Caregiver report of social-emotional functioning in infants and young children after inflicted traumatic brain injury.

Social-emotional difficulties are common sequelae of traumatic brain injury (TBI). Children who have experienced inflicted TBI (iTBI) may be at increased risk for social-emotional problems due to the risk factors associated with both early neurologic injury and with child maltreatment. We characterized the associations among injury severity, caregiver type (i.e., biological parents, non-kinship, kinship), and child social-emotional functioning in 41 infants and young children who had sustained iTBI and were seen in a large, regional children's hospital. This study was a retrospective analysis, utilizing data collected from the medical record as part of routine clinical care. Social-emotional functioning was assessed with the Bayley Scales of Infant and Toddler Development-Third Edition. Children with more severe injuries were rated as having worse social-emotional functioning. Caregiver type was associated with child social-emotional scores, above and beyond injury and demographic predictors. Biological parents were more likely to report better social-emotional skills than non-kinship caregivers, with the pattern of results suggesting that rater bias plays a role in this difference. In order to ensure that children are accurately identified for supports, these relationships should be considered when interpreting caregiver report of social-emotional skills.

Cognitive disengagement syndrome in pediatric spina bifida.

The primary aim of this study was to characterize Cognitive Disengagement Syndrome (CDS) symptomatology in youth with spina bifida (SB). One hundred and sixty-nine patients aged 5-19 years old were drawn from clinical cases seen through a multidisciplinary outpatient SB clinic at a children's hospital between 2017 and 2019. Parent-reported CDS and inattention were measured using Penny's Sluggish Cognitive Tempo Scale and the Vanderbilt ADHD Rating Scale. Self-reported internalizing symptoms were measured with the 25-item Revised Children's Anxiety and Depression Scale (RCADS-25). We replicated Penny's proposed 3-factor structure of CDS with slow, sleepy, and daydreamer components. The slow component of CDS overlapped heavily with inattention, while the sleepy and daydreamer components were distinct from inattention and internalizing symptoms. Eighteen percent (22 of 122) of the full sample met criteria for elevated CDS, and 39% (9 of 22) of those patients did not meet criteria for elevated inattention. Diagnosis of myelomeningocele and presence of a shunt were associated with greater CDS symptoms. CDS can be measured reliably in youth with SB and can be discriminated from inattention and internalizing symptoms in this population. ADHD rating scale measures fail to identify a substantial portion of the SB population with attention-related challenges. Standard screening for CDS symptoms in SB clinics may be important to help identify clinically impairing symptoms and design targeted treatment plans.

Quality of Life in Youth Soccer Players After Mild Traumatic Brain Injury.

CONTEXT: Pediatric mild traumatic brain injuries (mTBIs) represent an evolving field of interest in youth athletics. Although most players recover within 4 weeks, some have symptoms that last longer. Little is known about youth health-related quality of life (HRQoL) after mTBI. OBJECTIVES: To characterize youth HRQoL after soccer-related mTBI and to identify predictors of individual differences in HRQoL recovery. DESIGN: Prospective cohort study. SETTING: Youth soccer. PARTICIPANTS: Soccer players, aged 8 to 17 years, who sustained an mTBI (n = 23) or orthopaedic injury (OI, n = 24) or remained uninjured (n = 23) during a single season. MAIN OUTCOME MEASURE(S): We assessed HRQoL via the Pediatric Quality of Life Inventory, version 4.0, and postconcussive symptoms via the Health and Behavior Index. Serial assessments occurred at 24 to 48 hours, 7 days, 30 days, and 90 days postinjury via telephone interview. RESULTS: At 7 days postinjury, the mTBI and OI groups had poorer total HRQoL (F2,67 = 11.35, P < .001) than the uninjured control group. At 7 days, the mTBI group had the poorest psychosocial HRQoL, whereas the OI group had the poorest physical HRQoL. Differences between the mTBI and uninjured control groups resolved by 30 days. Within the mTBI group, players with significant postconcussive symptoms at 7 days had poorer total (F1,21 = 23.071, P ≤ .001; F1,21 = 5.798, P = .028), psychosocial (F1,21 = 16.488, P = < .001; F1,21 = 5.050, P = .039), and physical (F1,21 = 21.671, P = < .001; F1,21 = 5.119, P = .038) HRQoL at 7 and 30 days, respectively, than players with minimal symptoms; these differences resolved by 90 days. CONCLUSIONS: As a group, youth soccer players who sustained mTBI had transient impairments in HRQoL that resolved by 30 days. A subset of players with significant postconcussive symptoms at 7 days postinjury had poorer HRQoL for at least 30 days postinjury than those whose postconcussive symptoms had resolved within a week of injury. This suggests ongoing recovery in this subset at 30 days and the potential utility of HRQoL as a measure of recovery.

Processing Speed is Related to the General Psychopathology Factor in Youth.

The relationship between the p factor and cognition in youth has largely focused on general cognition (IQ) and executive functions (EF). Another cognitive construct, processing speed (PS), is dissociable from IQ and EF, but has received less research attention despite being related to many different mental health symptoms. The present sample included 795 youth, ages 11-16 from the Colorado Learning Disabilities Research Center (CLDRC) sample. Confirmatory factor analyses tested multiple p factor models, with the primary model being a second-order, multi-reporter p factor. We then tested the correlation between the p factor and a latent PS factor. There was a significant, negative correlation between the p factor and PS (r(87) = -0.42, p < .001), indicating that slower processing speed is associated with higher general mental health symptoms. This association is stronger than previously reported associations with IQ or EF. This finding was robust across models that used different raters (youth and caregiver) and modeling approaches (second-order vs. bifactor). Our findings indicate that PS is related to general psychopathology symptoms. This research points to processing speed as an important transdiagnostic construct that warrants further exploration across development.

Child, Parent, and Family Adjustment for Patients Followed in a Multidisciplinary Spina Bifida Clinic.

Objectives: To characterize child, parent, and family adjustment for patients followed in a multidisciplinary spina bifida (SB) clinic. Methods: Participants were drawn from clinical cases seen through a multidisciplinary outpatient SB clinic at a children's hospital between 2017 and 2019. Participants included 209 youth under 19 years old who were diagnosed with SB and their parents. Self-reported internalizing symptoms were measured in youth in grade 3 through 12 using the 25-item Revised Children's Anxiety and Depression Scale-25 (RCADS-25). Self- and parent-reported quality of life and family functioning were obtained using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales and Family Impact Modules. Results: A total of 45.7% of children and adolescents reported at-risk psychosocial functioning on the PedsQL. In contrast, only 5% of patients reported clinically elevated internalizing symptoms on the RCADS. Parents' quality of life and family functioning in the study were higher than in most studies of parents of children with other chronic health conditions, children with attention deficit-hyperactivity disorder, and healthy control samples. Conclusion: Our findings indicate that children and adolescents with SB are at risk for poor health-related quality of life (HRQOL); however, poorer HRQOL may not necessarily be associated with more severe psychiatric symptoms in this population. Examining resilience factors that may help to buffer against challenges to HRQOL will be important in informing future interventions.

Sequencing Deficits and Phonological Speech Errors, But Not Articulation Errors, Predict Later Literacy Skills.

PURPOSE: Speech sound disorder (SSD) in conjunction with a language disorder has been associated with poor literacy acquisition; however, no study has evaluated whether articulation, phonological, or sequencing skills are differentially related to reading skills. Therefore, this study examined the relationship between speech error types at ages 5-6 years and literacy at ages 7-9 years. Phonological errors were hypothesized to predict phonological awareness (PA) and literacy even while accounting for other speech error types and language skills. METHOD: One hundred twenty-three children, 86 with a history of speech impairment, completed a battery of speech, language, and literacy tests at ages 5-6 years and again at ages 7-9 years. Speech production at ages 5-6 years was analyzed, and indices of articulation errors, phonological errors, and sequencing deficits were obtained. The relationships of these error types to concurrent language and preliteracy skills and to later literacy outcomes were assessed. RESULTS: As expected, phonological, but not articulation, errors at ages 5-6 years predicted concurrent PA and letter knowledge, as well as literacy at ages 7-9 years, even while accounting for language skills. Surprisingly, of all the error types, sequencing deficits showed the strongest relationship with PA (ages 5-6 years) and literacy (ages 7-9 years). CONCLUSIONS: These results suggest that some components of SSD uniquely predict preliteracy and literacy skills, even when controlling for language ability. Future investigations should examine further the association between sequencing deficits and literacy skills, test whether observed relationships hold at younger ages, and evaluate the efficacy of integrating literacy interventions into speech therapy to reduce later reading difficulties. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19624020.

Pediatric mTBI during the COVID-19 pandemic: considerations for evaluation and management.

The COVID-19 pandemic has changed healthcare utilization patterns and clinical practice, including pediatric mTBI evaluation and management. Providers treating pediatric mTBI, including neuropsychologists, have a unique role in evaluating and managing an already complex injury in the context of the COVID-19 pandemic with limited empirically based guidelines. In the present paper, we review usual, evidence-based pediatric mTBI care, highlight changes experienced by healthcare providers since the onset of the pandemic, and provide possible considerations and solutions. Three primary challenges to usual care are discussed, including changes to post-injury evaluation, management, and treatment of persistent symptoms. Changing patterns of healthcare utilization have created unique differences in mTBI identification and evaluation, including shifting injury frequency and mechanism, reluctance to seek healthcare, and increasing access to telemedicine. Typical injury management has been compromised by limited access to usual systems/activities (i.e., school, sports, social/leisure activities). Patients may be at higher risk for prolonged recovery due to pre-injury baseline elevations in acute and chronic stressors and reduced access to rehabilitative services targeting persistent symptoms. Considerations and solutions for addressing each of the three challenges are discussed. Neuropsychologists and other pediatric healthcare providers will need to continue to flexibly adapt to the changing needs of youth recovering from mTBI through the duration of the pandemic and beyond. Consistent with pre-pandemic consensus statements, neuropsychologists remain uniquely qualified to evaluate and manage mTBI and provide an increasingly integral role as members of multidisciplinary teams in the context of the global pandemic.Abbreviations: AAP: American Academy of Pediatrics; CDC: Centers for Disease Control and Prevention; COVID-19: coronavirus disease 19; ED: emergency department; mTBI: Mild traumatic brain injury.

How Specific Are Learning Disabilities?

Despite historical emphasis on "specific" learning disabilities (SLDs), academic skills are strongly correlated across the curriculum. Thus, one can ask how specific SLDs truly are. To answer this question, we used bifactor models to identify variance shared across academic domains (academic g), as well as variance unique to reading, mathematics, and writing. Participants were 686 children ages 8 to 16. Although the sample was overselected for learning disabilities, we intentionally included children across the full range of individual differences in this study in response to growing recognition that a dimensional, quantitative view of SLD is more accurate than a categorical view. Confirmatory factor analysis identified five academic domains (basic reading, reading comprehension, basic math, math problem-solving, and written expression); spelling clustered with basic reading and not writing. In the bifactor model, all measures loaded significantly on academic g. Basic reading and mathematics maintained variance distinct from academic g, consistent with the notion of SLDs in these domains. Writing did not maintain specific variance apart from academic g, and evidence for reading comprehension-specific variance was mixed. Academic g was strongly correlated with cognitive g (r = .72) but not identical to it. Implications for SLD diagnosis are discussed.

Concussion Symptom Treatment and Education Program: A Feasibility Study.

OBJECTIVE: To evaluate the feasibility and potential benefits of a manualized, brief cognitive-behavioral therapy-based intervention program for children and adolescents with persistent postconcussive symptoms. SETTING: Two outpatient pediatric concussion programs in the United States. PARTICIPANTS: Patients aged 8 to 17 years who sustained concussions between 2 and 12 months prior to enrollment. DESIGN: Pre-/postretrospective study. MAIN MEASURES: SCAT-3; HBI; PedsQL 4.0 Generic Core Scales; and RCADS. RESULTS: Thirty children and adolescents completed the treatment program. Self- and parent-reported postconcussive symptoms, quality of life, and internalizing symptoms significantly improved with treatment. Mixed-effects models revealed a significant decline in self-reported postconcussive symptoms across treatment sessions, a = -2.07, SE = 0.25, P < .001. The largest change occurred between sessions 2 and 3, following the session focusing on concussion psychoeducation and sleep hygiene (estimated mean change between sessions 2 and 3 = -4.72, P < .0001). CONCLUSIONS: Our findings indicate that a 6-session manualized cognitive behavioral intervention is feasible to initiate in an outpatient clinic 1 to 12 months following a pediatric mild traumatic brain injury. With a manualized format, clinicians at most levels of training should be able to implement this treatment manual and flexibly adapt as needed when working with children and adolescents who are experiencing delayed symptom recovery following concussion.

The Multiple Deficit Model: Progress, Problems, and Prospects.

The multiple deficit model (MDM) was proposed because the prevailing single-deficit model provided an inadequate account of atypical neuropsychological development. Across methods and levels of analysis, there has been support for the two fundamental tenets of the MDM, that multiple predictors contribute probabilistically to neurodevelopmental disorders and shared risk factors contribute to comorbidity. Diagnostically, the multiplicity of factors means that no single cognitive deficit or combination of deficits can be used to rule in or out most neurodevelopmental disorders. Challenges for the MDM are that the theory is difficult to falsify and that current cross-sectional studies cannot establish causality. Prospects for further development of the MDM include incorporating an explicit focus on promotive and protective factors and pursuing mechanistic connections between multiple factors across levels of analysis.

A Longitudinal Investigation of Symptom Recovery following Concussion in Youth Soccer.

OBJECTIVE: To prospectively evaluate symptom outcomes after youth soccer-related concussion. STUDY DESIGN: Using a prospective cohort design, we enrolled male and female competitive soccer players age 8-17 years into 3 groups: concussed (n = 23), matched control (n = 23), and orthopedic injury (n = 24). Postconcussive symptoms were monitored serially via both athlete and parent report at days 1-2, 4, 7, 10, 30, and 90. RESULTS: Repeated-measures analyses revealed a significant time by group interaction (F [12, 402] = 19.91, P < .001). In the initial days postinjury, the concussed group reported greater symptoms than the comparison groups, with more symptoms reported by athletes on average than parents. By 10 days, concussed athletes did not differ from the matched controls by either rater's report, but they did differ from the orthopedic injury group by parent report. At 30 days, no differences were apparent among groups. At 30 days, 100% of concussed youth and 91% of parents rated symptoms as back to preinjury levels using reliable change indices. At 30 days, 86% of athletes had been cleared to return to full game play. CONCLUSIONS: The natural clinical history of concussion symptoms in youth competitive soccer players was similar to that seen in older athletes, with resolution in days to a few weeks. Additional study will be required to investigate which factors best predict symptom outcomes for individual athletes and how symptom report relates to performance-based outcome measures and underlying neurophysiologic recovery.

Utility of matrix reasoning as an embedded performance validity indicator in pediatric mild traumatic brain injury.

The present study examined the utility of the Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II) Matrix Reasoning (MR) subtest in detecting suspect effort among a pediatric mild traumatic brain injury (mTBI) sample. The sample consisted of 526 clinically referred patients aged 8-16 years. Sixteen percent of participants failed the Medical Symptom Validity Test, which was used to categorize the sample into adequate and suspect effort groups. No background or injury-related variables differentiated the two groups. Comparisons between the adequate and suspect effort groups revealed significant differences in MR performance (p < .001; d = 1.46). A subsample (n = 206) where first item missed data were available was also analyzed; suspect effort participants missed their first item significantly earlier than adequate effort participants. In the entire sample, a MR cutoff T-score of 43 resulted in sensitivity of 57% and specificity of 90%. Receiver operating characteristic area under the curve for MR T-score was .804. Within this relatively high-functioning pediatric population with mTBI, MR appeared to have good utility as an embedded validity indicator, with classification statistics comparable to many of the most commonly used embedded indices used with adults.

Featured Article: Interpersonal Stressors and Resources as Predictors of Adolescent Adjustment Following Traumatic Brain Injury.

Objective: The present study sought to examine adolescents' perceptions of their interpersonal stressors and resources across parent, sibling, friend, and school relationships, and the longitudinal associations with self-reported adjustment after traumatic brain injury (TBI) over a 12-month period. Methods: We examined the main effects of stressors and resources on internalizing and externalizing symptoms in 152 adolescents who had sustained complicated mild-to-severe TBI. We also investigated the conjoint effects of stressors and resources and the moderating effects of TBI severity with stressors and resources on outcomes. Results: High stressors consistently predicted worse adjustment. High resources were generally only associated with fewer internalizing symptoms. Main effects were qualified by interactions between school stressors and resources in predicting externalizing symptoms and between friend stressors and resources in predicting internalizing and externalizing symptoms. For school stressors, the effects of resources on externalizing symptoms functioned as a buffer. In comparison, the buffering effects of friend resources on internalizing and externalizing symptoms disappeared at moderate-to-high levels of friend stress. Moderating effects of TBI severity were also observed, such that as family resources increased, only adolescents with complicated mild-to-moderate TBI, but not those with severe TBI, experienced decreases in internalizing and eternalizing symptoms. Conclusion: Interpersonal stressors and social support have important implications for adolescent adjustment after TBI. Adolescents with low levels of school resources, with high levels of friend stress, and who sustain severe TBI are at greatest risk for difficulties with adjustment.

Literacy acquisition influences children's rapid automatized naming.

Previous research has established that learning to read improves children's performance on reading-related phonological tasks, including phoneme awareness (PA) and nonword repetition. Few studies have investigated whether literacy acquisition also promotes children's rapid automatized naming (RAN). We tested the hypothesis that literacy acquisition should influence RAN in an international, longitudinal population sample of twins. Cross-lagged path models evaluated the relationships among literacy, PA, and RAN across four time points from pre-kindergarten through grade 4. Consistent with previous research, literacy showed bidirectional relationships with reading-related oral language skills. We found novel evidence for an effect of earlier literacy on later RAN, which was most evident in children at early phases of literacy development. In contrast, the influence of earlier RAN on later literacy was predominant among older children. These findings imply that the association between these two related skills is moderated by development. Implications for models of reading development and for dyslexia research are discussed.

Explaining the sex difference in dyslexia.

BACKGROUND: Males are diagnosed with dyslexia more frequently than females, even in epidemiological samples. This may be explained by greater variance in males' reading performance. METHODS: We expand on previous research by rigorously testing the variance difference theory, and testing for mediation of the sex difference by cognitive correlates. We developed an analytic framework that can be applied to group differences in any psychiatric disorder. RESULTS: Males' overrepresentation in the low performance tail of the reading distribution was accounted for by mean and variance differences across sex. There was no sex difference at the high performance tail. Processing speed (PS) and inhibitory control partially mediated the sex difference. Verbal reasoning emerged as a strength in males. CONCLUSIONS: Our results complement a previous finding that PS partially mediates the sex difference in symptoms of attention deficit/hyperactivity disorder (ADHD), and helps explain the sex difference in both dyslexia and ADHD and their comorbidity.

Cognitive Prediction of Reading, Math, and Attention: Shared and Unique Influences.

The current study tested a multiple-cognitive predictor model of word reading, math ability, and attention in a community-based sample of twins ages 8 to 16 years ( N = 636). The objective was to identify cognitive predictors unique to each skill domain as well as cognitive predictors shared among skills that could help explain their overlap and thus help illuminate the basis for comorbidity of related disorders (reading disability, math disability, and attention deficit hyperactivity disorder). Results indicated that processing speed contributes to the overlap between reading and attention as well as math and attention, whereas verbal comprehension contributes to the overlap between reading and math. There was no evidence that executive functioning skills help account for covariation among these skill domains. Instead, specific executive functions differentially related to certain outcomes (i.e., working memory to math and inhibition to attention). We explored whether the model varied in younger versus older children and found only minor differences. Results are interpreted within the context of the multiple deficit framework for neurodevelopmental disorders.

Parent satisfaction with neuropsychological consultation after pediatric mild traumatic brain injury.

Few studies have focused on consumer satisfaction following neuropsychological evaluation. We sought to examine parent satisfaction with neuropsychological consultation following a mild traumatic brain injury (TBI) in school-age children. We surveyed 71 parents of 8- to 17-year-olds participating in a prospective longitudinal study examining neuropsychological consultation as an intervention for persistent postconcussive symptoms. Children had sustained injuries between 2 and 12 months prior to enrollment. Neuropsychological consultation occurred on average 5 months post-injury. Parent satisfaction data were collected via telephone approximately 4 months after the neuropsychological consultation. The vast majority of parents were quite satisfied with the service (e.g., 94% overall satisfaction rate; 96% rated the service as good or excellent). Satisfaction rates were associated positively with time since injury and negatively with parental education. No other child, parent, or provider variable correlated with satisfaction. The results add to the relatively sparse literature on parent satisfaction with neuropsychological evaluation. A pressing future need in pediatric neuropsychology is to examine the satisfaction of other consumers of the service, including healthcare personnel, educators, and the child patients themselves.

The impact of pediatric neuropsychological consultation in mild traumatic brain injury: a model for providing feedback after invalid performance.

OBJECTIVE: In recent years, pediatric practitioners have increasingly recognized the importance of objectively measuring performance validity during clinical assessments. Yet, no studies have examined the impact of neuropsychological consultation when invalid performance has been identified in pediatric populations and little published guidance exists for clinical management. Here we provide a conceptual model for providing feedback after noncredible performance has been detected. In a pilot study, we examine caregiver satisfaction and postconcussive symptoms following provision of this feedback for patients seen through our concussion program. METHODS: Participants (N = 70) were 8-17-year-olds with a history of mild traumatic brain injury who underwent an abbreviated neuropsychological evaluation between 2 and 12 months post-injury. We examined postconcussive symptom reduction and caregiver satisfaction after neuropsychological evaluation between groups of patients who were determined to have provided noncredible effort (n = 9) and those for whom no validity concerns were present (n = 61). RESULTS: We found similarly high levels of caregiver satisfaction between groups and greater reduction in self-reported symptoms after feedback was provided using the model with children with noncredible presentations compared to those with credible presentations. CONCLUSION: The current study lends preliminary support to the idea that the identification and communication of invalid performance can be a beneficial clinical intervention that promotes high levels of caregiver satisfaction and a reduction in self-reported and caregiver-reported symptoms.

The Role of Neuropsychological Evaluation in the Clinical Management of Concussion.

Most people are expected to recover quickly and completely after sustaining a single, uncomplicated concussion. When unexpected difficulties are apparent or recovery is not progressing as expected, a neuropsychological evaluation may help to clarify the injury and noninjury variables that could be serving to prolong recovery. Interventions tailored to the needs of a specific patient can then be implemented to assist in improving functioning and minimizing distress.