Social and behavioral outcomes: pre-injury to six months following childhood traumatic brain injury

Twenty Years of Blast-Induced Neurotrauma: Current State of Knowledge

Blast-induced neurotrauma (BINT) is an important injury paradigm of neurotrauma research. This short communication summarizes the current knowledge of BINT. We divide the BINT research into several broad categories-blast wave generation in laboratory, biomechanics, pathology, behavioral outcomes, repetitive blast in animal models, and clinical and neuroimaging investigations in humans. Publications from 2000 to 2023 in each subdomain were considered. The analysis of the literature has brought out salient aspects. Primary blast waves can be simulated reasonably in a laboratory using carefully designed shock tubes. Various biomechanics-based theories of BINT have been proposed; each of these theories may contribute to BINT by generating a unique biomechanical signature. The injury thresholds for BINT are in the nascent stages. Thresholds for rodents are reasonably established, but such thresholds (guided by primary blast data) are unavailable in humans. Single blast exposure animal studies suggest dose-dependent neuronal pathologies predominantly initiated by blood-brain barrier permeability and oxidative stress. The pathologies were typically reversible, with dose-dependent recovery times. Behavioral changes in animals include anxiety, auditory and recognition memory deficits, and fear conditioning. The repetitive blast exposure manifests similar pathologies in animals, however, at lower blast overpressures. White matter irregularities and cortical volume and thickness alterations have been observed in neuroimaging investigations of military personnel exposed to blast. Behavioral changes in human cohorts include sleep disorders, poor motor skills, cognitive dysfunction, depression, and anxiety. Overall, this article provides a concise synopsis of current understanding, consensus, controversies, and potential future directions.

Caregiver report of social-emotional functioning in infants and young children after inflicted traumatic brain injury

Social-emotional difficulties are common sequelae of traumatic brain injury (TBI). Children who have experienced inflicted TBI (iTBI) may be at increased risk for social-emotional problems due to the risk factors associated with both early neurologic injury and with child maltreatment. We characterized the associations among injury severity, caregiver type (i.e., biological parents, non-kinship, kinship), and child social-emotional functioning in 41 infants and young children who had sustained iTBI and were seen in a large, regional children's hospital. This study was a retrospective analysis, utilizing data collected from the medical record as part of routine clinical care. Social-emotional functioning was assessed with the Bayley Scales of Infant and Toddler Development-Third Edition. Children with more severe injuries were rated as having worse social-emotional functioning. Caregiver type was associated with child social-emotional scores, above and beyond injury and demographic predictors. Biological parents were more likely to report better social-emotional skills than non-kinship caregivers, with the pattern of results suggesting that rater bias plays a role in this difference. In order to ensure that children are accurately identified for supports, these relationships should be considered when interpreting caregiver report of social-emotional skills.

A randomized controlled trial of cognitive behavioural therapy for managing anxiety in adolescents with acquired brain injury

The aim of this randomized controlled trial was to evaluate an adapted cognitive behavioural therapy (CBT) programme for treating anxiety in adolescents with acquired brain injury (ABI). Participants with ABI (12-19 years, N = 36) recruited from two sites were randomly allocated into either the intervention receiving 11 sessions of CBT (n = 19) or a wait-list control group (n = 17). The primary outcome was participants' anxiety and secondary outcomes were participants' depression, self-perception, and participation in daily activities, and parental stress, measured at (i) pre-intervention, (ii) immediately post-intervention, (iii) 2 months post-intervention and (iv) 6 months post-intervention. Repeated measures ANOVAs revealed significant treatment effects with the intervention group demonstrating greater improvements in self-reported anxiety, as well as self- and parent-reported depression from pre- to immediately post-treatment, compared to wait-list controls. Little evidence of treatment effects was found for the remaining outcomes (parent-reported anxiety, self-perception, daily participation, and parental stress). Significant improvement in self-reported anxiety found immediately post-treatment was maintained at two- and six-month follow-up. Findings provide support for adapted CBT as an effective means of reducing anxious and depressive symptomatology in adolescents with ABI compared to waitlist controls, and offer support for the use of these techniques to manage anxiety in this population.

Field assessment of acute auditory responses to environmental exposures in close quarters tactics training

OBJECTIVE

The purpose of this study was to evaluate auditory performance of military instructors as part of a training course involving noise and blast exposure. Boothless audiometry was used to estimate the test-retest reliability of the auditory measures under realistic field conditions and to determine risk of acute auditory injury during standard training practices.

DESIGN AND STUDY SAMPLE

Thirteen U.S. Marine instructors participated in study activities. An audiologic testing suite embedded in a noise-attenuating headset was used to test various tone detection tasks on subjects after exposure. Acoustic exposures were captured with sound level meters.

RESULTS

Boothless audiometry provide highly repeatable results for various tests of auditory performance in the field environment. In this test population, changes in auditory performance pre- and post-noise exposure were minimal for most measures. The notable exception was binaural (NoSπ) tone detection, which showed significant degradations both as a function of pre- and post-noise exposure on the same day and as a result of cumulative noise exposure over the period of the study.

CONCLUSIONS

Study outcomes are consistent with prior laboratory and epidemiological work and suggest a link between the binaural processes required for NoSπ detection and the hearing-related issues reported by blast-exposed service members.

The Australian and New Zealand brain injury lifespan cohort protocol: Leveraging common data elements to characterise longitudinal outcome and recovery

INTRODUCTION

Cognitive, behavioural, academic, mental health and social impairments are common following paediatric traumatic brain injury (TBI). However, studies are often reliant on small samples of children drawn from narrow age bands, and employ highly variable methodologies, which make it challenging to generalise existing research findings and understand the lifetime history of TBI.

METHOD AND ANALYSIS

This study will synthesise common data sets from national (Victoria, New South Wales, Queensland) and international (New Zealand) collaborators, such that common data elements from multiple cohorts recruited from these four sites will be extracted and harmonised. Participant-level harmonised data will then be pooled to create a single integrated data set of participants including common cognitive, social, academic and mental health outcome variables. The large sample size (n=1816), consisting of participants with mild, moderate and severe TBI, will provide statistical power to answer important questions that cannot be addressed by small, individual cohorts. Complex statistical modelling, such as generalised estimation equation, multilevel and latent growth models, will be conducted.

ETHICS AND DISSEMINATION

Ethics approval was granted by the Human Research Ethics Committee (HREC) of the Royal Children's Hospital (RCH), Melbourne (HREC Reference Number 2019.168). The approved study protocol will be used for all study-related procedures. Findings will be translated into clinical practice, inform policy decisions, guide the appropriate allocation of limited healthcare resources and support the implementation of individualised care.

Social Functioning and Autistic Behaviors in Youth Following Acquired Brain Injury

Children and adolescents who survive the pediatric intensive care unit (PICU) with an acquired brain injury (ABI) often demonstrate a variety of physical, cognitive, emotional/behavioral, and social sequelae termed post-intensive care syndrome (PICS). Social communication and interaction challenges have also been observed clinically, and there is growing literature documenting these occurrences in youth following ABI. The extent of these social changes varies among patients, and a subset of patients go on to exhibit social and behavioral profiles closely resembling those of autistic youth. We reviewed empirical research regarding social functioning in youth following ABI, as well as the overlap between individuals with ABI and autistic youth, published from January 2009 to August 2022 on PubMed and Scopus databases. Clinical case examples from a well-established post-PICU follow-up program are also provided to exemplify the complexity of this phenomenon.

More to the story than executive function: Effortful control soon after injury predicts long-term functional and social outcomes following pediatric traumatic brain injury in young children

OBJECTIVE

To examine the impact of early traumatic brain injury (TBI) on effortful control (EC) over time and the relationship of EC and executive functioning (EF) to long-term functional and social outcomes.

METHOD

Parents of children (N = 206, ages 3-7) with moderate-to-severe TBI or orthopedic injuries (OIs) rated EC using the Child Behavior Questionnaire at 1 (pre-injury), 6, 12, and 18 months post-injury. Child functioning and social competence were assessed at 7 years post-injury. Mixed models examined the effects of injury, time since injury, and their interaction on EC. General linear models examined the associations of pre-injury EC and EC at 18 months with long-term functional and social outcomes. Models controlled for EF to assess the unique contribution of EC to outcomes.

RESULTS

Children with severe TBI had significantly lower EC than both the OI and moderate TBI groups at each post-injury time point. Both pre-injury and 18-month EC were associated with long-term outcomes. Among those with low EC at baseline, children with moderate and severe TBI had more functional impairment than those with OI; however, no group differences were noted at high levels of EC. EC had main effects on parent-reported social competence that did not vary by injury type.

CONCLUSIONS

Findings suggest that EC is sensitive to TBI effects and is a unique predictor of functional outcomes, independent of EF. High EC could serve as a protective factor, and as such measures of EC could be used to identify children for more intensive intervention.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Convergent validity of the child behavior checklist sleep items in children with moderate to severe traumatic brain injury

AIM

The Child Behavior Checklist (CBCL) includes several sleep items. We aimed to examine the convergent validity of CBCL sleep scores with validated sleep measures, and to explore their functional correlates.

METHODS

This cross-sectional study included 44 children with moderate to severe TBI, aged 6-15 years. Parents completed the CBCL and Sleep Disturbance Scale for Children (SDSC), and children wore actigraphy watches.

RESULTS

We found significant, albeit differential, associations between CBCL and SDSC sleep scores. Specifically: (i) "trouble sleeping" with SDSC total score, (ii) "trouble sleeping" and "nightmares" with SDSC initiating and maintaining sleep, (iii) "talks/walks in sleep" with SDSC arousal, and (iv) "overtired," "sleeps more" and CBCL sleep composite with SDSC excessive somnolence. The CBCL item "sleeps less" was the only significant predictor of functioning; children who slept less had lower social competence. No associations were found between CBCL sleep scores and actigraphy.

CONCLUSIONS

The CBCL does not provide a comprehensive assessment of sleep disturbances in children with moderate to severe TBI. Nevertheless, certain CBCL sleep items demonstrate initial convergent validity with subscales of the SDSC assessing select types of sleep disturbances. The CBCL may be useful in research and clinical situations when administration of more comprehensive assessment sleep tools is not viable.

Met and unmet rehabilitative needs among pediatric patients with moderate to severe TBI

OBJECTIVE

Estimate the probability of met and unmet post-acute rehabilitative needs among pediatric patients with moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

One hundred and thirty children who received acute and post-acute rehabilitative services at a hospital for children.

METHODS

Prospective, observational study. Recommended service needs (1. Medical, 2. Psychological, 3. Cognitive/Educational, 4. Medically Based Therapies, 5. Community/Caregiver/Family Support) were collected at discharge and 1, 6, 12, and 18 months post-injury. Probabilities were estimated using nonlinear logistic regression models. The impact of age at discharge was also assessed.

RESULTS

Over time, the estimated probability of need for Medical, Medically Based Therapies, and Cognitive/Educational services were consistently high. Whereas unmet need for Medical and Medically Based Therapies were low, unmet need for Cognitive/Educational services were relatively high. Need for Psychological and Community/Caregiver/Family Support services increased in the months post-discharge, as did the probability of unmet need. Older age at discharge was associated with need for Psychological and Community/Caregiver Family Support services.

CONCLUSIONS

Findings support the long-term monitoring of need for Psychological and Community/Caregiver/Family Support services among children with moderate to severe TBI. Future research to explore the etiology of unmet needs is warranted.

Emotional Aspects of Pediatric Post-Intensive Care Syndrome Following Traumatic Brain Injury

Children with traumatic brain injury (TBI) requiring neurocritical care are at risk for neurocognitive, emotional, physical, and psychosocial difficulties, collectively known as Post-Intensive Care Syndrome. Our study assessed parent-reported emotional functioning and identified risk factors for emotional sequelae in the acute recovery phase. Fifty-three children between 5 and 18 years old hospitalized for TBI were assessed 1-month following discharge. Relevant injury-, child-, and family-specific variables were collected. Emotional functioning was assessed using PROMIS Parent Proxy Report Short Forms for Anxiety and Depressive Symptoms. We used Chi-square tests to evaluate differences between children with and without elevations in anxiety and depressive symptoms. Logistic regression determined predictors of elevations in symptoms among significant variables. Parents frequently endorsed moderate or worse anxiety (45.2%) and depressive (32.1%) symptoms among children. Mechanism of injury and elevated parent post-traumatic stress disorder (PTSD) symptoms were associated with elevated anxiety and depressive symptoms, while direct family involvement in the accident/injury was associated only with elevated anxiety symptoms. Results from logistic regression indicated that only elevated parent PTSD symptoms were a significant predictor for child anxiety and depressive symptoms. Anxiety and depressive symptoms are prevalent in the acute recovery phase of TBI. Consistent with previous research, elevations in anxiety and depressive symptoms were more related to psychosocial factors than injury severity. High levels of parent PTSD symptoms and their relationship with children's internalizing symptoms highlight the need for mental health treatment for TBI patients and their families.

Personality Traits and Social Supports in Adolescents With Persistent Postconcussion Symptoms

OBJECTIVES

To determine whether adolescents with persistent postconcussion symptoms (PPCS) differ from healthy peers in their personality traits and social supports.

SETTING

Specialty Concussion Clinic and Primary Care Clinic affiliated with an academic medical center.

PARTICIPANTS

Ninety-seven adolescents (42 with PPCS, 55 healthy peers; age: 15 ± 2 years).

DESIGN

Participants completed a web-based survey that included medical and demographic characteristics, mechanisms of concussion, 10-item Big Five Inventory, and Child and Adolescent Social Support Scale. A Student's 2-tailed t test with multiple testing corrections was used to compare the youths with PPCS to healthy peers.

MAIN MEASURES

The primary outcome was PPCS, defined by the presence of 2 or more concussion-related symptoms on the Post-Concussion Symptom Scale (PCSS), lasting for more than 4 weeks after initial injury. The secondary outcome was perceived personality traits and social support, based on the 10-item Big Five Inventory and the Child and Adolescent Social Support Scale, respectively.

RESULTS

The PPCS group had higher neuroticism scores on their Big Five Inventory than healthy peers. They also reported less social support from teachers and classmates than healthy peers.

CONCLUSION

Youths with PPCS report specific personality and social support characteristics that differ from their peers. These findings suggest that individual personality and school-based social supports may influence concussion recovery.

Parent-reported family impact in children and young adults with acquired brain injury in the outpatient rehabilitation setting

Purpose: To increase knowledge/awareness on family impact (FI) after acquired brain injury (ABI) in rehabilitation settings, it is essential to investigate the associations between patient-functioning and impact on families. This has been explored in hospital-based cohorts, but not in rehabilitation settings.Methods: A cross-sectional, multi-center study among parents of children/young adults (aged 5-24 years) with ABI referred to rehabilitation was performed. Patient/injury/family-characteristics were noted, and parents completed the PedsQL™Family-Impact-Module and PedsQL™generic-core-4.0 to assess FI and health-related quality of life (HRQoL). Univariate- and multivariable-regression analyses were performed to investigate associations between HRQoL/patient/injury/family-related factors and FI.Results: 246 families participated; patients' median age was 14 year (IQR 11-16), 65 had non-traumatic-brain-injury (nTBI) (26%), 127 were female. FI was found to be considerable (median FIM-score 71.9, IQR:60-85). Especially referral to rehabilitation >6 months after onset, diminished patients' mental/emotional health and HRQoL (child/family factors), and premorbid problems were associated with higher FI.Conclusions: In this rehabilitation cohort, pediatric ABI caused considerably higher FI than in hospital-based studies with referral to rehabilitation >6 months, diminished child/family factors and presence of premorbid problems increasing FI. Assessing and monitoring FI and its associated factors enables professionals to individualize treatment, psychoeducation, support and follow-up.

Participation Restrictions among Children and Young Adults with Acquired Brain Injury in a Pediatric Outpatient Rehabilitation Cohort: The Patients' and Parents' Perspective

Improving participation is an important aim in outpatient rehabilitation treatment. Knowledge regarding participation restrictions in children and young adults with acquired brain injury (ABI) is scarce and little is known regarding the differences in perspectives between patients and parents in the outpatient rehabilitation setting. The aims are to describe participation restrictions among children/young adults (5–24 years) with ABI and investigating differences between patients’ and parents’ perspectives. At admission in 10 rehabilitation centers, patients and parents were asked to complete the Child and Adolescent Scale of Participation (CASP; score 0–100; lower score = more restrictions) and injury/patient/family-related questions. CASP scores were categorized (full/somewhat-limited/limited/very-limited participation). Patient/parent-reported outcomes were compared using the Wilcoxon signed-rank test. 223 patients and 245 parents participated (209 paired-samples). Median patients’ age was 14 years (IQR; 11–16), 135 were female (52%), 195 had traumatic brain injury (75%). The median CASP score reported by patients was 82.5 (IQR: 67.5–90) and by parents 91.3 (IQR: 80.0–97.5) (difference = p < 0.05). The score of 58 patients (26%) and 25 parents (10%) was classified as ‘very-limited’. Twenty-six percent of children and young adults referred for rehabilitation after ABI had “very-limited” participation. Overall, parents rated their child’s participation better than patients themselves. Quantifying participation restrictions after ABI and considering both perspectives is important for outpatient rehabilitation treatment.

Psychosocial functioning at 4-years after pediatric mild traumatic brain injury

Objective: Behavioral and emotional difficulties are reported following pediatric mild traumatic brain injury (TBI). But few studies have used a broad conceptual approach to examine children's long-term psychosocial outcomes. This study examines children's psychosocial outcomes at 4-years after mild TBI and associated factors.Methods: Parents of 93 children (<16 years) with mild TBI completed subscales of age-appropriate versions of the Strengths and Difficulties Questionnaire, the Behavior Rating Inventory of Executive Function, the Pediatric Quality of Life Inventory, and the Adolescent Scale of Participation questionnaire at 4-years post-injury.Results: Mean group-level scores were statistically significantly higher for hyperactivity/inattention and lower for emotional functioning than published norms. Levels of participation were greater compared to those observed in normative samples. More than 19% met published criteria for clinically significant hyperactivity/inattention, emotional functioning problems, peer relationship problems, and social functioning difficulties. Lower family socio-economic status and greater parental anxiety and depression were associated with overall psychosocial difficulties.Conclusions: Findings indicate that as a group, children with mild TBI are characterized by elevated rates of behavioral, emotional, and social difficulties at 4-years post-injury. Parent mental health may be an untapped opportunity to support children's psychosocial development following mild TBI, with replication required in larger samples.

Caregiver and Child Behavioral Health Service Utilization Following Pediatric Traumatic Brain Injury

Given sparse literature examining receipt of behavioral health service in children and caregivers following traumatic brain injury (TBI), we sought to identify predictors of unmet need. We performed an individual participant data meta-analysis using generalized linear mixed-effect models to examine predictors of behavioral health service use and unmet need. We included 572 children, ages 3 to 18, who were hospitalized overnight following complicated mild to severe TBI between 2002 and 2015. Caregivers completed ratings of depression and distress, child behavior problems, family functioning, and behavioral health service utilization. For children, unmet behavioral health service need was defined as an elevation on one or more child behavior problem scales without receipt of behavioral health services. For caregivers, unmet need was defined as an elevation on either a depression or distress scale without behavioral health service utilization. Among those with behavioral health needs, rates of unmet need were high for both children (77.8%) and caregivers (71.4%). Poorer family functioning was related to more unmet need in children (F(1, 497) = 6.57, p = 0.01; OR = 1.8) and caregivers (F(1, 492) = 17.54, p < 0.001; OR = 2.7). Children with unmarried caregivers also had more unmet behavioral health service need than those with married caregivers (F(1, 497) = 12.14, p < 0.001; OR = 2.2). In conclusion, unmet needs are common after pediatric TBI and relate to family factors. The findings underscore the importance of monitoring service needs following pediatric TBI and point to disparities in service use.

Activities and Participation in the First 6 Months After Mild Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI).

METHODS

A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers.

MAIN MEASURES

Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning.

RESULTS

Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level.

DISCUSSION

Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

[Formula: see text] Investigation of children and adolescents' mood and self-concept after acquired brain injury

Few studies have examined the self-reported mental health of children with an acquired brain injury (ABI). The current study aimed to: 1) identify levels of child-reported depressive and anxiety symptoms and poor self-concept, 2) investigate demographic and injury-related factors associated with children's mood and self-concept, and 3) examine associations between children's self-reported mental health and parents' reports of children's emotional and behavioral functioning in children specifically with traumatic brain injury (TBI). 122 children (66% male) aged 8-16 years with ABI of mixed etiology were consecutively recruited through an outpatient rehabilitation clinic. Children were administered the Beck Youth Inventories - Second Edition, and parents completed the Adaptive Behavior Assessment System and the Child Behavior Checklist (CBCL). Relative to the norms, 16.4% of children scored in the clinical range for the depression and anxiety scales, and 24.6% reported clinically low self-concept. Children with lower functional status had greater anxiety symptoms. Older children (13-16 years) reported significantly higher depressive and anxiety symptoms and lower self-concept than younger children (8-12 years). A significant interaction between age and sex indicated that older girls reported greater depressive and anxiety symptoms than younger girls whereas no age-based differences were found for boys. Parent-reported total emotional and behavioral problems were positively associated with children's self-reported depressive and anxiety symptoms and were negatively correlated with self-concept. These findings indicate that adolescents, particularly girls, may be at heightened risk of poor mental health following ABI. Further research investigating the reasons for these demographic differences may inform developmentally sensitive interventions.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents

OBJECTIVE

This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI).

METHODS

A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors.

RESULTS

Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045).

DISCUSSION

Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Exploring the role of perceived vs. observed behavioral outcomes in parental grief reaction following pediatric acquired brain injury

BACKGROUND

Pediatric acquired brain injury may result in a significant gap between the "pre" and "post-injury" child.

OBJECTIVE

We aimed to quantitatively explore the mechanism underlying parents' loss experience by examining the mediating role of behavioral outcomes (observed-problems and perceived-change) in the relationship between injury severity and grief.

METHOD

The study employed a cross-sectional retrospective design and comprised 40 parents of children (aged 3-18 years) with moderate-severe brain injury. Data for each parent included an adapted version of the Two-Track Bereavement Questionnaire and Socio-demographics; Data for each child included the child's Information Processing Speed Index; the Child Behavioral Checklist and Parental Perception of Behavioral Changes scale.

RESULTS

Slowed information processing speed was significantly associated with elevated ratings on both measures of behavioral outcomes and with intensified grief. Mediation analyses revealed that parental perceived behavioral change, significantly mediate the relationship between information processing speed and grief; the Child Behavioral Checklist total score also mediated the same relationship but only in 90% confidence interval.

CONCLUSIONS

Findings reveal the adverse impact of behavioral outcomes on grief and suggest parents' loss experience to be stemming primarily from their subjective perception over their "changed-child", rather than the observed problems. Implications for clinical practice are discussed.

Recovery Trajectories of Child and Family Outcomes Following Online Family Problem-Solving Therapy for Children and Adolescents after Traumatic Brain Injury

OBJECTIVES

We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time.

METHODS

We examined data from 359 children with complicated mild to severe TBI, aged 5-18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent-child conflict).

RESULTS

We found a main effect for measure for both child and family outcomes [F(3, 731) = 7.35, p < .001; F(3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [t(731) = -5.15, p < .001, and t(731) = -3.90, p = .002, respectively, for child outcomes; t(532) = -4.81, p < .001, and t(532) = -3.80, p < .001, respectively, for family outcomes].

CONCLUSIONS

The results suggest limited differences in the measures' responsiveness to treatment while highlighting OFPST's utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.

Participation seven years after severe childhood traumatic brain injury. Disabil Rehabil 2019;42:2402-2411. [PMID: 30950661 DOI: 10.1080/09638288.2019.1594398]

Purpose: Participation in home, school and community activities is considered as the ultimate aim of rehabilitation. The aims of this study were to examine participation seven years post-severe childhood traumatic brain injury and factors associated with participation.Materials and methods: Participants were enrolled in the Traumatisme Grave de l'Enfant (Severe Childhood Injury) cohort study following severe accidental childhood traumatic brain injury. Participation seven years post-injury, was examined using parent- and self-report forms of the Child and Adolescent Scale of Participation among 37 patients [62% males, mean age 15.4 years (SD = 4.4), mean length of coma 6.68 days (SD = 4.96)] and 33 matched controls.Results: Parent reports indicated significantly lower participation among patients compared to controls, but the self-reports did not. In the traumatic brain injury group, parent-reported participation was variable, with 22% of the patients clearly showing greater restrictions than controls. Participation restrictions were significantly associated with injury severity, poor functional outcome one-year post-injury, executive and behavioral difficulties and higher fatigue levels seven years post-injury, but not with pre-injury nor family factors.Conclusions: Several years after severe childhood traumatic brain injury, participation appears to depend more on injury-related factors than on environmental factors. In self-reports assessments of participation, it could be difficult for children and adolescents to distinguish capacity from performance.Implications for rehabilitationParticipation outcomes were highly variable in a sample of patients who sustained severe childhood traumatic brain injury.Participation should be assessed systematically following severe traumatic brain injury, both initially but also in the long-term, ideally using a combination of self- and proxy-report measures.Among patients with severe injuries, the influence of initial brain injury severity markers on participation seems much stronger than that of social/family environment factors.Children's and adolescents' self-reported participation assessed with the Child and Adolescent Scale of Participation may be difficult to interpret.

Neurological outcome in children and youth with acquired brain injury 2-year post-injury

OBJECTIVE

To determine neurological outcome in children and youth with acquired brain injury (ABI) and explore associated factors.

DESIGN

Cross-sectional study, two-years post-injury.

PATIENTS

Hospital-based sample (n=112) aged 6-22 years.

METHODS

Neurological outcome and participation were assessed with a multidimensional neurological examination and the Child and Adolescent Scale of Participation. Logistic regression analyses were used to explore the relationships.

RESULTS

Both sensorimotor and cognitive deficits were found in 30-31%, language deficits and behavioural deficits in 10-17%. Non-traumatic injury had a negative impact on neurological outcome, specifically regarding sensorimotor and language deficits. Lower education level showed a significantly poorer neurological outcome. High levels of age-expected participation were reported, with a significant relation between deficits and participation restrictions, especially at school.

CONCLUSION

One out of three have a poor neurological outcome, related to type of injury and lower level of education. The amount of deficits is associated with participation restrictions.

Community-based interventions for adolescents following traumatic brain injury: A systematic review

BACKGROUND

Chronic impairment following childhood traumatic brain injury has the potential to increase risk of negative outcomes. This highlights potential value in community-based rehabilitation programs.

OBJECTIVES

To identify research studies examining existing intervention programmes available in community-based rehabilitation to adolescents following TBI to assist with the transition back into the community.

METHODS

A systematic review of community-based interventions was conducted across different national contexts. All included studies involved a clinical population with TBI, aged 11 to 25 years inclusive. Risk of bias was rated for each included study.

RESULTS

Seventeen studies were identified for inclusion in the review, of these eleven distinct interventions were found. The quality of evidence was largely weak and highly variable.

CONCLUSION

The results suggest some improvement in adolescent outcomes following community-based interventions, however higher quality evidence is needed to support specific interventions.

The Cellie Coping Kit for Children with Injury: Initial feasibility, acceptability, and outcomes

PURPOSE

Physical and psychological challenges can arise from paediatric injury, which can impact child health outcomes. Evidence-based resources to promote recovery are limited. The low cost, portable Cellie Coping Kit for Children with Injury provides evidence-based strategies to help children manage injury-related challenges. This study aimed to describe intervention feasibility and explore initial outcomes (learning, quality of life [QOL], and trauma symptoms).

METHODS

Three independent pilot studies were conducted. Child-parent dyads (n = 61) participated in the intervention; ~36% completed a 4-week follow-up assessment.

RESULTS

Results suggested that the intervention was feasible (e.g., 95% of parents would recommend the intervention; >85% reported that it was easy to use). Over 70% of participants reported learning new skills. No statistically significant differences were detected for children's QOL or trauma symptoms preintervention to postintervention.

CONCLUSION

Preliminary research suggests that the Cellie Coping Kit for Children with Injuries is a feasible, low-cost, preventive intervention, which may provide families with strategies to promote recovery from paediatric injury. Future research, including a randomized controlled trial, ought to further examine targeted long-term intervention outcomes.

Effect of concussion history on symptom burden and recovery following pediatric sports-related concussion

OBJECTIVE The aim of this study was to examine differences in symptom burden and duration until physician-documented clinical recovery among pediatric patients with sports-related concussion (SRC) with and without a history of concussion. METHODS A retrospective chart review was performed for all pediatric patients (7-19 years old) referred to the Pan Am Concussion Program in Winnipeg, Canada, with an SRC and evaluated < 30 days postinjury between September 1, 2013, and August 1, 2015. RESULTS A total of 322 patients with SRC (64.91% male, mean age 13.96 years) who were evaluated a median of 7 days (interquartile range [IQR] 5-11 days) postinjury were included. Patients without a history of concussion endorsed significantly fewer concussion symptoms at initial assessment (median 5.5 symptoms, IQR 1-10 symptoms) than those with a previous concussion (median 7 symptoms, IQR 2-13.25 symptoms; p = 0.036). The median Post-Concussion Symptom Scale scores were 9 (IQR 1-23) for patients with no concussion history and 13 (IQR 3-33) for those with a history of concussion (p = 0.032). For patients with no previous concussion, the median number of days until physician-documented clinical recovery was 23 (IQR 15-44 days) compared with 25 days (IQR 18-43 days) for those with a history of concussion (p = 0.281). There was no significant difference in the proportion of patients who experienced delayed time until physician-documented clinical recovery (> 1 month postinjury) between the groups (p = 0.584). CONCLUSIONS Although a history of concussion may be associated with increased symptom burden following pediatric SRC, there was no difference in the time until physician-documented clinical recovery. Pediatric patients with SRC who have a history of concussion should be managed on an individualized basis. Future work is needed to examine the short- and long-term effects of multiple concussions in children and adolescents.

Predicting Fatigue 12 Months after Child Traumatic Brain Injury: Child Factors and Postinjury Symptoms

OBJECTIVES

Fatigue is a common and persisting symptom after childhood brain injury. This study examined whether child characteristics and symptomatology preinjury or 6 months postinjury (pain, sleep, and mood, inattention) predicted fatigue at 12months postinjury.

METHODS

Parents of 79 children (0-18 years) rated fatigue at 12 months after injury on a multidimensional scale (general, sleep/rest, and cognitive). Demographic and clinical data were collected at injury. Parents rated child sleep, pain, physical/motor function, mood, and inattention at injury (preinjury description), and 6 months postinjury. Children were divided into two traumatic brain injury severity groups: mild TBI (n=57) and moderate/severe TBI (n=27). Hierarchical regression models were used to examine (i) preinjury factors and (ii) symptoms 6 months postinjury predictive of fatigue (general, sleep/rest, and cognitive) at 12 months postinjury.

RESULTS

Sleep/rest fatigue was predicted by preinjury fatigue (7% of variance) and psychological symptoms preinjury (10% of variance). General fatigue was predicted by physical/motor symptoms (27%), sleep (10%) and mood symptoms (9%) 6 months postinjury. Sleep/rest fatigue was predicted by physical/motor symptoms (10%), sleep symptoms (13%) and mood symptoms (9%) 6 months postinjury. Cognitive fatigue was predicted by physical/motor symptoms (17%) 6 months postinjury.

CONCLUSIONS

Preinjury fatigue and psychological functioning identified those at greatest risk of fatigue 12 months post-TBI. Predictors of specific fatigue domains at 12 months differed across each of the domains, although consistently included physical/motor function as well as sleep and mood symptoms postinjury. (JINS, 2018, 24, 224-236).

White matter microstructure predicts longitudinal social cognitive outcomes after paediatric traumatic brain injury: a diffusion tensor imaging study

BACKGROUND

Deficits in social cognition may be among the most profound and disabling sequelae of paediatric traumatic brain injury (TBI); however, the neuroanatomical correlates of longitudinal outcomes in this domain remain unexplored. This study aimed to characterize social cognitive outcomes longitudinally after paediatric TBI, and to evaluate the use of sub-acute diffusion tensor imaging (DTI) to predict these outcomes.

METHODS

The sample included 52 children with mild complex-severe TBI who were assessed on cognitive theory of mind (ToM), pragmatic language and affective ToM at 6- and 24-months post-injury. For comparison, 43 typically developing controls (TDCs) of similar age and sex were recruited. DTI data were acquired sub-acutely (mean = 5.5 weeks post-injury) in a subset of 65 children (TBI = 35; TDC = 30) to evaluate longitudinal prospective relationships between white matter microstructure assessed using Tract-Based Spatial Statistics and social cognitive outcomes.

RESULTS

Whole brain voxel-wise analysis revealed significantly higher mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) in the sub-acute TBI group compared with TDC, with differences observed predominantly in the splenium of the corpus callosum (sCC), sagittal stratum (SS), dorsal cingulum (DC), uncinate fasciculus (UF) and middle and superior cerebellar peduncles (MCP & SCP, respectively). Relative to TDCs, children with TBI showed poorer cognitive ToM, affective ToM and pragmatic language at 6-months post-insult, and those deficits were related to abnormal diffusivity of the sCC, SS, DC, UF, MCP and SCP. Moreover, children with TBI showed poorer affective ToM and pragmatic language at 24-months post-injury, and those outcomes were predicted by sub-acute alterations in diffusivity of the DC and MCP.

CONCLUSIONS

Abnormal microstructure within frontal-temporal, limbic and cerebro-cerebellar white matter may be a risk factor for long-term social difficulties observed in children with TBI. DTI may have potential to unlock early prognostic markers of long-term social outcomes.

Post-concussive symptoms after a mild traumatic brain injury during childhood and adolescence

OBJECTIVE

Mild traumatic brain injury (mTBI) is common injury during childhood and adolescence but the long-term outcomes are poorly understood. This study examined post-concussive symptoms and behavioural outcomes in children and adolescents up to 24 months post-mTBI.

METHOD

Parents of children aged 8-15 years with mTBI completed the BASC-2 and Rivermead Post-Concussion Symptoms Questionnaire at baseline, 1-, 6-, 12- and 24 months post-injury. An age-matched traumatic brain injury-free cohort was recruited and assessed at 12- and 24 months.

RESULTS

PCSs decreased significantly over the first 12 months post-injury. At 12- and 24 months post-injury, the mTBI group reported more PCSs and behavioural symptoms compared to controls. Parents of children with mTBI were more likely to report ≥4 problematic PCS symptoms (28% at both time points) compared to controls (7.7% and 1.7% at 12 and 24 months, respectively). The mTBI group was 4.63 times more likely to have four or more ongoing PCS symptoms at 12 months post-injury compared to controls. Headache was the most common acute post-injury symptom (55%), while the most commonly reported persistent symptoms were irritability, frustration, forgetfulness and fatigue.

CONCLUSIONS

PCSs are common 2 years post-mTBI in childhood or adolescence. Given this, additional intervention and support is needed for families post-injury.

Pragmatic skills after childhood traumatic brain injury: Parents' perspectives

The purpose of this study was to characterize pragmatic deficits after childhood traumatic brain injury (TBI) within the home environment social contexts where they occur. We used a descriptive qualitative approach to describe parents' experiences in communicating with their child with TBI. Participants were ten mothers of children ages 6-12 years who had sustained a moderate to severe TBI more than one year prior to the study. Mothers' experiences were collected through semi-structured interviews and questionnaires. Interviews were analyzed using a deductive framework to develop social contexts and pragmatic deficit themes for communication in the home. Overall, mothers primarily described their children with TBI as exhibiting average or near average pragmatic skills at home, but nine observed some pragmatic deficits and/or social behavior problems. There were four in-home social contexts in which pragmatic deficits were observed. Emergent themes also included outside-of-the home social contexts and social behavior problems. There was some overlap of pragmatic deficit and social behavior problem themes among contexts, but many deficits were context specific. This study's pragmatic deficit themes expanded on prior childhood TBI pragmatic investigations by identifying contexts in and outside of the home in which pragmatic deficits may occur after TBI. Learning Outcomes Readers will be able to describe the day-to-day social contexts that may be impacted by pragmatic deficits after childhood TBI. Readers will be able to compare the pragmatic deficit themes identified as occurring in the home to those occurring outside of the home.

The effect of socio-economic status on non-fatal outcome after injury: A systematic review

BACKGROUND

Over the past decades, the number of survivors of injuries has rapidly grown. It has become important to focus more on the determinants of non-fatal outcome. Although socio-economic status (SES) is considered to be a fundamental determinant of health in general, the role of SES as a determinant of non-fatal outcome after injury is largely unknown.

METHODS

An online search was conducted in November 2015 using Embase, Medline, Web of Science, Cinahl, Cochrane, Google scholar and PubMed. Studies examining the relation between SES and a physical or psychological outcome measure, or using SES as a confounder in a general trauma population were included. There were no restrictions regarding study design. The 'Quality in Prognostic Studies tool' was used to assess the methodological quality of the included studies.

RESULTS

The 24 included studies showed large variations in methodological quality. The number of participants ranged from 56 to 4639, and assessments of the measures ranged from immediately to 6year post-injury. Studies used a large number of variables as indicators of SES. Participant's educational level was used most frequently. The majority of the studies used a multivariable technique to analyse the relation between SES and non-fatal outcome after injury. All studies found a positive association (80% of studies significant, n=19) between increased SES and better non-fatal outcome after injury.

CONCLUSION

Although an adequate and valid measure of SES is lacking, the results of this review showed that SES is an important determinant of non-fatal outcome after injury. Future research should focus on the definition and measurement of SES and should further underpin the effect of SES on non-fatal outcome after injury.

Social and Behavioral Outcomes following Childhood Traumatic Brain Injury: What Predicts Outcome at 12 Months Post-Insult?

This study sought to investigate social and behavioral outcomes 12 months following childhood traumatic brain injury (TBI) and to identify predictors of these outcomes. The study also compared rates of impairment in social and behavioral outcomes at 12 months post-injury between children with TBI and a typically developing (TD) control group. The study comprised 114 children ages 5.5 to 16.0 years, 79 with mild, moderate, or severe TBI and 35 TD children, group-matched for age, sex and socio-economic status. Children with TBI were recruited via consecutive hospital admissions and TD children from the community. Social and behavioral outcomes were measured via parent-rated questionnaires. Analysis of covariance models identified a significant mean difference between the mild and moderate groups for social problems only, but the moderate and severe TBI groups showed a higher rate of impairment, particularly in externalizing problems. Pre-injury function, injury severity, parent mental health, and child self-esteem all contributed significantly to predicting social and behavioral outcomes. Both injury and non-injury factors should be considered when identifying children at risk for long-term difficulties in social and behavioral domains.

Sex-dependent changes in neuronal morphology and psychosocial behaviors after pediatric brain injury

Chronic social behavior problems after pediatric traumatic brain injury (TBI) significantly contribute to poor quality of life for survivors. Using a well-characterized mouse model of early childhood TBI, we have previously demonstrated that young brain-injured mice develop social deficits by adulthood. As biological sex may influence both normal and aberrant social development, we here evaluated potential sex differences in post-TBI psychosocial deficits by comparing the behavior of male and female mice at adulthood (8 weeks post-injury). Secondly, we hypothesized that pediatric TBI would influence neuronal morphology identified by Golgi-Cox staining in the hippocampus and prefrontal cortex, regions involved in social cognition and behavior, before the onset of social problems (3 weeks post-injury). Morphological analysis of pyramidal neurons in the ipsilateral prefrontal cortex and granule cells of the hippocampal dentate gyrus revealed a reduction in dendritic complexity after pediatric TBI. This was most apparent in TBI males, whereas neurons from females were less affected. At adulthood, consistent with previous studies, TBI males showed deficits in sociability and social recognition. TBI females also showed a reduction in sociability, but intact social recognition and increased sociosexual avoidance. Together, these findings indicate that sex is a determinant of regional neuroplasticity and social outcomes after pediatric TBI. Reduced neuronal complexity in the prefrontal cortex and hippocampus, several weeks after injury in male mice, appears to precede the subsequent emergence of social deficits. Sex-specific alterations in the social brain network are thus implicated as an underlying mechanism of social dysfunction after pediatric TBI.

A Systematic Review of Psychiatric, Psychological, and Behavioural Outcomes following Mild Traumatic Brain Injury in Children and Adolescents

BACKGROUND

Evidence regarding longer-term psychiatric, psychological, and behavioural outcomes (for example, anxiety, mood disorders, depression, and attention disorders) following mild traumatic brain injury (mTBI) in children and adolescents has not been previously synthesized.

OBJECTIVE

To conduct a systematic review of the available evidence examining psychiatric, psychological, and behavioural outcomes following mTBI in children and adolescents.

MATERIALS AND METHODS

Nine electronic databases were systematically searched from 1980 to August 2014. Studies selected met the following criteria: original data; study design was a randomized controlled trial, quasi-experimental design, cohort or historical cohort study, case-control study, or cross-sectional study; exposure included mTBI (including concussion); population included children and adolescents (<19 years) at the time of mTBI, as well as a comparison group (for example, healthy children, children with orthopaedic injuries); and included psychiatric, psychological, or behavioural outcomes (for example, anxiety, mood disorders, depression, attention disorders). Two authors independently assessed the quality and level of evidence with the Downs and Black (DB) criteria and Oxford Centre of Evidence-Based Medicine (OCEBM) model, respectively, for each manuscript.

RESULTS

Of 9472 studies identified in the initial search, 30 were included and scored. Heterogeneity in methodology and injury definition precluded meta-analyses. The median methodological quality for all 30 studies, based on the DB criteria, was 15/33 (range 6 to 19). The highest level of evidence demonstrated by all reviewed studies was level 2b based on OCEBM criteria, with the majority (28/30 studies) classified at this level. Based on the literature included in this systematic review, psychological and psychiatric problems in children with a history of mTBI were found to be more prevalent when mTBI is associated with hospitalization, when assessment occurs earlier in the recovery period (that is, resolves over time), when there are multiple previous mTBIs, in individuals with preexisting psychiatric illness, when outcomes are based on retrospective recall, and when the comparison group is noninjured healthy children (as opposed to children with injuries not involving the head).

CONCLUSIONS

Overall, few rigorous prospective studies have examined psychological, behavioural, and psychiatric outcomes following mTBI. In the absence of true reports of preinjury problems and when ideally comparing mild TBI to non-TBI injured controls, there is little evidence to suggest that psychological, behavioural, and/or psychiatric problems persist beyond the acute and subacute period following an mTBI in children and adolescents.

Social dysfunction after pediatric traumatic brain injury: A translational perspective

Social dysfunction is common after traumatic brain injury (TBI), contributing to reduced quality of life for survivors. Factors which influence the development or persistence of social deficits after injury remain poorly understood, particularly in the context of ongoing brain maturation during childhood and adolescence. Aberrant social interactions have recently been modeled in adult and juvenile rodents after experimental TBI, providing an opportunity to gain new insights into the underlying neurobiology of these behaviors. Here, we review our current understanding of social dysfunction in both humans and rodent models of TBI, with a focus on brain injuries acquired during early development. Modulators of social outcomes are discussed, including injury-related and environmental risk and resilience factors. Disruption of social brain network connectivity and aberrant neuroendocrine function are identified as potential mechanisms of social impairments after pediatric TBI. Throughout, we highlight the overlap and disparities between outcome measures and findings from clinical and experimental approaches, and explore the translational potential of future research to prevent or ameliorate social dysfunction after childhood TBI.

Frontal Lobe Contusion in Mice Chronically Impairs Prefrontal-Dependent Behavior

Traumatic brain injury (TBI) is a major cause of chronic disability in the world. Moderate to severe TBI often results in damage to the frontal lobe region and leads to cognitive, emotional, and social behavioral sequelae that negatively affect quality of life. More specifically, TBI patients often develop persistent deficits in social behavior, anxiety, and executive functions such as attention, mental flexibility, and task switching. These deficits are intrinsically associated with prefrontal cortex (PFC) functionality. Currently, there is a lack of analogous, behaviorally characterized TBI models for investigating frontal lobe injuries despite the prevalence of focal contusions to the frontal lobe in TBI patients. We used the controlled cortical impact (CCI) model in mice to generate a frontal lobe contusion and studied behavioral changes associated with PFC function. We found that unilateral frontal lobe contusion in mice produced long-term impairments to social recognition and reversal learning while having only a minor effect on anxiety and completely sparing rule shifting and hippocampal-dependent behavior.

Modeling community integration in workers with delayed recovery from mild traumatic brain injury

Background

Delayed recovery in persons after mild traumatic brain injury (mTBI) is poorly understood. Community integration (CI) is endorsed by persons with neurological disorders as an important outcome. We aimed to describe CI and its associated factors in insured Ontario workers with delayed recovery following mTBI.

Methods

A cross-sectional study of insured workers in the chronic phase following mTBI was performed at a rehabilitation hospital in Ontario, Canada. Sociodemographic, occupational, injury-related, clinical, and claim-related data were collected from self-reports, medical assessments, and insurers’ referral files. Community Integration Questionnaire (CIQ) scores were compared using analysis of variance or Spearman’s correlation tests. Stepwise multivariable linear regression models were used to evaluate the associations with CI.

Results

Ninety-four workers with mTBI (45.2 ± 9.9 years old, 61.2 % male) at 197 days post-injury (interquartile range, 139–416 days) were included. The CIQ total and subscale scores were similar to those reported in more severe TBI samples. The CIQ scores were moderately to strongly correlated with various sociodemographic, claim-related, and clinical variables. In the multivariable regression analysis, several covariates accounted for 36.4 % of the CIQ variance in the final fully adjusted model.

Discussion

This study evaluated CI in workers with mTBI, and analyzed its associated variables. Analysis revealed insomnia, head or neck pain, being married or in a relationship, time since injury, and a diagnosis of possible/probable malingering were independently associated with limited CI.

Conclusions

Workers with delayed recovery from mTBI experience difficulty with CI. Insomnia is a particularly relevant covariate, explaining the greater part of its variance. To enhance participation, care should focus on clinical and non-clinical covariates.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0432-z) contains supplementary material, which is available to authorized users.