0.28), but not in knowledge application.Conclusion: Given the prevalence of traumatic brain injury, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in traumatic brain injury professional development. In the Classroom is one such approach.Implications for rehabilitationWithout training in TBI, educators will be poorly prepared to monitor students' post-injury challenges and to address learning and behavioral challenges as they occur.Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Family appraisal of paediatric acquired brain injury: a social work clinical intervention trial

OBJECTIVE

To compare the efficacy of a new intervention 'Family Forward' with 'Usual Care' social work practice in optimising family appraisal of a child's acquired brain injury to ensure better adaptation during the inpatient rehabilitation phase of care and early transition home.

RESEARCH DESIGN

Single site, prospective, sequential comparison group design.

METHODS AND PROCEDURES

Families were recruited on admission to an inpatient rehabilitation service based at a tertiary paediatric hospital. The 'Usual Care' group (n = 22; 29 parents) recruitment, intervention and data collection were completed first (Phase 1), followed by the 'Family Forward' group (n = 25; 43 parents) (Phase 2). Parents/caregivers completed measures: (Impact of Event Scale- Revised: IES-R; Parents Experience of Childhood Illness and Brief Illness Perception Questionnaire: Brief IPQ) at the time of their child's inpatient rehabilitation admission, inpatient rehabilitation discharge, and 6 weeks post-discharge.

MAIN OUTCOMES AND RESULTS

There were more children with traumatic brain injuries in the Family Forward group (n = 13) than Usual Care (n = 6) and the Family Forward group had a longer hospital admission (days, M = 56.4, SD = 46.1 vs. M = 37.5, SD = 16.4, p = 0.019). No significant group differences were found for family appraisal outcomes at any of the three time-points. Both groups reported reductions in trauma and grief responses, emotional experiences and perceptions of their child's injury at post-intervention and follow-up. Both groups continued to have depleted emotional resources (PECI scale) at 6 weeks post-discharge.

CONCLUSIONS

The study contributes important insights into family appraisal experience in the early stages following paediatric acquired brain injury. In this context, 'Family Forward' needs to incorporate interventions that support and promote ongoing family appraisal as issues related to their child's injury arise over time. Future research is needed to focus on whether the Family Forward approach does sustain family system adaptation (a key aim informing the design of the intervention) over the longer term.

Social Participation and Navigation (SPAN): Description and usability of app-based coaching intervention for adolescents with TBI

BACKGROUND

Adolescents with brain injury (BI) often experience impairment in participation, which is an important predictor of outcomes.

OBJECTIVE

Describe the Social Participation and Navigation (SPAN) program, and report participant feedback and preliminary outcomes.

METHOD

Four adolescents and four coaches participated. SPAN included a mobile app, online didactic information, and peer coaching. Adolescents met weekly with coaches via video-conference, developed participation goals, and plans to achieve goals. Social and behavioral functioning before and after was assessed, and feedback about SPAN was collected.

RESULTS

SPAN was well received. Participants used the app to define and achieve goals. Medium to large effect sizes were found on adolescent self-reported measures, with negligible effects on parent-report measures. Positive and critical feedback is described.

CONCLUSIONS

Findings support the usability of SPAN, which has the potential to improve social participation of adolescents with a history of TBI through an innovative use of technology and peer coaching.

Paediatric Rehabilitation Ingredients Measure: a new tool for identifying paediatric neurorehabilitation content

AIM

To develop an instrument (Paediatric Rehabilitation Ingredients Measure [PRISM]) for quantitative estimation of contents of interdisciplinary neurorehabilitation for use in studies of relationships between rehabilitation treatment delivered and severity-adjusted outcomes after acquired brain injury (ABI).

METHOD

The measure was developed using an ingredients-mediators-outcomes model consistent with the International Classification of Functioning, Disability and Health, a literature review, and other current initiatives in the development of rehabilitation treatment taxonomies, with item codevelopment in workshops with rehabilitation professionals. Interrater reliability was assessed in inpatient and residential paediatric rehabilitation settings.

RESULTS

Although sometimes an initially unfamiliar perspective on rehabilitation practice, PRISM's acceptability amongst professionals was excellent. Internal consistency of scores was sometimes an issue for users unfamiliar with the tool; however, this improved with practice and interrater reliability (assessed by Kendall's W) was good. The tool was felt to have particular value in facilitating interdisciplinary communication and working. Modifications to the design of the tool have improved internal consistency.

INTERPRETATION

PRISM supports identification of the 'active ingredients' of an interdisciplinary rehabilitation package and facilitates interdisciplinary communication. It also has potential as a research tool examining relationships between rehabilitation delivered and severity-adjusted outcomes observed after paediatric ABI.

WHAT THIS PAPER ADDS

Identifying contribution of rehabilitation to outcomes after acquired brain injury requires quantification of rehabilitation 'dose' and 'content'. Previous approaches to 'parsing' of rehabilitation dose and content may have overemphasized one-to-one sessions with therapists. We present a novel, holistic tool for identification of ingredients of an interdisciplinary rehabilitation package. It supports interdisciplinary communication and has potential as a research tool.

Exploring Summarization Differences for Two Types of Expository Discourse in Adolescents With Traumatic Brain Injury

PURPOSE

Annually, nearly 700,000 U.S. children and adolescents experience a traumatic brain injury (TBI). Many of them struggle academically, despite failing to qualify for special education services because their cognitive communication impairments are subtle.

METHOD

In this exploratory study, five adolescents with TBI provided verbal summaries of two expository lectures (compare-contrast, cause-effect) and participated in cognitive and expressive syntax testing. Their performance on these tasks was compared descriptively to that of 50 adolescents with typical development.

RESULTS

For adolescents with TBI, mean summary quality scores for both exposition types were at least 1 SD lower than those of adolescents with typical development and notably 2 SDs below for the cause-effect passage. The adolescents with TBI who had below-average cognitive scores showed better performance on compare-contrast summaries compared to cause-effect, whereas the majority of adolescents with typical development showed the opposite tendency.

CONCLUSIONS

These results provide preliminary evidence that students with TBI, particularly those with cognitive deficits, may struggle with expository discourse despite acceptable performance on a measure of expressive syntax. This study also indicates that researchers should explore how students with TBI perform on academically relevant discourse tasks in order to inform future assessment and intervention efforts.

SUPPLEMENTAL MATERIALS

https://doi.org/10.23641/asha.5572786.

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

OBJECTIVE

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

SETTING

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

PARTICIPANTS

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

DESIGN

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

MAIN MEASURES

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

CONCLUSION

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

Technology-assisted rehabilitation interventions following pediatric brain injury

INTRODUCTION

Following traumatic brain injury (TBI), children experience a variety of physical, motor, speech, and cognitive deficits that can have a long-term detrimental impact. The emergence and popularity of new technologies has led to research into the development of various apps, gaming systems, websites, and robotics that might be applied to rehabilitation. The objective of this narrative review was to describe the current literature regarding technologically-assisted interventions for the rehabilitation of motor, neurocognitive, behavioral, and family impairments following pediatric TBI.

EVIDENCE ACQUISITION

We conducted a series of searches for peer-reviewed manuscripts published between 2000 and 2017 that included a technology-assisted component in the domains of motor, language/communication, cognition, behavior, social competence/functioning, family, and academic/school-based functioning.

EVIDENCE SYNTHESIS

Findings suggested several benefits of utilizing technology in TBI rehabilitation including facilitating engagement/adherence, increasing access to therapies, and improving generalizability across settings. There is fairly robust evidence regarding the efficacy of online family problem-solving therapy in improving behavior problems, executive functioning, and family functioning. There was less compelling, but still promising, evidence regarding the efficacy other technology for motor deficits, apps for social skills, and computerized programs for cognitive skills. Overall, many studies were limited in the rigor of their methodology due to small heterogeneous samples and lack of control groups.

CONCLUSIONS

Technology-assisted interventions have the potential to enhance pediatric rehabilitation after TBI. Future research is needed to further support their efficacy with larger controlled trials and to identify characteristics of children who are most likely to benefit.

A summary on the effectiveness of the Amsterdam memory and attention training for children (Amat-c) in children with brain injury

OBJECTIVE

To summarise the current research on the effectiveness of the Amsterdam Memory and Attention Training for Children (Amat-c).

METHODS

A literature search was conducted to find articles published about the Amat-c, using PubMed, psychINFO, and PsychBITE databases. Relevant search terms included Amat-c, attention and memory, and childhood ABI.

RESULTS

Our literature search identified 7 articles that described 5 separate studies including 61 children in total (mostly TBI). Only one study had a control group. All results indicated positive effects on memory and attention, although in three of the studies, these results were not statistically tested. Positive results were generally maintained six months follow up.

CONCLUSIONS

This review showed that the Amat-c is effective for treating attention and memory disturbances in children with ABI. However, evidence is limited and training material is outdated. We suggest that the Amat-c should be digitised and implemented in a school setting and further evaluated.

Informing design of an app-based coaching intervention to promote social participation of teenagers with traumatic brain injury

OBJECTIVE

To examine perspectives of multiple stakeholders to inform the design of an app-based coaching intervention to promote social participation in teenagers with traumatic brain injury (TBI).

METHODS

Teenagers and college students with and without TBI and parents of teenagers with TBI were recruited from two children's hospitals and two universities in the USA (n = 39). Data were collected via interviews, focus groups, and surveys and examined using descriptive statistics and content analyses.

RESULTS

Teenagers with TBI reported more social participation barriers and fewer strategies for addressing these barriers than teenagers without TBI. There was consensus across groups about the value of college student coaches and use of smartphones and apps. Participants expressed mixed views on the use of chat rooms and degree of parent involvement.

CONCLUSION

Results provided insights about the possible benefits of the intervention, and informed its initial design (e.g., desired coach qualities, and type of coach training and supervision).

Beyond academic performance: Practice implications for working with students following traumatic brain injury

PURPOSE

Speech-language pathologists (SLPs) have a key role in supporting educational participation for secondary and tertiary students with traumatic brain injury (TBI). This article aims to (i) explore issues identified by students with TBI that affect educational participation beyond their academic performance, (ii) offer a framework based on research evidence to guide the practice of SLPs and (iii) explore strategies that may expand the traditional roles of SLPs to support students beyond academic performance.

METHOD

Data were drawn from an earlier qualitative research project in which three adolescent males were interviewed about their experiences of returning to education after severe TBI. Interviews were recorded, transcribed verbatim and analysed using a grounded theory approach.

RESULT

Six themes were identified that had a substantial impact beyond academic performance: poor community awareness of TBI, the invisible nature of TBI, getting back to everyday life, planning to return to education, being accepted and adjusting to long-term changes. Incorporating these factors, a clinical framework is put forward to guide SLPs in developing strategies for promoting positive educational participation.

CONCLUSION

By considering factors beyond academic performance and addressing these in intervention, SLPs may significantly improve the overall educational success and wellbeing of students living with TBI.