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Objective: In 2018, the Centers for Disease Control Prevention (CDC) published an evidence-based guideline on the diagnosis and management of mild traumatic brain injury (mTBI) among children. This commentary summarizes the key recommendations in the CDC Pediatric mTBI Guideline most relevant for neuropsychologists and discusses research gaps and topics that should receive attention in future iterations of the Guideline. Method: We described the methods used to develop the Guideline, which included a comprehensive Systematic Review. We also distilled and presented key practice strategies reflected in Guideline. Results: To optimize care of pediatric patients with mTBI, neuropsychologists should: use validated, age-appropriate symptom scales, assess evidence-based risk factors for prolonged recovery, provide patients with instructions on return to activity customized to their symptoms, and counsel patients to return gradually to nonsports activities after a short period of rest. Future iterations of the Guideline should encompass a review and guidance on care of patients with psychiatric and psychological difficulties, as well as the potential use of imaging to assess patients with persistent symptoms. Expanded research on mTBI among girls, children age 8 and under, and effective treatments for pediatric mTBI will be beneficial to inform care practices. Conclusions: Recommendations in the CDC Pediatric mTBI Guideline highlight multiple opportunities for neuropsychologists to take action to improve the care of young patients with mTBI and to advance research in the field. Multiple resources and tools are available to support implementation of these recommendations into clinical practice.

Purpose : Examine the impact of traumatic brain injury (TBI) on parenting behavior over time. Method : Included 206 children (3-7 years old) with moderate to severe TBI or orthopedic injury, using a prospective longitudinal cohort study design. Assessments completed at baseline, 6-months, 12-months, 18-months, 3.5 years, and 6.8 years after injury. Dependent variables included authoritative, permissive, and authoritarian parenting. Results : Injury characteristics had limited impact on parenting behaviors over time. Levels of authoritative parenting remained stable over time; however, levels of warmth and involvement declined over time for those with TBI. Levels of permissive and authoritarian parenting declined for all participants by 3.5 years post injury. SES and stressors impacted parenting behaviors. Conclusions : While there was limited effect of TBI on parenting behavior over time, it remains unclear how individuals respond to these parenting behaviors years after injury. Clinicians should monitor family and parenting behaviors to foster an environment to promote positive recovery.

Objectives: We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time., Methods: We examined data from 359 children with complicated mild to severe TBI, aged 5-18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent-child conflict)., Results: We found a main effect for measure for both child and family outcomes [F(3, 731) = 7.35, p < .001; F(3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [t(731) = -5.15, p < .001, and t(731) = -3.90, p = .002, respectively, for child outcomes; t(532) = -4.81, p < .001, and t(532) = -3.80, p < .001, respectively, for family outcomes]., Conclusions: The results suggest limited differences in the measures' responsiveness to treatment while highlighting OFPST's utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.

Objective: To examine parent and family outcomes of a randomized controlled trial (RCT) comparing Teen Online Problem-Solving with Family (TOPS-F), Teen Online Problem-Solving-Teen Only (TOPS-TO), or access to Internet resources alone (Internet resource comparison [IRC])., Design: Three-arm RCT., Setting: Four children's hospitals and 1 general medical center in Ohio and Colorado., Participants: Children and adolescents (N=152), 11-18 years old, hospitalized for complicated mild to severe traumatic brain injury in the previous 18 months., Interventions: Intervention groups: TOPS-F, TOPS-TO, and IRC., Main Outcome Measure: Parental depression (CES-D), parental psychological distress (SCL-90-GSI), family functioning (FAD-GF), cohesiveness (PARQ), and conflict (IBQ) were assessed pre- and post-treatment. Treatment effects and the moderating effect of the number of parents in the home (single vs 2-parent families)., Results: Number of parents moderated treatment effects with effects ranging from trending to statistically significant for depression, family functioning, cohesion, and conflict. Among single parents, TOPS-TO reported better family functioning than TOPS-F and greater cohesion and less conflict than IRC. Among 2-parent families, TOPS-F reported less depression than IRC and less depression and greater cohesion than TOPS-TO. The effect of family composition was also noted within TOPS-TO and TOPS-F. In TOPS-F, 2-parent families reported less depression than single-parent families. In TOPS-TO single parents reported greater cohesion and better family functioning than 2-parent families., Conclusions: Findings support the TOPS intervention improves family outcomes, with differential effects noted for single vs 2-parent households. The TOPS-TO format appeared more beneficial for single-parent households, while TOPS-F was more beneficial for 2-parent households, highlighting the importance of considering family composition when determining the best treatment modality., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This scoping review aimed to summarize the existing knowledge base regarding depression and depressive symptoms in pediatric traumatic brain injury (TBI) and to identify gaps in the literature in an effort to guide future research., Methods: MEDLINE Ovid and PsycINFO Ovid databases were each searched by the authors using search terms intended to identify any original research study that examined depressive symptoms in children (ie, aged 0-18 years) with TBI., Results: A total of 14 published studies were included in the review. The studies included examined the prevalence of depression, risk factors associated with depression, and depression as a predictor of other TBI-related outcomes., Conclusion: Existing research suggests that depressive symptoms are more common in a TBI population than in a healthy or orthopedically injured population. Injury-related factors such as lesions in the brain and the presence of pain, as well as noninjury factors such as older age at injury and low socioeconomic status, may be predictive of depressive symptoms. Depression is likely a secondary outcome of pediatric TBI rather than a direct result of the injury itself. Overall, a relative dearth of research exists on this topic; thus, the review concludes by proposing future research directions.

Although there are several techniques to analyze diffusion-weighted imaging, any technique must be sufficiently sensitive to detect clinical abnormalities. This is especially critical in disorders like mild traumatic brain injury (mTBI), where pathology is likely to be subtle. mTBI represents a major public health concern, especially for youth under 15 years of age. However, the developmental period from birth to 18 years is also a time of tremendous brain changes. Therefore, it is important to establish the degree of age- and sex-related differences. Participants were children aged 8-15 years with mTBI or mild orthopedic injuries. Imaging was obtained within 10 days of injury. We performed tract-based spatial statistics (TBSS), deterministic tractography using Automated Fiber Quantification (AFQ), and probabilistic tractography using TRACULA (TRActs Constrained by UnderLying Anatomy) to evaluate whether any method provided improved sensitivity at identifying group, developmental, and/or sex-related differences. Although there were no group differences from any of the three analyses, many of the tracts, but not all, revealed increases of fractional anisotropy and decreases of axial, radial, and mean diffusivity with age. TBSS analyses resulted in age-related changes across all white matter tracts. AFQ and TRACULA revealed age-related changes within the corpus callosum, cingulum cingulate, corticospinal tract, inferior and superior longitudinal fasciculus, and uncinate fasciculus. The results are in many ways consistent across all three methods. However, results from the tractography methods provided improved sensitivity and better tract-specific results for identifying developmental and sex-related differences within the brain., (© 2017 Wiley Periodicals, Inc.)

Objective: To evaluate the effectiveness of Internet-based Interacting Together Everyday: Recovery After Childhood TBI (I-InTERACT) versus abbreviated parent training (Express) or access to online resources (internet resources comparison [IRC]) in improving parenting skills and decreasing behavior problems after early traumatic brain injury (TBI)., Method: In this randomized, controlled, clinical trial, 113 children 3 to 9 years old previously hospitalized for moderate to severe TBI were randomly assigned to receive Express (n = 36), I-InTERACT (n = 39), or IRC (n = 38). Express included 7 online parent skills sessions, and I-InTERACT delivered 10 to 14 sessions addressing parenting skills, TBI education, stress, and anger management. The 2 interventions coupled online modules with therapist coaching through a Health Insurance Portability and Accountability Act-compliant Skype link. The IRC group received access to online TBI and parent skills resources. Co-primary outcomes were blinded ratings of parenting skills and parent report of behavior problems and problem intensity on the Eyberg Child Behavior Inventory (ECBI). Outcomes were assessed before treatment and 3 and 6 months after treatment, with the latter constituting the primary endpoint., Results: The Express and I-InTERACT groups displayed higher levels of positive parenting at follow-up. Only the I-InTERACT group had lower levels of negative parenting at 6 months. The Express group had lower ECBI intensity scores than the IRC group. Baseline symptom levels moderated improvements; children in the Express and I-InTERACT groups with higher baseline symptoms demonstrated greater improvements than those in the IRC group. Changes in parenting skills mediated improvements in behavior in those with higher baseline symptoms., Conclusion: Brief online parent skills training can effectively decrease behavior problems after early TBI in children with existing behavioral symptoms. Clinical trial registration information-Internet-based Interacting Together Everyday, Recovery After Childhood TBI (I-InTERACT)-RRTC; http://clinicaltrials.gov/; NCT01214694., (Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Deficits in theory of mind (ToM) are common after neurological insult acquired in the first and second decade of life, however the contribution of large-scale neural networks to ToM deficits in children with brain injury is unclear. Using paediatric traumatic brain injury (TBI) as a model, this study investigated the sub-acute effect of paediatric traumatic brain injury on grey-matter volume of three large-scale, domain-general brain networks (the Default Mode Network, DMN; the Central Executive Network, CEN; and the Salience Network, SN), as well as two domain-specific neural networks implicated in social-affective processes (the Cerebro-Cerebellar Mentalizing Network, CCMN and the Mirror Neuron/Empathy Network, MNEN). We also evaluated prospective structure-function relationships between these large-scale neural networks and cognitive, affective and conative ToM. 3D T1- weighted magnetic resonance imaging sequences were acquired sub-acutely in 137 children [TBI: n = 103; typically developing (TD) children: n = 34]. All children were assessed on measures of ToM at 24-months post-injury. Children with severe TBI showed sub-acute volumetric reductions in the CCMN, SN, MNEN, CEN and DMN, as well as reduced grey-matter volumes of several hub regions of these neural networks. Volumetric reductions in the CCMN and several of its hub regions, including the cerebellum, predicted poorer cognitive ToM. In contrast, poorer affective and conative ToM were predicted by volumetric reductions in the SN and MNEN, respectively. Overall, results suggest that cognitive, affective and conative ToM may be prospectively predicted by individual differences in structure of different neural systems-the CCMN, SN and MNEN, respectively. The prospective relationship between cerebellar volume and cognitive ToM outcomes is a novel finding in our paediatric brain injury sample and suggests that the cerebellum may play a role in the neural networks important for ToM. These findings are discussed in relation to neurocognitive models of ToM. We conclude that detection of sub-acute volumetric abnormalities of large-scale neural networks and their hub regions may aid in the early identification of children at risk for chronic social-cognitive impairment., (© The Author (2017). Published by Oxford University Press.)

Purpose/objective: To describe the Teen Online Problem Solving-Teen Only (TOPS-TO) intervention relative to the original Teen Online Problem Solving-Family (TOPS-F) intervention, to describe a randomized controlled trial to assess intervention efficacy, and to report feasibility and acceptability of the TOPS-TO intervention. Research method and design: This is a multisite randomized controlled trial, including 152 teens (49 TOPS-F, 51 TOPS-TO, 52 IRC) between the ages of 11-18 who were hospitalized for a moderate to severe traumatic brain injury in the previous 18 months. Assessments were completed at baseline, 6-months post baseline, and 12-months post baseline. Data discussed include adherence and satisfaction data collected at the 6-month assessment (treatment completion) for TOPS-F and TOPS-TO., Results: Adherence measures (sessions completed, dropout rates, duration of treatment engagement, and rates of program completion) were similar across treatment groups. Overall, teen and parent reported satisfaction was high and similar across groups. Teens spent a similar amount of time on the TOPS website across groups, and parents in the TOPS-F spent more time on the TOPS website than those in the TOPS-TO group (p = .002). Parents in the TOPS-F group rated the TOPS website as more helpful than those in the TOPS-TO group (p = .05)., Conclusions/implications: TOPS-TO intervention is a feasible and acceptable intervention approach. Parents may perceive greater benefit from the family based intervention. Further examination is required to understand the comparative efficacy in improving child and family outcomes, and who is likely to benefit from each approach. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Objective: To examine the association of problem-solving with functioning in youth with traumatic brain injury (TBI)., Design: Cross-sectional evaluation of pretreatment data from a randomized controlled trial., Setting: Four children's hospitals and 1 general hospital, with level 1 trauma units., Participants: Youth, ages 11 to 18 years, who sustained moderate or severe TBI in the last 18 months (N=153)., Main Outcome Measures: Problem-solving skills were assessed using the Social Problem-Solving Inventory (SPSI) and the Dodge Social Information Processing Short Stories. Everyday functioning was assessed based on a structured clinical interview using the Child and Adolescent Functional Assessment Scale (CAFAS) and via adolescent ratings on the Youth Self Report (YSR). Correlations and multiple regression analyses were used to examine associations among measures., Results: The TBI group endorsed lower levels of maladaptive problem-solving (negative problem orientation, careless/impulsive responding, and avoidant style) and lower levels of rational problem-solving, resulting in higher total problem-solving scores for the TBI group compared with a normative sample (P<.001). Dodge Social Information Processing Short Stories dimensions were correlated (r=.23-.37) with SPSI subscales in the anticipated direction. Although both maladaptive (P<.001) and adaptive (P=.006) problem-solving composites were associated with overall functioning on the CAFAS, only maladaptive problem-solving (P<.001) was related to the YSR total when outcomes were continuous. For the both CAFAS and YSR logistic models, maladaptive style was significantly associated with greater risk of impairment (P=.001)., Conclusions: Problem-solving after TBI differs from normative samples and is associated with functional impairments. The relation of problem-solving deficits after TBI with global functioning merits further investigation, with consideration of the potential effects of problem-solving interventions on functional outcomes., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across recovery trajectories using latent class growth modeling (LCGM)., Method: A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups., Results: Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories., Conclusion: The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries.