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.

Growing recognition and concerns of non-credible performance in pediatric populations have led clinicians to investigate the utility of performance and symptom validity tests (PVT/SVTs) among children and adolescents. Yet current research has indicated that a minority of clinicians routinely utilize a free-standing PVT in pediatric neuropsychological evaluations. The current article investigates the rationale for using PVT/SVTs, and the impact that failure of such exams have on other neurocognitive tests. A review of common adult PVTs and their appropriateness for use with specific pediatric clinical populations is presented, as well as empirical evidence for evaluating embedded validity indicators. The limited literature on SVTs with youth is also reviewed and provides additional insight into symptom exaggeration. There are various reasons children would provide noncredible performance, many of which are different from adults. A review of how the clinician should handle this behavior in pediatric evaluations is provided and what patient populations may present with a higher base rate of failure. Finally, various approaches are offered on how to explain these results to children and their caregivers.

To evaluate the effects of the Lystedt Law on emergency department (ED) utilization for concussion in New York.

Objective: To evaluate the effects of the Lystedt Law on emergency department (ED) utilization for concussion in New York. Background: To address concussion in youth sports, the first Lystedt Law was passed in 2009, and by 2014, one existed in each US state. Previous studies have shown increased healthcare utilization for sports-related concussion (SRC) corresponding with passage of the Lystedt Laws, however no study has examined data past 2012. Design/Methods: We conducted a retrospective analysis using the New York State Department of Health SPARCS database. Our study sample included 5.2 million patients aged 12–18 who presented to the ED between 1/1/2005 and 12/31/2014. We examined trends in the prevalence of ED utilization for concussion, and trends in imaging ordered during concussion workup. Prevalence of ankle injury was used as a static control. Concussion and ankle injury were identified by ICD-9 code; sports-related injuries were specified by E-code; imaging studies were identified by CPT code. Results: From 2005 to 2014, there was a 1.4% increase in ED utilization for concussion and a 0.53% increase for SRC, with the greatest increases coming from 2008–2010. Both sexes followed similar trends. During this period, ankle injury and sports-related ankle injury decreased in prevalence by 0.47% and 0.13%, respectively. Additionally, prevalence of imaging for SRC also decreased from 53.3% to 41%. All p-values for trend were less than 0.001. Conclusions: The prevalence of ED visits for concussion and SRC visits increased, consistent with findings from other studies. The greatest increases in prevalence came before the passage of the New York Lystedt Law in 2011, suggesting that other factors, such as general public awareness, may have driven these changes. Additionally, despite increasing ED utilization for concussion, the prevalence of head imaging during emergency evaluation for concussion decreased, suggesting that providers are became familiar with appropriate management of SRC. Disclosure: Dr. Baker has nothing to disclose. Dr. Kulick has nothing to disclose. Dr. Boehme has nothing to disclose. Dr. Noble has received personal compensation for activities with St. Barnabas Hospital.

The primary aim of this study was to characterize parent- and youth-reported health-related quality of life (HRQOL) for youth experiencing persistent symptoms following mild traumatic brain injury (mTBI). The youth in the current study were participating in a longitudinal project examining neuropsychological consultation as an intervention for persistent symptoms after mTBI. Participants included 71 youth aged 8 to17 years old who had sustained mild head injuries 2 to 12 months prior to enrollment and who were referred clinically to an outpatient pediatric concussion program because of concerns about persistent problems. Parents and children completed the PedsQL over the phone at the time of enrollment. Child- and parent-reported HRQOL was significantly worse than for other pediatric populations with a variety of chronic health conditions. HRQOL was not associated with injury-related factors. One important novel finding was that families involved in litigation reported significantly lower HRQOL than families not involved in litigation. Providers would benefit from screening for involvement in litigation early on. Children who experience persistent symptomatology and impaired functioning following mTBI are likely to benefit most from early intervention and reassurance de-emphasizing injury-related factors and focusing on cognitive–behavioral treatment aimed at improving adaptive coping, pain management, and stress reduction.

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.

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.

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.

OBJECTIVE:To examine the efficacy of a one-time neuropsychological consultation as an intervention for youth with persistent postconcussive symptoms following mild traumatic brain injury.STUDY DESIGN:Using a prospective interrupted time series design, we enrolled 80 patients aged 8-17 years referred consecutively for clinical neuropsychological consultation. Patients needed to have sustained injury between 2 and 12 months prior to enrollment. Parent and child postconcussive symptom ratings were used as the primary outcome measures and were collected at 6 time points, 3 before the neuropsychological consultation and 3 after. Repeated measure ANOVA was used to estimate the magnitude of change in symptom ratings before and after the neuropsychological intervention.RESULTS:The decrease in symptoms for the week prior to consultation was nonsignificant by both child (P = .63) and parent (P = .19) report. In contrast, for both reporters, the decrease in symptoms at 1 week and 3 months postconsultation was significant (P < .0001). The difference in reported change was also significant when comparing the week before the intervention to the 3 months after (child: P < .0001; parent: P = .0009).CONCLUSIONS:Postconcussive symptoms decreased significantly following the neuropsychological consultation. The primary limitation of the study is that it lacked randomization and a control group. The results warrant further research into the benefits of neuropsychological consultation after mild traumatic brain injury and provide justification for clinical providers to consider referring to neuropsychologists in the face of persistent postconcussive symptoms.

Abstract 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.

Inadequate effort during neuropsychological examination results in inaccurate representations of an individual's true abilities and difficulties. As such, performance validity tests (PVTs) are strongly recommended as standard practice during adult-based evaluations. One concern with using PVTs with children is that failure reflects immature cognitive ability rather than non-credible effort. The current study examined performance on the Medical Symptom Validity Test (MSVT) in two large pediatric clinical samples with strikingly different neuropsychological profiles: (1) mild traumatic brain injury (mTBI; n = 510) and (2) fetal alcohol spectrum disorder (FASD; n = 120). Despite higher IQ scores and reading ability, the mTBI group performed significantly worse than the FASD group on all effort indices. Sixteen percent of the mTBI group failed the MSVT, whereas only 5% of the FASD group did. Our findings support the idea that the MSVT measures effort, not ability, in most cases and help to justify incorporating PVTs into pediatric neuropsychological batteries.

This study aimed to characterize preinjury emotional-behavioral functioning in pediatric patients with lingering problems after mild traumatic brain injury (TBI). The clinical case series design included 278 patients 8-17 years old. Parents retrospectively rated children's preinjury emotional-behavioral functioning on a broadband questionnaire. The rate of clinically significant preinjury anxiety was elevated compared with national norms. The number of previous TBIs was associated with clinically significant preinjury externalizing problems, suggesting a link between externalizing disorders and mild TBI exposure. Premorbid emotional-behavioral difficulties may play an important role in the establishment or maintenance of lingering symptoms after pediatric mild TBI.

In adult populations, research on methodologies to identify noncredible performance and exaggerated symptoms during neuropsychological evaluations has grown exponentially in the past two decades. Far less work has focused on methods appropriate for children. Although several recent studies have used stand-alone performance validity tests with younger populations, a near absence of pediatric work has investigated other indices to identify response bias. The present study examined the relationship between the validity scales from the self-report Behavior Assessment System for Children, Second Edition (BASC-2) and performance on the Medical Symptom Validity Test (MSVT), a stand-alone performance validity test. The sample consisted of 274 clinically referred patients with mild traumatic brain injuries aged 8 through 17 years. Fifty patients failed the MSVT based on actuarial criteria. The majority of these patients (92%) provided valid self-report BASC-2 profiles, with only three patients (6%) producing an invalid profile due to an elevated F index. Analysis of valid/invalid self-report BASC-2 profiles and MSVT pass/fail did not reveal a significant relationship ( p = 0.471, two-tailed Fisher’s exact test). These findings suggest that performance validity tests like the MSVT provide substantively different information about the validity of a neuropsychological profile than that provided by the self-report validity scales of the BASC-2.

The Rey 15-Item Test (FIT) is a performance validity test commonly used in adult neuropsychological assessment. FIT classification statistics across studies have been variable, so a recognition trial was created to enhance the measure (Boone, K. B., Salazar, X., Lu, P., Warner-Chacon, K., & Razani, J. (2002). The Rey 15-Item recognition trial: A technique to enhance sensitivity of the Rey 15-Item Memorization Test. Journal of Clinical and Experimental Neuropsychology, 24(5), 561-573.). The current study assessed the utility of the FIT and recognition trial in a pediatric mild traumatic brain injury sample (N=319, M=14.57 years). All participants were administered the FIT and recognition trial as part of an abbreviated clinical neuropsychological evaluation. Failure on the Medical Symptom Validity Test was used as the criterion for noncredible effort. Fifteen percent of the sample met the criterion. The traditional adult cutoff score of<9 on the FIT recall trial yielded excellent specificity (98%), but very poor sensitivity (12%). When the recognition trial was utilized, a total score of<26 resulted in the best combined cutoff score (sensitivity=55%, specificity=91%). Results indicate that the FIT with recognition trial may be useful in the assessment of noncredible effort with children and adolescents, at least among relatively high-functioning populations.

In adult populations, embedded performance validity indicators are well established, as they are time efficient, resistant to coaching, and allow for more continuous monitoring of effort than standalone measures. Although several recent studies have demonstrated the appropriateness of using standalone validity tests with school-age children, a paucity of pediatric work has examined embedded indicators. The present study investigated the value of a simple automatized sequences task to detect performance invalidity in 439 clinically referred patients with mild head injury aged 8 through 17 years. Sixteen percent of the participants failed the Medical Symptom Validity Test (MSVT). Thirteen percent failed the MSVT and also performed below established cutoffs on either the Test of Memory Malingering or Wechsler Digit Span subtest. The group classified as providing invalid data performed significantly worse than the group passing the MSVT across all sequencing conditions. Sensitivity and specificity for the total time on the sequencing task compared favorably to data produced for many respected adult-based embedded indicators (i.e., sensitivity around 50% when specificity ≥ 90%). Classification statistics for any embedded performance validity test can be expected to be worse in more severely affected populations; however, the current sequencing task appears to have value in detecting invalid performance in relatively high-functioning older children and adolescents. The fact that the task takes less than a couple of minutes to administer makes it especially appealing.

BACKGROUND:A minority of pediatric patients who have mild traumatic brain injury (mTBI) report persistent postconcussive symptoms. In adults, failure on validity tests, which help to detect exaggerated or feigned problems, is associated with symptom complaints. No pediatric studies have examined the relationship between validity test performance and symptom report. We hypothesized that children failing a validity test would report significantly more postconcussive symptoms than those passing.METHODS:Using a consecutive clinical case series design, we examined 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mTBI. Participants were administered a validity test (Medical Symptom Validity Test; MSVT) and completed a graded symptom scale as part of a neuropsychological battery.RESULTS:A total of 23 participants (12%) failed the MSVT. The Fail group endorsed significantly more postconcussive symptoms than the Pass group, with a large effect size (P < .001; d = 1.1). MSVT performance remained a robust unique predictor of symptom report even after controlling for other influential factors (eg, female gender, premorbid psychiatric problems).CONCLUSIONS:A subset of children who had persistent complaints after mTBI may be exaggerating or feigning symptoms. If such negative response bias remains undetected, errors in etiologic statements and less than optimal treatment may occur. Because the detection of invalid responding is well established in neuropsychology, clinical neuropsychologists should be incorporated routinely into clinical care for patients who have persistent complaints. To better control for noninjury effects in future pediatric mTBI studies, researchers should add validity tests to neurobehavioral outcome batteries.

BACKGROUND:Although research focused on mild traumatic brain injury (mTBI) has proliferated in recent years, few studies have examined the significance of a previous history of mTBI in children. OBJECTIVE:To compare the acute injury presentation and neuropsychological recovery in a pediatric sample after mTBI. METHODS:Participants 8 to 16 years of age were divided into 4 groups: no previous injury history, history of 1 mTBI, history of 2 mTBIs, and history of ≥ 3 mTBIs. Participants were evaluated within 3 months of the most recent injury by clinical interview and an abbreviated neuropsychological test battery. RESULTS:After the index mTBI, the groups did not differ in their likelihood to display a loss of consciousness, nor did they differ on neuropsychological test performance. CONCLUSION:Overall, contrary to our hypotheses, we found no demonstrable difference between those children with a self-reported mTBI history and those without after an index mTBI.

To date, few studies have examined the use of embedded performance validity indicators in pediatric populations. The present study examined the utility of variables within the California Verbal Learning Test, Children's Version (CVLT-C) in detecting noncredible effort among a pediatric mild traumatic brain injury sample. The sample consisted of 411 clinically referred patients aged 8-16 years. A total of 13% of the participants failed both the Medical Symptom Validity Test and at least one other performance validity measure. No demographic or injury-related variables differentiated the noncredible and adequate effort groups. The noncredible group performed significantly worse than the adequate effort group across a majority of CVLT-C variables. Logistic regression analysis revealed that the Recognition Discriminability (RD) score was the most robust in predicting noncredible effort. Among this relatively high-functioning sample, an RD cutoff z-score of -0.5 resulted in sensitivity of 55% and specificity of 91%. A more conservative RD cutoff z-score of -1.0 resulted in sensitivity of 41% and specificity of 97%. These findings are comparable to the classification statistics found for many embedded indicators in the adult literature. Although only moderately sensitive, the RD score on the CVLT-C appears to have good utility in identifying noncredible effort in a relatively high-functioning pediatric mTBI population.

This handbook covers basic neurodevelopmental research that any pediatric neuropsychologist will need to know. The authors discuss practical issues in pediatric assessment, and provide a comprehensive overview of the most common medical conditions that neuropsycholoigists encounter while dealing with pediatric populations. The book also describes a variety of professional issues that neuropsychologists must confront during their daily practice, such as ethics, multiculturalism, child abuse, forensics, and psychopharmacology. Also discussed are school-based issues such as special education law, consulting with school staff, and reintegrating children back into mainstream schools.