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Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture
Open accessAbstract
Background: Cognitive fatigue is a common yet underrecognized consequence of pediatric traumatic brain injury (TBI), with significant implications for quality of life, academic performance, and long-term recovery. Despite its prevalence, there is no gold standard for assessing cognitive fatigue in children, and existing tools vary widely in scope and sensitivity. Objective: This scoping review aims to identify and evaluate the outcome measures currently used to assess cognitive fatigue in pediatric TBI populations over the past decade (2014–2024). Methods: Following the PRISMA-ScR guidelines, a systematic search was conducted using PubMed, Scopus, Cochrane, ScienceDirect, and Google Scholar. Studies included focused on children and adolescents with TBI and utilized at least one outcome measure assessing cognitive fatigue. Ten years of literature were reviewed to provide a comprehensive overview of available tools. Results: A total of 10 studies met the inclusion criteria. The most commonly used instrument was the Pediatric Quality of Life Inventory (PedsQL) Multidimensional Fatigue Scale, followed by the PROMIS® Pediatric Fatigue Item Bank and related subjective self- and parent-report tools. These measures primarily captured generalized fatigue, with limited specificity for cognitive domains. Few studies incorporated performance-based or objective assessments. Methodological gaps included heterogeneity in assessment timelines, lack of standardization, and minimal inclusion of younger children or those with severe injuries. Conclusion: Current tools for assessing cognitive fatigue in pediatric TBI populations lack developmental sensitivity, specificity, and ecological validity. There is an urgent need to develop and validate comprehensive, age-appropriate instruments that incorporate both subjective and objective components. Future tools should address fluctuations in cognitive fatigue and support individualized rehabilitation strategies aimed at improving functional outcomes and quality of life
Overview
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TL;DR
This scoping review identified 10 studies (2014–2024) using outcome measures for cognitive fatigue in pediatric TBI, finding that the PedsQL Multidimensional Fatigue Scale and PROMIS Pediatric Fatigue Item Bank were most common but mainly captured generalized fatigue. The authors conclude current tools lack developmental sensitivity, cognitive specificity, and ecological validity, and call for combined subjective and objective, age-appropriate measures.
Key findings
- Ten studies met inclusion criteria; the most commonly used instrument was the PedsQL Multidimensional Fatigue Scale, followed by the PROMIS® Pediatric Fatigue Item Bank and related subjective self- and parent-report tools.
- These measures primarily captured generalized fatigue, with limited specificity for cognitive domains; few studies incorporated performance-based or objective assessments.
- Methodological gaps included heterogeneity in assessment timelines, lack of standardization, and minimal inclusion of younger children or those with severe injuries.
- The introduction reports that up to 60% of children with TBI experience chronic fatigue, and post-ABI fatigue is linked to reduced physical, cognitive, and emotional functioning.
Methods
- Scoping review following PRISMA-ScR; searched PubMed, Scopus, Cochrane, ScienceDirect, and Google Scholar for English-language full-text articles from February 2014 to December 2024 using keywords: traumatic brain injury, assessment, cognitive fatigue, outcome measures, quality of life.
- Included studies focused on children and adolescents with TBI and used at least one outcome measure assessing cognitive fatigue; data from review articles, meta-analyses, original publications, and randomized controlled trials were analysed.
- Ten studies met inclusion criteria; the review compiled and evaluated their outcome measures, domains, assessment timelines, findings, and methodological gaps.
Limitations
- The paper states methodological gaps in the reviewed literature: heterogeneity in assessment timelines, lack of standardization, and minimal inclusion of younger children or those with severe injuries; it also states current tools lack developmental sensitivity, specificity, and ecological validity.
- The paper notes that PedsQL relies on subjective reports and may miss task-specific or fluctuating cognitive fatigue, children under 8 may lack introspective ability, caregiver reports may be biased, PROMIS primarily reflects generalized fatigue, BRIEF lacks fatigue specificity, and objective/physiological markers are invasive and resource-intensive.
- Evident from the text: the review itself does not report a formal limitations section, risk-of-bias assessment, or quality appraisal; it is restricted to English-language articles, 2014–2024, and 10 included studies, with full-text access as an exclusion reason.
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In the paper
“Methodological gaps included heterogeneity in assessment timelines, lack of standardization, and minimal inclusion of younger children or those with severe injuries.”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Abstract
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“Methodological gaps included heterogeneity in assessment timelines, lack of standardization, and minimal inclusion of younger children or those with severe injuries.”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Abstract
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
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In the paper
“Methodological gaps included heterogeneity in assessment timelines, lack of standardization, and minimal inclusion of younger children or those with severe injuries.”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Abstract
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
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In the paper
“Few studies incorporated performance-based or objective assessments.”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Abstract
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The most commonly used instrument was the Pediatric Quality of Life Inventory (PedsQL) Multidimensional Fatigue Scale, followed by the PROMIS® Pediatric Fatigue Item Bank and related subjective self-and parent-report tools.”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Abstract
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Inclusion and Exclusion Criteria
“Uncovering corticostriatal correlates of cognitive fatigue in pediatric acquired brain disorder: Evidence from traumatic brain injury.(14) Ryan NP”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > References
“14. Crichton AJ, Babl F, Oakley E, Greenham M, Hearps S, Delzoppo C, et al. Prediction of Multidimensional Fatigue After Childhood Brain Injury.”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Inclusion and Exclusion Criteria
“Varni et al 2002 stated that one of the most widely used tools in pediatric fatigue research is the Pediatric Quality of Life Inventory (PedsQL) Multidimensional Fatigue Scale”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > References
“15. Holtzer R, Shuman M, Mahoney JR, Lipton R, Verghese J. Cognitive Fatigue Defined in the Context of Attention Networks.”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Inclusion and Exclusion Criteria
“The Behavior Rating Inventory of Executive Function (BRIEF) has been suggested as an indirect tool for assessing executive function-related fatigue in children (19).”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > References
“19. Lai JS, Stucky BD, Thissen D, Varni JW, DeWitt EM, Irwin DE, et al. Development and psychometric properties of the PROMIS(®) pediatric fatigue item banks.”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Inclusion and Exclusion Criteria
“A recent systematic review by Capone et al. (2024) confirmed that across pediatric neurorehabilitation settings, there is no universally adopted measure for cognitive fatigue, and existing tools show considerable heterogeneity in content, administration mode, and psychometric quality (21).”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > References
“21. De Nardi L, Lanzetta MA, Ghirigato E, Barbi E, Gortani G. Approach to the child with fatigue: A focus for the general pediatrician. Front Pediatr [Internet]. 2022 Dec 2”
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > Inclusion and Exclusion Criteria
“3. Cognitive Fatigue in Pediatric Traumatic Brain Injury: A Meta-Analysis and Scoping Review(7) Riccardi JS, Ciccia A”
§ Assessing Cognitive Fatigue in Pediatric Traumatic Brain Injury: Are We Capturing the Whole Picture > References
“8. Riccardi JS, Ciccia A. Cognitive Fatigue in Pediatric Traumatic Brain Injury: A Meta-Analysis and Scoping Review.”
Citations
Cites
Behavior Rating Inventory of Executive Function
Gioia, G. A., lsquith, P. K., Guy, S. C., & Kenworthy, L. (2022) · PsycTESTS Dataset · doi:10.1037/t73087-000 · Cited by 901
Research works printed but not linked: 18
- ARAKI T, YOKOTA H, MORITA A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo). 2017 Feb;57(2):82-93.
- Blackwell LS, Grell R. Pediatric Traumatic Brain Injury: Impact on the Developing Brain. Pediatr Neurol. 2023 Nov 1;148:215-22.
- Satapathy MC, Dash D, Mishra SS, Tripathy SR, Nath PC, Jena SP. Spectrum and outcome of traumatic brain injury in children <15 years: A tertiary level experience in India. Int J Crit Illn Inj Sci. 2016;6(1):16 -20.
- Riccardi JS, Ciccia A. Cognitive Fatigue in Pediatric Traumatic Brain Injury: A Meta-Analysis and Scoping Review. J Head Trauma Rehabil. 2021 Aug;36(4):226.
- Fatigue recovery and connected factors following paediatric concussion | British Journal of Sports Medicine [Internet]. [cited 2024 Dec 8]. Available from: https://bjsm.bmj.com/content/58/2/59
- Available from: https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2021.719915/full · doi:10.3389/fneur.2021.719915/full
- Riccardi JS, Ciccia A. Cognitive Fatigue in Pediatric Traumatic Brain Injury: A Meta-Analysis and Scoping Review. J Head Trauma Rehabil. 2021 Aug 1;36(4):226-41.
- Luther M, Poppert Cordts KM, Williams CN. Sleep disturbances after pediatric traumatic brain injury: a systematic review of prevalence, risk factors, and association with recovery. Sleep. 2020 Oct 13;43(10):zsaa083.
- Câmara-Costa H, Francillette L, Opatowski M, Toure H, Brugel D, Laurent-Vannier A, et al. Self-and Parent- Reported Fatigue 7 Years After Severe Childhood Traumatic Brain Injury: Results of the Traumatisme Grave de l'Enfant Prospective Longitudinal Study. J Head Trauma Rehabil. 2020;35(2):104-16.
- Crichton A, Anderson V, Oakley E, Greenham M, Hearps S, Delzoppo C, et al. Fatigue Following Traumatic Brain Injury in Children and Adolescents: A Longitudinal Follow-Up 6 to 12 Months After Injury. J Head Trauma Rehabil. 2018;33(3):200-9.
- Crichton A, Oakley E, Babl FE, Greenham M, Hearps S, Delzoppo C, et al. Predicting Fatigue 12 Months after Child Traumatic Brain Injury: Child Factors and Postinjury Symptoms. J Int Neuropsychol Soc JINS. 2018 Mar;24(3):224-36.
- Crichton AJ, Babl F, Oakley E, Greenham M, Hearps S, Delzoppo C, et al. Prediction of Multidimensional Fatigue After Childhood Brain Injury. J Head Trauma Rehabil. 2017;32(2):107-16.
- Holtzer R, Shuman M, Mahoney JR, Lipton R, Verghese J. Cognitive Fatigue Defined in the Context of Attention Networks. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2011 Jan;18(1):108-28.
- Varni JW, Limbers CA, Bryant WP, Wilson DP. The PedsQL multidimensional fatigue scale in pediatric obesity: feasibility, reliability and validity. Int J Pediatr Obes IJPO Off J Int Assoc Study Obes. 2010;5(1):34 - 42.
- Sommer A, Grothus S, Grochowska K, Claus BB, Stahlschmidt L, Wager J. Assessing fatigue in children and adolescents: Psychometric validation of the German version of the PROMIS® Pediatric Short Form v2.0 -Fatigue 10a in school children and pediatric chronic pain patients. Qual Life Res Int J Qual Life Asp Journal of Neonatal Surgery | Year: 2025 | Volume: 14 | Issue: 19s Treat Care Rehabil. 2022 Apr;31(4):1257-66.
- Lai JS, Stucky BD, Thissen D, Varni JW, DeWitt EM, Irwin DE, et al. Development and psychometric properties of the PROMIS(®) pediatric fatigue item banks. Qual Life Res Int J Qual Life Asp Treat Care Rehabil. 2013 Nov;22(9):2417-27.
- De Nardi L, Lanzetta MA, Ghirigato E, Barbi E, Gortani G. Approach to the child with fatigue: A focus for the general pediatrician. Front Pediatr [Internet]. 2022 Dec 2 [cited 2025 Apr 8];10. Available from: https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2022.1044170/full · doi:10.3389/fped.2022.1044170/full
- Dickens A, Champion AJ, Schenke KC. Fatigue management: a systematic review of objective measurement techniques for cognitive fatigue. J Clin Exp Neuropsychol. 2024 Oct;46(8):776-93. ..
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Metadata
- Authors
- Palekar, P., Sukey, B., & Palekar, T. J.
- ORCID
- Palekar, Tushar J
- Venue
- Journal of Neonatal Surgery
- Publisher
- Skyler Publication
- Published
- 2025-04-29
- Volume
- 14
- Issue
- 19S
- Pages
- 750-759
- ISSN
- 2226-0439 (ISSN-L)
- OpenAlex
- W4410325039
- Semantic Scholar
- 0d3bc7d181d81887d47389273c9c464aa0abb778
- Cited by
- 0
- References
- 1
- FWCI
- 0.00
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- Journal of Neonatal Surgery (publishedVersion, cc-by)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury Research
- Health Sciences › Medicine › Clinical Neurology › Traumatic Brain Injury and Neurovascular Disturbances
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Childhood Cancer Survivors' Quality of Life
- Keywords
- mental fatigue, pediatric traumatic brain injury, outcome measures, fatigue assessment tools, PedsQL Multidimensional Fatigue Scale, performance-based assessment, quality of life, cognitive rehabilitation
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