Depression After Mild Traumatic Brain Injury: A Review of Current Research

Research pertaining to the occurrence of depression and/or depression symptomatology after a Mild Traumatic Brain Injury (MTBI) was reviewed. We found that methodological differences such as the criteria used to assess MTBI and depression, time that elapsed since brain injury, and control group variations confounded comparisons across studies. Nevertheless, the studies are consistent with at least a 35% prevalence of, and left frontal damage with depression after MTBI, an overlap of symptoms of depression and Postconcussion Syndrome (PCS), and indicate that depression can continue for many years following the injury. Our conclusion is that MTBI is the triggering event for a set of pathophysiological changes and a concomitant depressive episode in a vulnerable subset of the population. Due to a paucity of research, it cannot be definitively concluded that the underlying substrates of depression seen after MTBI and clinical depression are the same. Implications for future investigations are discussed.     

Prevalence and Correlates of Depressive Symptoms Following Traumatic Brain Injuries in Children

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.     

Traumatic Brain Injury in School-Age Children Academic and Social Outcome

School-aged children with a traumatic brain injury (TBI) require extraordinary effort and energy from individuals in their school, home, and community. The purpose of this study was to examine the academic, behavioral, and social outcomes of a cohort of children and adolescents following TBI. A comprehensive assessment of cognitive functioning, achievement, and adaptive behavior was administered to 43 school-aged children 2 years after their TBI. Premorbid functioning for each participant was obtained from state-mandated test scores assessed prior to the TBI. The predictive utility of premorbid functioning, TBI severity, and age at injury were examined. Findings revealed that premorbid functions were significant predictors of reading and spelling achievement and adaptive functioning. Severity of injury was predictive of adaptive functioning. Implications of findings include program development, reintegration into school, and educating parents and teachers.     

亚低温在重型颅脑损伤患者救治中的应用与思考

重型颅脑损伤是致死、致残的主要原因之一。亚低温（MHT）的应用为重型颅脑损伤患者的救治提供了新的思路和方法,国内外多个临床试验证实了其在救治中的有效性和实用性。本文结合国内外相关诊疗指南、循证医学证据和文献,辩证探讨了MHT在重型颅脑损伤患者救治中的适应证及机制、操作方法及时间窗、并发症及临床决策问题。     

Using Medical Family Therapy with Parents of an Adult Child with Traumatic Brain Injury

Abstract

Acquired traumatic brain injury (ATBI) is a public health concern causing approximately 2.5 million emergency room visits in the United States annually. Medical family therapy (MedFT) displays how biological issues impact each area of a client’s life. This paper highlights how MedFT can be utilized with parents of an adult child with ATBI; the case is presented as treatment occurred with benefits of the inclusion of MedFT. Researchers propose a call to the field of marriage and family therapy to increase access of MedFT to afford more opportunities to help families who experience medical conditions.     

Agreement Between Parent and Teacher Ratings of Disruptive Behavior Disorders in Children with Clinically Diagnosed ADHD

This study investigated the agreement between parent and teacher ratings of DSM-IV symptoms of Attention Deficit Hyperactivity Disorder (ADHD) and related disorders: Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD). A sample of 55 children in the age range of 6–12 years with clinically diagnosed ADHD participated in the study. Parents and teachers were asked to complete the Disruptive Behavior Disorder Rating Scale (DBDRS; W. E., Pelham, E. M., Gnagy, K. E., Greenslade, & R. Milich, 1992). No association was found between parent and teacher ratings of inattention and hyperactivity/impulsivity. However, moderate to high levels of agreement were obtained for ratings of symptoms that characterized ODD and CD. The observed low levels of agreement between parent and teacher ratings of ADHD symptoms may be attributed to different perceptions of the problem behavior by parents and teachers, medication effects, or the situation specificity of children's behavior. It is recommended that the diagnostic criterion of symptom pervasiveness for the diagnosis of ADHD be operationalized more clearly.     

Depression Following Traumatic Brain Injury: The Validity of the CES-D as a Brief Screening Device

The validity, reliability, and factor structure of the Center for Epidemiological Studies-Depression Scale (CES-D) was examined with 253 patients seen for neuropsychological evaluation following traumatic brain injury (TBI). All patients completed the CES-D; 31 also completed the Beck Depression Inventory (BDI) and 17 completed the Minnesota Multiphasic Personality Inventory-II (MMPI-II). The CES-D demonstrated good concurrent, construct validity, significantly correlating with the BDI (r = .673, p < .0001) and the MMPI-II (Depression Scale T score r = .536, p = .027). The CES-D also demonstrated good internal consistency (coefficient alpha = .8195) and split-half reliability (Spearman–Brown r = .8284). Principal components factor analysis with varimax rotation resulted in a four-factor solution that accounted for 56.01% of the variance. The factor structure differed from the originally reported factor structure, and indicated that somatic difficulties were strongly associated with dysphoric affect in TBI patients. The CES-D is a valid and reliable screening instrument for use with TBI patients.     

Construct and Criterion Validity of the Comprehensive Trail Making Test in Children and Adolescents with Traumatic Brain Injury

The current study examined the construct and criterion validity of the Comprehensive Trail Making Test (CTMT) when used to evaluate children and adolescents with traumatic brain injury (TBI). Participants included 100 children and adolescents, 50 who had sustained TBI and 50 normal comparisons (NC). Analyses indicated that the CTMT factor scores were significantly correlated with tests of perceptual organizational ability, processing speed, and motor function and provided support for its construct validity. Additionally, correlations between the various CTMT scores suggested that a different pattern of associations was present in the TBI group compared to the NC group. Finally, the TBI group performed significantly worse (p < .001) on all of the CTMT scores, including each of the five CTMT trails as well as the factor and composite index scores. Results support the construct and criterion validity of the CTMT when used to assess children and adolescents with TBI.     

Adapting Cognitive Processing Therapy to Treat Co-Occurring Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: A Case Study

This case study aims to provide evidence for the effectiveness of adapting a particular manualized cognitive behavioral therapy intervention to treat co-occurring posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). This study presents the treatment of a woman who experienced co-occurring mTBI and PTSD following a motor vehicle accident, a dual diagnosis that was established through a flexible assessment approach involving interviews as well as standardized psychological, neuropsychological, and neurobehavioral testing. Treatment planning led to a-priori adaptation of Cognitive Processing Therapy (CPT) to treat both her PTSD symptoms and the sequelae associated with her mTBI. The therapist maintained fidelity to the manualized structure and content of CPT protocol, adapting portions of the treatment to add specific emphasis on issues of identity confusion and role loss in service of addressing these common functional impairments that can accompany mTBI. Discussion focuses on application of CPT for future treatment of comorbid PTSD and TBI amidst complicating factors, including role losses and medical and safety issues. This case study is especially relevant due to the prevalence of co-occurring PTSD and TBI across a variety of populations.     

Psychobiological Treatment Response to a Two-Week Posttraumatic Stress Disorder and Mild Traumatic Brain Injury Integrated Treatment Program: A Case Report

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) demonstrate high prevalence and comorbidity among post-9/11 veterans. Veterans with this comorbidity often present with multiple co-occurring healthcare needs and increased clinical complexity. The current case report describes the clinical presentation of a veteran with mild TBI and PTSD, both before, during, and after treatment within a multidisciplinary 2-week intensive outpatient program involving prolonged exposure, evidence-based PTSD treatment, and Cognitive Symptom Management and Rehabilitation Therapy, evidence-based treatment for postconcussive symptoms. Mr. A was a 25-year-old White, transgender male who presented with a complex mental health history. At intake, presenting complaints included anxiety, panic attacks, nightmares, and depression secondary to military sexual trauma, as well as reported cognitive difficulties secondary to a concussion. He met current criteria for PTSD as well as panic disorder with agoraphobia. Head injury history consisted of a motor vehicle collision with less than 30 seconds loss of consciousness, brief posttraumatic amnesia, and alterations of consciousness. Mr. A demonstrated habituation during individual exposure sessions as assessed via skin conductance during imaginal exposures and decreased subjective ratings during in vivo exposures, as well as a decrease in trauma-potentiated startle response to trauma cues. Posttreatment data indicates significant reduction in neurobehavioral, posttraumatic stress, and depression symptoms and significant improvement in subjective cognitive functioning. The current findings support the feasibility and efficacy of short-term integrated treatment for complex clinical presentations and the need for larger scale research investigating combined PTSD and TBI intervention.     

Physical and Mental Health and Functioning Among Traumatic Brain Injury Close Relatives: The Role of Posttraumatic Stress Symptoms

Severe Traumatic brain injury (sTBI) often instigates widespread long-lasting disability and is accompanied by extensive rehabilitation. Unsurprisingly, sTBI also holds malignant consequences for patients’ close relatives. The burden caused by the injury and its severity explains some of the ramifications for the relatives. Additionally, some findings demonstrate that patients with sTBI and their relatives develop posttraumatic stress (PTS) symptoms. However, although the link between PTS symptoms and physical and mental health is well-documented in literature, the effect of PTS symptoms on relatives of patients with sTBI has barely been examined. This study examines the influence of PTS symptoms of patients with sTBI and their relatives on the physical and mental health and functioning of the relatives. Patients who sustained a severe sTBI (Abbreviated Injury Scale of the head region > 3) and close relatives were included in a multi-center, prospective cohort study (TRAST-MI). One-hundred patients and their relatives were assessed at 2, 6, and 12 months post injury. Outcome variables included health-related quality of life (SF-12) as well as emotional, cognitive, interpersonal, and total functioning (PCRS). Relatives’ physical health was predicted by relatives’ PTS symptoms (Slope=−1.76; p = .043), and mental health was predicted by both patients’ (Slope=−2.77; p = .034) and relatives’ (Slope=−6.59; p < .001) PTS symptoms. Functioning level was only predicted by patients’ PTS symptoms (Slope=−.25; p_<.001). The findings emphasize that TBI should be considered a comprehensive traumatic experience reaching further than mere physical damage to the brain and its direct consequences, affecting the injured individual and close relatives.     

Self-Report Measures to Identify Post Traumatic Stress Disorder and/or Mild Traumatic Brain Injury and Associated Symptoms in Military Veterans of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)

Individuals serving in Iraq and Afghanistan sustain injuries associated with physical and psychological trauma. Among such injuries, mild traumatic brain injury (mTBI) and post traumatic stress disorder (PTSD) are common. Self-report measures are frequently used to identify mTBI and/or PTSD and symptoms associated with these conditions. In addition to providing information regarding mTBI and PTSD, the goal of this literature review was to identify and present information on the psychometric properties of measures used to obtain information regarding these common conditions among Veterans who have returned from Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF). A comprehensive review of studies in which self-report measures were used to evaluate mTBI, PTSD, and associated symptoms among OEF/OIF Veterans is presented. Findings suggest that additional work is needed to identify psychometrically sound and clinically useful self-report measures that assess mTBI and PTSD and associated symptoms among OEF/OIF Veterans.     

Psychiatric Hospitalization and School and Community Adjustment of Children and Adolescents with Acquired Brain Injury

There is a high prevalence of psychiatric disorders in children and adolescents who have acquired brain injury (ABI). We examined the records of 82 students with ABI who were admitted to a community-based school for education and neurorehabilitation over a three-year period to determine how many experienced one or more psychiatric hospitalizations before admission, and whether hospitalization status was related to positive school and community adjustment. Results were that 30.4% of the students had a documented history of one or more psychiatric hospitalizations. Of this group, 60.0% were able to be maintained in the community-based school program and 40.0% were discharged to other settings. When discharged, 70.0% of students entered more restrictive treatment programs (e.g., psychiatric hospital, secure residential facility, residential school). The number of psychiatric hospitalizations did not predict discharge from the community-based school and was unrelated to the type of discharge setting. Clinical and research issues concerning psychiatric disorders in children and adolescents with ABI in relation to post-acute adjustment are discussed.     

The Relationship Between Parental Report on the BRIEF and Performance-Based Measures of Executive Function in Children with Moderate to Severe Traumatic Brain Injury

The Behavior Rating Inventory of Executive Function (BRIEF) is a questionnaire that assesses parental observations of behaviors associated with executive function in children in the home environment. The current investigation examines the relationship between the BRIEF and individually-administered neuropsychological tests in children with traumatic brain injury. Forty-eight children with moderate to severe traumatic brain injury were administered the WISC-III and several performance-based tests of executive function (the Wisconsin Card Sorting Test, Trail Making Test Part B, verbal fluency), and a parent completed the BRIEF. Results indicate that the Metacognition Index from the BRIEF correlates with Verbal IQ, but none of the index scores from the BRIEF correlate with any of the performance-based tests of executive function. Results are discussed with respect to the ecological validity of standardized clinical neuropsychological tests of executive function.     

A Pilot Randomized Trial of an Online Parenting Skills Program for Pediatric Traumatic Brain Injury: Improvements in Parenting and Child Behavior

This pilot study examined changes in parenting skills and child behavior following participation in an online positive parenting skills program designed for young children with traumatic brain injury (TBI). Thirty-seven families with a child between 3 and 9 years of age who sustained a moderate to severe TBI were randomly assigned to one of two interventions: online parenting skills training (n = 20) or access to Internet resources on managing brain injury (n = 17). Parent–child interaction observations and parent ratings of child behavior were collected pre- and post-treatment. Generalized estimating equations and mixed models were used to examine changes in parenting skills and child behavior problems as well as the moderating role of family income on treatment response. Participants in the parenting skills group displayed significant improvements in observed positive parenting skills relative to participants in the Internet resource group. Income moderated improvements in parent ratings of child behavior, with participants in the low-income parenting skills group and high-income Internet resource group reporting the greatest improvements in behavior. This is the first randomized controlled trial examining online parenting skills training for families of young children with TBI. Improvements in positive parenting skills and child behavior support the utility of this intervention, particularly for families from lower socioeconomic backgrounds.     

累积创伤对儿童复杂性创伤后应激障碍的影响：经验回避与消极认知情绪调节策略的中介作用

为探讨儿童的累积创伤与复杂性创伤后应激障碍(CPTSD)的关系机制,研究以方便取样法选取河南省7所小学的3478名4~5年级、有创伤经历的儿童为被试,采用创伤经历核查表、抑郁的行为激活问卷、认知情绪调节问卷和国际创伤问卷进行测试。结果发现:(1)累积创伤、经验回避、消极认知情绪调节策略和CPTSD之间具有显著相关性,且累积创伤能够显著正向预测CPTSD;(2)经验回避和消极认知情绪调节策略在累积创伤和CPTSD之间起显著的中介作用。具体为:一是经验回避的中介作用;二是灾难化的中介作用;三是经验回避-自责、经验回避-沉思、经验回避-灾难化的链式中介作用。因此,减少创伤事件的发生,激活儿童行为,调整消极认知情绪是改善和预防儿童CPTSD的重要途径。