Impact of childhood brain injury on work and family finances

Psychiatric sequelae of traumatic brain injury - future directions in research

Despite growing appreciation that traumatic brain injury (TBI) is an important public health burden, our understanding of the psychiatric and behavioural consequences of TBI remains limited. These changes are particularly detrimental to a person's sense of self, their relationships and their participation in the wider community, and they continue to have devastating individual and cumulative effects long after TBI. This Review relates specifically to TBIs that confer objective clinical or biomarker evidence of structural brain injury; symptomatic head injuries without such evidence are outside the scope of this article. Common psychiatric, affective and behavioural sequelae of TBI and their proposed underlying mechanisms are outlined, along with a brief overview of current treatments. Suggestions for how scientists and clinicians can work together in the future to address the chasms in clinical care and knowledge are discussed in depth.

The Relationship Between Traumatic Injury in Children and Long-Term Use of Health and Social Services by Children and Their Families

To increase understanding of relationships between general traumatic injury in children and long-term use of resources in the health care and social services (HSS) sectors by these children and their families 8-10 years after traumatic injury. This study was a cross-sectional retrospective cohort study of prognosis from 2001 to 2003 that quantified recent expenditures on and use of HSS by children and also by their parents. Forty-eight cases of children were selected from the Hamilton Health Sciences pediatric trauma database in the period from January 2001 to December 2003 after incurring a traumatic injury with Injury Severity Score greater than 12. The average total cost to the HSS system per child's family was $4,326.62 during the preceding 6 months. During the same period, average use of HSS was 7 visits. Total service costs incurred by caregivers of injured children increased with severity of the traumatic injury (p= .009). Caregiver HSS use was higher when the injury was caused by a motor vehicle accident than by other types of accidents (p< .001) and increased with the injury severity (p< .001). HSS use by children was related to gender (p< .001), injury mechanism (p< .001), age at accident (p< .001), and time since accident (p= .012), among other factors. Pediatric trauma appears to have long-term effects on expenditures on and use of HSS by the affected children and their families. The findings emphasize the need for long-term assessment and possible delivery of services to the families of the injured children.

Isolated head injury is a cause of shock in pediatric trauma patients

OBJECTIVES

Current trauma resuscitation protocols from the American College of Surgeons, Committee on Trauma, recommend intravascular volume expansion to treat shock after major trauma, assuming that hemorrhage is present. However, this assumption may not be correct. The purpose of this study was to identify the proportion of children with severe shock after trauma presenting with isolated head injury versus hemorrhagic injury.

METHODS

A retrospective review of all pediatric trauma patients (aged 0-15 years) was conducted over a 5-year period. Severe shock was defined as the presence of both an elevated blood lactate level and low blood pressure for age. Traumatic injuries were classified as hemorrhagic injuries, head injuries, combined hemorrhagic and head injuries, or other injuries, by analyzing International Classification of Diseases, Ninth Revision diagnostic codes.

RESULTS

A total of 31 (5%) of 680 pediatric trauma patients presented with severe shock. Among these 31 pediatric trauma patients, 9 (29%) had isolated head injury. Isolated head injury among children with shock was most frequently observed among children younger than 5 years (50%), and a decreased trend was noted with increasing age (23% for children 5-11 years and 0% for children 12-15 years [P = 0.03, Cochran-Armitage exact trend test]).

CONCLUSIONS

Isolated head injury was observed in 29% of children 0 to 15 years of age with severe shock after trauma and in 50% of children younger than 5 years. Head injury is an important cause of severe shock in pediatric trauma, particularly among young children.

Family environment influences emotion recognition following paediatric traumatic brain injury

OBJECTIVE

This study investigated the relationship between family functioning and performance on two tasks of emotion recognition (emotional prosody and face emotion recognition) and a cognitive control procedure (the Flanker task) following paediatric traumatic brain injury (TBI) or orthopaedic injury (OI).

METHODS

A total of 142 children (75 TBI, 67 OI) were assessed on three occasions: baseline, 3 months and 1 year post-injury on the two emotion recognition tasks and the Flanker task. Caregivers also completed the Life Stressors and Resources Scale (LISRES) on each occasion. Growth curve analysis was used to analyse the data.

RESULTS

Results indicated that family functioning influenced performance on the emotional prosody and Flanker tasks but not on the face emotion recognition task. Findings on both the emotional prosody and Flanker tasks were generally similar across groups. However, financial resources emerged as significantly related to emotional prosody performance in the TBI group only (p = 0.0123).

CONCLUSIONS

Findings suggest family functioning variables--especially financial resources--can influence performance on an emotional processing task following TBI in children.

Spousal relationship satisfaction following acquired brain injury: The role of insight and socio-emotional skill

Spousal relationships following brain injury are particularly vulnerable to strain and breakdown. Changes in personality and socio-emotional processing and behaviour have been implicated as causal factors. We examined spousal relationship satisfaction following an acquired brain injury to one partner. Couples affected by chronic pain and a group of healthy couples were used for comparison and control. Compared to healthy controls current satisfaction was poorer in the brain injury couples, and satisfaction with the relationship had reduced from pre to post-injury. We found an especially important role for empathy, which differentiated between the groups in terms of functioning and insight.

Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States

OBJECTIVE

The goal was to examine the influence of sociodemographic characteristics and health care system factors on the utilization of hospital resources by US children < or = 17 years of age with a diagnosis of traumatic brain injury.

METHODS

A retrospective analysis of data from the Healthcare Cost and Utilization Project Kids' Inpatient Database, from January 1, 2000, to December 31, 2000, was performed. National estimates of traumatic brain injury-associated hospitalization rates and resource use were calculated with Kids' Inpatient Database sample weighting methods.

RESULTS

Of 2,516,833 encounters between January 1, 2000, and December 31, 2000, 25,783 cases involved patients < or = 17 years of age with a recorded diagnosis of traumatic brain injury. On the basis of these data, there were an estimated 50,658 traumatic brain injury-associated hospitalizations among children < or = 17 years of age in the United States in 2000. The traumatic brain injury-associated hospitalization rate was 70 cases per 100,000 children < or = 17 years of age per year; 15- to 17-year-old patients had the highest hospitalization rate (125 cases per 100,000 children per year). Pediatric inpatients accrued more than $1 billion in total charges for traumatic brain injury-associated hospitalizations in this study. In the multivariate regression models, older age, Medicaid insurance status, and admission to any type of children's hospital were associated with a longer length of stay for pediatric traumatic brain injury-associated hospitalizations. Older age, longer length of stay, and in-hospital death predicted higher total charges for traumatic brain injury-associated hospitalizations.

CONCLUSION

Pediatric traumatic brain injury is a substantial contributor to the health resource burden in the United States, accounting for more than $1 billion in total hospital charges annually.

CNS injury research; reviewing the last decade: methodological errors and a proposal for a new strategy

During the last decades the field of Traumatic Brain Injury (TBI) has been characterized by a paucity of new treatments. This is in contrast to the amount of pre-clinical experimental work and the number of clinical trials done. This paper aims to contribute to the ongoing debate on the reasons that have led to this phenomenon. A reasonable suggestion could be the presence of methodological limitations when comparing and integrating experimental results. The first methodological drawback, which is shortly discussed, is the insistence (during the last decades) on the concept of "similarity to the human pathology" as the main criterion to evaluate results, and the constant effort to create a "super model" that would fully replicate human TBI cases. The second methodological limitation examined is the lack of a common way to present and analyze data. It is proposed that the basic neuro-histo-pathology of each injury model should serve as the ground on which hypotheses should be built, as it could constitute the common basis for comparisons between different experimental settings. In this context, 95 papers reporting experimental results from various models of animal CNS injury were reviewed in order to examine the extent to which results were presented and analyzed using a common basis. No such common basis was observed; moreover, the review revealed a remarkable lack of histopathological examination of the animals, especially when biochemical and/or behavioral endpoints were assessed. It is argued that this practice deprives data of an objective common basis. Conclusively, a new theoretical way of organizing experimental work in the field of TBI is briefly presented.

Medical Costs of Mild to Moderate Traumatic Brain Injury in Children

OBJECTIVE

To estimate healthcare expenditures of children with mild to moderate traumatic brain injury (TBI) outside of acute care settings.

DESIGN

Data from the 1997-2000 Medical Expenditure Panel Survey were used to produce estimates of expenditures for a natural sample of 196 children with TBI.

RESULTS

Expenditures for TBI-related services in children averaged $77.9 million per year. Average per capita expenditure was $1044, of which $166 was for TBI-related services and $878 was for all other health services.

CONCLUSION

Although total costs of TBI in children are high, the average costs are much lower than those previous reports because youth with minor trauma were not included in prior samples.

Recovery of injured children: parent perspectives on family needs

OBJECTIVE

To study the broader impact of emotional and financial burdens of injury in children on their families, along with solutions to these problems.

DESIGN

Focus groups were conducted to reveal the needs of parents and children after injury. Audiotaped semistructured interviews were conducted by a team of qualitative researchers.

SETTING

Tertiary care children's hospital.

PARTICIPANTS

Mothers of children who had sustained traumatic injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary of reported themes of experience and suggested interventions. Data were analyzed by using content analysis software.

RESULTS

Overall satisfaction with care was high. Parents expressed concerns with communication, access to care, and the transition both within the phases of medical care and from medical care into the community. Consistent financial and social stressors were voiced, along with the need for peer support during all phases of care.

CONCLUSIONS

Parents provided valuable insight into their needs after their child's injury. Attention to constructive communication, clarification of the system of care, continued family-centered care, and development of peer support programs may meet the needs of caregivers and therefore facilitate improvement in pediatric injury recovery.

Costs of childhood physical abuse: comparing inflicted and unintentional traumatic brain injuries

OBJECTIVES

To estimate the effect of early childhood abuse (ie, inflicted injury) on medical costs of head trauma.

METHODS

Abstracts of patient records were drawn from the annual 1993-2000 Colorado state-mandated hospital discharge database maintained by the Colorado Hospital Association. The 2 dependent variables were total charges (TC) and length of stay. Our key independent variable was the nature of injury, ie, inflicted or unintentional; other independent variables were age, severity level, death, and trauma designation of the hospital. Comparisons of variables between patients with inflicted and unintentional head trauma were performed using Student's t tests or chi2 statistics. Ordinary least squares regression was used to estimate the marginal and total effects of inflicted injury on TC and LOS.

RESULTS

Of the 1097 head trauma patients <3 years old, 814 had unintentional and 283 had inflicted head trauma. Head trauma was defined using the Centers for Disease Control definition of traumatic brain injury. Patients with inflicted injuries were younger and had a higher average severity level and overall mortality rate than did patients with unintentional head trauma. The regression models showed that, controlling for age and severity, patients with inflicted head trauma stayed in the hospital 52% longer (2 days), and had a mean total bill 89% higher (4232 dollars more) than did patients with unintentional head trauma.

CONCLUSIONS

The findings from multivariate models of TC and length of stay corroborate the simpler univariate findings of earlier studies. By focusing on the impact of those cases of child abuse that lead to a specific, severe clinical entity (traumatic brain injury), we isolated a significant economic impact of abuse on health care expenditures for injury.

Long-term adjustment of families following traumatic brain injury where comprehensive rehabilitation has been provided

OBJECTIVES

The present study aimed to examine long-term family and emotional adjustment in close relatives of individuals with TBI, who had access to comprehensive rehabilitation services. It also examined the relative influence thereon of factors including injury severity, handicap and cognitive and behavioural changes in the injured person, relationship with the injured person and caregiver status.

METHODS

Participants were 143 TBI individuals and their close relatives. They completed the Family Assessment Device (FAD), Leeds Scales of Anxiety and Depression, Structured Outcome Questionnaire, CHART, SIP Psychosocial Dimension and Novaco Anger Control Questionnaire 2-5 years post-injury.

RESULTS

Results showed that families were, on average, functioning in the normal range on the FAD. Anxiety and depression were more likely to be present in those responsible for care of their injured relative. There were no differences between spouses and parents. Presence of cognitive, behavioural and emotional changes was the strongest predictor of anxiety and depression in relatives and of unhealthy family functioning.

CONCLUSIONS

Every attempt should be made to develop models of long-term support and care that alleviate these sources of burden on relatives.

Social and behavioural effects of traumatic brain injury in children

Traumatic brain injury (TBI) is the leading cause of death and permanent disability in children and adolescents. Although cognitive and behavioural effects have now been reported for all degrees of TBI severity in children, other aspects of functioning which might be related (such as psychosocial adjustment), have been neglected. In the present study the social and behavioural effects of TBI were assessed by comparing 27 TBI children with 27 controls. TBI children demonstrated significantly lower levels of self-esteem and adaptive behaviour, and higher levels of loneliness, maladaptive behaviour and aggressive/antisocial behaviour. These findings confirm the previously demonstrated detrimental effects of TBI on children's behavioural functioning and offer new evidence for the detrimental effects of TBI on children's social functioning.