Early effects of traumatic brain injury on young children's language performance: a preliminary linguistic analysis

Language skills undergo rapid development during the early childhood years, so that by the time children start school they are competent communicators with well established syntactic, semantic and pragmatic abilities for their age. Little is known about the effects of traumatic brain injury (TBI) on the acquisition of these language skills during the early childhood years. This study used a prospective, cross-sectional design to compare the language abilities of young children following their head injury. Fifteen brain injured children, aged between 4-6 years, were divided into three injury groups depending on severity of injury, i.e. mild, moderate and severe, and compared with a matched community control group. They were assessed within 3 months of sustaining their injury on a range of expressive and receptive language tests, and free speech conversation samples, which were analysed pragmatically and syntactically. Results indicated that the severe group performed most poorly on language tasks. It is suggested that linguistic evaluation is an important component of follow up at least for the severe head injured population.     

Quality-of-life: Child and parent perspectives following severe traumatic brain injury

Purpose: Traumatic brain injury (TBI) can produce temporary or permanent impairment. Quality-of-life (QoL) after TBI has been well studied in adults, but less so in children. The aim of this study was to assess the QoL of children with TBI and compare the findings with the evaluations of parents and children without brain injury.

Methods: Participants were 23 children with TBI, mean age 11 years, who had been treated at the SARAH Network of Rehabilitation Hospitals. Participants were matched by age, sex, parents’ socio-cultural level and place of residence with 23 other children who had no history of brain injury. The instruments used were the SARAH QoL Questionnaire for Children and Adolescents, Wechsler Intelligence Scale for Children, the SARAH Physical-Functional Classification of the Child and Adolescent and a structured interview with parents.

Results: The results demonstrated that, in an average 4 years after the accident, all of the children with TBI were attending school and most could walk independently. The parents’ reports about post-TBI problems were marginally associated with the children's self-evaluations. The parents showed important concerns regarding their child across all dimensions of life.

Conclusions: Children with TBI report significantly reduced QoL compared to a control group in the physical, psychological, cognitive and total score dimensions. However, TBI children with average academic performance (65%) obtained the same QoL scores as the control group.     

Social communication mediates the relationship between emotion perception and externalizing behaviors in young adult survivors of pediatric traumatic brain injury (TBI)

Traumatic brain injury (TBI) is a common cause of childhood disability, and is associated with elevated risk for long-term social impairment. Though social (pragmatic) communication deficits may be among the most debilitating consequences of childhood TBI, few studies have examined very long-term communication outcomes as children with TBI make the transition to young adulthood. In addition, the extent to which reduced social function contributes to externalizing behaviors in survivors of childhood TBI remains poorly understood. The present study aimed to evaluate the extent of social communication difficulty among young adult survivors of childhood TBI (n = 34, injury age: 1.0–7.0 years; M time since injury: 16.55 years) and examine relations among aspects of social function including emotion perception, social communication and externalizing behaviors rated by close-other proxies. Compared to controls the TBI group had significantly greater social communication difficulty, which was associated with more frequent externalizing behaviors and poorer emotion perception. Analyses demonstrated that reduced social communication mediated the association between poorer emotion perception and more frequent externalizing behaviors. Our findings indicate that socio-cognitive impairments may indirectly increase the risk for externalizing behaviors among young adult survivors of childhood TBI, and underscore the need for targeted social skills interventions delivered soon after injury, and into the very long-term.     

An analysis of communication in conversation after severe traumatic brain injury

Background and objective: Communication disorders have been reported following severe traumatic brain injury. However, we have little information about patient behaviour during dyadic interaction. Here, we analyzed conversation at the rehabilitation and chronic phase post traumatic brain injury (TBI), to define the main mechanisms of verbal and non‐verbal communication disorders and relationship with other cognitive difficulties. Methods: Sixteen patients were evaluated at the rehabilitation phase (2–12 months) and 18 at the chronic phase (after 2 years) following severe TBI. They were compared with equivalent groups of matching (gender, age, education level) control subjects. We used the Lille Communication Test, which comprises three parts: participation to communication (greeting, attention, engagement), verbal communication (verbal comprehension, speech outflow, intelligibility, word production, syntax, verbal pragmatics, verbal feedback) and non‐verbal communication (understanding gestures, affective expressivity, producing gestures, pragmatics, non‐verbal feedback). We also investigated executive functions (Stroop test, trail‐making test, categorical evocation), language (Montreal‐Toulouse protocol) and behaviour (Neurobehavioural Rating Scale). Verbal communication disorders were relatively equivalent at the rehabilitation and chronic phases. Results: Patients were impaired (P ≤ 0.01) in their participation to communication, especially in greeting behaviour. Verbal communication was mostly affected by difficulties in producing fluent and intelligible language and using pragmatics (responding to open questions, presenting new information and introducing new themes, organizing discourse and adapting to interlocutor knowledge). Non‐verbal communication was impaired by difficulties in using pragmatics (mostly adapted prosody). Participation and verbal communication correlated with the executive functions, language and behavioural assessment. Conclusions: Disorders of social communication justify systematic assessment in patients with TBI.     

Educational skills: Long-term outcome and predictors following paediatric traumatic brain injury

Given that reading, spelling and arithmetic skills are acquired through childhood, their development may be compromised following a childhood traumatic brain injury (TBI). The present study examined educational skills (reading accuracy, spelling and arithmetic) at a mean follow-up interval of 6.8 years post-injury in children who had sustained a mild, moderate, or severe TBI at two ages: ‘Young’ (age at injury: 3–7 years, n = 48) and ‘Old’: (age at injury: 8–12 years, n = 36). Comparisons between the young and old TBI groups resulted in inconsistent findings. While a dose-response relationship for severity was evident for the young group, this was not always the case for the old group. Significant predictors of outcome included both severity and acute intellectual function.     

Continuous electroencephalography in pediatric traumatic brain injury: Seizure characteristics and outcomes

BackgroundTraumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality. Secondary injury that occurs as a result of a direct impact plays a crucial role in patient prognosis. The guidelines for the management of severe TBI target treatment of secondary injury. Posttraumatic seizure, one of the secondary injury sequelae, contributes to further damage to the injured brain. Continuous electroencephalography (cEEG) helps detect both clinical and subclinical seizure, which aids early detection and prompt treatment.ObjectiveThe aim of this study was to examine the relationship between cEEG findings in pediatric traumatic brain injury and neurocognitive/functional outcomes.MethodsThis study focuses on a subgroup of a larger prospective parent study that examined children admitted to a level-1 trauma hospital. The subgroup included sixteen children admitted to the pediatric intensive care unit (PICU) who received cEEG monitoring. Characteristics included demographics, cEEG reports, and antiseizure medication. We also examined outcome scores at the time of discharge and 4–6 weeks postdischarge using the Glasgow Outcome Scale — Extended Pediatrics and center-based speech pathology neurocognitive/functional evaluation scores.ResultsSixteen patients were included in this study. Patients with severe TBI made up the majority of those that received cEEG monitoring. Nonaccidental trauma was the most frequent TBI etiology (75%), and subdural hematoma was the most common lesion diagnosed by CT scan (75%). Fifteen patients received antiseizure medication, and levetiracetam was the medication of choice. Four patients (25%) developed seizures during PICU admission, and 3 patients had subclinical seizures that were detected by cEEG. One of these patients also had both a clinical and subclinical seizure. Nonaccidental trauma was an etiology of TBI in all patients with seizures. Characteristics of a nonreactive pattern, severe/burst suppression, and lack of sleep architecture, on cEEG, were associated with poor neurocognitive/functional outcome.ConclusionContinuous electroencephalography demonstrated a pattern that associated seizures and poor outcomes in patients with moderate to severe traumatic brain injury, particularly in a subgroup of patients with nonaccidental trauma. Best practice should include institution-based TBI cEEG protocols, which may detect seizure activity early and promote outcomes. Future studies should include examination of individual cEEG characteristics to help improve outcomes in pediatric TBI.     

A prospective study of the linguistic skills of children with closed-head injuries

Abstract

Little research in the paediatric closed-head injury (CHI) literature has attempted to follow the course of recovery of CHI children over a prolonged period, particularly in the area of linguistic recovery. The present study documented the course of recovery of the linguistic skills of a group of 11 CHI children over an 18-month period post-injury. All of the CHI children studied demonstrated measurable gains in a number of speech and language skills during the 18-month period post-injury. The results indicated that childhood CHI did not permanently disrupt the acquisition of any of the speech and language skills observed. A number of subjects did, however, continue to demonstrate measurable deficits in some language areas even at 18 months post-injury.     

The use of gesture following traumatic brain injury: a preliminary analysis

Background: Gesture and its effects on speech production has been a topic of interest, especially in studies of individuals with language impairment. Research on word retrieval in participants with aphasia has demonstrated increased gesture or coverbal movement during confrontation naming tasks or spontaneous conversation. Although word retrieval difficulties are also prevalent following traumatic brain injury (TBI), comparatively little research has been published with regard to gesture in the population with TBI.

Aims: The current study aimed to investigate the nature and pattern of gestures in individuals with TBI and to compare these to gestures produced by healthy adults.

Methods & Procedures: Gestural performance of 30 participants with TBI was analysed in comparison with 32 controls with no history of brain injury during the Test of Adolescent/Adult Word Finding (TAWF). The groups were compared on the frequency, type or pattern, and handedness of gesture.

Outcomes & Results: Individuals with TBI produced gestures and coverbal movements (auxiliary or extra movements unrelated to speech) approximately three times more frequently than the control participants on the TAWF. Both the groups employed iconic gesture most frequently, and pointing was frequently demonstrated by individuals with TBI, but not utilised by healthy adults. Finally, a significant difference in hand preference for gesture was revealed. While the control group demonstrated a right hand preference, there was no clear hand preference in the group with TBI.

Conclusions: Individuals with TBI demonstrated significantly greater gestural usage compared to healthy adults. The current data offer preliminary patterns of gestural use following TBI. However, the role of facilitation remains unclear. It is possible that gestures facilitate word retrieval, or perhaps they are employed to resolve a word retrieval block.     

The emergence of age‐dependent social cognitive deficits after generalized insult to the developing brain: A longitudinal prospective analysis using susceptibility‐weighted imaging

Childhood and adolescence are critical periods for maturation of neurobiological processes that underlie complex social and emotional behavior including Theory of Mind (ToM). While structural correlates of ToM are well described in adults, less is known about the anatomical regions subsuming these skills in the developing brain or the impact of cerebral insult on the acquisition and establishment of high‐level social cognitive skills. This study aimed to examine the differential influence of age‐at‐insult and brain pathology on ToM in a sample of children and adolescents with traumatic brain injury (TBI). Children and adolescents with TBI (n = 112) were categorized according to timing of brain insult: (i) middle childhood (5–9 years; n = 41); (ii) late childhood (10–11 years; n = 39); and (iii) adolescence (12–15 years; n = 32) and group‐matched for age, gender, and socioeconomic status to a typically developing (TD) control group (n = 43). Participants underwent magnetic resonance imaging including a susceptibility‐weighted imaging (SWI) sequence 2–8 weeks postinjury and were assessed on a battery of ToM tasks at 6‐ and 24‐months after injury. Results showed that for adolescents with TBI, social cognitive dysfunction at 6‐ and 24‐months postinjury was associated with diffuse neuropathology and a greater number of lesions detected using SWI. In the late childhood TBI group, we found a time‐dependent emergence of social cognitive impairment, linked to diffuse neuropathology. The middle childhood TBI group demonstrated performance unrelated to SWI pathology and comparable to TD controls. Findings indicate that the full extent of social cognitive deficits may not be realized until the associated skills reach maturity. Evidence for brain structure–function relationships suggests that the integrity of an anatomically distributed network of brain regions and their connections is necessary for the acquisition and establishment of high‐level social cognitive skills. Hum Brain Mapp 36:1677–1691, 2015. © 2014 Wiley Periodicals, Inc.     

The relationship between SDF-1α/CXCR4 and neural stem cells appearing in damaged area after traumatic brain injury in rats

Abstract

Objective: The actual relationship between neural stem cells and SDF-1α/CXCR4 after brain injury has not yet been elucidated, although recent studies have speculated that stromal cell-derived factor-1α (SDF-1α) and its receptor, CXCR4, could contribute to neural stem cells migration after brain injury. In the present study, the temporal relationship between neural stem cells (NSCs) and SDF-1α/CXCR4 around a damaged area was investigated using a rat traumatic brain injury (TBI) model.

Methods: We used molecular biology techniques and immunohistochemistry to investigate the relationship between SDF-1α/CXCR4 expression and NSCs existence around a damaged area after TBI in the rat brain.

Results: SDF-1α mRNA expression and SDF-1α protein synthesis did not increase after TBI. However, SDF-1α leaked from the injured area and diffused into the cortex 1–3 days after TBI. Subsequently, the levels of CXCR4 mRNA expression and CXCR4 protein synthesis increased significantly. Many small cells with a nestin-positive cytoplasm and fibers also showed immunopositivity for both CXCR4 and SOX-2, but not for GFAP, 3–7 days after TBI. Moreover, a proportion of the CXCR4-positive cells and fibers also showed immunostaining for neurofilaments.

Discussion: These results suggest that the leaked SDF-1α attracted CXCR4-positive NSCs as well as elongated nerve fibers. It is considered that the SDF-1α/CXCR4 system in the brain contributes to neural stem cells appearance and maturation after TBI. Therefore, exploitation of the SDF-1α/CXCR4 system around a damaged area may improve the brain dysfunction after TBI.     

Preliminary findings of altered functional connectivity of the default mode network linked to functional outcomes one year after pediatric traumatic brain injury

ABSTRACT

Purpose and Method: This study examined functional connectivity of the default mode network (DMN) and examined brain–behavior relationships in a pilot cohort of children with chronic mild to moderate traumatic brain injury (TBI). Results: Compared to uninjured peers, children with TBI demonstrated less anti-correlated functional connectivity between DMN and right Brodmann Area 40 (BA 40). In children with TBI, more anomalous less anti-correlated) connectivity between DMN and right BA 40 was linked to poorer performance on response inhibition tasks. Conclusion: Collectively, these preliminary findings suggest that functional connectivity between DMN and BA 40 may relate to longterm functional outcomes in chronic pediatric TBI.     

Social communication in young children with traumatic brain injury: Relations with corpus callosum morphometry

The purpose of the present investigation was to characterize the relations of specific social communication behaviors, including joint attention, gestures, and verbalization, with surface area of midsagittal corpus callosum (CC) subregions in children who sustained traumatic brain injury (TBI) before 7 years of age. Participants sustained mild (n = 10) or moderate–severe (n = 26) noninflicted TBI. The mean age at injury was 33.6 months; mean age at MRI was 44.4 months. The CC was divided into seven subregions. Relative to young children with mild TBI, those with moderate–severe TBI had smaller surface area of the isthmus. A semi-structured sequence of social interactions between the child and an examiner was videotaped and coded for specific social initiation and response behaviors. Social responses were similar across severity groups. Even though the complexity of their language was similar, children with moderate–severe TBI used more gestures than those with mild TBI to initiate social overtures; this may indicate a developmental lag or deficit as the use of gestural communication typically diminishes after age 2. After controlling for age at scan and for total brain volume, the correlation of social interaction response and initiation scores with the midsagittal surface area of the CC regions was examined. For the total group, responding to a social overture using joint attention was significantly and positively correlated with surface area of all regions, except the rostrum. Initiating joint attention was specifically and negatively correlated with surface area of the anterior midbody. Use of gestures to initiate a social interaction correlated significantly and positively with surface area of the anterior and posterior midbody. Social response and initiation behaviors were selectively related to regional callosal surface areas in young children with TBI. Specific brainbehavior relations indicate early regional specialization of anterior and posterior CC for social communication.     

Responsiveness and discriminant validity of the Child and Adolescent Scale of Participation across three years for children and youth with traumatic brain injury

ABSTRACT

Purpose: To examine responsiveness and discriminant validity of the Child and Adolescent Scale of Participation (CASP) across three years. Methods: Examined longitudinal data on 515 children and youth with TBI and arm injuries. Repeated measures analyses of variance were used to examine CASP scores (pre-injury; 3, 12, 24, 36 months post-injury). Results: Scores decreased from pre-injury to 3 months, but significantly only for moderate and severe TBI groups. Scores gradually increased post-injury for all groups except severe TBI. Scores were consistently lowest for severe TBI, followed by moderate TBI, mild TBI, and arm injury across time. Severe TBI scores were significantly lower than scores for mild TBI and arm injury, but not moderate TBI. Conclusions: CASP scores were responsive to change over time at most measurements and differentiated between groups, particularly severe TBI. Further research is needed with a larger sample of children with moderate/severe TBI as they were underrepresented in this study.     

Problem solving with friends: Discourse participation and performance of individuals with and without traumatic brain injury

Background: Traumatic brain injury (TBI) is a leading cause of hospitalisation and disability worldwide. There is general consensus in the literature reporting poor communication and social outcomes for individuals with TBI. While the literature is extensive in describing cognitive communication difficulties manifesting in the discourse of individuals with TBI, it does not include genres that represent everyday interactions. Furthermore, there are very few studies in the literature that explore interactions of individuals with TBI and their friends, even though it is common for individuals with TBI to lose friends within the first year of their injury.

Aims: To explore discourse participation and performance of individuals with and without TBI in a shared problem‐solving task with their friends.

Methods & Procedures: Ten participants with severe TBI were matched with ten control participants for sex, age, and education. Participants problem‐solved names and functions of unfamiliar objects with their friends. The resulting discourse was transcribed, divided into moves, and analysed for its generic structure potential (GSP) within a systemic functional linguistics approach. The number of moves contributed by each participant (participation) and frequencies of moves assigned to generic structural elements (performance) were tallied and then statistically analysed.

Results & Outcomes: There was no significant difference in discourse participation and performance between participants with and without TBI. Individuals with and without TBI mostly talked about the task, gave thesis propositions, offered the possible function of the object, and gave rationales for their decisions. These may be obligatory (not optional) elements of problem‐solving discourse. Individuals without TBI used significantly more tangential and unrelated talk, which may be indicative of more frequent and successful attempts to engage in social chat, even in a goal‐driven activity.

Conclusions: Competent discourse participation and performance is possible for individuals with TBI when they engage in meaningful interactions with friends. Problem solving may be a useful therapy genre for maximising communication outcomes of individuals with TBI, as it encourages the involvement of friends and elicits social chat as well as other creative language options.     

Auditory and verbal memory predictors of spoken language skills in children with cochlear implants

BackgroundLarge variability in individual spoken language outcomes remains a persistent finding in the group of children with cochlear implants (CIs), particularly in their grammatical development.AimsIn the present study, we examined the extent of delay in lexical and morphosyntactic spoken language levels of children with CIs as compared to those of a normative sample of age-matched children with normal hearing. Furthermore, the predictive value of auditory and verbal memory factors in the spoken language performance of implanted children was analyzed.Methods & proceduresThirty-nine profoundly deaf children with CIs were assessed using a test battery including measures of lexical, grammatical, auditory and verbal memory tests. Furthermore, child-related demographic characteristics were taken into account.Outcomes & resultsThe majority of the children with CIs did not reach age-equivalent lexical and morphosyntactic language skills. Multiple linear regression analyses revealed that lexical spoken language performance in children with CIs was best predicted by age at testing, phoneme perception, and auditory word closure. The morphosyntactic language outcomes of the CI group were best predicted by lexicon, auditory word closure, and auditory memory for words.ConclusionsQualitatively good speech perception skills appear to be crucial for lexical and grammatical development in children with CIs. Furthermore, strongly developed vocabulary skills and verbal memory abilities predict morphosyntactic language skills.     

Language deficits following dominant hemisphere tumour resection are significantly underestimated by syndrome-based aphasia assessments

ABSTRACT

Background: In assessing post-operative language impairment, clinical teams typically rely on “aphasia subtype” classifications, based on post-stroke patterns of impairment. However, this approach may significantly underestimate the prevalence of post-surgical language impairments due to the different pathophysiological mechanisms involved. There is a paucity of research in chronic post-surgical patients.

Aims: We investigated post-surgical language performance in the chronic phase.

Methods & Procedures: Using both the Western Aphasia battery Revised (WAB-R) and the Comprehensive Aphasia test (CAT), we assessed a range of language skills in 26 right-handed patients approximately 6–12 months after they underwent surgery to remove a primary tumour in their left cerebral hemisphere. Participants’ self-reports of their speech and language skills post-surgery were also collected.

Outcomes and Results: Following surgery, 77% of patients scored below normal cut-off on one or more language subtests of the CAT battery. This contrasted with only 27% on the WAB AQ. The CAT findings were supported by subjective data, with 58% of patients self-reporting post-surgical communication difficulty.

Conclusions: Our results show that current “aphasia subtype” testing is inadequate, and is likely to significantly underestimate chronic language deficits in this population. Alternative approaches to formal language assessment need to be used in this group of patients whose pattern of impairments is very different from that observed in post-stroke aphasia.     

Early speech perception in Mandarin-speaking children at one-year post cochlear implantation

PurposeThe aim in this study was to examine early speech perception outcomes in Mandarin-speaking children during the first year of cochlear implant (CI) use.MethodA hierarchical early speech perception battery was administered to 80 children before and 3, 6, and 12 months after implantation. Demographic information was obtained to evaluate its relationship with these outcomes.ResultsRegardless of dialect exposure and whether a hearing aid was trialed before implantation, implant recipients were able to attain similar pre-lingual auditory skills after 12 months of CI use. Children speaking Mandarin developed early Mandarin speech perception faster than those with greater exposure to other Chinese dialects. In addition, children with better pre-implant hearing levels and younger age at implantation attained significantly better speech perception scores after 12 months of CI use. Better pre-implant hearing levels and higher maternal education level were also associated with a significantly steeper growth in early speech perception ability.ConclusionsMandarin-speaking children with CIs are able to attain early speech perception results comparable to those of their English-speaking counterparts. In addition, consistent single language input via CI probably enhances early speech perception development at least during the first-year of CI use.     

The persistence of sleep disturbance and its correlates in children with moderate to severe traumatic brain injury: A longitudinal study

ObjectivesThe primary aim was to examine whether sleep disturbances persist in children in the chronic stage of recovery from moderate or severe traumatic brain injury (TBI). The secondary aim was to examine whether memory difficulties and/or other previously identified factors relate to sleep disturbances in children with moderate to severe TBI.MethodsThis longitudinal study included 21 children with moderate to severe TBI, 8–18 years old, recruited from an urban tertiary paediatric specialised brain injury rehabilitation unit. Participants were seen 5 years and again 7 years post-injury, on average. Sleep disturbances were assessed with Sleep Disturbance Scale for Children (SDSC). Correlates that were considered included indicators of TBI severity, and questionnaires assessing everyday memory, fatigue, internalizing and externalizing behaviors and pain intensity.ResultsThe SDSC scores of children with moderate to severe TBI indicated greater disturbances in initiating and maintaining sleep, arousal, sleep-wake transition, and excessive somnolence relative to the norms, at follow-up. The mean SDSC scores and the number of participants with subclinical to clinical sleep disturbances on the SDSC remained unchanged from baseline to follow-up. At follow-up, the SDSC initiating and maintaining sleep, and excessive somnolence scales were associated with poorer everyday memory and greater fatigue.ConclusionsChildren with moderate to severe TBI experience ongoing sleep disturbances for years post-injury. Greater sleep disturbances are associated with worse functional outcomes. Further research into sleep disturbances and development of treatments is important, as it could improve the outcomes of children with TBI.     

Traumatic brain injury decreases serotonin transporter expression in the rat cerebrum

Objectives: An association has been postulated between traumatic brain injury (TBI) and depression. The serotonin transporter (SERT) regulates the concentration of serotonin in the synaptic cleft and represents a molecular target for antidepressants. We hypothesized that SERT expression in the brain changes following TBI.

Methods: We performed immunohistochemistry, real-time polymerase chain reaction analysis for mRNA and western blot analysis for protein to examine the time-dependent changes in SERT expression in the cerebrum during the first 14 days after TBI, using a controlled cortical impact model in rats.

Results: SERT immunoreactivity in neuronal fibres within the area adjacent to the cortical contusion decreased 1 to 14 days after injury. Significantly decreased SERT mRNA and protein expression were noted in the area adjacent to the cortical contusion 7 days after injury. There were no significant changes in SERT expression in the cingulum of the injured brain.

Discussion: The findings of this study indicate that TBI decreases SERT expression in the cerebral cortex. The decreased levels of SERT expression after TBI may result in decreased serotonin neurotransmission in the brain and indicate a possible relationship with depression following TBI.