Pediatric mTBI Research Articles

Childhood Mild Traumatic Brain Injury is Reliably Associated with Anxiety but Not Other Examined Psychiatric Outcomes at Two-Year Follow-up, After Adjusting for Prior Mental Health.

Evidence that mild traumatic brain injury (mTBI) causes psychiatric problems in children has been mixed. Investigating this issue has been difficult due to the lack of representative longitudinal data that includes adequate measures of mTBI, subsequent mental health symptoms and service use. We used data from the ABCD longitudinal cohort study to examine the association between mTBI and psychiatric diagnoses, symptoms and psychiatric service use in over 11,000 children. In both children reporting (i) previous mTBI at baseline and (ii) previously uninjured children reporting new cases of mTBI since baseline, we examined psychiatric outcomes and service use at 2-year follow-up. We also compared mTBI cases to a comparison group of participants with orthopaedic injury but without mTBI. Mixed-effects models were used and adjusted for demographic and social covariates, with missing data imputed using random forest multiple imputation. To account for baseline mental health, we used propensity-score matching to identify a comparison sample matched on confounding variables and baseline outcome measures. When examined without adjustment for baseline mental health, both lifetime mTBI at baseline and new occurrence of mTBI at 2-year follow-up were reliably associated with an increased risk of DSM-5 anxiety and behavioural disorders, a range of psychiatric symptom scores and increased service use. Controlling for baseline mental health in the mTBI group using propensity-score matching eliminated all statistically reliable associations apart from anxiety disorder diagnosis and symptoms, which remain associated at 2-year follow-up. Evidence for association with medication use was inconsistent. Consistent evidence supporting an association between paediatric mTBI and subsequent anxiety was found; however, similar associations were not observed for other mental health outcomes. Regardless of potential causality, children with mTBI are likely to present with high levels of mental health difficulties, and this remains an important comorbidity that clinicians should be aware of.

Exploring sex differences in pediatric mild traumatic brain injury: clinical characteristics and recovery patterns of pediatric mTBI patients with non-credible effort

This study investigates sex differences in demographic and injury-related characteristics, along with recovery patterns, in children with mild traumatic brain injury (mTBI) who failed at least one Performance Validity Test (PVT). A retrospective analysis of 186 patients (8–18 years old; 65.1% females) from a specialty concussion clinic with non-credible effort on PVTs was conducted. Data on demographics, injury-related characteristics, symptoms, as well as recovery patterns, were analyzed. There were significant sex differences in age at injury, pre-injury academic status, ADHD prevalence, physical activity levels, and post-injury emotional symptoms. Girls exhibited longer recovery times, had more clinical visits, and received different provider recommendations. This study revealed significant sex differences between boys and girls with mTBI and non-credible effort on PVTs. These findings underscore the need for sex-informed approaches in pediatric mTBI management and highlight areas for future research.

Balance Performance After Mild Traumatic Brain Injury in Children and Adolescents: Instrumented BESS in the Acute Situation and Over Time.

Background: Mild traumatic brain injury (mTBI) in the pediatric population is a significant public health concern, often associated with persistent post-concussion symptoms, including postural instability. Current tools for assessing postural control, such as the Balance Error Scoring System (BESS), lack integration with objective metrics. Incorporating force plate sensors into BESS assessments may enhance diagnostic accuracy and support return-to-play or sports decisions. This study evaluates postural performance in children with mTBI compared to controls using an instrumented BESS and examines recovery trajectories after mTBI. Methods: This prospective, longitudinal study included 31 children with mTBI (12.01 ± 3.28 years, 20 females) and 31 controls (12.31 ± 3.27 years, 18 females). Postural control was assessed using an instrumented BESS protocol during standing on a ground reaction force plate at three timepoints: within 72 h post injury (T1), at two weeks (T2), and three months after trauma (T3). Posturographic parameters derived from the displacement of the center of pressure included the ellipse area, path length, and mean velocity in the anterior-posterior and medio-lateral directions. Symptom burden was monitored using the Post-Concussion Symptom Inventory (PCSI). Results: The BESS total scores did not differ significantly between the groups at any timepoint. A significant reduction in BESS errors over time was observed exclusively in the two-legged stance on a soft surface (p = 0.047). The instrumented BESS revealed higher body swaying in the mTBI group compared to controls, particularly under demanding conditions. Significant between-group differences were most frequently observed in single-leg soft surface (38% of comparisons) and two-legged soft surface stances (29%). In those cases, path length and mean velocity differed between groups, respectively. Ellipse area did not show significant differences across conditions. Conclusions: An instrumented BESS has the potential to enhance the detection of subtle postural deficits in pediatric mTBI patients. Specifically, more demanding conditions with altered sensory-proprioceptive input and path length as an outcome measure should be focused on. This study underscores the need for tailored and age-appropriate objective and quantitative balance assessments to improve diagnostic precision in pediatric mTBI populations.

Cortical Morphometric Similarity Remodeling in Traumatic Brain Injury Links Cognitive Impairments with Transcriptional Changes and Type-Specific Cells.

The heterogeneous injuries and resulting cognitive deficits pose significant challenges in the clinical management of mild traumatic brain injury (mTBI). However, the pathophysiological mechanisms related to heterogeneities of mTBI are still unclear. This study aims to explore the mechanisms underlying brain remodeling by examining the morphometric similarity (MS) alterations and corresponding transcriptomic signatures across adult and pediatric mTBI (adult mTBI: 112 acute patients, 47 follow-up chronic patients, 66 healthy controls [HCs]; pediatric mTBI: 30 acute patients, 31 HCs). A healthy adult cohort (N = 840) is included to derive the modularized brain MS networks representing interregional cortical connectivity. Subsequently, cortical MS remodeling patterns are identified involving mostly MS increases in the frontal modules with typical high MS and decreases in the occipital module with typical low MS, with more pronounced changes observed in the developing brain with mTBI. The abnormal MS changes are correlated with variable cognitive impairments. Moreover, cortical MS remodeling is also associated with the genes enriched in CA1 pyramidal cells and neuron-specific biological processes. The transcription-related cortical remodeling in mTBI might reveal the disruption of brain cellular architecture. Therapeutic modalities to intervene in specific cortex and tackle CA1 over-activation might better encircle the neurobiology of TBI.

Cross-Lagged Associations Among Sleep, Headache, and Pain in Pediatric Mild Traumatic Brain Injury: An A-CAP Study.

To test cross-lagged associations among sleep, headache, and pain in pediatric mild traumatic brain injury (mTBI). Children and adolescents aged 8.0 to 16.9years who sustained a mTBI and presented to 1 of 5 pediatric emergency departments across Canada completed assessments at 1-week, 3 months, and 6 months post-injury as part of a larger prospective cohort study. Sleep disturbance was measured using 7 sleep items from the Child Behaviour Checklist. Sleep duration was measured using average weekday and weekend sleep from the Healthy Lifestyle Behaviours Questionnaire. Pain intensity was measured using an 11-point numerical rating scale. Headache severity and associated functional impairment were measured using the Headache Impact Test and 1 item from the Health and Behaviour Inventory. Analyses included trivariate-indicator random-intercept cross-lagged panel models. Of 633 recruited children, 563 were included in the current study. Headache showed significant within-person, bidirectional, cross-lagged associations with sleep disturbance and duration, as well as with pain intensity. More specifically, worse headache predicted greater sleep disturbance (1-week to 3 months and 3 months to 6 months: Bs = .47, Ps ≤ .013) and shorter sleep duration (1-week to 3 months: B = -.21, P = .006), while greater sleep disturbance predicted worse headache (1-week to 3 months: B = .08, P = .001). Worse headache also predicted higher pain intensity (1-week to 3 months & 3 months to 6 months: Bs ≥ 1.27, P s < .001), while higher pain intensity predicted worse headache (3 months to 6 months: Bs ≥ .03, Ps ≤ .042). No cross-lagged associations involving sleep disturbance or duration with pain intensity were significant. Significant bi-directional, cross-lagged associations exist between headache and both sleep and pain. The findings suggest that early intervention for headaches may help prevent later sleep disturbance and pain after pediatric mTBI.

Patterns of Change in Functional Connectivity and Motor Performance Are Different in Youth Recently Recovered from Concussion

Adolescents who have sustained a concussion or mild traumatic brain injury (mTBI) are prone to repeat injuries which may be related to subtle motor deficits persisting after clinical recovery. Cross-sectional research has found that these deficits are associated with altered functional connectivity among somatomotor, dorsal attention, and default mode networks. However, our understanding of how these brain–behavior relationships change over time after clinical recovery is limited. In this study, we examined categorical and dimensional trajectories of functional connectivity and subtle motor performance in youth clinically recovered from mTBI and never-injured controls (10–17 years). All participants completed task-based and resting-state functional magnetic resonance imaging scans and the Physical and Neurological Examination of Subtle Signs (PANESS) at initial and 3-month follow-up visits. We examined somatomotor-dorsal attention and somatomotor-default mode network connectivity and their association with PANESS performance. Compared with controls, a larger proportion of youth recovered from mTBI showed increases in somatomotor-dorsal attention functional connectivity over time; in contrast, there were no differences in somatomotor-default mode connectivity trajectories between youth recovered from mTBI and controls. Relative to controls, youth recovered from mTBI who showed greater increases in somatomotor-dorsal attention connectivity over time also completed motor tasks more slowly at the 3-month compared with the initial visit. Collectively, these findings suggest that longitudinal changes in somatomotor-dorsal attention functional connectivity may be associated with lingering motor learning deficits after clinical recovery from pediatric mTBI. Further research is necessary to understand how trajectories of functional connectivity and motor performance can inform individual-level outcomes, for instance, susceptibility to future injuries in both youth who are never injured and those clinically recovered from mTBI.

Does new research address persistent questions since the publication of the CDC's 2018 pediatric mTBI guideline.

Due to the potential debilitating sequelae following pediatric mTBI, the CDC published the Guideline on the Diagnosis and Management of mTBI Among Children in 2018. However, the guideline identified several key gaps in our clinical knowledge to support several clinical recommendations. The objective of this review is to evaluate if subsequent research has addressed these gaps in clinical practice recommendations. A literature review was conducted in PubMed using keywords from the CDC guidelines for the years of July 2015-January 2021. Articles were screened by title and abstract so only studies with children < 18years of age and those focusing on mTBI were included. A total of 531 articles were identified after screening. Forty-three percent was prospective; 24% were case reports, literature reviews, comments, or protocols; 19% were retrospective, 7% were cross-sectional, 4% were RCTs, and 4% were systematic reviews/meta-analyses. Forty-nine percent focused on diagnosis, 17% on prognosis, and 34% on treatment. The four most published topics were neuropsychological tools (28%), risk factors for intracranial injury and computed tomography (11%), cognitive/physical rest (11%), and return to school (10%). Since the release of the 2018 CDC guidelines, the majority of publications addressing pediatric mTBI have been prospective studies evaluating the clinical application of neuropsychological tools in concussion management. While these studies do address several of the clinical gaps noted by the CDC regarding the diagnosis and prognosis of pediatric mTBI, there remains a lack of high-quality studies focused on improving pediatric concussion treatment and outcomes.

Developmental considerations in the quest for paediatric mTBI biomarkers.

Developmental considerations in the quest for paediatric mTBI biomarkers.

Contextual Considerations for the Neuropsychological Assessment of Pediatric mTBI

Mild traumatic brain injury (mTBI), also known as concussion, is a common injury in the pediatric population. In 2014, children aged 0 to 19 made up 32% (812,000) of the 2.5 million TBI-related emergency department visits in the United States, which does not reflect the much higher number of children with a brain injury who do not present to medical centers (Black & Zablotsky, 2021). Similar to psychiatric diagnoses, a diagnosis of mTBI/concussion is made using clinical features and symptoms that are classified under cognitive, affective, and somatic domains, with none of the symptoms pathognomonic for TBI. Symptoms secondary to a mTBI are time limited and show a typical trajectory, and in a majority of cases, lead to full resolution. When this expected pattern is not observed, contributing comorbid and premorbid factors need to be considered for a thorough understanding of etiology. Accurate psychoeducation and prompt intervention, which begin with early screening (e.g., vulnerabilities, comorbidities, risk factors), are needed to empower the systems that support a child. Although comorbid factors are many and a thorough review is outside the scope of this case series, the three cases presented represent a common constellation of factors (e.g., neurodevelopmental, environmental, and adverse/traumatic experiences) that interplay with contextual factors in a diagnostic workup and treatment planning. This case series will also present relevant literature to briefly introduce various social and cognitive outcomes following mTBI relative to more severe injuries, define aspects that differentiate mTBI from more severe injuries, and discuss the influence of environment and other contextual factors across the severity spectrum.

Sleep Disturbance and Postconcussive Symptoms in Pediatric Mild Traumatic Brain Injury and Orthopedic Injury.

Sleep disturbance (SD) is common after pediatric mild traumatic brain injury (mTBI) and may predict increased postconcussive symptoms (PCS) and prolonged recovery. Our objective was to investigate the relation of SD with PCS in children with mTBI and those with orthopedic injury (OI). Emergency departments (EDs) at 2 children's hospitals in the Midwestern United States. Children and adolescents aged 8 to 16years old diagnosed with either a mTBI ( n =143) or OI ( n =74) and recruited within 24hours postinjury. Observational, prospective, concurrent cohort study with longitudinal follow-up. Parents rated children's preinjury sleep retrospectively shortly after injury, and postinjury sleep at 3 and 6months postinjury, using the Sleep Disorders Inventory for Students. Parents rated children's preinjury symptoms retrospectively in the emergency department, and parents and children rated PCS at 3 and 6months, using the Health and Behavior Inventory and the Postconcussive Symptom Interview. Weekly ratings on the Health and Behavior Inventory were also obtained remotely. Postinjury SD was modestly but not significantly higher in the mTBI group compared to the OI group ( P =.060, d =0.32). Children with mTBI who were symptomatic postacutely based on parent ratings had worse parent-rated sleep outcomes at 3 and 6months postinjury compared to children who were not symptomatic. Greater preinjury SD also predicted more postinjury SD and more severe PCS regardless of injury type. The results suggest potential bidirectional associations between SD and PCS after mTBI. Studies of treatments for SD following pediatric mTBI are needed.

Alterations of cerebrovascular reactivity following pediatric mild traumatic brain injury are independent of neurodevelopmental changes

Cerebrovascular dysfunction following mild traumatic brain injury (mTBI) is understudied relative to other microstructural injuries, especially during neurodevelopment. The blood-oxygen level dependent response was used to investigate cerebrovascular reactivity (CVR) in response to hypercapnia following pediatric mTBI (pmTBI; ages 8–18 years), as well as pseudocontinuous arterial spin labeling to measure cerebral blood flow (CBF). Data were collected ∼1-week (N = 107) and 4 months (N = 73) post-injury. Sex- and age-matched healthy controls (HC) underwent identical examinations at comparable time points (N = 110 and N = 91). Subtle clinical and cognitive deficits existed at ∼1 week that resolved for some, but not all domains at 4 months post-injury. At both visits, pmTBI showed an increased maximal fit between end-tidal CO2 regressor and the cerebrovascular response across multiple regions (primarily fronto-temporal), as well as increased latency to maximal fit in independent regions (primarily posterior). Hypoperfusion was also noted within the bilateral cerebellum. A biphasic relationship existed between CVR amplitude and age (i.e., positive until 14.5 years, negative thereafter) in both gray and white matter, but these neurodevelopment effects did not moderate injury effects. CVR metrics were not associated with post-concussive symptoms or cognitive deficits. In conclusion, cerebrovascular dysfunction may persist for up to four months following pmTBI.

Diagnostic potential of IL6 and other blood-based inflammatory biomarkers in mild traumatic brain injury among children.

Inflammatory biomarkers, as indicators of biological states, provide a valuable approach for accurate and reproducible measurements, crucial for the effective management of mild traumatic brain injury (mTBI) in pediatric patients. This study aims to assess the diagnostic utility of blood-based inflammatory markers IL6, IL8, and IL10 in children with mTBI, including those who did not undergo computed tomography (CT) scans. A prospective multicentric cohort study involving 285 pediatric mTBI patients was conducted, stratified into CT-scanned and non-CT-scanned groups within 24 h post-trauma, alongside 74 control subjects. Biomarker levels were quantitatively analyzed using ELISA. Sensitivity and specificity metrics were calculated to determine the diagnostic efficacy of each biomarker. A total of 223 mTBI patients (78%) did not undergo CT scan examination but were kept in observation for symptoms monitoring at the emergency department (ED) for more than 6 h (in-hospital-observation patients). Among CT-scanned patients (n = 62), 14 (23%) were positive (CT+). Elevated levels of IL6 and IL10 were found in mTBI children compared to controls. Within mTBI patients, IL6 was significantly increased in CT+ patients compared to both CT- and in-hospital-observation patients. No significant differences were observed for IL8 among the compared groups. IL6 yielded a specificity of 48% in identifying CT- and in-hospital-observation patients, with 100% sensitivity in excluding all CT+ cases. These performances were maintained whether IL6 was measured within 6 h or within 24 h after the trauma. The inflammatory marker IL6 emerges as a robust biomarker, showing promising stratification value for pediatric mTBI patients undergoing CT scans or staying in observation in a pediatric ED.

Association of Psychological Resilience, Cognitive Reserve, and Brain Reserve with Post-Concussive Symptoms in Children with Mild Traumatic Brain Injury and Orthopedic Injury: An A-CAP Study.

Protective factors, including psychological resilience, cognitive reserve, and brain reserve, may be positively associated with recovery after pediatric mild traumatic brain injury (mTBI) but are yet to be studied concurrently. We sought to examine these factors as moderators of post-concussive symptoms (PCS) in pediatric mTBI compared with mild orthopedic injury (OI). Participants included 967 children (633 mTBI, 334 OI) aged 8-16.99 years, recruited from 5 Canadian pediatric emergency departments as part of a prospective longitudinal cohort study. At 10 days post-injury, psychological resilience was measured using the Connor-Davidson Resilience Scale and brain reserve was measured using total brain volume derived from structural magnetic resonance imaging. Cognitive reserve was measured at 3 months post-injury using IQ scores from the Wechsler Abbreviated Scale of Intelligence-Second Edition. Cognitive and somatic PCS were measured using child and parent ratings on the Health and Behavior Inventory, completed weekly for 3 months and biweekly to 6 months. Analyses involved generalized least-squares regression models using restricted cubic splines. Covariates included age at injury, sex, racialized identity, material and social deprivation, pre-injury migraine and concussion history, and retrospective pre-injury PCS. Psychological resilience moderated group differences in parent-reported PCS. At 30 days post-injury, estimated group differences in parent-reported cognitive and somatic PCS (mTBI > OI) were larger at higher (75th percentile) resilience scores (Est = 2.25 [0.87, 3.64] and Est = 2.38 [1.76, 3.00], respectively) than at lower (25th percentile) resilience scores (Est = 1.44 [0.01, 2.86] and Est = 2.08 [1.45, 2.71], respectively). Resilience did not moderate group differences in child-reported PCS but was negatively associated with child-reported PCS in both groups (ps ≤ 0.001). Brain reserve (i.e., total brain volume [TBV]) also moderated group differences, but only for parent-reported somatic PCS (p = 0.018). Group difference (mTBI > OI) at 30 days was larger at smaller (25th percentile) TBV (Est = 2.78 [2.17, 3.38]) than at larger (75th percentile) TBV (Est = 1.95 [1.31, 2.59]). TBV was not associated with parent-reported cognitive PCS or child-reported PCS. IQ did not moderate PCS in either group but had a significant non-linear association in both groups with child-reported somatic PCS (p = 0.018) and parent-reported PCS (p < 0.001), with higher PCS scores at both lower and higher IQs. These findings suggest that higher resilience predicts fewer PCS, but less strongly after mTBI than OI; greater brain reserve may reduce the effect of mTBI on somatic PCS; and cognitive reserve has an unexpected curvilinear association with PCS across injury types. The results highlight the importance of protective factors as predictors of recovery and potential targets for intervention following pediatric mTBI.

Shorter Telomere Length Is Associated With Older Age, Poor Sleep Hygiene, and Orthopedic Injury, but Not Mild Traumatic Brain Injury, in a Cohort of Canadian Children.

Predicting recovery following pediatric mild traumatic brain injury (mTBI) remains challenging. The identification of objective biomarkers for prognostic purposes could improve clinical outcomes. Telomere length (TL) has previously been used as a prognostic marker of cellular health in the context of mTBI and other neurobiological conditions. While psychosocial and environmental factors are associated with recovery outcomes following pediatric mTBI, the relationship between these factors and TL has not been investigated. This study sought to examine the relationships between TL and psychosocial and environmental factors, in a cohort of Canadian children with mTBI or orthopedic injury (OI). Saliva was collected at a postacute (median 7days) timepoint following injury to assess TL from a prospective longitudinal cohort of children aged 8 to 17years with either mTBI (n=202) or OI (n=90), recruited from 3 Canadian sites. Questionnaires regarding psychosocial and environmental factors were obtained at a postacute follow-up visit and injury outcomes were assessed at a 3-month visit. Univariable associations between TL and psychosocial, environmental, and outcome variables were assessed using Spearman's correlation. Further adjusted analyses of these associations were performed by including injury group, age, sex, and site as covariates in multivariable generalized linear models with a Poisson family, log link function, and robust variance estimates. After adjusting for age, sex, and site, TL in participants with OI was 7% shorter than those with mTBI (adjusted mean ratio=0.93; 95% confidence interval, 0.89-0.98; P =.003). As expected, increasing age was negatively associated with TL (Spearman's r =-0.14, P =.016). Sleep hygiene at 3months was positively associated with TL (adjusted mean ratio=1.010; 95% confidence interval, 1.001-1.020; P =.039). The relationships between TL and psychosocial and environmental factors in pediatric mTBI and OI are complex. TL may provide information regarding sleep quality in children recovering from mTBI or OI; however, further investigation into TL biomarker validity should employ a noninjured comparison group.

Impaired episodic verbal memory recall after 1 week and elevated forgetting in children after mild traumatic brain injury - results from a short-term longitudinal study.

There is preliminary evidence that children after traumatic brain injury (TBI) have accelerated long-term forgetting (ALF), i.e., an adequate learning and memory performance in standardized memory tests, but an excessive rate of forgetting over delays of days or weeks. The main aim of this study was to investigate episodic memory performance, including delayed retrieval 1 week after learning, in children after mild TBI (mTBI). This prospective study with two time-points (T1: 1 week after injury and T2: 3-6 months after injury), included data of 64 children after mTBI and 57 healthy control children aged between 8 and 16 years. We assessed episodic learning and memory using an auditory word learning test and compared executive functions (interference control, working memory, semantic fluency and flexibility) and divided attention between groups. We explored correlations between memory performance and executive functions. Furthermore, we examined predictive factors for delayed memory retrieval 1 week after learning as well as for forgetting over time. Compared to healthy controls, patients showed an impaired delayed recall and recognition performance 3-6 months after injury. Executive functions, but not divided attention, were reduced in children after mTBI. Furthermore, parents rated episodic memory as impaired 3-6 months after injury. Additionally, verbal learning and group, but not executive functions, were predictive for delayed recall performance at both time-points, whereas forgetting was predicted by group. Delayed recall and forgetting over time were significantly different between groups, both post-acutely and in the chronic phase after pediatric mTBI, even in a very mildly injured patient sample. Delayed memory performance should be included in clinical evaluations of episodic memory and further research is needed to understand the mechanisms of ALF.

Executive functioning, behavior, and white matter microstructure in the chronic phase after pediatric mild traumatic brain injury: results from the adolescent brain cognitive development study

BackgroundMild traumatic brain injury (mTBI) is common in children. Long-term cognitive and behavioral outcomes as well as underlying structural brain alterations following pediatric mTBI have yet to be determined. In addition, the effect of age-at-injury on long-term outcomes is largely unknown.MethodsChildren with a history of mTBI (n = 406; Mage = 10 years, SDage = 0.63 years) who participated in the Adolescent Brain Cognitive Development (ABCD) study were matched (1:2 ratio) with typically developing children (TDC; n = 812) and orthopedic injury (OI) controls (n = 812). Task-based executive functioning, parent-rated executive functioning and emotion-regulation, and self-reported impulsivity were assessed cross-sectionally. Regression models were used to examine the effect of mTBI on these domains. The effect of age-at-injury was assessed by comparing children with their first mTBI at either 0-3, 4-7, or 8-10 years to the respective matched TDC controls. Fractional anisotropy (FA) and mean diffusivity (MD), both MRI-based measures of white matter microstructure, were compared between children with mTBI and controls.ResultsChildren with a history of mTBI displayed higher parent-rated executive dysfunction, higher impulsivity, and poorer self-regulation compared to both control groups. At closer investigation, these differences to TDC were only present in one respective age-at-injury group. No alterations were found in task-based executive functioning or white matter microstructure.ConclusionsFindings suggest that everyday executive function, impulsivity, and emotion-regulation are affected years after pediatric mTBI. Outcomes were specific to the age at which the injury occurred, suggesting that functioning is differently affected by pediatric mTBI during vulnerable periods. Groups did not differ in white matter microstructure.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

39 Measuring Psychological Resilience as a Predictor of mTBI Recovery: Is There Value Added to the Clinical Exam?

Objective:Recent studies have begun to explore the role of psychological resilience in pediatric mTBI recovery, with findings associating higher levels of resilience with shorter recovery and lower levels of resilience mediated by pre-injury anxiety and depression associated with persistent symptoms. The purpose of this study is to extend the current literature by further exploring the relationship between resilience, post-injury emotional changes, and length of recovery from pediatric mTBI. Based upon previous literature, we predicted that resilience would explain a unique portion of the variance in length of recovery above and beyond acute post-injury emotional symptoms in adolescents recovering from mTBI compared with orthopedic injured (OI) controls.Participants and Methods:The current study pulled data from a larger project utilizing a prospective cohort design in two cohorts of high school student-athletes aged 14-18 (N = 32). Participants with mTBI (n = 17) or OI (n = 15) sustained during sport were recruited within 10 days of injury from a quaternary care setting. Participants completed a neuropsychological screening evaluation within one week of enrollment, including self-report rating scales of resilience (Connor-Davidson Resilience Scale-10; CD-RISC) and self- and parent-reported post-concussion symptoms (Post-Concussion Symptom Inventory, Second Edition; PCSI-2). Hierarchical regression analysis was performed with days from injury to recovery as the dependent variable. Predictors were entered in three steps: (1) group (mTBI/OI) and sex, (2) PCSI self- and parent-reported post-injury change in emotional symptoms, and (3) CD-RISC raw score. Bonferroni correction was utilized to control for multiple comparisons.Results:Group and sex did not provide significant prediction when entered into the first block of the model (p= .61). Introducing PCSI emotional ratings in the second block showed statistically significant improvement, F (2,26) = 5.12, p&lt; .01), accounting for 31% of the variance in recovery length. Addition of the CD-RISC in the third block was not statistically significant (p=.59). Post hoc testing indicated parent ratings on the PCSI were significantly associated with recovery length t(32) = 3.16, p &lt; .01, while self-reported ratings were not (p=.54).Conclusions:Findings indicated that psychological resilience did not explain a unique portion of the variance in length of recovery above and beyond acute parent report of postinjury emotional symptoms in adolescents recovering from mTBI compared with orthopedic injured (OI) controls. Interestingly, sex, group (mTBI vs. OI), and self-reported acute postinjury emotional symptoms were not significant predictors of recovery length in this sample. Results highlight the significant role of acute changes in emotional symptoms in adolescents recovering from mTBI and OI in predicting length of recovery, as well as the importance of obtaining separate caregiver report. A more robust understanding of factors contributing to recovery from injury can help inform and improve preventive measures and treatment plants for those at risk or impacted; however, psychological resilience may not uniquely contribute to predicting length of recovery in acutely injured adolescents, limiting value added to the clinical exam. Future studies should explore the relationship between type of injury and recovery time in larger samples.

Evidence of Ongoing Cerebral Microstructural Reorganization in Children With Persisting Symptoms Following Mild Traumatic Brain Injury: A NODDI DTI Analysis.

Approximately 300-550 children per 100,000 sustain a mild traumatic brain injury (mTBI) each year, of whom ∼25-30% have long-term cognitive problems. Following mTBI, free water (FW) accumulation occurs in white matter (WM) tracts. Diffusion tensor imaging (DTI) can be used to investigate structural integrity following mTBI. Compared with conventional DTI, neurite orientation dispersion and density imaging (NODDI) orientation dispersion index (ODI) and fraction of isolated free water (FISO) metrics may allow a more advanced insight into microstructural damage following pediatric mTBI. In this longitudinal study, we used NODDI to explore whole-brain and tract-specific differences in ODI and FISO in children with persistent symptoms after mTBI (n = 80) and in children displaying clinical recovery (n = 32) at 1 and 2-3 months post-mTBI compared with healthy controls (HCs) (n = 21). Two-way repeated measures analysis of variance (ANOVA) and voxelwise two-sample t tests were conducted to compare whole-brain and tract-specific diffusion across groups. All results were corrected at positive false discovery rate (pFDR) <0.05. We also examined the association between NODDI metrics and clinical outcomes, using logistical regression to investigate the value of NODDI metrics in predicting future recovery from mTBI. Whole-brain ODI was significantly increased in symptomatic participants compared with HCs at both 1 and 2 months post-injury, where the uncinate fasciculus (UF) and inferior fronto-occipital fasciculus (IFOF) were particularly implicated. Using region of interest (ROI) analysis in significant WM, bilateral IFOF and UF voxels, symptomatic participants had the highest ODI in all ROIs. ODI was lower in asymptomatic participants, and HCs had the lowest ODI in all ROIs. No changes in FISO were found across groups or over time. WM ODI was moderately correlated with a higher youth-reported post-concussion symptom inventory (PCSI) score. With 87% predictive power, ODI (1 month post-injury) and clinical predictors (age, sex, PCSI score, attention scores) were a more sensitive predictor of recovery at 2-3 months post-injury than fractional anisotropy (FA) and clinical predictors, or clinical predictors alone. FISO could not predict recovery at 2-3 months post-injury. Therefore, we found that ODI was significantly increased in symptomatic children following mTBI compared with HCs at 1 month post-injury, and progressively decreased over time alongside clinical recovery. We found no significant differences in FISO between groups or over time. WM ODI at 1 month was a more sensitive predictor of clinical recovery at 2-3 months post-injury than FA, FISO, or clinical measures alone. Our results show evidence of ongoing microstructural reorganization or neuroinflammation between 1 and 2-3 months post-injury, further supporting delayed return to play in children who remain symptomatic. We recommend future research examining the clinical utility of NODDI following mTBI to predict recovery or persistence of post-concussion symptoms and thereby inform management of mTBI.

The Relationship Between Parental and Family Functioning and Post-Concussive Symptoms After Pediatric Mild Traumatic Brain Injury: A Scoping Review.

This scoping review aimed to address the following questions: (1) Does mild traumatic brain injury (mTBI) result in more parental distress or poorer family functioning than other injuries? (2) Does pre-injury or acute parental distress and family functioning predict post-concussive symptoms (PCS) after mTBI? and (3) Do acute PCS predict later parental distress and family functioning? The subjects of this review were children/adolescents who had sustained an mTBI before age 18 and underwent assessment of PCS and parent or family functioning. MEDLINE®, PsycInfo, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and CENTRAL databases were searched to identify original, empirical, peer-reviewed research published in English. PCS measures included parent- and child-reported symptom counts and continuous scales. Parent and family measures assessed parental stress, psychological adjustment, anxiety, psychiatric history, parent-child interactions, family burden, and general family functioning. A total of 11,163 articles were screened, leading to the inclusion of 15 studies, with 2569 participants (mTBI = 2222; control = 347). Collectively, the included articles suggest that mTBI may not result in greater parental distress or poorer family functioning than other types of injuries. Pre-injury or acute phase parental and family functioning appears to predict subsequent PCS after mTBI, depending on the specific family characteristic being studied. Early PCS may also predict subsequent parental and family functioning, although findings were mixed in terms of predicting more positive or negative family outcomes. The available evidence suggests that parent and family functioning may have an important, perhaps bidirectional, association with PCS after pediatric mTBI. However, further research is needed to provide a more thorough understanding of this association.