Cognitive and psychosocial outcome after head injury in children

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

Medical and Cognitive Outcome in Children with Traumatic Brain Injury

Background:

Head injury is an important cause of morbidity and mortality in pediatrics. Comprehensive studies on outcome are scarce despite significant clinical concern that multiple areas of functioning may be impaired following moderate to severe head injury. The literature suggests that sequelae include not only medical problems but also impairments in cognitive functioning.

Methods:

Aretrospective medical and psychology chart review of patients, age 1-18 years, admitted to the Children's Hospital of Eastern Ontario with moderate (Glasgow Coma Scale [GCS] 9-12) or severe head injury (GCS ≤ 8) from November 1, 1993 until December 31, 1998 was conducted. Correlations were performed between medical variables (i.e., GCS, Pediatric Risk of Mortality [PRISM] III score, duration of ICU and hospital stay) and measures of intelligence and memory functioning.

Results:

Eighty-three children age 1 to 18 were included. Seventy percent of the children were classified as having a severe head injury. There was a mortality rate of thirteen percent. Younger age at injury, lower GCS, and higher PRISM III scores predicted higher mortality. Medical complications were documented systematically. Forty-four patients underwent at least one cognitive assessment and 17 of these children had intelligence testing at three points in time: baseline (< four months), early recovery (five to 15 months) and follow-up (16 to 38 months). The mean intelligence and memory scores fell within the average range at the latest point in follow-up. For those children who underwent three serial assessments, the mean verbal and performance IQ fell within the low average range at baseline improving significantly to fall within the average range by early recovery. Continued improvements were apparent in verbal memory beyond early recovery, with the mean obtained at follow-up falling within 1 SD of the normative mean. Despite the return to normal ranges for the group means the proportion of scores falling below 1.5 standard deviations from the mean was greater than population norms for verbal IQ, performance IQ and verbal memory. Lower GCS scores and longer duration of stay in ICU or hospital were predictive of lower nonverbal intelligence. Lower GCS was also predictive of lower visual memory scores.

Conclusions:

This study describes a population of Canadian children who suffered moderate or severe traumatic brain injury. Initial GCS was the best predictor of mortality and cognitive outcome. These children demonstrated a temporal improvement in intelligence and memory functioning, with their mean performance on these cognitive measures falling within the average range at 16 to 38 months postinjury, although there was considerable variability in the outcomes between individuals.

Children, Brain Injury and the Resiliency Model of Family Adaptation

The Resiliency Model of Family Stress, Adjustment and Adaptation is a theoretical framework used in this article to understand how families adapt when their child has had a traumatic injury. This article describes the Resiliency Model in relation to the findings of studies on families where a child has sustained a brain injury. Identifying the factors impacting on the family and the adaptation process they experience provides valuable insight and information for the provision of family-centred services.

Adolescent psychiatric symptoms following preschool childhood mild traumatic brain injury: evidence from a birth cohort

OBJECTIVE

To determine whether childhood mild traumatic brain injury (MTBI) is associated with behavioral problems in adolescence.

PARTICIPANTS

Children from a longitudinal birth cohort (initial N = 1265) were assigned to 1 of 3 groups: (1) inpatient group (n = 19) comprised children admitted to hospital for MTBI before age 5 years; (2) outpatient group (n = 57), children with any incidence of MTBI before age 5 seen by a general practitioner or at an accident and emergency department and sent home; (3) reference control group (n = 839).

OUTCOME MEASURES

Maternal and self-report regarding attention deficit/hyperactivity disorder, conduct disorder, anxiety disorder, mood disorder, and alcohol or illicit substance abuse/dependence obtained using Diagnostic and Statistical Manual of Mental Disorders (Third Edition Revised) criteria.

RESULTS

At age 14 to 16 years, children who had been hospitalized for MTBI during preschool years were significantly more likely to show symptoms of attention deficit/hyperactivity disorder (odds ratio = 4.2), conduct disorder/oppositional defiant disorder (odds ratio = 6.2), substance abuse (odds ratio = 3.6), and mood disorder (odds ratio = 3.1) but not anxiety disorder.

CONCLUSIONS

Preschool MTBI is associated with persistent negative effects on psychosocial development. These continuing problems are consistent with the view that preschool years represent a period of particular vulnerability following MTBI.

Impact of early intervention on outcome after mild traumatic brain injury in children

OBJECTIVE

The impact of mild head injury or mild traumatic brain injury (TBI) in children is variable, and determinants of outcome remain poorly understood. There have been no previous attempts to evaluate the impact of interventions to improve outcome. Results of previous intervention studies in adults have been mixed. This study aimed to evaluate the impact of providing information on outcome measured in terms of reported symptoms, cognitive performance, and psychological adjustment in children 3 months after injury.

METHODS

A total of 61 children with mild TBI were assessed 1 week and 3 months after injury, and 58 children with mild TBI were assessed 3 months after injury only. They were compared with 2 control groups (N = 45 and 47) of children with minor injuries not involving the head. Participants completed measures of preinjury behavior and psychological adjustment, postconcussion symptoms, and tests of attention, speed of information processing, and memory. Children with mild TBI seen at 1 week were also given an information booklet outlining symptoms associated with mild TBI and suggested coping strategies. Those seen 3 months after injury only did not receive this booklet.

RESULTS

Children with mild TBI reported more symptoms than controls at 1 week but demonstrated no impairment on neuropsychological measures. Initial symptoms had resolved for most children by 3 months after injury, but a small group of children who had previous head injury or a history of learning or behavioral difficulties reported ongoing problems. The group not seen at 1 week and not given the information booklet reported more symptoms overall and was more stressed 3 months after injury.

CONCLUSIONS

Providing an information booklet reduces anxiety and thereby lowers the incidence of ongoing problems.

Cognitive and behavioral outcome following mild traumatic head injury in children

OBJECTIVES

To investigate outcome in children with mild traumatic head injury (THI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems.

DESIGN

Postconcussional symptomatology, behavior ratings, and neuropsychological test performance were examined at 1 week and 3 months postinjury.

SETTING

Participants were recruited from successive presentations to emergency departments of two major hospitals.

PARTICIPANTS

130 Children with mild THI were compared with 96 children having other minor injuries as controls.

RESULTS

Children with mild THI experienced headaches, dizziness, and fatigue but exhibited no cognitive impairments, relative to controls, at 1 week postinjury. By 3 months, symptoms had resolved. However, 17% of children showed significant ongoing problems. They were more likely to have a history of previous head injury, learning difficulties, neurological or psychiatric problems, or family stressors.

CONCLUSIONS

Persisting problems following mild head injury in children are more common in those with previous head injury, preexisting learning difficulties, or neurological, psychiatric, or family problems. These "at-risk" children should be identified in the emergency department and monitored.

Motor performance following a mild traumatic brain injury in children: an exploratory study

Mild Traumatic Brain Injury (TBI) is a common occurrence in the paediatric population and, as the concept of motor performance has not been assessed specifically in this population, the purpose of this study was to determine if motor performance deficits are present and can be objectively identified in a sample of children having sustained a mild TBI (Glasgow Coma Scale score 13-15). Twenty-eight children aged between 5 and 15 years were recruited immediately post-trauma. Subjects were considered normal on standard neurological exam at the time of discharge. They were assessed 13-18 days post-trauma using the Bruininks-Oseretsky Test of Motor Proficiency, a norm referenced clinical standardized assessment tool. Compared to published norms, motor performance was significantly lower in domains of balance, response speed and running speed an agility (t-test p < 0.01), and significantly higher in domains of upper extremity coordination and visual motor control (t-test p < 0.01). Although excellent performance can be observed in domains requiring upper limb coordination, motor planning and execution of motor tasks, deficits in balance and response speed can be identified in a significant number of children even after mild TBI. More specific and sensitive evaluations are necessary to identify the exact nature of the problems and evaluate their functional impact on daily activities.

Performance of children with traumatic brain injury on the Cognitive Assessment System

Children and adolescents with traumatic brain injury (TBI) were compared to a matched sample of neurologically normal children and adolescents on several measures of cognitive processing. Each of the children in the TBI group had experienced a closed head injury of moderate to severe magnitude. Participants in both the TBI (n = 22) and control (n = 22) groups ranged in age from 9 to 17 years and lived in the midwestern United States. They were all administered the Cognitive Assessment System (Naglieri & Das, 1997a). Children with TBI earned significantly lower scores in the domains of Planning and Attention than the matched control group. Within-group comparisons showed that the TBI group s Planning and Attention scores were significantly lower than their Simultaneous and Successive scores. The results are consistent with previous literature demonstrating poor performance on measures of attention and executive functions among children who have experienced TBI.