Sleep Disturbance in Children With Moderate or Severe Traumatic Brain Injury Compared With Children With Orthopedic Injury

Predicting and improving outcome in severe pediatric traumatic brain injury

INTRODUCTION

Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments.

AREAS COVERED

The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions.

EXPERT OPINION

There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

ABBREVIATIONS

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

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.

Traumatic Brain Injury Characteristics Predictive of Subsequent Sleep-Wake Disturbances in Pediatric Patients

Simple Summary

Traumatic brain injury is a leading cause of death and disabilities in children and adolescents. Poor sleep after brain injury can slow recovery and worsen outcomes. We investigated clinical sleep problems following pediatric brain injury. We examined characteristics of the injury and details about the patients that may be risk factors for developing sleep problems. The number of patients that developed problems with their sleep after a brain injury was similar between genders. The probability of insomnia increased with increasing patient age. The probability of ‘difficulty sleeping’ was highest in 7–9 year-old brain-injured patients. Older patients had a shorter time between brain injury and sleep problems compared to younger patients. Patients with severe brain injury had the shortest time between brain injury and development of sleep problems, whereas patients with mild or moderate brain injury had comparable times between brain injury and the onset of poor sleep. Multiple characteristics of brain injury and patient details were identified as risk factors for developing sleep problems following a brain injury in children. Untreated sleep problems after a brain injury can worsen symptoms, lengthen hospital stays, and delay return to school. Identifying risk factors could improve the diagnosis, management, and treatment of sleep problems in survivors of pediatric brain injury.

Abstract

The objective of this study was to determine the prevalence of sleep-wake disturbances (SWD) following pediatric traumatic brain injury (TBI), and to examine characteristics of TBI and patient demographics that might be predictive of subsequent SWD development. This single-institution retrospective study included patients diagnosed with a TBI during 2008–2019 who also had a subsequent diagnosis of an SWD. Data were collected using ICD-9/10 codes for 207 patients and included the following: age at initial TBI, gender, TBI severity, number of TBIs diagnosed prior to SWD diagnosis, type of SWD, and time from initial TBI to SWD diagnosis. Multinomial logit and negative-binomial models were fit to investigate whether the multiple types of SWD and the time to onset of SWD following TBI could be predicted by patient variables. Distributions of SWD diagnosed after TBI were similar between genders. The probability of insomnia increased with increasing patient age. The probability of ‘difficulty sleeping’ was highest in 7–9 year-old TBI patients. Older TBI patients had shorter time to SWD onset than younger patients. Patients with severe TBI had the shortest time to SWD onset, whereas patients with mild or moderate TBI had comparable times to SWD onset. Multiple TBI characteristics and patient demographics were predictive of a subsequent SWD diagnosis in the pediatric population. This is an important step toward increasing education among providers, parents, and patients about the risk of developing SWD following TBI.

Behavioral interventions for sleep disturbances in children with neurological and neurodevelopmental disorders: a systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVES

Sleep disturbances are common and associated with negative functional and health consequences in children with neurological and neurodevelopmental disorders (NNDDs) and represent an important potential target for behavioral interventions. This systematic review examined the efficacy of behavioral sleep interventions (BSIs) for children with NNDDs and comorbid sleep disturbances.

METHODS

A systematic search of MEDLINE, EMBASE, PsychINFO, and CENTRAL was conducted in April 2019. Randomized controlled trials (RCTs) of BSI for children with NNDDS were included. Meta-analysis and GRADE quality ratings were performed on sleep and secondary functional outcomes (cognition, academics, and behavior).

RESULTS

Nine RCTs were identified (n = 690; Mage = 8.39 ± 2.64years; 71.11% male). The quality of the evidence was predominantly rated as moderate. Posttreatment improvements in sleep were found on self-reported sleep disturbances (total sleep disturbance [standardized mean difference, i.e. SMD = 0.89], night wakings [SMD = 0.52], bedtime resistance [SMD = 0.53], parasomnias [SMD = 0.34], sleep anxiety [SMD = 0.50]) and self-reported sleep patterns (sleep duration [SMD = 0.30], sleep onset duration [SMD = 0.75]) and (2) objectively measured actigraphic sleep patterns (total sleep time [MD = 18.09 min; SMD = 0.32], sleep onset latency [MD = 11.96 min; SMD = 0.41]). Improvements in sleep (self-reported, not actigraphy) were maintained at follow-up, but few studies conducted follow-up assessments resulting in low-quality evidence. Reduction in total behavioral problems (SMD = 0.48) posttreatment and attention/hyperactivity (SMD = 0.28) at follow-up was found. Changes in cognition and academic skills were not examined in any studies.

CONCLUSIONS

BSIs improve sleep, at least in the short term, in children with NNDDs. Benefits may extend to functional improvements in behavior. More rigorous RCTs involving placebo controls, blinded outcome assessment, longer follow-up durations, and assessment of functional outcomes are required.

The persistence of sleep disturbance and its correlates in children with moderate to severe traumatic brain injury: A longitudinal study

OBJECTIVES

The primary aim was to examine whether sleep disturbances persist in children in the chronic stage of recovery from moderate or severe traumatic brain injury (TBI). The secondary aim was to examine whether memory difficulties and/or other previously identified factors relate to sleep disturbances in children with moderate to severe TBI.

METHODS

This longitudinal study included 21 children with moderate to severe TBI, 8-18 years old, recruited from an urban tertiary paediatric specialised brain injury rehabilitation unit. Participants were seen 5 years and again 7 years post-injury, on average. Sleep disturbances were assessed with Sleep Disturbance Scale for Children (SDSC). Correlates that were considered included indicators of TBI severity, and questionnaires assessing everyday memory, fatigue, internalizing and externalizing behaviors and pain intensity.

RESULTS

The SDSC scores of children with moderate to severe TBI indicated greater disturbances in initiating and maintaining sleep, arousal, sleep-wake transition, and excessive somnolence relative to the norms, at follow-up. The mean SDSC scores and the number of participants with subclinical to clinical sleep disturbances on the SDSC remained unchanged from baseline to follow-up. At follow-up, the SDSC initiating and maintaining sleep, and excessive somnolence scales were associated with poorer everyday memory and greater fatigue.

CONCLUSIONS

Children with moderate to severe TBI experience ongoing sleep disturbances for years post-injury. Greater sleep disturbances are associated with worse functional outcomes. Further research into sleep disturbances and development of treatments is important, as it could improve the outcomes of children with TBI.

Children who sustained traumatic brain injury take longer to fall asleep compared to children who sustained orthopedic injuries: actigraphy findings

Objective: Primary: to examine objective sleep outcomes in children who sustained moderate to severe traumatic brain injury (TBI). Secondary: to examine the relation of objective sleep with subjective sleep, fatigue, and injury variables.Setting: A single tertiary brain injury unit.Participants: Children (5-15 years) with moderate to severe TBI (n = 23) or orthopedic injury (OI; n = 13).Design: Cohort study.Measures: Primary: objective sleep measure (actigraphy watch). Secondary: subjective sleep measure (questionnaire), fatigue questionnaire, and injury variables.Results: On actigraphy, children with TBI had longer sleep onset latency compared to children with OI. On the sleep questionnaire, children with TBI obtained higher scores for total sleep disturbance, initiating and maintaining sleep, and excessive somnolence. On the fatigue questionnaire, greater difficulties were found for total, sleep/rest, and cognitive fatigue for the TBI group. In the TBI group, actigraphy data did not correlate with sleep questionnaire, fatigue, or injury variables.Conclusion: Our study showed evidence of objective and subjective sleep disturbance in children with moderate to severe TBI, but these two types of sleep measures were not related. It is possible that distinct mechanisms underpin objective and subjective sleep disturbance, which may require different interventions.

Acceptability, feasibility, and usability of a manualized cognitive behavioural programme for treatment of insomnia in children who sustained traumatic brain injury: A service providers' perspective

Sleep disturbances, especially insomnia, are common and associated with poor outcomes in children following traumatic brain injury (TBI). Yet, clinical treatment guidelines are lacking. Thus, we developed a manualized cognitive-behavioural programme for treatment of insomnia (CBT-I) in children who sustained TBI. The aim of this study was to determine acceptability, feasibility, and usability of the programme from the service providers' perspective. This observational study used an explanatory mixed-methods design. Fifteen clinicians experienced in working with children, patients with sleep disturbances or brain injuries participated. On review of the treatment programme, clinicians completed an online survey assessing (i) the overall format, aesthetics, and clarity of the programme, and (i) the overall quality of the intervention. Analyses involved descriptive statistics and a thematic analysis. Clinician's ratings indicated a high level of agreement in the acceptability, feasibility, and usability of the programme, ranging from 70.9% (the therapist manual) to 86.9% (the intervention approach). Thematic analysis revealed suggestions that related to the developmental appropriateness, feasibility, and usability of the programme. The findings of our study will be used to modify the CBT-I treatment programme that will be further validated in a feasibility clinical trial involving children aged 6-10 years who sustained TBI.

A feasibility and acceptability study of cognitive behavioural treatment for insomnia in adolescents with traumatic brain injury: A-B with follow up design, randomized baseline, and replication across participants

Difficulties falling asleep or staying asleep (symptoms of insomnia) are common following paediatric traumatic brain injury (TBI). Yet, interventions to treat insomnia in this population have not yet been reported. This single-case series examined the feasibility and acceptability of cognitive behavioral treatment for insomnia (CBT-I) for adolescents (n = 5, aged 11-13 years) with TBI, and explored changes in sleep and fatigue post-treatment. Adolescents were randomly assigned to two conditions: a 7- or 14-days baseline, followed by 4 weeks of manualised CBT-I delivered individually. To assess feasibility and acceptability we compared recruitment and retention rates, and questionnaire scores to a-priori set criteria. We explored treatment efficacy and functional gains in sleep and fatigue from baseline to follow-up using structured visual analysis of time-series graphs, and reliable change indices or changes in clinical classification. Feasibility and acceptability indicators met a-priori criteria, but therapists noticed limited adolescent engagement in sessions. Clinically significant improvements were found in sleep, in 3 out of 4 cases, and fatigue, in all cases. Our study provides preliminary evidence that CBT-I is feasible for insomnia treatment in adolescents with TBI and provides directions for development of future treatment studies.