What contributes to quality of life in adult survivors of childhood traumatic brain injury?

Exploring emotional distress symptom clusters in young adults with childhood traumatic brain injury

BACKGROUND

Depression, anxiety, and stress are persistent and co-occurring symptoms in survivors of childhood traumatic brain injury (TBI), and often impact on health-related quality of life (HRQoL). This paper explored emotional distress symptom clusters and associated factors in young adults with childhood TBI.

METHODS

We included 54 young adults who sustained mild (n = 14), moderate (n = 27), and severe (n = 13) childhood TBI, at 20 years post-injury. The Depression Anxiety Stress Scale was administered. Cluster group membership was identified using two-step clustering and hierarchical clustering methods, and associated factors were assessed with multiple regression models.

RESULTS

Two symptom cluster groups were identified, including a No Distress (n = 66%) and an Elevated Distress (n = 33%) group, with the latter showing significantly higher symptoms of depression, anxiety, and stress (all p < .001). Elevated Distress group membership was linked to tobacco use and poor sleep quality, while poor HRQoL was associated with younger age at injury and Elevated Distress group membership.

CONCLUSIONS

Using cluster methodology, we showed that one-third of young adults with childhood TBI had elevated emotional distress symptoms. This underscores the complex emotional profile of this subgroup and the need for assessment, analysis, and treatment methods that target a range of symptoms rather than relying on single-diagnostic protocols.

ABBREVIATIONS

ANOVA: Analysis of Variance; CT: Computed Tomography; DASS: Depression Anxiety Stress Scale; GCS: Glasgow Coma Scale; HREC: Human Research Ethics Committee; HRQoL: Health-Related Quality of Life; IBM: International Business Machines Corporation; MRI: Magnetic Resonance Imaging; PTA: Post-Traumatic Amnesia; QoL: Quality of Life; QOLIBRI: Quality of Life after Brain Injury Scale; REDCap: Research Electronic Data Capture; SES: Socioeconomic Status; SPSS: Statistical Package for the Social Sciences; TBI: Traumatic Brain Injury.

Biopsychosocial correlates of fatigue in young adult survivors of childhood traumatic brain injury: A prospective cohort study

This prospective cohort study aimed to evaluate the potential role of injury, socio-demographic and individual psychological factors in predicting long-term fatigue outcomes in young adult survivors of childhood TBI at 16-years post-injury. The study included 51 young adults diagnosed with childhood TBI from 2-12 years of age. Twenty age-and-sex-matched controls were included for comparison. Findings showed that almost one-in-four TBI participants (24%) endorsed clinically elevated fatigue at 16-years post-injury. Despite the relatively large proportion of TBI participants endorsing clinically significant fatigue, group comparisons revealed that the TBI and control groups did not significantly differ on fatigue symptom severity or rates of clinically elevated fatigue. For the TBI group, post-injury fatigue was significantly associated with socio-demographic and psychological factors, including lower educational level, higher depression symptom severity, and more frequent substance use. Higher fatigue was also associated with lower self-reported quality of life (QoL) in the physical, psychological, and environmental domains, even after controlling for depressive symptom severity, socio-demographic, and injury-related factors. Overall, findings show that a substantial proportion of young adults with a history of childhood TBI experience clinically elevated fatigue at 16-years post-injury. Identification and treatment of modifiable risk-factors (e.g. depression symptoms, substance use) has potential to reduce fatigue.

Environmental modifications to rehabilitate social behavior deficits after acquired brain injury: What is the evidence?

Social behavior deficits are a common, debilitating consequence of traumatic brain injury and stroke, particularly when sustained during childhood. Numerous factors influence the manifestation of social problems after acquired brain injuries, raising the question of whether environmental manipulations can minimize or prevent such deficits. Here, we examine both clinical and preclinical evidence addressing this question, with a particular focus on environmental enrichment paradigms and differing housing conditions. We aimed to understand whether environmental manipulations can ameliorate injury-induced social behavior deficits. In summary, promising data from experimental models supports a beneficial role of environmental enrichment on social behavior. However, limited studies have considered social outcomes in the chronic setting, and few studies have addressed the social context specifically as an important component of the post-injury environment. Clinically, limited high-caliber evidence supports the use of specific interventions for social deficits after acquired brain injuries. An improved understanding of how the post-injury environment interacts with the injured brain, particularly during development, is needed to validate the implementation of rehabilitative interventions that involve manipulating an individuals' environment.

Modulating chronic outcomes after pediatric traumatic brain injury: Distinct effects of social and environmental enrichment

Impairments in social and cognitive function are a common consequence of pediatric traumatic brain injury (TBI). Rehabilitation has the potential to promote optimal behavioral recovery. Here, we evaluated whether an enhanced social and/or cognitive environment could improve long-term outcomes in a preclinical model of pediatric TBI. Male C57Bl/6 J mice received a moderately-severe TBI or sham procedure at postnatal day 21. After one week, mice were randomized to different social conditions (minimal socialization, n = 2/cage; or social grouping, n = 6/cage), and housing conditions (standard cage, or environmental enrichment (EE), incorporating sensory, motor, and cognitive stimuli). After 8 weeks, neurobehavioral outcomes were assessed, followed by post-mortem neuropathology. We found that TBI mice exhibited hyperactivity, spatial memory deficits, reduced anxiety-like behavior, and reduced sensorimotor performance compared to age-matched sham controls. Pro-social and sociosexual behaviors were also reduced in TBI mice. EE increased sensorimotor performance, and the duration of sociosexual interactions. Conversely, social housing reduced hyperactivity and altered anxiety-like behavior in TBI mice, and reduced same-sex social investigation. TBI mice showed impaired spatial memory retention, except for TBI mice exposed to both EE and group housing. In the brain, while TBI led to significant regional tissue atrophy, social housing had modest neuroprotective effects on hippocampal volumes, neurogenesis, and oligodendrocyte progenitor numbers. In conclusion, manipulation of the post-injury environment has benefit for chronic behavioral outcomes, but the benefits are specific to the type of enrichment available. This study improves understanding of modifiable factors that may be harnessed to optimize long-term outcomes for survivors of early-life TBI.

A new model to guide identity-focused multidisciplinary rehabilitation for children and young people following acquired brain injury: I-FoRM

A complexity of biological, psychological, environmental and systemic factors influences a child's adaption after acquired brain injury (ABI), all of which transform as the child matures. Multidisciplinary rehabilitation teams are challenged by balancing family system needs and the child's needs, whilst promoting the child's functional skills in difficult or unappealing tasks. This paper presents the conceptual basis for a model for use in childhood ABI neurorehabilitation to address these challenges. A non-systematic narrative review of literature pertinent to integrated neurorehabilitation of pediatric ABI was conducted. Contemporary models of adult and pediatric psychosocial adaptation involving identity following ABI were reviewed. Key findings were then synthesized with models of pediatric resilience and self-concept development. The resulting model describes a cyclical adaptation process whereby the child learns experientially about their self and their world after ABI. Processes of identity development play a central role - particularly emotive processes of self-evaluation - by influencing the child's motivation for participation, tolerance for challenge, self-regulation and emerging self-awareness. The model directs clinicians to use the psychosocial processes of identity development to enhance the child's willingness and capacity to engage in the daily challenges of rehabilitation. Further systematic development and evaluation of the model is needed.

Social Cognition in Paediatric Traumatic Brain Injury: A Systematic Review and Meta-analysis

Recent evidence suggests social cognitive deficits may be among the most profound and disabling consequences of childhood traumatic brain injury (TBI); however, it is only over the last decade that this area has received increasing research attention. This study aims to systematically review all studies reporting on the effects of childhood TBI on social cognition. Meta-analytic techniques were employed to determine the magnitude of social cognitive deficits in childhood TBI. Literature searches were conducted in electronic databases (Medline/PubMed, Scopus, Cochrane, EMBASE, PsycINFO and CINAHL) to retrieve relevant articles on social cognitive outcomes of paediatric TBI published from 2007-2019. The systematic review identified fourteen eligible studies, which examined the effect of paediatric TBI on five dimensions of social cognition, including emotion recognition or perception, theory of Mind (ToM), pragmatic language, moral reasoning, and social problem solving. Of these studies, eleven articles were included in subsequent meta-analyses, which included 482 children with TBI. Meta-analysis using a random-effects model revealed non-significant differences between TBI and typically developing (TD) control groups on measures of emotion perception or recognition. In contrast, children and adolescents with TBI performed significantly worse than control groups on ToM and pragmatic language tasks, with small and medium effect sizes, respectively (Hedge's g = -0.46; -0.73). Meta-regression indicated that post-injury social cognitive deficits were not moderated by child age. While the effect of time since injury was not statistically significant, poorer social cognitive outcomes are documented soon after injury. Despite relatively intact basic social cognitive skills (i.e. emotion perception or recognition) children and adolescents with TBI are vulnerable to deficits in higher-order aspects of social cognition, including ToM and pragmatic language. These findings underscore the importance of further research, using well-validated, standardised outcome instruments, in larger paediatric TBI samples. Furthermore, longitudinal prospective studies are needed to evaluate the respective contribution of injury and non-injury factors to individual variation in outcome and recovery of social cognition after paediatric TBI.

Predictors of participation and quality of life following major traumatic injuries in childhood: a systematic review

OBJECTIVE

Review the literature on predictors of participation and quality of life in children and young people who sustained a traumatic brain injury (TBI), spinal cord injury (SCI), and/or multi-trauma in a motor vehicle or other accident or trauma.

DESIGN

This systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The protocol was registered on PROSPERO (registration number CRD42020131698). Electronic databases were searched for studies published between January 2000 and August 2020. Prospective and retrospective cohort studies were considered and risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

The search yielded 5771 articles of which 30 studies met the inclusion criteria. Nineteen studies included patients with TBI and 11 with SCI. No studies of patients with multi-trauma met criteria. Evidence was found for associations with various factors (e.g., injury severity, level of education, mental health problems), although these findings are limited due to the quality of the studies (5 studies moderate and 25 high risk of bias).

CONCLUSION

Research on predictors of participation and quality of life following major traumatic injuries in childhood is lacking. More methodologically sound prospective, longitudinal studies are needed across different injury groups to further elucidate predictors of outcome.IMPLICATIONS FOR REHABILITATIONWhile long-term participation and quality of life is influenced by injury characteristics (i.e., injury severity), a number of potential modifiable factors can be targeted to improve outcomes following traumatic injuries in childhood.Young people should be provided with support to stay in school and pursue further education.Early intervention and prevention of mental health problems may improve long-term outcomes.Better management of ongoing medical problems and greater support for functional independence may improve participation.

Sleep Disturbances in Young Adults with Childhood Traumatic Brain Injury: Relationship with Fatigue, Depression, and Quality of Life

OBJECTIVE

This study assessed the consequences of childhood traumatic brain injury (TBI) on sleep, fatigue, depression, and quality of life (QoL) outcomes and explored the relationships between these variables at 20 years following childhood TBI.

PARTICIPANTS

We followed up 54 young adults with mild, moderate, and severe TBI, and 13 typically developing control (TDC) participants, recruited at the time of TBI.

METHODS

Sleep was assessed with the Pittsburgh Sleep Quality Index and actigraphy.

RESULTS

At 20 years postinjury, results showed no significant difference between whole TBI group and TDC participants on subjective sleep quality; however, the moderate TBI group reported significantly poorer subjective sleep quality compared to those with severe TBI. Poorer subjective sleep was associated with increased symptoms of fatigue, depression, and poorer perceptions of General Health in the TBI group. Actigraphic sleep efficiency, fatigue, depression, and QoL outcomes were not significantly different between TBI and TDC or among TBI severity groups.

CONCLUSIONS

These preliminary findings underscore associations between subjective sleep disturbance, fatigue, depression, and QoL in this TBI sample, and mostly comparable outcomes in sleep, fatigue, depression, and QoL between the TBI and TDC groups. Further research is required to clarify these findings.

Pediatric traumatic brain injury and abusive head trauma

Childhood traumatic brain injury (TBI) commonly occurs during brain development and can have direct, immediately observable neurologic, cognitive, and behavioral consequences. However, it can also disrupt subsequent brain development, and long-term outcomes are a combination of preinjury development and abilities, consequences of brain injury, as well as delayed impaired development of skills that were immature at the time of injury. There is a growing number of studies on mild TBI/sport-related concussions, describing initial symptoms and their evolution over time and providing guidelines for effective management of symptoms and return to activity/school/sports. Mild TBI usually does not lead to long-term cognitive or academic consequences, despite reports of behavioral/psychologic issues postinjury. Regarding moderate to severe TBI, injury to the brain is more severe, with evidence of a number of detrimental consequences in various domains. Patients can display neurologic impairments (e.g., motor deficits, signs of cerebellar disorder, posttraumatic epilepsy), medical problems (e.g., endocrine pituitary deficits, sleep-wake abnormalities), or sensory deficits (e.g., visual, olfactory deficits). The most commonly reported deficits are in the cognitive-behavioral field, which tend to be significantly disabling in the long-term, impacting the development of autonomy, socialization and academic achievement, participation, quality of life, and later, independence and ability to enter the workforce (e.g., intellectual deficits, slow processing speed, attention, memory, executive functions deficits, impulsivity, intolerance to frustration). A number of factors influence outcomes following pediatric TBI, including preinjury stage of development and abilities, brain injury severity, age at injury (with younger age at injury most often associated with worse outcomes), and a number of family/environment factors (e.g., parental education and occupation, family functioning, parenting style, warmth and responsiveness, access to rehabilitation and care). Interventions should identify and target these specific factors, given their major role in postinjury outcomes. Abusive head trauma (AHT) occurs in very young children (most often <6 months) and is a form of severe TBI, usually associated with delay before appropriate care is sought. Outcomes are systematically worse following AHT than following accidental TBI, even when controlling for age at injury and injury severity. Children with moderate to severe TBI and AHT usually require specific, coordinated, multidisciplinary, and long-term rehabilitation interventions and school adaptations, until transition to adult services. Interventions should be patient- and family-centered, focusing on specific goals, comprising education about TBI, and promoting optimal parenting, communication, and collaborative problem-solving.

Self- and parent-reported Quality of Life 7 years after severe childhood traumatic brain injury in the Traumatisme Grave de l'Enfant cohort: associations with objective and subjective factors and outcomes

PURPOSE

To investigate self- and parent-reported Health-Related Quality-of-Life (HRQoL) and their associations after severe childhood traumatic brain injury (TBI) in the Traumatisme Grave de l'Enfant (TGE) cohort.

METHODS

Self- (n = 34) and/or parent-reports (n = 25) of HRQoL were collected for 38 participants (age 7-22 years) 7 years after severe childhood TBI. The collected data included sociodemographic characteristics, injury severity indices, and overall disability and functional outcome at 3-months, 1- and 2-years post-injury. At 7-years post-injury, data were collected in the TBI group and in a control group (n = 33): overall disability (Glasgow Outcome Scale Extended), intellectual ability (IQ), and questionnaires assessing HRQoL (Pediatric Quality of Life Inventory), executive functions (Behavior Rating Inventory of Executive Functions), behavior (Child Behavior Checklist), fatigue (Multidimensional Fatigue Scale) and participation (Child and Adolescent Scale of Participation).

RESULTS

Parent- and self-reports of HRQoL were significantly lower in the TBI group than in the control group. Parent-rated HRQoL was not associated with objectively assessed factors, whereas self-reported HRQoL was associated with gender (worse in females) and initial functional outcome. All questionnaire scores completed by the same informant (self or parent) were strongly inter-correlated.

CONCLUSIONS

Reported HRQoL 7-years after severe childhood TBI is low compared to controls, weakly or not-related to objective factors, such as injury severity indices, clinically assessed functional outcomes, or IQ, but strongly related to reports by the same informant of executive deficits, behavior problems, fatigue, and participation.

Objective sleep outcomes 20 years after traumatic brain injury in childhood

Purpose: To assess objective sleep outcomes and correlates in young adults with a history of childhood traumatic brain injury.Materials and methods: Participants included 45 young adults who sustained brain injury in childhood (mild = 12, moderate = 22, and severe = 11) and 13 typically developing control participants. Sleep was assessed with actigraphy and sleep diaries recorded over 14 consecutive days. Rates of good sleep (sleep efficiency ≥ 85%) and poor sleep (sleep efficiency < 85%) were also evaluated.Results: At 20-years postinjury, participants with traumatic brain injury and controls presented with similar outcomes across the objective sleep parameters (all p > 0.050) and rates of poor sleepers were also similar between these groups (p = 0.735): 67% and 77%, respectively. However, moderate and severe traumatic brain injury and female sex were associated with longer sleep duration.Conclusions: These findings provide preliminary insights into objective sleep outcome and associated factors in the very-long-term after childhood brain injuries. They also indicate the need to monitor sleep outcomes in young adults with and without traumatic brain injury.Implication for rehabilitationSustaining traumatic brain injury in childhood can impact on several functional domains including sleep.Sleep disturbances, particularly insomnia-related symptoms, are common in this population, with evidence of poor outcomes reported until adolescence postinjury, while outcomes beyond adolescence remain unexplored.In this first investigation of objective sleep outcomes in young adults with a history of childhood traumatic brain injury, we showed that insomnia-related symptoms are highly prevalent in both young adults with traumatic brain injury (67%) and healthy controls (77%).These findings suggest the need to routinely evaluate and treat sleep problem in young adults in general, irrespective of history of childhood traumatic brain injury.

Psychological and behavioural difficulties following severe TBI in adolescence: a comparison with a sample of peers with brain lesions of other origin and with a control group

OBJECTIVE

To describe behavioural and adjustment problems in a group of 57 adolescents with severe traumatic brain injury (TBI) and compare them with a clinical group of peers with brain lesions of other origin (N = 33) and a control group of healthy adolescents (N = 48).

METHODS

All subjects received an age-appropriate assessment, including the child behaviour checklist (CBCL) 4/18, the strengths and difficulties questionnaire (SDQ) and the vineland adaptive behaviour scales (VABS).

RESULTS

Compared with healthy peers, adolescents with TBI presented with more marked behavioural problems on most CBCL scales (Internalization and Externalization domains were both affected) and on the SDQ Hyperactivity and Peer problems scales. They also showed a more impaired functioning in most VABS domains. Compared with adolescents with brain lesions of other aetiology, patients with TBI showed more conduct problems on the SDQ scale, but no significant differences were found on the CBCL scales. Regarding the VABS, patients with other lesions presented with the worst outcome in the Motor and Daily Living Skills domains.

CONCLUSIONS

Adolescents with TBI are exposed at a very high risk to develop behavioural and psychological disturbances with the potential to severely affect their social re-entry. Further knowledge is needed to plan early and well-timed interventions.

"Trying to Get a Grip": Language Competence and Self-Reported Satisfaction With Social Relationships Three Decades Post-Childhood Traumatic Brain Injury

OBJECTIVE

(1) To investigate outcomes in language competence and self-reported satisfaction with social relationships in long-term survivors of childhood traumatic brain injury (TBI); and (2) to establish whether language competence contributes to self-reported satisfaction with social relationships decades after sustaining childhood TBI.

PARTICIPANTS

Twelve females and 8 males aged 30 to 55 (mean = 39.80, standard deviation = 7.54) years who sustained a TBI during childhood and were on average 31 years postinjury (standard deviation = 9.69). An additional 20 participants matched for age, sex, handedness, years of education, and socioeconomic status constituted a control group.

MAIN MEASURES

Test of Language Competence-Expanded Edition and the Quality of Life in Brain Injury questionnaire.

RESULTS

Individuals with a history of childhood TBI performed significantly poorer than their non-injured peers on 2 (Ambiguous Sentences and Oral Expression: Recreating Sentences) out of the 4 Test of Language Competence-Expanded Edition subtests used and on the Quality of Life in Brain Injury subscale assessing satisfaction with social relationships. In the TBI group, scores obtained on the Ambiguous Sentences subtest were found to be a significant predictor of satisfaction with social relationships, explaining 25% of the variance observed.

CONCLUSIONS

The implication of high-level language skills to self-reported satisfaction with social relationships many decades post-childhood TBI suggests that ongoing monitoring of emerging language skills and support throughout the school years and into adulthood may be warranted if adult survivors of childhood TBI are to experience satisfying social relationships.

Long-term classroom functioning and its association with neuropsychological and academic performance following traumatic brain injury during early childhood

OBJECTIVE

The present study utilized ecobehavioral assessment to examine classroom functioning several years following early childhood traumatic brain injury (TBI) or orthopedic injury (OI) and its association with injury factors, neuropsychological abilities, and academic performance.

METHOD

Participants included 39 children with moderate to severe TBI and 51 children with OI sustained between ages 3 and 7 years. At 7.2 (± 1.3) years post injury, ecobehavioral assessment was used to examine classroom functioning. Additional outcomes included neuropsychological tests, parent and teacher ratings of dysexecutive behavior, and teacher ratings of academic performance. Groups were compared on measures controlling for demographic characteristics, and associations among outcomes were examined using linear regression.

RESULTS

Children with TBI showed lower academic engagement relative to children with OI, as well as more frequent individual teacher attention for children with more severe injuries. For children with TBI, difficulties in classroom functioning were associated with lower cognitive flexibility and higher parent and teacher ratings of dysexecutive behavior. Lower scores on a test of fluid reasoning and a greater frequency of individual teacher attention were also associated with lower academic performance in children with TBI.

CONCLUSIONS

Difficulties in classroom functioning are evident several years after early childhood TBI and were associated with greater injury severity, neuropsychological weaknesses, and poorer academic performance. Children with impaired cognitive flexibility and fluid reasoning skills were at greatest risk for these difficulties and associated weaknesses in academic performance. Instructional interactions may be a potential target for intervention to promote academic progress in at-risk children. (PsycINFO Database Record

Psychological outcome after severe traumatic brain injury in adolescents and young adults: The chronic phase

OBJECTIVES

Young individuals surviving severe traumatic brain injury (TBI) frequently experience a wide range of cognitive, emotional and behavioural consequences. This cross-sectional follow-up study investigated psychological outcome of young survivors in the chronic phase, and whether psychological outcome was associated with improvement of functional abilities during sub-acute admission.

METHODS

Patients, who acquired a severe TBI during adolescence or early adulthood (n = 36) and received early intensive rehabilitation, were contacted for follow-up assessment concerning psychological outcome and completed the Adult Self Report 18-59 (ASR18-59). Demographic data, functional outcomes and severity measures were obtained from the local database.

RESULTS

The participants had a mean age of 24.1 years (SD = 4.1) at follow-up, and the mean time since injury was 72.1 months (SD = 44.2). Results showed significantly higher scores compared with the normative reference population in relation to the subscales withdrawal/isolation (p = 0.013), attention problems (p = 0.008) and intrusive behaviour (p = 0.046). Pearson correlation analyses showed that young survivors experiencing more functional improvement during inpatient rehabilitation had fewer psychological problems during the chronic phase in the subscales: withdrawal/isolation, rule breaking, intrusive behaviour and total problems.

CONCLUSION

Young patients reported psychological problems in several areas during the chronic phase of injury, which may hinder complete reintegration and participation in society. Larger functional improvement during sub-acute rehabilitation seemed to be associated with less psychological problems in the chronic phase.

Chapter 6 state of the science of pediatric traumatic brain injury: biomarkers and gene association studies

OBJECTIVES

Our objective is to review the most widely used biomarkers and gene studies reported in pediatric traumatic brain injury (TBI) literature, to describe their findings, and to discuss the discoveries and gaps that advance the understanding of brain injury and its associated outcomes. Ultimately, we aim to inform the science for future research priorities.

DATA SOURCES

We searched PubMed, MEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews for published English language studies conducted in the last 10 years to identify reviews and completed studies of biomarkers and gene associations in pediatric TBI. Of the 131 biomarker articles, only 16 were specific to pediatric TBI patients, whereas of the gene association studies in children with TBI, only four were included in this review.

CONCLUSION

Biomarker and gene attributes are grossly understudied in pediatric TBI in comparison to adults. Although recent advances recognize the importance of biomarkers in the study of brain injury, the limited number of studies and genomic associations in the injured brain has shown the need for common data elements, larger sample sizes, heterogeneity, and common collection methods that allow for greater understanding of the injured pediatric brain. By building on to the consortium of interprofessional scientists, continued research priorities would lead to improved outcome prediction and treatment strategies for children who experience a TBI.

IMPLICATIONS FOR NURSING RESEARCH

Understanding recent advances in biomarker and genomic studies in pediatric TBI is important because these advances may guide future research, collaborations, and interventions. It is also important to ensure that nursing is a part of this evolving science to promote improved outcomes in children with TBIs.

Health-related quality of life in children and youth with acquired brain injury: Two years after injury

OBJECTIVE

To determine health-related quality of life (HRQoL) in children and youth with acquired brain injury (ABI) two years post-injury and explore associated factors.

DESIGN

Cross-sectional.

SUBJECTS

Children and youth (n = 72; aged 6-22 years) with mild to severe ABI (87% mild).

METHODS

The primary outcome measures self-reported and parent-reported HRQoL were assessed with the Paediatric Quality of Life Inventory (PedsQL) and compared with age-appropriate reference values of the Dutch population. Spearman correlation coefficients (Rs) were used to explore relationships between HRQoL and sociodemographic and ABI characteristics, severity of impairments and presence of post-injury problems.

RESULTS

Children and youth with ABI and the reference population had similar self-reported HRQoL. However, as reported by parents, children with ABI aged 6-7 years and youth aged 13-18 years had poorer HRQoL regarding psychosocial health. Children's post-injury cognitive, behavioural and social problems were moderately associated with poorer HRQoL, especially psychosocial health (Rs ≥ 0.40). Severity nor type of injury were associated with children's HRQoL.

CONCLUSION

Two years post-injury, in children and youth with mild to severe ABI, reported HRQoL is similar to that in the general population, whereas parents reported less favourable outcomes. Post-injury cognitive, behavioural and social problems require ongoing attention during long-term follow-up.

Found in translation: Understanding the biology and behavior of experimental traumatic brain injury

The aim of this review is to discuss in greater detail the topics covered in the recent symposium entitled "Traumatic brain injury: laboratory and clinical perspectives," presented at the 2014 International Behavioral Neuroscience Society annual meeting. Herein, we review contemporary laboratory models of traumatic brain injury (TBI) including common assays for sensorimotor and cognitive behavior. New modalities to evaluate social behavior after injury to the developing brain, as well as the attentional set-shifting test (AST) as a measure of executive function in TBI, will be highlighted. Environmental enrichment (EE) will be discussed as a preclinical model of neurorehabilitation, and finally, an evidence-based approach to sports-related concussion will be considered. The review consists predominantly of published data, but some discussion of ongoing or future directions is provided.

Agreement on and predictors of long-term psychosocial development 16 years post-childhood traumatic brain injury

Childhood traumatic brain injury (CTBI) is one of the most common causes of childhood mortality and morbidity, with psychosocial impairment being among the most debilitating persisting consequences. Child and adolescent survivors of CTBI have fewer friends and lower self-esteem with a higher risk of developing a psychiatric disorder. In most research to date, findings in the psychosocial domain have been based on parent reports, with the child or adolescent only consulted infrequently. If there is a discrepancy identified between parent and child reported symptoms and behaviors, this is generally interpreted as resulting from impaired self-awareness in the child. The aim of this study was to 1) examine the agreement between self- and proxy-reported long-term psychosocial outcomes and 2) investigate the predictors of outcome 16 years post-CTBI. Thirty-three young adults (mean, 21.36 years; standard deviation, 2.75), with a CTBI sustained between 1 and 7 years of age, and a significant other completed questionnaires assessing the young adults' social and psychological functioning. Young adults and their significant other had good-to-excellent agreement on communication as well as alcohol and drug use scales. There was poorer agreement for the overall internalizing symptoms, anxious/depressed, withdrawn, thought, and rule-breaking behaviors. On the scales with poor agreement, there was no consistent contribution identified for any injury or preinjury factors. Preinjury adaptive behavior partly predicted withdrawn and overall internalizing symptoms, with a trend to also partly predict anxious/depressed and rule-breaking behavior reported by the significant other. Because young adults and significant others had poor agreement on the less-overt symptoms, these young adults may be at a higher risk of developing more-severe symptoms or disorders if it is not identified in time.

Sociosexual and communication deficits after traumatic injury to the developing murine brain

Despite the life-long implications of social and communication dysfunction after pediatric traumatic brain injury, there is a poor understanding of these deficits in terms of their developmental trajectory and underlying mechanisms. In a well-characterized murine model of pediatric brain injury, we recently demonstrated that pronounced deficits in social interactions emerge across maturation to adulthood after injury at postnatal day (p) 21, approximating a toddler-aged child. Extending these findings, we here hypothesized that these social deficits are dependent upon brain maturation at the time of injury, and coincide with abnormal sociosexual behaviors and communication. Age-dependent vulnerability of the developing brain to social deficits was addressed by comparing behavioral and neuroanatomical outcomes in mice injured at either a pediatric age (p21) or during adolescence (p35). Sociosexual behaviors including social investigation and mounting were evaluated in a resident-intruder paradigm at adulthood. These outcomes were complemented by assays of urine scent marking and ultrasonic vocalizations as indices of social communication. We provide evidence of sociosexual deficits after brain injury at p21, which manifest as reduced mounting behavior and scent marking towards an unfamiliar female at adulthood. In contrast, with the exception of the loss of social recognition in a three-chamber social approach task, mice that received TBI at adolescence were remarkably resilient to social deficits at adulthood. Increased emission of ultrasonic vocalizations (USVs) as well as preferential emission of high frequency USVs after injury was dependent upon both the stimulus and prior social experience. Contrary to the hypothesis that changes in white matter volume may underlie social dysfunction, injury at both p21 and p35 resulted in a similar degree of atrophy of the corpus callosum by adulthood. However, loss of hippocampal tissue was greater after p21 compared to p35 injury, suggesting that a longer period of lesion progression or differences in the kinetics of secondary pathogenesis after p21 injury may contribute to observed behavioral differences. Together, these findings indicate vulnerability of the developing brain to social dysfunction, and suggest that a younger age-at-insult results in poorer social and sociosexual outcomes.

Young adults’ perspectives on their psychosocial outcomes 16 years following childhood traumatic brain injury

Purpose

– Childhood traumatic brain injury (CTBI) is one of the most common causes of mortality and disability in children and adolescents that impacts on neuropsychological, social and psychological development. A disruption of development in these areas often results in long-term problems with interpersonal relationships, participation in leisure and social activities and employment status. These social and psychological problems appear to persist longer in comparison to other functional consequences, although evidence is scarce. The purpose of this paper is to investigate social and psychological outcomes 15 years post-injury.

Design/methodology/approach

– In all, 36 participants post-CTBI (mean age 21.47 years, SD=2.74), 16 males) and 18 healthy controls (mean age 20.94 years, SD=2.21), 12 males) were recruited from a larger sample of a longitudinal study conducted at the Royal Children's Hospital, Melbourne, Australia. Information about social and psychological functioning was collected via questionnaires completed at 15 years post-injury.

Findings

– Results showed that post-CTBI, adolescents and young adults reported elevated risk of developing psychological problems following their transition into adulthood. CTBI survivors reported greatest problems on internalizing symptoms such as depression, anxiety and withdrawal.

Social implications

– Despite the reported psychological symptoms, the survivors of CTBI did not report more social problems than their peers. Further research is needed to identify long-term social and psychological problems so that optimal intervention may be provided.

Originality/value

– This is the first perspective longitudinal study investigating the young adults perspective of their long-term psychosocial outcomes following CTBI.

Depression and health related quality of life in adolescent survivors of a traumatic brain injury: a pilot study

Traumatic brain injury is (TBI) a leading cause of morbidity and mortality in youth. Adult survivors of a severe pediatric TBI are vulnerable to global impairments, including greater employment difficulties, poor quality of life (HRQoL) and increased risk of mental health problems. When estimating the health related quality of life in adolescents, the presence of anxiety and depression and the quality of social relationships are important considerations, because adolescents are entrenched in social development during this phase of maturation. The influence of anxiety, depression and loneliness on health related quality of life in adolescent survivors of TBI has not been documented. This pilot study aimed to identify and measure the relationship between anxiety, depression and loneliness and perceived health related quality of life in adolescent survivors of a TBI.

METHOD

mixed method/cohort pilot study (11 adolescents, mild to severe TBI; 9 parents), using self-report and proxy-report measures of anxiety, depression, health related quality of life, loneliness and clinical psychiatric interviews (adolescent only).

RESULTS

Self-reported depression was significantly correlated with self-reported HRQoL (rs [11] = -0.88, p<0.001). Age at injury was significantly correlated with self-reported HRQoL (rs [11] = -0.68, p = 0.02). Self-reported depression predicted self-reported HRQoL (R2 = 0.79, F [1, 10] = 33.48, p<0.001), but age at injury did not (R2 = 0.19, F [1, 10] = 2.09, p = 0.18).

CONCLUSIONS

Our results suggest that depression is a predictor of health related quality of life in youth post-TBI. The possibility of using targeted assessment and therapy for depression post-TBI to improve health related quality of life should be explored.

Subjective impact of traumatic brain injury on long-term outcome at a minimum of 10 years after trauma- first results of a survey on 368 patients from a single academic trauma center in Germany

Background

Traumatic Brain Injury (TBI) may lead to significant impairments in personal, social and professional life. However, knowledge of the influence on long-term outcome after TBI is sparse. We therefore aimed to investigate the subjective effects of TBI on long-term outcome at a minimum of 10 years after trauma in one of the largest study populations in Germany.

Methods

The current investigation represents a retrospective cohort study at a level I trauma center including physical examination or standardized questionnaires of patients with mild, moderate or severe isolated TBI with a minimum follow-up of 10 years. We investigated the subjective physical, psychological and social outcome evaluating the Glasgow Outcome Scale, short-form 12, and social as well as vocational living circumstances.

Results

368 patients aged 0 to 88 years were included. Patients with severe TBI were younger compared to patients with moderate or mild TBI (p < 0.05). Patients with severe TBI lived more often as single after the trauma impact. A significantly worse outcome was associated with higher severity of TBI resulting in an increased incidence of mental disability. A professional decline was analyzed in case of severe TBI resulting in significant loss of salary.

Conclusions

The severity of TBI significantly influenced the subjective social and living conditions. Subjective mental and physical outcome as well as professional life depended on the severity of TBI 10 years after the injury.

A preliminary investigation into psychosocial outcome and quality-of-life in adolescents following childhood traumatic brain injury

OBJECTIVE

This study investigated the long-term psychosocial outcome and quality-of-life (QoL) of 15-18 year olds, sustaining childhood traumatic brain injury (TBI) between birth and 5 years.

METHOD

Thirty-three participants (17 TBI parent-proxies, 16 control parent-proxies) were involved in the present study which compared parent-ratings for the TBI group and healthy controls on the Sydney Psychosocial Reintegration Scale-Child form (SPRS-C) and the Paediatric Quality of Life Inventory (PedsQL).

RESULTS

Despite comparable overall psychosocial reintegration scores, parents reported that their teens with TBI were more likely to experience poor QoL compared to controls. On further analysis, some aspects of psychosocial outcome appear to be compromised following childhood TBI.

CONCLUSIONS

Interventions targeting childhood TBI must consider QoL in addition to symptom reduction and be extended throughout adolescence. The limitations of the sample size are cause for concern; however, preliminary results do validate the need for future research efforts.

Social competence at 6 months following childhood traumatic brain injury

Children with traumatic brain injury (TBI) are at risk for social impairment. This study aimed to examine social function at 6 months post-TBI and to explore the contribution of injury, cognitive, and environmental influences. The sample included 136 children, 93 survivors of TBI, and 43 healthy controls. TBI participants were recruited on admission and underwent magnetic resonance imaging scan within 8 weeks of injury and behavioral assessment at 6 months post-injury. Healthy controls underwent magnetic resonance imaging scans and behavioral assessment on recruitment. Assessment included parent and child questionnaires tapping social outcome and child-direct testing of cognitive abilities important for social competence (communication, attention/executive function, social cognition). Injury characteristics and environmental measures were collected. At 6-months post-injury, social problems were evident, but not global. Social participation appeared most vulnerable, with more severe injuries leading to greater problems. Greater injury severity and poorer communication skills were associated with poorer social adjustment and social participation, with the impact of family function also significant. Processing speed, younger age, and male gender also contributed to social outcomes. Further follow-up is required to track the recovery of social skills and the changing influences of cognition, brain, and environment over time.

Persistence of disability 24 to 36 months after pediatric traumatic brain injury: a cohort study

This study examined the outcome of 0- to 17-year-old children 36 months after traumatic brain injury (TBI), and ascertained if there was any improvement in function between 24 and 36 months. Controls were children treated in the emergency department for an arm injury. Functional outcome 36 months after injury was measured by the Pediatric Quality of Life Inventory (PedsQL), the self-care and communication subscales of the Adaptive Behavior Assessment Scale-2nd edition (ABAS-II), and the Child and Adolescent Scale of Participation (CASP). At 36 months after TBI, those with moderate or severe TBI continued to have PedsQL scores that were 16.1 and 17.9 points, respectively, lower than at baseline, compared to the change seen among arm injury controls. Compared to the baseline assessment, children with moderate or severe TBI had significantly poorer functioning on the ABAS-II and poorer participation in activities (CASP). There was no significant improvement in any group on any outcomes between 24 and 36 months. Post-injury interventions that decrease the impact of these deficits on function and quality of life, as well as preventive interventions that reduce the likelihood of TBI, should be developed and tested.

Health-related quality of life of individuals with traumatic brain injury in Barranquilla, Colombia

OBJECTIVE

To assess health-related quality of life (HRQoL) of individuals with traumatic brain injury (TBI) in Barranquilla, Colombia.

PARTICIPANTS/METHODS

Thirty-one individuals with TBI and 61 healthy controls completed the SF-36, a self-report HRQoL measure composed of eight component areas: physical health problems, pain, role limitations due to physical problems or due to emotional problems, emotional well-being, social functioning, energy/fatigue and general health perceptions.

RESULTS

The samples were statistically similar with respect to age, gender and education and statistically different with respect to depression, SES, social support and cognition. Compared to healthy controls, individuals with TBI had significantly lower means on all SF-36 sub-scales. However, after adjusting for depression, SES, social support and cognitive performance, significant differences remained on three of the SF-36 sub-scales. Specifically, individuals with TBI had lower adjusted means on Role-Physical (p-value < 0.005), Role-Emotional (p-value < 0.005) and Bodily Pain (p-value < 0.05).

CONCLUSION

Even after controlling for depression, SES, social support and cognitive performance, individuals with TBI living in Barranquilla Colombia report having poorer quality of life across various domains, including Role-Physical, Role-Emotional and Bodily Pain. These findings suggest the need for rehabilitation health professionals to develop and implement culturally-appropriate interventions to improve quality of life in Colombian individuals with TBI.

Quality of life in children and adolescents post-TBI: a systematic review and meta-analysis

Traumatic brain injury is (TBI) a leading cause of morbidity and mortality in children and adolescents in first-world nations. Research from our team investigating adult survivors of pediatric TBI indicate that survivors of severe TBI are particularly vulnerable to global impairments, including poorer school performance, greater employment difficulties, poor quality of life (QoL), and increased risk of mental health problems. Investigation into less observable consequences, including QoL, has emerged recently as an important outcome to assess in TBI populations. The status of QoL in pediatric TBI populations is mixed, likely a reflection of the varied methodological and theoretical perspectives on QoL.

AIM

This systematic study will clarify the nature of QoL in survivors of pediatric TBI, and identify predictors of QoL in this group. Of 419 articles identified, 11 studies met our inclusion criteria, and 9 were ultimately analyzed in this review. Four studies reported good QoL and 5 poor QoL. The difference between good and poor QoL was statistically significant due to TBI severity [chi-square(3)=77.38, p<0.001], timing of outcome assessment [chi-square(1)=565, p<0.001], and definition of QoL [chi-square(3)=34.73, p<0.001]. The odds of having a poor QoL increased 5.8 times (RR=1.21) when injuries were more severe. Good outcomes are contingent on milder injuries, proxy reporting, and early assessment, whereas poor outcomes reflect more severe injuries and later assessment (≤ 6 months versus ≥ 1 year post-trauma, respectively).

Social function in children and adolescents after traumatic brain injury: a systematic review 1989-2011

Clinical reports and case studies suggest that traumatic brain injury (TBI) can have significant social consequences, with social dysfunction reported to be the most debilitating problem for child and adolescent survivors. From a social neuroscience perspective, evidence suggests that social skills are not localized to a specific brain region, but are mediated by an integrated neural network. Many components of this network are susceptible to disruption in the context of TBI. In early development, a brain injury can disrupt this neural network while it is in the process of being established, resulting in social dysfunction. In order to clarify the prevalence and nature of social dysfunction after child TBI, studies of social outcomes in children and adolescents after TBI over the last 23 years have been reviewed. Despite casting a wide net initially, only 28 articles met review criteria. These studies were characterized by methodological weaknesses, including variations in definitions of TBI, limited assessment tools, reliance on parent reports, small sample sizes, and absent control groups. Despite these limitations, the weight of evidence confirmed an elevated risk of social impairment in the context of moderate and severe injury. While rarely examined, younger age at insult, pathology to frontal regions and the corpus callosum, and social disadvantage and family dysfunction may also increase the likelihood of social difficulties. More research is needed to obtain an accurate picture of social outcomes post-brain injury.

Recovery from medial prefrontal cortex injury during adolescence: implications for age-dependent plasticity

Focal cortical injuries generate various behavioral deficits associated with different morphological changes. The age and the area of the injury determine the nature and extent of recovery represented by the level of performance in various behavioral tasks. Previously, we have shown that motor cortex injury in early (but not late) adolescence leads to behavioral deficits that do not recover spontaneously with time. Considering the fact that the pace of brain maturation differs in different brain areas, we undertook to examine the pattern of spontaneous recovery following medial prefrontal cortex (mPFC) lesion in early or late adolescence. A battery of motor tasks (postural asymmetry, skilled reaching, sunflower seed manipulation, forepaw inhibition in swimming) was used to investigate the pattern of behavioral recovery following mPFC lesions. Golgi-Cox analysis was used to examine dendritic reorganization of the relevant brain areas. The results indicated that rats perform poorly when receiving mPFC injuries in late adolescence in contrast to when they receive the lesion in early adolescence. Almost opposite pattern of recovery following motor cortex and medial prefrontal injuries in early and late adolescence will be discussed as an age-area dependent model for prognosis of brain injury during adolescence.

10 years outcome from childhood traumatic brain injury

Childhood traumatic brain injury (TBI) is a common, acquired disability, which has significant implications for subsequent development, and for later quality of life. To date few studies have documented outcomes in these children into adolescence, when academic, social and personal demands increase. The objective of this study was to document functional outcomes at 10 years post-injury, and to identify predictors of outcome including injury, socio-demographic and pre-injury characteristics. The study employed consecutive recruitment to a prospective, longitudinal study. Children with a diagnosis of TBI between 2 and 12 years were initially recruited and divided according to injury severity (mild, moderate, severe). The sample was reviewed at 10 years post-injury and intellectual, adaptive, executive and social domains were investigated. Results indicated that, at 10 years post child TBI, survivors' functional abilities fell overall within the low average to average range regardless of injury severity, suggesting no extreme impairments at a group level for any of the domains under investigation. Significant group differences were identified, though, for adaptive abilities and for speed of processing, with more severe injury associated with poorer performances in each instance. Further, a similar trend was identified for measures of intellectual ability and executive functions. Individual rates of impairment were considerably higher than population expectations across all severity groups for these domains. Although rates of social impairment were also elevated, they were less related to injury factors, suggesting that cognitive/adaptive outcomes and social consequences of TBI may have different bases.

Disability 3, 12, and 24 months after traumatic brain injury among children and adolescents

OBJECTIVE

To examine disability in children and adolescents after traumatic brain injury (TBI) across the spectrum of injury severity.

METHODS

This was a prospective cohort study of children younger than 18 years treated for a TBI (n = 729) or an arm injury (n = 197) between March 1, 2007, and September 30, 2008. The main outcome measures were disability in health-related quality of life, adaptive skills, and participation in social and community activities 3, 12, and 24 months after injury compared with preinjury functioning.

RESULTS

The health-related quality of life for children with moderate or severe TBI was lower at all follow-up times compared with baseline, but there was some improvement during the first 2 years after injury. Three months after injury, there was a substantial decrease in the level of activities in which children with moderate and severe TBI were able to participate; these activities improved at 12 and 24 months but were still significantly impaired. Communication and self-care abilities in children with moderate and severe TBI were lower at 3 months than at baseline and did not improve by 24 months. Children who met the definition of mild TBI but had an intracranial hemorrhage had lower quality-of-life scores at 3 months.

CONCLUSIONS

Children with moderate or severe TBI and children with mild TBI who had intracranial hemorrhage had substantial long-term reduction in their quality of life, participation in activities with others, and ability to communicate and care for themselves.

Quality of life in pediatric mild traumatic brain injury and its relationship to postconcussive symptoms

OBJECTIVES

Mild traumatic brain injury (TBI) and injury-related outcomes such as postconcussive symptoms (PCS) may influence health-related quality of life (HRQOL) in children.

METHODS

We evaluated HRQOL in 186 8- to 15-year-old children with mild TBI and 99 children with orthopedic injuries (OI). Parents rated the frequency and severity of PCS at an initial assessment within 2-weeks postinjury and rated HRQOL at 3- and 12-months postinjury.

RESULTS

The mild TBI and OI groups did not differ in psychosocial HRQOL, but the mild TBI group showed lower physical HRQOL at the 12-month follow-up. Somatic PCS were a significant predictor of physical HRQOL over time, and both cognitive and somatic PCS were significant predictors of psychosocial HRQOL over time. Children with higher PCS at the initial assessment had lower HRQOL scores at later time points.

CONCLUSIONS

Effective management of PCS may be associated with improvements in HRQOL following pediatric mild TBI.

Community integration following severe childhood traumatic brain injury

PURPOSE OF REVIEW

Severe childhood traumatic brain injury (TBI) is the leading cause of death and acquired disability in children, causing impairments in children's sensory-motor, cognitive and behavioural functioning, with devastating consequences on community integration. Community integration is the ultimate goal of rehabilitation; it is a complex outcome, with many variables contributing to it.

RECENT FINDINGS

Community integration and quality of life (QOL) are lower in children who sustained severe TBI at a younger age. Further, a wide range of injury-related, demographic and postinjury factors influence outcomes, and should serve as targets for specific interventions. An increasing number of interventions targeting cognitive, behavioural or family-related issues have been developed, with promising results.

SUMMARY

Children should benefit from early integrated patient and family-centred specific care, and receive long-term follow-up until early adulthood, with regular assessments, enabling detection and treatment of any emerging problem, and to ensure the acquisition of independent living skills and stable vocational outcome when this is possible. So far, few well conducted intervention studies are available, but their number is increasing with positive results on the trained skills. Well designed studies using large samples and looking at generalization of the skills in everyday life are needed.