Executive function outcomes of children with traumatic brain injury sustained before three years

A Preliminary Investigation of Stakeholders' Perspectives on Cognitive Fatigue After Childhood Brain Injury

BACKGROUND

Cognitive fatigue after childhood acquired brain injury (ABI) is known to negatively impact engagement in typical academic and social activities, yet limited evidence is available to inform speech-language pathologists' (SLPs') clinical practices. The purpose of this research study was to explore stakeholders' perspectives on cognitive fatigue for children with ABI to inform future directions for clinicians and researchers.

METHOD

Twelve parents of children with traumatic brain injury and 35 SLPs participated in an online survey with 33 and 49 questions, respectively, including participant characteristics and perspectives on cognitive fatigue.

RESULTS

Parents reported being between "somewhat" and "highly aware" about cognitive fatigue, whereas SLPs reported being between "neither aware or not aware" and "somewhat aware." Parents reported being between "somewhat comfortable" and "very comfortable," whereas SLPs reported being between "neither comfortable or uncomfortable" and "somewhat comfortable" addressing cognitive fatigue in children with ABI. SLPs "somewhat" to "strongly" agreed that cognitive fatigue for children with ABI was within their scope of practice. Parents and SLPs reported accommodations and strategies useful to managing cognitive fatigue in children with brain injury, as well as factors that worsen and lessen cognitive fatigue.

CONCLUSIONS

While additional foundational and translation research is needed, the perspectives of parents and SLPs begin to address a critical gap in SLPs' assessment and management of cognitive fatigue in children with ABI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24216576.

Self-perception and behavioural outcomes of early acquired brain injury

Acquired brain injury (ABI) occurs commonly in young children. Despite this, the psychosocial implications of ABI in young children are not established, with little understood about the impacts on self-perception and self-esteem. In this study we investigated self-perception, self-esteem and behaviour of children with early ABI. Children with an ABI (n = 47) before six years were compared to 17 typically developing controls (TDCs) matched on demographics. Children were aged 6-12 years and completed the Harter Self-Perception Profile. One parent completed the Child Behavior Checklist. No differences for self-perception and self-esteem were found between the groups. Parents of children with an early ABI reported more internalizing and externalizing behaviours. Children with more externalizing behaviour and social skill problems had more negative self-perceptions. Interaction effects were seen between socioeconomic status (SES) and child self-perception and behaviour. Specifically, children from families of higher SES had a more positive perception of their appearance and children from lower SES backgrounds had more externalizing behaviours and social problems. The study suggests that the relationship between ABI and self-perception and self-esteem is complicated and that children with behavioural problems have lowered feelings of competence. SES has an important role in self-perception and behavioural outcomes.

What About the Little Ones? Systematic Review of Cognitive and Behavioral Outcomes Following Early TBI

There is increasing empirical focus on the effects of early traumatic brain injuries (TBI; i.e., before the age of six years) on child development, but this literature has never been synthetized comprehensively. This systematic review aimed to document the cognitive, academic, behavioral, socio-affective, and adaptive consequences of early TBI. Four databases (Medline, PsycNET, CINAHL, PubMed) were systematically searched from 1990 to 2019 using key terms pertaining to TBI and early childhood. Of 12, 153 articles identified in the initial search, 43 were included. Children who sustain early TBI are at-risk for a range of difficulties, which are generally worse when injury is sustained at a younger age, injury severity is moderate to severe, and injury mechanisms are non-accidental. Early childhood is a sensitive period for the emergence and development of new skills and behaviors, and brain disruption during this time is not benign. Research, clinical management, intervention, and prevention efforts should be further developed with consideration of the unique characteristics of the early childhood period.

Cognitive Recovery During Inpatient Rehabilitation Following Pediatric Traumatic Brain Injury: A Pediatric Brain Injury Consortium Study

OBJECTIVES

To characterize the demographics, clinical course, and predictors of cognitive recovery among children and young adults receiving inpatient rehabilitation following pediatric traumatic brain injury (TBI).

DESIGN

Retrospective observational, multicenter study.

SETTING

Eight acute pediatric inpatient rehabilitation facilities in the United States with specialized programs for treating patients with TBI.

PARTICIPANTS

Children and young adults (0-21 years) with TBI (n = 234) receiving inpatient rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Admission and discharge status assessed by the WeeFIM Cognitive Developmental Functional Quotient (DFQ) and Cognitive and Linguistic Scale (CALS).

RESULTS

Patients admitted to pediatric inpatient rehabilitation are diverse in cognitive functioning. While the majority of patients make improvements, cognitive recovery is constrained for those admitted with the most severe cognitive impairments. Age, time since injury to rehabilitation admission, and admission WeeFIM Cognitive DFQ are significant predictors of cognitive functioning at discharge from inpatient rehabilitation.

CONCLUSIONS

This work establishes a multicenter Pediatric Brain Injury Consortium and characterized the demographics and clinical course of cognitive recovery during inpatient rehabilitation of pediatric patients with TBI to aid in prospective study design.

Trajectories in health recovery in the 12 months following a mild traumatic brain injury in children: findings from the BIONIC Study

INTRODUCTION There is growing consensus that adverse child outcomes may be evident in the early recovery phase following mild traumatic brain injury (TBI). However, controversy remains around the nature of children's longer-term recovery. AIM To examine child cognitive, behavioural and quality-of-life outcomes over 12 months following mild injury, and to identify prognostic factors associated with outcomes. METHODS A prospective sample of 222 children (aged 2-15 years at injury) with mild TBI was assessed using a cognitive testing battery and parent-report questionnaires at ≤ 14 days, 1, 6 and/or 12-months post-injury. RESULTS Parents reported significant improvements in their child's behavioural adjustment between baseline and 6 months (P = 0.003), with further improvements at 12 months following injury (P = 0.001). Cognitive recovery and quality-of-life improvements were more gradual with minimal changes in the first month (P > 0.05), but significant improvements by 12-months post-injury (P = 0.03, P = 0.02, respectively). Time since injury, male gender, living rurally and parent anxiety were associated with extent of recovery beyond the acute period. CONCLUSIONS Children's recovery from mild TBI continues beyond the initial 6 months following injury. Health-care providers need to be vigilant about the varying trajectories in children's recovery from TBI. On-going monitoring of children following injury will enable timely and proactive responses to persistent difficulties, with a view to minimising longer-term adverse consequences.

Longitudinal Developmental Outcomes after Traumatic Brain Injury in Young Children: Are Infants More Vulnerable Than Toddlers?

Children under 4 years of age have the highest incidence of traumatic brain injury (TBI) among the non-elderly and may be at high risk of poor developmental outcomes. We prospectively enrolled a cohort of children injured before 31 months old with TBI or orthopedic injury (OI), from 2013 to 2015 at two pediatric level 1 trauma centers to study very young children's developmental outcomes after injury. We used Ages & Stages-3 and Ages & Stages: Social-Emotional screening tools to measure children's development at pre-injury and 3 and 12 months post-injury. The cohort included 123 children with TBI categorized as mild (n = 48), complicated-mild or moderate (n = 54), and severe (n = 21) and 45 children with OI. Generalized linear models examined effects of injury severity and age at injury controlling for pre-injury ratings. Children with mild or complicated-mild/moderate TBI generally remained on developmental track. Compared to OI, children with severe TBI tended to have a negative developmental trajectory with decrements in communication (-7.07; 95% confidence interval [CI], -13.7, -0.48), gross motor (-15.2; 95% CI, -21.1, -9.19), problem solving (-11.6; 95% CI, -17.9, -5.29), personal-social (-16.8; 95% CI, -22.8, -10.8), and social-emotional (21.0; 95% CI, 7.32, 34.7) domains 12 months post-injury. Developmental effects from TBI differed by age at injury: Infants had more difficulties than older children in communication and problem-solving domains. Despite low developmental scores in 28% of the cohort, only 5% were receiving Early Childhood Intervention (ECI) services 12 months after injury. Early age at injury is a vulnerability factor after TBI. Young age and severe injury should prompt evaluation for ECI.

Executive Functions and Their Relation to Sleep Following Mild Traumatic Brain Injury in Preschoolers

OBJECTIVES

Traumatic brain injury (TBI) sustained during childhood is known to impact children's executive functioning. However, few studies have focused specifically on executive functioning after preschool TBI. TBI has also been associated with sleep disturbances, which are known to impair executive functions in healthy children. The aim of this study was to investigate executive functions in preschoolers with mild TBI, and to determine the role of sleep in the links between TBI and executive functioning.

METHODS

The sample was drawn from a longitudinal study and included 167 children, aged 18 to 60 months, divided into 2 groups: children with accidental mild TBI (n=84) and typically developing children (n=83). Children were assessed 6 months post-injury on executive function measures (inhibition and cognitive flexibility) and sleep measures (actigraphy data and parental rating of sleep problems).

RESULTS

The two groups did not differ in their executive abilities. However, relative to controls, children with mild TBI and shorter nighttime sleep duration or increased sleep problems exhibited poorer executive functions.

CONCLUSIONS

These results support a "double hazard" effect, whereby the combination of sleep disturbances and mild TBI results in poorer executive functions. The findings highlight the importance of assessing and monitoring the quality of sleep even after mild head injuries. Poor sleep may place children at risk for increased cognitive difficulties. (JINS, 2018, 24, 769-780).

Parent and child ratings of child behaviour following mild traumatic brain injury

BACKGROUND

Mild traumatic brain injury (mTBI) in children is most commonly associated with parent-reported child behaviour problems. The extent to which parent and child ratings align is unknown.

OBJECTIVES

To examine differences in child behaviour and patterns of recovery over the first 12 months following mTBI based on parent and child self-report.

METHODS

Ninety-nine children (8-15 years) with mTBI and one of their parents completed the Behavioural Assessment Scale for Children - version 2 to assess child hyperactivity, anxiety and depression at baseline, 1, 6 and 12 months post-injury. Differences between ratings from parents and children were evaluated using Bland-Altman limits of agreement analyses. Child recovery over time was examined using mixed models repeated measures analyses.

RESULTS

Parent and child ratings for child hyperactivity, anxiety and depression differed significantly at baseline and these differences remained constant at each follow-up. Parents tended to report more child hyperactivity, anxiety and depression. Over time, parents and children reported fewer child hyperactivity and anxiety problems.

CONCLUSIONS

Parents and children have poor agreement in ratings of child behaviour yet there is general agreement in patterns of recovery in the year following mTBI. Findings show the importance of considering both parent and self-report of child behaviour.

Adult cognitive outcomes following childhood mild traumatic brain injuries

OBJECTIVE

To investigate the adult cognitive outcomes of one versus multiple childhood mTBI and to examine the potential predictors of the outcomes.

METHODS

Review of neurosurgical files and hospital records, as well as community recruitment, yielded 169 participants, who were injured between ages 0-17 years and assessed between ages 18-30 years with at least five years post-injury. Each participant underwent a three-hour assessment. For data analysis, participants were grouped by type and number of injury.

RESULTS

The mTBI group exhibited some cognitive deficits but their performance fell between the control and moderate/severe TBI groups as expected. Those with one and multiple mTBI performed comparably across all cognitive domains. Cognitive outcomes were significantly predicted by estimated IQ but not by number of mTBI and age at injury.

CONCLUSION

Despite the detected cognitive deficits, those who sustained multiple mTBI did not exhibit worse or cumulative deficits compared to those with one mTBI.

Long-Term Neuropsychological Profiles and Their Role as Mediators of Adaptive Functioning after Traumatic Brain Injury in Early Childhood

The objectives of the study were to characterize long-term neuropsychological outcomes following traumatic brain injury (TBI) sustained during early childhood, and determine whether identified neuropsychological impairments mediated the effect of TBI on long-term adaptive functioning. Participants included 16 children with severe TBI, 42 children with moderate TBI, and 72 children with orthopedic injuries (OI) sustained between ages 3 and 7 years. Children completed neuropsychological tests and caregivers completed a structured interview of child adaptive functioning at 6.9 (±1.10) years post-injury. Profile analysis and multiple mediator modeling were employed. Children with severe TBI demonstrated poorer fluid reasoning and inhibitory control than both children with moderate TBI and OI, as well as slower processing speed than the OI group. Both fluid reasoning and processing speed were significant independent mediators of the effect of severe TBI on adaptive functioning. No neuropsychological measure significantly mediated the effect of moderate TBI on adaptive functioning. Children sustaining early severe TBI demonstrate persisting neuropsychological impairments into adolescence and young adulthood. The impact of severe TBI on children's long-term adaptive functioning is mediated in part by its effects on fluid reasoning and processing speed.

Topical review: negative behavioral and cognitive outcomes following traumatic brain injury in early childhood

OBJECTIVE

To summarize recent research on negative behavioral and cognitive outcomes following early childhood traumatic brain injury (TBI).

METHODS

Topical review of the literature published since the year 2000 examining behavioral and cognitive difficulties following TBI in early childhood.

RESULTS

Research findings from the reviewed studies demonstrate a variety of negative behavioral and cognitive outcomes following TBI in childhood, particularly for children <5 years of age. Negative outcomes include problems with externalizing behaviors, attention, language, and cognitive functioning (e.g., IQ, executive functioning). Furthermore, negative outcomes have been shown to persist up to 16 years following the injury.

CONCLUSIONS

The empirical studies reviewed demonstrate the increased risk for negative behavioral and cognitive outcomes following early childhood TBI. Furthermore, the review highlights current strengths and limitations of TBI research with young children and the need for multidisciplinary work examining outcomes for this vulnerable pediatric population.

Executive functions and theory of mind as predictors of social adjustment in childhood traumatic brain injury

This study examined whether executive function and theory of mind mediate the effects of pediatric traumatic brain injury (TBI) on social adjustment, relative to children with orthopedic injury (OI). Participants included 19 children with severe TBI, 41 children with complicated mild/moderate TBI, and 57 children with OI. They completed measures of executive function, as well as cognitive, affective, and conative theory of mind. Parents provided ratings of children's social adjustment. Children with severe TBI performed more poorly than children with OI on executive function and theory of mind tasks and were rated by parents as having more behavioral symptoms and worse communication and social skills. Executive function and theory of mind were positively correlated with social skills and communication skills, and negatively correlated with behavioral symptoms. In multiple mediator models, theory of mind and executive function were not significant direct predictors of any measure of social adjustment, but mediated the association between injury and adjustment for children with severe TBI. Theory of mind was a significant independent mediator when predicting social skills, but executive function was not. TBI in children, particularly severe injury, is associated with poor social adjustment. The impact of TBI on children's social adjustment is likely mediated by its effects on executive function and theory of mind.