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Despite growing research linking childhood traumatic brain injury (TBI) with reduced wellbeing, self-esteem, and psycho-social health, very few studies have examined self-esteem and its correlates in young adult survivors of childhood TBI. This very-long-term follow-up study evaluated self-esteem in 29 young adults with a history of childhood TBI (M time since injury = 13.84 years; SD = 0.74), and 10 typically developing controls (TDCs). All participants were originally recruited into a larger, longitudinal case-control study between 2007 and 2010. In the current follow-up study, both groups completed well-validated measures of self-esteem and mental health in young adulthood. Although group means for self-esteem did not significantly differ between TBI and TDC groups, a higher proportion of TBI participants rated their self-esteem in the clinical range (TBI group = 17%; TDC group = 0%). While self-esteem was not significantly associated with injury or pre-injury child or family characteristics, lower self-esteem was significantly correlated with greater concurrent feelings of loneliness (p = 0.007) and higher concurrent mood symptoms (p < 0.001).Our results suggest that social isolation and low mood may represent meaningful targets for psycho-social interventions to address poor self-worth in young adults with a history of childhood TBI.

Fatigue may be among the most profound and debilitating consequences of pediatric traumatic brain injury (TBI); however, neurostructural risk factors associated with post-injury fatigue remain elusive. This prospective study aimed to evaluate the independent value of susceptibility-weighted imaging (SWI) biomarkers, over-and-above known risk factors, to predict fatigue symptom severity in children with TBI. Forty-two children were examined with structural magnetic resonance imaging (sMRI), including a SWI sequence, within eight weeks post-injury. The PedsQL Multi-Dimensional Fatigue Scale (MFS) was administered 24 months post-injury. Compared with population expectations, the TBI group displayed significantly higher levels of general fatigue (Cohen d = 0.44), cognitive fatigue (Cohen d = 0.59), sleep/rest fatigue (Cohen d = 0.37), and total fatigue (Cohen d = 0.63). In multi-variate models adjusted for TBI severity, child demographic factors, and depression, we found that subacute volume of SWI lesions was independently associated with all fatigue symptom domains. The magnitude of the brain-behavior relationship varied by fatigue symptom domain, such that the strongest relationships were observed for the cognitive fatigue and total fatigue symptom scales. Overall, we found that total subacute volume of SWI lesions explained up to 24% additional variance in multi-dimensional fatigue, over-and-above known risk factors. The subacute SWI has potential to improve prediction of post-injury fatigue in children with TBI. Our preliminary findings suggest that volume of SWI lesions may represent a novel, independent biomarker of post-injury fatigue, which could help to identify high-risk children who are likely to benefit from targeted psychoeducation and/or preventive strategies to minimize risk of long-term post-injury fatigue.

BACKGROUND: Despite a well-established link between childhood traumatic brain injury (TBI) and elevated secondary attention-deficit/hyperactivity disorder (s-ADHD) symptomology, the neurostructural correlates of these symptoms are largely unknown. Based on the influential 'triple-network model' of ADHD, this prospective longitudinal investigation aimed to (i) assess the effect of childhood TBI on brain morphometry of higher-order cognitive networks proposed to play a key role in ADHD pathophysiology, including the default-mode network (DMN), salience network (SN) and central executive network (CEN); and (ii) assess the independent prognostic value of DMN, SN and CEN morphometry in predicting s-ADHD symptom severity after childhood TBI. METHODS: The study sample comprised 155 participants, including 112 children with medically confirmed mild-severe TBI ascertained from consecutive hospital admissions, and 43 typically developing (TD) children matched for age, sex and socio-economic status. High-resolution structural brain magnetic resonance imaging (MRI) sequences were acquired sub-acutely in a subset of 103 children with TBI and 34 TD children. Parents completed well-validated measures of ADHD symptom severity at 12-months post injury. RESULTS: Relative to TD children and those with milder levels of TBI severity (mild, complicated mild, moderate), children with severe TBI showed altered brain morphometry within large-scale, higher-order cognitive networks, including significantly diminished grey matter volumes within the DMN, SN and CEN. When compared with the TD group, the TBI group showed significantly higher ADHD symptomatology and higher rates of clinically elevated symptoms. In multivariable models adjusted for other well-established risk factors, altered DMN morphometry independently predicted higher s-ADHD symptomatology at 12-months post-injury, whilst SN and CEN morphometry were not significant independent predictors. CONCLUSIONS: Our prospective study find

Pediatric traumatic brain injury (TBI) can impact psycho-social functioning, including friendships and experiences of loneliness; however, few studies have explored associations between these factors and self-esteem. To address this gap, the objective of this study was to document inter-relationships between friendship quality, peer-related loneliness, and self-esteem 12 months post-injury. The sample in this prospective, longitudinal observational study consisted of 135 children, including 92 children with TBI (57 mild, 35 moderate-severe TBI) and 43 typically developing control (TDC) children. Children rated their friendship quality, loneliness, and self-esteem. Parents completed questionnaires measuring socioeconomic status and children's pre-injury functioning. At 12-month follow-up, ratings of friendship quality (perceived support and satisfaction with friendships), peer-related loneliness, and self-esteem were comparable between TBI and TDC participants. In mediation models, poorer quality friendships were associated with greater peer-related loneliness, and greater peer-related loneliness was related to reduced athletic and social self-esteem, at 12 months post-TBI. Loneliness with peers mediated the effects of both friendship support and friendship satisfaction on children's social self-esteem. Our preliminary findings suggest that regular monitoring of social interactions post-TBI might facilitate early identification of children who are likely to benefit from interventions targeting peer-related loneliness, which in turn may lower risk for poorer self-esteem.

Fatigue may be among the most profound and debilitating consequences of pediatric traumatic brain injury (TBI); however, neurostructural risk factors associated with post-injury fatigue remain elusive. This prospective study aimed to evaluate the independent value of susceptibility-weighted imaging (SWI) biomarkers, over-and-above known risk factors, to predict fatigue symptom severity in children with TBI. 42 children were examined with structural magnetic-resonance imaging (sMRI), including a SWI sequence, within 8-weeks post-injury. The PedsQL Multi-Dimensional Fatigue Scale (MFS) was administered 24-months post-injury. Compared to population expectations, the TBI group displayed significantly higher levels of general fatigue (Cohen's d = 0.44), cognitive fatigue (Cohen's d = 0.59), sleep/rest fatigue (Cohen's d = 0.37), and total fatigue (Cohen's d = 0.63). In multi-variate models adjusted for TBI severity, child demographic factors and depression, sub-acute volume of SWI lesions was independently associated with all fatigue symptom domains. The magnitude of the brain-behavior relationship varied by fatigue symptom domain, such that the strongest relationships were observed for the cognitive fatigue and total fatigue symptom scales. Overall, we found that total volume of SWI lesions explained up to 24% additional variance in multi-dimensional fatigue, over-and-above known risk factors. SWI has potential to improve prediction of post-injury fatigue in children with TBI. Our preliminary findings suggest that volume of SWI lesions may represent a novel, independent biomarker of post-injury fatigue scores, which could help to identify high-risk children who are likely to benefit from targeted psychoeducation and/or preventive strategies to minimize risk of persisting fatigue.

This prospective, longitudinal case-control study examined global and domain-specific aspects of self-esteem 6-months following pediatric traumatic brain injury (TBI) and evaluated the contribution of injury-related factors and parent mental health to child self-esteem. Participants included 103 children with mild-severe TBI representing consecutive admissions to the emergency department of the Royal Children's Hospital, Melbourne, Australia. Forty-three age-and-sex matched typically developing controls were recruited for comparison. Information regarding injury characteristics including age at injury and clinical indicators of TBI severity were collected for participants at recruitment, with research magnetic resonance imaging conducted 2-8 weeks later. At 6 months post-injury, children rated their global and domain-specific self-esteem (Harter Self-Perception Profile for Children), and ratings of parent mental health were collected (General Health Questionnaire). Self-esteem for behavioural and academic domains was significantly poorer for children with TBI relative to TD children. In the TBI group, higher child-rated scores of global and domain-specific aspects of self-esteem were associated with more severe TBI, presence of frontal neuropathology, younger age at injury, and lower parental symptoms of anxiety/insomnia. Given the psychological status of parents represents a potentially modifiable risk factor, it may form the target of clinical interventions designed to bolster child self-esteem following pediatric TBI.

Embedding digital technologies in healthcare has the potential to streamline and personalize medical care. However, healthcare systems are often fragmented, and therefore achieving a truly integrated digital health program can be challenging. To promote a streamlined, evidence-based approach to implementing digital health solutions in a healthcare system, the Murdoch Children's Research Institute (MCRI) established the Digital Health Translation and Implementation Program (DHTI) bringing together clinicians, researchers and digital health experts. From the program commencement, frontline clinical innovators have collaborated with DHTI team members to develop and implement digital solutions to address pain-points in the healthcare system. Throughout this program, important lessons have been learnt relating to the development, evaluation and implementation of digital solutions in the healthcare system. This paper explores these lessons and makes recommendations for the successful implementation of digital health solutions in healthcare systems under five main categories: (1) design and usability, (2) stakeholder engagement and uptake, (3) project management and resourcing, (4) process and implementation, and (5) evaluation. Recommendations suggested here are designed to support future healthcare-based digital health programs to maximize the impact digital solutions can have on the healthcare system and patients.

BACKGROUND: . Demographic and environmental factors can affect child recovery after traumatic brain injury (TBI); however, little is known about their role in predicting child perceptions of competence (i.e., subjective judgments of ability or a sense of adequacy). OBJECTIVES: . This prospective, cohort study examined the contribution of participant sex, age at assessment, socioeconomic status, parent-reported change in academic performance post-injury, and the quality of a child's relationship with their family (i.e., family affective involvement, intimacy, integration, and the nature of family roles) to child perceptions of global and academic competence 12 months after pediatric TBI. METHODS: . Participants included 127 children, 84 with a TBI (53 mild, 31 moderate-severe TBI; injury age: 5-15 years) and 43 age-matched typically developing (TD) controls. Children rated their perceptions of global and academic competence and degree of family intimacy and integration. Parents completed questionnaires measuring socioeconomic status, family affective involvement, and the nature of family roles. Parents also indicated whether they perceived a change in their child's post-injury academic performance. RESULTS: . Child perceptions of academic competence were significantly lower for children with moderate-severe TBI relative to TD children. In contrast, child perceptions of global competence were comparable between TBI and TD control groups. Socioeconomic status, age at assessment, parent-reported relative change in academic performance post-TBI, and family roles were associated with child perceptions of academic competence. Degree of family integration was the sole predictor of child perceptions of global competence. CONCLUSIONS: . Child perceptions of academic competence are vulnerable to the effects of moderate-severe TBI, particularly among older children and those from low socioeconomic backgrounds. Well-defined family roles for handling family functions and greater

AIM: To investigate whether a digital sleep intervention improves child and care giver sleep and psychosocial outcomes. METHODS: A total of 120 families with children aged 2-13 years, reporting moderate to severe child behavioural sleep problems, were recruited from a hospital sleep clinic waitlist or the community. Children from non-English speaking families, with known intellectual disability (IQ < 70) or severe medical problems excluded. Tailored behavioural sleep strategies were delivered to primary care givers via a smart phone app and complementary website. Eligible families completed a baseline questionnaire and child 'sleep check' then received the digital sleep intervention for 5 weeks, and then completed a post questionnaire. OUTCOMES: care giver report of child sleep as no/mild versus moderate/severe problem over past month (primary outcome); problem child sleep patterns (Brief Infant Sleep Questionnaire or Child Sleep Habits Questionnaire), child temperament, care giver mental health (Kessler 6), care giver sleep, health service use for their child's sleep and time off work/activities to access services. RESULTS: At follow up, care givers reported fewer moderate/severe child sleep problems (84.6-40.7%), improved problem child sleep patterns, better temperament and improved care giver mental health. Care giver sleep quality and quantity remained unchanged. Health service use (averaged over a 6-month period pre- and post-intervention) fell from 18.9% pre- to 14.1% post-intervention. CONCLUSION: A digital sleep intervention appears promising in improving sleep in children with moderate/severe behavioural sleep problems, and care giver mental health. It may be a useful alternative to face-to-face management of behavioural sleep problems.

Background Humans are by nature a social species, with much of human experience spent in social interaction. Unsurprisingly, social functioning is crucial to well-being and quality of life across the lifespan. While early intervention for social problems appears promising, our ability to identify the specific impairments underlying their social problems (eg, social communication) is restricted by a dearth of accurate, ecologically valid and comprehensive child-direct assessment tools. Current tools are largely limited to parent and teacher ratings scales, which may identify social dysfunction, but not its underlying cause, or adult-based experimental tools, which lack age-appropriate norms. The present study describes the development and standardisation of Paediatric Evaluation of Emotions, Relationships, and Socialisation (PEERS®), an iPad-based social skills assessment tool. Methods The PEERS project is a cross-sectional study involving two groups: (1) a normative group, recruited from early childhood, primary and secondary schools across metropolitan and regional Victoria, Australia; and (2) a clinical group, ascertained from outpatient services at The Royal Children's Hospital Melbourne (RCH). The project aims to establish normative data for PEERS®, a novel and comprehensive app-delivered child-direct measure of social skills for children and youth. The project involves recruiting and assessing 1000 children aged 4.0-17.11 years. Assessments consist of an intellectual screen, PEERS® subtests, and PEERS-Q, a self-report questionnaire of social skills. Parents and teachers also complete questionnaires relating to participants' social skills. Main analyses will comprise regression-based continuous norming, factor analysis and psychometric analysis of PEERS® and PEERS-Q. Ethics and dissemination Ethics approval has been obtained through the RCH Human Research Ethics Committee (34046), the Victorian Government Department of Education and Early Childhood Development (

Theory of Mind (ToM) forms an integral component of socially skilled behavior, and is critical for attaining developmentally appropriate goals. The protracted development of ToM is mediated by increasing connectivity between regions of the anatomically distributed 'mentalizing network', and may be vulnerable to disruption from pediatric traumatic brain injury (TBI). The present study aimed to evaluate the post-acute effects of TBI on first-order ToM, and examine relations between ToM and both local and global indices of macrostructural damage detected using susceptibility-weighted imaging (SWI). 104 children and adolescents with TBI and 43 age-matched typically developing (TD) controls underwent magnetic resonance imaging including a susceptibility-weighted imaging (SWI) sequence 2-8 weeks post-injury and were assessed on cognitive ToM tasks at 6-months after injury. Compared to TD controls and children with mild-moderate injuries, children with severe TBI showed significantly poorer ToM. Moreover, impairments in ToM were related to diffuse neuropathology, and parietal lobe lesions. Our findings support the vulnerability of the immature social brain network to disruption from TBI, and suggest that global macrostructural damage commonly associated with traumatic axonal injury (TAI) may contribute to structural disconnection of anatomically distributed regions that underlie ToM. This study suggests that SWI may be a valuable imaging biomarker to predict outcome and recovery of social cognition after pediatric TBI. Copyright © 2014 Elsevier Ltd. All rights reserved.

Childhood and adolescence are critical periods for maturation of neurobiological processes that underlie complex social and emotional behavior including Theory of Mind (ToM). While structural correlates of ToM are well described in adults, less is known about the anatomical regions subsuming these skills in the developing brain or the impact of cerebral insult on the acquisition and establishment of high-level social cognitive skills. This study aimed to examine the differential influence of age-at-insult and brain pathology on ToM in a sample of children and adolescents with traumatic brain injury (TBI). Children and adolescents with TBI (n=112) were categorized according to timing of brain insult: (i) middle childhood (5-9 years; n=41); (ii) late childhood (10-11 years; n=39); and (iii) adolescence (12-15 years; n=32) and group-matched for age, gender, and socioeconomic status to a typically developing (TD) control group (n=43). Participants underwent magnetic resonance imaging including a susceptibility-weighted imaging (SWI) sequence 2-8 weeks postinjury and were assessed on a battery of ToM tasks at 6- and 24-months after injury. Results showed that for adolescents with TBI, social cognitive dysfunction at 6- and 24-months postinjury was associated with diffuse neuropathology and a greater number of lesions detected using SWI. In the late childhood TBI group, we found a time-dependent emergence of social cognitive impairment, linked to diffuse neuropathology. The middle childhood TBI group demonstrated performance unrelated to SWI pathology and comparable to TD controls. Findings indicate that the full extent of social cognitive deficits may not be realized until the associated skills reach maturity. Evidence for brain structure-function relationships suggests that the integrity of an anatomically distributed network of brain regions and their connections is necessary for the acquisition and establishment of high-level social cognitive skills.Copyright © 2014 W

Introduction: Traumatic brain injury (TBI) sustained during childhood can cause difficulties in a wide range of physical, neurological, cognitive, social and functional domains. However, the ability of health professionals and researchers to accurately predict the outcome of pediatric TBI remains limited. The advent of advanced neuroimaging techniques shows some promise in improving outcome prediction, as they contribute to greater sensitivity in characterizing intracranial lesions underlying many cognitive and functional deficits. In this study, the relationship between lesions identified on susceptibility weighted imaging (SWI) and cognitive and functional outcomes was investigated following childhood TBI. Method(s): Participants between 5 and 14 years of age with varying levels of TBI severity (mild, mild complicated, moderate, severe, n = 106) underwent susceptibility weighted scanning on average 1-month post-injury and completed an assessment of intellectual functioning, processing speed, and behavioral and adaptive skills 6-month post-injury. Result(s): More severe TBI was generally associated with poorer intellectual functioning, greater behavioral problems and lower adaptive functioning. Number and volume of SWI lesions were significantly correlated with clinical outcome variables including Glasgow Coma Score (GCS), surgical intervention, length of hospital stay and length of intubation, as well as with intellectual functioning. Together, SWI and GCS accounted for a significant, though small, proportion of the variance in intellectual quotient (IQ). Conclusion(s): SWI is a sensitive technique for detecting brain lesions at all TBI severity levels and shows promise in contributing to prediction of cognitive outcomes in the initial stages post-injury. © 2012 Elsevier Ltd.

Introduction Novel neuroimaging techniques may have advantages over conventional MRI and CT in terms of reduced radiation exposure and greater sensitivity to detect brain injury. Susceptibility-weighted imaging (SWI) shows promise because of its heightened ability to detect hemorrhagic lesions; however, its use in pediatric TBI and clinical potential remain uncertain. Methods The ability of three imaging techniques (acute CT, conventional magnetic resonance imaging - cMRI, SWI) to reveal traumatic brain lesions was compared in 76 children (mean age 10.24, SD = 2.50 years, range 5.75 - 14.67 years) with varying levels (mild, mild complicated, moderate, severe) of traumatic brain injury (TBI). A non-contrast CT scan was obtained according to standard head trauma hospital guidelines during the Emergency Department visit. MR images, including SWI, were acquired as soon as possible after consent to the study on a 3T Siemens Trio scanner using a 32 channel matrix head coil. All scans were coded for presence or absence, extent, and type of traumatic brain lesions by two experts blind to the clinical details at presentation and to the CT scan results. Number and volume of SWI lesions were obtained using manual segmentation and correlated with standard clinical outcomes. Results Glasgow Coma Score was 13-15 in 54 patients (71%), 9-12 in 13 patients (17%) and < 8 in 9 patients (12%). CTs were completed in the ED; cMRI and SWI were completed at a mean of 36.11 (SD = 15.75) days post-injury. Detection of any lesions occurred in CT scan in 68%, cMRI in 54%, SWI in 86% of cases, and SWI detected additional lesions 30% of the time compared to CT and cMRI. Of note, there were 6 cases (18.9%) where only SWI detected lesions and all were in patients with mild TBI as defined by GCS 13 (1 case), 14 (3 cases), 15 (2 cases). In total, SWI was the most sensitive modality in 47.2% of cases, and more sensitive than CT, but at least as sensitive as cMRI in 21 cases (58.3%). An important obse