Bidirectional child-family influences on outcomes of traumatic brain injury in children.

Child behavior problems, injury-related family burden, and parent psychological distress were assessed longitudinally over the first year post injury in 40 children with severe traumatic brain injury (TBI), 52 with moderate TBI, and 55 with orthopedic injuries not involving brain insult. Parents rated children's preinjury behavior soon after injury. Postinjury child behavior and family outcomes were assessed at 6- and 12-month follow-ups. Findings from path analysis revealed both direct and indirect effects of TBI on child behavior and family outcomes, as well as cross-lagged child-family associations. Higher parent distress at 6 months predicted more child behavior problems at 12 months, controlling for earlier behavior problems; and more behavior problems at 6 months predicted poorer family outcomes at 12 months, controlling for earlier family outcomes. Support for bidirectional influences is tentative given that limited sample size precluded use of structural equation modeling. The findings nevertheless provide impetus for considering the influences of person-environment interactions on outcomes of TBI.     

The King's Outcome Scale for Childhood Head Injury and injury severity and outcome measures in children with traumatic brain injury

The aim of this study was to relate discharge King's Outcome Scale for Childhood Head Injury (KOSCHI) category to injury severity and detailed outcome measures obtained in the first year post-traumatic brain injury (TBI). We used a prospective cohort study. Eighty-one children with TBI were studied: 29 had severe, 15 moderate, and 37 mild TBI. The male:female ratio was 1.8:1. The mean age was 11 years 10 months (SD 3.6, range 5-16y). Discharge KOSCHI categories were good (n=34), moderate (n=39), severe (n=6), and unclassifiable (n=2). KOSCHI category correlated strongly with admission Glasgow Coma Score, length of hospital stay, and post-traumatic amnesia. It also correlated significantly with Verbal IQ and Performance IQ (Wechsler); measures of attention; health status (Health Utilities Index [HUI]); health-related quality of life (Pediatric Quality of Life Inventory [PedsQL]); depressive symptoms (Birleson Depression Scale) assessed within 3 months postTBI; and with Verbal IQ, selective attention (map mission), and HUI and PedsQL domains assessed at least 6 months post-TBI discharge. KOSCHI did not correlate with behaviour or executive function. We conclude that the KOSCHI scored at hospital discharge correlates with severity of injury and some cognitive, health status, and HRQL outcomes early after TBI. It is not helpful at predicting later difficulties, or behavioural and emotional problems.     

Longitudinal outcome and recovery of social problems after pediatric traumatic brain injury (TBI): Contribution of brain insult and family environment

Pediatric traumatic brain injury (TBI) can result in a range of social impairments, however longitudinal recovery is not well characterized, and clinicians are poorly equipped to identify children at risk for persisting difficulties. Using a longitudinal prospective design, this study aimed to evaluate the contribution of injury and non-injury related risk and resilience factors to longitudinal outcome and recovery of social problems from 12- to 24-months post-TBI. 78 children with TBI (injury age: 5.0–15.0 years) and 40 age and gender-matched typically developing (TD) children underwent magnetic resonance imaging including a susceptibility-weighted imaging (SWI) sequence 2–8 weeks post-injury (M = 39.25, SD = 27.64 days). At 12 and 24-months post- injury, parents completed questionnaires rating their child’s social functioning, and environmental factors including socioeconomic status, caregiver mental health and family functioning. Results revealed that longitudinal recovery profiles differed as a function of injury severity, such that among children with severe TBI, social problems significantly increased from 12- to 24-months post-injury, and were found to be significantly worse than TD controls and children with mild and moderate TBI. In contrast, children with mild and moderate injuries showed few problems at 12-months post-injury and little change over time. Pre-injury environment and SWI did not significantly contribute to outcome at 24-months, however concurrent caregiver mental health and family functioning explained a large and significant proportion of variance in these outcomes. Overall, this study shows that longitudinal recovery profiles differ as a function of injury severity, with evidence for late-emerging social problems among children with severe TBI. Poorer long-term social outcomes were associated with family dysfunction and poorer caregiver mental health at 24-months post injury, suggesting that efforts to optimize the child’s environment and bolster family coping resources may enhance recovery of social problems following pediatric TBI.     

A quantitative review of the effects of traumatic brain injury on cognitive functioning

Changes in cognitive functioning often result from traumatic brain injury (TBI) and predict other important aspects of psychosocial recovery. Despite this pivotal role, no quantitative review of cognitive functioning across the spectrum of TBI severity has been reported. We therefore conducted a meta-analysis of 39 mostly cross-sectional studies of the cognitive effects of mild head injury (MHI) and moderate-severe TBI from the acute phase through long-term follow-up. The studies reported 48 comparisons of patients (n = 1716) and control subjects (n = 1164). Averaged across all follow-up periods, the effect of moderate-severe TBI (weighted mean Cohen's d = -0.74) was more than three times the effect of MHI (weighted mean d = -0.24) on overall cognitive functioning. Further, the natural logarithm of the follow-up interval correlated very strongly with estimates of d among patients with MHI, but less so among those with moderate-severe TBI. In short, findings from published research suggest that overall cognitive functioning recovers most rapidly during the first few weeks following MHI, and essentially returns to baseline within 1-3 months. Cognitive functioning also improves during the first two years after moderate-severe TBI, but remains markedly impaired even among patients tested > 2 years post-injury.     

Caregiver burden during the year following severe traumatic brain injury

Fifty-two primary caregivers of people with a severe traumatic brain injury (TBI) were assessed at 6-months and 1-year postinjury. Caregiver appraisal of the person with TBI's physical, cognitive, emotional, behavioural, and social functioning was assessed. Caregiver psychosocial functioning and levels of subjective and objective burden were also assessed. Some aspects of the difficulties reported for the people with TBI remained stable, while others increased in frequency, over time. At 6-months postinjury, approximately one third of caregivers reported clinically significant symptoms of anxiety and depression, and poor social adjustment. By 1-year postinjury, the prevalence of anxiety and depression remained the same, although only one-quarter continued to report poor social adjustment. There was some evidence of adaptation by caregivers, as the frequency with which various types of objective burden were reported remained stable, while the distress caused by these decreased in the first year postinjury. It appears that the impact on caregivers of physical impairment is comparatively short-lived and that caregivers learn some practical ways to manage the behavioural problems of the people with TBI. Despite this, over time the person with TBI's behavioural and cognitive problems begins to play a larger role in the level of distress experienced by the caregiver. However, it is the person with TBI's social isolation that has a stable and consistent role in the experience of subjective burden for primary caregivers in the first year postinjury.     

The ties that bind: the relationship between caregiver burden and the neuropsychological functioning of TBI survivors

Advances in medical and assistive technology have increased the likelihood of survival following a traumatic brain injury (TBI). Consequently, families frequently must provide care to individuals with TBI. Because they are rarely prepared for the associated demanding medical needs and financial burden, family caregivers are at risk for physical and emotional problems, which can negatively influence their individual and family functioning. Whereas scholars have examined the influence of survivor functioning on caregiver burden, few have explicitly recognized that caregiver burden also influences survivor functioning. Results of a multivariate linear regression suggest that, in a sample of 51 pairs of TBI survivors and their caregivers living in Colombia, survivors receiving care from a family member who reported a higher level of burden had poorer objective neuropsychological functioning than those receiving care from a family member who reported a lower level of burden, after controlling for survivor education and history of occupational therapy. Therefore, a family-focused approach might maximize intervention effectiveness, especially for Latin American and Hispanic families, which tend to be characterized by a strong sense of familism. The emphasis on family can create problems in a healthcare system that views the individual as the primary unit.     

Caregiver Burden During the Year Following Severe Traumatic Brain Injury

Fifty-two primary caregivers of people with a severe traumatic brain injury (TBI) were assessed at 6-months and 1-year postinjury. Caregiver appraisal of the person with TBI's physical, cognitive, emotional, behavioural, and social functioning was assessed. Caregiver psychosocial functioning and levels of subjective and objective burden were also assessed. Some aspects of the difficulties reported for the people with TBI remained stable, while others increased in frequency, over time. At 6-months postinjury, approximately one third of caregivers reported clinically significant symptoms of anxiety and depression, and poor social adjustment. By 1-year postinjury, the prevalence of anxiety and depression remained the same, although only one-quarter continued to report poor social adjustment. There was some evidence of adaptation by care-givers, as the frequency with which various types of objective burden were reported remained stable, while the distress caused by these decreased in the first year postinjury. It appears that the impact on caregivers of physical impairment is comparatively short-lived and that caregivers learn some practical ways to manage the behavioural problems of the people with TBI. Despite this, over time the person with TBI's behavioural and cognitive problems begins to play a larger role in the level of distress experienced by the caregiver. However, it is the person with TBI's social isolation that has a stable and consistent role in the experience of subjective burden for primary caregivers in the first year postinjury.     

A quantitative review of the effects of traumatic brain injury on cognitive functioning

Changes in cognitive functioning often result from traumatic brain injury (TBI) and predict other important aspects of psychosocial recovery. Despite this pivotal role, no quantitative review of cognitive functioning across the spectrum of TBI severity has been reported. We therefore conducted a meta-analysis of 39 mostly cross-sectional studies of the cognitive effects of mild head injury (MHI) and moderate–severe TBI from the acute phase through long-term follow-up. The studies reported 48 comparisons of patients (n = 1716) and control subjects (n = 1164). Averaged across all follow-up periods, the effect of moderate–severe TBI (weighted mean Cohen‘s d = ?0.74) was more than three times the effect of MHI (weighted mean d = ?0.24) on overall cognitive functioning. Further, the natural logarithm of the follow-up interval correlated very strongly with estimates of d among patients with MHI, but less so among those with moderate–severe TBI. In short, findings from published research suggest that overall cognitive functioning recovers most rapidly during the first few weeks following MHI, and essentially returns to baseline within 1–3 months. Cognitive functioning also improves during the first two years after moderate–severe TBI, but remains markedly impaired even among patients tested >?2 years post-injury.     

Personality change disorder in children and adolescents following traumatic brain injury.

The occurrence of personality change due to traumatic brain injury (PC), and its clinical and neuroimaging correlates were investigated. Ninety-four children, ages 5 through 14 at the time of hospitalization following traumatic brain injury (TBI; severe TBI N = 37; mild-moderate TBI N = 57), were assessed. Standardized psychiatric, adaptive functioning, cognitive functioning, family functioning, family psychiatric history, severity of injury, and neuroimaging assessments were conducted. The Neuropsychiatric Rating Schedule (NPRS) was used to establish a diagnosis of PC. Approximately 40% of consecutively hospitalized severe TBI participants had ongoing persistent PC an average of 2 years postinjury. An additional approximately 20% had a history of a remitted and more transient PC. PC occurred in 5% of mild-moderate TBI but was always transient. Interrater reliability for the diagnosis of PC was good (Kappa = .70). In severe TBI participants, persistent PC was significantly associated with severity of injury, particularly impaired consciousness over 100 hr, adaptive and intellectual functioning decrements, and concurrent diagnosis of secondary attention deficit hyperactivity disorder, but was not significantly related to any psychosocial adversity variables. These findings suggest that PC is a frequent diagnosis following severe TBI in children and adolescents, but is much less common following mild-moderate TBI.     

Parental distress, parenting practices, and child adaptive outcomes following traumatic brain injury

Moderate and severe pediatric traumatic brain injuries (TBI) are associated with significant familial distress and child adaptive sequelae. Our aim was to examine the relationship between parental psychological distress, parenting practices (authoritarian, permissive, authoritative), and child adaptive functioning 12-36 months following TBI or orthopedic injury (OI). Injury type was hypothesized to moderate the relationship between parental distress and child adaptive functioning, demonstrating a significantly stronger relationship in the TBI relative to OI group. Authoritarian parenting practices were hypothesized to mediate relationship between parental distress and child adaptive functioning across groups. Groups (TBI n = 21, OI n = 23) did not differ significantly on age at injury, time since injury, sex, race, or SES. Parents completed the Brief Symptom Inventory, Parenting Practices Questionnaire, and Vineland-II. Moderation and mediation hypotheses were tested using hierarchical multiple regression and a bootstrapping approach, respectively. Results supported moderation and revealed that higher parental psychological distress was associated with lower child adaptive functioning in the TBI group only. Mediation results indicated that higher parental distress was associated with authoritarian parenting practices and lower adaptive functioning across groups. Results suggest that parenting practices are an important area of focus for studies attempting to elucidate the relationship between parent and child functioning following TBI.     

Functioning and disability 6–15 years after traumatic brain injuries in northern Sweden

Objectives –  To assess long‐term functioning and disability after traumatic brain injury (TBI). Material and methods –  Individuals (n = 88) in Norrbotten, northern Sweden, who had been transferred for neurosurgical care were assessed with internationally established TBI outcome measures 6–15 years post‐injury. Results –  There was an improvement in overall outcome from discharge from inpatient rehabilitation to follow‐up. Many individuals had a high degree of motor and cognitive functioning, which enabled them to live independently in their own home without assistance, but there remained a disability related to community reintegration and social participation. This affected their productivity and to some degree their marital stability. The remaining disability and reduced productivity were related to the age at injury and the injury severity. Conclusions –  Our data showed that individuals with a TBI can achieve and maintain a high degree of functioning many years after the injury. Increasing age and a greater injury severity contributed to their long‐term disability.     

Predictors of secondary attention-deficit/hyperactivity disorder in children and adolescents 6 to 24 months after traumatic brain injury

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively from 6 to 12 months (12-month assessment) and from 12 to 24 months (24-month assessment) postinjury with semistructured psychiatric interviews. Injury and preinjury psychosocial variables were assessed. RESULTS: SADHD occurred in 15 of 103 (15%) of participants between 6 and 12 months after injury and 17 of 82 (21%) in the second year after injury. SADHD was significantly (p < .05) comorbid with personality change due to TBI and new-onset disruptive behavior disorders. Preinjury adaptive function was a consistent predictor of SADHD. Regression analyses revealed that preinjury psychosocial adversity was an independent predictor of SADHD in the second year after injury. Neither severity of injury nor lesion location predicted SADHD from 6 to 24 months postinjury. CONCLUSIONS: Determination of preinjury psychosocial adversity and the child's preinjury functioning during the index hospitalization would improve identification of children at highest risk of development of SADHD.     

Predictors of change in participation rates following acquired brain injury: results of a longitudinal study

Aim The purpose of this study was (1) to examine the changes in participation rates over 1 year among children and adolescents after acquired brain injury and (2) to explore the effect of child and family factors on these changes. Method The participation levels of 136 children and young people (88 males; 48 females; age range 4y 11mo–17y 6mo; mean age 11y 6mo) after acquired brain injury (3≤ Glasgow Coma Scale score ≤15; mean 12.8) were assessed three times: at their return to school, and at 8 and 12 months after returning to school. The Children’s Assessment of Participation and Enjoyment measured the participants’ diversity and intensity of participation in out‐of‐school activities. At baseline, information on general family functioning and medical and demographic information was collected as possible predictors. Mixed‐effect model analyses of participation scores were performed while controlling for child’s age at injury. Results The severity of the injury explained rates of change across time for participation intensity in recreational, physical, and social activities. Household income influenced changes in the intensity of recreational activities, whereas family functioning predicted changes in the diversity of skill‐based activities. Interpretation Participation is a relevant outcome of recovery that needs to be assessed and monitored post brain injury. Special attention can be directed to severity of injury and family functioning when developing intervention plans.     

Predictors of attention-deficit/hyperactivity disorder within 6 months after pediatric traumatic brain injury

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively for 6 months (baseline and 6 months), with semistructured psychiatric interviews. Injury severity, lesion characteristics, and preinjury variables including psychiatric disorder, family psychiatric history, family psychiatric history of ADHD, family function, socioeconomic status, psychosocial adversity, and adaptive function were assessed with standardized instruments. RESULTS: SADHD in the first 6 months after injury occurred in 18 of 115 (16%) of returning participants. All subtypes of ADHD occurred. Socioeconomic status (p = .041) and orbitofrontal gyrus lesions (p = .005) independently significantly predicted SADHD. CONCLUSIONS: These findings are consistent with research on developmental ADHD that implicate psychosocial factors and prefrontal structural and functional differences between those with and without the disorder.     

Premorbid child and family functioning as predictors of post-concussive symptoms in children with mild traumatic brain injuries

Study aim

This study sought to determine whether premorbid child and family functioning accounts for or moderates group differences in post-concussive symptoms following mild traumatic brain injury (TBI) in childhood.

Methods

This prospective, longitudinal cohort study recruited 8- to 15-year-old children, 186 with mild TBI and 99 with orthopedic injuries (OI), from consecutive emergency department admissions. Parents and children rated post-concussive symptoms within 3 weeks of injury and at 1, 3, and 12 months post injury. Parents also provided retrospective ratings of pre-injury symptoms, as well as of premorbid child behavioral adjustment, overall family functioning, and other stressors and resources in the family environment.

Results

Children with mild TBI reported more post-concussive symptoms than those with OI, as did their parents, although premorbid child behavioral adjustment and symptoms also were significant predictors of post-concussive symptoms. Group differences in somatic symptoms as reported by parents were more pronounced among children from families that were higher functioning and had more environmental resources.

Discussion

Mild TBI during childhood results in more post-concussive symptoms than OI, even after children's premorbid adjustment is taken into account. Counter to expectations, post-concussive symptoms following mild TBI may actually be more apparent among children from higher-functioning families with greater resources.     

Long term psychosocial outcomes after mild head injury in early childhood

OBJECTIVES: The question of whether any adverse cognitive or psychosocial outcomes occur after mild head injury in early childhood has evoked considerable controversy. This study examined mild head injury before age 10 and potential differences in late childhood/early adolescence as a function of severity of mild injury and age at injury. METHODS: A fully prospective longitudinal design tracked a large birth cohort of children. Confirmed cases of mild head injury before age 10 were divided on the basis of outpatient medical attention (n=64-84) or inpatient observation (hospital overnight; n=26-28 ) and compared with the non-injured remainder of the cohort (reference group; n=613-807). A range of pre-injury and post-injury child and family characteristics were used to control for any potential confounds. Outcome after injury before and after age 5 was also assessed. RESULTS: After accounting for several demographic, family, and pre-injury characteristics, the inpatient but not the outpatient group displayed increased hyperactivity/inattention and conduct disorder between ages 10 to 13, as rated by both mothers and teachers. Psychosocial deficits were more prevalent in the inpatient subgroup injured before age 5. No clear effects were evident for various cognitive/academic measures, irrespective of severity of mild injury or age at injury. CONCLUSIONS: Most cases of mild head injury in young children do not produce any adverse effects, but long term problems in psychosocial function are possible in more severe cases, perhaps especially when this event occurs during the preschool years. The view that all mild head injuries in children are benign events requires revision and more objective measures are required to identify cases at risk.     

Outcome after traumatic brain injury sustained in older adulthood: a one-year longitudinal study.

OBJECTIVE: The objective of this study was to explore the effects of traumatic brain injury (TBI) on cognition and functioning in older adults in a one-year longitudinal study. METHODS: Participants with mild-to-moderate TBI were compared with an age-, gender-, and education-matched healthy comparison group on aspects of cognition. Neuropsychologic tests were administered at one year. Self-reported measures of functioning were completed at baseline, six months, and one year. Informants rated instrumental functioning at one year. RESULTS: Sixty-nine subjects aged 50 years and over (mean: 67 years; standard deviation: 7.9) and a comparison group of 79 participants were assessed. Patients with TBI had poorer processing speed, verbal memory, language, and executive function; they self-reported more psychologic distress, psychosocial dysfunction, and postconcussive symptoms; and they were rated as more impaired in functioning than the comparison group. TBI of moderate severity accounted for most of the between-group differences. CONCLUSION: TBI, particularly of moderate severity, led to poorer cognitive and psychosocial functioning one year postinjury among older adults. The clinical significance of this may become more evident with time in this vulnerable population.     

Functional memory skills following traumatic brain injury in young children

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre-school period. Forty-four children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 26). Children were evaluated acutely and at 12 months post-injury using the Rivermead Behavioural Memory Test for Children. Results failed to show a clear dose-response relationship between injury severity and memory function during the acute phase of recovery. However, this relationship developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems.     

Paediatric traumatic brain injury: A review of pertinent issues

Children with traumatic brain injury (TBI), regardless of the severity of the injury, often face challenges when living in home, school and community. Their needs are often overlooked and recognition of the long-term consequences is not always central to the management of the child in the school or community. This article provides references to pertinent literature and suggestions for intervention from the clinical experiences of four individuals with extensive experience of the family stresses, educational, cognitive-communicative and behavioural challenges that occur after TBI in children. It provides information regarding these issues, particularly educational situations, and suggests methods that may be useful for service providers and family members.     

Unique contribution of family functioning in caregivers of patients with mild to moderate dementia

The relationship between family functioning and dementia caregiving is complex. The present study examined the interrelationships between family functioning, caregiver burden, and patient characteristics. Participants were 72 live-in, family caregivers of patients with mild (n = 47) or moderate dementia (n = 25). Caregivers completed measures of burden, family functioning, depression, and anxiety. Ratings of patients' memory/behavior problems and patients' activities of daily living were also collected. Results indicated that higher levels of caregiver burden were significantly associated with increased caregiver depression and anxiety, greater frequency of memory and behavior problems in the dementia patient, worse activities of daily living, and poorer family functioning. Even after controlling for caregiver depression, caregiver anxiety, and frequency of memory/behavior problems in dementia patients, poorer family functioning continued to be associated with higher levels of caregiver burden. Caregivers with high levels of burden reported greater family dysfunction in communication and roles, regardless of their relationship to the patient (i.e., spouse or child). These findings suggest that including a family systems component in caregiver interventions may be beneficial in reducing burden in these very distressed individuals.