The Centers for Disease Control and Prevention recommends multimodal assessment to evaluate recovery from pediatric mild traumatic brain injury (mTBI) including symptom rating scales and neuropsychological testing. However, little is known about how strongly self-reported symptoms of mTBI are related to neuropsychological functioning, particularly in younger children. This study explored the relationship between self-reported symptoms and performance on neuropsychological measures in a sample of clinically referred school-aged children (n = 47) and adolescents (n = 104) within 4 weeks of sustaining an mTBI. All participants completed their age-respective Post-Concussion Symptom Inventory and a targeted neuropsychological battery as part of their clinical follow-up. Higher self-reported symptoms were moderately associated with reduced cognitive processing speed and poorer verbal recall memory in the adolescent group. Verbal recognition memory had the strongest relationship with symptom ratings across age groups, such that verbal recognition memory was moderately correlated with symptoms in school-aged children and strongly correlated with symptoms in adolescents. These findings suggest that the relationship between self-reported symptoms and performance on neuropsychological measures may vary based on the developmental level of the child. Furthermore, a higher symptom burden may contribute to cognitive inefficiencies that are exacerbated by sustained cognitive exertion (e.g., neuropsychological testing). Results from this study provide additional support for multimodal assessment following pediatric mTBI. With an increased understanding of child-reported symptoms and neuropsychological performance within the first few weeks following injury, neuropsychologists and psychologists could provide brief, targeted interventions to reduce the likelihood of persistent postconcussive symptoms and protracted recovery.

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.

High-dose chemotherapy (HDC) strategies were developed in brain tumor protocols for young children to prevent neuropsychological (NP) impairments associated with radiotherapy. However, comprehensive NP evaluations of these children treated with such strategies remain limited. We examined the long-term neurocognitive outcomes of young children (<6 years) with medulloblastoma, treated similarly, with a HDC strategy “according to” the chemotherapy regimen of the protocol CCG 99703. This retrospective study included young children less than 6 years of age at diagnosis of medulloblastoma treated from 1998 to 2011 at 7 North American institutions. Twenty-four patients who had at least one NP assessment post-treatment are the focus of the current study. Of 24 patients in this review, 15 (63%) were male and the mean age at diagnosis was 29.4 months (SD = 13.5). Posterior fossa syndrome (PFs) was reported in five patients (21%). Nine (37.5%) received radiotherapy (5 focal, 4 craniospinal). On average, children were assessed 3.5 years (SD = 1.8) post-diagnosis, and full-scale intellectual quotient (FSIQ) scores ranged from 56 to 119 (\({\bar{\text{X}}}\)= 92; SD = 16.8). The majority of children (74%) had low-average to average NP functioning. Very young children treated with radiotherapy, who needed hearing support or with PFs had worse neurocognitive outcomes. Clinically significant deficits (<10th percentile) in at least one area of NP functioning were found in 25% of the children. NP data obtained from this sample of survivors of medulloblastoma in early childhood, all treated with sequential HDC and 1/3 with radiotherapy, describe NP functioning within average normal limits overall. However, almost 25% of children had significant deficits in specific domains.

A web-based survey of validity test use by North American neuropsychologists was conducted, with 282 participants meeting inclusion criteria. Respondents indicated that they use a median of one stand-alone performance validity test (PVT), one embedded PVT, and one symptom validity test (SVT) per pediatric assessment. The vast majority of respondents indicated they give at least one PVT (92%) and at least one SVT (88%) during each pediatric assessment. A meaningful difference in validity use (i.e., at least a medium effect size) was only found for those who engage in forensic work, with those clinicians giving more stand-alone PVTs than those who do not conduct forensic work. The most frequently used validity measures in pediatric assessments are presented, as are reasons participants reported for both using and not using validity tests. Limitations and qualitative comparisons to other surveys on validity test use with adults are discussed.

Embedded validity measures can screen for possible noncredible performance, but there is a paucity of literature with youth who have neurological disorders. The purpose of this study is to examine the California Verbal Learning Test, Children's Version (CVLT-C) recognition discriminability (RD) score as an embedded validity marker in a sample of youth with neurological diagnoses. Youth between 5-16 years old (N = 294; mean age = 11.3, SD = 3.4) completed the CVLT-C and the Test of Memory Malingering (TOMM). Overall, 5.4% (n = 16) scored below the established cutoff on the TOMM; they were younger, had lower intellectual abilities, and worse performance on nearly all CVLT-C scores than those who scored above the TOMM cutoff. Using the CVLT-C RD score of z ≤ -0.5 (Baker et al. 2004), our sample had a sensitivity = .81 and specificity = .67. Using z ≤ -3.0 provided sensitivity at .44 with specificity at .90. A lower cutoff score of z ≤ -3.0 for CVLT-C RD is necessary in youth with neurological diagnoses.

Previous research has reported an imageability effect on visual word recognition. Words that are high in imageability are recognised more rapidly than are those lower in imageability. However, later researchers argued that imageability was confounded with age of acquisition. In the current research, these two factors were manipulated in a factorial design to assess their effect in a lexical decision task and a progressive demasking task. Across both tasks, there was a clear and robust effect of age of acquisition. In contrast, the imageability effect was only evident in the progressive demasking task. Both effects are explained within the connectionist framework in terms of network plasticity and semantic feedback activation.

Despite increasing interest in the use of performance validity tests with youth, relatively little is known about how children and adolescents with neurological diagnoses perform on these measures. The purpose of this study was to examine performance on the Test of Memory Malingering (TOMM) in a general pediatric neurologic sample. Data were obtained from 266 consecutive patients (mean age = 13.0, SD = 3.7, range = 5–18) referred for a neuropsychological assessment in a tertiary care pediatric hospital. As part of a broader neuropsychological battery, patients were administered the TOMM. In this sample, 94% of children passed the TOMM. Pass rate was 87% for 5–7 year-olds but was ≥ 90% for all other ages. Children with a history of stroke had the lowest pass rate (86%), with other diagnostic groups scoring ≥ 90%, including epilepsy, traumatic brain injury, and hydrocephalus. Lower TOMM performance was related to slower processing speed and weaker memory performance. The results support using the TOMM with children and adolescents who have neurological diagnoses. Caution may still be warranted when interpreting scores in those who are younger and/or who have more significant cognitive difficulty.

Bigler et al. (2013, The Clinical Neuropsychologist) contend that weak methodology and poor quality of the studies comprising our recent meta-analysis led us to miss detecting a subgroup of mild traumatic brain injury (mTBI) characterized by persisting symptomatic complaint and positive biomarkers for neurological damage. Our computation of non-significant Q, tau(2) , and I-2 statistics contradicts the existence of a subgroup of mTBI with poor outcome, or variation in effect size as a function of quality of research design. Consistent with this conclusion, the largest single contributor to our meta-analysis, Dikmen, Machamer, Winn, and Temkin (1995, Neuropsychology, 9, 80) yielded an effect size, 0.02, that was smaller than our overall effect size of 0.07 despite using the most liberal definition of mTBI: loss of consciousness less than 1 hour, with no exclusion of subjects who had positive CT scans. The evidence is weak for biomarkers of mTBI, such as diffusion tensor imaging and for demonstrable neuropathology in uncomplicated mTBI. Postconcussive symptoms, and reduced neuropsychological test scores are not specific to mTBI but can result from pre-existing psychosocial and psychiatric problems, expectancy effects and diagnosis threat. Moreover, neuropsychological impairment is seen in a variety of primary psychiatric disorders, which themselves are predictive of persistent complaints following mTBI. We urge use of prospective studies with orthopedic trauma controls in future investigations of mTBI to control for these confounding factors.

The relation between mood and executive functioning in children and adolescents has not been previously reported. This study examined the association between self-reported depressive symptoms in both clinical outpatient and psychiatric inpatient samples to the following measures of executive functioning: the Controlled Oral Word Association Test, Animal Naming, Trail Making Test, and Wisconsin Card Sorting Test. Records from children and adolescents aged 7–17 years old with an IQ > 70 were examined. Data were gathered at either an outpatient neuropsychology clinic (n = 89) or an inpatient psychiatric hospital setting (n = 81). Mood was measured with the Children’s Depression Inventory. Generally, statistical associations between self-reported depressive symptoms and executive functioning were small and non-significant. The variance predicted by mood on measures of executive functioning was minimal (generally less than 2 %) for the total sample, the outpatient group, inpatient group, and a subgroup who endorsed elevated mood symptoms. These results suggest that impaired performance on measures of executive functioning in children and adolescents is minimally related to self-reported depressive symptoms.

The meta-analytic findings of Binder etal. (1997) and Frencham etal. (2005) showed that the neuropsychological effect of mild traumatic brain injury (mTBI) was negligible in adults by 3 months post injury. Pertab etal. (2009) reported that verbal paired associates, coding tasks, and digit span yielded significant differences between mTBI and control groups. We re-analyzed data from the 25 studies used in the prior meta-analyses, correcting statistical and methodological limitations of previous efforts, and analyzed the chronicity data by discrete epochs. Three months post injury the effect size of -0.07 was not statistically different from zero and similar to that which has been found in several other meta-analyses (Belanger etal., 2005; Schretlen Shapiro, 2003). The effect size 7 days post injury was -0.39. The effect of mTBI immediately post injury was largest on Verbal and Visual Memory domains. However, 3 months post injury all domains improved to show non-significant effect sizes. These findings indicate that mTBI has an initial small effect on neuropsychological functioning that dissipates quickly. The evidence of recovery in the present meta-analysis is consistent with previous conclusions of both Binder etal. and Frencham etal. Our findings may not apply to people with a history of multiple concussions or complicated mTBIs.