Age at injury and long-term behavior problems after traumatic brain injury in young children

Objective: This study examined the effects of age at injury on the persistence of behavior problems and social skill deficits in young children with complicated mild to severe traumatic brain injury (TBI). Method: A concurrent cohort/prospective research design was used with repeated assessments of children with TBI (n = 82) or Orthopedic Injury (OI) (n = 114). Parents completed the Child Behavior Checklist, the Behavior Rating Inventory of Executive Functions, and the Preschool and Kindergarten Behavior Scales or the Home and Community Social and Behavior Scales shortly after injury to assess preinjury functioning, and at an extended follow-up an average of 38 months postinjury. Generalized linear modeling was used to examine the relationship of age at injury to the maintenance of behavior problems, and logistic regression was used to examine the persistence of clinically significant behavior problems. Results: At the extended follow-up, severe TBI was associated with significantly greater anxiety problems relative to the Group OI. With increasing time since injury, children who sustained a severe TBI at an earlier age had significantly higher levels of parent-reported symptoms of ADHD and anxiety than children who were older at injury. Conclusions: Findings suggest that longer-term treatment for behavior problems may be needed after severe TBI, particularly for those injured at an earlier age. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

A preliminary study of a traumatic injury prevention program

Abstract

This study examined the long-term impact of a five component spinal cord injury prevention program presented to adolescents. A sample of 445 teenagers who attended a junior high school in which an educational intervention was presented three years earlier and a control group of 379 students who had not been exposed to the intervention completed a questionnaire assessing their safety knowledge, attitudes, and self-reported behaviors. Total scores on the questionnaire between treatment and control groups differed significantly. Students in the treatment group reported significantly more frequent seat belt use, stronger belief that seat belts were important to their safety, lower likelihood of riding with friends who had been drinking, higher rates of friends' use of seat belts, greater awareness of the age group most likely to be injured, and increased knowledge that they could prevent spinal cord injury.     

Response inhibition in children with and without ADHD after traumatic brain injury

Children with attention‐deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) show deficient response inhibition. ADHD itself is a common consequence of TBI, known as secondary ADHD (S‐ADHD). Similarity in inhibitory control in children with TBI, S‐ADHD, and ADHD would implicate impaired frontal‐striatal systems; however, it is first necessary to delineate similarities and differences in inhibitory control in these conditions. We compared performance of children with ADHD and those with TBI without pre‐injury ADHD on a stop signal, response inhibition task. Participants were 274 children aged 6–14 years. There were 92 children with ADHD, 103 children with TBI, and 79 typically developing children who served as controls. Among the TBI participants, injury severity ranged from mild to severe. Children with ADHD and TBI showed deficient inhibition. The deficit in children with ADHD was as great as or greater than that in children with TBI, regardless of degree of TBI severity or the presence of S‐ADHD. The finding indicates that TBI results in deficient inhibition regardless of the development of S‐ADHD.     

Electrophysiological correlates of emotional face processing after mild traumatic brain injury in preschool children

Evidence suggests that social skills are affected by childhood mild traumatic brain injury (mTBI), but the neural and affective substrates of these difficulties are still underexplored. In particular, nothing is known about consequences on the perception of emotional facial expressions, despite its critical role in social interactions and the importance of the preschool period in the development of this ability. This study thus aimed to investigate the electrophysiological correlates of emotional facial expressions processing after early mTBI. To this end, 18 preschool children (mean age 53 ± 8 months) who sustained mTBI and 15 matched healthy controls (mean age 55 ± 11 months) were presented with pictures of faces expressing anger, happiness, or no emotion (neutral) while event-related potentials (ERP) were recorded. The main results revealed that P1 amplitude was higher for happy faces than for angry faces, and that N170 latency was shorter for emotional faces than for neutral faces in the control group only. These findings suggest that preschool children who sustain mTBI do not present the early emotional effects that are observed in healthy preschool children at visuospatial and visual expertise stages. This study provides new evidence regarding the consequences of childhood mTBI on socioemotional processing, by showing alterations of emotional facial expressions processing, an ability known to underlie social competence and appropriate social interactions.     

Posttraumatic stress symptoms in children following orthopedic or traumatic brain injury.

Examined posttraumatic stress (PTS) symptoms in children following pediatric traumatic brain injury (TBI). Children (ages 6-12) with TBI (n = 81) and orthopedic injury (OI; n = 59) were assessed 6 and 12 months postinjury. Parents of children with severe TBI reported higher levels of child PTS symptoms than did parents of children with moderate TBI or OI at the 6- and 12-month follow-ups. Group differences in child-reported PTS symptoms emerged at the 12-month follow-up with higher symptom levels reported by children with severe TBI than by those with moderate TBI or OI. At both follow-ups, rates of clinically significant symptom levels were higher in the severe TBI group than in the moderate TBI or OI groups. The group differences in parent and child reports were significant even after taking ethnicity, social disadvantage, and age at injury into account. Parent and child reports of child PTS symptoms were related to family socioeconomic status. Implications for clinical intervention with children and families following pediatric TBI are discussed.     

Children's spatial behavior is differentially affected after traumatic brain injury.

Spatial behavior in 20 children with severe traumatic brain injury (TBI) and 20 healthy controls was investigated using the Kiel Locomotor Maze. Children had to remember defined locations in an experimental chamber with completely controlled intra- and extra-maze cues until learning criterion was reached. In a second experiment, spatial orientation strategies were assessed. Children with TBI were shown to be impaired in spatial learning and spatial memory. Spatial orientation was found to be deficient even in cases where spatial learning and memory proved to be unimpaired, especially in tasks that demanded the use of relational place strategies. Children who suffered a TBI at an early age proved to be more severely impaired in spatial learning and orientation than older children.     

Impairment and recovery in inhibitory control after traumatic brain injury in children: effect of age at injury, injury severity and lesion location

We examined the effect of traumatic brain injury (TBI) on inhibitory control, trajectories of recovery of inhibitory control, and the effect of age at injury, severity, and lesion location on recovery. Participants were 127 children with TBI aged 5-16 years and 117 controls of similar age.Latency of response inhibition was measured with the stop signal task within 1 month of the injury and again at 3, 6, 12, and 24 months.Performance of children with TBI was compared with that of controls.Growth curve analyses showed impairments in response inhibition postinjury.Compared with controls, TBI children improved over time in response inhibition. Younger TBI children recovered better on response inhibition than older TBI children. No significant effect of severity or right frontal lesion on recovery of response inhibition was found. TBI has an acute effect on inhibitory control but which recovers over time.     

Lack of inhibition: a motivational deficit in children with attention deficit/hyperactivity disorder and children with traumatic brain injury.

Recent research has demonstrated that both brain-injured children and children with attention deficit/hyperactivity disorder (ADHD) suffer from response inhibition deficits. To investigate whether these deficits can be influenced by motivational factors, the stop-signal task was performed with and without reward contingencies for successful inhibition. Three groups of children between 8 and 12 years of age, participated in the study: 31 children with ADHD, 37 with traumatic brain injuries (TBI), and 26 normal controls. Results indicated that, although all groups showed comparable learning effects, reward contingencies had different effects on the groups. Whereas the performance of children with ADHD under reward contingencies were brought up to the performance level of normal controls, rewards were found less effective at improving response inhibition in children with TBI. The results further support a motivational/energetic explanation of the inhibitory deficit in children with ADHD, and of a primary response inhibition deficit due to structural brain damage in children with TBI.     

Family satisfaction with medical care after traumatic brain injury

Ratings during acute and follow-up care by 35 families having members with traumatic brain injury showed none of the medical facilities met families' needs though some aspects of patients' care were rated higher in hospitals. Findings suggest comprehensive surveys are needed.     

WAIS-III factor index score patterns after traumatic brain injury

Profile subtypes, based on the Wechsler Adult Intelligence Scale-Third Edition (WAIS-III) factor index scores, were examined in a sample of 166 patients with traumatic brain injury (TBI) by means of a two-stage clustering procedure. Three reliable subtypes were found that were differentiated primarily by level of performance across all factor index scores, although each of them demonstrated a relative weakness on the Processing Speed index. These subtypes were then validated on the basis of demographic variables, injury parameters, and additional psychometric measures that had not been included in the clustering procedures. The results indicated that performance on the WAIS-III after TBI was affected by both injury severity and level of education. It is concluded that there is no unique "signature" profile on the WAIS-III after TBI, except that a relative strength on the Processing Speed index is uncommon with this condition.     

Selective attention in children with learning disabilities.

49 children, aged 11 to 14 yr., a learning disabled group and a normal group, performed a primary, reading-like, card-sorting task. After they completed the primary task, they were tested for memory of incidental materials presented during learning. While the normal children showed better recall of incidental materials related to the primary task, 24 children with disabilities showed superior recall of material irrelevant to the primary task. The results were discussed in terms of alternative "motivational" and "developmental lag" interpretations.     

Decision-making deficit of a patient with axonal damage after traumatic brain injury

Patients with traumatic brain injury (TBI) were reported to have difficulty making advantageous decisions, but the underlying deficits of the network of brain areas involved in this process were not directly examined. We report a patient with TBI who demonstrated problematic behavior in situations of risk and complexity after cerebral injury from a traffic accident. The Iowa gambling task (IGT) was used to reveal his deficits in the decision-making process. To examine underlying deficits of the network of brain areas, we examined T1-weighted structural MRI, diffusion tensor imaging (DTI) and Tc-ECD SPECT in this patient. The patient showed abnormality in IGT. DTI-MRI results showed a significant decrease in fractional anisotropy (FA) in the fasciculus between the brain stem and cortical regions via the thalamus. He showed significant decrease in gray matter volumes in the bilateral insular cortex, hypothalamus, and posterior cingulate cortex, possibly reflecting Wallerian degeneration secondary to the fasciculus abnormalities. SPECT showed significant blood flow decrease in the broad cortical areas including the ventromedial prefrontal cortex (VM). Our study showed that the patient had dysfunctional decision-making process. Microstructural abnormality in the fasciculus, likely from the traffic accident, caused reduced afferent feedback to the brain, resulting in less efficient decision-making. Our findings support the somatic-marker hypothesis (SMH), where somatic feedback to the brain influences the decision-making process.     

Communicative impairment in traumatic brain injury: a complete pragmatic assessment

The aim of the present study was to examine the communicative abilities of traumatic brain injury patients (TBI). We wish to provide a complete assessment of their communicative ability/disability using a new experimental protocol, the Assessment Battery of Communication, (ABaCo) comprising five scales—linguistic, extralinguistic, paralinguistic, context and conversational—which investigate all the main pragmatic elements involved in a communicative exchange. The ABaCo was administered to 21 TBI subjects and to a control group. The results showed that performance by TBI patients was worse than that of controls on all scales; moreover they showed a trend of increasing difficulty in understanding and producing different pragmatic phenomena, i.e., standard communication acts, deceits and ironies, whether such phenomena are expressed through the linguistic or extralinguistic modality.     

Exploration of perceptual and motor inhibition in children with traumatic brain injury

Perceptual and motor inhibition were examined using conflict resolution tasks for 12 children with traumatic brain injury and 24 matched controls. Direct comparisons of inhibition performances between the two groups showed a specific and disproportionate impairment of motor inhibition (compared with perceptual inhibition) for the children with traumatic brain injury, which suggests that inhibition processes might be differentially impaired in children after traumatic brain injury.     

Predictors of neuropsychological test performance after pediatric traumatic brain injury

The influence of neurological and demographic variables on neuropsychological test performance was examined in 100 9-to 16-year-old children with traumatic brain injury (TBI). Regression analyses were conducted to determine the relative contributions of coma, neuroimaging findings, ethnicity, socioeconomic status, and gender to variance in performance on the Wechsler Intelligence Scale for Children-Third Edition (WISC-III), California Verbal Learning Test--Children's Version (CVLT-C), and the Children's Category Test. Both neurological and demographic variables contributed to performance on various WISC-III factor index scores as well as the CVLT-C. No evidence for a moderating effect of demographic variables was found, but speed of information processing mediated the effect of neurological and demographic variables on CLVT-C performance. It is concluded that demographic variables have an incremental effect on the neuropsychological test performance of children with TBI above and beyond the influence of injury severity.     

A web-based family problem-solving intervention for families of children with traumatic brain injury.

We developed a Web-based intervention for pediatric traumatic brain injury (TBI) and examined its feasibility for participants with limited computer experience. Six families, including parents, siblings, and children with TBI, were given computers, Web cameras, and high-speed Internet access. Weekly videoconferences with the therapist were conducted after participants completed on-line interactive experiences on problem solving, communication, and TBI-specific behavior management. Families were assigned to videoconference with NetMeeting (iBOT cameras) or ViaVideo. Participants ranked the Web site and videoconferences as moderately to very easy to use. ViaVideo participants rated videoconferencing significantly more favorably relative to face-to-face meetings than did NetMeeting participants. Both the Web site and videoconferencing were rated as very helpful. All families demonstrated improved outcomes on one or more target behaviors, including increased understanding of the injury and improved parent-child relationships. All parents and siblings and all but 1 child with TBI said they would recommend the program to others. We conclude that a face-to-face intervention can be successfully adapted to the Web for families with varied computer experience.     

Premorbid behavioral and psychosocial adjustment of children with traumatic brain injury

The premorbid adjustment of 85 six- to sixteen-year-old children with traumatic brain injury was assessed by means of standardized rating forms that were completed by the children's parents and teachers. Parents and teachers were in moderate agreement when rating children's premorbid functioning. Less than 11% of the children appeared to have premorbid disturbances. Premorbid adjustment did not appear to be clearly related to injury severity or to type of injury. It is concluded that premorbid behavioral and psychosocial factors are not strongly related to the incidence of traumatic brain injury in a sample of children with predominantly relatively severe injuries.The author gratefully acknowledges the assistance of Amy Herrema, Kevin Hogeterp, and Mary Jeanne Lynch in the data collection process.     

Social problem-solving skills in children with traumatic brain injury: long-term outcomes and prediction of social competence.

The effects of childhood traumatic brain injury (TBI) on social problem-solving were examined in 35 children with severe TBI, 40 children with moderate TBI, and 46 children with orthopedic injuries (OI). The children were recruited prospectively following injuries that occurred between 6 and 12 years of age. They were followed longitudinally, and ranged from 9 to 18 years of age at the time of the current study, which occurred on average 4 years post injury. They were administered a semi-structured interview used in previous research on social problem-solving to assess the developmental level of their responses to hypothetical dilemmas involving social conflict. Children in the severe TBI group defined the social dilemmas and generated alternative strategies to solve those dilemmas at the same developmental level as did children in the OI group. However, they articulated lower-level strategies as the best way to solve the dilemmas and used lower-level reasoning to evaluate the effectiveness of the strategies. After controlling for group membership, race, socioeconomic status, IQ, and age, children's social problem-solving, and particularly the developmental level of their preferred strategies for resolving conflicts, predicted parents ratings of children's social skills, peer relationships, aggressive behavior, and academic performance. The findings indicate that children with severe TBI demonstrate selective, long-term deficits in their social problem-solving skills that may help to account for their poor social and academic outcomes.     

Working memory outcomes following traumatic brain injury in children: A systematic review with meta-analysis

The aim of this review is to systematically examine the literature concerning multicomponent working memory (WM)—comprising a central executive (CE), two storage components (phonological loop, PL and visuo-spatial sketchpad, VSSP), and episodic buffer (EB)—in pediatric traumatic brain injury (TBI). Electronic searches were conducted of MEDLINE, PsychINFO and EMBASE up to October 2014 with the inclusion criteria of children and adolescents with TBI, and quantitative methods to assess at least one component of WM. Meta-analytic procedures calculated pooled effect sizes for WM outcomes. Of the studies examined, 27 met the inclusion criteria. Children with TBI exhibited deficits in the CE and PL, but not in the VSSP, and no study could be found which examined the EB. Qualitative analysis found that greater TBI severity was associated with poorer CE functioning in five out of nine studies. Differences in patterns of brain activation were evident in four out of five fMRI studies that examined WM in TBI children and controls. Deficits in CE were associated with poorer mathematical skills in the only study that examined relations between WM and academic deficits. Notwithstanding the heterogeneity of the studies reviewed, TBI places children at risk of WM deficits. Moreover, this meta-analysis suggests that various components of WM have differential vulnerability to pediatric TBI, with significant deficits found in the CE and PL, but not in the VSSP (although the VSSP has rarely been examined to date). Future studies should be theoretically driven, employ tasks assessing all components of the WM model and examine the functional ramifications (including academic outcomes) of WM deficits in this population.