Trajectories of Children's Executive Function After Traumatic Brain Injury

Goal management training for improving fatigue in children and adolescents with acquired brain injuries: A 2-year follow-up of a randomised controlled trial

To explore the long-term effectiveness of a paediatric adaptation of Goal Management Training (pGMT), relative to a psychoeducative program (pBHW), in reducing fatigue after pABI 2 years post-intervention. Thirty-eight youths and their parents completed the Paediatric Quality of Life - Multidimensional Fatigue Scale. Primary outcome measures were Total Fatigue Score, General fatigue, Cognitive fatigue, and Sleep/rest fatigue (parent-report). No significant differences in fatigue symptoms by the parental report was observed between the intervention groups at the 2-year follow-up (total score: F = .16, p = .69; general fatigue: F = .36, p = .55; sleep/rest: F = .48, p = .49; and cognitive fatigue: F = .09, p = .76), nor any time*group interactions (total score: F = .25, p = .86; general fatigue: F = .39, p = .76; sleep/rest: F = .20, p = .89; and cognitive fatigue: F = .08, p = .97). In total, 45% of the participants in the pGMT group and 25% in the pBHW group demonstrated a reliable positive clinical change. The significant improvements in fatigue symptoms that were demonstrated 6 months post-intervention could not be confirmed in this 2-year follow-up study. However, a continued positive tendency on most dimensions of fatigue for the participants in the pGMT group could be observed, suggesting that cognitive rehabilitation may help reduce fatigue.

Cognitive Orientation to daily Occupational Performance to improve occupational performance goals for children with executive function deficits after acquired brain injury

AIM

To determine the effectiveness of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach in improving the occupational performance goals of children and young people with executive function deficits after acquired brain injury (ABI) (e.g. etiologies such as stroke, encephalitis, brain tumor, and traumatic brain injury).

METHOD

A replicated single-case experimental study using a randomized multiple baseline design across participants and goals was used. Three clusters of four participants (12 participants, nine males and three females, aged 8-16 years) were included. The intervention consisted of 14 individual CO-OP sessions. Each participant chose four goals; three goals were trained during the intervention sessions and a fourth goal served as the control. The Goal Attainment Scale (GAS) was used as a repeated measure to determine goal achievement while the Canadian Occupational Performance Measure (COPM) was used to identify the perceived goal achievement of children, young people, and their parents.

RESULTS

For 26 of the 35 trained goals, the intervention led to statistically significant improvements in the GAS. Perceived occupational performance and satisfaction improved significantly for the trained goals (30 out of 35 goals for the COPM performance and satisfaction of participants; 26 out 31 goals for the COPM performance of parents; 24 out of 31 goals for the COPM satisfaction of parents) and were maintained at the follow-up. Almost all COPM control goal results were significant, but these changes were not supported by the GAS measures or the statistical analysis.

INTERPRETATION

The generally positive results of this study provide evidence of the benefits of using the CO-OP approach with this population.

Visualization of the Intracranial Pressure and Time Burden in Childhood Brain Trauma: What We Have Learned One Decade on With KidsBrainIT

To validate the intracranial pressure (ICP) dose-response visualization plot for the first time in a novel prospectively collected pediatric traumatic brain injury (pTBI) data set from the multi-center, multi-national KidsBrainIT consortium. Prospectively collected minute-by-minute ICP and mean arterial blood pressure time series of 104 pTBI patients were categorized in ICP intensity-duration episodes. These episodes were correlated with the 6-month Glasgow Outcome Score (GOS) and displayed in a color-coded ICP dose-response plot. The influence of cerebrovascular reactivity and cerebral perfusion pressure (CPP) were investigated. The generated ICP dose-response plot on the novel data set was similar to the previously published pediatric plot. This study confirmed that higher ICP episodes were tolerated for a shorter duration of time, with an approximately exponential decay curve delineating the positive and negative association zones. ICP above 20 mm Hg for any duration in time was associated with poor outcome in our patients. Cerebrovascular reactivity state did not influence their respective transition curves above 10 mm Hg ICP. CPP below 50 mm Hg was not tolerated, regardless of ICP and duration, and was associated with worse outcome. The ICP dose-response plot was reproduced in a novel and independent pTBI data set. ICP above 20 mm Hg and CPP below 50 mm Hg for any duration in time were associated with worse outcome. This highlighted a pressing need to reduce pediatric ICP therapeutic thresholds used at the bedside.

Executive functioning, behavior, and white matter microstructure in the chronic phase after pediatric mild traumatic brain injury: results from the adolescent brain cognitive development study

BACKGROUND

Mild traumatic brain injury (mTBI) is common in children. Long-term cognitive and behavioral outcomes as well as underlying structural brain alterations following pediatric mTBI have yet to be determined. In addition, the effect of age-at-injury on long-term outcomes is largely unknown.

METHODS

Children with a history of mTBI (n = 406; Mage = 10 years, SDage = 0.63 years) who participated in the Adolescent Brain Cognitive Development (ABCD) study were matched (1:2 ratio) with typically developing children (TDC; n = 812) and orthopedic injury (OI) controls (n = 812). Task-based executive functioning, parent-rated executive functioning and emotion-regulation, and self-reported impulsivity were assessed cross-sectionally. Regression models were used to examine the effect of mTBI on these domains. The effect of age-at-injury was assessed by comparing children with their first mTBI at either 0-3, 4-7, or 8-10 years to the respective matched TDC controls. Fractional anisotropy (FA) and mean diffusivity (MD), both MRI-based measures of white matter microstructure, were compared between children with mTBI and controls.

RESULTS

Children with a history of mTBI displayed higher parent-rated executive dysfunction, higher impulsivity, and poorer self-regulation compared to both control groups. At closer investigation, these differences to TDC were only present in one respective age-at-injury group. No alterations were found in task-based executive functioning or white matter microstructure.

CONCLUSIONS

Findings suggest that everyday executive function, impulsivity, and emotion-regulation are affected years after pediatric mTBI. Outcomes were specific to the age at which the injury occurred, suggesting that functioning is differently affected by pediatric mTBI during vulnerable periods. Groups did not differ in white matter microstructure.

Unmet health care needs over the first 2 years after pediatric traumatic brain injury

AIM

Few studies have addressed how children and adolescents with traumatic brain injuries (TBIs) access health care and educational services. This study aimed to investigate the course of symptoms during the first two years after TBI, whether symptoms implied a need for health care and/or educational services, and the extent of unmet needs. The association between unmet needs and health-related quality of life was also explored.

METHODS

This prospective cohort study was conducted at Oslo University Hospital, Norway, from 2015 to 2018. Forty-nine patients aged 1-15 years hospitalized due to TBI were included and followed for 24 months. Registration of symptoms and identification of unmet needs was based on clinical assessment, self-reports and interviews with patients and parents during the acute phase and at 6 and 24 months postinjury.

RESULTS

Twenty-five percent of the sample presented with unmet needs at 24 months. Compared to the group with no needs and met needs, these patients reported lasting cognitive and emotional symptoms affecting school and social interaction and scored lower on health-related quality of life.

CONCLUSION

Pediatric patients with TBI may have long-term symptom burden affecting school and social functioning, leading to unmet needs if targeted services are not provided.

New Functional Impairment After Hospital Discharge by Traumatic Brain Injury Mechanism in Younger Than 3 Years Old Admitted to the PICU in a Single Center Retrospective Study

OBJECTIVES

Children who suffer traumatic brain injury (TBI) are at high risk of morbidity and mortality. We hypothesized that in patients with TBI, the abusive head trauma (AHT) mechanism vs. accidental TBI (aTBI) would be associated with higher frequency of new functional impairment between baseline and later follow-up.

DESIGN

Retrospective single center cohort study.

SETTING AND PATIENTS

Children younger than 3 years old admitted with TBI to the PICU at a level 1 trauma center between 2014 and 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, TBI mechanism, and Functional Status Scale (FSS) scores at baseline, hospital discharge, short-term (median, 10 mo [interquartile range 3-12 mo]), and long-term (median, 4 yr [3-6 yr]) postdischarge were abstracted from the electronic health record. New impairment was defined as an increase in FSS greater than 1 from baseline. Patients who died were assigned the highest score (30). Multivariable logistic regression was performed to determine the association between TBI mechanism with new impairment. Over 6 years, there were 460 TBI children (170 AHT, 290 aTBI), of which 13 with AHT and four with aTBI died. Frequency of new impairment by follow-up interval, in AHT vs. aTBI patients, were as follows: hospital discharge (42/157 [27%] vs. 27/286 [9%]; p < 0.001), short-term (42/153 [27%] vs. 26/259 [10%]; p < 0.001), and long-term (32/114 [28%] vs. 18/178 [10%]; p < 0.001). Sensory, communication, and motor domains were worse in AHT patients at the short- and long-term timepoint. On multivariable analysis, AHT mechanism was associated with greater odds (odds ratio [95% CI]) of poor outcome (death and new impairment) at hospital discharge (4.4 [2.2-8.9]), short-term (2.7 [1.5-4.9]), and long-term timepoints (2.4 [1.2-4.8]; p < 0.05).

CONCLUSIONS

In patients younger than 3 years old admitted to the PICU after TBI, the AHT mechanism-vs. aTBI-is associated with greater odds of poor outcome in the follow-up period through to ~5 years postdischarge. New impairment occurred in multiple domains and only AHT patients further declined in FSS over time.

[Formula: see text] Interventions to improve executive functions in children and adolescents with acquired brain injury: a systematic review and multilevel meta-analysis

To investigate the effectiveness of interventions aiming to improve hot and cold executive functions (EFs) in children and adolescents with acquired brain injury (ABI) and to examine whether characteristics of the intervention, participants, etiology of ABI (Traumatic-brain-injury [TBI] or non-TBI), time of assessment, or study quality moderate intervention effects. Whereas cold EFs refer to purely cognitive EFs, hot EFs refer to the affective aspects of these cognitive skills. A total of 970 participants from 23 randomized-controlled-trial studies (112 effect sizes [ES]) were included. A three-level random effects approach (studies, ES, individual participants) was used. Moderation analyses were conducted through meta-regressions. The three-level random effects model showed a better fit than the two-level model. Almost all individual studies showed non-significant ES across outcomes but in combination interventions were effective (Cohen's d = 0.38, CI 0.16 ~ 0.61). Lower methodological quality, inclusion of participants with non-TBI, and parental participation predicted larger ES. Participants' age, time of assessment, number of sessions, and focus on hot or cold EFs were not related to ES. We found no evidence of publication bias. Interventions are effective with small to medium ES according to conventional criteria. Intervention effects do not seem to fade away with time. Parent participation in the intervention is important to improve EFs. The efficacy of interventions seems larger when non-TBI is part of the etiology of ABI. Variation between studies is relevant for tracing the effective intervention characteristics. Most studies are conducted in adolescence, and studies in early childhood are needed.

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

Fatigue, Executive Functioning, and Quality of Life: Exploring Relationships in Children With Traumatic Brain Injury

PURPOSE

The overall purpose of this study was to explore the relationship between fatigue, executive functioning, and quality of life for children with moderate-severe traumatic brain injury (TBI) between 8 and 17 years old.

METHOD

Fifteen parents of children with moderate-severe TBI (M = 10.06 years old) completed an online survey. Data from the following measures were included in this study's analyses: demographic and injury questions, the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF-2), Pediatric Quality of Life Inventory Generic Core Scale (PedsQL GCS)-parent report, and Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (PedsQL MFS)-parent report.

RESULTS

In a multiple regression, fatigue was found to be a significant predictor of quality of life for children with TBI, but executive functioning was not a significant predictor. When examining subdomains of functioning, worse sleep/rest fatigue and emotional executive functioning were most consistently associated with worse physical and psychosocial quality of life.

CONCLUSIONS

The findings of this study suggest that fatigue could be an important contributing factor to reduced quality of life for children with moderate-severe TBI. Medical and educational professionals, including speech-language pathologists, should assess children with TBI for the presence and impact of fatigue. Further research is needed to understand how different subdomains of fatigue might interact with executive functioning to impact quality of life.

Psychometric properties of the Behavior Rating Inventory of Executive Function, second edition (BRIEF2) self-report form in Iranian adolescents

BACKGROUND

This study investigated the psychometric properties of a Persian translation of the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2) Self-Report form.

METHOD

Participants were 589 typically developing adolescents (336 girls and 253 boys), ages 11-18 years old (M = 15.16; SD = 2.04), in Iran. They completed the Persian version of the BRIEF2 Self-Report form and Teenage Executive Functioning Inventory (TEXI). The Persian translated BRIEF2 psychometric properties were examined via internal consistency, test-retest reliability, convergent validity via associations with TEXI scores, and internal structure using structural equation modeling (SEM) to evaluate fit of the three-factor structure from the original English version BRIEF2.

RESULTS

Findings indicated the Persian version of BRIEF2 Self-Report form yielded scores with robust reliability, with internal consistency ranging from .87 to .93 and test-retest correlations ranging from .89 to .96, and adequate convergent validity, with correlations with the TEXI ranging from .48 to .79. SEM revealed that a three-factor solution was the best fitting model for the seven subscales of the Persian BRIEF2.

CONCLUSION

These findings support the clinical use of the Persian BRIEF2 in Iranian adolescents, including the interpretation of the BRIEF2 three-factor structure, as well as the multidimensional nature of executive functions.

An update on pediatric traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) remains the commonest neurological and neurosurgical cause of death and survivor disability among children and young adults. This review summarizes some of the important recent publications that have added to our understanding of the condition and advanced clinical practice.

METHODS

Targeted review of the literature on various aspects of paediatric TBI over the last 5 years.

RESULTS

Recent literature has provided new insights into the burden of paediatric TBI and patient outcome across geographical divides and the severity spectrum. Although CT scans remain a standard, rapid sequence MRI without sedation has been increasingly used in the frontline. Advanced MRI sequences are also being used to better understand pathology and to improve prognostication. Various initiatives in paediatric and adult TBI have contributed regionally and internationally to harmonising research efforts in mild and severe TBI. Emerging data on advanced brain monitoring from paediatric studies and extrapolated from adult studies continues to slowly advance our understanding of its role. There has been growing interest in non-invasive monitoring, although the clinical applications remain somewhat unclear. Contributions of the first large scale comparative effectiveness trial have advanced knowledge, especially for the use of hyperosmolar therapies and cerebrospinal fluid drainage in severe paediatric TBI. Finally, the growth of large and even global networks is a welcome development that addresses the limitations of small sample size and generalizability typical of single-centre studies.

CONCLUSION

Publications in recent years have contributed iteratively to progress in understanding paediatric TBI and how best to manage patients.

Pediatric Palliative Care Referral Criteria Following Moderate or Severe Traumatic Brain Injuries

Introduction/Aims: Traumatic brain injuries (TBIs) are one of the leading causes of death and disability in children and adolescents. A significant number of those who survive suffer from the lasting cognitive, physical, or behavioral effects of TBI while the loss is devastating for families. The aim of the study is to characterize the pediatric population and formulate referral criteria for palliative care (PC) consults who would guide the most beneficial allocation of resources. Methods: This is an IRB-approved retrospective chart review study from January 1, 2017, to October 1, 2021, of persons presenting to the emergency department of a 467-bed quaternary pediatric hospital in the midwest with a moderate or severe TBI (ICD-10: S.06.2X and S.06.5X9A). Participants were excluded if they were admitted directly from an outside hospital or if the diagnosis code did not meet criteria. Results: N = 33 patients presented with moderate or severe TBI, of which 17 had PC consult. There were no significant between-group demographic differences. Significant differences in clinical and outcome variables formed the basis of proposed referral criteria for specialist PC for children and adolescents sustaining a moderate-to-severe traumatic brain injury. Discussion: PC programs are a finite resource and should be available to and focused on those with greatest need. The proposed criteria provide empirically based guidance on when to consult, or consider consulting, specialist pediatric PC. Further testing of these criteria and their relationship with improved outcomes are desirable.

Cognitive rehabilitation in paediatric acquired brain injury-A 2-year follow-up of a randomised controlled trial

Background

Goal management training (GMT), a metacognitive rehabilitation method that has been demonstrated to improve executive function (EF) in adults with acquired brain injury (ABI), could potentially be effective for children in the chronic phase of ABI. In a previously published randomised controlled trial (RCT), the efficacy of a paediatric adaptation of GMT (pGMT) compared to a psychoeducative control intervention (paediatric Brain Health Workshop, pBHW) was investigated. Comparable improvements in EF in both groups were found at 6-month follow-up. However, a specific effect of pGMT could not be conclusively proven. The present study reports 2-year follow-up data (T4; T1: baseline, T2: post-intervention, T3: 6-month follow-up, and T4: 2-year follow-up) from this original RCT.

Methods

A total of 38 children and adolescents and also their parents completed questionnaires tapping into daily life EF. Explorative analyses were conducted comparing the 2-year follow-up data (T4) with the baseline (T1) and 6-month follow-up data (T3) for T4-participants in the two intervention groups (pGMT; n = 21, pBHW; n = 17), and we also assessed T4-participants vs. non-responders (n = 38) in the RCT. Primary outcome measures were the Behavioural Regulation Index (BRI) and the Metacognition Index (MI) derived from the Behaviour Rating Inventory of Executive Function (BRIEF) parent report.

Results

No difference between intervention groups was found (BRI, F = 2.25, p = 0.143, MI, F = 1.6, p = 0.213), and no time^*group interaction (BRI, F = 0.07, p = 0.976, MI, F = 0.137, p = 0.937) could be seen at the 2-year follow-up. Nevertheless, both pGMT and the pBHW groups improved daily EF as measured by parental reports over time from the baseline to T4 (p = 0.034). T4 participants and non-responders shared similar baseline characteristics.

Conclusion

Our results extend the findings from the 6-month follow-up previously published. Both pGMT and pBHW groups sustained their improvements in daily life EFs from the baseline, but additional effectiveness of pGMT relative to pBHW was not found.

Predicting Outcomes 2 Months and 1 Year After Inpatient Rehabilitation for Youth With TBI Using Duration of Impaired Consciousness and Serial Cognitive Assessment

OBJECTIVE

To examine predictive utility of the Glasgow Coma Scale (GCS), time to follow commands (TFC), length of posttraumatic amnesia (PTA), duration of impaired consciousness (TFC+PTA), and the Cognitive and Linguistic Scale (CALS) scores in predicting outcomes on the Glasgow Outcome Scale-Extended, Pediatric Revision (GOS-E Peds) for children with traumatic brain injury (TBI) at 2 months and 1 year after discharge from rehabilitation.

SETTING

A large, urban pediatric medical center and inpatient rehabilitation program.

PARTICIPANTS

Sixty youth with moderate-to-severe TBI (mean age at injury = 13.7 years; range = 5-20).

DESIGN

A retrospective chart review.

MAIN MEASURES

Lowest postresuscitation GCS, TFC, PTA, TFC+PTA, inpatient rehabilitation admission and discharge CALS scores, GOS-E Peds at 2-month and 1-year follow-ups.

RESULTS

CALS scores were significantly correlated with the GOS-E Peds at both time points (weak-to-moderate correlation for admission scores and moderate correlation for discharge scores). TFC and TFC+PTA were correlated with GOS-E Peds scores at a 2-month follow-up and TFC remained a predictor at a 1-year follow-up. The GCS and PTA were not correlated with the GOS-E Peds. In the stepwise linear regression model, only the CALS at discharge was a significant predictor of the GOS-E Peds at the 2-month and 1-year follow-ups.

CONCLUSIONS

In our correlational analysis, better performance on the CALS was associated with less long-term disability, and longer TFC was associated with more long-term disability, as measured by the GOS-E Peds. In this sample, the CALS at discharge was the only retained significant predictor of GOS-E Peds scores at 2-month and 1-year follow-ups, accounting for roughly 25% of the variance in GOS-E scores. As previous research suggests, variables related to rate of recovery may be better predictors of outcome than variables related to severity of injury at a single time point (eg, GCS). Future multisite studies are needed to increase sample size and standardize data collection methods for clinical and research purposes.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Professional stakeholders' perceptions of barriers to behavioral health care following pediatric traumatic brain injury

OBJECTIVE

To examine professional stakeholders' perspectives of barriers to behavioral health care (BHC) follow-up and telepsychology after pediatric traumatic brain injury (TBI).

METHODS

Twenty-nine professionals participated in a focus group (FG) or key informant interview (KII) between January and March 2020. Professionals answered questions about facilitators and barriers to BHC follow-up and telepsychology. Given widespread telepsychology implementation since COVID-19, a follow-up survey assessing telehealth perceptions since the pandemic was sent out in December 2020. Nineteen professionals completed the survey.

RESULTS

Professionals identified individual (e.g., family factors, insurance coverage/finances, transportation/distance, availability, planning follow-up care) and system-level (e.g., lack of access to BHC providers) barriers to BHC post-injury. Possible solutions, like collaborative follow-up care, were also identified. Generally, clinical professionals have favorable impressions of telepsychology and utilized services as a delivery modality for clinical care. Though telepsychology could reduce barriers to care, professionals also expressed concerns (e.g., technology issues, security/safety) and challenges (e.g., funding, accessibility, training/licensure for clinicians) with implementing telepsychology.

CONCLUSION

Barriers identified highlight the need for context-specific solutions to increase BHC access, with telepsychology generally recognized as a beneficial modality for BHC. Future work should continue to focus on understanding barriers to BHC and potential solutions after pediatric TBI.

Surface-based abnormalities of the executive frontostriatial circuit in pediatric TBI

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Cortical thickness of the dorsolateral prefrontal cortex is reduced in pediatric TBI.

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Shape abnormalities of the caudate and mediodorsal nucleus of the thalamus are a feature of pediatric TBI.

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Surface-based abnormalities of the dorsolateral prefrontal loop do not appear to relate to executive functioning.

Childhood traumatic brain injury (TBI) is one of the most common causes of acquired disability and has significant implications for executive functions (EF), such as impaired attention, planning, and initiation that are predictive of everyday functioning. Evidence has suggested attentional features of executive functioning require behavioral flexibility that is dependent on frontostriatial circuitry. The purpose of this study was to evaluate surface-based deformation of a specific frontostriatial circuit in pediatric TBI and its role in EF. Regions of interest included: the dorsolateral prefrontal cortex (DLPFC), caudate nucleus, globus pallidus, and the mediodorsal nucleus of the thalamus (MD). T1-weighted magnetic resonance images were obtained in a sample of children ages 8–13 with complicated mild, moderate, or severe TBI (n = 32) and a group of comparison children with orthopedic injury (OI; n = 30). Brain regions were characterized using high-dimensional surface-based brain mapping procedures. Aspects of EF were assessed using select subtests from the Test of Everyday Attention for Children (TEA-Ch). General linear models tested group and hemisphere differences in DLPFC cortical thickness and subcortical shape of deep-brain regions; Pearson correlations tested relationships with EF. Main effects for group were found in both cortical thickness of the DLPFC (F_1,60 = 4.30, p = 0.042) and MD mean deformation (F_1,60 = 6.50, p = 0.01) all with lower values in the TBI group. Statistical surface maps revealed significant inward deformation on ventral-medial aspects of the caudate in TBI relative to OI, but null results in the globus pallidus. No significant relationships between EF and any region of interest were observed. Overall, findings revealed abnormalities in multiple aspects of a frontostriatial circuit in pediatric TBI, which may reflect broader pathophysiological mechanisms. Increased consideration for the role of deep-brain structures in pediatric TBI can aid in the clinical characterization of anticipated long-term developmental effects of these individuals.

Trajectory of Long-Term Outcome in Severe Pediatric Diffuse Axonal Injury: An Exploratory Study

Introduction: Pediatric severe traumatic brain injury (TBI) is one of the leading causes of disability and death. One of the classic pathoanatomic brain injury lesions following severe pediatric TBI is diffuse (multifocal) axonal injury (DAI). In this single institution study, our overarching goal was to describe the clinical characteristics and long-term outcome trajectory of severe pediatric TBI patients with DAI.

Methods: Pediatric patients (<18 years of age) with severe TBI who had DAI were retrospectively reviewed. We evaluated the effect of age, sex, Glasgow Coma Scale (GCS) score, early fever ≥ 38.5°C during the first day post-injury, the extent of ICP-directed therapy needed with the Pediatric Intensity Level of Therapy (PILOT) score, and MRI within the first week following trauma and analyzed their association with outcome using the Glasgow Outcome Score—Extended (GOS-E) scale at discharge, 6 months, 1, 5, and 10 years following injury.

Results: Fifty-six pediatric patients with severe traumatic DAI were analyzed. The majority of the patients were >5 years of age and male. There were 2 mortalities. At discharge, 56% (30/54) of the surviving patients had unfavorable outcome. Sixty five percent (35/54) of surviving children were followed up to 10 years post-injury, and 71% (25/35) of them made a favorable recovery. Early fever and extensive DAI on MRI were associated with worse long-term outcomes.

Conclusion: We describe the long-term trajectory outcome of severe pediatric TBI patients with pure DAI. While this was a single institution study with a small sample size, the majority of the children survived. Over one-third of our surviving children were lost to follow-up. Of the surviving children who had follow-up for 10 years after injury, the majority of these children made a favorable recovery.

As Time Goes by: Understanding Child and Family Factors Shaping Behavioral Outcomes After Traumatic Brain Injury

Objective: To model pre-injury child and family factors associated with the trajectory of internalizing and externalizing behavior problems across the first 3 years in children with pediatric traumatic brain injury (TBI) relative to children with orthopedic injuries (OI). Parent-reported emotional symptoms and conduct problems were expected to have unique and shared predictors. We hypothesized that TBI, female sex, greater pre-injury executive dysfunction, adjustment problems, lower income, and family dysfunction would be associated with less favorable outcomes. Methods: In a prospective longitudinal cohort study, we examined the level of behavior problems at 12 months after injury and rate of change from pre-injury to 12 months and from 12 to 36 months in children ages 4-15 years with mild to severe TBI relative to children with OI. A structural equation model framework incorporated injury characteristics, child demographic variables, as well as pre-injury child reserve and family attributes. Internalizing and externalizing behavior problems were indexed using the parent-rated Emotional Symptoms and Conduct Problems scales from the Strengths and Difficulties questionnaire. Results: The analysis cohort of 534 children [64% boys, M (SD) 8.8 (4.3) years of age] included 395 with mild to severe TBI and 139 with OI. Behavior ratings were higher after TBI than OI but did not differ by TBI severity. TBI, higher pre-injury executive dysfunction, and lower income predicted the level and trajectory of both Emotional Symptoms and Conduct Problems at 12 months. Female sex and poorer family functioning were vulnerability factors associated with greater increase and change in Emotional Symptoms by 12 months after injury; unique predictors of Conduct Problems included younger age and prior emotional/behavioral problems. Across the long-term follow-up from 12 to 36 months, Emotional Symptoms increased significantly and Conduct Problems stabilized. TBI was not a significant predictor of change during the chronic stage of recovery. Conclusions: After TBI, Emotional Symptoms and Conduct Problem scores were elevated, had different trajectories of change, increased or stayed elevated from 12 to 36 months after TBI, and did not return to pre-injury levels across the 3 year follow-up. These findings highlight the importance of addressing behavioral problems after TBI across an extended time frame.