Pediatric concussion frequently disrupts school participation, yet approaches to returning to the academic environment remain inconsistently implemented despite growing consensus on the benefits of early, supported school re-entry. This review synthesizes the extant literature on the evidence, clinical guidelines, educational policy, and multidisciplinary practice to examine return to school related issues for youth following concussion and to identify gaps between established recommendations and real-world applications. Across national and international guidelines, early return to school with symptom-limited cognitive activity is consistently endorsed, while prolonged cognitive rest and delayed academic re-entry are no longer supported. Additionally, students commonly experience learning, sensory, emotional, and environmental challenges that extend beyond school re-entry alone, especially in secondary settings with greater demand variability, highlighting limitations of narrowly framed “return-to-learn” (RTL) and “return-to-school” (RTS) models.Evidence indicates that concussion-related school difficulty reflects an interaction among personal factors such as symptom burden and cognitive endurance, with medical guidance, environmental demands, and institutional constraints, with older students potentially facing disproportionate challenges. Although multidisciplinary care models—including school-based teams, rehabilitation providers, and mental health and medical professionals—are widely recommended, operational guidance for role delineation, communication, and accommodation fidelity remains limited, oftentimes resulting in delays in implementation. As a result, practices related to returning students to the academic environment vary widely across schools and jurisdictions, contributing to inequitable access to effective supports. This review emphasizes the need to facilitate supported return to full school participation rather than solely academic reintegration and outlines practical strategies and research priorities to improve implementation and outcomes.

Since the original descriptions by Giza and Hovda of the acute neurometabolic cascade of concussion 25 years ago, there has been a broad evolution in the understanding of concussion and other types of traumatic brain injuries (TBI) to include not only acute, neuro, and metabolic aspects of pathophysiology but also the impact and risk of TBI on numerous molecular and cellular processes, neural networks and physiologic systems. This review summarizes research and clinical advancements in the neurometabolic cascade of TBI, recognizing that evolution beyond this postinjury neuronal perspective is key to unlocking improved therapies and reduction of long-term risk.

The extant literature shows inconsistent associations between self-reported cognitive complaints and neurocognitive test performance following concussion. Characterizing this relationship is needed because discrepancies may lead to under-treatment or over-medicalization of distress-driven symptoms. This analysis examined the association between self-reported cognitive symptoms and cognitive performance testing in a large cohort of concussed youth as part of the CARE4Kids longitudinal study. The sample included 324 symptomatic concussed youth aged 11 to 17 years evaluated 7–35 days post-injury. Self-reported pre-injury and post-injury cognitive symptoms (attention, memory, processing speed, mental fog) were measured by the PCSI-2 (Post Concussion Symptom Inventory, 2nd Ed) producing the Retrospective Adjusted Post-Injury Difference (RAPID) score which represents the injury-related symptom load. Cognitive performance was measured by various subtests of the NIH Toolbox measuring attention, processing speed, memory, executive functions, vocabulary knowledge. A consistent pattern of statistically significant, inverse associations was found between the cognitive performance tests and self-reported pre-injury and post-injury symptom reports, but these associations yielded negligible effect sizes, ranging from η2 of .01 to .04. Notably, these associations were absent when cognitive performance tests were correlated with the injury-related symptom load (RAPID scores). Self-reported cognitive symptoms are negligibly associated with cognitive performance measures in concussed youth, with this discrepancy even more apparent when injury-specific symptom burden is evaluated. These results underscore the importance of using clinical judgement when considering both self-reported and performance data in the assessment of post-concussive cognitive functioning to guide psychoeducation, treatment planning, and research.

Traumatic brain injury (TBI) presents a public health concern as a leading cause of death and disability in children. Pediatric populations are particularly vulnerable to adverse outcomes following TBI due to periods of rapid growth, synaptic pruning, and myelination. Pediatric patients with moderate-severe TBI (msTBI) and healthy controls were evaluated from the post-acute (2-5 months) to chronic phase (13-19 months) of recovery using diffusion magnetic resonance imaging (dMRI) and interhemispheric transfer time (IHTT), which is an event-related potential measure the speed of information transfer across the corpus callosum. We previously identified two subgroups of patients based on IHTT, with one group showing a significantly slower IHTT (TBI-slow), poorer cognitive performance, and progressive structural damage. In contrast, the other group (TBI-normal) did not differ from controls on IHTT or cognitive performance and showed relative structural recovery over time. Here, we examined group differences in restricted diffusion imaging (RDI), which is a dMRI metric sensitive to inflammation. Comparing TBI-slow, TBI-normal, and controls on RDI cross-sectionally, dMRI connectometry analysis revealed higher RDI across the white matter in the TBI-slow group compared to both the control and TBI-normal groups. Longitudinal analyses indicated that while both TBI groups exhibited a decrease in RDI over time, suggesting resolution of neuroinflammation and recovery, the decreases in the TBI-slow group were smaller. The differences in RDI between TBI-slow and TBI-normal suggest that inflammation may play a key role in the prolonged recovery, including brain structure, cognitive performance, and symptom reports, of pediatric patients with msTBI.

An extensive library of symptom inventories has been developed over time to measure clinical symptoms of traumatic brain injury (TBI), but this variety has led to several long-standing issues. Most notably, results drawn from different settings and studies are not comparable. This creates a fundamental problem in TBI diagnostics and outcome prediction, namely that it is not possible to equate results drawn from distinct tools and symptom inventories. Here, we present an approach using semantic textual similarity (STS) to link symptoms and scores across previously incongruous symptom inventories by ranking item text similarities according to their conceptual likeness. We tested the ability of four pretrained deep learning models to screen thousands of symptom description pairs for related content-a challenging task typically requiring expert panels. Models were tasked to predict symptom severity across four different inventories for 6,607 participants drawn from 16 international data sources. The STS approach achieved 74.8% accuracy across five tasks, outperforming other models tested. Correlation and factor analysis found the properties of the scales were broadly preserved under conversion. This work suggests that incorporating contextual, semantic information can assist expert decision-making processes, yielding broad gains for the harmonization of TBI assessment.

Characterize the impact of social health determinants on access to care and symptoms for youth with mTBIs.

Siblings of individuals with neurodevelopmental conditions (NDCs) are situated within a complex system of risk and resilience factors for poor outcomes, many of which overlap with the risk of traumatic brain injury (TBI) and correlate with poorer recovery trajectories. This study used Bayesian analyses to characterize and compare TBI and biopsychosocial risk factors among 632 siblings (207 NDC, 425 controls; mean age 20.54 years, range 10-30, 78.48% female). NDC siblings had a higher self-reported lifetime history of TBI compared to controls (14.98% versus 6.35%), with most reporting more than one TBI, and at an earlier age. TBI history was associated with psychiatric diagnoses and subclinical NDC features. Family and structural factors related to TBI included poorer parent-child relationship, NDC diagnoses of autism or fetal alcohol spectrum disorder, minority ethnicity, and lower income. Findings have implications for health literacy, TBI education and screening, and implementation of family support.

Abstract Objective Pain catastrophizing is a maladaptive cognitive appraisal towards pain, where exaggerated negative schemas about pain are associated with greater likelihood of pain persisting (Chaves & Brown, 1987). We hypothesized that similar mechanisms might underlie the development of persistent concussion symptoms. We adapted a measure of pain catastrophizing to assess concussion symptom catastrophizing and examined its psychometric properties. Method Participants included 292 youth with diagnosed concussions, 57% female and mean age 14.5 years (SD 1.8) in the Care4Kids national study. First administration (T1) and second administration (T2) were about 1 and 3 months post-injury, respectively. The Pain Catastrophizing Scale (PCS) – Child version was adapted with concussion symptoms, and named the Concussion Catastrophizing Scale (CCS). Results At T1, the original PCS three-dimension structure (Rumination, Magnification, and Helplessness) was supported with goodness of fit statistic as follows: χ2 (51) = 144.96, p 0.57, p < 0.001). Internal consistency reliability for the CCS Total score was strong (coefficient alpha =0.91). Test–retest reliability over the 2 month period was moderate (r = 0.45), moderated in part due to individual variability in recovery. At T2, significant decreases were found in the Total CCS score. Conclusion(s) Our results indicate preliminary support for the CCS-Child version as a measure of concussion symptoms catastrophizing in pediatric populations. Additional evidence of reliability and validity is needed prior to clinical use.

Privilege and marginalization associated with racial background have been posited as contributors to why Black athletes face disparities within their care, treatment, and recovery from sport-related concussion (SRC). However, empirical findings have limited exploration on how disparate outcomes have emerged, and the interaction with systems of biases, power and disenfranchisement. To understand concussion care disparities, a qualitative content analysis was conducted in three phases: [I] identifying salient literature on racial differences for Black athletes with SRC (N = 29), [II] qualitative analysis of literature to determine salient topics, themes and patterns within the literature, and [III] constructing a novel ecological-systems framework that encapsulates the 'why' and 'how' related to psychosocial and sociocultural experiences of power, access, and biases for Black athletes. The content analysis yielded two patterns, where concussion care decisions are influenced by (1) biased, unconscious beliefs that posit Black athletes as uniquely invincible to injury and pain, and (2) inadequate access to concussion knowledge and resources, which both moderate SRC injury risk, diagnosis, recovery and outcomes. Ultimately, our novel framework provides a clear thread on how historical, macro-level policy and perceptions can impact micro-level clinical care and decision-making for Black athletes with SRC.

BACKGROUND:Mental health disorders are linked to prolonged concussion symptoms. However, the association of premorbid anxiety/depression symptoms with postconcussion return-to-play timelines and total symptom burden is unclear. OBJECTIVE:To examine the association of self-reported premorbid anxiety/depression symptoms in collegiate student-athletes with (1) recovery times until asymptomatic, (2) return-to-play, and (3) postconcussion symptom burden. STUDY DESIGN:Athletes in the Concussion Assessment, Research and Education Consortium completed baseline concussion assessments (Sport Concussion Assessment Tool [SCAT3] and Brief Symptom Inventory-18 [BSI-18]). Athletes were tested postinjury at <6 hours, 24 to 48 hours, time of asymptomatic and start of return-to-play protocol, unrestricted return-to-play, and 6 months after injury. Injured athletes were categorized into 4 groups based on BSI-18 scores: (1) B-ANX, elevated anxiety symptoms only; (2) B-DEP, elevated depression symptoms only; (3) B-ANX&DEP, elevated anxiety and depression symptoms; and (4) B-NEITHER, no elevated anxiety or depression symptoms. Relationship between age, sex, BSI-18 group, SCAT3 total symptom and severity scores, and time to asymptomatic status and return-to-play was assessed with Pearson's chi-squared test and robust analysis of variance. LEVEL OF EVIDENCE:Level 3. RESULTS:Among 1329 athletes with 1352 concussions, no respondents had a self-reported premorbid diagnosis of anxiety/depression. There was no difference in time until asymptomatic or time until return-to-play between BSI-18 groups (P = 0.15 and P = 0.11, respectively). B-ANX, B-DEP, and B-ANX&DEP groups did not have higher total symptom or severity scores postinjury compared with the B-NEITHER group. CONCLUSION:Baseline anxiety/depression symptoms in collegiate student-athletes without a mental health diagnosis are not associated with longer recovery times until asymptomatic, longer time to return-to-play, or higher postconcussion total symptom and severity scores compared with athletes without baseline symptoms. CLINICAL RELEVANCE:Anxiety and depression symptoms without a clear mental health diagnosis should be considered differently from other comorbidities when discussing prolonged recovery in collegiate student-athletes.

Deficits in memory performance have been linked to a wide range of neurological and neuropsychiatric conditions. While many studies have assessed the memory impacts of individual conditions, this study considers a broader perspective by evaluating how memory recall is differentially associated with nine common neuropsychiatric conditions using data drawn from 55 international studies, aggregating 15,883 unique participants aged 15–90. The effects of dementia, mild cognitive impairment, Parkinson’s disease, traumatic brain injury, stroke, depression, attention-deficit/hyperactivity disorder (ADHD), schizophrenia, and bipolar disorder on immediate, short-, and long-delay verbal learning and memory (VLM) scores were estimated relative to matched healthy individuals. Random forest models identified age, years of education, and site as important VLM covariates. A Bayesian harmonization approach was used to isolate and remove site effects. Regression estimated the adjusted association of each clinical group with VLM scores. Memory deficits were strongly associated with dementia and schizophrenia (p < 0.001), while neither depression nor ADHD showed consistent associations with VLM scores (p > 0.05). Differences associated with clinical conditions were larger for longer delayed recall duration items. By comparing VLM across clinical conditions, this study provides a foundation for enhanced diagnostic precision and offers new insights into disease management of comorbid disorders.

Introduction: Neuroimaging has expanded our understanding of pediatric brain disorders in which white matter organization and connectivity are crucial to functioning. Paralleling the known pathobiology of many neurodevelopmental disorders, traumatic brain injury (TBI) in childhood can alter trajectories of brain development. Specifically, diffusion tensor imaging (DTI) studies in TBI have demonstrated white matter (WM) abnormalities that suggest microstructural disruptions that may underlie atypical neurodevelopment. The neurocognitive correlates of these previous findings will be explored in this study. Methods: Indicators of WM organization were collected in 44 pediatric patients with moderate/severe TBI and 76 controls over two post-injury time points: T1 (8-20 weeks) and T2 (54-96 weeks). Our previous work identified two TBI subgroups based on information processing differences: one with slower interhemispheric transfer times (IHTT) of visual information than controls and another with comparable IHTT. We extend this prior work by evaluating neurocognitive trajectories associated with divergent WM structure post-injury in slow and normal IHTT TBI subgroups. Results: At T1, both TBI subgroups performed significantly worse than controls on a norm-referenced working memory index (WMI), but only the Normal IHTT TBI subgroup significantly improved over the 12-month follow-up period (p = 0.014) to match controls (p = 0.119). In contrast, the Slow IHTT TBI subgroup did not show any recovery in working memory performance over time and performed more poorly than the control group (p < 0.001) at T2. Improvement in one of the two WMI subtests was associated with DTI indicators of WM disorganization in CC tracts to the precentral, postcentral, frontal, and parietal cortices. IHTT and WM mean diffusivity predicted 79% of the variance in cognitive recovery from T1 to T2 when also accounting for other known predictors of TBI recovery. Discussion: In the year following TBI, some pediatric patients experienced persisting working memory disturbance while others exhibited recovery; stratification was based on an event-related potential marker. More or less improvement in neurocognition was also associated with the degree of WM disorganization. IHTT, measured post-acutely after TBI, and progression of WM disorganization over time predicted neurocognitive trajectories at the chronic timeframe - potentially representing a prognostic biomarker.

Abstract Purpose There is an apparent phenomenon where Black adult and pediatric athletes face disparities within their care, treatment, and recovery from mild traumatic brain injury (mTBI), or concussion while playing their sport: previous literature has demonstrated that Black athletes who have experienced sports-related concussions (SRC) are less likely to demonstrate concussion knowledge and symptom identification, as well as intention to report injury and overall poorer psychosocial outcomes following injury. Overall, the axis of privilege and marginalization associated with Race, can impact presentation for care, receiving diagnoses, symptom reporting and tracking, and the process of recovery or return to baseline functioning. However, empirical findings from publications do not elucidate why nor how these various factors compound. The purpose of this literature review was to (I) identify salient literature on racial differences for Black athletes with SRC, and (II) create a framework that encapsulates the “why”and “how” sociocultural experiences of power, access, and biases can impact Black athletes. The authors used Ecological Systems Theory (EST; Bronfenbrenner, 1979) to create a novel organization-systems model of identified findings and theory that demonstrate and support racial disparities within SRC and larger mTBI literature. Method A comprehensive literature search was employed to identify recent empirical studies and theoretical perspectives on racial disparities in mTBI for Black populations and athletes (N = 30). Publications for literature review were identified through the following Boolean search parameter on Google Scholar: [((race OR racial) OR (Black* OR African* OR BIPOC*)) AND (*brain injury OR “mild traumatic brain injury” OR mTBI OR concussion) AND (sport* OR athlet*)], where publications of interest were compiled and annotated by authors. Inclusion criterion for publication was established by the team as: (a) focusing on an element of concussion or mild traumatic brain injury, such as patient risk for injury, diagnosis, recovery or post-injury outcomes, (b) participants‚Äô racial background (race) must have been either an independent variable included within an analysis for quantitative designs, or be a salient topic or variable of interest within qualitative designs, and (c) published between 2018 and 2023. Publications from all journals and topic areas were included if the paper met above criterion. Results Approximately, two major patterns emerged that may underlie current empirical data on diagnoses, injury recovery and post injury outcomes. The two patterns illustrate how both clinicians and athletes (1) biased, unconscious beliefs that posit Black athletic bodies as invincible to injury & pain, and athletes (2) indirect and direct access to concussion knowledge and resources, can moderate the likelihood of SRC injury risk, diagnosis, recovery and post-injury outcomes for Black athletes across various athletic age and ability levels. Conclusions Ultimately, the organizational EST model for each pattern provides a clear thread on how historical, and macro-level policy and perceptions, can impact micro-level clinical care and decision-making for Black athletes and their experiences with SRC. Future directions suggest an application of EST models or further qualitative investigation with clinicians and Black athletes to understand more microsystem-level perceptions, beliefs, and thought processes that spur and impact clinical care.