Caregiver report of social-emotional functioning in infants and young children after inflicted traumatic brain injury

Social-emotional difficulties are common sequelae of traumatic brain injury (TBI). Children who have experienced inflicted TBI (iTBI) may be at increased risk for social-emotional problems due to the risk factors associated with both early neurologic injury and with child maltreatment. We characterized the associations among injury severity, caregiver type (i.e., biological parents, non-kinship, kinship), and child social-emotional functioning in 41 infants and young children who had sustained iTBI and were seen in a large, regional children's hospital. This study was a retrospective analysis, utilizing data collected from the medical record as part of routine clinical care. Social-emotional functioning was assessed with the Bayley Scales of Infant and Toddler Development-Third Edition. Children with more severe injuries were rated as having worse social-emotional functioning. Caregiver type was associated with child social-emotional scores, above and beyond injury and demographic predictors. Biological parents were more likely to report better social-emotional skills than non-kinship caregivers, with the pattern of results suggesting that rater bias plays a role in this difference. In order to ensure that children are accurately identified for supports, these relationships should be considered when interpreting caregiver report of social-emotional skills.

Cumulative Febrile, Respiratory, and Gastrointestinal Illness Among Infants in Rural Guatemala and Association With Neurodevelopmental and Growth Outcomes

BACKGROUND

Infectious disease exposures in early life are increasingly recognized as a risk factor for poor subsequent growth and neurodevelopment. We aimed to evaluate the association between cumulative illness with neurodevelopment and growth outcomes in a birth cohort of Guatemalan infants.

METHODS

From June 2017 to July 2018, infants 0-3 months of age living in a resource-limited region of rural southwest Guatemala were enrolled and underwent weekly at-home surveillance for caregiver-reported cough, fever, and vomiting/diarrhea. They also underwent anthropometric assessments and neurodevelopmental testing with the Mullen Scales of Early Learning (MSEL) at enrollment, 6 months, and 1 year.

RESULTS

Of 499 enrolled infants, 430 (86.2%) completed all study procedures and were included in the analysis. At 12-15 months of age, 140 (32.6%) infants had stunting (length-for-age Z [LAZ] score < -2 SD) and 72 (16.7%) had microcephaly (occipital-frontal circumference [OFC] < -2 SD). In multivariable analysis, greater cumulative instances of reported cough illness (beta = -0.08/illness-week, P = 0.06) and febrile illness (beta = -0.36/illness-week, P < 0.001) were marginally or significantly associated with lower MSEL Early Learning Composite (ELC) Score at 12-15 months, respectively; there was no association with any illness (cough, fever, and/or vomiting/diarrhea; P = 0.27) or with cumulative instances of diarrheal/vomiting illness alone ( P = 0.66). No association was shown between cumulative instances of illness and stunting or microcephaly at 12-15 months.

CONCLUSIONS

These findings highlight the negative cumulative consequences of frequent febrile and respiratory illness on neurodevelopment during infancy. Future studies should explore pathogen-specific illnesses, host response associated with these syndromic illnesses, and their association with neurodevelopment.

Let's Stop Complaining That Early Childhood Assessments Do Not Predict IQ

This Viewpoint discusses the concern about the long-term predictive validity of early childhood development (ECD) assessments and how this concern reflects a misunderstanding of the constructs of ECD and intelligence, how they are assessed, and the myriad of other influences on the growth and trajectory of intellectual ability in children.

The influence of sociodemographic factors and response style on caregiver report of infant developmental status

Caregiver report is the most feasible way to assess early childhood development but is susceptible to the influences of response style and sociodemographic factors. In a sample of 571 caregiver-infant dyads (47.8% female; 48% White), we compared caregiver reports on the Ages and Stages Questionnaire-Third Edition (ASQ-3) with reports on a novel, web-based assessment, PediaTrac™. Ratings on PediaTrac correlated with ratings on the ASQ-3 at all time points (2, 4, 6, and 9 months). Caregiver age, response style, and sociodemographic factors accounted for significant variance on both measures. Developmental reporting of early childhood skills is influenced by caregiver response style and sociodemographic factors. These influences must be considered in order to ensure the accurate identification of infant developmental status.

Caregiver rating of early childhood development: Reliability and validity of the ASQ-3 in rural Guatemala

BACKGROUND

Although performance-based assessment of early childhood development is preferred, there are a number of limitations to this methodology in low resource settings (LRSs). Hence, clinicians and researchers often rely on caregiver report screening tools. The Ages and Stages Questionnaire 3 (ASQ) is one of the most widely used caregiver report measures globally. Adequate psychometric properties have been demonstrated in high income settings, especially when used in older children, high- risk children, or those with severe neurodevelopmental delays. However, its utility is more variable within very young children and for use in LRSs.

METHODS

The reliability and validity of the ASQ was determined for children ages 0-5 years living in rural Guatemala. Internal consistency and test-retest reliability were assessed, as well as concurrent and predictive validity. Sensitivity, specificity, positive and negative predictive values related to performance-based developmental assessment (Mullen Scales of Early Learning; MSEL) and growth status (i.e. stunting) were also calculated.

RESULTS

Internal consistency reliability for the ASQ was adequate, except when results were limited by small sample size. Test-retest reliability ranged from low to moderate (r = 0.08-0.43; p < 0.05-0.01). However, there was significant variability in mean scores over time across ASQ domain scores. In terms of validity, the ASQ did not discriminate adequately between children who performed within or below age-expectations on performance-based developmental testing or those with and without stunting.

CONCLUSIONS

The ASQ did not demonstrate adequate psychometric properties in rural Guatemala, consistent with concerns documented in other LRSs. These results indicate that existing caregiver report screening measures of early childhood development should be utilized with caution in LRSs, and alternative methods for assessment or in the development and utilization of caregiver report measures should be considered.

Parent Report of Health Related Quality of Life in Young Children in Rural Guatemala: Implementation, Reliability, and Validity of the PedsQL in Stunting and Wasting

In this study, we review the implementation, reliability, and validity of the Pediatric Quality of Life Inventory (PedsQL), a measure of health-related quality of life, in young children in rural Guatemala. Mothers of 842 children (age range = 1-60 months) completed the PedsQL Generic Core Scales 4.0 serially for 1 year. Low (Pearson’s r = 0.28, P < .0001) to moderate (Pearson’s r = 0.65, P < .0001) consistency in responding over time was shown. The PedsQL did not discriminate reliably between healthy children and those with stunting or wasting. PedsQL scores were not lower during the time of an acute illness. While we found low to moderate evidence for the reliability of the PedsQL in healthy children, it did not discriminate between healthy children and those with stunting, wasting or other acute illness.

Reliability and Validity of an Adapted and Translated Version of the Mullen Scales of Early Learning (AT-MSEL) in Rural Guatemala

BACKGROUND

A growing literature base supports the use of tests developed in high-income countries to assess children in low resource settings when carefully translated, adapted, and applied. Evaluation of psychometric properties of adapted and translated measures within populations is necessary. The current project sought to evaluate the reliability and validity of an adapted and translated version of the Mullen Scales of Early Learning (AT-MSEL) in rural Guatelama.

METHODS

The reliability and validity of the AT-MSEL in rural Guatemala were analyzed for children ages 0-5 years.

RESULTS

Interrater reliability coefficients (ICC = 0.99-1.0) and internal consistency (Cronbach's alpha = 0.91-0.93) were excellent for all subscales. General linear models utilizing paired data showed consistency between standard scores (p < 0.0001). Mean raw scores increased with chronological age, as expected. Across age groups, subscales were significantly, positively correlated with one another (p < 0.05 - < 0.001) with one exception, visual reception and expressive language at the 0-10 month age range (p = 0.43).

CONCLUSIONS

The AT- MSEL showed strong psychometric properties in a sample of young children in rural Guatemala. Findings demonstrate that the AT-MSEL can be used validly and reliably within this specific population of children. This work supports the concept that tests developed in high-income countries can be used to assess children in low resource settings when carefully translated, adapted and applied.

Responding to the Zika Epidemic: Preparation of a Neurodevelopmental Testing Protocol to Evaluate Young Children in Rural Guatemala

The ongoing Zika virus (ZIKV) epidemic in Latin America presented a unique opportunity to develop a neurodevelopmental assessment protocol for children in a lower middle-income country. Although studies of neurodevelopment in young children have taken place in many diverse global settings, we are not aware of any study that has provided a high level of detail about how a measure was selected and then specifically translated and adapted in a low-resource setting. Here, we describe considerations in measurement selection and then the process of translation and adaptation to assess neurodevelopmental outcomes of infants and young children with postnatal exposure to ZIKV in rural Guatemala. We provide a framework to other research teams seeking to develop similar assessment models across the globe.

Performance of Young Children in Rural Guatemala on the Mullen Scales of Early Learning

Objective

The literature supports using tests developed in high-income countries to assess children in low and lower-middle income countries (LMICs) when carefully translated, adapted, and applied (Holding et al., 2018; Mitchell et al., 2017). Research has shown the Mullen Scales of Early Learning (MSEL) to have adequate validity and sensitivity when used in LMICs (Bangirana et al., 2014; Koura et al., 2013), as well as equivalency to the American normative sample in lower risk populations (Bornman et al., 2010). Here, we describe the pattern of MSEL results in rural Guatemala.

Participants and Method

Children (n = 842; M enrollment age = 15.9 months; range 0-5 years) enrolled in an observational study of postnatal Zika exposure in rural Guatemala were administered an adapted and translated version of the MSEL (Connery et al., in press). To date, 352 children completed one, 393 children completed two, and 97 children completed three MSELs, for a total of 1,429 administrations.

Results

MSEL composite scores were similar to the American normative sample in children &lt;12 months (M = 93.3, SD = 11.1), but lower for children ages 1-5 years (mean = 71.1, SD = 15.1, p &lt; 0.0001). Moreover, lower scores were observed in children ages 1-5 years for all MSEL subscales, with the largest differences observed in receptive language (&lt;12 years: mean = 47.8, SD = 7.1; 1-5 years: mean = 35.1, SD = 10.0, p &lt; 0.0001).

Conclusions

Results are consistent with research that demonstrates a widening gap in test performance over time between children from higher and lower risk communities (Fernald et al., 2011; Paxson et al., 2005; Schady et al., 2015). Although findings are not meant to diagnose individual children, they highlight population changes in neurodevelopmental skills and the need for a better understanding of developmental patterns in LMICs. Future analyses will evaluate the impact of developmental risk factors over time and the performance of the MSEL in this population.

References

Bangirana, P., Opoka, R. O., Boivin, M. J., Idro, R., Hodges, J. S., Romero, R. A., … John, C. C. (2014). Severe Malarial Anemia is Associated With Long-term Neurocognitive Impairment. Clinical Infectious Diseases, 59(3), 336–344. https://doi.org/10.1093/cid/ciu293. Bornman, J., Sevcik, R. A., Romski, M., & Pae, H. K. (2010). Successfully Translating Language and Culture when Adapting Assessment Measures, ppi_254 111.118. Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1741-1130.2010.00254.x. Fernald, L. C. H., Weber, A., Galasso, E., & Ratsifandrihamanana, L. (2011). Socioeconomic gradients and child development in a very low income population: Evidence from Madagascar. Developmental Science, 14(4), 832–847. https://doi.org/10.1111/j.1467-7687.2010.01032.x. Holding, P., Anum, A., van de Vijver, F. J. R., Vokhiwa, M., Bugase, N., Hossen, T., … Gomes, M. (2018). Can we measure cognitive constructs consistently within and across cultures? Evidence from a test battery in Bangladesh, Ghana, and Tanzania. Applied Neuropsychology: Child, 7(1), 1-13 https://doi.org/10.1080/21622965.2016.1206823. Koura, K. G., Boivin, M. J., Davidson, L. L., Ouédraogo, S., Zoumenou, R., Alao, M. J., … Bodeau-Livinec, F. (2013). Usefulness of child development assessments for low-resource settings in francophone Africa. Journal of Developmental and Behavioral Pediatrics : JDBP, 34(7), 486–93. https://doi.org/10.1097/DBP.0b013e31829d211c. Mitchell, J. M., Tomlinson, M., Bland, R. M., Houle, B., Stein, A., & Rochat, T. J. (2017). Confirmatory factor analysis of the Kaufman assessment battery in a sample of primary school-aged children in rural South Africa. South African Journal of Psychology, 1–19. https://doi.org/10.1177/0081246317741822. Paxson, C., Schady, N., Izquierdo, S., León, M., Lucio, R., Ponce, J., … Hall, W. (2005). Cognitive Development among Young Children in Ecuador The Roles of Wealth, Health, and Parenting. Retrieved from http://econ.worldbank.org. Schady, N., Behrman, J., Araujo, M. C., Azuero, R., Bernal, R., Bravo, D., … Vakis, R. (2015). Wealth gradients in early childhood cognitive development in five Latin American countries. The Journal of Human Resources, 50(2), 446–463. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25983344.

Receptive language skills among young children in rural Guatemala: The relationship between the Test de Vocabulario en Imagenes Peabody and a translated and adapted version of the Mullen Scales of Early Learning

BACKGROUND

Children in low- and lower middle income countries (LMICs) often have poorer language skills compared with children from high-income countries. Limited availability of culturally and linguistically appropriate assessment measures in LMICs, especially for young children, can hinder early identification and prevention efforts. Here, we describe receptive language (RL) skills among young children in rural Guatemala and report on the validity of a translated and culturally adapted developmental measure of RL.

METHODS

Children (n = 157; m = 53.6 months, range = 42-68 months) enrolled in a prospective cohort study of postnatally acquired Zika virus infection were administered the Test de Vocabulario en Imagenes Peabody (TVIP) and the RL scale from a translated and adapted version of the Mullen Scales of Early Learning (MSEL). Performance on the TVIP was compared with the Latin American normative sample. Correlational analysis examined the relationship between performance on the TVIP and the MSEL-RL.

RESULTS

Mean scores were significantly below the normative sample mean on the TVIP, t(126) = -11.04, p < .001; d = 1.00. Performance on the TVIP among children who passed the practice items (n = 127) was significantly positively associated with performance on the MSEL-RL (r = .50, p < .001), but not significantly associated with age or gender. Older age (p < .0001) and female gender (p = .018) were associated with passing the TVIP practice items.

CONCLUSIONS

Delays in RL vocabulary were identified among young children in rural Guatemala on the TVIP. The association between scores on the TVIP and the RL scale of the MSEL provides preliminary support for the construct validity of this translated and adapted version of the MSEL.

Preinjury Emotional-Behavioral Functioning of Children With Lingering Problems After Mild Traumatic Brain Injury

This study aimed to characterize preinjury emotional-behavioral functioning in pediatric patients with lingering problems after mild traumatic brain injury (TBI). The clinical case series design included 278 patients 8-17 years old. Parents retrospectively rated children's preinjury emotional-behavioral functioning on a broadband questionnaire. The rate of clinically significant preinjury anxiety was elevated compared with national norms. The number of previous TBIs was associated with clinically significant preinjury externalizing problems, suggesting a link between externalizing disorders and mild TBI exposure. Premorbid emotional-behavioral difficulties may play an important role in the establishment or maintenance of lingering symptoms after pediatric mild TBI.

The impact of pediatric neuropsychological consultation in mild traumatic brain injury: a model for providing feedback after invalid performance

OBJECTIVE

In recent years, pediatric practitioners have increasingly recognized the importance of objectively measuring performance validity during clinical assessments. Yet, no studies have examined the impact of neuropsychological consultation when invalid performance has been identified in pediatric populations and little published guidance exists for clinical management. Here we provide a conceptual model for providing feedback after noncredible performance has been detected. In a pilot study, we examine caregiver satisfaction and postconcussive symptoms following provision of this feedback for patients seen through our concussion program.

METHODS

Participants (N = 70) were 8-17-year-olds with a history of mild traumatic brain injury who underwent an abbreviated neuropsychological evaluation between 2 and 12 months post-injury. We examined postconcussive symptom reduction and caregiver satisfaction after neuropsychological evaluation between groups of patients who were determined to have provided noncredible effort (n = 9) and those for whom no validity concerns were present (n = 61).

RESULTS

We found similarly high levels of caregiver satisfaction between groups and greater reduction in self-reported symptoms after feedback was provided using the model with children with noncredible presentations compared to those with credible presentations.

CONCLUSION

The current study lends preliminary support to the idea that the identification and communication of invalid performance can be a beneficial clinical intervention that promotes high levels of caregiver satisfaction and a reduction in self-reported and caregiver-reported symptoms.

A Pilot Study Investigating Neuropsychological Consultation as an Intervention for Persistent Postconcussive Symptoms in a Pediatric Sample

OBJECTIVE

To examine the efficacy of a one-time neuropsychological consultation as an intervention for youth with persistent postconcussive symptoms following mild traumatic brain injury.

STUDY DESIGN

Using a prospective interrupted time series design, we enrolled 80 patients aged 8-17 years referred consecutively for clinical neuropsychological consultation. Patients needed to have sustained injury between 2 and 12 months prior to enrollment. Parent and child postconcussive symptom ratings were used as the primary outcome measures and were collected at 6 time points, 3 before the neuropsychological consultation and 3 after. Repeated measure ANOVA was used to estimate the magnitude of change in symptom ratings before and after the neuropsychological intervention.

RESULTS

The decrease in symptoms for the week prior to consultation was nonsignificant by both child (P = .63) and parent (P = .19) report. In contrast, for both reporters, the decrease in symptoms at 1 week and 3 months postconsultation was significant (P < .0001). The difference in reported change was also significant when comparing the week before the intervention to the 3 months after (child: P < .0001; parent: P = .0009).

CONCLUSIONS

Postconcussive symptoms decreased significantly following the neuropsychological consultation. The primary limitation of the study is that it lacked randomization and a control group. The results warrant further research into the benefits of neuropsychological consultation after mild traumatic brain injury and provide justification for clinical providers to consider referring to neuropsychologists in the face of persistent postconcussive symptoms.

Parent satisfaction with neuropsychological consultation after pediatric mild traumatic brain injury

Few studies have focused on consumer satisfaction following neuropsychological evaluation. We sought to examine parent satisfaction with neuropsychological consultation following a mild traumatic brain injury (TBI) in school-age children. We surveyed 71 parents of 8- to 17-year-olds participating in a prospective longitudinal study examining neuropsychological consultation as an intervention for persistent postconcussive symptoms. Children had sustained injuries between 2 and 12 months prior to enrollment. Neuropsychological consultation occurred on average 5 months post-injury. Parent satisfaction data were collected via telephone approximately 4 months after the neuropsychological consultation. The vast majority of parents were quite satisfied with the service (e.g., 94% overall satisfaction rate; 96% rated the service as good or excellent). Satisfaction rates were associated positively with time since injury and negatively with parental education. No other child, parent, or provider variable correlated with satisfaction. The results add to the relatively sparse literature on parent satisfaction with neuropsychological evaluation. A pressing future need in pediatric neuropsychology is to examine the satisfaction of other consumers of the service, including healthcare personnel, educators, and the child patients themselves.

The relationship between initial physical examination findings and failure on objective validity testing during neuropsychological evaluation after pediatric mild traumatic brain injury

Background:

The symptomatology after mild traumatic brain injury (mTBI) is complex as symptoms are subjective and nonspecific. It is important to differentiate symptoms as neurologically based or caused by noninjury factors. Symptom exaggeration has been found to influence postinjury presentation, and objective validity tests are used to help differentiate these cases. This study examines how concussed patients seen for initial medical workup may present with noncredible effort during follow-up neuropsychological examination and identifies physical findings during evaluation that best predict noncredible performance.

Hypothesis:

A portion of pediatric patients will demonstrate noncredible effort during neuropsychological testing after mTBI, predicted by failure of certain vestibular and cognitive tests during initial examination.

Study Design:

Retrospective cohort.

Level of Evidence:

Level 4.

Methods:

Participants (n = 80) underwent evaluation by a sports medicine physician ≤3 months from injury, were subsequently seen for a neuropsychological examination, and completed the Medical Symptom Validity Test (MSVT). Variables included results of a mental status examination (orientation), serial 7s examination, Romberg test, and heel-to-toe walking test. The primary outcome variable of interest was pass/fail of the MSVT.

Results:

Of the participants, 51% were male and 49% were female. Eighteen of 80 (23%) failed the MSVT. Based on univariable logistic regression analysis, the outcomes of the Romberg test (P = 0.0037) and heel-to-toe walking test(P = 0.0066) were identified as significant independent predictors of MSVT failure. In a multivariable model, outcome of Romberg test was the only significant predictor of MSVT failure. The probability of MSVT failure was 66.7% (95% CI, 33.3% to 88.9%) when a subject failed the Romberg test.

Conclusion:

A meaningful percentage of pediatric subjects present evidence of noncredible performance during neuropsychological examination after mTBI. Initial examination findings in some cases may represent symptom exaggeration.

Postconcussive symptom exaggeration after pediatric mild traumatic brain injury

BACKGROUND

A minority of pediatric patients who have mild traumatic brain injury (mTBI) report persistent postconcussive symptoms. In adults, failure on validity tests, which help to detect exaggerated or feigned problems, is associated with symptom complaints. No pediatric studies have examined the relationship between validity test performance and symptom report. We hypothesized that children failing a validity test would report significantly more postconcussive symptoms than those passing.

METHODS

Using a consecutive clinical case series design, we examined 191 patients aged 8 to 17 years seen for neuropsychological evaluation after mTBI. Participants were administered a validity test (Medical Symptom Validity Test; MSVT) and completed a graded symptom scale as part of a neuropsychological battery.

RESULTS

A total of 23 participants (12%) failed the MSVT. The Fail group endorsed significantly more postconcussive symptoms than the Pass group, with a large effect size (P < .001; d = 1.1). MSVT performance remained a robust unique predictor of symptom report even after controlling for other influential factors (eg, female gender, premorbid psychiatric problems).

CONCLUSIONS

A subset of children who had persistent complaints after mTBI may be exaggerating or feigning symptoms. If such negative response bias remains undetected, errors in etiologic statements and less than optimal treatment may occur. Because the detection of invalid responding is well established in neuropsychology, clinical neuropsychologists should be incorporated routinely into clinical care for patients who have persistent complaints. To better control for noninjury effects in future pediatric mTBI studies, researchers should add validity tests to neurobehavioral outcome batteries.

The effects of multiple mild traumatic brain injuries on acute injury presentation and neuropsychological recovery in children

BACKGROUND

Although research focused on mild traumatic brain injury (mTBI) has proliferated in recent years, few studies have examined the significance of a previous history of mTBI in children.

OBJECTIVE

To compare the acute injury presentation and neuropsychological recovery in a pediatric sample after mTBI.

METHODS

Participants 8 to 16 years of age were divided into 4 groups: no previous injury history, history of 1 mTBI, history of 2 mTBIs, and history of ≥ 3 mTBIs. Participants were evaluated within 3 months of the most recent injury by clinical interview and an abbreviated neuropsychological test battery.

RESULTS

After the index mTBI, the groups did not differ in their likelihood to display a loss of consciousness, nor did they differ on neuropsychological test performance.

CONCLUSION

Overall, contrary to our hypotheses, we found no demonstrable difference between those children with a self-reported mTBI history and those without after an index mTBI.

The Relationship Between the Self-Report BASC-2 Validity Indicators and Performance Validity Test Failure After Pediatric Mild Traumatic Brain Injury

In adult populations, research on methodologies to identify noncredible performance and exaggerated symptoms during neuropsychological evaluations has grown exponentially in the past two decades. Far less work has focused on methods appropriate for children. Although several recent studies have used stand-alone performance validity tests with younger populations, a near absence of pediatric work has investigated other indices to identify response bias. The present study examined the relationship between the validity scales from the self-report Behavior Assessment System for Children, Second Edition (BASC-2) and performance on the Medical Symptom Validity Test (MSVT), a stand-alone performance validity test. The sample consisted of 274 clinically referred patients with mild traumatic brain injuries aged 8 through 17 years. Fifty patients failed the MSVT based on actuarial criteria. The majority of these patients (92%) provided valid self-report BASC-2 profiles, with only three patients (6%) producing an invalid profile due to an elevated F index. Analysis of valid/invalid self-report BASC-2 profiles and MSVT pass/fail did not reveal a significant relationship ( p = 0.471, two-tailed Fisher’s exact test). These findings suggest that performance validity tests like the MSVT provide substantively different information about the validity of a neuropsychological profile than that provided by the self-report validity scales of the BASC-2.