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.     

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.     

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.     

Assessing the Effects of Traumatic Brain Injury on Family Functioning: Conceptual and Methodological Issues

Reviewed empirical literature published since 1975 on the effectsof pediatric traumatic brain injury (TBI) on the family. Fewsystematic, hypothesis-driven investigations of the impact ofTBI on family functioning have been conducted. However, existingfindings indicate that severe TBI can adversely affect familiesand individual family members. Certain factors, such as poorpreinjury functioning and parental psychological disorder, appearto place families at greater risk for long-term disruption.Issues associated with the conceptualization of the impact ofTBI on various aspects of family functioning are discussed andmethodological considerations are outlined. Special attentionis given to novel strategies for studying these complex, multifacetedissues. Finally, a framework is proposed for examining the processesof family adaptation after pediatric TBI to guide future researchdirections.     

An online family intervention to reduce parental distress following pediatric brain injury

This study examined whether an online problem-solving intervention could improve parental adjustment following pediatric traumatic brain injury (TBI). Families of children with moderate-to-severe TBI were recruited from the trauma registry of a large children's hospital and randomly assigned to receive online family problem solving therapy (FPS; n = 20) or Internet resources (IRC; n = 20) in addition to usual care. The FPS group reported significantly less global distress, depressive symptoms, and anxiety at follow-up than did the IRC group after controlling for baseline symptoms. The FPS group also reported significant improvements in problem-solving skills, although the groups did not differ significantly at follow-up. Findings suggest that an online, skill-building approach can be effective in facilitating parental adaptation after TBI.     

Long-term potentiation deficits and excitability changes following traumatic brain injury

The effects of traumatic brain injury (TBI) on hippocampal long-term potentiation (LTP) and cellular excitability were assessed at postinjury days 2, 7, and 15. TBI was induced using a well-characterized central fluid-percussion model. LTP of the Schaffer collateral/commissural system was assessed in vivo in urethane-anesthetized rats. Significant LTP of the population excitatory postsynaptic potential (EPSP) slope was found only in controls, and no recovery to control levels was observed for any postinjury time point. Four measurement parameters reflecting pyramidal cell discharges (population spike) indicated that TBI significantly increased cellular excitability at postinjury day 2: (1) pretetanus baseline recording showed that TBI reduced population spike threshold and latency; (2) tetanic stimulation (400 Hz) increased population spike amplitudes to a greater degree in injured animals than in control animals; (3) tetanus-induced population spike latency shifts were greater in injured cases; and (4) tetanic stimulation elevated EPSP to spike ratios (E-S potentiation) to a greater degree in injured animals. These parameters returned to control levels, as measured on postinjury days 7 and 15. These results suggest that TBI-induced excitability changes persist at least through 2 days postinjury and involve a differential impairment of mechanisms subserving LTP of synaptic efficacy and mechanisms related to action potential generation     

Sleep disturbances following mild traumatic brain injury in childhood

OBJECTIVE: To examine objective and subjective reports of sleep disturbance in school-aged children who had sustained mild traumatic brain injury (TBI) at least 6 months prior to the study. METHODS: Eighteen children aged 7-12 years with a history of mild TBI (GCS 13-15. LOC < 15 min) were compared to 30 children with orthopedic injuries using actigraphy and parental and self-report sleep questionnaires. RESULTS: Parents reported greater sleep disturbance in the mild TBI group. No significant differences were found in parental ratings of daytime sleepiness, child-reported sleep difficulties, or objective (actigraph) sleep measures. CONCLUSIONS: The finding of greater parental reports of sleep disturbance following mild TBI 6 months after injury requires greater exploration and future research with a larger sample followed from the point of injury would seem appropriate.     

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.     

Psychological adaptation and social support of parents of pediatric cancer patients: a prospective longitudinal study

OBJECTIVE: To investigate levels of support and the concurrent and prospective effects of support on the psychological functioning of parents of children with cancer in a prospective longitudinal study. METHODS: Parents' (n = 128) self-perceived level of psychological distress, quantity of support, and dissatisfaction with support were assessed, at diagnosis, at 6, and at 12 months. RESULTS: Parents received most support at diagnosis. Self-perceived quantity decreased with time, but parents indicated they remained equally satisfied. Support significantly predicted concurrent and prospective distress of fathers, but not of mothers. Dissatisfaction with support and negative interactions were consistent risk factors for fathers. Mothers who adjusted well psychologically received more support and were less dissatisfied than mothers who remained clinically distressed. Nevertheless, no persisting effect of support was found. CONCLUSIONS: Findings illustrate that social support varies with the stress situation and with gender. Identification of vulnerable parents at diagnosis on the basis of their perception of received quantity of and dissatisfaction with support seems difficult. Intervention efforts aimed at mobilization of needed support may be efficacious.     

Impaired emotional contagion following severe traumatic brain injury

Empathy deficits are widely-documented in individuals after severe traumatic brain injury (TBI). This study examined the relationship between empathy deficits and psychophysiological responsivity in adults with TBI to determine if impaired responsivity is ameliorated through repeated emotional stimulus presentations. Nineteen TBI participants (13 males; 41 years) and 25 control participants (14 males; 31 years) viewed five repetitions of six 2-min film clip segments containing pleasant, unpleasant, and neutral content. Facial muscle responses (zygomaticus and corrugator), tonic heart rate (HR) and skin conductance level (SCL) were recorded. Mean responses for each viewing period were compared to a pre-experiment 2-min resting baseline period. Self-reported emotional empathy was also assessed. TBI participants demonstrated identical EMG response patterns to controls, i.e. an initial large facial response to both pleasant and unpleasant films, followed by habituation over repetitions for pleasant films, and sustained response to unpleasant films. Additionally, an increase in both arousal and HR deceleration to stimulus repetitions was found, which was larger for TBI participants. Compared to controls, TBI participants self-reported lower emotional empathy, and had lower resting arousal, and these measures were positively correlated. Results are consistent with TBI producing impairments in emotional empathy and responsivity. While some normalisation of physiological arousal appeared with repeated stimulus presentations, this came at the cost of greater attentional effort.     

Sleep and wake disturbances following traumatic brain injury

Traumatic brain injury (TBI) is a major health concern in industrialised countries. Sleep and wake disturbances are among the most persistent and disabling sequelae after TBI. Yet, despite the widespread complaints of post-TBI sleep and wake disturbances, studies on their etiology, pathophysiology, and treatments remain inconclusive. This narrative review aims to summarise the current state of knowledge regarding the nature of sleep and wake disturbances following TBI, both subjective and objective, spanning all levels of severity and phases post-injury. A second goal is to outline the various causes of post-TBI sleep-wake disturbances. Globally, although sleep-wake complaints are reported in all studies and across all levels of severity, consensus regarding the objective nature of these disturbances is not unanimous and varies widely across studies. In order to optimise recovery in TBI survivors, further studies are required to shed light on the complexity and heterogeneity of post-TBI sleep and wake disturbances, and to fully grasp the best timing and approach for intervention.     

Comparing social learning and family systems correlates of adaptation in youths with IDDM.

Evaluated social learning and family systems theoretical models to determine (a) whether illness-specific family relations (based on social learning theory) and general family behaviors (based on family systems theory) relate uniquely to the youths' illness-specific and psychosocial adaptation, and (b) whether these types of family relations covary or whether they represent distinct aspects of family functioning. Participants included 95 youths with insulin-dependent diabetes mellitus (IDDM) and their parents. Positive and supportive family relations (illness-specific family support, general family affection, general family adaptability) as well as conflictual and nonsupportive relations (i.e., illness-specific family nonsupport, general family conflict) were assessed. Results suggest that both illness-specific and general family relations uniquely predict the youths' dietary adherence and general psychosocial adaptation. Because illness-specific and general family relations also covary, broad-based models that include both types of family functioning seem warranted.     

Coping and family functioning predict longitudinal psychological adaptation of siblings of childhood cancer patients

OBJECTIVE: To assess associations of coping and family functioning with psychosocial adjustment in siblings of pediatric cancer patients at 1, 6, 12, and 24 months after diagnosis. METHODS: Eighty-three siblings (ages 7-19 years) participated. Effects on anxiety, quality of life, behavioral-emotional problems, and emotional reactions to the illness were investigated. Data-analysis was performed with multilevel mixed modeling. RESULTS: Psychosocial functioning was impaired at 1 month but ameliorated over time. Adjustment problems were associated with high family adaptation and cohesion, older age, and female gender. Lower anxiety, insecurity, loneliness, and illness involvement were related to siblings' ability to remain optimistic. Insecurity and illness involvement were positively related to reliance on the medical specialist and a tendency to seek information about the illness. CONCLUSIONS: Siblings of pediatric cancer patients are most affected by the illness in the first months. Children at risk may be identified according to sibling age and gender and according to long-term family adaptation processes and sibling coping abilities.     

Serving families who have served: providing family therapy and support in interdisciplinary polytrauma rehabilitation

Severe polytraumatic injuries sustained in combat operations require intensive rehabilitation and often result in complex, long-term disabilities. Understandably, these significant injuries have a substantial emotional impact on families. In this article, the authors discuss the importance of a family-centered care philosophy, the interdisciplinary team approach, the therapeutic milieu, and two family-systems treatments (medical family therapy and ambiguous loss theory). A case example illustrates the key processes of psychological support and therapy when treating polytrauma patients and their families.     

Parent and family factors associated with child adjustment to pediatric cancer

OBJECTIVE: To identify factors that influence the association between parent and child distress among families of children with cancer and comparison peers. METHODS: Parent and child distress, social support, and family environment were assessed among families of 95 children with cancer (94 mothers, 67 fathers) and 98 comparison peers (97 mothers, 77 fathers). RESULTS: Significant associations were found between parent and child distress. For models examining the impact of fathers' distress on children, several moderators were identified (i.e., family environment, child age and gender, a cancer diagnosis, and treatment severity). Family environment also partially mediated father and child distress. CONCLUSIONS: Children whose parents were distressed were more likely to be distressed themselves. Subgroups of children were particularly vulnerable, indicating a need to identify further mechanisms of risk and resilience and to develop family-based interventions. Support was found for including fathers as independent sources of information in pediatric psychology research and clinical practice.     

Putting the pieces together: preliminary efficacy of a web-based family intervention for children with traumatic brain injury

OBJECTIVE: To report preliminary efficacy data from a Web-based family problem-solving intervention to improve parent and child adaptation. METHOD: Eight parents and six children with moderate to severe traumatic brain injury (TBI) who were injured more than 15 months earlier (M = 16 months) participated in the intervention. Families were given computers, Web cameras, and high-speed Internet access. Weekly videoconferences with the therapist were conducted after they completed self-guided Web exercises on problem-solving, communication, and antecedent behavior management strategies. RESULTS: Paired t tests comparing pre- and post-intervention scores revealed significant improvements in injury-related burden, parental psychiatric symptoms, depression, and parenting stress. There were also significant reductions in antisocial behaviors in the injured child, but not in self-reported depressive symptoms. CONCLUSIONS: These findings suggest that a computer-based intervention may successfully be used to improve both parent and child outcomes following TBI in children.     

Severity level and injury track determine outcome following a penetrating ballistic-like brain injury in the rat

Penetrating ballistic brain injury (PBBI) is a high-energy transfer wound causing direct damage to the cerebrum. Outcome is directly related to the ballistic's anatomical path and degree of energy transfer. In this study we evaluated differences in outcome induced by altering the ‘projectile’ paths and severity levels of a simulated bullet wound using a newly characterized rat model of PBBI. Severity levels (5, 10, and 15%) were compared across three distinct injury paths: (1) unilateral ‘frontal’, (2) ‘bilateral’ hemispheric, and (3) unilateral ‘caudal’ (including cerebellum/midbrain). Outcome was assessed by differences in mortality rate and motor dysfunction (e.g. neurological and balance beam deficits). Results indicated that outcome was dependent not only on the severity level of PBBI (P < 0.001, r = 0.535) but also brain regions injured (P < 0.001, r = 0.398). A unilateral caudal injury was associated with the highest degree of mortality (up to 100%) and motor dysfunction (64–100% disability). Bilateral hemispheric injuries were also potentially fatal, while the best outcomes were associated with a unilateral frontal injury (no mortality and 14–39% motor disability). These data closely resemble clinical reports of ballistic wounds to the head and further validate the rat PBBI model with the ultimate intent to investigate novel therapeutic approaches for diagnosis and treatment of the neuropathological damage associated with PBBI.     

Regional difference of reactive astrogliosis following traumatic brain injury revealed by hGFAP-GFP transgenic mice

Reactive astrocytes greatly influence the wound healing and neuronal regeneration processes following brain injury. However, the origin and fate of reactive astrocytes appear to be different depending on the type, severity and duration of brain injury. Using the cryogenic traumatic brain injury model, here we comprehensively addressed the regional differences of reactive astrocytes in the injured cortex. In the proximal region of injury site, NG2-expressing and cytoplasmic Olig2-labeled cells were densely localized 3 days after the injury. Next to this proximal layer, most of reactive astrocytes did not express NG2 but exhibited radial glia-like shape with elongated processes. Accordingly, they expressed the progenitor or radial glial markers, such as vimentin, brain lipid binding protein (BLBP) and the green fluorescent protein (GFP) under the control of the human GFAP (hGFAP) promoter. However, only few glial fibrillary acidic protein (GFAP) expressing astrocytes were found in this layer. Distal to the injury site, most of astrocytes strongly expressed GFAP with hypertonic morphology. At day 15 after injury, all layers expressing GFAP and other marker expressions disappeared, indicating the termination of reactive astrogliosis. Taken together, our data suggest that reactive astrogliosis occurs in a regionally segregated manner in the early phase of brain injury.     

Brain edema and protein expression of c-Fos and c-Jun in the brain after diffused brain injury

Objective: To investigate brain edema and protein expression of c-Fos and c-Jun in brain after diffuse brain injury, and to investigate the pathological change after brain injury, which may provide evidence for the clinical treatment of diffused brain injury. Methods: Marmarou method was used to establish the diffuse brain injury in rats. Results: After diffused brain injury, brain water content increased at 1 h, reached the peak at 1 d and remained at a high level at 7 d when compared with control group. One day after injury, diffuse subarachnoid hemorrhage was observed in the brain. HE staining showed vascular swelling and bleeding at the cortex and corpus callosum at 1 d. β-APP expression was found at the brainstem, hippocampus, thalamus, corpus callosum and periventricular regions. Pathological examination of ultrathin sections showed evidence edema and fracture of axons at 3 d after brain injury. The brain injury caused severe cerebral ischemia. The c-Fos and c-Jun expression increased at 1 h. The c-Fos expression peaked at 3 h (P < 0.05), then reduced, reached a maximal level again at 3 d (P < 0.05), and reduced significantly at 7 d but remained at a higher level when compared with control group (P < 0.05). The number of c-Jun positive cells peaked at 6 h (P < 0.05), then reduced, reached a maximal level again at 3 d and reduced markedly but still remained at a higher level when compared with control group (P < 0.05). Conclusion: After diffuse brain injury, brain water content and c-Fos/c-Jun expression change over time.     

Elevation of brain and adrenal immunoreactive opioid peptide levels in rats during adaptation to physical exercise

Research Institute of General Pathology and Pathological Physiology, Academy of Medical Sciences of the USSR, Moscow. All-Union Mental Health Research Center, Academy of Medical Sciences of the USSR, Moscow. (Presented by Academician of the Academy of Medical Sciences of the USSR G. N. Kryzhanovskii.) Translated from Byulleten' Éksperimental'noi Biologii i Meditsiny, Vol. 105, No. 2, pp. 145–158, February, 1988.