Michael W. Kirkwood

Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population

Athletic concussion is a growing focus of attention for pediatricians. Although numerous literature reviews and clinical guidelines are now available pertaining to athletic concussion, few have focused on the pediatric athlete in particular. Sport-related concussions occur relatively frequently in children and adolescents, and primary health care providers are often responsible for coordinating clinical management. Here we summarize the scientific literature pertinent to the care of young athletes. We examine how concussion affects younger and older athletes differently at biomechanical, pathophysiological, neurobehavioral, and contextual levels. We also discuss important issues in clinical management, including preparticipation assessment, concussion evaluation and recovery tracking, and when and how to return pediatric athletes to play sports. We also briefly cover non–sport-related interventions (eg, school support). With proper management, most children and adolescents sustaining a sport-related concussion can be expected to recover fully.

Social problem-solving skills in children with traumatic brain injury: long-term outcomes and prediction of social competence.

The effects of childhood traumatic brain injury (TBI) on social problem-solving were examined in 35 children with severe TBI, 40 children with moderate TBI, and 46 children with orthopedic injuries (OI). The children were recruited prospectively following injuries that occurred between 6 and 12 years of age. They were followed longitudinally, and ranged from 9 to 18 years of age at the time of the current study, which occurred on average 4 years post injury. They were administered a semi-structured interview used in previous research on social problem-solving to assess the developmental level of their responses to hypothetical dilemmas involving social conflict. Children in the severe TBI group defined the social dilemmas and generated alternative strategies to solve those dilemmas at the same developmental level as did children in the OI group. However, they articulated lower-level strategies as the best way to solve the dilemmas and used lower-level reasoning to evaluate the effectiveness of the strategies. After controlling for group membership, race, socioeconomic status, IQ, and age, childrens social problem-solving, and particularly the developmental level of their preferred strategies for resolving conflicts, predicted parents ratings of childrens social skills, peer relationships, aggressive behavior, and academic performance. The findings indicate that children with severe TBI demonstrate selective, long-term deficits in their social problem-solving skills that may help to account for their poor social and academic outcomes.

Visual-spatial skills in children after open-heart surgery

ABSTRACT. This study was part of a randomized clinical trial comparing the central nervous system effects of the two vital organ‐support methods used in infant cardiac surgery: total circulatory arrest and low‐flow cardiopulmonary bypass. The extent to which visual‐spatial deficits are (1) associated with surgical and perioperative variables, (2) attributable to visual‐perceptual, motor control, or metacognitive deficits, and (3) associated with adaptive difficulties at home or school was evaluated. The subjects were 155 8‐year‐old children with D‐transposition of the great arteries who underwent the arterial switch operation before 3 months of age. As part of a comprehensive evaluation, the Rey‐Osterrieth Complex Figure (ROCF) was administered. ROCF copy productions were classified as having a Basal Organization Level of 1 (low) or 2 or greater. A five‐category clinical rating was also assigned. More than half of the children in the cohort (52%) had copy productions scored at Level 1, more than twice the expected frequency. The risk of having a low score was not associated with vital organ support method or other surgical variables. On the basis of comparisons of the relative fits of nested logistic regression models, poor visual‐perceptual abilities were more predictive of having a Level 1 score than either motor control or metacognitive deficits. Children with poor copy production scores had lower mathematics scores, but not lower reading scores or poorer parent and teacher ratings of adaptive competence. The percentage of children receiving remedial school services was associated with ROCF clinical rating, ranging from 58% in the worst category to 8% in the best category. Visual‐spatial deficits are common among children after infant heart surgery and seem to reflect visual‐perceptual rather than motor control or metacognitive deficits. In addition, these deficits do not seem to be clearly associated with the intraoperative methods or postoperative events evaluated. J Dev Behav Pediatr 24:169‐179, 2003. Index terms: congenital heart disease, visual‐spatial skills, transposition of the great arteries, Rey‐Osterrieth Complex Figure.

Evaluation of the Standardized Assessment of Concussion in a Pediatric Emergency Department

OBJECTIVE: The Standardized Assessment of Concussion (SAC) is a validated tool for identifying the effects of mild traumatic brain injury (mTBI). Previous research focused on sport-related sideline evaluation of adolescents and adults. Our goal was to evaluate performance of the SAC among subjects with and without head injury in a pediatric emergency department (ED). METHODS: This was an observational study of children 6 to 18 years of age who presented to an ED with blunt head injury (case-patients) or minor extremity injury (controls). SAC and graded-symptom-checklist scores were compared. American Academy of Neurology concussion grades, presence of loss of consciousness and posttraumatic amnesia were also compared with SAC and graded-symptom-checklist scores among case-patients. RESULTS: Three hundred forty-eight children were enrolled. SAC scores trended lower (greater cognitive deficits) for case-patients compared with controls but did not reach significance. Graded-symptom-checklist scores were significantly higher among case-patients. Presence of altered mental status magnified this effect. There was no correlation between SAC scores and other indicators of mTBI. There was a positive correlation between graded-symptom-checklist scores and posttraumatic amnesia and American Academy of Neurology concussion grade. CONCLUSIONS: The graded symptom checklist reliably identified mTBI symptoms for all children aged 6 years and older. SAC scores tended to be lower for case-patients compared with controls but did not reach significance. Patients with altered mental status at the time of injury manifest an increased number and severity of symptoms. Additional research into strategies to identify cognitive deficits related to mTBI and classify mTBI severity in children is needed.

Prevalence and correlates of depressive symptoms following traumatic brain injuries in children.

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of childrens neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to childrens verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.

The Value of the WISC-IV Digit Span Subtest in Detecting Noncredible Performance during Pediatric Neuropsychological Examinations

In adult populations, research on methodologies to identify negative response bias has grown exponentially in the last two decades. Far less work has focused on methods appropriate for children. Although several recent studies have demonstrated the appropriateness of using stand-alone symptom validity tests with younger populations, a near absence of pediatric work has investigated embedded validity indicators. The present study examined the classification value of several scores derived from the WISC-IV Digit Span subtest. The sample consisted of 274 clinically referred mild traumatic brain injury patients aged 8 through 16 years. Fourteen percent of the participants failed both the Medical Symptom Validity Test and Test of Memory Malingering, which was used as the criterion for noncredible effort. For age-corrected scaled scores, a score of ≤5 resulted in the optimal cut-score, yielding sensitivity of 51% and specificity of 96%. For Reliable Digit Span, the optimal cut-score was ≤6, with sensitivity of 51% and specificity of 92%. Although only moderately sensitive, Digit Span scores are likely to have good utility in identifying noncredible performance in relatively high-functioning older children and adolescents. Indeed, classification statistics produced in this pediatric sample compare favorably with those produced in many real-world adult patients.

The implications of symptom validity test failure for ability-based test performance in a pediatric sample.

If an examinee exerts inadequate effort to perform well during a psychological or neuropsychological exam, the resulting data will represent an inaccurate representation of the individuals true abilities and difficulties. In adult populations, methodologies to identify noncredible effort have grown exponentially in the last 2 decades. Though a comparatively modest amount of work has focused on tools to identify noncredible effort in pediatric populations, recent research has demonstrated that children can consistently pass several stand-alone symptom validity tests (SVTs) using cutoffs established with adults. However, no identified studies have examined the implications of pediatric SVT failure for ability-based test performance. The current sample consisted of 276 children aged 8-16 years referred consecutively for outpatient clinical neuropsychological consultation following mild traumatic brain injury (TBI). An earlier subgroup of this same case series that also included 17-year-olds was presented in Kirkwood and Kirk (2010). Nineteen percent of the current sample performed below the actuarial cutoff on the Medical Symptom Validity Test (MSVT). No background or injury-related variable differentiated those who passed from those who failed the MSVT. Performance on the MSVT was correlated significantly with performance on all ability-based tests and explained 38% of the total ability-based test variance. Participants failing the MSVT performed significantly worse on nearly all neuropsychological tests, with large effect sizes apparent across most tests. The results provide compelling evidence that practitioners should add objective SVTs to the evaluation of school-aged youth, even when secondary gain issues might not be readily apparent and particularly following mild TBI.

Performance on the Test of Memory Malingering (TOMM) among a large clinic-referred pediatric sample

Growing concerns with suboptimal effort in pediatric populations have led clinicians to investigate the utility of symptom validity tests (SVT) among children and adolescents. Performance on the Test of Memory Malingering (TOMM) was analyzed among a clinical sample of individuals ranging in age from 5 through 16 years. The 101 patients were referred for a variety of learning, developmental, psychiatric, and neurological concerns. All children were administered the TOMM as part of a clinical neuropsychological evaluation. Within the sample, 4 patients did not meet the adult cutoff criteria for passing the TOMM. Three of the 4 patients also demonstrated suboptimal effort on another SVT. Results revealed statistically significant correlations between TOMM performance and age, intelligence, and memory. Despite these correlations, 97 out of the 101 performed at or above the adult cutoff score. The findings suggest that children perform similarly to adults on the TOMM and that the TOMM is appropriate for use with pediatric clinical populations as young as 5 years.

Acute concussion symptom severity and delayed symptom resolution

BACKGROUND AND OBJECTIVES: Up to 30% of children who have concussion initially evaluated in the emergency department (ED) display delayed symptom resolution (DSR). Greater initial symptom severity may be an easily quantifiable predictor of DSR. We hypothesized that greater symptom severity immediately after injury increases the risk for DSR. METHODS: We conducted a prospective longitudinal cohort study of children 8 to 18 years old presenting to the ED with concussion. Acute symptom severity was assessed using a graded symptom inventory. Presence of DSR was assessed 1 month later. Graded symptom inventory scores were tested for association with DSR by sensitivity analysis. We conducted a similar analysis for post-concussion syndrome (PCS) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Potential symptoms characteristic of DSR were explored by using hierarchical cluster analysis. RESULTS: We enrolled 234 subjects; 179 (76%) completed follow-up. Thirty-eight subjects (21%) experienced DSR. Initial symptom severity was not significantly associated with DSR 1 month after concussion. A total of 22 subjects (12%) had PCS. Scores >10 (possible range, 0–28) were associated with an increased risk for PCS (RR, 3.1; 95% confidence interval 1.2–8.0). Three of 6 of the most characteristic symptoms of DSR were also most characteristic of early symptom resolution. However, cognitive symptoms were more characteristic of subjects reporting DSR. CONCLUSIONS: Greater symptom severity measured at ED presentation does not predict DSR but is associated with PCS. Risk stratification therefore depends on how the persistent symptoms are defined. Cognitive symptoms may warrant particular attention in future study. Follow-up is recommended for all patients after ED evaluation of concussion to monitor for DSR.

Sources of poor performance on the Rey-Osterrieth Complex Figure Test among children with learning difficulties: a dynamic assessment approach.

A dynamic assessment approach was used to examine the source of poor performance on the Rey–Osterrieth Complex Figure Test (ROCF) among 202 school-age children referred for learning difficulties. The ROCF was administered in the standard format and then in a structured format that highlighted the designs organizational framework. Manipulating encoding in this way improved recall to at least age-level for the majority of children. Those children who did not benefit from the structured format had relatively poor visual organizational skills. For most children with learning problems, poor ROCF performance stems from metacognitive difficulties; for a minority, the source appears to be more perceptual. A dynamic assessment procedure can enhance the diagnostic utility of the ROCF for children.