The relationship of parental warm responsiveness and negativity to emerging behavior problems following traumatic brain injury in young children

Parenting behaviors play a critical role in the child's behavioral development, particularly for children with neurological deficits. This study examined the relationship of parental warm responsiveness and negativity to changes in behavior following traumatic brain injury (TBI) in young children relative to an age-matched cohort of children with orthopedic injuries (OI). It was hypothesized that responsive parenting would buffer the adverse effects of TBI on child behavior, whereas parental negativity would exacerbate these effects. Children, ages 3-7 years, hospitalized for TBI (n = 80) or OI (n = 113), were seen acutely and again 6 months later. Parent-child dyads were videotaped during free play. Parents completed behavior ratings (Child Behavior Checklist; T. M. Achenbach & L. A. Rescorla, 2001) at both visits, with baseline ratings reflecting preinjury behavior. Hypotheses were tested using multiple regression, with preinjury behavior ratings, race, income, child IQ, family functioning, and acute parental distress serving as covariates. Parental responsiveness and negativity had stronger associations with emerging externalizing behaviors and attention-deficit/hyperactivity disorder symptoms among children with severe TBI. Findings suggest that parenting quality may facilitate or impede behavioral recovery following early TBI. Interventions that increase positive parenting may partially ameliorate emerging behavior problems.     

Lateralized brain injury and behavior problems in children

This study investigated the types of behavior problems found in children with lateralized brain lesions. Children referred for neuropsychological assessment were assigned to dominant (DH) or nondominant (NDH) groups on the basis of history of neurological disease or injury, findings on neurological examination, functional and structural laboratory findings, and neuropsychological assessment. Over two-thirds fell into the clinical range of behavior problems by parental report on the Achenbach Child Behavior Checklist. Degrees of pathology were nearly equal. DH children showed more externalizing than internalizing symptomatology. NDH children showed more internalizing than externalizing behavior problems. Results are discussed in terms of symptom formation based on lateralization of lesion.     

Clients' perspectives on problems many years after traumatic brain injury

This study investigated the types of self-reported main problems that persons report many years following a traumatic brain injury. This preliminary study is part of a large ongoing study of disability and handicap in adults following traumatic brain injury. As part of an extensive interview, subjects were asked an open-ended question regarding their current main problems which they thought resulted from their traumatic brain injury. Responses were obtained from 166 adult subjects (119 men and 47 women) whose time postinjury ranged from 9 to 24 years. Categories for responses were subsequently developed. The most commonly reported categories of problems were those relating to movement (39%), cognition (36%), and sensory impairment (31%). Findings suggest that subjects' long-term concerns were related to specific impairments more than to psychosocial, emotional, or behavioral issues. Methodological issues concerning this research are discussed in relation to findings.     

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.     

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.     

Selective learning in children after traumatic brain injury: a preliminary study.

Selective learning (SL) is the ability to select items to learn from among other items. It requires the use of the executive processes of metacognitive control and working memory, which are considered to be mediated by the frontal cortex and its circuitry. We studied the efficiency with which verbal items of greater value are selectively learned from among items varying in value in 14 children ages 8-15 years who had sustained severe traumatic brain injury (TBI) and in 39 typically developing age-matched children. We hypothesized that children with TBI would be disproportionately compromised in selective learning efficiency in contrast to memory span when compared to normally developing children. The results supported our hypothesis, as children with TBI performed significantly worse than controls on a measure of selective learning efficiency, but the two groups performed similarly on a measure of word recall within the same task. Furthermore, the effect of TBI on performance was demonstrated to take place at the time of encoding, rather than at retrieval.     

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.     

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.     

Parental ratings of daily behavior and child cognitive test performance after pediatric mild traumatic brain injury

This study aimed to evaluate the degree to which the Behavior Rating Inventory of Executive Function (BRIEF) and Child Behavior Checklist (CBCL) measure overlapping vs. distinct constructs in pediatric patients with mild traumatic brain injury (TBI), and to examine the demographic and injury correlates of such constructs as well as those of cognitive test performance. A total of 100 parents completed the BRIEF and the CBCL within 1 to 12 months after the injury of their child. Groups were contrasted based on the presence vs. absence of impairment on, respectively, the BRIEF and the CBCL. Exploratory maximum likelihood factor analysis was used to evaluate latent constructs. Correlates of the various factor scores were evaluated through regression analysis and contrasted with those of a test of verbal learning and memory.The results revealed that the BRIEF and the CBCL disagree about the presence vs. absence of impairment in about one quarter of cases. A prior history of attention deficit/hyperactivity disorder (ADHD) was associated with an increased likelihood of impairment on both the BRIEF and the CBCL, whereas prior outpatient psychiatric treatment was associated with the increased likelihood of selective impairment on the CBCL. Latent constructs manifested themselves along cognitive regulation, emotional adjustment and behavioral regulation factors. Whereas premorbid characteristics were the exclusive correlates of these factors, performance on a test of verbal learning and memory was negatively affected by intracranial lesions on neuroimaging.It is concluded that the BRIEF and the CBCL offer complementary and non-redundant information about daily functioning after pediatric mild TBI. The correlates of cognitive test performance and parental behavior ratings after such injuries are different and reflect a divergence between premorbid and injury-related influences.     

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.     

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.     

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.     

A review of social disinhibition after traumatic brain injury

Acquired social disinhibition refers to a debilitating behavioural syndrome commonly reported after a severe traumatic brain injury (TBI) and is characterized by inappropriate social behaviour, often described as immaturity and insensitivity towards others. These behaviours can have enduring effects on the social capability of the individual and their relationships with others. However, research into socially disinhibited behaviour after TBI has been thwarted by a lack of consensus in the literature on definition and measurement. This review provides an overview of our current understanding of the definition, measurement, prevalence, associated outcomes, neuropathology, and underlying mechanisms of social disinhibition after TBI. In addition, suggestions are made for future research to further our understanding of this syndrome with the eventual aim of rehabilitating problematic behaviours. It is concluded that an improved understanding of what causes disinhibited behaviour after TBI will be necessary for the development of effective treatment strategies aimed at the rehabilitation of underlying impairments.     

Using choice to increase on-task behavior in individuals with traumatic brain injury

An ABA'B design was used to evaluate the effects of choice on task engagement for 3 adults who had been diagnosed with traumatic brain injury. A yoked-control condition, in which tasks that were selected by each participant were assigned subsequently to that participant by a trainer, was implemented to help distinguish between the effects of task preference and choice. The results for all 3 participants indicated that permitting individuals to choose from a list of tasks increased on-task behavior.     

Theory of mind skills 1 year after traumatic brain injury in 6- to 8-year-old children

This study examined the longer-term effects of traumatic brain injury (TBI) on theory of mind (ToM) skills of children who were between the ages of 5 and 7 years at the time of injury. Fifty-two children with orthopaedic injury, 30 children with moderate TBI, and 12 children with severe TBI were evaluated approximately 1 year post-injury (mean age=6.98 years, SD=0.59, range=6.02–8.26). Children with severe TBI did not engage in representation of first- and second-order mental states at a developmental level comparable to their peers, suggesting stagnation or lack of development, as well as regression of putatively existing ToM skills. Age, task-specific cognitive demands, and verbal abilities were strong predictors of ToM performance. However, even after taking those factors into account, children with severe TBI had poorer ToM performance than children with orthopaedic injuries.     

Comprehensive Trail Making Test performance in children and adolescents with traumatic brain injury

The sensitivity of the Trail Making Test to brain damage has been well-established over many years, making it one of the most commonly used tests in clinical neuropsychological evaluations. The current study examined the validity of scores from a newer version of the Trail Making Test, the Comprehensive Trail Making Test (CTMT), in children and adolescents with traumatic brain injury (TBI). Participants included 242 children and adolescents, 121 with sustained TBI and 121 normal control participants, who were matched to the individuals with TBI on age and sex. Receiver operating characteristic analysis indicated that the CTMT composite index provided the best overall classification, with a correct classification rate of 79%. Differences between the TBI and control groups remained stable across age. These findings indicate that the CTMT is sensitive to TBI and overall demonstrates classification rates that are comparable with some other versions of the Trail Making Test. Whether the CTMT will exhibit similar classification accuracy in adults with TBI and for other neurological disorders awaits further investigation.     

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.