Table 2.
Summary of clinical recommendations contained in the CDC guideline relevant to neuropsychologists.
| Summary of CDC pediatric mTBI guideline recommendations | Level of evidencea | Available resources to support implementation |
|---|---|---|
| DIAGNOSIS | ||
| mTBI is a clinical diagnosis and is not dependent on imaging or skull X-rays. | B | PECARN decision rules (Kuppermann et al., 2009) Examples of validated assessment scales: (Gioia et al., 2009) • Post-Concussion Symptom Inventory • Health and Behavior Inventory • Post-Concussion Symptom Scale • Acute Concussion Evaluation |
| Validated decision rules assessing a combination of risk factors should be used to assess the likelihood of mTBI prior to obtaining head CT. | B | |
| Age-appropriate, validated postconcussive symptom rating scales should be used acutely to assist with diagnosis. | B | |
| The SAC should not be used exclusively to identify pediatric mTBI. | B | |
| Age-appropriate computerized cognitive testing may be used in the acute period. | C | |
| In cases of acutely worsening symptoms of headache, especially in the setting of other risk factors, consider emergent neuroimaging to assess for more severe intracranial injuries. | B | |
| Insufficient evidence supports the routine use of MRI, SPECT, or serum biomarkers for diagnostic purposes. | B, B, R (respectively) | |
| PROGNOSIS | ||
| Healthcare providers should counsel patients/families that the large majority of children who sustain mTBI will recover by 1–3 months. | B | CDC HEADS UP handouts: • “Caring for Your Child’s Concussion” (Centers for Disease Control and Prevention, 2018a) • “How Can I Help My Child Recover After a Concussion” (Centers for Disease Control and Prevention, 2018b) |
| Premorbid history should be assessed because recovery might be delayed in those with: | B | |
| • history of mTBI | ||
| • increased pre-injury “postconcussive” symptoms | ||
| • pre-injury neurological or psychiatric disorder | ||
| • learning difficulties | ||
| • lower cognitive ability | ||
| • family and social stressors | ||
| Though no single factor is strongly predictive of outcome, providers should screen for known risk factors of prolonged recovery to aid in providing counseling to patients and families. Prolonged recovery is associated with the following risk factors: | B | |
| • older ages (i.e. adolescence) | ||
| • Hispanic ethnicity | ||
| • lower socioeconomic status | ||
| • more severe presentation of mTBI, including | ||
| intracranial hemorrhage | ||
| • higher levels of acute postconcussive symptoms | ||
| • female sex | ||
| MANAGEMENT AND TREATMENT | ||
| A combination of tools should be used to monitor recovery including age-appropriate, validated postconcussive symptom rating scales. | B | CDC HEADS UP handouts: • “Caring for Your Child’s Concussion” (Centers for Disease Control and Prevention, 2018a) • “How Can I Help My Child Recover After a Concussion” (Centers for Disease Control and Prevention, 2018b) Consensus Statement on Concussion in Sport (McCrory et al., 2017) |
| Validated cognitive and balance tests may be used. | C | |
| Healthcare providers should encourage some restriction on activities in the first few days after mTBI, but then encourage activities (including school) that do not significantly exacerbate symptoms. An active rehabilitation program should be offered thereafter as needed. | B | |
| Patients should be cleared to return to all activities when they return to their pre-injury status. | B | |
| Educational supports should be adjusted on an ongoing basis until the patient has returned to pre-injury levels. | B | |
| Patients who demonstrate prolonged symptoms and academic difficulties should be referred for evaluation by a specialist in pediatric mTBI. | B | |
| Chronic headache following mTBI is likely multifactorial, so providers should refer for multidisciplinary evaluation and treatment, with consideration of analgesic overuse. | B | |
| Healthcare providers should give recommendations for sleep hygiene to facilitate recovery. | B | |
| Understanding the etiology of cognitive dysfunction after mTBI is important in determining appropriate treatment and management. | B | |
| Neuropsychological evaluation can assist in determining etiology of cognitive dysfunction and directing treatment. | C | |
a
Through the modified GRADE process, CDC assigned one of the action levels to each recommendation: Level A: (Must do) Almost all patients in almost all circumstances would want the recommendation followed; Level B: (Should/Should not do) Most patients in most circumstances would want the recommendation followed; Level C: (May do) Some patients in some circumstances would want the recommendation followed; Level R: Do only in a research setting.