Traumatic brain injury in children and adolescents: psychiatric disorders in the first three months

The Relationship Between Trauma Exposure and Obsessive-Compulsive Disorder in Youth: A Systematic Review

Extant literature suggests a possible relationship between childhood trauma exposure and the development and trajectory of obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorder (OCD); however, this relationship is poorly understood. We conducted a systematic review that examined trauma exposure and OCS/OCD in youth. Primary inclusion criteria were English-language articles that addressed a sample with participants under 18 years of age. 46 articles met criteria for review, and were categorized into three groups of overlap: Post-traumatic Stress Disorder (PTSD) and OCS or OCD (n = 3), clearly defined Criterion A event trauma exposure and OCS or OCD (n = 30), and less well-defined potential trauma exposure and OCS or OCD (n = 13). There was mixed evidence linking trauma exposure and the development of OCS or OCD in youth. Major methodological limitations preclude formal conclusions. More research on co-occurring trauma exposure and OCD/OCS in youth is needed to advance research and improve treatment.

Association between pediatric TBI and mental health and substance use disorders: A scoping review

BACKGROUND

The relationship between pediatric Traumatic Brain Injury (TBI) and long-term mental health and substance use disorders is not well known, resulting in inadequate prevention and management strategies. The aim of this scoping review is to review the evidence on pediatric TBI and the development of mental health disorders and substance use later in life and to identify gaps in the literature to inform future research.

METHODS

We searched multiple databases for original articles published between September 2002 and September 2022 on TBI-related mental health and/or substance use disorders in children and youth. Two independent reviewers performed the screening using Arksey and O'Malley and Levac et al.'s scoping review framework.

RESULTS

A total of six papers are included in this scoping review. Studies included are comprised of cross-sectional and prospective longitudinal cohort studies.

DISCUSSION

A correlation between pediatric TBI and development of certain mental health disorders and substance use is suggested, although much of the current evidence is mixed and does not account for confounding variables. Future studies should aim to closely examine these links and identify modifiers that can influence these relationships.

Novel Psychiatric Disorder 6 Months After Traumatic Brain Injury in Children and Adolescents

OBJECTIVE

To investigate the factors predictive of novel psychiatric disorders in the interval 0-6 months following traumatic brain injury (TBI).

METHODS

Children ages 5-14 years consecutively hospitalized for mild to severe TBI at five hospitals were recruited. Participants were evaluated at baseline (soon after injury) for pre-injury characteristics including psychiatric disorders, socioeconomic status (SES), psychosocial adversity, family function, family psychiatric history, and adaptive function. In addition to the psychosocial variables, injury severity and lesion location detected with acquisition of a research MRI were measured to develop a biopsychosocial predictive model for development of novel psychiatric disorders. Psychiatric outcome, including occurrence of a novel psychiatric disorder, was assessed 6 months after the injury.

RESULTS

The recruited sample numbered 177 children, and 141 children (80%) returned for the six-month assessment. Of the 141 children, 58 (41%) developed a novel psychiatric disorder. In univariable analyses, novel psychiatric disorder was significantly associated with lower SES, higher psychosocial adversity, and lesions in frontal lobe locations, such as frontal white matter, superior frontal gyrus, inferior frontal gyrus, and orbital gyrus. Multivariable analyses found that novel psychiatric disorder was independently and significantly associated with frontal-lobe white matter, superior frontal gyrus, and orbital gyrus lesions.

CONCLUSION

The results demonstrate that occurrence of novel psychiatric disorders following pediatric TBI requiring hospitalization is common and has identifiable psychosocial and specific biological predictors. However, only the lesion predictors were independently related to this adverse psychiatric outcome.

Mental Health Outcomes Across the Lifespan in Individuals With Persistent Post-Concussion Symptoms: A Scoping Review

Objective:

Concussion is a common yet heterogenous injury. Approximately 15–30% of cases present with persistent post-concussion symptoms (PPCS), continuing 4 weeks or more post-injury in children, youth, and adolescents, and 3 months or more in adults. There are known bidirectional links between PPCS and mental health outcomes. The focus of this scoping review is to explore the literature on mental health outcomes in individuals experiencing PPCS. Research objectives were to explore: (1) the mental health outcomes of individuals with PPCS and types of assessments used to identify mental health outcomes this group, and (2) how mental health outcomes compare in terms of similarities and differences among pediatric and adult populations with PPCS.

Method

Ovid MEDLINE; EMBASE; CINAHL, and PsycInfo databases were searched. After title and abstract screening of 11,920 studies, 481 articles were reviewed. Twenty-five papers met inclusion criteria. Results were organized by mental health outcomes of pediatric and adult populations, separately.

Results

There was a significantly higher number of studies devoted to adult populations. Of the 25 studies, 19 (76%) focused on adults, while six (24%) focused on adolescents. In adult populations, studies focused on symptoms of: anxiety (n = 2), depression (n = 8), and anxiety and depression (n = 9). Two studies assessed other emotional outcomes (10.5%). Within pediatric populations, an equal number of studies explored symptoms of: anxiety (n = 2), depression (n = 2), and anxiety and depression (n = 2). No studies focused on other emotional outcomes. Studies ranged greatly in methods, design, and control group. Most studies reported higher psychiatric symptoms of anxiety and/or depression in those with PPCS compared to individuals with recovered concussion or healthy controls.

Discussion

This review contributes to the understanding of mental health outcomes in those experiencing PPCS. Mental health and PPCS requires greater attention in pediatric populations, and consider strategies for those experiencing PPCS and mental health impacts. Future studies should consider including a wider range of emotional outcomes in their design, not limited to anxiety and depression. Study results may lead to improvements and research in the identification, assessment, and management of PPCS and mental health.

Traumatic Brain Injury in Children and Adolescents: Psychiatric Disorders 24 Years Later

OBJECTIVE

The investigators aimed to extend findings regarding predictive factors of psychiatric outcomes among children and adolescents with traumatic brain injury (TBI) from 2 to 24 years postinjury.

METHODS

Youths aged 6-14 years who were hospitalized following TBI from 1992 to 1994 were assessed at baseline for TBI severity and for preinjury psychiatric, adaptive, and behavioral functioning; family functioning; family psychiatric history; socioeconomic status; and intelligence within weeks of injury. Predictors of psychiatric outcomes following pediatric TBI at 3, 6, 12, and 24 months postinjury have previously been reported. In this study, repeat psychiatric assessments were completed at 24 years postinjury with the same cohort, now adults aged 29-39 years, with the outcome measure being presence of a psychiatric disorder not present before the TBI ("novel psychiatric disorder").

RESULTS

Fifty participants with pediatric TBI were initially enrolled, and the long-term outcome analyses focused on data from 45 individuals. Novel psychiatric disorder was present in 24 out of 45 (53%) participants. Presence of a current novel psychiatric disorder was independently predicted by the presence of a preinjury lifetime psychiatric disorder and by severity of TBI.

CONCLUSIONS

Long-term psychiatric outcome (mean=23.92 years [SD=2.17]) in children and adolescents hospitalized for TBI can be predicted at the point of the initial hospitalization encounter by the presence of a preinjury psychiatric disorder and by greater injury severity.

Three-Month Psychiatric Outcome of Pediatric Mild Traumatic Brain Injury: A Controlled Study

The objective was to clarify occurrence, phenomenology, and risk factors for novel psychiatric disorder (NPD) in the first 3 months after mild traumatic brain injury (mTBI) and orthopedic injury (OI). Children aged 8-15 years with mTBI (n = 220) and with OI but no TBI (n = 110) from consecutive admissions to an emergency department were followed prospectively at baseline and 3 months post-injury with semi-structured psychiatric interviews to document the number of NPDs that developed in each participant. Pre-injury child variables (adaptive, cognitive, and academic function, and psychiatric disorder), pre-injury family variables (socioeconomic status, family psychiatric history, and family function), and injury severity were assessed and analyzed as potential confounders and predictors of NPD. NPD occurred at a significantly higher frequency in children with mTBI versus OI in analyses unadjusted (mean ratio [MR] 3.647, 95% confidence interval [CI₉₅] (1.264, 15.405), p = 0.014) and adjusted (MR = 3.724, CI₉₅ (1.264, 15.945), p = 0.015) for potential confounders. In multi-predictor analyses, the factors besides mTBI that were significantly associated with higher NPD frequency after adjustment for each other were pre-injury lifetime psychiatric disorder [MR = 2.284, CI₉₅ (1.026, 5.305), p = 0.043]; high versus low family psychiatric history [MR = 2.748, CI₉₅ (1.201, 6.839), p = 0.016], and worse socio-economic status [MR = 0.618 per additional unit, CI₉₅ (0.383, 0.973), p = 0.037]. These findings demonstrate that mild injury to the brain compared with an OI had a significantly greater deleterious effect on psychiatric outcome in the first 3 months post-injury. This effect was present even after accounting for specific child and family variables, which were themselves independently related to the adverse psychiatric outcome.

Long-Term Psychiatric Outcomes in Adults with History of Pediatric Traumatic Brain Injury

The objective of the study was to compare psychiatric outcomes in adults with and without history of pediatric traumatic brain injury (TBI). Youth ages 6 to 14 years hospitalized for TBI from 1992 to 1994 were assessed at baseline and at 3, 6, 12, and 24 months post-injury. In the current study, psychiatric assessments were repeated at 24 years post-injury with the same cohort, now adults ages 29 to 39 years. A control group of healthy adults also was recruited for one-time cross-sectional assessments. Outcome measures included: 1) presence of a psychiatric disorder since the 24-month assessment not present before the TBI ("novel psychiatric disorder," NPD), or in the control group, the presence of a psychiatric disorder that developed after the mean age of injury of the TBI group plus 2 years; and 2) Time-to-Event for onset of an NPD during the same time periods. In the TBI group, NPDs were significantly more common, and presence of a current NPD was significantly predicted by presence of a pre-injury lifetime psychiatric disorder and by abnormal day-of-injury computed tomography (CT) scan. Compared with controls, the TBI group also had significantly shorter Time-to-Event for onset of any NPD. These findings demonstrate that long-term psychiatric outcomes in adults previously hospitalized for pediatric TBI are significantly worse when compared with adult controls without history of pediatric TBI, both in terms of prevalence and earlier onset of NPD. Further, in the TBI group, long-term NPD outcome is predicted independently by presence of pre-injury psychiatric disorder and abnormal day-of-injury CT scan.

Benefits of Methylphenidate for Long-Term Attention Problems After Traumatic Brain Injury in Childhood: A Randomized, Double-Masked, Placebo-Controlled, Dose-Titration, Crossover Trial

OBJECTIVE

To characterize the benefits and optimal dose of long-acting methylphenidate for management of long-term attention problems after childhood traumatic brain injury (TBI).

DESIGN

Phase 2, randomized, double-masked, placebo-controlled, dose-titration, crossover clinical trial.

SETTING

Outpatient, clinical research.

PARTICIPANTS

Twenty-six children aged 6 to 17 years who were at least 6 months post-TBI and met criteria for attention-deficit hyperactivity disorder (ADHD) at the time of enrollment.

OUTCOME MEASURES

Vanderbilt Rating Scale of attention problems, Pittsburgh Side Effects Rating Scale, and vital signs.

RESULTS

Among the 26 participants randomized, 20 completed the trial. The mean ages at injury and enrollment were 6.3 and 11.5 years, respectively. Eight participants had a severe TBI. On an optimal dose of medication, greater reductions were found on the Vanderbilt Parent Rating Scale for the medicated condition than for placebo (P = .022, effect size = 0.59). The mean optimal dose of methylphenidate was 40.5 mg (1.00 mg/kg/day). Preinjury ADHD diagnosis status was not associated with a differential medication response. Methylphenidate was associated with weight loss (∼1 kg), increased systolic blood pressure (∼3- to 6-point increase), and mild reported changes in appetite.

CONCLUSION

Findings support use of long-acting methylphenidate for management of long-term attention problems after pediatric TBI. Larger trials are warranted of stimulant medications, including comparative effectiveness and combination medication and nonmedication interventions.

Depression and Depressive Symptoms in Pediatric Traumatic Brain Injury: A Scoping Review

OBJECTIVE

This scoping review aimed to summarize the existing knowledge base regarding depression and depressive symptoms in pediatric traumatic brain injury (TBI) and to identify gaps in the literature in an effort to guide future research.

METHODS

MEDLINE Ovid and PsycINFO Ovid databases were each searched by the authors using search terms intended to identify any original research study that examined depressive symptoms in children (ie, aged 0-18 years) with TBI.

RESULTS

A total of 14 published studies were included in the review. The studies included examined the prevalence of depression, risk factors associated with depression, and depression as a predictor of other TBI-related outcomes.

CONCLUSION

Existing research suggests that depressive symptoms are more common in a TBI population than in a healthy or orthopedically injured population. Injury-related factors such as lesions in the brain and the presence of pain, as well as noninjury factors such as older age at injury and low socioeconomic status, may be predictive of depressive symptoms. Depression is likely a secondary outcome of pediatric TBI rather than a direct result of the injury itself. Overall, a relative dearth of research exists on this topic; thus, the review concludes by proposing future research directions.

Mental Health after Unintentional Injury in a Pediatric Managed-Medicaid Population

OBJECTIVES

The purpose of this study was to compare the rates of mental health diagnoses and psychotropic prescriptions pre- and posthospitalization for injury in a managed-Medicaid population. We hypothesized that children have increased rates of mental health diagnoses and psychotropic prescriptions after injury.

STUDY DESIGN

We investigated children (n = 2208) ≤18 years of age treated at a pediatric trauma center from 2005 to 2015 who were enrolled in a managed-Medicaid program at hospital admission and for at least 1 healthcare visit in the preceding year. We used Poisson regression models to estimate rates of mental health diagnoses and psychotropic prescriptions that occurred in the 12 months pre- and postinjury.

RESULTS

The rate of mental health diagnoses preinjury was 95.9 per 1000 person-years, which increased to 156.7 per 1000 postinjury (rate ratio [RR] 1.63, 95% CI 1.39-1.92). Children ages 0-4 years with burns were more likely to have mental health diagnoses postinjury (race and ethnicity adjusted RR [aRR] 8.56, 95% CI 3.30-22.2). Children with head injuries were also more likely to have mental health diagnoses postinjury: ages 0-4 years (aRR 3.87, 95% CI 1.31-11.5); ages 5-9 (aRR 3.11, 95% CI 1.27-7.59); ages 10-14 (aRR 2.17, 95% CI 1.27-3.73); and ages 15-18 (aRR 5.37, 95% CI 2.12-13.6). The rate of psychotropic prescriptions preinjury was 121.7 per 1000 person-years and increased to 310.9 per 1000 postinjury (RR 2.55, 95% CI 2.26-2.89).

CONCLUSIONS

We identified increased mental health diagnoses and psychotropic prescriptions in children following hospitalization for injury.

Comparative effectiveness of family problem-solving therapy (F-PST) for adolescents after traumatic brain injury: Protocol for a randomized, multicenter, clinical trial

Introduction

The objective of this manuscript is to describe the methodology that will be used to test the comparative effectiveness, feasibility, and acceptability of three formats of family problem solving therapy (F-PST) for improving functional outcomes of complicated mild to severe adolescent TBI.

Methods

Three-arm comparative effectiveness, randomized clinical trial (RCT) design. We describe the protocol of a three-arm RCT comparing the effectiveness of three modalities of F-PST to reduce executive dysfunction and behavior problems following TBI in adolescence. The RCT will compare the relative effectiveness among face-to-face; online and self-directed; and therapist-supported online modes of treatment.

Ethics and dissemination

It is anticipated that findings from this work will inform future clinical care practices, with implications for treatment of other patient populations of youth with psychological symptoms arising from neurological conditions. Institutional review board approval will be obtained from all sites prior to commencement of the study.

Siblings' experiences of their relationship with a brother or sister with a pediatric acquired brain injury

Primary purpose: Child acquired brain injury has significant impact on the family, including siblings. This study aimed to explore siblings' experiences of their relationship with their brother or sister with acquired brain injury in order to make recommendations for health professionals working with this population.Research design: Semi-structured interviews were conducted with five siblings of children with acquired brain injury aged between 9 and 12 years and analyzed using interpretative phenomenological analysis.Results: The analysis resulted in four themes: (i) Coping with "a nightmare that you live"; (ii) Disconnection from family relationships; (iii) My sibling is different but "still the same underneath all this thing"; and (iv) Changing togetherness.Conclusions: The siblings in this study experienced a high level of distress with the near loss of their brother or sister. This was followed by difficulty in adjusting to the physical and psychological changes in their injured sibling and the impact on their sibling role and relationship. The changes were experienced alongside disruption to family relationships. Important clinical implications include the inclusion of siblings in their injured sibling's care and the provision of information and support for this group.Implications for RehabilitationSiblings of children with an acquired brain injury experience significant challenges while trying to adapt to their changing sibling relationship and feelings of disconnection with their family.This study highlights a need to work systemically with families of childhood brain injury and recognize siblings' important role in their family unit and therefore involve them in their brother/sister's care and rehabilitation.This study also highlights a need to support siblings to cope with the trauma and provide information to validate and understand their experience.

Neurosensory Deficits Vary as a Function of Point of Care in Pediatric Mild Traumatic Brain Injury

Neurosensory abnormalities are frequently observed following pediatric mild traumatic brain injury (pmTBI) and may underlie the expression of several common concussion symptoms and delay recovery. Importantly, active evaluation of neurosensory functioning more closely approximates real-world (e.g., physical and academic) environments that provoke symptom worsening. The current study determined whether symptom provocation (i.e., during neurosensory examination) improved classification accuracy relative to pre-examination symptom levels and whether symptoms varied as a function of point of care. Eighty-one pmTBI were recruited from the pediatric emergency department (PED; n = 40) or outpatient concussion clinic (n = 41), along with matched (age, sex, and education) healthy controls (HC; n = 40). All participants completed a brief (∼ 12 min) standardized neurosensory examination and clinical questionnaires. The magnitude of symptom provocation upon neurosensory examination was significantly higher for concussion clinic than for PED patients. Symptom provocation significantly improved diagnostic classification accuracy relative to pre-examination symptom levels, although the magnitude of improvement was modest, and was greater in the concussion clinic. In contrast, PED patients exhibited worse performance on measures of balance, vision, and oculomotor functioning than the concussion clinic patients, with no differences observed between both samples and HC. Despite modest sample sizes, current findings suggest that point of care represents a critical but highly under-studied variable that may influence outcomes following pmTBI. Studies that rely on recruitment from a single point of care may not generalize to the entire pmTBI population in terms of how neurosensory deficits affect recovery.

Adolescents' internalizing problems following traumatic brain injury are related to parents' psychiatric symptoms

BACKGROUND

A small body of previous research has demonstrated that pediatric traumatic brain injury (TBI) increases risk for internalizing problems, but findings have varied regarding their predictors and correlates.

METHODS

We examined the level and correlates of internalizing symptoms in 130 teens who had sustained a complicated mild to severe TBI within the past 1 to 6 months. Internalizing problems were measured via both maternal- and paternal-report Child Behavior Checklist. We also measured family functioning, parent psychiatric symptoms, and postinjury teen neurocognitive function.

RESULTS

Mean parental ratings of internalizing problems were within the normal range. Depending on informant, 22% to 26% of the sample demonstrated clinically elevated internalizing problems. In multiple and binary logistic regression models, only parent psychiatric symptoms consistently provided unique prediction of teen internalizing symptoms. For maternal but not paternal report, female gender was associated with greater internalizing problems.

CONCLUSION

Parent and teen emotional problems are associated following adolescent TBI. Possible reasons for this relationship, including the effects of TBI on the family unit, are discussed.

Neuropsychiatry of pediatric traumatic brain injury

Pediatric traumatic brain injury (TBI) is a major public health problem. Psychiatric disorders with onset before the injury are more common than population base rates. Novel (postinjury onset) psychiatric disorders (NPD) are also common and complicate child function after injury. Novel disorders include personality change due to TBI, secondary attention-deficit/hyperactivity disorder, other disruptive behavior disorders, and internalizing disorders. This article reviews preinjury psychiatric disorders as well as biopsychosocial risk factors and treatments for NPD.

Family function and its relationship to injury severity and psychiatric outcome in children with acquired brain injury: a systematized review

AIM

The psychological and psychiatric outcome of children with acquired brain injury is influenced by many variables. A review was undertaken to clarify the contribution of family function, how it relates to injury severity, and what particular aspects of family function influence psychological outcome in this group.

METHOD

A systematized review of the literature of studies published between 1970 and 2012 from OvidMedline, PsychoInfo, PsycARTICLES, and Cochrane was undertaken focusing on family function, injury severity, and psychiatric outcome.

RESULTS

Thirty-six papers met the inclusion criteria. Injury severity was linked to the development of organic personality change. Family function before injury, measured by the Family Assessment Device or the Clinical Rating Scale, had a statistically significant effect on general psychological functioning in six out of eight studies. Family function had a significant effect for oppositional defiant disorder and secondary attention-deficit-hyperactivity disorder. The effects of family function may differ depending on the age of the child and the severity of the injury. Some styles of parenting moderated recovery. After injury, family function was related to the child's contemporaneous psychiatric symptoms. The level of evidence for these papers was 3 or 4 (Oxford Centre for Evidence-based Medicine criteria).

INTERPRETATION

Screening for some aspects of family functioning before injury and family function during the rehabilitation phase may identify children at risk of psychiatric disorders.

Behavioral predictors of outpatient mental health service utilization within 6 months after traumatic brain injury in adolescents

OBJECTIVES

To characterize utilization of mental health services and determine the ability of a behavior problem and clinical functioning assessment to predict utilization of such services within the first 6 months after moderate and severe traumatic brain injury in a large cohort of adolescents.

DESIGN

Multicenter cross-sectional study.

SETTING

Outpatient setting of 4 tertiary pediatric hospitals, 2 tertiary general medical centers, and 1 specialized children's hospital.

PARTICIPANTS

Adolescents age 12-17 years (n = 132), 1-6 months after moderate-to-severe traumatic brain injury.

METHODS

Logistic regression was used to determine the association of mental health service utilization with clinical functioning as assessed by the Child and Adolescent Functional Assessment Scale and behavior problems assessed by the Child Behavioral Checklist.

MAIN OUTCOME MEASUREMENT

Mental health service utilization measured by the Service Assessment for Children and Adolescents.

RESULTS

Behavioral or functional impairment occurred in 37%-56%. Of the total study population, 24.2% reported receiving outpatient mental health services, 8.3% reported receiving school services, and 28.8% reported receiving any type of mental health service. Use of any (school or outpatient) mental health service was associated with borderline to impaired total Child and Adolescent Functional Assessment Scale (odds ratio 3.50 [95% confidence interval, 1.46-8.40]; P < .01) and the Child Behavioral Checklist Total Competence (odds ratio 5.08 [95% confidence interval, 2.02-12.76]; P < .01).

CONCLUSIONS

A large proportion of participants had unmet mental health needs. Both the Child and Adolescent Functional Assessment Scale and the Child Behavioral Checklist identified individuals who would likely benefit from mental health services in outpatient or school settings. Future research should focus on methods to ensure early identification by health care providers of adolescents with traumatic brain injury in need of mental health services.

Prevalence of epileptic and nonepileptic events after pediatric traumatic brain injury

Though posttraumatic epilepsy (PTE) is a prominent sequela of traumatic brain injury (TBI), other nonepileptic phenomena also warrant consideration. Within two UCLA pediatric TBI cohorts, we categorized five spell types: 1) PTE; 2) Epilepsy with other potential etiologies (cortical dysplasia, primary generalized); 3) Psychopathology; 4) Behavior misinterpreted as seizures; and 5) Other neurologic events. The two cohort subsets differed slightly in injury severity, but they were otherwise similar. Overall, PTE occurred in 40%, other epilepsy etiologies in 14%, and nonepileptic spells collectively in 46%. Among children with spells, PTE was associated with severe TBI (p=0.001), whereas psychopathology (p=0.014) and epilepsy with other etiologies (p=0.006) were associated with milder TBI severity. Posttraumatic epilepsy (p=0.002) and misinterpreted behavior (p=0.049) occurred with younger injury age. Psychopathology (p=0.020) and other neurologic events (p=0.002) occurred with older injury age. In evaluating possible PTE, clinicians should maintain a broad differential diagnosis to prevent misdiagnosis and inappropriate treatment.

Psychiatric disorders in children and adolescents six-to-twelve months after mild traumatic brain injury

The objective of this study was to understand how novel psychiatric disorders (NPD) in children with mild traumatic brain injury (MTBI) are related to pre-injury variables, injury-related variables, and concurrent neurocognitive outcome. A group of 79 children, ages 5 to 14 years, who had experienced MTBI, were studied from consecutive hospital admissions with semistructured psychiatric interviews soon after injury (baseline); 60 children were reassessed 12 months post-injury. Standardized instruments were used to assess injury severity; lesion characteristics; pre-injury variables, including psychiatric disorder, family psychiatric history, family functioning, socioeconomic status, psychosocial adversity, adaptive functioning, and post-injury neurocognitive and adaptive functioning. NPD occurred in 17 of 60 participants (28%) in the 6-12-month interval after injury, with disorders that were significantly associated with socioeconomic status, psychosocial adversity, estimated pre-injury academic functioning, and concurrent deficits in adaptive functioning, academic performance, processing speed, memory, and expressive language. NPD was not significantly associated with pre-injury adaptive functioning, injury severity, family psychiatric history, pre-injury psychiatric disorder, lesion location, gender, or age at injury. These findings suggest that the short-term psychiatric morbidity associated with MTBI in children occurs more commonly than previously reported and is related to both pre-injury social factors and concurrent neurocognitive functioning.

Depression in children and adolescents in the first 6 months after traumatic brain injury

The objective was to assess the nature, rate, predictive factors, and neuroimaging correlates of novel (new-onset) depressive disorders, both definite and subclinical, after traumatic brain injury (TBI). Children with TBI from consecutive admissions were enrolled and studied with psychiatric interviews soon after injury (baseline), and again 6 months post-injury. Novel definite/subclinical depressive disorders at 6-month follow up occurred in 11% (n=15) of the children and subsets of children with non-anxious depression (n=9) and anxious depression (n=6) were identified. Novel definite/subclinical depressive disorder was significantly associated with older age at the time of injury, family history of anxiety disorder, left inferior frontal gyrus (IFG) lesions, and right frontal white matter lesions. Non-anxious depressions were associated with older age at injury, left IFG and left temporal pole lesions. Anxious depressions were associated with family history of anxiety disorder, Personality Change due to TBI, right frontal white matter lesions, and left parietal lesions. These findings, which are similar to those reported after adult TBI, identify both similarities and differences in non-anxious and anxious depression following childhood TBI with respect to lesion laterality, genetic factors (in the form of family psychiatric history of anxiety disorder), age at injury, and more generalized affective dysregulation.

Efficacy of cognitive behavioural therapy for children and adolescents with traumatic brain injury

PURPOSE

Behavioural and psychological disorders after traumatic brain injury (TBI) are very common. The purposes of this study were to estimate the frequency of these problems in our sample, to evaluate the effectiveness of cognitive behavioural therapy (CBT) and to assess the predictive value of important clinical variables for the treatment outcome.

METHOD

Forty patients aged 4-18 years were included in this study. Twenty-eight patients received CBT at our Institute (clinical group), while 12 patients did not receive any treatment at all (control group). The CBCL/4-18 and the VABS were administered to parents at the beginning of the study and after 12 months.

RESULTS

A high frequency of psychological and behavioural problems was found in both groups of patients. After CBT, the clinical group showed a significant advantage on several CBCL scales and a greater increase in adaptive behaviour on the VABS Socialisation domain. The Glasgow Coma Scale score, days of unconsciousness and age at injury were not predictors of the severity of psychological problems at the follow-up for the patients of the clinical group.

CONCLUSIONS

Our results suggest that CBT is an effective intervention for young patients with psychological problems after TBI.

Classifying psychiatric disorders after traumatic brain injury and orthopaedic injury in children: adequacy of K-SADS versus CBCL

PRIMARY OBJECTIVE

[corrected] To evaluate the convergence between the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) for the diagnosis of psychiatric disorders and the Child Behavior Checklist (CBCL).

RESEARCH DESIGN

Cross-sectional psychiatric study of 72 children with traumatic brain injuries or orthopaedic injuries aged 5-14.

METHODS AND PROCEDURES

Sensitivity, specificity, total predictive value and odds ratio were calculated to evaluate the association between CBCL summary scores and K-SADS diagnosis of at least one psychiatric disorder (K-SADS-1), and of CBCL subscales and K-SADS diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD). Lowered cut-off scores of t > or = 60 were used.

MAIN OUTCOMES AND RESULTS

Convergence between the CBCL total problem scale and K-SADS-1 was poor. Convergence between 'at least one elevated CBCL subscale' and K-SADS-1, and between CBCL attention problems and social problems scales and K-SADS diagnosis of ADHD was excellent.

CONCLUSIONS

Caution is needed when using the total problem scale of CBCL in predicting global psychological impairment because underestimation of problems is likely. The attention and social problems scales of CBCL can be used to estimate ADHD.

The McMaster family assessment device and clinical rating scale: Questionnaire vs interview in childhood traumatic brain injury

Two modalities of family assessment based on the McMaster Model of Family Functioning (MMFF), including a self-report questionairre (Family Assessment Device-FAD) and a clinical interview (McMaster Structured Interview For Families-McSIFF) as scored on the McMaster Clinical Rating Scale (MCRS) were compared in an attempt to explore the inter-changeability of the two. Significant correlations were hypothesized between the FAD and MCRS in both prospective and retrospective groups and that correlations would increase over three data points in the prospective study. The sample included 50 children and adolescents (ages 6-4) with traumatic brain injury (TBI) from a prospective study. In addition, 72 children and adolescents (ages 5-14), consisting of 24 patients with severe TBI, individually matched to a comparison group of 24 mild TBI patients and a control group of 24 orthopaedic patients were included from a retrospective study. Significant correlations between the FAD and MCRS were found across both studies, with increasing correlations at each successive data point in the prospective study. Agreement between the two measures regarding classification of families as clinical vs healthy was also statistically significant at the majority of assessment occasions; however, most specific indices of agreement were only modest. The clinical and research implications of these findings are discussed.

An evaluation of the paediatric acquired brain injury community outreach programme (PABICOP)

PRIMARY OBJECTIVE

To examine the utility of a coordinated, family/community-focused programme (PABICOP) vs. a standard approach for improving outcomes for children with ABI and their families.

RESEARCH DESIGN

Pre-test-post-test design, with comparison group and follow-up.

METHODS AND PROCEDURES

Ninety-six children (64 children receiving PABICOP services and 32 children receiving standard care) participated in the study. Measures were completed at baseline and 3 and 12 months later.

MAIN OUTCOMES AND RESULTS

Parents/caregivers with more than 10 contacts with PABICOP scored significantly higher on an ABI knowledge quiz than either parents/caregivers with 10 contacts or less or the comparison group at post-test and follow-up. Parents/caregivers with 10 contacts or less with PABICOP reported significantly greater improvements in children's school and total competence on the CBCL than either parents/caregivers with more than 10 contacts or the comparison group at post-test and follow-up.

CONCLUSIONS

PABICOP may be more useful for enhancing knowledge of ABI for parents/caregivers and for integrating children into the community over a 1-year period than a standard approach. The amount of service received appears to influence outcomes.

Working memory performance following paediatric traumatic brain injury

PRIMARY OBJECTIVE

The present study investigated working memory ability in children who sustained moderate-to-severe traumatic brain injuries in relation to pre-injury, injury-related and developmental factors. It was hypothesized that there would be a correlation between performance- and rater-based working memory measures; factors predictive of working memory impairment would include earlier age at injury, more severe injury, longer time since injury and poorer overall cognitive functioning; and working memory performance would be significantly impaired when compared to normative populations.

METHODS AND PROCEDURES

Working memory was assessed in 62 children using a traditional performance measure (digit span backward) and parent report (Behaviour Rating Inventory of Executive Function (BRIEF)).

MAIN OUTCOMES AND RESULTS

Contrary to prediction, there was no statistical association between performance- and rater-based measures of working memory. Regression analyses revealed injury severity, time-since-injury, overall cognitive ability and attention span were predictive of working memory performance. As a group, working memory was impaired relative to normative samples on both measures.

CONCLUSIONS

Performance- and rater-based working memory measures, while not significantly correlated, are both sensitive to acquired cognitive dysfunction following paediatric traumatic brain injury. Demographic and clinical factors may be used to predict cognitive outcomes, educate caregivers and design clinical interventions.

Attempted and completed suicide in adolescence

Suicide is the third leading cause of death in adolescence, and medically serious suicide attempts occur in approximately 3% of adolescents. This review examines a number of risk factors that contribute to suicidal behavior. A prior suicide attempt is one of the best predictors of both a repeat attempt and eventual completed suicide. Depression, disruptive behavior disorders, and substance-use disorders also place adolescents at high risk for suicidal behavior, with comorbidity further increasing risk. Research on families indicates that suicidal behavior is transmitted through families. Groups at high risk for suicidal behavior include gay, lesbian, and bisexual youths, incarcerated adolescents, and homeless/runaway teens. Although abnormalities in the serotonergic system have not been consistently linked to suicidal behavior, genetic and neurobiologic studies suggest that impulsive aggression may be the mechanism through which decreased serotonergic activity is related to suicidal behavior. Findings from prevention and intervention studies are modest and indicate the need for substantially more theory-driven treatment research.

Suicidal behavior and mild traumatic brain injury in major depression

Traumatic brain injury (TBI) is associated with psychiatric illness, suicidal ideation, suicide attempts, and completed suicide. We investigated the relationship between mild TBI and other risk factors for suicidal behavior in major depressive episode. We hypothesized that mild TBI would be associated with suicidal behavior at least partly because of shared risk factors that contribute to the diathesis for suicidal acts. Depressed patients (N = 325) presenting for treatment were evaluated for psychopathology, traumatic history, and suicidal behavior. Data were analyzed using Student t -test, chi-square statistic, or Fisher exact test. A backward stepwise logistic regression model (N = 255) examined the relationship between attempter status and variables that differed in the TBI and non-TBI patients. Forty-four percent of all subjects reported mild TBI. Subjects with TBI were more likely to be male, have a history of substance abuse, have cluster B personality disorder, and be more aggressive and hostile compared with subjects without TBI. They were also more likely to be suicide attempters, although their suicidal behavior was not different from that of suicide attempters without TBI. Attempt status was mostly predicted by aggression and hostility, but not the presence of TBI. Of note, for males, a history of TBI increased the likelihood of being a suicide attempter, whereas the risk was elevated for females regardless of TBI history. Our data suggest that suicidal behavior and TBI share antecedent risk factors: hostility and aggression. Future studies may yield confirmation using a prospective design.

Anxiety after severe pediatric closed head injury

OBJECTIVE

To assess the frequency of anxiety symptoms and disorders 1 year after severe pediatric closed head injury (CHI) and to determine the risk factors associated with these postinjury outcomes.

METHOD

Ninety-seven subjects were prospectively followed for 1 year after severe CHI (Glasgow Coma Scale Score = 3-8). Assessments of preinjury and 1-year postinjury psychiatric status and psychosocial adversity were conducted. Frequency of anxiety symptoms and disorders 1 year after injury were the outcome measures. Data collection occurred between 1992 and 1996.

RESULTS

There was a significant increase in the total number of anxiety symptoms after injury compared with before injury. The most frequent symptoms were overanxious symptoms, followed by obsessive-compulsive symptoms, separation anxiety symptoms, and simple phobia symptoms. There was a trend toward an increase in the frequency of overanxious disorder after injury. Preinjury anxiety symptoms correlated positively with postinjury anxiety symptoms and disorders. Younger age at injury correlated positively with postinjury anxiety symptoms.

CONCLUSIONS

One year after severe CHI, children are at risk for a variety of anxiety symptoms and, possibly, overanxious disorder. Preinjury anxiety and younger age at injury are risk factors for these disturbances.

Lifetime and novel psychiatric disorders after pediatric traumatic brain injury

OBJECTIVE

To assess lifetime and current psychiatric disorders at least 1 year after traumatic brain injury (TBI) in children and adolescents.

METHOD

Forty-six youths who sustained a TBI between the ages of 6 through 15 years were evaluated at least 1 year post-TBI to identify the presence of lifetime and/or novel psychiatric disorders. Semistructured interviews of the parent and child and standardized parent self-report rating instruments were used.

RESULTS

Attention-deficit/hyperactivity disorder and depressive disorders were the most common lifetime and novel diagnoses. A wide variety and high rate of novel psychiatric disorders were identified; 74% of these disorders persisted in 48% of the injured children. Internalizing disorders were more likely to resolve than externalizing disorders. Both interviews and parent ratings were sensitive to current externalizing behaviors; interviews more often detected internalizing disorders, whereas parent ratings also identified cognitive difficulties.

CONCLUSIONS

Findings were generally consistent with previous research demonstrating the high rate of novel psychiatric disorders following pediatric TBI. Psychiatric interviews were sensitive in identifying both lifetime and novel disorders.

Predicting adherence to recommendations by parents of clinic-referred children

The authors examined predictors of parents' adherence to recommendations made by psychologists after the evaluation of clinic-referred children. Parents or legal guardians of 93 children aged 4 to 12 years participated. The major findings were that (a) child behavior problem severity, parent recall of recommendations, parent satisfaction with the child's psychological evaluation, and locus of control were not significantly associated with adherence; (b) number of perceived barriers was the most salient predictor of adherence to recommendations, regardless of recommendation type; and (c) adherence rates to psychological services recommendations were significantly lower, compared with those for school-based or professional nonpsychological recommendations. Implications for more research on predictors of adherence to recommendations and clinical strategies for overcoming barriers to adherence are discussed.

Case study: bipolar disorder after head injury

A case of bipolar disorder subsequent to a mild head injury in a 15-year-old girl is reported. Review of the literature indicates that this is an extremely rare outcome. Lack of adequate follow-up studies makes it difficult to accurately predict type and severity of psychiatric outcome. Assessment and management involves ongoing consideration of both organic and psychosocial factors even after initial negative investigations.

Adolescent suicide as a public health threat

TOPIC

Adolescent suicide patterns.

PURPOSE

To raise awareness of the seriousness of adolescent suicidal behavior by reviewing international research on adolescent suicide and evaluating the prospects for identification and intervention.

SOURCES

Published literature.

CONCLUSIONS

Adolescent suicide research is complicated and often contradictory, but it does provide some insight into prevalence, risk factors, screening tools, and interventions. For completers, the problem may be intractable. But a few broad-based identification and prevention efforts show promise, and psychotherapy is a proven success. Even if suicide rates remain high, treatment of attempters should prevent further self-harm and reduce the completion rate, and thus should be funded.

Posttraumatic stress symptoms in children following orthopedic or traumatic brain injury

Examined posttraumatic stress (PTS) symptoms in children following pediatric traumatic brain injury (TBI). Children (ages 6-12) with TBI (n = 81) and orthopedic injury (OI; n = 59) were assessed 6 and 12 months postinjury. Parents of children with severe TBI reported higher levels of child PTS symptoms than did parents of children with moderate TBI or OI at the 6- and 12-month follow-ups. Group differences in child-reported PTS symptoms emerged at the 12-month follow-up with higher symptom levels reported by children with severe TBI than by those with moderate TBI or OI. At both follow-ups, rates of clinically significant symptom levels were higher in the severe TBI group than in the moderate TBI or OI groups. The group differences in parent and child reports were significant even after taking ethnicity, social disadvantage, and age at injury into account. Parent and child reports of child PTS symptoms were related to family socioeconomic status. Implications for clinical intervention with children and families following pediatric TBI are discussed.

Posttraumatic stress symptomatology after childhood traumatic brain injury

The purpose of this study was to quantify and to identify predictors of posttraumatic stress disorder (PTSD) symptomatology after traumatic brain injury (TBI). Fifty children aged 6 to 14 years, hospitalized after TBI, were assessed soon after TBI regarding injury severity and preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; neuroimaging was also analyzed. Psychiatric assessments were repeated 3, 6, 12, and 24 months after TBI. Only 2 of 46 (4%) subjects with at least one follow-up assessment developed PTSD. However, the frequency with which subjects experienced at least one PTSD symptom ranged from 68% in the first 3 months to 12% at 2 years in assessed children. The presence of an internalizing disorder at time of injury followed by greater injury severity were the most consistent predictors of PTSD symptomatology. It is apparent, therefore, that PTSD and subsyndromal posttraumatic stress disturbances occur despite neurogenic amnesia. These problems should be treated, particularly if symptoms persist beyond 3 months.

Attention-deficit hyperactivity symptomatology after traumatic brain injury: a prospective study

OBJECTIVE

To study prospectively the course of attention-deficit hyperactivity (ADH) symptomatology in children and adolescents after traumatic brain injury (TBI). It was hypothesized that ADH symptomatology would be significantly related to severity of injury.

METHOD

Subjects were children (n = 50) aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, socioeconomic, family functioning, and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales, and neuroimaging was analyzed.

RESULTS

The main finding of this study was that change in ADH symptomatology in the first 2 years after TBI in children and adolescents was significantly related to severity of injury. Overall ADH symptomatology during the study was significantly related to a measure of family dysfunction when family psychiatric history, socioeconomic status, and severity of injury were controlled.

CONCLUSION

The presence of a positive "dose-response" relationship between severity of injury and change in ADH symptoms, present from the 3-month assessment, was consistent with an effect directly related to brain damage.

Parental report of occurrences and consequences of traumatic brain injury among delinquent and non-delinquent youth

Completed questionnaires from parents of youths attending a public middle school or high school and parents of youths admitted to an institution for juvenile delinquents provided information about incidents of traumatic brain injury (TBI) in their children. Results revealed that approximately 40% of the non-delinquent youth and 50% of the delinquent youth had sustained one or more TBIs during their childhood or youth. The majority of injuries appeared to be mild and had no permanent consequences. However, the parents of more than one-third of the delinquent youth with TBI histories reported long-term effects on academic performance, behavior and emotional control, activity level, and/or interactions with friends and family members; parental reports of long-term effects occurred significantly less frequently among the non-delinquent youth. The most common causes of TBI differed between the two adolescent populations. Non-delinquent youth sustained TBIs most frequently from blows to the head during sporting events, and delinquent youth sustained TBIs with approximately equal frequency from sporting events, fall, motor vehicle accidents and fights.

Oppositional defiant disorder symptomatology after traumatic brain injury: a prospective study

Our goal was to prospectively study the course of oppositional defiant disorder (ODD) symptomatology in children and adolescents in the first 2 years after traumatic brain injury (TBI). Fifty children aged 6 to 14, hospitalized after TBI, were assessed soon after TBI regarding injury severity; preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; and neuroimaging was analyzed. ODD symptomatology in the first year after TBI was related to preinjury family function, social class, and preinjury ODD symptomatology. Increased severity of TBI predicted ODD symptomatology 2 years after injury. Change (from before TBI) in ODD symptomatology at 6, 12, and 24 months after TBI was influenced by socioeconomic status. Only at 2 years after injury was severity of injury a predictor of change in ODD symptomatology. The influence of psychosocial factors appears greater than severity of injury in accounting for ODD symptomatology and change in such symptomatology in the first but not the second year after TBI in children and adolescents. This appears related to persistence of new ODD symptomatology after more serious TBI.

Premorbid prevalence of ADHD and development of secondary ADHD after closed head injury

OBJECTIVE

To determine premorbid prevalence of attention-deficit hyperactivity disorder (ADHD) in children with moderate and severe closed head injury (CHI), to determine incidence of ADHD 1 year after injury, and to characterize children who develop ADHD by demographic, neuropsychiatric, and outcome variables.

METHOD

Ninety-nine children who had severe and moderate CHI were followed up for 1 year. Premorbid and 1-year postinjury psychiatric status were ascertained by parent and child structured interviews and questionnaires measuring affective lability, aggression, apathy, and social judgment.

RESULTS

Premorbid prevalence of ADHD was 0.20, significantly higher than in a reference population (0.045). Fifteen of the remaining 80 children (0.19) developed full ADHD criteria (except for age of onset) by the end of the first year. Children who developed secondary ADHD (S-ADHD) had significantly greater premorbid psychosocial adversity, posttraumatic affective lability and aggression, posttraumatic psychiatric comorbidity, and overall disability than children who did not develop S-ADHD.

CONCLUSIONS

There is an excess prevalence of premorbid ADHD among children who present with moderate and severe CHI. Children with high psychosocial adversity are more likely to develop S-ADHD after CHI. S-ADHD has criteria in common with personality change due to CHI, a deficit in behavioral inhibition being the major overlapping feature.

The Neuropsychiatric Rating Schedule: reliability and validity

OBJECTIVE

To evaluate reliability and validity for the Neuropsychiatric Rating Schedule (NPRS) interview designed to permit diagnosis of organic personality syndrome (OPS) or personality change due to a general medical condition (PC).

METHOD

Subjects from prospective (n = 50) and retrospective (n = 72) studies of traumatic brain injury were aged 6 through 18 years. Parents and children were informants for the NPRS. Convergent and discriminant validity of subtypes of OPS/PC were assessed against standard scales completed by parents and teachers. Interrater reliability data (n = 20), test-retest reliability data (n = 42), as well as sensitivity-to-change data (n = 37) were collected.

RESULTS

All subtypes of OPS/PC were diagnosed, but apathy and paranoia subtypes were rare. Rating scale data supported convergent validity of OPS/PC subtypes generated with the NPRS. Affective instability, rage/aggression, and inappropriate social judgment were moderately to highly correlated, but apathy and paranoia could be discriminated from each of these subtypes. Interrater agreement for NPRS items was fair to excellent for all but one item (paranoia). Test-retest reliability was fair to good, and sensitivity to change was demonstrated.

CONCLUSION

The NPRS generated reliable and valid diagnoses of the common subtypes of OPS/PC.

Child and adolescent traumatic brain injury: correlates of disruptive behaviour disorders

A record review focused on children and adolescents, with a history of traumatic brain injury (TBI), who were consecutively admitted to a brain injury clinic in which all new patients are psychiatrically evaluated. Correlates of post-injury oppositional defiant disorder/conduct disorder (ODD/CD) and post-injury attention deficit hyperactivity disorder (AHD) were investigated. Subjects who developed ODD/CD following TBI, when compared to subjects without a lifetime history of the disorder, had significantly more impaired family functioning, showed a trend toward a greater family history of alcohol dependence/abuse and suffered a milder TBI. In contrast, there were no variables which discriminated between subjects who developed ADHD following injury and those with no lifetime history of ADHD. It is difficult to determine whether ODD, CD and ADHD occurring after TBI in the patient is related to the TBI, directly or indirectly. Appropriate clinical assessment requires consideration of the important mediating role of family functioning, severity of injury and family psychiatric history.

Child and adolescent traumatic brain injury: correlates of injury severity

A record review focused on children and adolescents, with a history of traumatic brain injury, who were consecutively admitted to a brain injury clinic in which all new patients are psychiatrically evaluated. Significant correlates of severity of injury in the cognitive, education and communication domains of functioning included Performance IQ but not Verbal IQ nor standardized ratings of language or learning disability. Current organic personality syndrome (OPS) but not attention deficit hyperactivity disorder or oppositional defiant disorder/conduct disorder diagnostic status was significantly related to severity. In conclusion, the findings in this referred sample are similar to prospective studies indicating that Performance IQ appears sensitive in reflecting brain damage. The finding linking OPS to severity of injury is not surprising. This is because OPS is a diagnosis which is dependent on the clinician's judgment of the likelihood that the organic factor is etiologically related to a defined behavioural syndrome. The diagnosis therefore requires a clinical judgment that the threshold of severity of a presumed organic etiological factor has been reached.

Predictors of family functioning after traumatic brain injury in children and adolescents

OBJECTIVE

To assess factors predictive of family outcome in the first 2 years after traumatic brain injury (TBI) in children and adolescents.

METHOD

Subjects were children aged 6 to 14 at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury factors (psychiatric family functioning, and family life events), injury factors (severity of injury), and postinjury factors (coping and development of a psychiatric disorder, never before present, i.e., "novel") were conducted using standard clinical scales. The outcome measure was family function as assessed with standardized family functioning interviews (at 12 and 24 months after TBI) and primary caretaker self-report questionnaires (at 3 and 6 months after TBI).

RESULTS

Fifty subjects enrolled, and the analyses focused on 37, 41, 43, and 42 subjects assessed at the 3-, 6-, 12-, and 24-month follow-up evaluations, respectively. The strongest influences on family functioning after childhood TBI are preinjury family functioning, the development of a "novel" psychiatric disorder in the child, and preinjury family life events or stressors.

CONCLUSIONS

These data suggest that there are families, identifiable through clinical assessment, at increased risk for family dysfunction after a child's TBI. Early identification and treatment of the child's psychopathology and family dysfunction may attenuate the associated morbidity.

Traumatic brain injury in children and adolescents: psychiatric disorders at two years

OBJECTIVE

To extend findings regarding predictive factors of psychiatric outcome from the first to the second year after traumatic brain injury (TBI) in children and adolescents.

METHOD

Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the presence of a psychiatric disorder, not present before the injury ("novel"), during the second year after TBI.

RESULTS

Fifty subjects enrolled, and the analyses focused on 42 subjects followed at 24 months. Severity of injury, preinjury family function, and preinjury lifetime psychiatric history predicted the development of a "novel" psychiatric disorder present in the second year.

CONCLUSION

These data suggest that there are children, identifiable through clinical assessment, at increased risk for "novel" psychiatric disorders in the second year after TBI.

Traumatic brain injury in children and adolescents: psychiatric disorders in the second three months

Psychiatric disorders may be common after traumatic brain injury (TBI) in children, yet there is a death of prospective studies examining this problem. Fifty children aged 6 to 14, hospitalized after TBI, were assessed soon after TBI regarding preinjury psychiatric, behavioral, adaptive, and family functioning, family psychiatric history status and injury severity. The outcome measure was the presence of a "novel" psychiatric disorder (not present before the injury) during the second 3 months after the injury. Forty-two subjects were reassessed at 6 months. Severity of injury, family psychiatric history, and family function predicted a novel psychiatric disorder. Among children suffering a mild/moderate injury, those with preinjury lifetime psychiatric disorders were no longer (as they had been in the first 3 months) at higher risk than those without such a lifetime history. Thus, there appeared to be children, identifiable through clinical assessment, at increased risk for novel psychiatric disorders after TBI.

Traumatic brain injury in a child psychiatry outpatient clinic: a controlled study

OBJECTIVE

To demonstrate the similarity of children with a history of traumatic brain injury (TBI), particularly mild TBI, to matched children without such a history, within a child psychiatry outpatient clinic.

METHOD

This is a chart review of patients presenting to a child psychiatry outpatient clinic over a 3-year period. Children with TBI were matched by age, sex, race, and social class to children with no history of TBI. Axis I and II diagnoses, use of special education services, and IQ scores were compared.

RESULTS

Seventy-four (5.6%) of 1,333 consecutive clinic cases had a definite TBI. Of these, 64 were mild. Only 3 of 59 comparisons that were made between TBI and control subjects were significant. A developmental communication disorder cluster was significantly more frequent in the TBI group. Autism and a pervasive developmental disorder cluster were significantly more frequent in the control group.

CONCLUSION

In a child psychiatry clinic, patients with a history of TBI are virtually indistinguishable from matched children without TBI. Caution should be exercised before attributing the child's problems, especially long-term problems, to the TBI unless the injury was severe or the child is exhibiting related phobic or posttraumatic stress symptomatology.