Identifying children and adolescents with cognitive dysfunction following mild traumatic brain injury—Preliminary findings on abbreviated neuropsychological testing

Processing Speed in Children with Traumatic Brain Injury

Abstract: Traumatic brain injury (TBI) is a common cause of childhood morbidity and mortality. Information processing speed (IPS) is a central construct of neuropsychology and a mediator for a range of cognitive functions. In adults, the negative effects of TBI on IPS are well documented. This review qualitatively describes the impact of TBI on IPS in children and adolescents and examines various influencing factors. We included a total of 37 studies in the review that explored IPS using various clinical assessments. These clinical assessments often examine other neuropsychological functions besides IPS. In 29 of these studies, we found a negative effect of TBI on IPS. While injury severity has small but consistent effects on IPS, the effects of age at injury, time since injury, and gender were less evident. Because it is a central construct of neuropsychological functions, IPS should be assessed after TBI.

Return to Learn ECHO: Telementoring for School Personnel to Help Children Return to School and Learning After Mild Traumatic Brain Injury

BACKGROUND

Return to learn (RTL) after mild traumatic brain injury (mTBI) presents unique challenges for school professionals. A multidisciplinary team approach is necessary yet training school professionals is logistically difficult. This paper describes an innovative pilot RTL program and its evaluation.

METHODS

Utilizing the telehealth/telementoring program Project ECHO® (Extension for Community Healthcare Outcomes), this study utilized a multidisciplinary team of subject matter experts to deliver five 1-hour sessions across 5 cohorts of school-based professionals (total of 133 participants). The evaluation used a mixed-methods approach of post-session and post-program participant surveys and post-program participant focus groups.

RESULTS

Participants who completed a post-program survey reported statistically significant improvements in essential aspects of RTL knowledge and self-efficacy. This included improvements in how to manage a student with an mTBI (44.8% to 86.9%), benefits of early return to school for students following mTBI (31.8% to 86.9%), and the importance of written RTL policies/procedures (55.1% to 97.1%).

CONCLUSIONS

This study demonstrates that RTL training via a telementoring approach may be a positive and effective way to train school-based professionals and improve knowledge and self-efficacy, especially when attending face-to-face trainings are difficult. This model has the potential to produce programmatic and systematic improvements for RTL education.

Speech-Language Pathology Assessment of School-Age Children With Traumatic Brain Injury: A Scoping Review

PURPOSE

The purpose of this study was to describe evidenced-based assessment practices for school-age children with any severity of traumatic brain injury (TBI) that could inform the practice of speech-language pathologists (SLPs).

METHOD

A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Included studies were assigned thematic labels related to the International Classification of Functioning, Disability and Health framework.

RESULTS

A total of 30 articles met inclusion criteria for this study. Most studies included adolescent or teenage participants with mild TBIs in the acute stages of recovery. Twenty-two different assessments were reported on for children with TBI addressing body structure/function (n = 19 assessments), activities and participation (n = 1 assessment), and contextual factors (n = 3 assessments).

CONCLUSIONS

Current assessments have a clear focus on body structure/function for adolescents after childhood TBI, with little research evidence to address activities and participation or contextual factors. The limited amount of functional assessments directly related to the SLP scope of practice stresses the need for additional research on ecologically valid and comprehensive assessment approaches for school-age children with TBI. The results of this review could be utilized as a resource in providing theoretical, evidence-based, and person-centered evaluation methods for children with TBI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20422170.

Pediatric concussion working memory outcomes: a scoping review

Objective: Characterize the working memory (WM) profile of children and youth who have experienced concussion by systematically synthesizing existing literature on the neuropsychological outcomes of these injuries.Methods: Implemented a peer-reviewed search strategy combining key concepts of concussion/mild traumatic brain injury (mTBI), WM, and pediatrics across MedLine, Embase, PsycINFO, and CINAHL. Included studies written in English with extractable results on a WM outcome measure in individuals aged 21 and under who experienced concussion. Applied narrative synthesis to identify trends in the literature. Assessed risk of bias and quality using the NHLBI's Quality Assessment of Observational Cohort and Cross-Sectional Studies.Results: 40 articles met inclusion criteria. 34/40 studies compared WM performance in children or youth with concussion to healthy controls, pre-injury performance, or normative values, of which 15 reported significantly lower WM performance in the concussion sample. Visual/spatial WM was more consistently impacted than verbal WM. Cognitive demanding dual-task conditions were also reliably impacted.Conclusion: Literature indicated that WM is vulnerable to negative outcomes following pediatric concussion, yet the nature of outcomes is variable. Clinicians and researchers should implement comprehensive and theoretically motivated WM assessments to better understand the WM components impacted by injury.

Involvement in litigation in children with PTSD following motor vehicle accident: Associations with emotional distress and treatment outcomes

OBJECTIVES

Litigation is common in the context of Post-traumatic Stress Disorder (PTSD) and mild Traumatic Brain Injury (mTBI), adding contradicting motivations to individuals' engagement in psychotherapeutic interventions. This study's main goal was to explore the relationship between litigation status and emotional distress among children with PTSD following motor vehicle accidents (MVAs). We also present preliminary findings from a pilot study on treatment efficacy for children with PTSD, with and without litigation.

METHODS

Participants included 76 children with PTSD following MVA and their main caregiving parent. The associations between litigation status (litigation involvement, litigation phase, and litigation's emotional impact) and children's global distress, PTSD, persistent post-concussion symptoms (PPCS), and sub-optimal effort, and parents' PTSD symptoms were assessed before and after intervention for PTSD. Comorbid mTBI was explored as a possible moderating factor.

RESULTS

Involvement in litigation was not related to children's and parents' pre-intervention distress, nor to the presence of mTBI or to children's effort. However, higher emotional impact of litigation on parents was associated with children's higher PPCS pre-intervention. A pilot study on intervention outcomes found an improvement both in children with and without litigation involvement. A greater decrease in PPCS following intervention was found in children of parents with higher emotional impact of litigation.

CONCLUSIONS

The emotional impact of litigation on parents should be considered while addressing children in litigation context. However, this study's preliminary findings suggest that children with litigation involvement may benefit from treatment, thus litigation should not serve solely as an exclusion criterion for psychological intervention. A larger study should further explore this issue.

Executive (dys)function after traumatic brain injury: special considerations for behavioral pharmacology

Executive function is an umbrella term that includes cognitive processes such as decision-making, impulse control, attention, behavioral flexibility, and working memory. Each of these processes depends largely upon monoaminergic (dopaminergic, serotonergic, and noradrenergic) neurotransmission in the frontal cortex, striatum, and hippocampus, among other brain areas. Traumatic brain injury (TBI) induces disruptions in monoaminergic signaling along several steps in the neurotransmission process - synthesis, distribution, and breakdown - and in turn, produces long-lasting deficits in several executive function domains. Understanding how TBI alters monoamingeric neurotransmission and executive function will advance basic knowledge of the underlying principles that govern executive function and potentially further treatment of cognitive deficits following such injury. In this review, we examine the influence of TBI on the following measures of executive function - impulsivity, behavioral flexibility, and working memory. We also describe monoaminergic-systems changes following TBI. Given that TBI patients experience alterations in monoaminergic signaling following injury, they may represent a unique population with regard to pharmacotherapy. We conclude this review by discussing some considerations for pharmacotherapy in the field of TBI.

Gender differences in quality of life and symptom expression during recovery from concussion

Pediatric concussion is a significant health concern for parents, medical providers, and schools. This study was designed to gain insight into gender differences in perspectives of children and adolescents recovering from concussion. Specifically, the study explored whether males and females reported different symptom loads for physical symptoms and quality of life after concussion. The Pediatric Life After Concussion Evaluation Scale (PLACES) and the Post Concussion Symptom Scale (PCSS) were completed by 277 participants ages 9-21, with a mean age of 14.8 years. The sample was 47.5% female and 52.5% male. The study showed that overall, females reported more physical and somatic symptoms (Total PCSS, p = .001), worse quality of life during recovery (PLACES, p = .008), difficulty with cognition (p = .001), and elevated emotional symptoms than males (p = .02). When an interaction between gender and time since injury was considered, there were significant interactions for the PCSS, with females experiencing higher physical and cognitive symptom load during the period spanning 1-12 weeks (1-4 weeks: M = 33.18, SD = 27.03; 5-11 weeks: M = 15.0, SD = 16.76). However, for those individuals experiencing symptoms for longer than 12 weeks, males expressed a higher physical and cognitive symptom load (M = 32.36, SD = 26.59). Findings indicate that there are gender differences in the expression of symptoms and perceptions of quality of life after concussion.

Gender Differences in Neurocognitive Performance Among Children With Posttraumatic Stress Disorder and Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) are frequent sequelae after motor vehicle accidents (MVAs). These two pathologies often have overlapping neurocognitive deficits across several domains, such as attention, memory, and executive functions. The present study was an effort to examine the contribution of gender to these overlapping symptoms. To this end, psychodiagnostic and neuropsychological data were collected on 61 children and adolescents 3 months following MVA. All participants were diagnosed with PTSD, and about half (n = 33) also received a diagnosis of mTBI. Analyses of variance revealed significant interactions between gender and mTBI (ηp2=.15), such that girls with mTBIs preformed significantly worse than noninjured girls on measures of executive functions (Cohen's d = 3.88) and sustained attention (Cohen's d = 3.24). Boys, on the other hand, did not differ significantly on any of those measures, irrespective of TBI injury status. Similarly, comparisons to the normative population revealed that, whereas boys showed impaired neurocognitive performances regardless of TBI status, impaired performances in girls were limited to those cases in which the girls were comorbid for PTSD and mTBI. It appears then that whereas PTSD alone might explain boys' reduced neurocognitive performance, among girls the comorbidity of PTSD and mTBI is required to account for performance deficits.

Concussion: pathophysiology and clinical translation

The majority of the 3.8 million estimated annual traumatic brain injuries (TBI) in the United States are mild TBIs, or concussions, and they occur primarily in adolescents and young adults. A concussion is a brain injury associated with rapid brain movement and characteristic clinical symptoms, with no associated objective biomarkers or overt pathologic brain changes, thereby making it difficult to diagnose by neuroimaging or other objective diagnostic tests. Most concussion symptoms are transient and resolve within 1-2 weeks. Concussions share similar acute pathophysiologic perturbations to more severe TBI: there is a rapid release of neurotransmitters, which causes ionic disequilibrium across neuronal membranes. Re-establishing ionic homeostasis consumes energy and leads to dynamic changes in cerebral glucose uptake. The magnitude and duration of these changes are related to injury severity, with milder injuries showing faster normalization. Cerebral sex differences add further variation to concussion manifestation. Relative to the male brain, the female brain has higher overall cerebral blood flow, and demonstrates regional differences in glucose metabolism, inflammatory responses, and connectivity. Understanding the pathophysiology and clinical translation of concussion can move research towards management paradigms that will minimize the risk for prolonged recovery and repeat injury.

Virtual reality as an ecologically valid tool for assessing multifaceted episodic memory in children and adolescents

The majority of episodic memory (EM) tests are far removed from what we experience in daily life and from the definition of this type of memory. This study examines the developmental trajectory of the main aspects of episodic memory—what, where, and when—and of feature binding in a naturalistic virtual environment. A population of 125 participants aged from 6 to 24 years was asked to navigate, by using a joystick, in a virtual urban environment composed of specific areas, and to memorize as many elements as possible (e.g., scenes, details, spatial and temporal contexts). The ability to recall factual content associated to details or spatiotemporal context increased steadily from the age of 8 to young adulthood. These results indicate main developmental differences in feature binding abilities in naturalistic events which are very sensitive to age in comparison with a standard EM assessment. Virtual reality therefore appears to be an appropriate technique to assess crucial aspects of EM development in children and adolescents and it should provide helpful tools for the detection of subtle memory deficits.

Post-concussive symptoms and neuropsychological performance in the post-acute period following pediatric mild traumatic brain injury

OBJECTIVE

There is evidence that children after mild traumatic brain injuries (mTBI) suffer ongoing post-concussive symptoms (PCS). However, results concerning neuropsychological outcome after mTBI are controversial. Thus, our aim was to examine group differences regarding neuropsychological outcome and PCS. Additionally, we explored the influence of current and pre-injury everyday attention problems on neuropsychological outcome in children after mTBI.

METHOD

In a prospective short-term longitudinal study, 40 children (aged 6-16 years) after mTBI and 38 children after orthopedic injury (OI) underwent neuropsychological, socio-behavioral and PCS assessments in the acute stage and at 1 week, at 4 weeks, and 4 months after the injury.

RESULTS

Parents of children after mTBI observed significantly more PCS compared to parents of children after OI, especially in the acute stage. Our results revealed no neuropsychological or socio-behavioral differences over time between both groups. However, in children after mTBI, we found negative correlations between elevated levels of everyday attention problems and reduced neuropsychological performance. Furthermore, there was a negative influence of pre-injury everyday attention problems on neuropsychological performance in children after mTBI.

CONCLUSION

In accordance with earlier studies, parents of children after mTBI initially observed significantly more PCS compared to parents of children after OI. There were no neuropsychological or socio-behavioral group differences between children after mTBI and OI in the post-acute period. However, our exploratory findings concerning the influence of everyday attention problems on neuropsychological outcome indicate that current and pre-injury everyday attention problems were negatively associated with neuropsychological performance in children after mTBI.