The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns.

OBJECTIVE: To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation. SETTING: Inpatient pediatric rehabilitation. PARTICIPANTS: In total, 234 children with TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission. DESIGN: Multicenter, retrospective medical record review. MAIN MEASURES: Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day). RESULTS: Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported. CONCLUSION: This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.

Training in Neurorehabilitation Psychology: Defining Competencies, Requisite Skill Sets, and a Proposed Developmental Pathway.

Psychologists have been applying neurorehabilitation models of care for many years. These practitioners come from different training backgrounds and use a variety of titles to refer to themselves despite considerable overlap in practice patterns, professional identification, and salary. Titles like 'neurorehabilitation psychologist' and 'rehabilitation neuropsychologist' are sometimes used by practitioners in the field to indicate their specialty area, but are not formally recognized by the American Psychological Association, the American Board of Professional Psychology, or by training councils in clinical neuropsychology (CN) or rehabilitation psychology (RP). Neither the CN or RP specialties alone fully address or define the competencies, skill sets, and clinical experiences required to provide high quality, comprehensive neurorehabilitation psychology services across settings. Therefore, irrespective of practice setting, we believe that both clinical neuropsychologists and rehabilitation psychologists should ideally have mastery of specific, overlapping competencies and a philosophical approach to care that we call neurorehabilitation psychology in this paper. Trainees and early career professionals who aspire to practice in this arena are often pressured to prioritize either CN or RP pathways over the other, with anxiety about perceived and real potential for falling short in their training goals. In the absence of an explicit training path or formal guidelines, these professionals emerge only after the opportunity, privilege, or frank luck of working with specific mentors or in exceptional patient care settings that lend themselves to obtaining integrated competencies in neurorehabilitation psychology. This paper reflects the efforts of 7 practitioners to preliminarily define the practice and philosophies of neurorehabilitation psychology, the skill sets and competencies deemed essential for best practice, and essential training pathway elements. We propose competencies designed to maximize the integrity of training and provide clear guideposts for professional development.

Return to Learn After Traumatic Brain Injury.

A successful return of youth back to school after traumatic brain injury (TBI) is an important aspect of post-injury management. Regardless of the severity of the injury, returning to school is an important aspect of improving recovery and outcomes. Often temporary informal school adjustments suffice in supporting children returning to school after concussion. For those with more a significant TBI, often formal school supports and interventions are important. Given the resiliency and recovery often seen after pediatric brain injury, close monitoring, serial evaluations, and fluid supports are important in accurately identifying what specific sequelae require support in the school setting.

A survey of pediatric neuropsychologists serving inpatient rehabilitation, Part II: billing, time allocation and tracking, and professional identity and perceptions.

Professional challenges have been documented in broad surveys of neuropsychologists. While previous surveyors have included pediatric neuropsychologists, few, if any, have specifically examined practices among those who primarily work in pediatric inpatient rehabilitation settings. Therefore, the aim of this study was to survey neuropsychologists in this setting. Thirty neuropsychologists from the U.S. and one from Canada that work in inpatient pediatric rehabilitation participated in an online survey. Most respondents (83.3%) billed for their inpatient time. Sixty-four percent indicated that payor type (private vs. public) affected services a moderate amount to a lot; this was primarily due to payor's influence on length of stay. Most providers had productivity expectations (66.7%). Among those that had productivity expectations, three-quarters used "hours billed;" 37.5% were solely or additionally tracked by relative value units (RVUs). The majority of respondents conducted some type of clinical data collection, usually for research purposes. With respect to professional identity, most respondents indicated positivity about their role. The top challenges endorsed were related to workload/ability to meet the patients' needs and billing/productivity. Issues related to billing and payor may influence aspects of pediatric inpatient rehabilitation neuropsychological care. Managing challenges related to billing and the time demands associated with providing inpatient services were top concerns for many respondents. Most sites surveyed were involved in data collection, usually for research purposes; increased data collection efforts are needed to aid with program development and evaluation and to demonstrate the added value of neuropsychological services from a patient care perspective.

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.

Prescribing Patterns of Amantadine During Pediatric Inpatient Rehabilitation After Traumatic Brain Injury: A Multicentered Retrospective Review From the Pediatric Brain Injury Consortium.

OBJECTIVES: To describe dosing practices for amantadine hydrochloride and related adverse effects among children and young adults with traumatic brain injury (TBI) admitted to pediatric inpatient rehabilitation units. SETTING: Eight pediatric acute inpatient rehabilitation units located throughout the United States comprising the Pediatric Brain Injury Consortium. PARTICIPANTS: Two-hundred thirty-four children and young adults aged 2 months to 21 years with TBI. DESIGN: Retrospective data revie. MAIN OUTCOME MEASURES: Demographic variables associated with the use of amantadine, amantadine dose, and reported adverse effects. RESULTS: Forty-nine patients (21%) aged 0.9 to 20 years received amantadine during inpatient rehabilitation. Forty-five percent of patients admitted to inpatient rehabilitation with a disorder of consciousness (DoC) were treated with amantadine, while 14% of children admitted with higher levels of functioning received amantadine. Children with DoC who were not treated with amantadine were younger than those with DoC who received amantadine (median 3.0 vs 11.6 years, P = .008). Recorded doses of amantadine ranged from 0.7 to 13.5 mg/kg/d; the highest total daily dose was 400 mg/d. Adverse effects were reported in 8 patients (16%); nausea/abdominal discomfort and agitation were most common, each reported in 3 patients. The highest reported dose without an adverse effect was 10.1 mg/kg/d. CONCLUSION: During pediatric inpatient rehabilitation, amantadine was prescribed to children across a range of ages and injury severity and was most commonly prescribed to older children with DoC. Dosing varied widely, with weight-based dosing for younger/smaller children at both lower and higher doses than what had been previously reported. Prospective studies are needed to characterize the safety and tolerability of higher amantadine doses and optimize amantadine dosing parameters for children with TBI.

Clinical and training practices: A survey of pediatric neuropsychologists serving inpatient rehabilitation.

Neuropsychologists in inpatient pediatric rehabilitation settings collaborate with an interdisciplinary team to educate, evaluate, and provide intervention to patients with acquired brain injury and their families, but there are no known studies that describe or define these clinical services. Thirty-one neuropsychologists in pediatric inpatient rehabilitation settings completed an online survey. Neuropsychologists (68.2% female; 86.4% with PhD versus PsyD) from the U.S. and Canada, who represented 22 pediatric inpatient rehabilitation sites comprised the final sample. Most sites (63.6%) were embedded within medical centers, with providers dedicating 2 to 32 hours (M = 14.25, SD = 9.26) weekly to onsite inpatient rehabilitation efforts. Providers most often saw patients with traumatic brain injury and other acquired brain injuries, including stroke and brain tumor. Trainees from various levels, most commonly post-doctoral fellows, provided clinical services on inpatient units, many with some degree of independence. Clinical practices that were standard across all or most sites included targeted discharge evaluations, serial cognitive monitoring, neuropsychology consultation to rehabilitation and non-rehabilitation units, and follow-up clinics. Provision of services was influenced by multiple factors including patient diagnosis, timing of return to school, inpatient census, and payor's effect on length of stay. Findings highlight many programmatic consistencies across sites and serve as an important initial step to guiding pediatric neuropsychology providers seeking to understand the current landscape of clinical care. Future efforts are needed to establish a true clinical guideline for practice. Although preliminary, data also support establishment of neuropsychology training programs, justify administrative resources, and serve to educate recipients of neuropsychology services.

Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

OBJECTIVES: To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI). DESIGN: Retrospective observational, multicenter study. SETTING: Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI. PARTICIPANTS: Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS). RESULTS: Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation. CONCLUSIONS: This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.

Acute Imaging Findings Predict Recovery of Cognitive and Motor Function after Inpatient Rehabilitation for Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study.

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children; survivors experience long-term cognitive and motor deficits. To date, studies predicting outcome following pediatric TBI have primarily focused on acute behavioral responses and proxy measures of injury severity; unsurprisingly, these measures explain very little of the variance following heterogenous injury. In adults, certain acute imaging biomarkers help predict cognitive and motor recovery following moderate to severe TBI. This multi-center, retrospective study, characterizes the day-of-injury computed tomographic (CT) reports of pediatric, adolescent, and young adult patients (2 months to 21 years old) who received inpatient rehabilitation services for TBI (n = 247). The study also determines the prognostic utility of CT findings for cognitive and motor outcomes assessed by the Pediatric Functional Independence Measure, converted to age-appropriate developmental functional quotient (DFQ), at discharge from rehabilitation. Subdural hematomas (66%), contusions (63%), and subarachnoid hemorrhages (59%) were the most common lesions; the majority of subjects had less severe Rotterdam CT scores (88%, ≤ 3). After controlling for age, gender, mechanism of injury, length of acute hospital stay, and admission DFQ in multivariate regression analyses, the highest Rotterdam score (ß = -25.2, p < 0.01) and complete cisternal effacement (ß = -19.4, p < 0.05) were associated with lower motor DFQ, and intraventricular hemorrhage was associated with lower motor (ß = -3.7, p < 0.05) and cognitive DFQ (ß = -4.9, p < 0.05). These results suggest that direct detection of intracranial injury provides valuable information to aid in prediction of recovery after pediatric TBI, and needs to be accounted for in future studies of prognosis and intervention.

A randomized problem-solving trial for adolescent brain injury: Changes in social competence.

PURPOSE/OBJECTIVE: Traumatic brain injury (TBI) in adolescence has well documented effects on social competence. Few studies have examined the effects of behavioral interventions on social competence or identified factors associated with changes in social competence after injury. Research Method/Design: Adolescents with moderate to severe TBI ages 12-17 years were randomized within 6 months of injury to either a problem solving and communication (CAPS) group that received online counseling (n = 65) or an Internet resources comparison (IRC) group (n = 67) for a comparative effectiveness trial. Parent-report measures of social competence (Child Behavior Checklist, CBCL; Home and Community Social Behavior Scales, HCSBS; Behavioral and Emotional Rating Scale, BERS-2) were administered at baseline (preintervention) and approximately 6 months later. Analyses examined these measures in relation to treatment group, TBI severity, and age. Regression analyses were also conducted to examine baseline measures of cognition as predictors of social competence after TBI. RESULTS: CAPS had a more positive effect than the comparison condition on the HCSBS and BERS-2 for younger teens with moderate TBI and older teens with severe TBI. More parent-rated executive dysfunction at baseline was related to both lower concurrent levels of social competence and less positive gains in competence over time, whereas higher baseline IQ predicted greater gains in competence. CONCLUSIONS/IMPLICATIONS: CAPS may be effective for improving social competence for teens after TBI, with benefits dependent on the teen's age and injury severity. Parent-rated executive dysfunction, moreover, has utility in predicting both lower concurrent levels of social competence and subsequent postinjury gains in competence. (PsycINFO Database Record

Neural substrates of inhibitory and emotional processing in adolescents with traumatic brain injury.

PURPOSE: Disturbances of emotional regulation and social difficulties are common in children and adolescents with traumatic brain injury (TBI). Recent research suggests that developments within ``socio-emotional'' brain systems during early adolescence and more protracted development of "cognitive control'' systems have implications for emotional and behavioral regulation during adolescence. However, few functional neuroimaging studies have directly examined the interaction of these neuropsychological processes in adolescents with TBI. The current study examined how affective processing might modulate inhibitory processing in an Emotional Go/NoGo paradigm. METHOD: The study uses a cross-sectional, age, gender, and maternal education matched design.A response inhibition paradigm (i.e., the Go/NoGo task with emotional faces) was used to examine emotional-cognition interaction in 11 adolescents with complicated mild to moderate TBI, at least 12 months post injury, and 14 typically-developing (TD) adolescents using functional magnetic resonance imaging (fMRI). Participants saw adult facial expressions of emotions (happy, sad, fearful, and angry) and were instructed to respond (``go'') on all expressions other than angry (``no-go''). RESULTS: Preliminary results (p= 0.001 uncorrected, cluster size = 50) showed higher levels of inhibition-related activation in TD adolescents than in adolescents with TBI in several brain regions including anterior cingulate and motor/premotor regions. CONCLUSION: These results suggest that TBI in adolescence might alter brain activation patterns and interrupt the development of brain networks governing emotion-cognition interactions.

Neural correlates of risky decision making in adolescents with and without traumatic brain injury using the balloon analog risk task.

We studied risky decision making (RDM) in 8 healthy adolescents (TC) and 11 adolescents with mild to moderate traumatic brain injuries (TBI) using the Balloon Analog Risk Task (BART) and functional magnetic resonance imaging (fMRI). Participants inflated simulated balloons (with more points awarded to bigger balloons), which might burst at any time. Increasing brain activation levels were associated with increasing balloon size in a largely bilateral network, including cerebellar, inferior parietal, limbic, and frontal areas. Both groups performed similarly and activated similar networks.

Iowa gambling task performance in overweight children and adolescents at risk for obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a nocturnal respiratory disorder associated with cognitive and behavioral sequelae, including impairments in executive functioning (EF). Previous literature has focused on "cool" EF, meaning abilities such as working memory and planning that do not involve affective control requirements. Little is known about the impact OSA may have on "hot" EF that involves regulation of affect and risk-related decision-making, and that may be particularly salient during adolescence, when these skills are rapidly developing. This study examined performance on the Iowa Gambling Task (IGT), a task believed to assess aspects of "hot" EF, in overweight adolescents at risk for OSA. Consistent with hypotheses, individuals without OSA made more beneficial decisions on the IGT over time, but participants with OSA did not benefit from feedback and continued to make choices associated with higher initial rewards, but greater long-term losses. The relationship between developmental level and IGT performance was moderated by OSA status. Individuals with OSA did not demonstrate the expected developmental gains in performance during the IGT. This finding suggests that OSA may impact the development of critical aspects of EF, or at least the expression of these skills during the developmentally important period of adolescence.

Emotion labeling and socio-emotional outcomes 18 months after early childhood traumatic brain injury.

A growing body of literature has documented evidence for emotion labeling (EL) deficits after traumatic brain injury (TBI); however, long-term effects of TBI on EL abilities, particularly among young children, are unclear. We investigated EL abilities and socio-emotional outcomes in 32 children with moderate-severe TBI, 23 with complicated-mild TBI, and 82 children with orthopedic injuries (OI), shortly after injury and at 18 months post-injury. All children were between 3:0 and 6:11 years of age at the time of injury. Repeated measures analyses indicated that all groups showed improved EL performance between acute and 18-month assessments, but that the moderate-severe TBI group improved at a slower rate than the OI group, so that the two groups showed significantly different performance at 18 months. Emotion labeling ability did not significantly contribute to the prediction of socio-emotional outcomes after controlling for pre-injury functioning. These results provide preliminary evidence of emerging EL deficits after early childhood TBI that are related to injury severity but that do not predict social and behavioral outcomes.

Neural correlates of interference control in adolescents with traumatic brain injury: functional magnetic resonance imaging study of the counting stroop task.

Difficulty in inhibition or cognitive control is a common and significant sequela of pediatric traumatic brain injury (TBI). The present study used functional MRI to examine one specific inhibitory function, interference control, in 11 adolescents, aged 12-16 years, (mean age, 15.7 years) with TBI who were at least 1 year postinjury and 11 age-matched typically developing control participants (TC) (mean age, 15.2 years). Participants completed a Counting Stroop task with 2 main conditions: (1) a neutral condition requiring the counting of animal words and (2) an interference condition in which mismatched number words were counted. Both TBI and TC adolescents activated similar networks of brain regions relevant to interference control, but the TBI group showed higher levels of activation relative to the TC group in multiple brain areas within this network, including predominantly right frontal and parietal regions. Findings of greater activation of the relevant neural network in the TBI group are consistent with recent fMRI findings using other interference control paradigms with individuals with a history of TBI.

Preliminary fMRI findings in experimentally sleep-restricted adolescents engaged in a working memory task.

Here we report preliminary findings from a small-sample functional magnetic resonance imaging (fMRI) study of healthy adolescents who completed a working memory task in the context of a chronic sleep restriction experiment. Findings were consistent with those previously obtained on acutely sleep-deprived adults. Our data suggest that, when asked to maintain attention and burdened by chronic sleep restriction, the adolescent brain responds via compensatory mechanisms that accentuate the typical activation patterns of attention-relevant brain regions. Specifically, it appeared that regions that are normally active during an attention-demanding working memory task in the well-rested brain became even more active to maintain performance after chronic sleep restriction. In contrast, regions in which activity is normally suppressed during such a task in the well-rested brain showed even greater suppression to maintain performance after chronic sleep restriction. Although limited by the small sample, study results provide important evidence of feasibility, as well as guidance for future research into the functional neurological effects of chronic sleep restriction in general, the effects of sleep restriction in children and adolescents, and the neuroscience of attention and its disorders in children.