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Russell K, Walld R, Bolton JM, Chateau D, Ellis MJ. Incidence of Subsequent Mental Health Disorders and Social Adversity Following Pediatric Concussion: A Longitudinal, Population-Based Study. J Pediatr 2023; 259:113436. [PMID: 37088182 DOI: 10.1016/j.jpeds.2023.113436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 02/28/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To determine the long-term risk of new adverse psychosocial outcomes among adolescents diagnosed with a concussion compared with those not diagnosed. STUDY DESIGN A retrospective, population-based cohort study was conducted. Adolescents (10-18 years) with a physician-diagnosed concussion between 2000 and 2005 were matched on neighborhood and age with 5 controls without concussion from the general population. New-onset mental health disorders, medication use, social, and justice outcomes were extracted using datasets linked to the population data repository. Adolescents were followed for 11-16 years. Adjusted hazard ratios (95% CIs) were estimated. RESULTS In total, 2082 adolescents with a concussion were matched to 10 510 without. Adolescents with a concussion had an increased risk of any mental health disorder (HR 1.34; 95% CI 1.25-1.45), mood disorder (HR 1.30; 95% 1.18-1.43), psychosis (HR 1.43; 95% CI 1.18-1.74), substance abuse disorder (HR 1.67; 95% 1.31-2.14), and receiving a psychotropic prescription (HR 1.31; 95% CI 1.20-1.42). Female adolescents had an increased risk of ADHD following concussion (HR 1.89; 95% CI 1.17-3.05). Adolescents with a concussion had an increased risk of being accused (HR 1.22; 95% CI 1.11-1.34), victim (HR 1.29; 95% CI 1.11-1.48), or witness (HR 1.16; 95% CI 1.01-1.32) of a crime, or contact with Child and Family Services (HR 1.33; 95% CI 1.10-1.62). There was no association between concussion and attempting or completing suicide, receiving housing support, or collecting income support. CONCLUSIONS Concussion was associated with an increased risk for multiple adverse psychosocial outcomes. Future work should focus on early identification of those at risk of these outcomes to help optimize longitudinal medical care and support.
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Affiliation(s)
- Kelly Russell
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; Excellence in Neurodevelopment and Rehabilitation Research in Child Health Research Theme - Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.
| | - Randy Walld
- Manitoba Center for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James M Bolton
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel Chateau
- Manitoba Center for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada; National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
| | - Michael J Ellis
- Department of Surgery, Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada; Pan Am Concussion Program, Winnipeg, Manitoba, Canada
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Lima Santos JP, Jia-Richards M, Kontos AP, Collins MW, Versace A. Emotional Regulation and Adolescent Concussion: Overview and Role of Neuroimaging. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6274. [PMID: 37444121 PMCID: PMC10341732 DOI: 10.3390/ijerph20136274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023]
Abstract
Emotional dysregulation symptoms following a concussion are associated with an increased risk for emotional dysregulation disorders (e.g., depression and anxiety), especially in adolescents. However, predicting the emergence or worsening of emotional dysregulation symptoms after concussion and the extent to which this predates the onset of subsequent psychiatric morbidity after injury remains challenging. Although advanced neuroimaging techniques, such as functional magnetic resonance imaging and diffusion magnetic resonance imaging, have been used to detect and monitor concussion-related brain abnormalities in research settings, their clinical utility remains limited. In this narrative review, we have performed a comprehensive search of the available literature regarding emotional regulation, adolescent concussion, and advanced neuroimaging techniques in electronic databases (PubMed, Scopus, and Google Scholar). We highlight clinical evidence showing the heightened susceptibility of adolescents to experiencing emotional dysregulation symptoms following a concussion. Furthermore, we describe and provide empirical support for widely used magnetic resonance imaging modalities (i.e., functional and diffusion imaging), which are utilized to detect abnormalities in circuits responsible for emotional regulation. Additionally, we assess how these abnormalities relate to the emotional dysregulation symptoms often reported by adolescents post-injury. Yet, it remains to be determined if a progression of concussion-related abnormalities exists, especially in brain regions that undergo significant developmental changes during adolescence. We conclude that neuroimaging techniques hold potential as clinically useful tools for predicting and, ultimately, monitoring the treatment response to emotional dysregulation in adolescents following a concussion.
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Affiliation(s)
- João Paulo Lima Santos
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.J.-R.); (A.V.)
| | - Meilin Jia-Richards
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.J.-R.); (A.V.)
| | - Anthony P. Kontos
- Department of Orthopaedic Surgery, UPMC Sports Concussion Program, University of Pittsburgh, Pittsburgh, PA 15213, USA; (A.P.K.); (M.W.C.)
| | - Michael W. Collins
- Department of Orthopaedic Surgery, UPMC Sports Concussion Program, University of Pittsburgh, Pittsburgh, PA 15213, USA; (A.P.K.); (M.W.C.)
| | - Amelia Versace
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.J.-R.); (A.V.)
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von Steinbuechel N, Krenz U, Bockhop F, Koerte IK, Timmermann D, Cunitz K, Zeldovich M, Andelic N, Rojczyk P, Bonfert MV, Berweck S, Kieslich M, Brockmann K, Roediger M, Lendt M, Buchheim A, Muehlan H, Holloway I, Olabarrieta-Landa L. A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury. J Clin Med 2023; 12:3895. [PMID: 37373590 DOI: 10.3390/jcm12123895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023] Open
Abstract
In the field of pediatric traumatic brain injury (TBI), relationships between pre-injury and injury-related characteristics and post-TBI outcomes (functional recovery, post-concussion depression, anxiety) and their impact on disease-specific health-related quality of life (HRQoL) are under-investigated. Here, a multidimensional conceptual model was tested using a structural equation model (SEM). The final SEM evaluates the associations between these four latent variables. We retrospectively investigated 152 children (8-12 years) and 148 adolescents (13-17 years) after TBI at the recruiting clinics or online. The final SEM displayed a fair goodness-of-fit (SRMR = 0.09, RMSEA = 0.08 with 90% CI [0.068, 0.085], GFI = 0.87, CFI = 0.83), explaining 39% of the variance across the four latent variables and 45% of the variance in HRQoL in particular. The relationships between pre-injury and post-injury outcomes and between post-injury outcomes and TBI-specific HRQoL were moderately strong. Especially, pre-injury characteristics (children's age, sensory, cognitive, or physical impairments, neurological and chronic diseases, and parental education) may aggravate post-injury outcomes, which in turn may influence TBI-specific HRQoL negatively. Thus, the SEM comprises potential risk factors for developing negative post-injury outcomes, impacting TBI-specific HRQoL. Our findings may assist healthcare providers and parents in the management, therapy, rehabilitation, and care of pediatric individuals after TBI.
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Affiliation(s)
- Nicole von Steinbuechel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Ugne Krenz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Fabian Bockhop
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Inga K Koerte
- cBRAIN/Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, LMU University Hospital, Ludwig-Maximilian University, Nussbaumstrasse 5, 80336 Munich, Germany
| | - Dagmar Timmermann
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Katrin Cunitz
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Nada Andelic
- Research Centre for Habilitation and Rehabilitation Models and Services (CHARM), Department of Health and Society, University of Oslo, 0316 Oslo, Norway
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, 0424 Oslo, Norway
| | - Philine Rojczyk
- cBRAIN/Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, LMU University Hospital, Ludwig-Maximilian University, Nussbaumstrasse 5, 80336 Munich, Germany
| | - Michaela Veronika Bonfert
- Department of Pediatric Neurology and Developmental Medicine, LMU Center for Development and Children with Medical Complexity, Dr. von Hauner Children's Hospital, LMU University Hospital, Haydnstr. 5, 80336 Munich, Germany
| | - Steffen Berweck
- Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology, Schoen Klinik, Krankenhausstraße 20, 83569 Vogtareuth, Germany
| | - Matthias Kieslich
- Department of Paediatric Neurology, Hospital of Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Knut Brockmann
- Interdisciplinary Pediatric Center for Children with Developmental Disabilities and Severe Chronic Disorders, Department of Pediatrics and Adolescent Medicine, University Medical Center, Robert-Koch-Str. 40, 37075 Göttingen, Germany
| | - Maike Roediger
- Department of Pediatric Intensive Care Medicine and Neonatology, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster, Germany
| | - Michael Lendt
- Neuropediatrics, St. Mauritius Therapeutic Clinic, Strümper Straße 111, 40670 Meerbusch, Germany
| | - Anna Buchheim
- Institut für Psychologie, Universität Innsbruck, Innrain 52 f, 6020 Innsbruck, Austria
| | - Holger Muehlan
- Department of Health and Prevention, University of Greifswald, Robert-Blum-Str. 13, 17487 Greifswald, Germany
| | - Ivana Holloway
- Institute of Medical Psychology and Medical Sociology, University Medical Center Göttingen, Waldweg 37A, 37073 Göttingen, Germany
| | - Laiene Olabarrieta-Landa
- Departamento de Ciencias de la Salud, Universidad Pública de Navarra, Campus de Arrosadía, 31006 Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain
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Esterov D, Witkowski J, McCall DM, Weaver AL, Brown AW. Long-Term Risk for Mood and Anxiety Disorders After Pediatric Traumatic Brain Injury: A Population-Based, Birth Cohort Analysis. J Head Trauma Rehabil 2023; 38:E212-E222. [PMID: 36731039 PMCID: PMC10413284 DOI: 10.1097/htr.0000000000000825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine whether exposure to traumatic brain injury (TBI) before 10 years of age is associated with development of a mood or anxiety disorder by 25 years of age, and whether sex or injury severity influences this risk. SETTING Olmsted County, Minnesota. PARTICIPANTS A total of 5518 persons born from January 1, 1976, through December 31, 1982. DESIGN Population-based, birth cohort study. Children sustaining TBI before 10 years of age (index date) were confirmed by manual record review and classified by injury severity using the Mayo Classification System. Each TBI case was age- and sex-matched to 2 referents from the same birth cohort without a history of TBI at the index date. Cox proportional hazards models were fit to compare the risk of a subsequent clinically diagnosed mood or anxiety disorder by 25 years of age between TBI cases and referents. Separate analysis was performed stratified by sex and injury severity. MAIN MEASURES Incidence of mood and anxiety disorders determined through clinical diagnostic codes and manual record review. RESULTS The study included 562 children (238 females [42.3%] and 324 males [57.7%]) with TBI before 10 years of age (mean [SD] age at TBI: 4.7 [2.8] years). At least 1 mood or anxiety disorder was diagnosed for 115 persons with TBI and 215 referents. No statistically significant association existed between childhood TBI status and anxiety disorder (adjusted hazard ratio [aHR], 1.01 [95% confidence interval (CI), 0.71-1.43]; P = .97) or mood disorder (aHR, 1.16 [95% CI, 0.92-1.47]; P = .21). However, females who sustained TBI had a significantly increased risk of a subsequently diagnosed mood disorder compared with age-matched female referents (aHR, 1.40 [95% CI, 1.04-1.89]; P = .03). CONCLUSIONS This study suggests that isolated TBI before 10 years of age is not significantly associated with an increased risk of anxiety or mood disorder by 25 years of age, though females may be at an increased risk.
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Affiliation(s)
- Dmitry Esterov
- Department of Physical Medicine and Rehabilitation (Drs Esterov and Brown), Division of Clinical Trials and Biostatistics (Ms Weaver), Mayo Clinic, Rochester, Minnesota; and Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota (Drs Witkowski and McCall). Dr Witkowski is now with the Department of Physical Medicine and Rehabilitation, Northwestern Medicine, Wheaton, Illinois. Dr McCall is now with the Gundersen Health System, La Crosse, Wisconsin
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5
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Jung E, Ryu HH. High-sensitivity C-reactive protein is a predictor of depression in patients with mild traumatic brain injury. Heliyon 2023; 9:e14783. [PMID: 37012911 PMCID: PMC10066530 DOI: 10.1016/j.heliyon.2023.e14783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/28/2023] Open
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Lambert M, Sheldrake E, Deneault AA, Wheeler A, Burke M, Scratch S. Depressive Symptoms in Individuals With Persistent Postconcussion Symptoms: A Systematic Review and Meta-Analysis. JAMA Netw Open 2022; 5:e2248453. [PMID: 36574246 PMCID: PMC9857135 DOI: 10.1001/jamanetworkopen.2022.48453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Approximately 15% to 30% of individuals with a history of concussion present with persistent postconcussion symptoms (PPCS). Individuals with PPCS are at greater risk of experiencing depressive symptoms. OBJECTIVE To synthesize the association between depressive symptoms and PPCS in children, adolescents, and adults via meta-analysis and to investigate potential moderators of that association. DATA SOURCES Systematic search of Ovid Medline, CINAHL, PsycInfo, and Embase from 1995 to January 2022 was performed. Additionally, references from included studies were hand-searched to ensure relevant articles were captured in the search. STUDY SELECTION Studies that involved participants who experienced PPCS and quantified depressive symptoms were included. The definition of PPCS was limited to physician-diagnosed or self-reported concussion, with symptoms lasting for a minimum of 4 weeks postinjury. Two authors independently screened all articles to determine study eligibility. DATA EXTRACTION AND SYNTHESIS Study characteristics were extracted independently by 2 trained investigators. Study data were meta-analyzed using a random-effects meta-analysis. EXPOSURE PPCS. MAIN OUTCOMES AND MEASURES The the primary outcome was depressive symptoms. RESULTS Data were extracted from 18 studies with a total of 9101 participants. Of the 18 studies, all were cohort studies, and 13 (72%) comprised adult populations. The mean (SD) time since concussion was 21.3 (18.7) weeks. After accounting for potential publication bias, the random-effects meta-analysis found a significant positive association between PPCS and depressive symptoms, (odds ratio, 4.56; 95% CI, 2.82-7.37; P < .001). There were no significant moderators, likely due to the small number of studies included. CONCLUSIONS AND RELEVANCE In this meta-analysis, experiencing PPCS was associated with a higher risk of experiencing depressive symptoms. There are several important clinical and health policy implications of the findings. Most notably, the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported.
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Affiliation(s)
- Maude Lambert
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
- Bloorview Research Institute, Toronto, Ontario, Canada
| | - Elena Sheldrake
- Bloorview Research Institute, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | | | - Anne Wheeler
- Neuroscience and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Burke
- Neuropsychiatry Program, Department of Psychiatry, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Shannon Scratch
- Bloorview Research Institute, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury. CHILDREN 2022; 9:children9091321. [PMID: 36138630 PMCID: PMC9497748 DOI: 10.3390/children9091321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/19/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022]
Abstract
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.
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Max JE, Drake I, Vaida F, Hesselink JR, Ewing-Cobbs L, Schachar RJ, Chapman SB, Bigler ED, Wilde EA, Saunders AE, Yang TT, Tymofiyeva O, Levin HS. Novel Psychiatric Disorder 6 Months After Traumatic Brain Injury in Children and Adolescents. J Neuropsychiatry Clin Neurosci 2022; 35:141-150. [PMID: 35989573 PMCID: PMC10317586 DOI: 10.1176/appi.neuropsych.21120301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate the factors predictive of novel psychiatric disorders in the interval 0-6 months following traumatic brain injury (TBI). METHODS Children ages 5-14 years consecutively hospitalized for mild to severe TBI at five hospitals were recruited. Participants were evaluated at baseline (soon after injury) for pre-injury characteristics including psychiatric disorders, socioeconomic status (SES), psychosocial adversity, family function, family psychiatric history, and adaptive function. In addition to the psychosocial variables, injury severity and lesion location detected with acquisition of a research MRI were measured to develop a biopsychosocial predictive model for development of novel psychiatric disorders. Psychiatric outcome, including occurrence of a novel psychiatric disorder, was assessed 6 months after the injury. RESULTS The recruited sample numbered 177 children, and 141 children (80%) returned for the six-month assessment. Of the 141 children, 58 (41%) developed a novel psychiatric disorder. In univariable analyses, novel psychiatric disorder was significantly associated with lower SES, higher psychosocial adversity, and lesions in frontal lobe locations, such as frontal white matter, superior frontal gyrus, inferior frontal gyrus, and orbital gyrus. Multivariable analyses found that novel psychiatric disorder was independently and significantly associated with frontal-lobe white matter, superior frontal gyrus, and orbital gyrus lesions. CONCLUSION The results demonstrate that occurrence of novel psychiatric disorders following pediatric TBI requiring hospitalization is common and has identifiable psychosocial and specific biological predictors. However, only the lesion predictors were independently related to this adverse psychiatric outcome.
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Affiliation(s)
- Jeffrey E. Max
- University of California, San Diego, Department of Psychiatry
- Rady Children’s Hospital, San Diego
| | | | - Florin Vaida
- University of California, San Diego, Herbert Wertheim School of Public Health, Division of Biostatistics & Bioinformatics
| | | | | | | | | | - Erin D. Bigler
- Brigham Young University, Department of Psychology
- University of Utah, TBI and Concussion Center, Department of Neurology
| | - Elisabeth A. Wilde
- University of Utah, TBI and Concussion Center, Department of Neurology
- Baylor College of Medicine, Department of Physical Medicine and Rehabilitation
| | | | - Tony T. Yang
- University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, Weill Institute for Neurosciences
| | - Olga Tymofiyeva
- University of California, San Francisco, Department of Radiology and Biomedical Imaging
| | - Harvey S. Levin
- Baylor College of Medicine, Department of Physical Medicine and Rehabilitation
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9
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Roberts H, Ford TJ, Karl A, Reynolds S, Limond J, Adlam ALR. Mood Disorders in Young People With Acquired Brain Injury: An Integrated Model. Front Hum Neurosci 2022; 16:835897. [PMID: 35754774 PMCID: PMC9218558 DOI: 10.3389/fnhum.2022.835897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/19/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose/Objective Young people with paediatric acquired brain injury (pABI) are twice as likely to develop a mood disorder as their peers, frequently have significant unmet socio-emotional needs, and are at over double the risk of going on to use adult mental health services. Recent years have seen significant advances in the development of interventions for young people with mood disorders. However, evidence-based approaches to mood disorders in pABI are lacking and surprisingly little work has evaluated clinical and neuro-developmental models of mood disorders in this population. Method We review the literature regarding key mechanisms hypothesised to account for the increased vulnerability to mood disorders in pABI: First, we summarise the direct neurocognitive consequences of pABI, considering the key areas of the brain implicated in vulnerability to mood disorders within a neurodevelopmental framework. Second, we outline five key factors that contribute to the heightened prevalence of mood disorders in young people following ABI. Finally, we synthesise these, integrating neuro-cognitive, developmental and systemic factors to guide clinical formulation. Results and Implications We present a framework that synthesises the key mechanisms identified in our review, namely the direct effects of pABI, neurocognitive and neuroendocrine factors implicated in mood and anxiety disorders, maladaptive neuroplasticity and trauma, structural and systemic factors, and psychological adjustment and developmental context. This framework is the first attempt to provide integrated guidance on the multiple factors that contribute to elevated life-long risk of mood disorders following pABI.
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Affiliation(s)
| | - Tamsin J Ford
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Anke Karl
- Psychology, University of Exeter, Exeter, United Kingdom
| | - Shirley Reynolds
- Department of Psychology, University of Reading, Reading, United Kingdom
| | - Jenny Limond
- Psychology, University of Exeter, Exeter, United Kingdom
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Esterov D, Witkowski J, McCall DM, Wi CI, Weaver AL, Brown AW. Risk factors for development of long-term mood and anxiety disorder after pediatric traumatic brain injury: a population-based, birth cohort analysis. Brain Inj 2022; 36:722-732. [PMID: 35604956 PMCID: PMC10364060 DOI: 10.1080/02699052.2022.2077987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVES The objective of this study was to identify characteristics associated with an increased risk of anxiety and mood disorder prior to 25 years of age, in children who sustained a traumatic brain injury (TBI) prior to age 10. METHODS This population-based study identified 562 TBI cases from a 1976-1982 birth cohort in Olmsted County, Minnesota. TBI cases were manually confirmed and classified by injury severity. Separate Cox proportional hazards regression models were fit to estimate the association of TBI and secondary non-TBI related characteristics with the risk of a subsequent clinically determined anxiety or mood disorder. Multivariable-adjusted population attributable risk (PAR) estimates were calculated for TBI characteristics. RESULTS Older age at initial TBI and extracranial injury at time of initial TBI were significantly associated with an increased risk of anxiety (adjusted HR [95% CI]: 1.33 [1.16, 1.52] per 1-year increase and 2.41 [1.26, 4.59]), respectively. Older age at initial TBI was significantly associated with an increased risk of a mood disorder (adjusted HR 1.17 [1.08-1.27]). CONCLUSION In individuals sustaining a TBI prior to age 10, age at injury greater than 5 years old was the largest contributor to development of a mood or anxiety disorder.
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Affiliation(s)
- Dmitry Esterov
- Department of Physical Medicine and Rehabilitation, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Julie Witkowski
- Mayo Clinic, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Dana M McCall
- Mayo Clinic, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Chung-Il Wi
- Department of Pediatric and Adolescent Medicine, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Amy L Weaver
- Division of Clinical Trials and Biostatistics, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Allen W Brown
- Department of Physical Medicine and Rehabilitation, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Kalra S, Banderwal R, Arora K, Kumar S, Singh G, Chawla PA, Behl T, Sehgal A, Singh S, Bhatia S, Al-Harrasi A, Aleya L, Dhiman A. An update on pathophysiology and treatment of sports-mediated brain injury. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:16786-16798. [PMID: 34994929 DOI: 10.1007/s11356-021-18391-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Abstract
Traumatic brain injury (TBI) is a neurological disorder which represents a major health issue worldwide. It causes mortality and disability among all group ages, caused by external force, sports-related events or violence and road traffic accidents. In the USA, approximately one-third people die annually due to injury and 1.7 million people suffer from traumatic brain injury. Every year in India around 1.6 million individuals suffer from sustain brain injury with 200,000 deaths and approximately one million person needed recovery treatment at any stage of time. Sports-related head impact and trauma has become an extremely controversial public health and medico-legal problem that accounts for 20% of all brain injury (including concussion). It is difficult to reverse the primary injury but the secondary injury can be minimized by using proper pharmacological intervention during the initial hours of injury. This article highlights the pathophysiology and types of TBI along with treatment therapies. Till date, there is no single medication that can decrease the progression of the disease so that symptomatic treatment is given to the patient by determining proper pathology. Recently various herbal medicine therapies and traditional supplements have been developed for TBI. Nutritional supplementation and nutraceuticals have exposed potential in the treatment of TBI when used before and after TBI. The compiled data will enable the readers to know the pathophysiology as well as the allopathic and natural remedies to treat the TBI.
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Affiliation(s)
- Sunishtha Kalra
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Rittu Banderwal
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Kaushal Arora
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Sandeep Kumar
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Govind Singh
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India
| | - Pooja A Chawla
- Department of Pharmaceutical Chemistry and Analysis, ISF College of Pharmacy Moga, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Aayush Sehgal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Sukhbir Singh
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Saurabh Bhatia
- School of Health Science, University of Petroleum and Energy Studies, Dehradun, Uttarakhand, India
- Natural & Medical Sciences Research Centre, University of Nizwa, Birkat Al Mauz, Nizwa, Oman
| | - Ahmed Al-Harrasi
- Natural & Medical Sciences Research Centre, University of Nizwa, Birkat Al Mauz, Nizwa, Oman
| | - Lotfi Aleya
- Chrono-Environment Laboratory, UMR CNRS 6249, Bourgogne Franche-Comté University, Besançon, France
| | - Anju Dhiman
- Department of Pharmaceutical Sciences, Maharshi Dayanand University, Rohtak, Haryana, India.
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12
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Role of Inflammation in Traumatic Brain Injury-Associated Risk for Neuropsychiatric Disorders: State of the Evidence and Where Do We Go From Here. Biol Psychiatry 2022; 91:438-448. [PMID: 34955170 DOI: 10.1016/j.biopsych.2021.11.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 10/01/2021] [Accepted: 11/02/2021] [Indexed: 02/06/2023]
Abstract
In the past decade, there has been an increasing awareness that traumatic brain injury (TBI) and concussion substantially increase the risk for developing psychiatric disorders. Even mild TBI increases the risk for depression and anxiety disorders such as posttraumatic stress disorder by two- to threefold, predisposing patients to further functional impairment. This strong epidemiological link supports examination of potential mechanisms driving neuropsychiatric symptom development after TBI. One potential mechanism for increased neuropsychiatric symptoms after TBI is via inflammatory processes, as central nervous system inflammation can last years after initial injury. There is emerging preliminary evidence that TBI patients with posttraumatic stress disorder or depression exhibit increased central and peripheral inflammatory markers compared with TBI patients without these comorbidities. Growing evidence has demonstrated that immune signaling in animals plays an integral role in depressive- and anxiety-like behaviors after severe stress or brain injury. In this review, we will 1) discuss current evidence for chronic inflammation after TBI in the development of neuropsychiatric symptoms, 2) highlight potential microglial activation and cytokine signaling contributions, and 3) discuss potential promise and pitfalls for immune-targeted interventions and biomarker strategies to identify and treat TBI patients with immune-related neuropsychiatric symptoms.
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13
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Schwab N, Leung E, Hazrati LN. Cellular Senescence in Traumatic Brain Injury: Evidence and Perspectives. Front Aging Neurosci 2021; 13:742632. [PMID: 34650425 PMCID: PMC8505896 DOI: 10.3389/fnagi.2021.742632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/03/2021] [Indexed: 12/14/2022] Open
Abstract
Mild traumatic brain injury (mTBI) can lead to long-term neurological dysfunction and increase one's risk of neurodegenerative disease. Several repercussions of mTBI have been identified and well-studied, including neuroinflammation, gliosis, microgliosis, excitotoxicity, and proteinopathy – however the pathophysiological mechanisms activating these pathways after mTBI remains controversial and unclear. Emerging research suggests DNA damage-induced cellular senescence as a possible driver of mTBI-related sequalae. Cellular senescence is a state of chronic cell-cycle arrest and inflammation associated with physiological aging, mood disorders, dementia, and various neurodegenerative pathologies. This narrative review evaluates the existing studies which identify DNA damage or cellular senescence after TBI (including mild, moderate, and severe TBI) in both experimental animal models and human studies, and outlines how cellular senescence may functionally explain both the molecular and clinical manifestations of TBI. Studies on this subject clearly show accumulation of various forms of DNA damage (including oxidative damage, single-strand breaks, and double-strand breaks) and senescent cells after TBI, and indicate that cellular senescence may be an early event after TBI. Further studies are required to understand the role of sex, cell-type specific mechanisms, and temporal patterns, as senescence may be a pathway of interest to target for therapeutic purposes including prognosis and treatment.
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Affiliation(s)
- Nicole Schwab
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Emily Leung
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
| | - Lili-Naz Hazrati
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.,The Hospital for Sick Children, Toronto, ON, Canada
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14
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Behavior Problems Following Childhood TBI: The Role of Sex, Age, and Time Since Injury. J Head Trauma Rehabil 2021; 35:E393-E404. [PMID: 32108717 DOI: 10.1097/htr.0000000000000567] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the frequency of behavioral problems after childhood traumatic brain injury (TBI) and their associations with injury severity, sex, and social environmental factors. SETTING Children's hospitals in the Midwestern/Western United States. PARTICIPANTS 381 boys and 210 girls with moderate (n = 359) and severe (n = 227) TBI, with an average age at injury of 11.7 years (range 0.3-18) who were injured ≤3 years ago. DESIGN Secondary data analysis of a multistudy cohort. MAIN MEASURES Child Behavior Checklist (CBCL) administered pretreatment. RESULTS Thirty-seven percent had borderline/clinical elevations on the CBCL Total Problem Scale, with comparable rates of Internalizing and Externalizing problems (33% and 31%, respectively). Less parental education was associated with higher rates of internalizing, externalizing, and total problems. Time since injury had a linear association with internalizing symptoms, with greater symptoms at longer postinjury intervals. Younger boys had significantly higher levels of oppositional defiant symptoms than girls, whereas older girls had significantly greater attention-deficit hyperactivity disorder symptoms than boys. CONCLUSIONS Pediatric TBI is associated with high rates of behavior problems, with lower socioeconomic status predicting substantially elevated risk. Associations of higher levels of internalizing symptoms with greater time since injury highlight the importance of tracking children over time.
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15
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Impact of Secondary ADHD on Long-Term Outcomes After Early Childhood Traumatic Brain Injury. J Head Trauma Rehabil 2021; 35:E271-E279. [PMID: 31834065 PMCID: PMC7205557 DOI: 10.1097/htr.0000000000000550] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the impact of secondary attention-deficit/hyperactivity disorder (SADHD) on long-term global and executive functioning in adolescents after traumatic brain injury (TBI). SETTING Three tertiary cared children's hospitals and 1 general hospital. PARTICIPANTS One hundred twenty children (TBI: n = 54; orthopedic injury: n = 66) without preinjury ADHD evaluated approximately 6.8 years postinjury. DESIGN Cross-sectional data analysis from a prospective, longitudinal study. MAIN MEASURES Outcomes included functional impairment (Child and Adolescent Functional Assessment Scale) and executive functioning (Behavior Rating Inventory of Executive Function [BRIEF]). RESULTS SADHD moderated the association of injury type with the BRIEF-Behavioral Regulation Index (F1,113 = 4.42, P = .04) and the Child and Adolescent Functional Assessment Scale (F1,112 = 8.95, P = .003). TBI was only associated with poorer outcomes in the context of SADHD. SADHD was also associated with poorer outcomes on the BRIEF-Global Executive Composite (F1,113 = 52.92, P < .0001) and BRIEF-Metacognitive Index scores (F1,113 = 48.64, P < .0001) across groups. Adolescents with TBI had greater BRIEF-Global Executive Composite scores than those with orthopedic injury (F1,113 = 5.00, P = .03). CONCLUSIONS Although SADHD was associated with poorer functioning across groups, its adverse effects on behavioral regulation and overall functioning were amplified following TBI. TBI + SADHD may confer an elevated risk for significant impairments in early adolescence.
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16
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Mulligan T, Barker-Collo S, Gibson K, Jones K. You only get one brain. Adult reflections on acute and ongoing symptom experiences after traumatic brain injury in adolescence. Brain Inj 2021; 35:1308-1315. [PMID: 34487437 DOI: 10.1080/02699052.2021.1972336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND This research adds to the scarce literature regarding adolescent experiences of traumatic brain injury (TBI). It uses a qualitative methodology to explore the symptoms experienced after sustaining a TBI at this unique stage of development including their persistence into adulthood. METHODS Thirteen adults (aged 20-25 years; mean 23 years) who sustained a mild-moderate TBI during adolescence (aged 13-17 years at injury), approximately 7.7 years (range = 6.7-8.0 years) prior, participated in the research. Semi-structured individual interviews, analyzed using thematic analysis, explored participants' experiences surrounding and following their TBIs. RESULTS TBI during adolescence can result in significant acute symptoms, particularly headaches, fatigue, and difficulties in thinking. Participants' descriptions of the extent and impact of these symptoms reflected feelings of frustration and often anxiety and/or depression. Difficulties could persist for years post-TBI and sometimes had not resolved at all. CONCLUSIONS Even mild TBI during adolescence can result in significant acute and ongoing symptoms, which can contribute to emotional distress in the long term.
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Affiliation(s)
- Therese Mulligan
- School of Psychology, The University of Auckland, Auckland, New Zealand
| | | | - Kerry Gibson
- School of Psychology, The University of Auckland, Auckland, New Zealand
| | - Kelly Jones
- National Institute for Stroke and Applied Neurorehabilitation, Auckland University of Technology, Auckland, New Zealand
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17
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Marcynyszyn LA, McCarty CA, Rivara FP, Johnson AM, Wang J, Zatzick DF. Parent Traumatic Events and Adolescent Internalizing Symptoms: The Mediating Role of Parental Depression Among Youth with Persistent Post-concussive Symptoms. J Pediatr Psychol 2021; 46:547-556. [PMID: 33411915 DOI: 10.1093/jpepsy/jsaa128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/07/2020] [Accepted: 12/13/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Research has demonstrated associations between parental depression (PD) and negative psychological outcomes among their children. However, little is known about the pathways through which lifetime parent traumatic events (PTEs) influence their adolescents' internalizing symptoms. Our study examined whether PD mediates the association between PTE and adolescent depressive and anxious symptoms among youth with persistent postconcussive symptoms (PPCS). METHODS We used baseline data from a randomized effectiveness trial of collaborative care for treatment of persistent postconcussive symptoms among sports-injured adolescents aged 11-18 years. Parent-adolescent dyads were recruited from pediatric clinics throughout western Washington. Eligible adolescents had three or more PPCS that lasted for at least 1 month but <9 months and spoke English. Of 1,870 potentially eligible adolescents, 1,480 (79%) were excluded for not meeting the inclusion criteria. Of the eligible 390 adolescents, 189 (49%) declined to participate/consent. Participants included 200 parent-adolescent dyads (adolescent Mage = 14.7 years, SD = 1.7). Parent respondents were mostly female (83%) and mothers (81%). Adolescents reported on their depressive (Patient Health Questionnaire-9; PHQ-9) and anxious symptoms (Revised Child Anxiety and Depression Scale-Short Version [anxiety subscale]) and parents reported on their depressive symptoms (M = 3.7, SD = 3.7; PHQ-9). RESULTS Mediation analyses revealed two (out of four) significant indirect effects of PTE on both adolescent and parent report of depressive symptoms, but not anxiety. CONCLUSIONS This study elucidates one pathway (PD) through which PTE history influences adolescent depressive symptoms, supporting a two-generation approach to pediatric patient care for youth experiencing PPCS.
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Affiliation(s)
- Lyscha A Marcynyszyn
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
| | - Carolyn A McCarty
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute.,Department of Pediatrics, University of Washington
| | - Frederick P Rivara
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute.,Department of Pediatrics, University of Washington.,Harborview Injury Prevention and Research Center, University of Washington
| | - Ashleigh M Johnson
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute
| | - Jin Wang
- Department of Pediatrics, University of Washington.,Harborview Injury Prevention and Research Center, University of Washington
| | - Douglas F Zatzick
- Harborview Injury Prevention and Research Center, University of Washington.,Psychiatry and Behavioral Sciences, University of Washington
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18
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Bradbury KR, Williams C, Leonard S, Holding E, Turner E, Wagner AE, Piantino J, Luther M, Hall TA. Emotional Aspects of Pediatric Post-Intensive Care Syndrome Following Traumatic Brain Injury. JOURNAL OF CHILD & ADOLESCENT TRAUMA 2021; 14:177-187. [PMID: 33986904 PMCID: PMC8099982 DOI: 10.1007/s40653-020-00332-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 05/05/2023]
Abstract
Children with traumatic brain injury (TBI) requiring neurocritical care are at risk for neurocognitive, emotional, physical, and psychosocial difficulties, collectively known as Post-Intensive Care Syndrome. Our study assessed parent-reported emotional functioning and identified risk factors for emotional sequelae in the acute recovery phase. Fifty-three children between 5 and 18 years old hospitalized for TBI were assessed 1-month following discharge. Relevant injury-, child-, and family-specific variables were collected. Emotional functioning was assessed using PROMIS Parent Proxy Report Short Forms for Anxiety and Depressive Symptoms. We used Chi-square tests to evaluate differences between children with and without elevations in anxiety and depressive symptoms. Logistic regression determined predictors of elevations in symptoms among significant variables. Parents frequently endorsed moderate or worse anxiety (45.2%) and depressive (32.1%) symptoms among children. Mechanism of injury and elevated parent post-traumatic stress disorder (PTSD) symptoms were associated with elevated anxiety and depressive symptoms, while direct family involvement in the accident/injury was associated only with elevated anxiety symptoms. Results from logistic regression indicated that only elevated parent PTSD symptoms were a significant predictor for child anxiety and depressive symptoms. Anxiety and depressive symptoms are prevalent in the acute recovery phase of TBI. Consistent with previous research, elevations in anxiety and depressive symptoms were more related to psychosocial factors than injury severity. High levels of parent PTSD symptoms and their relationship with children's internalizing symptoms highlight the need for mental health treatment for TBI patients and their families.
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Affiliation(s)
- Kathryn R. Bradbury
- Division of Pediatric Psychology, Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
- Children’s Neuropsychological Services, 26 Chestnut Street, Suite 2E, Andover, MA USA
| | - Cydni Williams
- Division of Pediatric Critical Care, Department of Pediatrics, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University and Doernbecher Children’s Hospital, Portland, OR USA
| | - Skyler Leonard
- Division of Pediatric Psychology, Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
| | - Emily Holding
- Division of Pediatric Psychology, Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
| | - Elise Turner
- Division of Pediatric Psychology, Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
| | - Amanda E. Wagner
- Division of Pediatric Psychology, Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
- Child Mind Institute, San Mateo, CA USA
| | - Juan Piantino
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University and Doernbecher Children’s Hospital, Portland, OR USA
- Division of Pediatric Neurology, Department of Pediatrics, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
| | - Madison Luther
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University and Doernbecher Children’s Hospital, Portland, OR USA
| | - Trevor A. Hall
- Division of Pediatric Psychology, Department of Pediatrics, Institute on Development and Disability, Oregon Health & Science University and Doernbecher Children’s Hospital, Portland, OR USA
- Pediatric Critical Care and Neurotrauma Recovery Program, Oregon Health and Science University and Doernbecher Children’s Hospital, Portland, OR USA
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19
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Botchway EN, Godfrey C, Ryan NP, Hearps S, Nicholas CL, Anderson VA, Catroppa C. Sleep Disturbances in Young Adults with Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life. Brain Inj 2020; 34:1579-1589. [PMID: 33054410 DOI: 10.1080/02699052.2020.1832704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study assessed the consequences of childhood traumatic brain injury (TBI) on sleep, fatigue, depression, and quality of life (QoL) outcomes and explored the relationships between these variables at 20 years following childhood TBI. PARTICIPANTS We followed up 54 young adults with mild, moderate, and severe TBI, and 13 typically developing control (TDC) participants, recruited at the time of TBI. METHODS Sleep was assessed with the Pittsburgh Sleep Quality Index and actigraphy. RESULTS At 20 years postinjury, results showed no significant difference between whole TBI group and TDC participants on subjective sleep quality; however, the moderate TBI group reported significantly poorer subjective sleep quality compared to those with severe TBI. Poorer subjective sleep was associated with increased symptoms of fatigue, depression, and poorer perceptions of General Health in the TBI group. Actigraphic sleep efficiency, fatigue, depression, and QoL outcomes were not significantly different between TBI and TDC or among TBI severity groups. CONCLUSIONS These preliminary findings underscore associations between subjective sleep disturbance, fatigue, depression, and QoL in this TBI sample, and mostly comparable outcomes in sleep, fatigue, depression, and QoL between the TBI and TDC groups. Further research is required to clarify these findings.
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Affiliation(s)
- Edith N Botchway
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Department of Psychology, Royal Children's Hospital , Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne , Melbourne, Australia
| | - Celia Godfrey
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Department of Psychology, Royal Children's Hospital , Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne , Melbourne, Australia
| | - Nicholas P Ryan
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Department of Psychology, Royal Children's Hospital , Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne , Melbourne, Australia.,Cognitive Neuroscience Unit, Deakin University , Geelong, Victoria, Australia
| | - Stephen Hearps
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Department of Psychology, Royal Children's Hospital , Parkville, Victoria, Australia
| | - Christian L Nicholas
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Melbourne School of Psychological Sciences, University of Melbourne , Melbourne, Australia.,Institute for Breathing and Sleep, Austin Health , Heidelberg, Victoria, Australia
| | - Vicki A Anderson
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Department of Psychology, Royal Children's Hospital , Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne , Melbourne, Australia.,Melbourne School of Psychological Sciences, University of Melbourne , Melbourne, Australia
| | - Cathy Catroppa
- Clinical Science, Murdoch Children's Research Institute , Parkville, Victoria, Australsia.,Department of Psychology, Royal Children's Hospital , Parkville, Victoria, Australia.,Melbourne School of Psychological Sciences, University of Melbourne , Melbourne, Australia
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20
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Severo L, Godinho D, Machado F, Hartmann D, Fighera MR, Soares FA, Furian AF, Oliveira MS, Royes LF. The role of mitochondrial bioenergetics and oxidative stress in depressive behavior in recurrent concussion model in mice. Life Sci 2020; 257:117991. [PMID: 32569782 DOI: 10.1016/j.lfs.2020.117991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/09/2020] [Accepted: 06/18/2020] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) is a public health problem in which even though 80 to 90% of cases are considered mild, usually starts a sequence of neurological disorders that can last a considerable time. Most of the research of this injury has been focused on oxidative stress and functional deficits; however, mechanisms that underlie the development of neuropsychiatric disorders remain little researched. Due to this, the present authors decided to investigate whether recurrent concussion protocols alter depressive-like phenotype behavior, and whether mitochondria play an indispensable role in this behavior or not. The experimental data revealed, for the first time, that the present protocol of recurrent concussions (4, 7, and 10 injuries) in mice did not alter immobility time during tail suspension tests (TSTs), but decreased hippocampal mitochondrial respiration and increased expression of proteins such as nuclear factor erythroid 2-related factor 2 (Nrf2) and superoxide (SOD2). This experimental data suggests that bioenergetic changes elicited by recurrent concussion did not induce depressive-like behavior, but activated the transcription factor of responsive antioxidant elements (ARE) that delay or prevent secondary cascades in this neurological disease.
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Affiliation(s)
- Leandro Severo
- Programa de Pós-Graduação em Ciências Biológicas, Bioquímica Toxicológica Universidade Federal de Santa Maria, 97105-900, Brazil; Laboratório de Bioquímica do Exercício Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil.
| | - Douglas Godinho
- Programa de Pós-Graduação em Ciências Biológicas, Bioquímica Toxicológica Universidade Federal de Santa Maria, 97105-900, Brazil; Laboratório de Bioquímica do Exercício Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil
| | - Felipe Machado
- Laboratório de Bioquímica do Exercício Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil
| | - Diane Hartmann
- Centro de Ciências Naturais e Exatas, Departamento de Bioquímica e Biologia Molecular, Universidade Federal de Santa Maria, 97105-900, Brazil
| | - Michele Rechia Fighera
- Programa de Pós-Graduação em Ciências Biológicas, Bioquímica Toxicológica Universidade Federal de Santa Maria, 97105-900, Brazil; Laboratório de Bioquímica do Exercício Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil
| | - Félix Alexandre Soares
- Centro de Ciências Naturais e Exatas, Departamento de Bioquímica e Biologia Molecular, Universidade Federal de Santa Maria, 97105-900, Brazil
| | - Ana Flavia Furian
- Centro de Ciências da Saúde, Programa de Pós-Graduação em Farmacologia-Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil
| | - Mauro Schneider Oliveira
- Centro de Ciências da Saúde, Programa de Pós-Graduação em Farmacologia-Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil
| | - Luiz Fernando Royes
- Programa de Pós-Graduação em Ciências Biológicas, Bioquímica Toxicológica Universidade Federal de Santa Maria, 97105-900, Brazil; Laboratório de Bioquímica do Exercício Universidade Federal de Santa Maria, 97105-900 Santa Maria, RS, Brazil.
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21
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Hendry K, Ownsworth T, Waters AM, Jackson M, Lloyd O. [Formula: see text] Investigation of children and adolescents' mood and self-concept after acquired brain injury. Child Neuropsychol 2020; 26:1005-1025. [PMID: 32253978 DOI: 10.1080/09297049.2020.1750577] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Few studies have examined the self-reported mental health of children with an acquired brain injury (ABI). The current study aimed to: 1) identify levels of child-reported depressive and anxiety symptoms and poor self-concept, 2) investigate demographic and injury-related factors associated with children's mood and self-concept, and 3) examine associations between children's self-reported mental health and parents' reports of children's emotional and behavioral functioning in children specifically with traumatic brain injury (TBI). 122 children (66% male) aged 8-16 years with ABI of mixed etiology were consecutively recruited through an outpatient rehabilitation clinic. Children were administered the Beck Youth Inventories - Second Edition, and parents completed the Adaptive Behavior Assessment System and the Child Behavior Checklist (CBCL). Relative to the norms, 16.4% of children scored in the clinical range for the depression and anxiety scales, and 24.6% reported clinically low self-concept. Children with lower functional status had greater anxiety symptoms. Older children (13-16 years) reported significantly higher depressive and anxiety symptoms and lower self-concept than younger children (8-12 years). A significant interaction between age and sex indicated that older girls reported greater depressive and anxiety symptoms than younger girls whereas no age-based differences were found for boys. Parent-reported total emotional and behavioral problems were positively associated with children's self-reported depressive and anxiety symptoms and were negatively correlated with self-concept. These findings indicate that adolescents, particularly girls, may be at heightened risk of poor mental health following ABI. Further research investigating the reasons for these demographic differences may inform developmentally sensitive interventions.
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Affiliation(s)
- Kathryn Hendry
- School of Applied Psychology & Menzies Health Institute of Queensland, GriffithUniversity , Brisbane, Australia
| | - Tamara Ownsworth
- School of Applied Psychology & Menzies Health Institute of Queensland, GriffithUniversity , Brisbane, Australia
| | - Allison M Waters
- School of Applied Psychology & Menzies Health Institute of Queensland, GriffithUniversity , Brisbane, Australia
| | - Megan Jackson
- School of Psychological Sciences, University of Melbourne , Melbourne, Australia.,Queensland Paediatric Rehabilitation Service, The Queensland Children's Hospital, Children's Health Queensland , Brisbane, Australia.,School of Psychology, University of Queensland , Brisbane, Australia
| | - Owen Lloyd
- School of Applied Psychology & Menzies Health Institute of Queensland, GriffithUniversity , Brisbane, Australia.,Queensland Paediatric Rehabilitation Service, The Queensland Children's Hospital, Children's Health Queensland , Brisbane, Australia.,School of Psychology, University of Queensland , Brisbane, Australia
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22
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Lindsey HM, Wilde EA, Caeyenberghs K, Dennis EL. Longitudinal Neuroimaging in Pediatric Traumatic Brain Injury: Current State and Consideration of Factors That Influence Recovery. Front Neurol 2019; 10:1296. [PMID: 31920920 PMCID: PMC6927298 DOI: 10.3389/fneur.2019.01296] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/25/2019] [Indexed: 12/13/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability for children and adolescents in the U.S. and other developed and developing countries. Injury to the immature brain varies greatly from that of the mature, adult brain due to numerous developmental, pre-injury, and injury-related factors that work together to influence the trajectory of recovery during the course of typical brain development. Substantial damage to brain structure often underlies subsequent functional limitations that persist for years following pediatric TBI. Advances in neuroimaging have established an important role in the acute management of pediatric TBI, and magnetic resonance imaging (MRI) techniques have a particular relevance for the sequential assessment of long-term consequences from injuries sustained to the developing brain. The present paper will discuss the various factors that influence recovery and review the findings from the present neuroimaging literature to assess altered development and long-term outcome following pediatric TBI. Four MR-based neuroimaging modalities have been used to examine recovery from pediatric TBI longitudinally: (1) T1-weighted structural MRI is sensitive to morphological changes in gray matter volume and cortical thickness, (2) diffusion-weighted MRI is sensitive to changes in the microstructural integrity of white matter, (3) MR spectroscopy provides a sensitive assessment of metabolic and neurochemical alterations in the brain, and (4) functional MRI provides insight into the functional changes that occur as a result of structural damage and typical developmental processes. As reviewed in this paper, 13 cohorts have contributed to only 20 studies published to date using neuroimaging to examine longitudinal changes after TBI in pediatric patients. The results of these studies demonstrate considerable heterogeneity in post-injury outcome; however, the existing literature consistently shows that alterations in brain structure, function, and metabolism can persist for an extended period of time post-injury. With larger sample sizes and multi-site cooperation, future studies will be able to further examine potential moderators of outcome, such as the developmental, pre-injury, and injury-related factors discussed in the present review.
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Affiliation(s)
- Hannah M. Lindsey
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- Department of Psychology, Brigham Young University, Provo, UT, United States
| | - Elisabeth A. Wilde
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, United States
| | - Karen Caeyenberghs
- Cognitive Neuroscience Unit, School of Psychology, Deakin University, Burwood, VIC, Australia
| | - Emily L. Dennis
- Department of Neurology, University of Utah, Salt Lake City, UT, United States
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23
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Fischer JT, Hannay HJ, Alfano CA, Swank PR, Ewing-Cobbs L. Sleep disturbances and internalizing behavior problems following pediatric traumatic injury. Neuropsychology 2019. [PMID: 29528681 DOI: 10.1037/neu0000420] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury. METHOD Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes. RESULTS Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury. CONCLUSIONS Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record
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Affiliation(s)
| | - H Julia Hannay
- Texas Institute For Measurement, Evaluation, And Statistics, University of Houston
| | | | - Paul R Swank
- School of Public Health, University of Texas Health Science Center at Houston
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24
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Eftaxas DM, Canto AI. School Psychologists’ Knowledge of Traumatic Brain Injuries and Willingness to Lead a Concussion Team. JOURNAL OF APPLIED SCHOOL PSYCHOLOGY 2019. [DOI: 10.1080/15377903.2019.1669094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Danielle M. Eftaxas
- Department of Educational Psychology & Learning Systems (EPLS), Florida State University College of Education, Tallahassee, Florida, USA
| | - Angela I. Canto
- Southeastern Behavioral Health LLC, Tallahassee, Florida, USA
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25
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Depression and Depressive Symptoms in Pediatric Traumatic Brain Injury: A Scoping Review. J Head Trauma Rehabil 2019; 33:E18-E30. [PMID: 28926485 DOI: 10.1097/htr.0000000000000343] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This scoping review aimed to summarize the existing knowledge base regarding depression and depressive symptoms in pediatric traumatic brain injury (TBI) and to identify gaps in the literature in an effort to guide future research. METHODS MEDLINE Ovid and PsycINFO Ovid databases were each searched by the authors using search terms intended to identify any original research study that examined depressive symptoms in children (ie, aged 0-18 years) with TBI. RESULTS A total of 14 published studies were included in the review. The studies included examined the prevalence of depression, risk factors associated with depression, and depression as a predictor of other TBI-related outcomes. CONCLUSION Existing research suggests that depressive symptoms are more common in a TBI population than in a healthy or orthopedically injured population. Injury-related factors such as lesions in the brain and the presence of pain, as well as noninjury factors such as older age at injury and low socioeconomic status, may be predictive of depressive symptoms. Depression is likely a secondary outcome of pediatric TBI rather than a direct result of the injury itself. Overall, a relative dearth of research exists on this topic; thus, the review concludes by proposing future research directions.
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26
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DeMatteo CA, Randall S, Lin CYA, Claridge EA. What Comes First: Return to School or Return to Activity for Youth After Concussion? Maybe We Don't Have to Choose. Front Neurol 2019; 10:792. [PMID: 31396150 PMCID: PMC6664873 DOI: 10.3389/fneur.2019.00792] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/09/2019] [Indexed: 12/16/2022] Open
Abstract
Objectives: Return to School (RTS) and Return to Activity/Play (RTA) protocols are important in concussion management. Minimal evidence exists as to sequence and whether progression can occur simultaneously. Experts recommend that children/youth fully return to school before beginning RTA protocols. This study investigates recovery trajectories of children/youth while following RTA and RTS protocols simultaneously, with the following objectives: (1) to compare rates and patterns of progression through the stages of both protocols; (2) to evaluate symptom trajectories of youth post-concussion while progressing through stages of RTS and RTA; and (3) to propose a new model for concussion management in youth that involves the integration of Return to Activity and Return to School protocols. Methods: In a 3-year prospective-cohort study of 139 children/youth aged 5-18 years with concussive injury, self-reported symptoms using PCSS and stage of protocols were evaluated every 48 h using electronic surveys until full return to school and activity/sport were attained. Information regarding school accommodation and achievement was collected. Results: Sample mean age is 13 years, 46% male. Youth are returning to school with accommodations significantly quicker than RTA (p = 0.001). Significant negative correlations between total PCSS score and stage of RTS protocol were found at: 1-week (r = -0.376, p < 0.0001; r = -0.317, p = 0.0003), 1-month (r = -0.483, p < 0.0001; r = -0.555, p < 0.0001), and 3-months (r = -0.598, p < 0.0001; r = -0.617, p < 0.0001); indicating lower symptom scores correlated with higher guideline stages. Median full return to school time is 35 days with 21% of youth symptomatic at full return. Median return time to full sport competition is 38 days with 15% still symptomatic. Sixty-four percent of youth reported experiencing school problems during recovery and 30% at symptom resolution, with 31% reporting a drop in their grades during recovery and 18% at study completion. Conclusions: Children/youth return to school faster than they return to play in spite of the self-reported, school-related symptoms they experience while moving through the protocols. Youth can progress simultaneously through the RTS and RTA protocols during stages 1-3. Considering the numbers of youth having school difficulties post-concussion, full contact sport, stage 6, of RTA, should be delayed until full and successful reintegration back to school has been achieved. In light of the huge variability in recovery, determining how to resume participation in activities despite ongoing symptoms is still the challenge for each individual child. There is much to be learned with further research needed in this area.
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Affiliation(s)
- Carol A. DeMatteo
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
- CanChild Centre for Disability Research, McMaster University, Hamilton, ON, Canada
| | - Sarah Randall
- CanChild Centre for Disability Research, McMaster University, Hamilton, ON, Canada
| | - Chia-Yu A. Lin
- CanChild Centre for Disability Research, McMaster University, Hamilton, ON, Canada
- ARiEAL, Centre for Advanced Research in Experimental and Applied Linguistics, McMaster University, Hamilton, ON, Canada
| | - Everett A. Claridge
- CanChild Centre for Disability Research, McMaster University, Hamilton, ON, Canada
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27
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Kinder HA, Baker EW, Howerth EW, Duberstein KJ, West FD. Controlled Cortical Impact Leads to Cognitive and Motor Function Deficits that Correspond to Cellular Pathology in a Piglet Traumatic Brain Injury Model. J Neurotrauma 2019; 36:2810-2826. [PMID: 31084390 DOI: 10.1089/neu.2019.6405] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in the United States, with children who sustain a TBI having a greater risk of developing long-lasting cognitive, behavioral, and motor function deficits. This has led to increased interest in utilizing large animal models to study pathophysiologic and functional changes after injury in hopes of identifying novel therapeutic targets. In the present study, a controlled cortical impact (CCI) piglet TBI model was utilized to evaluate cognitive, motor, and histopathologic outcomes. CCI injury (4 m/sec velocity, 9 mm depression, 400 msec dwell time) was induced at the parietal cortex. Compared with normal pigs (n = 5), TBI pigs (n = 5) exhibited appreciable cognitive deficiencies, including significantly impaired spatial memory in spatial T-maze testing and a significant decrease in exploratory behaviors followed by marked hyperactivity in open field testing. Additionally, gait analysis revealed significant increases in cycle time and stance percent, significant decreases in hind reach, and a shift in the total pressure index from the front to the hind limb on the affected side, suggesting TBI impairs gait and balance. Pigs were sacrificed 28 days post-TBI and histological analysis revealed that TBI lead to a significant decrease in neurons and a significant increase in microglia activation and astrogliosis/astrocytosis at the perilesional area, a significant loss in neurons at the dorsal hippocampus, and significantly increased neuroblast proliferation at the subventricular zone. These data demonstrate a strong relationship between TBI-induced cellular changes and functional outcomes in our piglet TBI model that lay the framework for future studies that assess the ability of therapeutic interventions to contribute to functional improvements.
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Affiliation(s)
- Holly A Kinder
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia.,Department of Animal and Dairy Science, University of Georgia, Athens, Georgia
| | - Emily W Baker
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia.,Department of Animal and Dairy Science, University of Georgia, Athens, Georgia
| | - Elizabeth W Howerth
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia.,Department of Pathology, University of Georgia, Athens, Georgia
| | - Kylee J Duberstein
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia.,Department of Animal and Dairy Science, University of Georgia, Athens, Georgia
| | - Franklin D West
- Regenerative Bioscience Center, University of Georgia, Athens, Georgia.,Department of Animal and Dairy Science, University of Georgia, Athens, Georgia
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28
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Ewing-Cobbs L, DeMaster D, Watson CG, Prasad MR, Cox CS, Kramer LA, Fischer JT, Duque G, Swank PR. Post-Traumatic Stress Symptoms after Pediatric Injury: Relation to Pre-Frontal Limbic Circuitry. J Neurotrauma 2019; 36:1738-1751. [PMID: 30672379 DOI: 10.1089/neu.2018.6071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pre-frontal limbic circuitry is vulnerable to effects of stress and injury. We examined microstructure of pre-frontal limbic circuitry after traumatic brain injury (TBI) or extracranial injury (EI) and its relation to post-traumatic stress symptoms (PTSS). Participants aged 8 to 15 years who sustained mild to severe TBI (n = 53) or EI (n = 26) in motor vehicle incidents were compared with healthy children (n = 38) in a prospective longitudinal study. At the seven-week follow-up, diffusion tensor imaging was obtained in all groups; injured children completed PTSS ratings using a validated scale. Using probabilistic diffusion tensor tractography, pathways were seeded from bilateral amygdalae and hippocampi to estimate the trajectory of white matter connecting them to each other and to targeted pre-frontal cortical (PFC) regions. Microstructure was estimated using fractional anisotropy (FA) in white matter and mean diffusivity (MD) in gray matter. Pre-frontal limbic microstructure was similar across groups, except for reduced FA in the right hippocampus to orbital PFC pathway in the injured versus healthy group. We examined microstructure of components of pre-frontal limbic circuitry with concurrently obtained PTSS cluster scores in the injured children. Neither microstructure nor PTSS scores differed significantly in the TBI and EI groups. Across PTSS factors, specific symptom clusters were related positively to higher FA and MD. Higher hyperarousal, avoidance, and re-experiencing symptoms were associated with higher FA in amygdala to pre-frontal and hippocampus to amygdala pathways. Higher hippocampal MD had a central role in hyperarousal and emotional numbing symptoms. Age moderated the relation of white and gray matter microstructure with hyperarousal scores. Our findings are consistent with models of traumatic stress that implicate disrupted top-down PFC and hippocampal moderation of overreactive subcortical threat arousal systems. Alterations in limbic pre-frontal circuitry and PTSS place children with either brain or body injuries at elevated risk for both current and future psychological health problems.
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Affiliation(s)
- Linda Ewing-Cobbs
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Dana DeMaster
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Christopher G Watson
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Mary R Prasad
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Charles S Cox
- 2 Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, Texas
| | - Larry A Kramer
- 4 Department of Interventional Radiology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jesse T Fischer
- 5 Department of Psychology, University of Houston, Houston, Texas
| | - Gerardo Duque
- 1 Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
| | - Paul R Swank
- 3 School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
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29
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Sleep Disturbance in Children With Moderate or Severe Traumatic Brain Injury Compared With Children With Orthopedic Injury. J Head Trauma Rehabil 2019; 34:122-131. [DOI: 10.1097/htr.0000000000000426] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Zamani A, Mychasiuk R, Semple BD. Determinants of social behavior deficits and recovery after pediatric traumatic brain injury. Exp Neurol 2019; 314:34-45. [PMID: 30653969 DOI: 10.1016/j.expneurol.2019.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/29/2018] [Accepted: 01/12/2019] [Indexed: 12/15/2022]
Abstract
Traumatic brain injury (TBI) during early childhood is associated with a particularly high risk of developing social behavior impairments, including deficits in social cognition that manifest as reduced social interactions, with profound consequences for the individuals' quality of life. A number of pre-injury, post-injury, and injury-related factors have been identified or hypothesized to determine the extent of social behavior problems after childhood TBI. These include variables associated with the individual themselves (e.g. age, genetics, the injury severity, and extent of white matter damage), proximal environmental factors (e.g. family functioning, parental mental health), and more distal environmental factors (e.g. socioeconomic status, access to resources). In this review, we synthesize the available evidence demonstrating which of these determinants influence risk versus resilience to social behavior deficits after pediatric TBI, drawing upon the available clinical and preclinical literature. Injury-related pathology in neuroanatomical regions associated with social cognition and behaviors will also be described, with a focus on findings from magnetic resonance imaging and diffusion tensor imaging. Finally, study limitations and suggested future directions are highlighted. In summary, while no single variable can alone accurately predict the manifestation of social behavior problems after TBI during early childhood, an increased understanding of how both injury and environmental factors can influence social outcomes provides a useful framework for the development of more effective rehabilitation strategies aiming to optimize recovery for young brain-injured patients.
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Affiliation(s)
- Akram Zamani
- Department of Neuroscience, Monash University, Prahran, VIC, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Monash University, Prahran, VIC, Australia; Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Bridgette D Semple
- Department of Neuroscience, Monash University, Prahran, VIC, Australia; Department of Medicine (Royal Melbourne Hospital), The University of Melbourne, Parkville, VIC, Australia.
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31
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Huh JW, Raghupathi R. Therapeutic strategies to target acute and long-term sequelae of pediatric traumatic brain injury. Neuropharmacology 2018; 145:153-159. [PMID: 29933010 DOI: 10.1016/j.neuropharm.2018.06.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 12/15/2022]
Abstract
Pediatric traumatic brain injury (TBI) remains one of the leading causes of morbidity and mortality in children. Experimental and clinical studies demonstrate that the developmental age, the type of injury (diffuse vs. focal) and sex may play important roles in the response of the developing brain to a traumatic injury. Advancements in acute neurosurgical interventions and neurocritical care have improved and led to a decrease in mortality rates over the past decades. However, survivors are left with life-long behavioral deficits underscoring the need to better define the cellular mechanisms underlying these functional changes. A better understanding of these mechanisms some of which begin in the acute post-traumatic period may likely lead to targeted treatment strategies. Key considerations in designing pre-clinical experiments to test therapeutic strategies in pediatric TBI include the use of age-appropriate and pathologically-relevant models, functional outcomes that are tested as animals age into adolescence and beyond, sex as a biological variable and the recognition that doses and dosing strategies that have been demonstrated to be effective in animal models of adult TBI may not be effective in the developing brain. This article is part of the Special Issue entitled "Novel Treatments for Traumatic Brain Injury".
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Affiliation(s)
- Jimmy W Huh
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ramesh Raghupathi
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, USA.
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32
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Pastore V, Galbiati S, Recla M, Colombo K, Beretta E, Strazzer S. Psychological and behavioural difficulties following severe TBI in adolescence: a comparison with a sample of peers with brain lesions of other origin and with a control group. Brain Inj 2018; 32:1011-1020. [PMID: 29738269 DOI: 10.1080/02699052.2018.1469041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To describe behavioural and adjustment problems in a group of 57 adolescents with severe traumatic brain injury (TBI) and compare them with a clinical group of peers with brain lesions of other origin (N = 33) and a control group of healthy adolescents (N = 48). METHODS All subjects received an age-appropriate assessment, including the child behaviour checklist (CBCL) 4/18, the strengths and difficulties questionnaire (SDQ) and the vineland adaptive behaviour scales (VABS). RESULTS Compared with healthy peers, adolescents with TBI presented with more marked behavioural problems on most CBCL scales (Internalization and Externalization domains were both affected) and on the SDQ Hyperactivity and Peer problems scales. They also showed a more impaired functioning in most VABS domains. Compared with adolescents with brain lesions of other aetiology, patients with TBI showed more conduct problems on the SDQ scale, but no significant differences were found on the CBCL scales. Regarding the VABS, patients with other lesions presented with the worst outcome in the Motor and Daily Living Skills domains. CONCLUSIONS Adolescents with TBI are exposed at a very high risk to develop behavioural and psychological disturbances with the potential to severely affect their social re-entry. Further knowledge is needed to plan early and well-timed interventions.
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Affiliation(s)
- Valentina Pastore
- a Neurophysiatric Department , 'Eugenio Medea' Scientific Institute , Lecco , Bosisio Parini , Italy
| | - Susanna Galbiati
- a Neurophysiatric Department , 'Eugenio Medea' Scientific Institute , Lecco , Bosisio Parini , Italy
| | - Monica Recla
- a Neurophysiatric Department , 'Eugenio Medea' Scientific Institute , Lecco , Bosisio Parini , Italy
| | - Katia Colombo
- a Neurophysiatric Department , 'Eugenio Medea' Scientific Institute , Lecco , Bosisio Parini , Italy
| | - Elena Beretta
- a Neurophysiatric Department , 'Eugenio Medea' Scientific Institute , Lecco , Bosisio Parini , Italy
| | - Sandra Strazzer
- a Neurophysiatric Department , 'Eugenio Medea' Scientific Institute , Lecco , Bosisio Parini , Italy
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33
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Rodriguez-Grande B, Obenaus A, Ichkova A, Aussudre J, Bessy T, Barse E, Hiba B, Catheline G, Barrière G, Badaut J. Gliovascular changes precede white matter damage and long-term disorders in juvenile mild closed head injury. Glia 2018; 66:1663-1677. [DOI: 10.1002/glia.23336] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/09/2018] [Accepted: 03/16/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Beatriz Rodriguez-Grande
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
| | - Andre Obenaus
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
- Department of Pediatrics; Loma Linda University School of Medicine; Loma Linda California
- Basic Science Department; Loma Linda University School of Medicine; Loma Linda California
- Center for Glial-Neuronal Interactions, Division of Biomedical Sciences; UC Riverside; Riverside California
- Department of Pediatrics; University of California, Irvine; Irvine California
| | - Aleksandra Ichkova
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
| | - Justine Aussudre
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
| | - Thomas Bessy
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
| | - Elodie Barse
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
- EPHE, PSL; Bordeaux France
| | - Bassem Hiba
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
| | - Gwénaëlle Catheline
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
- EPHE, PSL; Bordeaux France
| | - Grégory Barrière
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
| | - Jerome Badaut
- CNRS UMR5287, Institut de Neurosciences Cognitives et Intégratives d'Aquitaine, University of Bordeaux; Bordeaux France
- Basic Science Department; Loma Linda University School of Medicine; Loma Linda California
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34
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Morse AM, Garner DR. Traumatic Brain Injury, Sleep Disorders, and Psychiatric Disorders: An Underrecognized Relationship. Med Sci (Basel) 2018; 6:E15. [PMID: 29462866 PMCID: PMC5872172 DOI: 10.3390/medsci6010015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 12/28/2022] Open
Abstract
Traumatic brain injury (TBI) is commonplace among pediatric patients and has a complex, but intimate relationship with psychiatric disease and disordered sleep. Understanding the factors that influence the risk for the development of TBI in pediatrics is a critical component of beginning to address the consequences of TBI. Features that may increase risk for experiencing TBI sometimes overlap with factors that influence the development of post-concussive syndrome (PCS) and recovery course. Post-concussive syndrome includes physical, psychological, cognitive and sleep-wake dysfunction. The comorbid presence of sleep-wake dysfunction and psychiatric symptoms can lead to a more protracted recovery and deleterious outcomes. Therefore, a multidisciplinary evaluation following TBI is necessary. Treatment is generally symptom specific and mainly based on adult studies. Further research is necessary to enhance diagnostic and therapeutic approaches, as well as improve the understanding of contributing pathophysiology for the shared development of psychiatric disease and sleep-wake dysfunction following TBI.
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Affiliation(s)
- Anne M Morse
- Janet Weis Children's Hospital, Department of Pediatric Neurology and Sleep Medicine, Geisinger Medical Center, MC 14-12, 100 N Academy Blvd, Danville, PA 17822, USA.
| | - David R Garner
- Department of Pediatrics, Geisinger Medical Center, Danville, PA 17822, USA.
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35
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Bodnar CN, Morganti JM, Bachstetter AD. Depression following a traumatic brain injury: uncovering cytokine dysregulation as a pathogenic mechanism. Neural Regen Res 2018; 13:1693-1704. [PMID: 30136679 PMCID: PMC6128046 DOI: 10.4103/1673-5374.238604] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A substantial number of individuals have long-lasting adverse effects from a traumatic brain injury (TBI). Depression is one of these long-term complications that influences many aspects of life. Depression can limit the ability to return to work, and even worsen cognitive function and contribute to dementia. The mechanistic cause for the increased depression risk associated with a TBI remains to be defined. As TBI results in chronic neuroinflammation, and priming of glia to a secondary challenge, the inflammatory theory of depression provides a promising framework for investigating the cause of depression following a TBI. Increases in cytokines similar to those seen in depression in the general population are also increased following a TBI. Biomarker levels of cytokines peak within hours-to-days after the injury, yet pro-inflammatory cytokines may still be elevated above physiological levels months-to-years following TBI, which is the time frame in which post-TBI depression can persist. As tumor necrosis factor α and interleukin 1 can signal directly at the neuronal synapse, pathophysiological levels of these cytokines can detrimentally alter neuronal synaptic physiology. The purpose of this review is to outline the current evidence for the inflammatory hypothesis of depression specifically as it relates to depression following a TBI. Moreover, we will illustrate the potential synaptic mechanisms by which tumor necrosis factor α and interleukin 1 could contribute to depression. The association of inflammation with the development of depression is compelling; however, in the context of post-TBI depression, the role of inflammation is understudied. This review attempts to highlight the need to understand and treat the psychological complications of a TBI, potentially by neuroimmune modulation, as the neuropsychiatric disabilities can have a great impact on the rehabilitation from the injury, and overall quality of life.
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Affiliation(s)
- Colleen N Bodnar
- Spinal Cord & Brain Injury Research Center, University of Kentucky; Department of Neuroscience, University of Kentucky, Lexington, KY, USA
| | - Josh M Morganti
- Department of Neuroscience, University of Kentucky; Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Adam D Bachstetter
- Spinal Cord & Brain Injury Research Center, University of Kentucky; Department of Neuroscience, University of Kentucky, Lexington, KY, USA
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36
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Stein E, Howard W, Rowhani-Rahbar A, Rivara FP, Zatzick D, McCarty CA. Longitudinal trajectories of post-concussive and depressive symptoms in adolescents with prolonged recovery from concussion. Brain Inj 2017; 31:1736-1744. [PMID: 29115868 PMCID: PMC6194147 DOI: 10.1080/02699052.2017.1380843] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 09/06/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
PRIMARY OBJECTIVE To investigate the symptom trajectories of depressive and post-concussive symptoms (PCS) in slow-to-recover adolescents to understand how the two sets of symptoms are related. RESEARCH DESIGN We used data from a randomized clinical trial of a collaborative care intervention for post-concussive symptoms to better understand how these two sets of symptoms change in parallel over 6 months. METHODS AND PROCEDURE PCS and depressive symptom scores for 49 adolescents (ages 11-17) were measured at enrolment and after 1, 3, and 6 months. Latent growth curve modelling for parallel processes was used to simultaneously examine change in PCS and depressive symptoms over time and to evaluate the influence of one change process on the other. MAIN OUTCOMES AND RESULTS On average, patients enrolled 66 days following injury (Interquartile range (IQR) 43.5, 88.5). PCS and depressive symptoms were significantly associated at enrolment and over time, and both decreased over the course of 6 months. Higher PCS at enrolment predicted a greater decrease in depressive symptoms over time. CONCLUSIONS Our results suggest that clinicians should screen for and treat depressive symptoms in patients with high post-concussive symptoms one month following injury.
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Affiliation(s)
- Elizabeth Stein
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development
| | - Waylon Howard
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development
| | - Ali Rowhani-Rahbar
- University of Washington, Department of Epidemiology
- University of Washington, Harborview Injury Prevention and Research Center
| | - Frederick P. Rivara
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development
- University of Washington, Harborview Injury Prevention and Research Center
- University of Washington, Department of Pediatrics
| | - Douglas Zatzick
- University of Washington, Harborview Injury Prevention and Research Center
- University of Washington, Department of Psychiatry and Behavioral Sciences
| | - Carolyn A. McCarty
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development
- University of Washington, Department of Pediatrics
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Treble-Barna A, Zang H, Zhang N, Taylor HG, Stancin T, Yeates KO, Wade SL. Observed parent behaviors as time-varying moderators of problem behaviors following traumatic brain injury in young children. Dev Psychol 2017; 52:1777-1792. [PMID: 27786528 DOI: 10.1037/dev0000208] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Parent behaviors moderate the adverse consequences of pediatric traumatic brain injury (TBI); however, it is unknown how these moderating effects change over time. This study examined the moderating effect of observed parent behaviors over time since injury on the relation between TBI and behavioral outcomes. Participants included children, ages 3-7 years, hospitalized for moderate (n = 52) or severe (n = 20) TBI or orthopedic injury (OI; n = 95). Parent-child dyads were videotaped during structured task and free play conditions, and parents completed child behavior ratings. Linear mixed models using a lagged, time-varying moderator analysis examined the relationship of observed parent behaviors at the baseline, 6-month, and 12-month assessments to child behavior problems at 6 months, 12 months, and 18 months postinjury, after controlling for preinjury levels of child behavior problems. The effect of TBI on behavior was exacerbated by less favorable parent behaviors, and buffered by more favorable parent behaviors, in children with severe TBI over the first 12 months postinjury. By 18 months postinjury, however, the moderating effect of parent behaviors diminished, such that children with severe TBI showed more behavior problems relative to children with moderate TBI or OI regardless of parent behaviors or in response to parent behaviors that were initially protective. The results suggest that the moderating effects of the family environment are complex and likely vary in relation to both recovery and developmental factors, with potentially important implications for targets and timing of intervention. (PsycINFO Database Record
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Affiliation(s)
- Amery Treble-Barna
- Division of Physical Medicine & Rehabilitation, Cincinnati Children's Hospital Medical Center
| | - Huaiyu Zang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center
| | - Nanhua Zhang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center
| | - H Gerry Taylor
- Division of Developmental and Behavioral Pediatrics and Psychology, Rainbow Babies and Children's Hospital
| | - Terry Stancin
- Department of Psychiatry, Case Western Reserve University School of Medicine
| | | | - Shari L Wade
- Division of Physical Medicine & Rehabilitation, Cincinnati Children's Hospital Medical Center
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Jackson TL, Braun JM, Mello M, Triche EW, Buka SL. The relationship between early childhood head injury and later life criminal behaviour: a longitudinal cohort study. J Epidemiol Community Health 2017; 71:800-805. [DOI: 10.1136/jech-2016-208582] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 05/18/2017] [Accepted: 05/25/2017] [Indexed: 11/04/2022]
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Stazyk K, DeMatteo C, Moll S, Missiuna C. Depression in youth recovering from concussion: Correlates and predictors. Brain Inj 2017; 31:631-638. [PMID: 28326857 DOI: 10.1080/02699052.2017.1283533] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Although depression can be a serious consequence of concussion, little is known about the factors that predict depression and concussion recovery outcomes in children. The purpose of this study was to explore the risk and possible predictors of developing significant depressive symptoms in children recovering from concussion. METHODS A prospective cohort study was conducted in a paediatric tertiary care clinic. Depression data were collected from 92 children using the Children's Depression Inventory-2 (CDI-2) screening tool. Correlations, t-tests and logistic regression were used to examine the associations between depression scores and demographic as well as injury-related factors. RESULTS Depressive symptoms were found in 22% of the children (T score on CDI-2 >65). Children with evidence of depressive symptomatology had significantly higher mean post-concussive symptom inventory (PCSI) scores in recovery (p = 0.004) than children who were not depressed. Variables of i) Sex; ii) hospital admission; iii) number of head injuries; iv) post-concussion symptom score and v) experience of prolonged symptoms were predictive of clinically significant CDI T scores, explaining 36% of the variation in the binary logistic model. CONCLUSION Depression is commonly reported in this subset of children. High post-concussive symptom scores and hospital admission were strong predictors of depression. Screening for depression should be standard practice in concussion management in children and youth.
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Affiliation(s)
- Kathy Stazyk
- a School of Rehabilitative Science, McMaster University , Hamilton , Ontario , Canada.,b CanChild Centre for Childhood Disability Research, McMaster University , Hamilton , Ontario , Canada
| | - Carol DeMatteo
- a School of Rehabilitative Science, McMaster University , Hamilton , Ontario , Canada.,b CanChild Centre for Childhood Disability Research, McMaster University , Hamilton , Ontario , Canada
| | - Sandra Moll
- a School of Rehabilitative Science, McMaster University , Hamilton , Ontario , Canada
| | - Cheryl Missiuna
- a School of Rehabilitative Science, McMaster University , Hamilton , Ontario , Canada.,b CanChild Centre for Childhood Disability Research, McMaster University , Hamilton , Ontario , Canada
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Klein TA, Graves JM. A Comparison of Psychiatric and Nonpsychiatric Nurse Practitioner Knowledge and Management Recommendations Regarding Adolescent Mild Traumatic Brain Injury. J Am Psychiatr Nurses Assoc 2017; 23:37-49. [PMID: 27601433 DOI: 10.1177/1078390316668992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nurse practitioners (NPs) are statutorily authorized to provide assessment and cognitive recommendations for concussion in most states. Their scope of practice includes assessment and management of concussion sequalae including anxiety, insomnia, and depression, as well as return to school and activity guidance. OBJECTIVES Analysis of symptom-based diagnosis of mild traumatic brain injury (TBI) in adolescents, including return to school and school workload recommendations comparing psychiatric and nonpsychiatric NPs. DESIGN Cross-sectional Web-based survey with embedded videos using standardized actors and scripts randomized for patient sex and sport. A total of 4,849 NPs licensed in Oregon or Washington were invited by e-mail to view and respond to this study, with a response rate of 23%. RESULTS Psychiatric mental health nurse practitioners (PMHNPs) were 44% less likely than family NPs to report using standardized concussion tools. 17% had completed continuing education on mild TBI compared to 54.5% of family NPs. Seven PMHNPs provided additional feedback related to discomfort in completing the survey due to lack of comfort or experience. Return to school recommendations and reduced workload advice did not significantly differ by NP type. CONCLUSION PMHNPs may support individualized assessment through concussion evaluation, use of standardized tools, and differential consideration of TBI for mental health symptoms. More research is required related to the role and contribution of cognitive rest to full recovery.
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Affiliation(s)
- Tracy A Klein
- 1 Tracy A. Klein, PhD, FNP, ARNP, FAANP, FRE, FAAN, Washington State University Vancouver, Vancouver, WA, USA
| | - Janessa M Graves
- 2 Janessa M. Graves, PhD, MPH, Washington State University Spokane, Spokane, WA, USA
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Catroppa C, Hearps S, Crossley L, Yeates K, Beauchamp M, Fusella J, Anderson V. Social and Behavioral Outcomes following Childhood Traumatic Brain Injury: What Predicts Outcome at 12 Months Post-Insult? J Neurotrauma 2016; 34:1439-1447. [PMID: 27809667 DOI: 10.1089/neu.2016.4594] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study sought to investigate social and behavioral outcomes 12 months following childhood traumatic brain injury (TBI) and to identify predictors of these outcomes. The study also compared rates of impairment in social and behavioral outcomes at 12 months post-injury between children with TBI and a typically developing (TD) control group. The study comprised 114 children ages 5.5 to 16.0 years, 79 with mild, moderate, or severe TBI and 35 TD children, group-matched for age, sex and socio-economic status. Children with TBI were recruited via consecutive hospital admissions and TD children from the community. Social and behavioral outcomes were measured via parent-rated questionnaires. Analysis of covariance models identified a significant mean difference between the mild and moderate groups for social problems only, but the moderate and severe TBI groups showed a higher rate of impairment, particularly in externalizing problems. Pre-injury function, injury severity, parent mental health, and child self-esteem all contributed significantly to predicting social and behavioral outcomes. Both injury and non-injury factors should be considered when identifying children at risk for long-term difficulties in social and behavioral domains.
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Affiliation(s)
- Cathy Catroppa
- 1 Murdoch Children's Research Institute , Victoria, Australia
| | - Stephen Hearps
- 1 Murdoch Children's Research Institute , Victoria, Australia
| | - Louise Crossley
- 1 Murdoch Children's Research Institute , Victoria, Australia
| | - Keith Yeates
- 2 Yeates, Keith; Alberta Children's Hospital Research Institute , Calgary, Alberta, Canada
| | - Miriam Beauchamp
- 3 Department of Psychology, University of Montreal , Montreal, Quebec, Canada
| | | | - Vicki Anderson
- 1 Murdoch Children's Research Institute , Victoria, Australia .,5 Department of Psychology, Royal Children's Hospital , Melbourne, Australia .,6 Department of Psychological Sciences and Pediatrics, University of Melbourne , Melbourne, Australia
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Symptoms of Persistent Behavior Problems in Children With Mild Traumatic Brain Injury. J Head Trauma Rehabil 2016; 30:302-10. [PMID: 25629259 DOI: 10.1097/htr.0000000000000106] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To investigate the effects of mild traumatic brain injury (mTBI) in children on symptom ratings of behavior problems across the first-year postinjury. SETTING Emergency departments of 2 regional children's hospitals. PARTICIPANTS Parents of 176 children with mTBI and 90 children with orthopedic injury aged 8 to 15 years. DESIGN Group comparisons of postinjury parent and teacher ratings of child behavior problems controlling for background factors. MAIN MEASURES Child Behavior Checklist and Teacher's Report Form. RESULTS For younger but not older children in the sample, children with mTBI compared with children with orthopedic injury had higher postinjury ratings on the Child Behavior Checklist Total Behavior Problem scale (t264 = 3.34, P < .001) and higher rates of T-scores of 60 or more on this scale (odds ratio = 3.00; 95% confidence interval, 1.33-6.77; P = .008). For children with mTBI, hospitalization, motor vehicle accidents, loss of consciousness, and magnetic resonance imaging abnormality were associated with higher parent or teacher ratings. CONCLUSIONS School-aged children with mTBI are at risk for persistent symptoms of behavior problems, especially if mTBI is more severe or occurs at a younger age. The findings justify monitoring of behavior long after injury and further research to identify risk factors for these symptoms and their association with clinical disorders.
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Kramer MM, Davies SC. Challenges and Supports During the Transition from High School to College for Students with Traumatic Brain Injuries. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s40688-016-0095-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chi YC, Wu HL, Chu CP, Huang MC, Lee PC, Chen YY. Traumatic brain injury and affective disorder: A nationwide cohort study in Taiwan, 2000-2010. J Affect Disord 2016; 191:56-61. [PMID: 26650968 DOI: 10.1016/j.jad.2015.11.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/23/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Studies investigating the relationship between head injury and the subsequent onset of affective disorders often show conflicting results. AIMS To investigate the risk of affective disorders following traumatic brain injury in a large Taiwanese cohort. METHOD This retrospective cohort study makes use of the National Health Insurance Research Database. A cohort containing 68,376 individuals who experienced traumatic brain injury (TBI) during 2000-2010 and had no prior history of mental disorders before the injury was identified. Using Cox Proportional Hazards regression, the subsequent risk of affective disorders was determined. RESULTS TBI was associated with a higher risk of both bipolar disorder (Hazard Ratio [HR]=1.42, 95% Confidence Interval [CI]=[1.26, 1.59]) and major depression (HR=1.41, 95% CI=[1.28, 1.54]). More severe injury was associated with greater risk. The first year following the injury was the highest risk period for major depression, while the highest risk period for bipolar disorder was delayed until two to four years following the injury. LIMITATIONS Using a claims database, we were unable to assess confounding variables that were not contained in the data set. CONCLUSIONS The elevated risks of affective disorders after TBI speak to the psychiatric need of individuals who suffer from brain injury. Early detection and timely intervention may help prevent secondary and tertiary disability associated with head trauma.
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Affiliation(s)
- Ying-Chen Chi
- Department of Education & Research, Taipei City Hospital, Taipei City, Taiwan; Department of Information Management, University of Kang Ning, Taipei City, Taiwan
| | - Hyun-Ling Wu
- National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan
| | - Chih-Pang Chu
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei City, Taiwan
| | - Ming-Chyi Huang
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei City, Taiwan; Department of Psychiatry, School of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Pei-Chen Lee
- National Taipei University of Nursing and Health Sciences, Taipei City, Taiwan.
| | - Ying-Yeh Chen
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei City, Taiwan; Institute of Public Health and Department of Public Health, National Yang-Ming University, Taipei City, Taiwan.
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Ellis MJ, Ritchie LJ, Koltek M, Hosain S, Cordingley D, Chu S, Selci E, Leiter J, Russell K. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr 2015; 16:709-18. [PMID: 26359916 DOI: 10.3171/2015.5.peds15220] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECT The objectives of this study were twofold: (1) to examine the prevalence of emotional symptoms among children and adolescents with a sports-related concussion (SRC) who were referred to a multidisciplinary pediatric concussion program and (2) to examine the prevalence, clinical features, risk factors, and management of postinjury psychiatric outcomes among those in this clinical population. METHODS The authors conducted a retrospective chart review of all patients with SRC referred to a multidisciplinary pediatric concussion program between September 2013 and October 2014. Clinical assessments carried out by a single neurosurgeon included clinical history, physical examination, and Post-Concussion Symptom Scale (PCSS) scoring. Postinjury psychiatric outcomes were defined as a subjective worsening of symptoms of a preinjury psychiatric disorder or new and isolated suicidal ideation or diagnosis of a novel psychiatric disorder (NPD). An NPD was defined as a newly diagnosed psychiatric disorder that occurred in a patient with or without a lifetime preinjury psychiatric disorder after a concussion. Clinical resources, therapeutic interventions, and clinical and return-to-play outcomes are summarized. RESULTS One hundred seventy-four patients (mean age 14.2 years, 61.5% male) were included in the study. At least 1 emotional symptom was reported in 49.4% of the patients, and the median emotional PCSS subscore was 4 (interquartile range 1-8) among those who reported at least 1 emotional symptom. Overall, 20 (11.5%) of the patients met the study criteria for a postinjury psychiatric outcome, including 14 patients with an NPD, 2 patients with isolated suicidal ideation, and 4 patients with worsening symptoms of a preinjury psychiatric disorder. Female sex, a higher initial PCSS score, a higher emotional PCSS subscore, presence of a preinjury psychiatric history, and presence of a family history of psychiatric illness were significantly associated with postinjury psychiatric outcomes. Interventions for patients with postinjury psychiatric outcomes included pharmacological therapy alone in 2 patients (10%), cognitive behavioral therapy alone in 4 (20%), multimodal therapy in 9 (45%), and no treatment in 5 (25%). Overall, 5 (25%) of the patients with postinjury psychiatric disorders were medically cleared to return to full sports participation, whereas 5 (25%) were lost to follow-up and 9 (45%) remained in treatment by the multidisciplinary concussion program at the end of the study period. One patient who was asymptomatic at the time of initial consultation committed suicide. CONCLUSIONS Emotional symptoms were commonly reported among pediatric patients with SRC referred to a multidisciplinary pediatric concussion program. In some cases, these symptoms contributed to the development of an NPD, isolated suicidal ideation, and worsening symptoms of a preexisting psychiatric disorder. Future research is needed to clarify the prevalence, pathophysiology, risk factors, and evidence-based management of postinjury psychiatric outcomes after pediatric SRC. Successful management of these patients requires prompt recognition and multidisciplinary care by experts with clinical training and experience in concussion and psychiatry.
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Affiliation(s)
- Michael J Ellis
- Departments of 1 Surgery.,Pediatrics and Child Health.,Section of Neurosurgery, University of Manitoba;,Pan Am Concussion Program;,Childrens Hospital Research Institute of Manitoba; and.,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Lesley J Ritchie
- Clinical Health Psychology, and.,Pan Am Concussion Program;,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Mark Koltek
- Psychiatry, and.,Pan Am Concussion Program;,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Shahid Hosain
- Psychiatry, and.,Pan Am Concussion Program;,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Dean Cordingley
- Pan Am Concussion Program;,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Stephanie Chu
- Pediatrics and Child Health.,Childrens Hospital Research Institute of Manitoba; and.,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Erin Selci
- Pediatrics and Child Health.,Childrens Hospital Research Institute of Manitoba; and.,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Jeff Leiter
- Departments of 1 Surgery.,Pan Am Concussion Program;,Canada North Concussion Network, Winnipeg, Manitoba, Canada
| | - Kelly Russell
- Pediatrics and Child Health.,Childrens Hospital Research Institute of Manitoba; and.,Canada North Concussion Network, Winnipeg, Manitoba, Canada
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Schrieff-Elson LE, Thomas KGF, Rohlwink UK, Figaji AA. Low brain oxygenation and differences in neuropsychological outcomes following severe pediatric TBI. Childs Nerv Syst 2015; 31:2257-68. [PMID: 26337700 DOI: 10.1007/s00381-015-2892-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/24/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Preventing secondary injury by controlling physiological parameters (e.g. intracranial pressure [ICP], cerebral perfusion pressure [CPP] and brain tissue oxygen [PbtO2]) has a potential to improve outcome. Low PbtO2 is independently associated with poor clinical outcomes in both adults and children. However, no studies have investigated associations between low PbtO2 and neuropsychological and behavioural outcomes following severe pediatric TBI (pTBI). METHODS We used a quasi-experimental case-control design to investigate these relationships. A sample of 11 TBI patients with a Glasgow Coma Scale score ≤8 who had PbtO2 and ICP monitoring at the Red Cross War Memorial Children's Hospital underwent neuropsychological evaluation ≥1 year post-injury. Their performance was compared to that of 11 demographically matched healthy controls. We then assigned each TBI participant into one of two subgroups, (1) children who had experienced at least one episode of PbtO2 ≤ 10 mmHg or (2) children for whom PbtO2 > 10 mmHg throughout the monitoring period, and compared their results on neuropsychological evaluation. RESULTS TBI participants performed significantly more poorly than controls in several cognitive domains (IQ, attention, visual memory, executive functions and expressive language) and behavioural (e.g. externalizing behaviour) domains. The PbtO2 ≤ 10 mmHg group performed significantly worse than the PbtO2 > 10 mmHg group in several cognitive domains (IQ, attention, verbal memory, executive functions and expressive language), but not on behavioural measures. CONCLUSION Results demonstrate that low PbtO2 may be prognostic of not only mortality but also neuropsychological outcomes.
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Affiliation(s)
- L E Schrieff-Elson
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa.
| | - K G F Thomas
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Cape Town, South Africa
| | - U K Rohlwink
- Division of Neurosurgery, Department of Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - A A Figaji
- Division of Neurosurgery, Department of Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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DEMATTEO CAROL, VOLTERMAN KIMBERLYA, BREITHAUPT PETERG, CLARIDGE EVERETTA, ADAMICH JOHN, TIMMONS BRIANW. Exertion Testing in Youth with Mild Traumatic Brain Injury/Concussion. Med Sci Sports Exerc 2015; 47:2283-90. [DOI: 10.1249/mss.0000000000000682] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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48
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TBI and Concussions in Student Athletes: How do Severity of Injury, Age, and Gender Influence Recovery. JOURNAL OF PEDIATRIC NEUROPSYCHOLOGY 2015. [DOI: 10.1007/s40817-015-0010-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Schachar RJ, Park LS, Dennis M. Mental Health Implications of Traumatic Brain Injury (TBI) in Children and Youth. JOURNAL OF THE CANADIAN ACADEMY OF CHILD AND ADOLESCENT PSYCHIATRY = JOURNAL DE L'ACADEMIE CANADIENNE DE PSYCHIATRIE DE L'ENFANT ET DE L'ADOLESCENT 2015; 24:100-108. [PMID: 26379721 PMCID: PMC4558980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/16/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is the most common cause of death and disability in children and adolescents. Psychopathology is an established risk factor for, and a frequent consequence of, TBI. This paper reviews the literature relating psychopathology and TBI. METHOD Selective literature review. RESULTS The risk of sustaining a TBI is increased by pre-existing psychopathology (particularly ADHD and aggression) and psychosocial adversity. Even among individuals with no psychopathology prior to the injury, TBI is frequently followed by mental illness especially ADHD, personality change, conduct disorder and, less frequently, by post-traumatic stress and anxiety disorders. The outcome of TBI can be partially predicted by pre-injury adjustment and injury severity, but less well by age at injury. Few individuals receive treatment for mental illness following TBI. CONCLUSION TBI has substantial relevance to mental health professionals and their clinical practice. Available evidence, while limited, indicates that the risk for TBI in children and adolescents is increased in the presence of several, potentially treatable mental health conditions and that the outcome of TBI involves a range of mental health problems, many of which are treatable. Prevention and management efforts targeting psychiatric risks and outcomes are an urgent priority. Child and adolescent mental health professionals can play a critical role in the prevention and treatment of TBI through advocacy, education, policy development and clinical practice.
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Affiliation(s)
- Russell James Schachar
- Senior Scientist, Program in Neurosciences and Mental Health, Research Institute, Staff Psychiatrist, Department of Psychiatry, The Hospital for Sick Children, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto Dominion Bank Financial Group Chair in Child and Adolescent Psychiatry, Toronto, Ontario
| | - Laura Seohyun Park
- Clinical Research Project Coordinator, Program in Neurosciences and Mental Health, Research Institute, The Hospital for Sick Children, Toronto, Ontario
| | - Maureen Dennis
- Senior Scientist, Program Neurosciences and Mental Health, Research Institute, Department of Psychology, The Hospital for Sick Children, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario
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Richard YF, Swaine BR, Sylvestre MP, Lesage A, Zhang X, Feldman DE. The association between traumatic brain injury and suicide: are kids at risk? Am J Epidemiol 2015; 182:177-84. [PMID: 26121988 DOI: 10.1093/aje/kwv014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 01/16/2015] [Indexed: 11/14/2022] Open
Abstract
Traumatic brain injury (TBI) in late adolescence and adulthood is associated with a higher risk of suicide; however, it is unknown whether this association is also present in people who sustained a TBI during childhood. The purpose of the present study was to determine whether experiencing a TBI during childhood is a risk factor for suicide later in life and to examine whether the risk of suicide differs by sex or injury severity. A cohort of 135,703 children aged 0-17 years was identified from the Quebec population-based physician reimbursement database in 1987, and follow-up was conducted until 2008. Of the children in this cohort, 21,047 had sustained a TBI. Using a survival analysis with time-dependent indicators of TBI, we found a higher risk of suicide for people who sustained a TBI during childhood (hazard ratio (HR) = 1.49, 95% confidence interval (CI): 1.04, 2.14), adolescence (HR = 1.57, 95% CI: 1.09, 2.26), and adulthood (HR = 2.53, 95% CI: 1.79, 3.59). When compared with less severe injuries, such as concussions and cranial fractures, more severe injuries, such as intracranial hemorrhages, were associated with a higher risk of suicide (HR = 2.18 vs. 2.77, respectively). Repeated injuries were associated with higher risks of suicide in all age groups.
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