Injury Severity Influences Long-Term Cognitive Control in Pediatric "Mild" Traumatic Brain Injury

Pediatric "mild" traumatic brain injury (pmTBI), or concussion, is increasingly associated with persisting and often undiagnosed cognitive difficulties, particularly, in adolescents. Emerging evidence suggests that these deficits are most pronounced during tasks requiring competing attentional demands (i.e., reactive control). However, it remains unclear how injury severity, indexed by loss of consciousness and/or posttraumatic amnesia (LOC/PTA) interacts with neurodevelopment to shape long-term, modality-specific alterations in cognitive control. In this longitudinal fMRI study, we examined reactive cognitive control using a multimodal attention task in a large cohort of pmTBI (N = 236) and age- and sex-matched healthy controls (N = 212), across three timepoints (~1 week, ~4 months, and ~1 year) postinjury. Participants with LOC/PTA+ exhibited reduced task performance across both visual and auditory modalities, accompanied by persistent neural disruptions, indicating that greater injury severity is associated with more widespread, cross-modal impairments in attentional control. In contrast, participants without LOC/PTA- demonstrated increased neural activation early after injury, potentially reflecting compensatory recruitment in the auditory domain to maintain performance. However, this was accompanied by greater clinical burden (i.e., sleep disturbance, depression) and was followed by evidence of dysregulated control by ~1 year postinjury, suggesting that short-term neural compensation may carry longer-term consequences. Notably, neural differences across groups were primarily observed in the auditory domain, with alterations in frontotemporal and cerebellar regions. This modality-specific effect may reflect developmental shifts toward visual dominance during adolescence, which could increase processing demands for auditory information and render it more vulnerable to disruption following injury. Together these findings indicate that pmTBI is associated with persistent alterations in cognitive control processes that evolve over time as a function of injury severity.