Behavioral outcomes after pediatric closed head injury: relationships with age, severity, and lesion size

Correlation between early computed tomography findings and neurological outcome in pediatric traumatic brain injury patients

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Head computed tomography (CT) is frequently utilized for evaluating trauma-related characteristics, selecting treatment options, and monitoring complications in the early stages. This study assessed the relationship between cranial CT findings and early and late neurological outcomes in pediatric TBI patients admitted to the pediatric intensive care unit (PICU). The study included children aged 1 month to 18 years who were admitted to the PICU due to TBI between 2014 and 2020. Sociodemographic data, clinical characteristics, and cranial CT findings were analyzed. Patients were categorized based on their Glasgow Coma Scale (GCS) score. Of the 129 patients, 83 (64%) were male, and 46 (36%) were female, with a mean age of 6.8 years. Falls (n = 51, 39.5%) and in-vehicle traffic accidents (n = 35, 27.1%) were the most common trauma types observed. Normal brain imaging findings were found in 62.7% of the patients, while 37.3% exhibited intracranial pathology. Hemorrhage was the most frequent CT finding. Severe TBI (n = 26, p = 0.032) and mortality (n = 9, p = 0.017) were more prevalent in traffic accidents. The overall mortality rate in the study population was 10.1%. In children with TBI, cranial CT imaging serves as an essential initial method for patients with neurological manifestations. Particularly, a GCS score of ≤ 8, multiple hemorrhages, diffuse cerebral edema, and intraventricular bleeding are associated with sequelae and mortality.

Cross-sectional examination of the association of co-occurring alcohol misuse and traumatic brain injury on mental health and conduct problems in adolescents in Ontario, Canada

OBJECTIVE

This study describes the impact of traumatic brain injury (TBI) and hazardous drinking on mental health and behavioural issues among Ontario adolescents. In particular, we assessed the incremental co-occurrence of hazardous drinking with a history of TBI, in comparison to experiencing just one of these conditions.

METHODS

A cross-sectional subsample of 3130 Ontario adolescents attending grades 9-12, and aged 10-21 were surveyed in 2013 as a part of the Centre for Addiction and Mental Health's Ontario Student Drug Use and Health Survey. Recent (past year) and former (lifetime and excluding the last year) TBI were defined as trauma to the head that resulted in loss of consciousness for at least 5 min or overnight hospitalisation. Current hazardous drinking was derived using the Alcohol Use Disorders Identification Test (AUDIT).

RESULTS

An estimated 11.8% of Ontario adolescents (95% CI 10.1% to 13.8%) reported a history of former TBI and were not hazardous drinkers; 4.0% (95% CI 2.9% to 5.5%) reported recent TBI and were not hazardous drinkers; 13.7% (95% CI 12.3% to 15.3%) were hazardous drinkers who never had a TBI; 4.1% (95% CI 2.9% to 5.8%) had former TBI with co-occurring hazardous drinking; and 2.2% (95% CI 1.6% to 3.0%) had recent TBI with co-occurring hazardous drinking. Most odds increased significantly and were two to three times higher for reporting compromised mental health, violent and non-violent conduct behaviours, and reported victimisation for classifying as a hazardous drinker at the time of testing with co-occurring either former or recent TBI compared to classifying as not having either of these conditions. Adolescents classified as hazardous drinkers with former TBI had numerous and higher ORs for conduct behaviours than those with recent TBI.

CONCLUSIONS

Results emphasise the strong interplay between TBI and hazardous drinking and point to the need for integrating prevention efforts to reduce these conditions and their co-occurrence among adolescents.

Adaptive functioning following pediatric traumatic brain injury: Relationship to executive function and processing speed

OBJECTIVE

Pediatric traumatic brain injury (TBI) may affect children's ability to perform everyday tasks (i.e., adaptive functioning). Guided by the American Association for Intellectual and Developmental Disabilities (AAIDD) model, we explored the association between TBI and adaptive functioning at increasing levels of specificity (global, AAIDD domains, and subscales). We also examined the contributions of executive function and processing speed as mediators of TBI's effects on adaptive functioning.

METHOD

Children (ages 8-13) with severe TBI (STBI; n = 19), mild-moderate TBI (MTBI; n = 50), or orthopedic injury (OI; n = 60) completed measures of executive function (TEA-Ch) and processing speed (WISC-IV) an average of 2.7 years postinjury (SD = 1.2; range: 1-5.3). Parents rated children's adaptive functioning (ABAS-II, BASC-2, CASP).

RESULTS

STBI had lower global adaptive functioning (η2 = .04-.08) than the MTBI and OI groups, which typically did not differ. Deficits in the STBI group were particularly evident in the social domain, with specific deficits in social participation, leisure, and social adjustment (η2 = .06-.09). Jointly, executive function and processing speed were mediators of STBI's effects on global adaptive functioning and in conceptual and social domains. In the STBI group, executive function mediated social functioning, and processing speed mediated social participation.

CONCLUSIONS

Children with STBI experience deficits in adaptive functioning, particularly in social adjustment, with less pronounced deficits in conceptual and practical skills. Executive function and processing speed may mediate the effects of STBI on adaptive functioning. Targeting adaptive functioning and associated cognitive deficits for intervention may enhance quality of life for pediatric TBI survivors. (PsycINFO Database Record

Ongoing daytime behavioural problems in university students following childhood mild traumatic brain injury

Sleep is often disrupted in traumatic brain injury (TBI) and may be related to persistent behaviour problems; however, little is known about this relationship in young adults. This study explored associations between TBI, behavioural problems and sleep disturbances in 247 university students (197 non-TBI, 47 mild TBI, two moderate TBI, one severe TBI) aged 18-25 years, who completed validated measures for behaviour, sleep quality and history of TBI. Because of small group numbers, participants reporting moderate to severe TBI were excluded from the analyses. Results indicated that students with mild TBI reported higher levels of daytime dysfunction, somatic complaints, withdrawal, other behavioural complaints and internalizing behaviours compared with students with no TBI history. A correlational analysis indicated a moderate relationship between the above significant variables. Our results suggest that university students with a history of mild TBI are more likely to experience certain ongoing daytime behavioural problems, which are likely to negatively influence their academic functioning in tertiary education. This study highlights the importance of research on long-term problems following mild TBI in young adults aged 18-25 years--an age group often overlooked within the literature.

Life after Adolescent and Adult Moderate and Severe Traumatic Brain Injury: Self-Reported Executive, Emotional, and Behavioural Function 2-5 Years after Injury

Survivors of moderate-severe Traumatic Brain Injury (TBI) are at risk for long-term cognitive, emotional, and behavioural problems. This prospective cohort study investigated self-reported executive, emotional, and behavioural problems in the late chronic phase of moderate and severe TBI, if demographic characteristics (i.e., age, years of education), injury characteristics (Glasgow Coma Scale score, MRI findings such as traumatic axonal injury (TAI), or duration of posttraumatic amnesia), symptoms of depression, or neuropsychological variables in the first year after injury predicted long-term self-reported function. Self-reported executive, emotional, and behavioural functioning were assessed among individuals with moderate and severe TBI (N = 67, age range 15–65 years at time of injury) 2–5 years after TBI, compared to a healthy matched control group (N = 72). Results revealed significantly more attentional, emotional regulation, and psychological difficulties in the TBI group than controls. Demographic and early clinical variables were associated with poorer cognitive and emotional outcome. Fewer years of education and depressive symptoms predicted greater executive dysfunction. Younger age at injury predicted more aggressive and rule-breaking behaviour. TAI and depressive symptoms predicted Internalizing problems and greater executive dysfunction. In conclusion, age, education, TAI, and depression appear to elevate risk for poor long-term outcome, emphasising the need for long-term follow-up of patients presenting with risk factors.

Does what we measure matter? Quality-of-life defined by adolescents with brain injury

OBJECTIVES

To determine if domains included in popular measurement systems (e.g. the Peds QL™) reflect the adolescent survivor of a brain injury's sense of QoL and explore this relationship in reference to an emerging model of wellbeing in the adolescent with TBI.

METHODS

Mixed methods; adolescent QoL assessed using the PedsQL™ self-report and a semi-structured interview created by the lead author. Adolescent self-report was compared to adolescent narratives.

RESULTS

Ten adolescents participated. Adolescent PedsQL™ total was within normal limits. Adolescents reported that changes identified by the PedsQL were not important and did not impact on their sense of QoL. The importance on social components of QoL-as opposed to cognitive-provide additional support of the emerging model of wellbeing in adolescents with TBI.

CONCLUSIONS

The PedsQL can identify changes post-TBI, but fails to consider whether these changes are relevant to the adolescent. Alternate methods of exploring QoL-which emphasize the interaction of social networks and friendships, should be considered to avoid an oblique view of QoL outcomes after TBI.

Adolescents' internalizing problems following traumatic brain injury are related to parents' psychiatric symptoms

BACKGROUND

A small body of previous research has demonstrated that pediatric traumatic brain injury (TBI) increases risk for internalizing problems, but findings have varied regarding their predictors and correlates.

METHODS

We examined the level and correlates of internalizing symptoms in 130 teens who had sustained a complicated mild to severe TBI within the past 1 to 6 months. Internalizing problems were measured via both maternal- and paternal-report Child Behavior Checklist. We also measured family functioning, parent psychiatric symptoms, and postinjury teen neurocognitive function.

RESULTS

Mean parental ratings of internalizing problems were within the normal range. Depending on informant, 22% to 26% of the sample demonstrated clinically elevated internalizing problems. In multiple and binary logistic regression models, only parent psychiatric symptoms consistently provided unique prediction of teen internalizing symptoms. For maternal but not paternal report, female gender was associated with greater internalizing problems.

CONCLUSION

Parent and teen emotional problems are associated following adolescent TBI. Possible reasons for this relationship, including the effects of TBI on the family unit, are discussed.

Clinically-important brain injury and CT findings in pediatric mild traumatic brain injuries: a prospective study in a Chinese reference hospital

This study investigated injury patterns and the use of computed tomography (CT) among Chinese children with mild traumatic brain injury (MTBI). We enrolled children with MTBI who were treated within 24 hours of head trauma in the emergency department of Wuhan Medical Care Center for Women and Children in Wuhan, China. Characteristics of MTBIs were analyzed by age and gender. Results of cranial CT scan and clinically-important brain injury (ciTBI) for children were obtained. The definition of ciTBI was: death from TBI, intubation for more than 24 h for TBI, neurosurgery, or hospital admission of 2 nights or more. Of 455 eligible patients with MTBI, ciTBI occurred in two, and no one underwent neurosurgical intervention. CT scans were performed for 441 TBI patients (96.9%), and abnormal findings were reported for 147 patients (33.3%, 95% CI 29.0–37.8). Falls were the leading cause of MTBI (61.5%), followed by blows (18.9%) and traffic collisions (14.1%) for children in the 0–2 group and 10–14 group. For children aged between 3 and 9, the top three causes of TBI were falls, traffic collisions and blows. Leisure activity was the most reported activity when injuries occurred for all age groups. Sleeping/resting and walking ranked in the second and third place for children between 0 and 2 years of age, and walking and riding for the other two groups. The places where the majority injuries occurred were the home for the 0–2 and 3–9 years of age groups, and school for the 10–14 years of age group. There was no statistical difference between boys and girls with regard to the activity that caused the MTBI. This study highlights the important roles that parents and school administrators in the development of preventive measures to reduce the risk of traumatic brain injury in children. Also, identifying children who had a head trauma at very low risk of clinically important TBI for whom CT might be unnecessary is a priority area of research in China.

The effect of pediatric traumatic brain injury on behavioral outcomes: a systematic review

AIM

To review systematically the empirical evidence on traumatic brain injury (TBI) during childhood and subsequent behavioral problems.

METHOD

An initial literature search with keywords 'brain injury,''children,' and 'behavior' was conducted using Web of Knowledge and PubMed databases. Ancestry was also used. Original research studies published between 1990 and February 2012 focusing on behavioral outcomes of children sustaining TBI from ages 0 to 18 years were included.

RESULTS

Fifty studies, varying considerably in methodologies, were included in the review. Findings showed that up to 50% of brain-injured children are at risk for presenting with specific behavioral problems and disorders. These problems may emerge shortly or several years after injury and often persist and even worsen with time. These behavioral impairments appear to be moderated by the family environment.

INTERPRETATION

Survivors of childhood TBI are at risk for developing and sustaining behavioral impairments. Stronger research is needed to identify cognitive and environmental factors that contribute to the onset and maintenance of these problems. Healthcare providers should ensure adequate follow-up and assessment of a child's behavioral, social, and neurocognitive domains. Caregivers should be encouraged to provide positive environments and parenting styles, which may help reduce chronic behavioral problems after brain injury.

Disability 3, 12, and 24 months after traumatic brain injury among children and adolescents

OBJECTIVE

To examine disability in children and adolescents after traumatic brain injury (TBI) across the spectrum of injury severity.

METHODS

This was a prospective cohort study of children younger than 18 years treated for a TBI (n = 729) or an arm injury (n = 197) between March 1, 2007, and September 30, 2008. The main outcome measures were disability in health-related quality of life, adaptive skills, and participation in social and community activities 3, 12, and 24 months after injury compared with preinjury functioning.

RESULTS

The health-related quality of life for children with moderate or severe TBI was lower at all follow-up times compared with baseline, but there was some improvement during the first 2 years after injury. Three months after injury, there was a substantial decrease in the level of activities in which children with moderate and severe TBI were able to participate; these activities improved at 12 and 24 months but were still significantly impaired. Communication and self-care abilities in children with moderate and severe TBI were lower at 3 months than at baseline and did not improve by 24 months. Children who met the definition of mild TBI but had an intracranial hemorrhage had lower quality-of-life scores at 3 months.

CONCLUSIONS

Children with moderate or severe TBI and children with mild TBI who had intracranial hemorrhage had substantial long-term reduction in their quality of life, participation in activities with others, and ability to communicate and care for themselves.

Early bifrontal brain injury: disturbances in cognitive function development

We describe six psychomotor, language, and neuropsychological sequential developmental evaluations in a boy who sustained a severe bifrontal traumatic brain injury (TBI) at 19 months of age. Visuospatial, drawing, and writing skills failed to develop normally. Gradually increasing difficulties were noted in language leading to reading and spontaneous speech difficulties. The last two evaluations showed executive deficits in inhibition, flexibility, and working memory. Those executive abnormalities seemed to be involved in the other impairments. In conclusion, early frontal brain injury disorganizes the development of cognitive functions, and interactions exist between executive function and other cognitive functions during development.

Practitioner review: beyond shaken baby syndrome: what influences the outcomes for infants following traumatic brain injury?

BACKGROUND

Traumatic brain injury (TBI) in infancy is relatively common, and is likely to lead to poorer outcomes than injuries sustained later in childhood. While the headlines have been grabbed by infant TBI caused by abuse, often known as shaken baby syndrome, the evidence base for how to support children following TBI in infancy is thin. These children are likely to benefit from ongoing assessment and intervention, because brain injuries sustained in the first year of life can influence development in different ways over many years.

METHODS

A literature search was conducted and drawn together into a review aimed at informing practitioners working with children who had a brain injury in infancy. As there are so few evidence-based studies specifically looking at children who have sustained a TBI in infancy, ideas are drawn from a range of studies, including different age ranges and difficulties other than traumatic brain injury.

RESULTS

This paper outlines the issues around measuring outcomes for children following TBI in the first year of life. An explanation of outcomes which are more likely for children following TBI in infancy is provided, in the areas of mortality; convulsions; endocrine problems; sensory and motor skills; cognitive processing; language; academic attainments; executive functions; and psychosocial difficulties. The key factors influencing these outcomes are then set out, including severity of injury; pre-morbid situation; genetics; family factors and interventions.

CONCLUSIONS

Practitioners need to take a long-term, developmental view when assessing, understanding and supporting children who have sustained a TBI in their first year of life. The literature suggests some interventions which may be useful in prevention, acute care and longer-term rehabilitation, and further research is needed to assess their effectiveness.

The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children

OBJECTIVE

This study sought to determine whether the family environment moderates psychosocial outcomes after traumatic brain injury (TBI) in young children.

METHOD

Participants were recruited prospectively from consecutive hospital admissions of 3- to 6-year-old children, and included 19 with severe TBI, 56 with complicated mild/moderate TBI, and 99 with orthopedic injuries (OI). They completed 4 assessments across the first 18 months postinjury. The initial assessment included measures of parenting style, family functioning, and the quality of the home. Children's behavioral adjustment, adaptive functioning, and social competence were assessed at each occasion. Mixed model analyses examined the relationship of the family environment to psychosocial outcomes across time.

RESULTS

The OI and TBI groups differed significantly in social competence, but the family environment did not moderate the group difference, which was of medium magnitude. In contrast, group differences in behavioral adjustment became more pronounced across time at high levels of authoritarian and permissive parenting; among children with severe TBI, however, even those with low levels of permissive parenting showed increases in behavioral problems. For adaptive functioning, better home environments provided some protection following TBI, but not over time for the severe TBI group. These 3-way interactions of group, family environment, and time postinjury were all of medium magnitude.

CONCLUSION

The findings indicate that the family environment moderates the psychosocial outcomes of TBI in young children, but the moderating influence may wane with time among children with severe TBI.

Context-sensitive cognitive-behavioural supports for young children with TBI: A replication study

OBJECTIVE

To replicate an investigation of the effects of a multi-component cognitive-behavioural intervention on the challenging behaviour of two young children with growing behavioural concerns after TBI.

EXPERIMENTAL DESIGN

Single-subject reversal designs used to document the effects of the combined behavioural, cognitive and executive function intervention on the following dependent variables: frequency and intensity of aggressive behaviours, amount of work accomplished.

PARTICIPANTS

Two young children with escalating behaviour problems after TBI.

INTERVENTION

Integrated components of positive behaviour supports, cognitive supports (e.g. graphic organizers) and an executive function routine (goal-plan-do-review).

RESULTS

Reduced frequency and intensity of challenging behaviours; increased quantity of work completed.

CONCLUSIONS

Positive replication of previous single-subject experiments demonstrating the potential for successfully treating behaviour disorders in young children with TBI using a support-oriented intervention that combines behavioural, cognitive and executive function components.

Classifying psychiatric disorders after traumatic brain injury and orthopaedic injury in children: adequacy of K-SADS versus CBCL

PRIMARY OBJECTIVE

[corrected] To evaluate the convergence between the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) for the diagnosis of psychiatric disorders and the Child Behavior Checklist (CBCL).

RESEARCH DESIGN

Cross-sectional psychiatric study of 72 children with traumatic brain injuries or orthopaedic injuries aged 5-14.

METHODS AND PROCEDURES

Sensitivity, specificity, total predictive value and odds ratio were calculated to evaluate the association between CBCL summary scores and K-SADS diagnosis of at least one psychiatric disorder (K-SADS-1), and of CBCL subscales and K-SADS diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). Lowered cut-off scores of t > or = 60 were used.

MAIN OUTCOMES AND RESULTS

Convergence between the CBCL total problem scale and K-SADS-1 was poor. Convergence between 'at least one elevated CBCL subscale' and K-SADS-1, and between CBCL attention problems and social problems scales and K-SADS diagnosis of ADHD was excellent.

CONCLUSIONS

Caution is needed when using the total problem scale of CBCL in predicting global psychological impairment because underestimation of problems is likely. The attention and social problems scales of CBCL can be used to estimate ADHD.

Magnetic resonance imaging (MRI) findings and neuropsychological sequelae in children after severe traumatic brain injury: the role of cerebellar lesion

We studied the relationships between magnetic resonance imaging (MRI) findings and neuropsychological sequelae in children after severe traumatic brain injury. Twenty-three children ages 7-13 years underwent MRI assessment of brain lesion topography and volume and neuropsychological evaluations, more than 1 year after sustaining severe traumatic brain injury. Most children had lesions to the corpus callosum and frontal lobes. Total lesion volume and extent of cerebral atrophy did not impact on the neuropsychological evaluation. Additional relationships were observed: left frontal lesions with lower semantic verbal fluency, right occipital lesions with lower visual recognition task scores, dyscalculia with cerebellar lesions, and cerebellar damage with lower cognitive performances and lower visual recognition memory. This study demonstrates the significance of the cerebellum's role in neuropsychological outcomes after traumatic brain injury and the importance of the lesion depth classification in predicting functional results.

Pediatric brain injury: social, behavioral, and communication disability

Communication-related disability is common after childhood traumatic brain injury. In most cases, the problems are secondary to executive function, cognitive, or behavioral impairments. Many of the problems persist and have been documented in children with mild and severe injuries. Persistent disability tends to be more severe in children injured at younger ages and often grows in severity over the developmental years. After reviewing the outcome literature, this article presents current approaches to behavioral and social-communication disability.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-regulation and social and behavioral functioning following childhood traumatic brain injury

This study examined the impact of childhood traumatic brain injury (TBI) on self-regulation and social and behavioral functioning, and the role of self-regulation as a predictor of children's social and behavioral functioning. Participants included 65 children with moderate to severe TBI and 65 children without TBI, all between 6 and 11 years of age. Self-regulation and social and behavioral functioning were assessed 2 to 5 years following injury. Children with TBI displayed deficits in self-regulation and social and behavioral functioning, after controlling for socioeconomic status (SES), although the magnitude of the deficits was not related to injury severity. Self-regulation accounted for significant variance in children's social and behavioral functioning, after controlling for SES and group membership. Self-regulation may be an important determinant of children's social and behavioral functioning following TBI.

Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center

OBJECTIVE

To describe the results of an integrated pre- and in-hospital approach to critical care in a large population of children with severe traumatic brain injury and to identify the early predictors of their outcome.

DESIGN

A 9-yr retrospective review of the data of a trauma data bank.

SETTING

Level III pediatric trauma center.

PATIENTS

All children (1 month to 15 yrs) with severe traumatic brain injury (Glasgow Coma Scale </=8) hospitalized in our trauma center and followed until death or for >/=6 months after discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Univariate and further multivariate analyses were performed to determine independent predictive factors of death and outcome at discharge and 6 months later. The Glasgow Outcome Scale was used to evaluate outcome; a poor outcome referred to Glasgow Outcome Scale >/=3. Receiver operating characteristic curves were drawn to determine the threshold values of predictors of death and outcome. Analysis concerned 585 children (67% male and 33% female). Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were road traffic accidents and falls. Mean values for Glasgow Coma Scale, Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and 28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was <3 in 53% of the cases at discharge and 60% at 6 months. Multivariate analysis identified Glasgow Coma Scale, Injury Severity Score, and hypotension on arrival as independent predictors of death and poor outcome at discharge and at 6 months. Threshold values for death were 28 for Injury Severity Score and 5 for Glasgow Coma Scale. The same values were found for poor outcome, except for outcome at 6 months where threshold value for the Glasgow Coma Scale was 6.

CONCLUSIONS

Initial hypotension, Glasgow Coma Scale, and Injury Severity Score are independent predictors of outcome in children with traumatic brain injury. Threshold values can be calculated for predicting poor outcome. These variables can be easily and detected early in this population and used for quality assessment.

Severe outcome of children following trauma resulting from road accidents

OBJECTIVE

The aim of the study was to determine the risk factors of a severe outcome for children severely injured [killed or with an Injury Severity Score (ISS)>or=16] in a road accident.

MATERIALS AND METHODS

Casualties that occurred between 1996 and 2001 which involved children under 14 years of age were assessed in a population-based study based on data included in a French road trauma Registry. A severe traumatic brain injury (TBI) was defined as a head injury with an Abbreviated Injury Scale (AIS) severity score>or=3. A multivariate logistic regression was performed to quantify the risk of a "severe outcome" defined as death or an expected serious impairment 1 year later.

RESULTS

The annual incidence of an ISS of 16+ was 7.7 per 100,000 children. Among the 126 severely injured children included in this study, 40 died (including 16 immediate deaths), and a severe outcome was expected for 54 of the 86 survivors. Children with an "isolated severe TBI" and those with "multiple injuries including TBI" were more likely to have a severe outcome than those who had an "isolated severe injury without TBI" (OR: 7.91; 95%CI: 1.43-43.77 and OR: 8.37; 95%CI: 1.52-46.13, respectively). Age was inversely linked to a severe outcome. The unprotected motor vehicle occupants (MVO) had an odds ratio of 7.56 (95%CI: 1.07-53.56) compared to the protected MVO. Only 30% of children who survived a severe TBI were admitted to rehabilitation.

CONCLUSION

The mechanism of the injury, an injury pattern involving the head and a young age were associated with a severe outcome following a road accident. A majority of children severely injured were not referred to inpatient rehabilitation.

Response Inhibition After Traumatic Brain Injury (TBI) in Children: Impairment and Recovery

Children who experience traumatic brain injury (TBI) often show cognitive impairments postinjury, some of which recover over time. We examined the recovery of motor response inhibition immediately following TBI and over 2 years. We assessed the role of injury severity, age at injury, and lesion characteristics on initial impairment and recovery while considering the role of pre-injury psychiatric disorder. Participants were 136 children with TBI aged 5-16 years. Latency of motor response inhibition was measured with the stop-signal task within 1 month of the injury and again at 3, 6, 12, and 24 months. The performance of the TBI participants at each measurement occasion was standardized with 117 children of similar age, but without injury. Residualized latency scores were calculated. Growth curve analyses showed an initial impairment in response inhibition and improvement over the 2 years following injury. Younger TBI patients were initially more impaired although they exhibited greater recovery of response inhibition than did older TBI patients. Longer duration of coma, but not reactivity of pupils or Glasgow Coma Scale score, predicted initial deficit. Lesion characteristics or pre-injury attention deficit hyperactivity disorder did not predict initial impairment or recovery. Replication with longitudinal testing of a comparison group of children sustaining extracranial injury is necessary to confirm our findings.

Functional status after childhood traumatic brain injury

BACKGROUND

Identification of children after traumatic brain injury (TBI) likely to have functional deficits at trauma center discharge will facilitate care.

METHODS

Two logistic regression models were derived from data on 4,439 children after TBI 7 to 14 years old enrolled in the National Pediatric Trauma Registry between 1994 and 2001 to predict physical and cognitive disabilities.

RESULTS

Children with open or multiple fractures or closed fractures or injured by motor vehicles were 8.2, 3.5, or 2.5 times more likely, respectively, than those without those circumstances to have discharge physical disabilities. Likelihood of cognitive impairment was increased by factors of 3.2 and 5.8 in children obtunded or comatose on arrival. Preexisting cognitive deficits, injury severity, and intubation predicted physical and cognitive disabilities. The C statistic was 0.862 for the motor model and 0.860 for the cognitive model.

CONCLUSION

Predicting the likelihood of morbidity after acute management of childhood TBI can provide information pertinent to providing effective care.

Neuropsychological outcome of infant heart transplant recipients

OBJECTIVE

To assess long-term neuropsychological outcomes of infant heart transplant recipients.

STUDY DESIGN

Fifty-five children (mean age, 6.4 years) with a primary diagnosis of hypoplastic left heart syndrome or other cardiac disorders participated in the study. Six areas of risk were assessed (birth; preoperative, intraoperative, and postoperative status; long-term medical complications; and socioeconomic factors). Neuropsychological evaluations included the following: Wechsler Scales of Intelligence, Wechsler Individual Achievement Test, Berry Visual Motor Integration Scale, Comprehensive Evaluation of Language Function, and Achenbach Child Behavioral Checklist.

RESULTS

Intellectual functioning scores revealed a mean full-scale IQ of 81 +/- 19. Intraoperative and postoperative variables (bypass time, hospital course, and lowest posttransplant pH), long-term medical complications (serious infections and posttransplant surgical procedures), and socioeconomic factors were associated with cognitive functioning. Visual-motor functioning was also related to bypass and total support time.

CONCLUSIONS

Long-term outcomes reveal low-average neuropsychological functioning and are related to intrasurgical-postsurgical, long-term medical, and socioeconomic factors. The neuropsychological and psychosocial functioning of infant heart transplant recipients will be important to address as they mature during adolescence and adulthood.

Psychosocial outcome of TBI in children with unilateral frontal lesions

To evaluate effects of unilateral frontal lesions on psychosocial and global outcome of traumatic brain injury (TBI) in children, Study 1 compared matched groups of 22 school aged children who had sustained TBI either with or without unilateral frontal lesions. Study 2 evaluated effects of unilateral extrafrontal lesions in 18 TBI patients as compared with 18 nonlesional TBI patients. Communication, Daily Living, and Socialization domains and the Maladaptive Behavior Scale of the Vineland Adaptive Behavior Scales (VABS) were used to assess psychosocial outcome, and the Glasgow Outcome Scale (GOS) measured global outcome. All patients underwent magnetic resonance imaging at least 3 months post injury. Children with frontal lesions had worse scores on the Daily Living and Socialization domains and a higher frequency of maladaptive behavior than those without frontal lesions, but there was no difference in cognitive function. Disability was twice as common in the frontal lesion group relative to children without frontal lesions. Volume of frontal lesion was related to the Socialization domain. Side of lesion had no effect, nor did presence of an extrafrontal lesion (Study 2). Unilateral frontal lesions adversely affect late psychosocial outcome of TBI in children.

Does the child behavior checklist reveal psychopathological profiles of children with focal unilateral cortical lesions?

Psychopathological profiles were investigated in children with focal unilateral radiologically documented cortical lesions (15 right lesions and 22 left lesions). The 8 clinical subscales of the Child Behavior Checklist Parent Form (CBCL-P) and the Internalizing and Externalizing subscales were the dependent measures. The Internalizing and Externalizing scores did not dissociate as a function of lesion side. There were more Internalizing than Externalizing symptoms. Only the Attention Problems subscale yielded a significant difference as a function of lesion side; children with left lesions unexpectedly presented more problems. No significant differences were observed as a function offrontal versus nonfrontal lesion site, gender, or neurological variables on the Child Behavior Checklist (CBCL) subscales. Although sensitive to the presence of a focal lesion, the CBCL-P scarcely or misleadingly reflects any of the characteristics offocal unilateral cortical lesions in children. As suggested by the literature, most of the CBCL elevations in children with brain lesions could derive from the parent's and child's emotional response to any threatening medical condition.

Context-sensitive behavioral supports for young children with TBI: short-term effects and long-term outcome

OBJECTIVE

To investigate the effects of a multicomponent cognitive-behavioral intervention on the challenging behavior of two young children with growing behavioral concerns after traumatic brain injury.

DESIGN

Single-subject reversal designs were used to document the effects of the intervention on the specific dependent variables. In addition, qualitative data were collected to determine the children's long-term outcome and staff evaluations of the intervention.

PARTICIPANTS

Both children were normally developing before injury at age 5 years. Both experienced increasing behavior problems as expectations in school escalated.

MAIN OUTCOME MEASURES

Quantitative data included frequency and intensity of aggression and amount of work completed. Qualitative data included children's general engagement in school work and peer interaction and staff evaluations of the intervention.

INTERVENTION

The intervention included components of positive behavior supports, cognitive supports, and an executive function routine.

RESULTS

The targeted challenging behaviors were reduced to near zero with decreased intensity. Long-term outcome was positive.

CONCLUSIONS

These results illustrate the potential for successfully treating behavior disorders in young children with traumatic brain injury using a support-oriented intervention that combines behavioral and cognitive components.

Positive supports for people who experience behavioral and cognitive disability after brain injury: a review

BACKGROUND

Behavioral and cognitive problems are among the most common and troubling consequences of traumatic brain injury. Furthermore, behavioral and cognitive challenges typically interact in complex ways, necessitating an integrated approach to intervention and support.

OBJECTIVES

This article reviews literature on behavioral outcome in children and adults with traumatic brain injury, traditional approaches to behavioral intervention and cognitive rehabilitation, and the history, principles, and assessment and treatment procedures associated with context-sensitive, support-oriented approaches to behavioral and cognitive intervention. We propose a clinical framework that integrates cognitive and behavioral intervention themes.

Intensive positive behavior supports for adolescents with acquired brain injury: long-term outcomes in community settings

BACKGROUND

Based on the technologies of applied behavior analysis and person-centered planning, positive behavior support is a process for designing and implementing proactive behavioral interventions with the goal of positive lifestyle changes.

PARTICIPANTS

The two adolescents who received the intensive, longitudinal, multicomponent intervention had experienced escalating behavior challenges over several years after brain injury in early childhood.

MAIN OUTCOME MEASURES

Quantitative data included episodes of aggression and property destruction. Qualitative data included intensity of supports, family involvement, peer relationships, medication regime, vocational status, educational status, community access, and self-help skills.

RESEARCH DESIGN

A long-term, natural-environment, case-study method was used.

RESULTS

The targeted challenging behaviors were reduced to zero. In addition, the participants' domains of activity increased and self-management improved even as supports were systematically withdrawn.

CONCLUSIONS

These results illustrate the potential for successfully treating extreme chronic behavior disorders after childhood brain injury.

Long term psychosocial outcomes after mild head injury in early childhood

OBJECTIVES

The question of whether any adverse cognitive or psychosocial outcomes occur after mild head injury in early childhood has evoked considerable controversy. This study examined mild head injury before age 10 and potential differences in late childhood/early adolescence as a function of severity of mild injury and age at injury.

METHODS

A fully prospective longitudinal design tracked a large birth cohort of children. Confirmed cases of mild head injury before age 10 were divided on the basis of outpatient medical attention (n=64-84) or inpatient observation (hospital overnight; n=26-28 ) and compared with the non-injured remainder of the cohort (reference group; n=613-807). A range of pre-injury and post-injury child and family characteristics were used to control for any potential confounds. Outcome after injury before and after age 5 was also assessed.

RESULTS

After accounting for several demographic, family, and pre-injury characteristics, the inpatient but not the outpatient group displayed increased hyperactivity/inattention and conduct disorder between ages 10 to 13, as rated by both mothers and teachers. Psychosocial deficits were more prevalent in the inpatient subgroup injured before age 5. No clear effects were evident for various cognitive/academic measures, irrespective of severity of mild injury or age at injury.

CONCLUSIONS

Most cases of mild head injury in young children do not produce any adverse effects, but long term problems in psychosocial function are possible in more severe cases, perhaps especially when this event occurs during the preschool years. The view that all mild head injuries in children are benign events requires revision and more objective measures are required to identify cases at risk.

Health-related quality of life of children and adolescents after traumatic brain injury

OBJECTIVE

Relatively little is known about the longer-term impact of traumatic brain injury (TBI) on children's daily functioning, especially the broader outcome domain referred to as health-related quality of life (HRQL). The objective of the present study was to examine the nature and predictors of HRQL outcomes in children with moderate to severe TBI an average of 4 years postinjury.

METHODS

The study used a concurrent cohort-prospective design involving postinjury assessments of 3 groups of traumatically injured children and their families including 42 with severe TBI, 42 with moderate TBI, and 50 with orthopedic injuries only. Parent and child perceptions of HRQL and child adaptive behavior measures were obtained along with parent descriptions of the child's health problems and use of medical and mental health services. Predictors included indices of injury severity, social factors, and ratings of preinjury child behavior problems and school performance.

RESULTS

Based on parent report, adolescents who sustained severe TBI had lower HRQL related to overall psychosocial functioning and in the domains of behavior, mental health, general health, and family impact than adolescents who sustained orthopedic injuries only. Communication skills, daily living skills, and general adaptive functioning also were rated lower in the severe TBI group. In contrast to parent reports, adolescents with severe TBI did not rate their HRQL in most domains differently than did adolescents with orthopedic injuries. There were no group differences in frequency of persistent physical limitations. Sixty-seven percent of families of children with severe TBI used mental health counseling at some point after the injury. Risks for poorer HRQL outcomes were related to family social disadvantage and poorer preinjury child behavioral and academic functioning.

CONCLUSIONS

Findings underscore the importance of using comprehensive measures of HRQL, along with traditional indicators of functional outcomes, when evaluating the longer-term impact of injuries in children. Identification of predictors suggests the need for close monitoring and intervention of high-risk children.

A prospective study of short- and long-term outcomes after traumatic brain injury in children: behavior and achievement

Longitudinal behavior and achievement outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries not involving brain insult. Measures of preinjury child and family status and of postinjury achievement skills were administered shortly after injury. Assessments were repeated 3 times across a mean follow-up interval of 4 years. Results from mixed model analysis revealed persisting sequelae of TBI. Recovery of math skills was observed in the severe TBI group but only for children from less stressed families. Social disadvantage in children with TBI predicted more adverse behavioral sequelae and less favorable changes in some outcome measures. The findings suggest that pediatric TBI has long-term effects on behavior and achievement but that postinjury progress is influenced by the family environment.

Spontaneous facial expressivity in children with acquired brain injury

OBJECTIVES

To investigate spontaneous facial behavior during social interaction in children with acquired brain injury (ABI), and to explore possible links between ABI, facial expressivity, and caregiver-reported social competence.

DESIGN

Between-group comparisons using t tests, within-group comparisons using correlational analyses, correlational analyses of independent variables and outcome measures.

PARTICIPANTS

Sixteen school-aged children with ABI and 32 normally developing children of comparable age and gender.

MAIN OUTCOME MEASURE

Aspects of facial expressivity derived from coding scheme designed for this study.

RESULTS

Children with ABI were less expressive overall and tended to shift expressions less often than normally developing children. Several measures of expressivity were correlated with measures of social competence.

CONCLUSIONS

Brain injury inhibits production of some aspects of spontaneous facial expression. Results are suggestive of links between facial behavior and social skills.

An intervention for children with disorders of executive functions

This article describes a cognitive-behavioral approach to teaching metacognitive executive thinking strategies to children with disorders of executive function. The intervention is based on the notion that some children with disorders of executive function have disorders of higher level language, which predispose them to the executive impairments. It is proposed that teaching and reinforcing metacognitive thinking strategies may help advance verbal mediation of complex tasks and self-regulation of behavior. Despite the growing literature on developmental executive disorders, little has been written about interventions that may enable the children to acquire some of the requisite adaptive skills. The ideas expressed herein should be considered an invitation for the initiation of empirical studies of intervention and outcome effects.

Lifetime and novel psychiatric disorders after pediatric traumatic brain injury

OBJECTIVE

To assess lifetime and current psychiatric disorders at least 1 year after traumatic brain injury (TBI) in children and adolescents.

METHOD

Forty-six youths who sustained a TBI between the ages of 6 through 15 years were evaluated at least 1 year post-TBI to identify the presence of lifetime and/or novel psychiatric disorders. Semistructured interviews of the parent and child and standardized parent self-report rating instruments were used.

RESULTS

Attention-deficit/hyperactivity disorder and depressive disorders were the most common lifetime and novel diagnoses. A wide variety and high rate of novel psychiatric disorders were identified; 74% of these disorders persisted in 48% of the injured children. Internalizing disorders were more likely to resolve than externalizing disorders. Both interviews and parent ratings were sensitive to current externalizing behaviors; interviews more often detected internalizing disorders, whereas parent ratings also identified cognitive difficulties.

CONCLUSIONS

Findings were generally consistent with previous research demonstrating the high rate of novel psychiatric disorders following pediatric TBI. Psychiatric interviews were sensitive in identifying both lifetime and novel disorders.

Ecological validity of neuropsychological assessment in childhood traumatic brain injury

Empirical investigation of the degree to which testing predicts children's real-world functioning following traumatic brain injury (TBI) is sparse. This article reviews the research in neuropsychology, which offers only moderate correlations between test scores and everyday functioning. This line of research is hindered by several methodological issues: difficulty translating performance on standardized testing into real-world capacities, measurement of real-world functioning, developmental factors, and the influence of intervening variables in the natural environment. Ecologically valid assessment may require multiple data sources. More research is needed to respond effectively to questions about children's everyday functioning after traumatic brain injury.

Neuroimaging in pediatric traumatic head injury: diagnostic considerations and relationships to neurobehavioral outcome

Contemporary neuorimaging techniques in child traumatic brain injury are reviewed, with an emphasis on computerized tomography (CT) and magnetic resonance (MR) imaging. A brief overview of MR spectroscopy (MRS), functional MR imaging (fMRI), single-photon emission computed tomography (SPECT), and magnetoencephalography (MEG) is also provided because these techniques will likely constitute important neuroimaging techniques of the future. Numerous figures are provided to illustrate the multifaceted manner in which traumatic deficits can be imaged and the role of neuroimaging information as it relates to TBI outcome.

Severe head injury in children: impact of risk factors on outcome

BACKGROUND

Outcome after severe head injury has been shown in some studies to be more favorable in children than in adults. Mortality rates reported range between 20% and 40% for children. Only contradicting data are available regarding the impact of trauma modalities on long-term outcome, or the relative influence of head fractures, intracranial hemorrhages, and brain edema on survival or neurologic sequelae in children.

METHODS

A retrospective study in a tertiary care facility of long-term outcome of children after severe head injury, and analysis of risk factors for poor outcome. All children up to 16 years of age with severe head injury (Glasgow Coma Scale [GCS] score < or = 8), which have been treated in the pediatric intensive care unit from 1977 until 1994 in a single institution.

RESULTS

A total of 150 children with severe head injury (GCS score < or = 8) were treated, 92 of them (61.3%) had traffic-related injuries. The median age was 6.6 years (SD +/- 3.6). There were 96 boys (64%) and 54 girls (36%). Sixty-five children (43.3%) had skull fractures, 87 patients (58.0%) developed an intracranial hemorrhage, and 79 patients (52.7%) developed a diffuse brain swelling/edema visible in computed tomographic scans within 72 hours after trauma. Of 150 children treated, 33 died (22%). In most cases, death was related to the development of secondary brain edema. Fifty-nine children (39.3%) had severe neurologic impairments at the time of discharge. The most significant risk factors for adverse outcome, shown by multivariate analysis, were primary areflexia and secondary brain edema. The risk for development of brain edema and poor prognosis was well predicted by the GCS score.

CONCLUSION

The overall death rate in this study of children with severe head injury was low (22%) compared with other studies. However, the incidence of severe neurologic impairment at discharge remained high. The major risks for death or neurologic impairment were primary areflexia and the development of secondary brain swelling/edema, indicated by a low GCS score.

Adaptive functioning following traumatic brain injury and orthopedic injury: a controlled study

OBJECTIVE

To study adaptive functioning after severe traumatic brain injury (TBI).

DESIGN

Case-control study.

SETTING

A university hospital and three regional and four community hospitals.

SUBJECTS

A consecutive series (n=24) of children age 5 through 14 years who suffered severe TBI were individually matched to subjects who sustained a mild TBI and to a second group who sustained an orthopedic injury with no evidence of TBI.

MAIN OUTCOME MEASURES

Standardized adaptive functioning, intellectual, psychiatric, and neuroimaging assessments were conducted on average 2 years after injury.

RESULTS

Severe TBI was associated with significantly (p < .05) lower Vineland Adaptive Behavior composite, communication, and socialization standard scores and lower Child Behavior Checklist parent-rated social competence scores compared with children with orthopedic injury. Severe TBI and mild TBI subjects were significantly (p < .05) more impaired than orthopedic subjects on teacher-rated adaptive function. Family functioning, psychiatric disorder in the child, and IQ were significant variables, explaining between 22% and 47% of the variance in adaptive functioning outcomes.

CONCLUSIONS

Severe TBI is associated with significant deficits in child adaptive functioning. This association appears to be mediated by family dysfunction, child psychiatric disorder, and intellectual deficits.

Magnetic resonance imaging in relation to functional outcome of pediatric closed head injury: a test of the Ommaya-Gennarelli model

OBJECTIVE

To characterize late neuropathological findings of pediatric closed head injury (CHI), to assess depth of brain lesion in relation to acute severity, and to assess long-term outcome to test the Ommaya-Gennarelli model.

METHODS

Magnetic resonance imaging (MRI) at least 3 months postinjury in a prospective sample (n 5 169) and at least 3 years after CHI in a retrospective sample (n 5 82) was studied. Lesion volume was measured by planimetry. Acute CHI severity was measured by the Glasgow Coma Scale. Patients were classified according to the depth of the deepest parenchymal lesion into no lesion, subcortical, and deep central gray/brain stem groups. The outcomes were assessed by the Glasgow Outcome Scale and the Vineland Adaptive Behavior Scale, which were performed at the time of the MRI in the retrospective sample and up to 3 years postinjury in the prospective sample.

RESULTS

Focal brain lesions were present in 55.4% of the total sample. Depth of brain lesion was directly related to severity of acute impairment of consciousness and inversely related to outcome, as measured by both the Glasgow Outcome Scale and the Vineland Adaptive Behavior Scale. A rostrocaudal gradient of hemispheric lesion frequency was observed, whereas the posterior lesions of the corpus callosum were particularly common. Total lesion volume could not explain the depth of lesion effect.

CONCLUSION

Our findings extend support for the Ommaya-Gennarelli model to pediatric CHI, indicating that depth of brain lesion is related to functional outcome. The relative frequency of focal brain lesions revealed by late MRI is higher than that of previous findings using acute computed tomography. Future investigations could explore whether depth of lesion observed using late MRI is sensitive to neuroprotective interventions.