Long-term parental and family adaptation following pediatric brain injury

OBJECTIVE: To determine whether parents of children with traumatic brain injuries (TBI) report increased injury-related burden, distress, and family dysfunction and to examine the effects of attrition on the results. METHODS: Children with severe TBI, moderate TBI, and orthopedic injuries were followed at six time points from baseline to 6 years after injury. Parents completed measures of injury-related burden, psychological distress, and family functioning at each assessment. Mixed model analysis was used to examine long-term changes. RESULTS: Attrition was higher among families in the severe TBI group with lower burden thereby amplifying group differences. The severe TBI group reported higher injury-related burden over time after injury than the other groups. Family functioning was moderated by social resources. Families of children with severe TBI and low resources reporting deteriorating functioning over the follow-up interval. CONCLUSIONS: Although environmental advantages moderate long-term effects on family functioning, families of children with severe TBI experience long-standing injury-related burden.     

Family burden and parental distress following mild traumatic brain injury in children and its relationship to post-concussive symptoms

OBJECTIVE: To examine the relationship of mild traumatic brain injuries (TBI) and post-concussive symptoms (PCS) to post injury family burden and parental distress, using data from a prospective, longitudinal study. METHODS: Participants included 71 children with mild TBI with loss of consciousness (LOC), 110 with mild TBI without LOC, and 97 controls with orthopedic injuries not involving the head (OI), and their parents. Shortly after injury, parents and children completed a PCS interview and questionnaire, and parents rated premorbid family functioning. Parents also rated family burden and parental distress shortly after injury and at 3 months post injury. RESULTS: Mild TBI with LOC was associated with greater family burden at 3 months than OI, independent of socioeconomic status and premorbid family functioning. Higher PCS shortly after injury was related to higher ratings of family burden and distress at 3 months. CONCLUSIONS: Mild TBI are associated with family burden and distress more than mild injuries not involving the head, although PCS may influence post injury family burden and distress more than the injury per se. Clinical implications of the current findings are noted in the Discussion section.     

Brief report: parental report of sleep behaviors following moderate or severe pediatric traumatic brain injury

OBJECTIVE: Determine the effect of moderate and severe traumatic brain injuries (TBI) on the sleep of school-aged children. METHODS: A concurrent cohort-prospective design compared children aged 6-12 years who sustained moderate TBI (baseline n = 56), severe TBI (n = 53), or only orthopedic injuries (n = 80). Retrospective parental report of pre-injury sleep was collected about 3 weeks post-injury. Post-injury assessments occurred prospectively a mean of 6, 12, and 48 months later. RESULTS: Growth curve analyses compared the groups over time. The moderate TBI group had worse pre-injury sleep than the other groups. The moderate TBI and orthopedic injury groups displayed a small decline in sleep problems from pre- to post-injury. Children with severe TBI displayed increased post-injury sleep problems. CONCLUSIONS: Children who sustain severe TBI are at elevated risk for post-injury sleep problems. Because sleep problems may result in daytime impairments and family distress, additional clinical and research attention is warranted.     

Race as a moderator of parent and family outcomes following pediatric traumatic brain injury

OBJECTIVE: To use data from a prospective, longitudinal study to determine whether race moderates parent and family outcomes during the first year following pediatric traumatic brain injuries (TBI). METHOD: Participants included 73 white and 18 black children with moderate to severe TBI and their families, and 32 white and 23 black children with orthopedic injuries only (OI) and their families. Assessments of parent and family functioning occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. RESULTS: Race was a significant moderator of group differences in parental psychological distress and perceived family burden, by and large independent of socioeconomic status. The negative consequences of TBI were relatively less pronounced for parents of black children than for parents of white children at baseline, but became more pronounced at the two follow-ups. Black and white parents differed in preferred coping strategies, which may partially account for their different reactions to their children's injuries. CONCLUSIONS: The sociocultural factors associated with race may moderate the effects of pediatric TBI and OI on parents and families.     

Brief report: Evaluation of an interactive intervention designed to reduce pediatric distress during radiation therapy procedures

OBJECTIVE: To evaluate the efficacy of an interactive intervention in reducing distress related to radiation therapy (RT) among pediatric cancer participants as measured by occurrence of sedation, observed behavioral distress (OBD), and heart rate (HR). METHODS: Seventy-nine children receiving RT simulation were assigned randomly to a STARBRIGHT Hospital Pals group (i.e., interactive intervention group; IG) or modified control group (MCG). The interactive intervention included filmed modeling, exposure to an interactive Barney character, and passive auditory distraction. RESULTS: Children in the IG experienced significantly lower HR when compared with MCG participants. No differences were found in terms of sedation or OBD. CONCLUSIONS: The interactive intervention was effective at reducing RT-related distress (as measured by HR) and would be a useful tool in pediatric radiation oncology settings.     

Eliciting parental report following pediatric traumatic brain injury: preliminary findings on the Pediatric Inventory of Neurobehavioral Symptoms.

The current article presents preliminary normative data for the Pediatric Inventory of Neurobehavioral Symptoms (PINS), a parent rating scale consisting of symptoms associated with post-traumatic cerebral dysfunction, such as disinhibition, perseveration, reduced spontaneity, inappropriate affective responses, episodic phenomena, and disruptions of biologic function. Comparison data from a sample of 50 elementary age children who had sustained traumatic brain injury (TBI) reveals significant differences on the PINS total score and each of five subscale scores. Two of the 5 PINS subscales (Episodic Symptoms, Biologic Signs) significantly differentiated the TBI and Attention Deficit Hyperactivity Disorder (n = 35) groups, suggesting that these may be clinical features that distinguish post-traumatic cerebral dysfunction from developmental psychopathology. Despite the need for additional research, the PINS appears to be a promising new measure in advancing our understanding of the neurobehavioral sequelae of pediatric traumatic brain injury.     

Interpersonal stressors and resources as predictors of parental adaptation following pediatric traumatic injury

The authors examined the relationship of preinjury interpersonal resources and stressors to parental adaptation following pediatric traumatic brain injury (TBI) and orthopedic injury. Parents of children with severe TBI (n = 53), moderate TBI (n = 56), and orthopedic injuries (n = 80) were assessed soon after injury, 6 and 12 months after the initial evaluation, and at an extended follow-up with a mean of 4 years postinjury. General linear model analyses provide support for both main and moderating effects of stressors and resources on parental adjustment. Support from friends and spouse was associated with less psychological distress, whereas family and spouse stressors were associated with greater distress. The results also reveal a marked decline in injury-related stress over follow-up for families in the severe TBI group who reported a combination of high stressors and high resources. The decline suggests that interpersonal resources attenuated long-term family burden because of severe TBI. The findings are discussed in terms of their implications for intervention following TBI.     

Working memory and new learning following pediatric traumatic brain injury

Working memory (WM), the ability to monitor, process and maintain task relevant information on-line to respond to immediate environmental demands, is controlled by frontal systems (D'Esposito et al., 2006), which are particularly vulnerable to damage from a traumatic brain injury (TBI). This study employed the adult-based Working Memory model of Baddeley and Hitch (1974) to examine the relationship between working memory function and new verbal learning in children with TBI. A cross-sectional sample of 36 school-aged children with a moderate to severe TBI was compared to age-matched healthy Controls on a series of tasks assessing working memory subsystems: the Phonological Loop (PL) and Central Executive (CE). The TBI group performed significantly more poorly than Controls on the PL measure and the majority of CE tasks. On new learning tasks, the TBI group consistently produced fewer words than Controls across the learning and delayed recall phases. Results revealed impaired PL function related to poor encoding and acquisition on a new verbal learning task in the TBI group. CE retrieval deficits in the TBI group contributed to general memory dysfunction in acquisition, retrieval and recognition memory. These results suggest that the nature of learning and memory deficits in children with TBI is related to working memory impairment.     

Metacognition following pediatric traumatic brain injury: a preliminary study

Metacognition is one of the cognitive processes included under the general term executive functions. The executive functions are widely held to be under the control of the prefrontal cortex, an area often damaged after severe traumatic brain injury (TBI). We examined the metacognitive processing of a group of 9 children with TBI, and a group of 9 healthy, age-matched control children. Children with TBI showed significant impairments in their accuracy of prediction of the ease with which an item would be learned and their ability to predict recall of an item after a 2-hr delay. No significant differences in recall performance between the TBI and control groups were exhibited. The results are interpreted as suggesting an impairment in metacognitive processing resulting from frontal lobe damage after TBI in children. Additional research is necessary to confirm the relation of frontal lobe pathology and severity of injury to metacognitive impairments.     

The relationship of caregiver coping to family outcomes during the initial year following pediatric traumatic injury

This study identified coping strategies associated with caregiver outcomes following pediatric injury and examined injury type as a moderator of coping efficacy. Families of 103 children with traumatic brain injury (TBI) and 71 children with orthopedic injuries were followed prospectively during the initial year postinjury. The groups had comparable preinjury characteristics and hospitalization experiences but differed on neurological insult. In hierarchical regression analyses, acceptance was associated with lower burden and denial was associated with greater distress in both groups. Active coping resulted in higher distress following TBI but not orthopedic injuries. Conversely, the use of humor was related to diminishing distress following TBI but unrelated to distress following orthopedic injuries. Results are discussed in terms of the implications for intervention following TBI.     

A systematic review of interventions to reduce psychological distress in pediatric patients receiving radiation therapy

Objective

Radiation therapy (RT) is a cornerstone for management of pediatric cancer. For younger patients, unintended radiation to critical organs is a concern and children need to remain immobile. Distress in children is common so many centres sedate pediatric patients. Children often are unable to remain still, due to anxiety. Interventions to reduce distress could also reduce sedation rates. The objectives of this systematic review were to: review the interventions used to address pediatric RT patients' distress and anxiety and assess their effectiveness.

Effect of an intervention to reduce procedural pain and distress for children with HIV infection

OBJECTIVE: To evaluate a multicomponent pain management intervention, including cognitive behavioral strategies, for children with human immunodeficiency virus (HIV) infection undergoing routine venipuncture. METHODS: Following a baseline venipuncture, children were exposed to an intervention including preparation, relaxation, distraction, reinforcement, parent involvement, and EMLA (eutectic mixture of local anesthetics) cream, and followed for three additional venipuncture procedures. After each procedure, child distress was rated on the Procedure Behavior Checklist (PBCL), child self-report of pain was obtained using the FACES scale, and parent anxiety was reported on the State Trait Anxiety Inventory-State Scale (STAI). RESULTS: Significant reductions in child distress and pain were found by the second postintervention procedure and maintained at the third. Parent anxiety was significantly reduced by the second postintervention procedure, but many parents chose not to participate in the third postintervention procedure. CONCLUSIONS: With repeated exposure, a multicomponent pain management intervention, including cognitive behavioral strategies and EMLA, appears effective at reducing pain, distress, and parent anxiety for children with HIV.     

The impact of injury severity on executive function 7-10 years following pediatric traumatic brain injury

The impact of pediatric traumatic brain injury (TBI) on executive function (EF) development is well documented, with more severe injury associated with poorer outcome. Few studies have investigated the impact of pediatric TBI on EF in the long-term post-injury. The current study explored the relationship between injury severity and EF in participants with childhood TBI, following the transition into adulthood. The sample included 36 participants who had sustained TBI between 8-12 years of age. At 7-10 years post-injury, they now ranged between 16-22 years of age. Findings indicated that adolescents and young adults who suffered a more severe TBI during childhood tended to display a higher degree of executive dysfunction, but only in specific EF domains.     

Long-term behavior problems following pediatric traumatic brain injury: prevalence,predictors, and correlates

OBJECTIVE: To study identified rates of long-term behavior problems in children with traumatic brain injury (TBI) compared to children with only orthopedic injuries and risk factors and correlates for new behavior problems following TBI. METHODS: Sample included children with severe TBI (n = 42), moderate TBI (n = 41), and orthopedic injuries only (ORTHO;n = 50). The baseline assessment measured child behavior, adaptation, and neuropsychological, academic, and family functioning. Follow-ups were conducted at 6 and 12 months and at an extended follow-up a mean of 4 years after injury. RESULTS: The prevalence of caseness, defined as elevated behavior problem ratings, was higher in one or both TBI groups than in the ORTHO group at each follow-up (e.g., 36% of severe TBI group, 22% of moderate TBI group, and 10% of ORTHO group at extended follow-up). Most instances of postinjury-onset caseness at the extended follow-up were evident within the first year after TBI. Predictors were severe TBI, socioeconomic disadvantage, and preinjury behavioral concerns. Concurrent correlates included weakness in working memory and adaptive behavior skills, poorer behavior and school competence, and adverse family outcomes. CONCLUSIONS: Postinjury-onset caseness is persistent, risks are multifactorial, and correlates include child dysfunction and family sequelae.     

An intervention to reduce postpartum depressive symptoms: a randomized controlled trial

Depressive symptoms and depression are a common complication of childbirth, and a growing body of literature suggests that there are modifiable factors associated with their occurrence. We developed a behavioral educational intervention targeting these factors and successfully reduced postpartum depressive symptoms in a randomized trial among low-income black and Latina women. We now report results of 540 predominantly white, high-income mothers in a second randomized trial. Mothers in the intervention arm received a two-step intervention that prepared and educated mothers about modifiable factors associated with postpartum depressive symptoms (e.g., physical symptoms, low self-efficacy), bolstered social support, and enhanced management skills. The control arm received enhanced usual care. Participants were surveyed prior to randomization, 3 weeks, 3 months, and 6 months postpartum. Depressive symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS of 10 or greater). Prevalence of depressive symptoms postpartum was unexpectedly low precluding detection of difference in rates of depressive symptoms among intervention versus enhanced usual care posthospitalization: 3 weeks (6.0 vs. 5.6 %, p?=?0.83), 3 months (5.1 vs. 6.5 %, p?=?0.53), and 6 months (3.6 vs. 4.6 %, p?=?0.53).     

Inhibitory control following perinatal brain injury

Evidence from developmental, lesion, and neuroimaging studies indicates that the prefrontal cortex plays a major role in executive abilities, including inhibitory control. Proficient executive performance, however, relies not only on the integrity of the prefrontal cortex but also on its interactions with other brain regions. In the current study, the authors focused on the effect that early damage to the white matter tracts interconnecting prefrontal and other brain regions has on inhibitory control. Data were collected from 13 children with bilateral spastic cerebral palsy and from a control group of 20 children with no history of neurologic compromise. Converging evidence from 3 separate paradigms is presented that strongly suggests these children experience impairments in inhibitory control. Findings are discussed within the context of current cognitive and neuroanatomical models of inhibition.