Concussions are one of the most common causes of neurological morbidities in children. In addition to physical, cognitive, and emotional symptoms, a common complaint after concussion is the presence of sleep disturbances, such as trouble falling asleep. The present study sought to longitudinally assess the nature of sleep changes and their association with symptom recovery following concussion in a pediatric sample. Secondary analyses were conducted on a prospective, longitudinal, multicenter cohort study involving 2,991 children and adolescents (5-17 years) who presented to an emergency department within 48 h of a head trauma and who met diagnostic criteria for concussion consistent with the consensus statement prevailing at the time of data collection. Ratings of post-concussive symptoms and sleep disturbances were obtained at 5 pre-defined time points following concussion (weeks 1, 2, 4, 8, and 12), using the Post-Concussion Symptom Inventory (PCSI) and the sleep item of the Pediatric Quality of Life Inventory, respectively. Linear mixed models were fitted separately for the PCSI total score and the physical, cognitive, and emotional symptom subscales, adjusting for random participant effects. Model predictors included sleep, time, and time x sleep interaction. The model accounted for age, sex, maximum duration of previous concussion symptoms for individuals who had a previous concussion, prior diagnosis of developmental disorder, depression, and anxiety, and prior diagnosis of sleep disorders, as they are known risk factors for prolonged recovery. There was significant improvement in both sleep quality ratings (mean values per time point: week 1 = 76.3, SD = 30.1; week 2 = 81.6, SD = 28; week 4 = 82.4, SD = 27.4; week 8 = 86.6, SD = 24.2; week 12 = 89, SD = 22.8) and post-concussive symptoms across time points (mean delta values per time point: week 1 = 0.40, SD = 0.77; week 2 = 0.39, SD = 0.76; week 4 = 0.38, SD = 0.76; week 8 = 0.38, SD = 0.76; week 12 = 0.38, SD = 0.76) (all p < 0.001). Significant sleep*time interactions showed that better sleep was significantly associated with reduced global (β = 0.003, p = 0.030, 95% CI [0.00003, 0.0006]) and physical post-concussion symptoms (β = 0.007, p = 0.035, 95% CI [0.0005, 0.01]) after the injury relative to pre-injury levels, especially in early phases of recovery. Better sleep, regardless of the recovery period, was associated with greater reductions in patient-reported cognitive (β = -0.26, p = 0.0001, 95% CI [-0.34, -0.18]) and emotional symptoms (β = -0.28, p = 0.0001, 95% CI [-0.35, -0.20]) after concussion. The present findings indicate that better sleep is linked to more favorable post-concussion recovery as reflected by different clusters of symptoms. These results highlight the importance of investigating whether safeguarding sleep in children and adolescents with concussion may facilitate recovery.

Abstract Childhood brain tumor (BT) survivors treated with cranial radiation therapy (RT) frequently experience neurocognitive late effects, yet dose-sensitive neuroanatomical substrates of social–cognitive vulnerability remain uncharacterized. This exploratory study mapped region-specific RT dosimetry to social cognition, white matter integration, and executive/behavioral functioning. The RT sample included 14 participants (mAge=14.33, SD = 3.47;57.1% male) recruited from Alberta Children’s Hospital’s Long-Term Survivor Clinic. Neuropsychological assessment included the Wechsler Intelligence Scale for Children–Fifth Edition (WISC-V) indices of Working Memory and Processing Speed and the Test for the Evaluation of Emotions and Socialisation (TEEMS). Parent-reports measuring adaptive, executive and socioemotional functioning were also included. Planned diffusion tensor imaging will further characterize dose-sensitive white matter by quantifying diffusion anisotropy. Exploratory associations (Kendall’s τ and Spearman’s ρ) and dose-threshold contrasts (<30Gy vs ≥ 30Gy) were used. Higher right hippocampal and infratentorial mean doses related to poorer auditory working memory (τ and ρ, ps<.05;τ p< .05;ρ p<.01). Higher left amygdala and bilateral temporal-lobe doses related to poorer simple auditory digit registration (τ/ρ,ps< .05). For social cognition, slower social labeling performance related to left hippocampal and left temporal-lobe dose (τ/ρ, ps≤ .05), bilateral amygdala dose (τ ps< .05;ρ ps< .01), and sella mean dose (p<.05). Emotion recognition also associated with sella dose (ρ p<.05). Higher total dose correlated with poorer cognitive flexibility and attentional control (ps≤.01), and broader social and functional vulnerabilities (ps<.05) via parent-report. Dose-threshold contrasts (<30 vs ≥ 30Gy) indicated clinically meaningful impairments to rapid emotion labeling among groups that received more radiation for left temporal, amygdalae, hypothalamus, sella, and supratentorial regions while preserved performance was observed in < 30 Gy groups. Findings implicate hippocampal, temporal, amygdalae, infratentorial, sellar, and supratentorial dose exposure in auditory working-memory and rapid social-judgment with broader executive/adaptive sequelae. These patterns may inform region-sparing RT planning. Dose-sensitive white matter pathways may emerge via diffusion analysis.

OBJECTIVE:To examine the association of posttraumatic headache (PTH) type with postconcussive symptoms (PCS), pain intensity, and fluid cognitive function across recovery after pediatric concussion. METHODS:This prospective, longitudinal study recruited children (aged 8-16.99 years) within 24 hours of sustaining a concussion or mild orthopedic injury (OI) from two pediatric hospital emergency departments. Based on parent-proxy ratings of pre- and postinjury headache, children were classified as concussion with no PTH (n = 18), new PTH (n = 43), worse PTH (n = 58), or non-worsening chronic PTH (n = 19), and children with OI with no PTH (n = 58). Children and parents rated PCS and children rated pain intensity weekly up to 6 months. Children completed computerized testing of fluid cognition 10 days, 3 months, and 6- months postinjury. Mixed effects models compared groups across time on PCS, pain intensity, and cognition, controlling for preinjury scores and covariates. RESULTS:Group differences in PCS decreased over time. Cognitive and somatic PCS were higher in new, chronic, and worse PTH relative to no PTH (up to 8 weeks postinjury; d = 0.34 to 0.87 when significant) and OI (up to 5 weeks postinjury; d = 0.30 to 1.28 when significant). Pain intensity did not differ by group but declined with time postinjury. Fluid cognition was lower across time in chronic PTH versus no PTH (d = -0.76) and OI (d = -0.61) and in new PTH versus no PTH (d = -0.51). CONCLUSIONS:Onset of PTH was associated with worse PCS up to 8 weeks after pediatric concussion. Chronic PTH and new PTH were associated with moderately poorer fluid cognitive functioning up to 6 months postinjury. Pain declined over time regardless of PTH type.

The developmental mismatch hypothesis (DMH) proposes that a mismatch in maturational timing of the amygdala and prefrontal cortex (PFC) drives adolescent sensation-seeking behaviour. While some studies provide support for the DMH, few have evaluated sex differences or examined both grey and white matter. Here, we used T1-weighted and diffusion-weighted magnetic resonance imaging (MRI) to examine amygdala and PFC macrostructure and amygdala-PFC white matter microstructure development across 606 MRI sessions from 148 typically developing children and adolescents (76 females) aged 1.95-17.71 years. Using generalized additive mixed effects models, we evaluated the maturational timing of amygdala volume, four PFC subregion volumes, and fractional anisotropy and mean diffusivity of the uncinate fasciculus and amygdala-PFC white matter tracts. Amygdala and PFC maturation was consistent with the DMH in males but less so in females. Relative to males, females exhibited less amygdala development and shorter periods of PFC development. In contrast to gray matter volumes, white matter changed continuously from early childhood to late adolescence, but ended earlier in females than in males. Our findings show different amygdala-PFC maturation patterns and that the amygdala-PFC neural system reaches maturity earlier in females than in males. These important differences may underlie sex differences in sensation-seeking behaviour.

Introduction Concussion affects over 400 000 Canadians annually, with a range of causes and impacts on health-related quality of life. Research to date has disproportionately focused on athletes, military personnel and level I trauma centre patients, and may not be applicable to the broader community. The TRANSCENDENT Concussion Research Program aims to address patient- and clinician-identified research priorities, through the integration of clinical data from patients of all ages and injury mechanisms, patient-reported outcomes and objective biomarkers across factors of intersectionality. Seeking guidance from our Community Advisory Committee will ensure meaningful patient partnership and research findings that are relevant to the wider concussion community.Methods and analysis This prospective observational cohort study will recruit 5500 participants over 5 years from three 360 Concussion Care clinic locations across Ontario, Canada, with a subset of participants enrolling in specific objective assessments including testing of autonomic function, exercise tolerance, vision, advanced neuroimaging and fluid biomarkers. Analysis will be predicated on pre-specified research questions, and data shared with the Ontario Brain Institute’s Brain-CODE database. This work will represent one of the largest concussion databases to date, and by sharing it, we will advance the field of concussion and prevent siloing within brain health research.Ethics and dissemination This study was approved by the Children’s Hospital of Eastern Ontario Research Ethics Board and preregistered on OSF (25 June 2024); https://doi.org/10.17605/OSF.IO/HYDZC. Dissemination of findings will be multifaceted, including conference presentations, peer-reviewed publications and sharing of adapted materials (eg, videos, infographics, plain language summaries) with community groups and key knowledge users.

Objective To examine bidirectional associations between objective measures of sleep quantity and quality with postconcussion symptoms (PCS) scores in concussed youth during the first week postinjury and to explore the associations between sleep measures and time to symptom resolution. Study design We conducted a secondary analysis of a prospectively enrolled cohort of youth (11–17 years) with a physician diagnosed concussion within 72 hours of injury. During the first week postconcussion, sleep quantity (time in bed, total sleep time and daytime sleep) and sleep quality (sleep efficiency, WASO and number of awakenings) were measured using an ActiGraph. We evaluated bidirectional temporal associations between the sleep measures and PCS during the first week postinjury using cross-lagged panel models. We assessed the associations between sleep measures and time to symptom resolution using Cox proportional hazard models. Results Participants included 78 concussed youth, 34.6% females, mean age of 14.2 years (SD=2.1). Significant bidirectional associations were observed between PCS and both total sleep time and daytime total sleep in the first week postinjury. Increased daytime sleep was also associated with a decreased likelihood of symptom resolution, adjusted HR (aHR)=0.88, 95% CI=0.78, 0.999. An optimal total sleep time of 418 min per day was associated with a 2.1-fold increased likelihood of symptom resolution (aHR=2.1, 95% CI=1.3, 3.2). Conclusions Clinicians should provide guidance on sleep hygiene, including limiting daytime sleep/naps and getting the appropriate amount of nighttime sleep acutely postconcussion to aid recovery in youth.

This Special Communication reflects on progress in understanding the outcomes of pediatric traumatic brain injury (TBI) since the Journal of Head Trauma Rehabilitation special issue (volume 1, issue 4) on "head injury" in children appeared in 1986. We highlight the critical role that prospective, longitudinal cohort studies have played in advancing knowledge about both mild and moderate-severe pediatric TBI. We describe conceptual and methodological innovations that the past 40 years of research has spurred and summarize remaining challenges. These include the need for comparative effectiveness and randomized controlled trials to determine what interventions are effective, singly or in combination, as well as for implementation science to translate research into clinical practice, with the goal being to provide better care and improve outcomes for children with TBI and their families.

Background : Early physical activity (PA) after concussion may aid in symptom recovery, though its impact on other recovery domains, such as cognitive functioning, remains less explored. Objectives : (1) Examine the association between early PA (within 7 days post-injury) and cognitive inefficiency and impairment 4 weeks after pediatric concussion; (2) investigate the association between early PA and cognitive outcomes (memory and executive functioning, information processing speed, attention, visual-motor processing, and vocabulary) 4-week post-concussion. Setting : Emergency departments (EDs) of four Canadian pediatric hospitals within the Pediatric Emergency Research Canada (PERC) Network. Participants : Children aged 8–18 years presenting to the ED within 48 hours of a head injury and diagnosed with a concussion. Design : Planned secondary analysis of data from a prospective multicenter cohort study. Main Measures : Participants’ PA level was assessed at 1-week post-concussion through a self-report questionnaire in which they had to indicate their current level of recovery in terms of return to physical activities and sports. Early PA participation was defined as any level of PA other than “no activity” at the 1-week follow-up. Participants underwent comprehensive neuropsychological testing at 4-week post-concussion. Primary outcome measures included cognitive inefficiency and impairment (≥2 outcomes with z < −1.0 SD or <−1.5 SD below the normative mean, respectively). Secondary and tertiary outcome measures include t-scores and scaled scores from the 10 neuropsychological tasks, transformed to z-scores. Results : Early PA was not significantly associated with the likelihood of cognitive inefficiency or impairment ( P s ≥ .38). The early PA*sex interaction was related to verbal cognitive flexibility ( P = .02), with females engaging in early PA having better scores. Moreover, the early PA*age interaction was associated with attention ( P = .03), with younger children engaged in early PA performing worse. Conclusions : Early PA has no overall association with cognitive inefficiency or impairment but may be differentially associated with certain cognitive outcomes by age and sex.

OBJECTIVE:We examined cognitive performance in children with complicated mild-severe traumatic brain injury (TBI) versus orthopedic injury (OI) using the National Institutes of Health Toolbox Cognitive Battery (NIH TB-CB). METHOD:We recruited children ages 3-18, hospitalized with complicated mild-severe TBI (n = 231) or orthopedic injury (OI, n = 146). Cognition was assessed using the NIH TB-CB at six and twelve months post-injury. We used linear mixed models to assess associations of injury group (TBI versus OI), timepoint (six versus twelve months), and the interaction of injury group and timepoint with NIH TB-CB Total Cognition, Fluid Cognition, and Crystallized Cognition composites, adjusted for sex and socioeconomic status (SES), with Bonferroni correction. We evaluated differences in cognition stratified by injury severity (complicated mild-moderate TBI vs severe TBI) using ANCOVA, adjusting for sex and SES. RESULTS:Neither injury group nor the interaction of group and timepoint were associated with Total (group: p = 0.50; timepoint*group: p = 0.185), Fluid (group: p = 0.297; timepoint*group: p = 0.842), or Crystallized Cognition (group: p = 0.039; timepoint*group: p = 0.017). However, children with severe TBI performed significantly worse on Fluid and Total Cognition than children with complicated mild-moderate TBI at six months (Fluid: p = 0.004, partial η2 = 0.06, moderate effect, Total: p = 0.012 partial η2 = 0.03, small-moderate effect) and twelve months post-injury (Fluid: p < 0.001, partial η2 = 0.11, moderate-large effect, Total: p = 0.002, partial η2 = 0.06, moderate effect). CONCLUSIONS:The NIH TB-CB detects worse cognitive functioning in children with severe TBI six-twelve months post-injury, largely driven by differences in Fluid Cognition. Our findings suggest the NIH TB-CB may be suitable for monitoring cognition in children with TBI.

Objective Despite advances in imaging and fluid-based biomarkers, the care for pediatric “mild” traumatic brain injury (pmTBI) remains primarily dependent on clinical evaluation. However, the optimal clinical assessments for diagnosing pmTBI and predicting outcomes remain debated, including which individual test or combinations of assessments are most effective, and how this evolves as a function of time post-injury. Method Random Forest models were used to identify the most effective assessments for diagnostic (pmTBI vs. healthy controls) and outcome (pmTBI with favorable vs. poor outcomes, based on persisting symptoms) classification accuracy across a comprehensive battery including domains of self-reported clinical-ratings, paper-and-pencil cognitive tests, computerized cognitive tests, symptom provocation during neurosensory tests, and performance-based neurosensory measures. Assessments were conducted within 11-days, at 4-months and 1-year post-injury to examine acute and long-term recovery trajectories. A total of 323 pmTBI (180 males; age 14.5 ± 2.8 years) and 244 HC (134 males, 14.0 ± 2.9 years) were included (∼75 % 1-year retention) in final analyses. Results Self-reported clinical-ratings outperformed performance-based metrics across all visits in both models, with somatic complaints demonstrating the highest predictive validity. Cognitive tests of memory aided diagnostic classification, while emotional disturbances were predictive of outcome classification up-to 4-months. Retrospective ratings, reflecting trait-like characteristics, were more predictive for identifying individuals at risk of poor outcomes. Computerized cognitive and neurosensory tests had limited predictive value beyond 1-week post-injury. Conclusions Clinicians should adopt a tailored approach for clinical assessments across different post-injury intervals to enhance clinical care, shorten assessment batteries, and better understand recovery in children with “mild” TBI.

Objective: The American Congress of Rehabilitation Medicine (ACRM) substantially revised its diagnostic criteria for mild traumatic brain injury (mTBI) in 2023, encompassing acute symptoms and positive clinical and laboratory examinations, in addition to immediate signs of injury. This study aimed to apply these criteria to a large, diverse cohort and compare the diagnostic determination to physician impression of injury. Setting: A network of 3 concussion specialty clinics in Ontario, Canada. Participants: A total of 1447 patients (61.0% female; median age = 26 years [IQR: 15-42 years, range: 3-87 years]; days post-injury (median: 23 IQR: [13-47, 0-349]) completed initial evaluations between June 28, 2024 and June 18, 2025. Design: Prospective observational study. Main Measures: Occurrence rates were calculated, and binary/ordinal logistic regressions were applied to determine if individual criterion endorsement or diagnostic outcome (“Definite,” “Suspected,” and “No mTBI”) was associated with age, sex, symptoms at clinical presentation, or days post-injury. Additionally, concordance with physician impression was assessed similarly. Results: Criteria for signs, symptoms, and clinical examinations were all more likely to be endorsed with increasing symptom severity at presentation, as was an ACRM diagnostic outcome of definite mTBI. Shorter time post-injury was associated with positive clinical/laboratory examinations and the presence of confounding factors, in addition to a definite diagnostic outcome. A total of 18.4% of cases were classified less definitively as mTBI by physician impression than by the updated ACRM diagnosis, with physicians tending toward underdiagnosis, particularly in patients reporting lower current symptom severity. Conclusion: Use of the ACRM criteria clinically to determine if an injury qualifies as mTBI may be less susceptible to bias from ongoing symptom reporting than the physician impression of the injury.

Adverse childhood experiences (ACEs) and traumatic brain injuries (TBI) are highly prevalent globally, and both are associated with long-term negative health outcomes across the lifespan. Past research exploring the potential association between ACEs and TBI occurrence has demonstrated mixed findings. Thus, we conducted a systematic review and meta-analysis to examine the association between the ACEs measure and TBI occurrence. Moderator analyses were conducted to determine whether certain factors, including participant age, sex, and geographical location, modified the association between ACEs score and TBI occurrence. Searches were conducted in PsycINFO, MEDLINE, Embase, and CINHAL for studies published between January 1, 1998, and February 19, 2024. A total of 42 full-text articles were screened against inclusion criteria (i.e., measure of ACEs using the original 8- or 10-item scale or another composite measure of ACEs, TBI occurrence, and effect size for the association between ACEs score and TBI). Eight studies and 10 samples (N = 4954) were included in the meta-analysis. The data were synthesized using a random-effects multilevel meta-analysis, which revealed a significant large positive association between ACEs score and TBI occurrence, r = 0.31, 95% confidence interval [0.13, 0.49], p < 0.001. Moderator analyses did not yield significant results. The current findings demonstrate that individuals who reported a higher ACEs score were more likely to have reported sustaining a TBI, highlighting a need for trauma-informed efforts to prevent TBI and its adverse effects.

This study sought to identify trajectories of symptom status in children and adolescents with concussion across the first 6 months post-injury and to examine their biopsychosocial correlates. The study used data collected as part of a prospective, longitudinal cohort study, Advancing Concussion Assessment in Pediatrics (A-CAP), conducted from 2016 to 2019, which recruited 967 English- or French-speaking children 8.0 to <17 years old with either a concussion (N = 633) or mild orthopedic injury (OI; N = 334) from five pediatric emergency departments (EDs) in Canada. Participants rated post-injury symptoms weekly from 1 week to 3 months and biweekly from 3 to 6 months post-injury. The ratings of children with concussion were classified as symptomatic/asymptomatic relative to retrospective pre-injury symptom ratings using reliable change equations derived from the OI group. A set of 26 biopsychosocial variables, assessed in the ED or at a 1-week visit, was derived from core measures collected in the A-CAP study. They were grouped a priori into clusters of five to seven variables representing four domains (i.e., social determinants of health [SDoH], neurobiological, child psychosocial, and parent/family psychosocial). Symptom trajectories were examined using latent class growth analysis (LCGA). Multinomial logistic regression tested the independent and joint ability of the variables in the four domains to discriminate trajectories. Multiple imputation with chained equations was completed prior to multivariable analyses. Analyses included children with concussion with ≥1 post-injury symptom rating (N = 553; age m = 12.4 years, standard deviation = 2.5; 40.3% female). Based on multiple statistical criteria, as well as parsimony and interpretability, LCGA identified four distinct symptom trajectories: rapid recovery (n = 301, 54%); typical recovery (n = 106, 19%); slow recovery (n = 73, 13%); and chronically symptomatic (n = 73, 13%). Variables in the SDoH, neurobiological, and child psychosocial domains independently discriminated the trajectories (polytomous discrimination index [PDI] = 0.39-0.44). When combined, significant variables from those three domains showed the best overall discrimination (PDI = 0.49). The findings indicate that children with concussion display distinct symptom trajectories that differ on SDoH, neurobiological, and psychosocial variables, confirming that a biopsychosocial model is critical to understanding pediatric concussion recovery and guiding its management. The findings may inform clinical prognosis and suggest potential targets for clinical trials, including post-acute pain and loneliness, to reduce persisting symptoms after concussion.

OBJECTIVE:To develop metrics for pediatric-specific quality indicators (QIs) for trauma care using trauma registry data and evaluate their validity. BACKGROUND:A set of 23 QIs specific to pediatric trauma care and applicable to both pediatric and non-pediatric trauma centers (PTCs) was recently developed. Their validity needs to be assessed before implementation. METHODS:We extracted data on children admitted to any trauma center in a Canadian provincial trauma system between April 2016 and March 2022. We evaluated QIs using Agency for Healthcare Research and Quality criteria. RESULTS:The study sample comprised 10,711 pediatric trauma admissions. We developed metrics for 15 QIs. Six had moderate-to-high validity on all evaluable criteria: head computed tomography <60 minutes for children with Glasgow Coma Scale <13, documentation of a full set of vital signs in the emergency department, initial head computed tomography in patients at low-risk on a clinical decision rule, stabilization of femoral shaft fractures <24 hours, intracranial pressure monitoring in severe traumatic brain injury, and nutritional support <48 hours of intensive care unit admission. Four had moderate-to-high validity on all but one criterion: PTC transfer for neurotrauma and major multisystem trauma, PTC transfer for major orthopedic trauma, and antibiotics <60 minutes in open long bone fractures. CONCLUSIONS:This study shows the feasibility of operationalizing QIs for pediatric trauma using trauma registry data, and we provide coding definitions to do so. Results provide evidence on validity that may be used to guide the selection of QIs for performance improvement programs.