Intellectual outcome from preschool traumatic brain injury: a 5-year prospective, longitudinal study

Long-Term Neurodevelopmental Outcome of Children With Mild Traumatic Brain Injury

BACKGROUND

To investigate the long-term outcome of pediatric mild traumatic brain injury (mTBI) in terms of neurocognitive, behavioral, and school functioning and to identify clinical risk factors for adverse outcomes.

METHODS

This study describes the follow-up of a prospective multicenter sample of 89 children with mTBI 3.6 years postinjury and 89 neurologically healthy children matched for sex, age, and socioeconomic status. Neurodevelopmental outcomes were assessed using an intelligence test, behavioral questionnaires, computerized neurocognitive tests, and longitudinal (pre- and postinjury) standardized school performance data.

RESULTS

Children with mTBI exhibited intelligence in the average range but had more behavioral problems related to inattentiveness (P = 0.004, d = 0.47) and hyperactive impulsivity (P = 0.01, d = 0.40) and showed poorer neurocognitive performance in information processing stability (P = 0.003, d = -0.55) and Visual Working Memory (P = 0.04, d = -0.39) compared with matched peers. Longitudinal school performance data revealed poorer performance in Technical Reading up to two years postinjury (P = 0.005, d = -0.42) when compared with normative data. Clinical risk factors did not reveal predictive value for adverse outcomes in children with mTBI.

CONCLUSIONS

This study indicates that children with mTBI are at risk of long-term deficits in neurocognitive and behavioral functioning, with longitudinal evidence suggesting shortfalls in school performance up to two years postinjury. Clinical risk factors do not provide a solid basis for long-term neurodevelopmental prognosis. Findings emphasize the importance of, and challenges for, early identification of children at risk for adverse neurodevelopmental outcome after mTBI.

Early Childhood Concussion

The unconsolidated motor and cognitive skills that are typical of the early childhood period place infants, toddlers, and preschoolers at risk for a variety of traumatic injuries. Such injuries may include mild traumatic brain injury or concussion. Knowledge regarding the risk, diagnosis, outcomes, and management of early childhood concussion is limited, especially compared with what is known about concussion in school-age children, adolescents, and adults. This state-of-the-art review aims to provide current knowledge on the epidemiology, physical signs, behavior, and clinical outcomes associated with early childhood concussion. Research on this condition has been challenged by the need to adapt methods to the unique physical, behavioral, and developmental characteristics of young children. We provide information on observable symptoms associated with concussion, recommended approaches to care, and suggestions for overcoming barriers to research in this area. Developmentally appropriate efforts are needed to improve our ability to identify, evaluate, and treat early childhood concussion.

Exploring racial disparities and inequalities among children and youth with acquired brain injury: a systematic review

PURPOSE

Racial minoritized children and youth with acquired brain injury (ABI) often experience multiple forms of discrimination. The purpose of this systematic review was to understand the racial disparities in health care among children and youth with ABI and their caregivers.

METHOD

Six international databases (Ovid Medline, Embase, Healthstar, Psychinfo, Scopus, and Web of Science) were systematically searched for peer-reviewed articles. Studies were screened by two researchers who also conducted the data extraction and quality appraisal. A narrative synthesis approach was used to analyze the data.

RESULTS

Of the 8081 studies identified in the search, 34 met the inclusion criteria, which involved 838,052 children and youth with brain injuries (or caregivers representing them) across two countries. The following themes were noted in the studies in our review: (1) racial disparities in accessing care (i.e., diagnosis, hospital admission, length of stay, rehabilitation treatment); (2) racial disparities in ABI-related health outcomes (i.e., functional outcomes and mortality rates); and (3) factors affecting racial disparities (i.e., sources in injury, insurance and expenditures, and intersectionality).

CONCLUSIONS

Our findings reveal the concerning racial disparities among children and youth with ABI. Further research should explore solutions for addressing such racial disparities and solutions to address them.

The Use of Methylphenidate During Inpatient Rehabilitation After Pediatric Traumatic Brain Injury: Population Characteristics and Prescribing Patterns

OBJECTIVE

To understand how methylphenidate (MPH) is used in youth with traumatic brain injury (TBI) during inpatient pediatric rehabilitation.

SETTING

Inpatient pediatric rehabilitation.

PARTICIPANTS

In total, 234 children with TBI; 62 of whom received MPH and 172 who did not. Patients were on average 11.6 years of age (range, 2 months to 21 years); 88 of 234 were female; the most common mechanism of injury was motor vehicle collision (49%); median (IQR) acute hospital length of stay (LOS) and inpatient rehabilitation LOS were 16 (10-29) and 23 (14-39), respectively; 51 of 234 were in a disorder of consciousness cognitive state at time of inpatient rehabilitation admission.

DESIGN

Multicenter, retrospective medical record review.

MAIN MEASURES

Patient demographic data, time to inpatient pediatric rehabilitation admission (TTA), cognitive state, MPH dosing (mg/kg/day).

RESULTS

Patients who received MPH were older (P = .011); TTA was significantly longer in patients who received MPH than those who did not (P =.002). The lowest recorded dose range by weight was 0.05 to 0.89 mg/kg/d, representing an 18-fold difference; the weight-based range for the maximum dose was 0.11 to 0.97 mg/kg/d, a 9-fold difference. Patients in lower cognitive states at admission (P = .001) and at discharge (P = .030) were more likely to receive MPH. Five patients had side effects known to be associated with MPH; no serious adverse events were reported.

CONCLUSION

This multicenter study indicates that there is variable use of MPH during acute inpatient rehabilitation for children with TBI. Children who receive MPH tend to be older with lower cognitive states. Dosing practices are likely consistent with underdosing. Clinical indications for MPH use during inpatient pediatric rehabilitation should be better defined. The use of MPH, as well as its combination with other medications and treatments, during inpatient rehabilitation needs to be further explored.

Long-Term Outcomes of Pediatric Traumatic Brain Injury Following Inpatient Rehabilitation

OBJECTIVE

Assess residual disability in youth with traumatic brain injury (TBI) treated in a pediatric inpatient rehabilitation unit and examine associations of disability with inpatient status and measures of concurrent functioning.

SETTING

Large, urban, quaternary care children's hospital in the Midwestern United States.

PARTICIPANTS

Forty-five youth aged 6 to 18 years treated in an inpatient rehabilitation unit for mild-complicated to severe TBI at a minimum of 12 months postdischarge (mean = 3.5 years).

DESIGN

Retrospective chart review of clinical data collected from standard clinical care at admission and discharge combined with follow-up data examining current functioning at the time of study enrollment.

MAIN OUTCOME MEASURES

Glasgow Outcome Scale-Extended, Pediatric Revision (GOS-E Peds), Neurology Quality of Life Measurement System Short Form (NeuroQOL) Social Interaction with Peers and Cognitive Short Forms, Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale, Strengths and Difficulties Questionnaire, and the Behavior Rating Inventory of Executive Function, 2nd Edition (BRIEF-2).

RESULTS

Based on parent report at follow-up, 62% of the children had residual TBI-related disabilities on the GOS-E Peds, while 38% reported "good recovery." Children with residual disability also reported more long-term problems in overall health, social relationships, emotional regulation, behaviors, and executive functioning than those with no residual disability. Measures of functional independence and cognitive recovery at discharge were associated with these impairments.

CONCLUSIONS

More than half of the children with TBI in this study had residual disability more than 1 year after inpatient rehabilitation. Findings highlight the associations between measures of functional independence and cognitive recovery during inpatient rehabilitation with later outcomes and underscore the need for continued services to support the needs of children with TBI following their inpatient rehabilitation stay.

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

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

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

Regional Cortical Thickness Correlates of Intellectual Abilities Differ in Children With Traumatic Brain Injury Versus Those With Orthopedic Injury in the Chronic Post-Injury Phase

A decline in intellectual functioning (intelligence quotient [IQ]) is often observed following more severe forms of traumatic brain injury (TBI) and is a useful index for long-term outcome. Identifying brain correlates of IQ can serve to inform developmental trajectories of behavior in this population. Using magnetic resonance imaging (MRI), we examined the relationship between intellectual abilities and patterns of cortical thickness in children with a history of TBI or with orthopedic injury (OI) in the chronic phase of injury recovery. Participants were 47 children with OI and 58 children with TBI, with TBI severity ranging from complicated-mild to severe. Ages ranged from 8 to 14 years old, with an average age of 10.47 years, and an injury-to-test range of ∼1-5 years. The groups did not differ in age or sex. The intellectual ability estimate (full-scale [FS]IQ-2) was derived from a two-form (Vocabulary and Matrix Reasoning subtests) Wechsler Abbreviated Scale of Intelligence (WASI). MRI data were processed using the FreeSurfer toolkit and harmonized across data collection sites using neuroComBat procedures, while holding demographic features (i.e., sex, socioeconomic status [SES]), TBI status, and FSIQ-2 constant. Separate general linear models per group (TBI and OI) and a single interaction model with all participants were conducted with all significant results withstanding correction for multiple comparisons via permutation testing. Intellectual ability was higher (p < 0.001) in the OI group (FSIQ-2 = 110.81) than in the TBI group (FSIQ-2 = 99.81). In children with OI, bi-hemispheric regions, including the right pre-central gyrus and precuneus and bilateral inferior temporal and left occipital areas were related to IQ, such that higher IQ was associated with thicker cortex in these regions. In contrast, only cortical thickness in the right pre-central gyrus and bilateral cuneus positively related to IQ in children with TBI. Significant interaction effects were found in the bilateral temporal, parietal, and occipital lobes and left frontal regions, indicating that the relationship between IQ and cortical thickness differed between groups in these regions. Changes in cortical associations with IQ after TBI may reflect direct injury effects and/or adaptation in cortical structure and intellectual functioning, particularly in the bilateral posterior parietal and inferior temporal regions. This suggests that the substrates of intellectual ability are particularly susceptible to acquired injury in the integrative association cortex. Longitudinal work is needed to account for normal developmental changes and to investigate how cortical thickness and intellectual functioning and their association change over time following TBI. Improved understanding of how TBI-related cortical thickness alterations relate to cognitive outcome could lead to improved predictions of outcome following brain injury.

Speech-Language Pathology Treatment of Cognitive-Communication Deficits in School-Aged Children With Traumatic Brain Injury: A Scoping Review

PURPOSE

The purpose of this scoping review was to synthesize the current evidence-based treatment practices used with school-aged children with any severity of traumatic brain injury (TBI) that could benefit the practice of speech-language pathologists (SLPs).

METHOD

A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Included studies were assigned thematic labels based on a modified version of the Rehabilitation Treatment Specification System.

RESULTS

A total of 27 articles that covered 16 different treatment approaches met inclusion criteria for this study. Most studies included adolescent or teenage participants with moderate-severe TBIs. Treatment targets included executive functioning (n = 15), social competence (n = 6), postconcussive symptoms (n = 5), behavior (n = 3), family functioning (n = 1), and health-related quality of life (n = 1). The majority of current interventions for school-aged children with TBI include a multidisciplinary approach and components of family involvement education.

CONCLUSIONS

Further research is needed on interventions that are specifically implemented by SLPs as well as protocols that include more heterogeneous samples (e.g., varied sociodemographic factors and injury severity) to allow for the development and testing of ecologically valid intervention practice. SLPs can use the results of this scoping review to individualize treatment based on the child's areas of need while considering individual characteristics and to provide person-centered intervention for children with school-aged TBI.

A single mild juvenile TBI in male mice leads to regional brain tissue abnormalities at 12 months of age that correlate with cognitive impairment at the middle age

Traumatic brain injury (TBI) has the highest incidence amongst the pediatric population and its mild severity represents the most frequent cases. Moderate and severe injuries as well as repetitive mild TBI result in lasting morbidity. However, whether a single mild TBI sustained during childhood can produce long-lasting modifications within the brain is still debated. We aimed to assess the consequences of a single juvenile mild TBI (jmTBI) at 12 months post-injury in a mouse model. Non-invasive diffusion tensor imaging (DTI) revealed significant microstructural alterations in the hippocampus and the in the substantia innominata/nucleus basalis (SI/NB), structures known to be involved in spatial learning and memory. DTI changes paralled neuronal loss, increased astrocytic AQP4 and microglial activation in the hippocampus. In contrast, decreased astrocytic AQP4 expression and microglia activation were observed in SI/NB. Spatial learning and memory were impaired and correlated with alterations in DTI-derived derived fractional ansiotropy (FA) and axial diffusivity (AD). This study found that a single juvenile mild TBI leads to significant region-specific DTI microstructural alterations, distant from the site of impact, that correlated with cognitive discriminative novel object testing and spatial memory impairments at 12 months after a single concussive injury. Our findings suggest that exposure to jmTBI leads to a chronic abnormality, which confirms the need for continued monitoring of symptoms and the development of long-term treatment strategies to intervene in children with concussions.

Ableism among children and youth with acquired brain injury and their caregivers: a systematic review

PURPOSE

Children and youth with acquired brain injury (ABI) experience persistent discrimination and ableism. The purpose of this systematic review was to understand the experiences and impact of ableism among children and youth with ABI.

METHOD

Six international databases were systematically searched for articles from 2002-2022. Studies were screened independently by four researchers who performed the data extraction. Study quality was appraised using the Standard quality assessment criteria for evaluating primary research.

RESULTS

Of the 2085 studies identified in the search, 15 met the inclusion criteria, which involved 1442 children and youth with brain injuries or caregivers representing them. Studies in the review showed the following key trends: (1) incidence of ableism among children and youth with ABI; (2) experiences of ableism at the individual and institutional levels, (3) impact of ableism (i.e., mental health, social relationships, quality of life) and (4) coping strategies (i.e., resources, supports).

CONCLUSIONS

Our findings reveal the alarming incidence of ableism among youth with ABI. Therefore, there is a critical need for more research to explore youth's lived experiences of ableism, especially from their perspectives along with the co-development of solutions to help enhance their social inclusion and well-being.

Prediction Models for Neurocognitive Outcome of Mild Traumatic Brain Injury in Children: A Systematic Review

Mild traumatic brain injury (mTBI) is highly prevalent in children. Recent literature suggests that children with mTBI are at considerable risk of persisting neurocognitive deficits, threatening post-injury child development. Nevertheless, clinical tools for early identification of children at risk are currently not available. This systematic review aims to describe the available literature on neurocognitive outcome prediction models in children with mTBI. Findings are highly relevant for early identification of children at risk of persistent neurocognitive deficits, allowing targeted treatment of these children to optimize recovery. The electronic literature search was conducted in PubMed, EMBASE, CINAHL, Cochrane, PsychINFO and Web of Science on February 9, 2022. We included all studies with multi-variate models for neurocognitive outcome based on original data from only children (age <18 years) with mTBI. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, two authors independently performed data extraction and risk of bias analysis using the Prediction model Risk of Bias Assessment Tool (PROBAST). This systematic review identified eight original studies (nine articles) reporting prediction models for neurocognitive outcome, representing a total of 1033 children diagnosed with mTBI (mean age at injury = 10.5 years, 37.6% girls). Neurocognitive outcome assessment took place between 1 month and 7 years post-injury. Models were identified with significant predictive value for the following outcomes: memory, working memory, inhibition, processing speed, and general neurocognitive functioning. Prediction performance of these models varied greatly between weak and substantial (R² = 10.0%-54.7%). The best performing model was based on demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening to predict the presence of a deficit in general neurocognitive functioning at 12 months post-injury. This systematic review reflects the absence of robust prediction models for neurocognitive outcome of children with mTBI. The findings indicate that demographic factors, pre-morbid factors as well as acute and subacute clinical factors have relevance for neurocognitive outcome. Based on the available evidence, evaluation of demographic and pre-morbid risk factors in conjunction with a subacute neurocognitive screening may have the best potential to predict neurocognitive outcome in children with mTBI. The findings underline the importance of future research contributing to early identification of children at risk of persisting neurocognitive deficits.

Long-term neurorehabilitation outcomes of pediatric vs. adult onset acquired brain injury

Background

Functional outcomes of intensive neurorehabilitation for pediatric onset acquired brain injury (ABI) are understudied. The extent and pervasiveness of impairments are often uncovered years after an ABI and can worsen over time, leading to a cascade of academic, functional, and psychosocial difficulties.

Objective

To examine the long-term outcomes of survivors with pediatric onset vs. adult onset ABI who completed holistic milieu-oriented neurorehabilitation up to 30 years ago.

Methods

One hundred twenty-three survivors of ABI including a pediatric onset group (n = 22) and an adult onset group (n = 101) with heterogeneous neurological etiologies who attended holistic, milieu-oriented neurorehabilitation. Productivity, driving, and functional outcomes were evaluated using the Mayo-Portland Adaptability Inventory-4 (MPAI-4) and a psychosocial outcome questionnaire. Treatment for the pediatric onset group started much later than onset.

Results

A one-way analysis of covariance revealed no significant differences between the two groups on the MPAI-4. At the follow-up survey, there was no significant difference between age at onset of injury and productivity status. The average follow-up time was ~8 years (SD = 6.28) from time of discharge to the time of the survey. Although there was no significant difference between the two groups for driving at the time of admission, the adult onset group was significantly more likely to return to driving after treatment.

Conclusions

This study demonstrates the positive and enduring benefits of holistic, milieu-oriented neurorehabilitation for survivors of pediatric onset ABI regardless of the time between initial injury and engagement in rehabilitative therapies.

Rehabilitation in Pediatric Stroke: Cognition and Behavior

Pediatric stroke is associated with a range of maladaptive cognitive and behavioral outcomes that often require targeted intervention. Despite increasing research on neuropsychological outcomes over the past decade, evidence for effective therapies and interventions for the most commonly reported cognitive and behavioral challenges is still limited. The most widely prescribed interventions address more overt deficits in sensorimotor and speech/language functions, yet interventions for higher-order cognitive, linguistic and behavioral deficits are notably less defined. Moreover, concepts of rehabilitation in adult stroke cannot be easily translated directly to pediatric populations because the effect of stroke and recovery in the developing brain takes a very different course than in the mature brain. In pediatric stroke, neuropsychological deficits often emerge gradually over time necessitating a long-term approach to intervention. Furthermore, family and school context often play a much larger role. The goal of this review is to describe cognitive and behavioral interventions for perinatal and childhood stroke, as motor rehabilitation is covered elsewhere in this issue. We also discuss cognitive aspects of current rehabilitative therapies and technology. Acknowledging the current limited state of stroke-specific rehabilitation research in children, findings from pediatric acquired brain injury intervention and use of transdiagnostic approaches lend important insights. Because there is limited support for single domain (cognitive) trainings and translation of research rehabilitation programs to clinical practice can be challenging, the value of holistic multidisciplinary approaches to improve everyday function in children and adolescents following stroke is emphasized.

Effects of Pediatric Traumatic Brain Injury on Verbal IQ: A Systematic Review and Meta-Analysis

OBJECTIVES

To examine the effects of pediatric traumatic brain injury (TBI) on verbal IQ by severity and over time.

METHODS

A systematic review and subsequent meta-analysis of verbal IQ by TBI severity were conducted using a random effects model. Subgroup analysis included two epochs of time (e.g., <12 months postinjury and ≥12 months postinjury).

RESULTS

Nineteen articles met inclusion criteria after an extensive literature search in MEDLINE, PsycInfo, Embase, and CINAHL. Meta-analysis revealed negative effects of injury across severities for verbal IQ and at both time epochs except for mild TBI < 12 months postinjury. Statistical heterogeneity (i.e., between-study variability) stemmed from studies with inconsistent classification of mild TBI, small sample sizes, and in studies of mixed TBI severities, although not significant. Risk of bias on estimated effects was generally low (k = 15) except for studies with confounding bias (e.g., lack of group matching by socio-demographics; k = 2) and measurement bias (e.g., outdated measure at time of original study, translated measure; k = 2).

CONCLUSIONS

Children with TBI demonstrate long-term impairment in verbal IQ, regardless of severity. Future studies are encouraged to include scores from subtests within verbal IQ (e.g., vocabulary, similarities, comprehension) in addition to functional language measures (e.g., narrative discourse, reading comprehension, verbal reasoning) to elucidate higher-level language difficulties experienced in this population.

Traumatic Brain Injury in Children: Glial fibrillary Acidic Protein and Clinical Outcomes

OBJECTIVES

Glial fibrillary acidic protein (GFAP) is a neuronal protein released after traumatic brain injury (TBI) and detectable in serum samples. GFAP correlates with symptom severity in adults and may be a marker of brain injury in children with milder symptoms or preverbal children.

METHODS

GFAP was examined in children with severe TBI (initial Glasgow Coma Scale score <8), with mild TBI (Glasgow Coma Scale score 14/15), and at 0 to 4 and at 10 to 14 days after TBI and was compared with healthy age-matched controls. Mechanism, time points from injury, and symptoms were recorded.

RESULTS

The study enrolled 208 children including 110 with TBI (n = 104 mild, 6 severe) and controls (n = 98). GFAP was higher in mild TBI than in controls and highest in the severe TBI cohort, with a maximum value at 6 hours from injury. Vomiting was significantly associated with higher GFAP levels, but no association was found with amnesia, loss of consciousness, and the Sports Concussion Assessment Tool. Children reporting >1-point changes from their preinjury functioning on the Post-Concussive Symptom Inventory had higher initial GFAP but not total Post-Concussive Symptom Inventory score changes.

CONCLUSIONS

GFAP identifies children with TBI, even at the milder end of the spectrum, and is strongly associated with postinjury vomiting. It may be a useful marker of pediatric TBI; however, sampling is time critical.

Theory of mind and facial emotion recognition in adults with temporal lobe epilepsy: A meta-analysis

BACKGROUND

Mounting studies have investigated impairments in social cognitive domains (including theory of mind [ToM] and facial emotion recognition [FER] in adult patients with temporal lobe epilepsy (TLE). However, to date, inconsistent findings remain.

METHODS

A search of PubMed, Web of Science, and Embase databases was conducted until December 2021. Hedges g effect sizes were computed with a random-effects model. Meta-regressions were used to assess the potential confounding factors of between-study variability in effect sizes.

RESULTS

The meta-analysis included 41 studies, with a combined sample of 1,749 adult patients with TLE and 1,324 healthy controls (HCs). Relative to HCs, adult patients with TLE showed large impairments in ToM (g = -0.92) and cognitive ToM (g = -0.92), followed by medium impairments in affective ToM (g = -0.79) and FER (g = -0.77). Besides, no (statistically) significant differences were observed between the magnitude of social cognition impairment in adult with TLE who underwent and those who did not undergo epilepsy surgery. Meta-regressions exhibited that greater severity of executive functioning was associated with more severe ToM defects, and older age was associated with more severe FER defects.

CONCLUSIONS

Results of this meta-analysis suggest that adult patients with TLE show differential impairments in the core aspects of social cognitive domains (including ToM and FER), which may help in planning individualized treatment with appropriate cognitive and behavioral interventions.

Traumatic Brain Injury and School Readiness Among Preschool-Aged Children in the United States

BACKGROUND

The aim of this study is to examine the association between traumatic brain injury (TBI) and school readiness using a nationally representative sample of preschool-aged children in the United States.

METHODS

Using data on 15,402 preschool-aged children (ages three to five years) from the 2016 to 2018 cohorts of the National Survey of Children's Health, this study investigates the association between lifetime measure of TBI in children and four domains of school readiness: early learning skills, self-regulation, social-emotional development, and physical health/motor development.

RESULTS

Among this sample of preschool-aged children, 252 (1.64%) had experienced a TBI during their lifetime. Within school readiness domains, TBI was associated with a 62% to 99% increase in the rate of needs support/at-risk items and a 129% to 322% increase in the rate of at-risk items, contingent on the exact domain examined. Additional analyses reveal that, net of covariates, TBI reduced the predicted probability of being on-track across all four domains from approximately 0.424 for children with no history of TBI to 0.224 for children with a history of TBI.

CONCLUSIONS

A history of TBI was associated with reductions in school readiness within and across domains. Facilitating better communication between parents, pediatricians, and schools about both TBI and responses to TBI may result in the implementation of services and individualized, tailored instructional approaches that can improve educational outcomes.

Cumulative visits for care of minor injuries are associated with traumatic brain injury in young children

AIM

To evaluate the association between cumulative visits for care of minor injuries and risk of traumatic brain injuries in children aged ≤36 months.

METHODS

We conducted a retrospective analysis of children born from 2009 to 2012, using a health insurance claims database in Japan. We investigated the total number of visits where children aged 0-36 months presented for treatment of minor injuries such as superficial injuries, fractures, burns and foreign body ingestions. Logistic regression analysis was used to evaluate the association between the cumulative number of visits for treatment of minor injuries and traumatic brain injuries in children aged ≤36 months.

RESULTS

A total of 91 011 children were included in the analysis, 51% of whom were boys. Traumatic brain injuries were identified in 0.7% of these children. Cumulative visits for care of minor injuries among children aged 0-36 months were significantly associated with traumatic brain injuries by 36 months of age, with an odds ratio of 2.12 (95% confidence interval: 1.68-2.68) for multiple visits.

CONCLUSION

Cumulative visits for treatment of minor injuries during the first 36 months of life were associated with increased risk of traumatic brain injuries by 36 months of age.

Long-Term Intellectual Function After Traumatic Brain Injury in Very Young Children

OBJECTIVE

To investigate long-term intellectual function following a traumatic brain injury (TBI) in early childhood and to identify the contribution of injury and environment to outcome.

PARTICIPANTS

Fifty children younger than 3 years with a diagnosis of accidental TBI were recruited through a pediatric hospital emergency department. Children with TBI were compared with a group (n = 33) of typically developing children (TDC) matched on demographics.

DESIGN

Longitudinal, single-site, case-control study.

MEASURES

Children completed intellectual assessments (IQ) at 4.5 to 5.5 years of age (average 3.5 years after TBI) and at 7.5 to 9 years of age (average 6.5 years after TBI). Information on injury and environmental predictors of outcome was collected.

RESULTS

IQ scores for all groups were in the average range; however, children with TBI of any severity had lower scores than TDC at both time points. There was some suggestion of children with TBI achieving lower verbal IQ scores over time than TDC. IQ scores were predicted by family environment, not injury characteristics.

CONCLUSIONS

A TBI in early childhood is associated with lower IQ scores that persist several years postinjury. Socioeconomic status is an influential factor on IQ at 6.5 years post-TBI.

Pediatric traumatic brain injury and abusive head trauma

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

Preliminary Efficacy of Online Traumatic Brain Injury Professional Development for Educators: An Exploratory Randomized Clinical Trial

OBJECTIVE

To examine the efficacy of an online traumatic brain injury (TBI) professional development intervention, In the Classroom After Concussion: Best Practices for Student Success.

DESIGN

A randomized controlled trial with a sample of 100 general educators, who were randomly assigned to the In the Classroom Web site (treatment group) or the LEARNet Web site (control group). Participants completed the pretest, accessed the In the Classroom or LEARNet site and the posttest and completed follow-up assessments 60 days after posttest.

MEASURES

(1) Knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized self-efficacy measure.

RESULTS

On the posttest assessment, In the Classroom educators showed significantly greater gains in knowledge (P < .0001, d = 1.36 [large effect]), TBI knowledge application (P = .0261, d = 0.46), and general self-efficacy (P = .0106, d = 0.39) than the LEARNet controls. In the Classroom educators maintained significant gains in knowledge (P = .001, d = 0.82) and general self-efficacy (P = .018, d = 0.38) but not in TBI knowledge application (P = .921, d = 0.02).

CONCLUSION

Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Postconcussive Symptoms Following Mild TBI and Extracranial Injury: What Are the Contributing Factors?

OBJECTIVES

Whether mild traumatic brain injury (mTBI) sustained by children results in persistent or recurrent symptoms, over and above those experienced by children who solely sustain mild extracranial injuries, remains debated. The current prospective longitudinal case-controlled study aimed to examine the relative influence of injury and noninjury factors on symptoms in preschool and primary school-aged children who sustained an mTBI or mild extracranial injury at least 8 month earlier.

METHODS

Participants were 64 parents of children (31 mTBI, 33 trauma controls) who sustained injury between ages 2 and 12, whose postconcussive symptoms across the first 3-month postinjury have been previously described. The current study assessed postconcussive symptoms at 8 or more months postinjury (M = 24.3, SD = 8.4) and examined a range of injury and noninjury predictive factors.

RESULTS

At or beyond 8-month postinjury, symptom numbers in the mTBI group were comparable with those of the group who sustained mild extracranial injury. Educational attainment of parents (below or above high-school attainment level) was the only predictor of symptoms at follow-up, with preexisting learning difficulties approaching significance as a predictor.

CONCLUSIONS

While our earlier study found that mTBI was associated with symptoms at 3-month postinjury, follow-up at more than 8 months showed mTBI no longer predicted symptom reporting. While mTBI contributes significantly to the presence of symptoms in the first few months postinjury, researchers and healthcare practitioners in this field need to consider the potential impact of noninjury factors on persistent or recurrent symptoms after mTBI.

Trajectories and Predictors of Clinician-Determined Recovery after Child Concussion

By age 16, 20% of children will suffer a concussion. Many experience persisting post-concussive symptoms (PCS), the cause(s) of which remain unclear. We mapped concussion recovery to 3 months post-injury and explored non-modifiable (e.g., age, sex, pre-injury factors, injury mechanism, acute PCS) and modifiable (post-acute child symptoms) predictors of persisting symptoms in order to identify opportunities for early intervention. We conducted a prospective, longitudinal study in the emergency department of a tertiary, pediatric hospital recruiting children within 48 h of concussion (T0), with follow-up at 2 days (T1), 2 weeks (T2), 1 month (T3), and 3 months (T4). Primary outcome was T2 clinician diagnosis. Clinical history, injury mechanism, acute symptoms, and physical and cognitive function were assessed. Parents rated child behavior and fatigue, and their mental health. We enrolled 256 participants, 72% males: 62 (24.3%) were symptomatic at T2. Recovered and symptomatic groups endorsed similar pre-injury PCS, but group differences were found at T1 across all PCS subscales, except Emotional, where symptoms were not evident until T2. By T2, there was significant PCS reduction, steepest in the "Recovered" group, which also had a lower rate of pre-injury psychiatric diagnoses, acute CT scans and less severe parent-rated PCS at T1 than the symptomatic group. They all demonstrated lower parent-rated PCS and less internalizing behaviors (all, p < 0.01). No differences were detected for child age, sex, injury factors, pre-injury parent-rated PCS, or acute physical and cognitive status. Our findings also highlight the importance of considering both pre- and post-injury mental health status in managing post-concussion.

Longitudinal Neuroimaging in Pediatric Traumatic Brain Injury: Current State and Consideration of Factors That Influence Recovery

Traumatic brain injury (TBI) is a leading cause of death and disability for children and adolescents in the U.S. and other developed and developing countries. Injury to the immature brain varies greatly from that of the mature, adult brain due to numerous developmental, pre-injury, and injury-related factors that work together to influence the trajectory of recovery during the course of typical brain development. Substantial damage to brain structure often underlies subsequent functional limitations that persist for years following pediatric TBI. Advances in neuroimaging have established an important role in the acute management of pediatric TBI, and magnetic resonance imaging (MRI) techniques have a particular relevance for the sequential assessment of long-term consequences from injuries sustained to the developing brain. The present paper will discuss the various factors that influence recovery and review the findings from the present neuroimaging literature to assess altered development and long-term outcome following pediatric TBI. Four MR-based neuroimaging modalities have been used to examine recovery from pediatric TBI longitudinally: (1) T1-weighted structural MRI is sensitive to morphological changes in gray matter volume and cortical thickness, (2) diffusion-weighted MRI is sensitive to changes in the microstructural integrity of white matter, (3) MR spectroscopy provides a sensitive assessment of metabolic and neurochemical alterations in the brain, and (4) functional MRI provides insight into the functional changes that occur as a result of structural damage and typical developmental processes. As reviewed in this paper, 13 cohorts have contributed to only 20 studies published to date using neuroimaging to examine longitudinal changes after TBI in pediatric patients. The results of these studies demonstrate considerable heterogeneity in post-injury outcome; however, the existing literature consistently shows that alterations in brain structure, function, and metabolism can persist for an extended period of time post-injury. With larger sample sizes and multi-site cooperation, future studies will be able to further examine potential moderators of outcome, such as the developmental, pre-injury, and injury-related factors discussed in the present review.

Factors Predicting Outcomes in Surgically Treated Pediatric Traumatic Brain Injury

Introduction

Traumatic brain injury (TBI) is a common presentation to the pediatric emergency department. Understanding factors that predict outcomes will be useful in clinical decision-making and prognostication. The objective of this study was to identify important clinical parameters predictive of outcomes in pediatric TBI patients who underwent surgery.

Materials and Methods

This retrospective study included 43 pediatric TBI patients who underwent surgery from January 2011 to January 2017. Clinical parameters, including presenting signs and symptoms, mechanism of injury, intracranial pressure (ICP), need for inotropes, and computed tomography findings were collected. Outcomes were assessed using the Glasgow outcome score (GOS) based on the latest follow-up. Outcomes were divided into favorable (GOS 4-5) and unfavorable (GOS 1-3).

Results

Surgery was performed in 43 patients. The mean age was 9.6 ± 4.9. The mean follow-up period was 31 weeks. Thirty (70%) patients had favorable outcome and 13 (30%) had unfavorable outcome. On univariate analysis, mechanism of injury, vomiting, Glasgow coma scale score, pupil size and reactivity, hypotension, inotropic use, need for blood transfusion, and raised ICP (all P < 0.005) were significantly associated with outcomes. On step-wise logistic regression, only raised ICP (odds ratio [OR] = 35.6, P = 0.008) and hypotension (OR = 26.1, P = 0.01) were found to be statistically significant.

Conclusion

The present study suggests that the majority of pediatric TBI patients who required neurosurgical intervention have favorable outcomes. Closer attention should be paid to raised ICP and hypotension as they were strong predictors of unfavorable outcomes. These findings also help manage expectations of patients' family and clinicians.

A quasi-experimental study examining the effects of online traumatic brain injury professional development on educator knowledge, application, and efficacy in a practitioner setting

Background: Each year ∼700 000 U.S. children ages 0-19 years sustain a traumatic brain injury. Children who experience brain injury are at risk for impairments in executive function, processing speed, cognition, memory, attention, and behavior which can lead to school failure. However, few teachers or other educational professionals receive training on effectively working with students who have traumatic brain injury (TBI). The purpose of this study was to examine the efficacy of an online traumatic brain injury professional development intervention, In the Classroom after Concussion: Best Practices for Student Success.Methods: This quasi-experimental study examined the effects of online traumatic brain injury professional development (In the Classroom after Concussion: Best Practices for Student Success) on educator knowledge, knowledge application, and self-efficacy in a practitioner setting with a sample of 81 educators from all professional backgrounds. Participants completed the pretest, accessed the In the Classroom training and posttest, and completed follow-up assessments 30 days after the posttest. Measures: (1) knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized measure of educator self-efficacy.Results: On the posttest assessment, educators showed significant gains in knowledge (p = 0.001, r = 0.62), knowledge application (p = 0.001, r = 0.63), and self-efficacy (p = 0.008, r = 0.29). At 30-day follow up, educators maintained significant gains in knowledge (p = 0.001, r = 0.62) and self-efficacy (p value = 0.008, r = 0.28), but not in knowledge application.Conclusion: Given the prevalence of traumatic brain injury, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in traumatic brain injury professional development. In the Classroom is one such approach.Implications for rehabilitationWithout training in TBI, educators will be poorly prepared to monitor students' post-injury challenges and to address learning and behavioral challenges as they occur.Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Patterns of traumatic brain injury and six-month neuropsychological outcomes in Uganda

BACKGROUND

Traumatic brain injuries in Uganda are on the increase, however little is known about the neuropsychological outcomes in survivors. This study characterized patients with traumatic brain injury (TBI) and the associated six-month neuropsychological outcomes in a Ugandan tertiary hospital.

METHODS

Patients admitted at Mulago Hospital with head injury from November 2015 to April 2016 were prospectively enrolled during admission and followed up at six months after discharge to assess cognition, posttraumatic stress symptoms (PTSS), depression symptoms and physical disability. The outcomes were compared to a non-head-injury group recruited from among the caretakers, siblings and neighbours of the patients with age and sex entered as covariates.

RESULTS

One hundred and seventy-one patients and 145 non-head injury participants were enrolled. The age range for the whole sample was 1 to 69 years with the non-head injury group being older (mean age (SD) 33.34 (13.35) vs 29.34 (14.13) years of age, p = 0.01). Overall, motorcycle crashes (36/171, 38.6%) and being hit by an object (58/171, 33.9%) were the leading causes of TBI. Head injury from falls occurred more frequently in children < 18 years (13.8% vs 2.8%, p = 0.03). In adults 18 years and older, patients had higher rates of neurocognitive impairment (28.4% vs 6.6%, p < 0.0001), PTSS (43.9% vs 7.9%, p < 0.0001), depression symptoms (55.4% vs 10%, p < 0.0001) and physical disability (7.2% vs 0%, p = 0.002). Lower Glasgow Coma Score (GCS) on admission was associated with neurocognitive impairment (11.6 vs 13.1, p = 0.04) and physical disability (10 vs 12.9, p = 0.01) six months later.

CONCLUSION

This first such study in the East-African region shows that depth of coma on admission in TBI is associated with neurocognitive impairment and physical disability.

International survey on diagnostic and prognostic procedures in pediatric disorders of consciousness

AIMS

1. to investigate diagnostic and prognostic procedures routinely used by international professionals to assess children with disorders of consciousness (DoC); 2. to explore use and availability of internal and national guidelines for pediatric DoC; 3. to identify international differences in diagnostic/prognostic protocols.

METHODS

The International Brain Injury Association DoC Special Interest Group emailed a survey link to 43,469 professionals. The survey included questions on diagnostic/prognostic procedures and guidelines for children with DoC.

RESULTS

Data on 82 respondents [(50% physicians) primarily from Europe (43.9%)and North America (37.8%)] were analyzed. Common diagnostic tools included the Glasgow Coma Scale for clinical assessment (94%), the Coma Recovery Scale-Revised for outcome measurement (57%), and cerebral MRI (94%). Clinical features used most frequently to inform prognosis varied with patient age. Few respondents used national (28%) admission protocols for children with DoC, and most were unaware of published national guidelines for diagnostic (72%) and prognostic (85%) procedures. Compared to North American respondents, more European respondents were physicians and used neurophysiological data for prognosis.

CONCLUSIONS

This international survey provides useful information about diagnostic and prognostic procedures currently used for children with DoC and highlights the need for guidelines to promote best practices for diagnosis/prognosis in pediatric DoC.

Service Delivery in the Healthcare and Educational Systems for Children Following Traumatic Brain Injury: Gaps in Care

OBJECTIVE

To provide a review of evidence and consensus-based description of healthcare and educational service delivery and related recommendations for children with traumatic brain injury.

METHODS

Literature review and group discussion of best practices in management of children with traumatic brain injury (TBI) was performed to facilitate consensus-based recommendations from the American Congress on Rehabilitation Medicine's Pediatric and Adolescent Task Force on Brain Injury. This group represented pediatric researchers in public health, medicine, psychology, rehabilitation, and education.

RESULTS

Care for children with TBI in healthcare and educational systems is not well coordinated or integrated, resulting in increased risk for poor outcomes. Potential solutions include identifying at-risk children following TBI, evaluating their need for rehabilitation and transitional services, and improving utilization of educational services that support children across the lifespan.

CONCLUSION

Children with TBI are at risk for long-term consequences requiring management as well as monitoring following the injury. Current systems of care have challenges and inconsistencies leading to gaps in service delivery. Further efforts to improve knowledge of the long-term TBI effects in children, child and family needs, and identify best practices in pathways of care are essential for optimal care of children following TBI.

What is known about sexual health after pediatric acquired brain injury: A scoping review

BACKGROUND

Positive sexual development is a core task in the transition from childhood/adolescence to adulthood. Little is known about the extent of research addressing this topic after acquired brain injury (ABI).

OBJECTIVE

To identify publications (1980 to 2016) addressing positive sexual health among children/adolescents with ABI.

METHODS

A scoping review.

RESULTS

A search conducted using OVID and PubMed databases yielded 2021 citations with 28 publications meeting the inclusion criteria (six reviews, one expert account, 19 observational and two intervention studies). Teenagers with ABI reported poorer body image, feeling less sexually or physically attractive than sex and age matched non brain-damaged controls. The one study with findings on sexual orientation, reported 15% of adolescents with ABI identified as lesbian, gay or bisexual. Precocious puberty was a rare outcome from ABI, but the most common focus of the publications (14/28). Finally, two case studies (genital touching and classroom masturbation respectively) found that behavioral interventions were an effective means of extinguishing inappropriate sexual behaviour after childhood ABI.

CONCLUSIONS

Sexual health is a neglected area of research in post-ABI care for children/adolescents. A better understanding of the needs and challenges will help rehabilitation professionals and parents provide more informed and effective supports.

Systematic review of rehabilitation intervention outcomes of adult and paediatric patients with infectious encephalitis

OBJECTIVE

Although a range of rehabilitation interventions have been applied to restore function after infectious encephalitis, there is a lack of literature summarising the benefits of these interventions. This systematic review aims to synthesise current scientific knowledge on outcome measures following rehabilitative interventions among children and adults with infectious encephalitis, with a specific focus on the influence of the age, sex, baseline status and intervention type.

SEARCH STRATEGY

Five scholarly databases (MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials), three sources of grey literature (Google, Google Scholar and Grey Matters) and reference lists of included publications were systematically searched. Literature published before 15 December 2017 and focused on patients with infectious encephalitis in any rehabilitation setting were included. Quality assessment was completed using the Downs and Black rating scale.

RESULTS

Of the 12 737 reference titles screened, 20 studies were included in this review. All of the studies had sample sizes of less than 25 patients and received a score of less than 15 out of 31 points on the Downs and Black rating scale. Findings showed a variety of interventions has been applied to alleviate sequelae from infectious encephalitis, including using cognitive therapy (nine studies), behavioural therapy (five studies), physical therapy (two studies) or two or more therapies (four studies). There was inconclusive evidence on the effect of sex, age and baseline functional abilities on outcomes. Due to clinical and methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSION

Evidence suggests the potential for a beneficial effect of rehabilitation interventions in patients with infectious encephalitis. Future research is required to identify all effect modifiers and to determine the effect of time in the natural course of recovery. An enhanced set of known effect modifiers will support the process of future evaluation of a client-centred rehabilitation intervention.

TRIAL REGISTRATION NUMBER

CRD42015029217.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of Recovery Following Pediatric Traumatic Brain Injury

OBJECTIVES

We analyzed a prospective database of pediatric traumatic brain injury patients to identify predictors of outcome and describe the change in function over time. We hypothesized that neurologic status at hospital discharge would not reflect the long-term neurologic recovery state.

DESIGN

This is a descriptive cohort analysis of a single-center prospective database of pediatric traumatic brain injury patients from 2001 to 2012. Functional outcome was assessed at hospital discharge, and the Glasgow Outcome Scale Extended Pediatrics or Glasgow Outcome Scale was assessed on average at 15.8 months after injury.

SETTING

Children's Medical Center Dallas, a single-center PICU and Level 1 Trauma Center.

PATIENTS

Patients, 0-17 years old, with complicated-mild/moderate or severe accidental traumatic brain injury.

MEASUREMENTS AND MAIN RESULTS

Dichotomized long-term outcome was favorable in 217 of 258 patients (84%), 80 of 82 patients (98%) with complicated-mild/moderate injury and 133 of 172 severe patients (77%). In the bivariate analysis, younger age, motor vehicle collision as a mechanism of injury, intracranial pressure monitor placement, cardiopulmonary resuscitation at scene or emergency department, increased hospital length of stay, increased ventilator days (all with p < 0.01) and occurrence of seizures (p = 0.03) were significantly associated with an unfavorable outcome. In multiple regression analysis, younger age (p = 0.03), motor vehicle collision (p = 0.01), cardiopulmonary resuscitation (p < 0.01), and ventilator days (p < 0.01) remained significant. Remarkably, 28 of 60 children (47%) with an unfavorable Glasgow Outcome Scale at hospital discharge improved to a favorable outcome. In severe patients with an unfavorable outcome at hospital discharge, younger age was identified as a risk factor for remaining in an unfavorable condition (p = 0.1).

CONCLUSIONS

Despite a poor neurologic status at hospital discharge, many children after traumatic brain injury will significantly improve at long-term assessment. The factors most associated with outcomes were age, cardiopulmonary resuscitation, motor vehicle collision, intracranial pressure placement, days on a ventilator, hospital length of stay, and seizures. The factor most associated with improvement from an unfavorable neurologic status at discharge was being older.

Neuroimaging of the Injured Pediatric Brain: Methods and New Lessons

Traumatic brain injury (TBI) is a significant public health problem in the United States, especially for children and adolescents. Current epidemiological data estimate over 600,000 patients younger than 20 years are treated for TBI in emergency rooms annually. While many patients experience a full recovery, for others there can be long-lasting cognitive, neurological, psychological, and behavioral disruptions. TBI in youth can disrupt ongoing brain development and create added family stress during a formative period. The neuroimaging methods used to assess brain injury improve each year, providing researchers a more detailed characterization of the injury and recovery process. In this review, we cover current imaging methods used to quantify brain disruption post-injury, including structural magnetic resonance imaging (MRI), diffusion MRI, functional MRI, resting state fMRI, and magnetic resonance spectroscopy (MRS), with brief coverage of other methods, including electroencephalography (EEG), single-photon emission computed tomography (SPECT), and positron emission tomography (PET). We include studies focusing on pediatric moderate-severe TBI from 2 months post-injury and beyond. While the morbidity of pediatric TBI is considerable, continuing advances in imaging methods have the potential to identify new treatment targets that can lead to significant improvements in outcome.

Recovery Trajectories of Executive Functioning After Pediatric TBI: A Latent Class Growth Modeling Analysis

OBJECTIVE

To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across recovery trajectories using latent class growth modeling (LCGM).

METHOD

A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups.

RESULTS

Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories.

CONCLUSION

The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries.

Caregiver-report of symptoms following traumatic brain injury in a small clinical sample of preschool-aged children

PURPOSE

Preschool-aged children have a high rate of traumatic brain injuries (TBI). Anecdotally, caregivers of young children describe symptoms not typically associated with TBI. The objective of this study was to preliminarily describe symptoms reported following TBI in an outpatient sample of preschool-aged children.

METHODS

Retrospective chart review was completed of the first specialty clinic visit by 28 children ages 3 through 5 years with TBI (32% mild, 50% moderate, 18% severe) to identify post-injury symptoms elicited by caregiver interview including querying of symptoms listed on the Acute Concussion Evaluation (ACE) plus an open-ended request to describe any other symptoms.

RESULTS

Visits occurred on average 38 days post-injury. Caregivers endorsed typical post-concussive symptoms, with headache being most common. In addition, caregivers described other symptoms not captured by the ACE which were grouped into the following categories: Appetite Changes, Behavioral Dysregulation, Decreased Engagement, Disrupted Sleep, Enuresis, Increased Dependence, and Stomachaches.

CONCLUSIONS

Caregivers of preschool-aged children with TBI endorse that young children experience many typical post-concussive symptoms but also a range of other symptoms which may not be typically associated with TBI. Additional work is needed to determine whether specialized evaluation tools and educational materials may be useful for this age group.

Local and global challenges in pediatric traumatic brain injury outcome and rehabilitation assessment

Traumatic brain injury (TBI) is a major public health problem associated with high morbidity and mortality rates in children in both high- and low- and middle-income countries. Predicting outcome after pediatric TBI is challenging given the wide range of injury and non-injury-related factors which may have an impact. Some of these factors are relevant globally (like heterogeneity in patient and injury-related factors and research methodology) and others are more specific to local contexts (like sociodemographic and cultural factors). The assessment of rehabilitation outcomes post-TBI are similarly challenging given the various methodological limitations, disparities in access to rehabilitation, and limited awareness of deficits, which are encountered globally, as well as the lack of services in the local settings. In this article, we discuss these global and local challenges to outcome and rehabilitation assessment following pediatric TBI.

Cognitive Reserve as a Modifier of Clinical Expression in Chronic Traumatic Encephalopathy: A Preliminary Examination

This study conducted a preliminary examination on cognitive reserve (CR) as a modifier of symptom expression in subjects with autopsy-confirmed chronic traumatic encephalopathy (CTE). The sample included 25 former professional football players neuropathologically diagnosed with CTE stage III or IV. Next of kin interviews ascertained age at cognitive and behavioral/mood symptom onset and demographic/athletic characteristics. Years of education and occupational attainment defined CR. High occupational achievement predicted later age at cognitive (p=0.02) and behavioral/mood (p=0.02) onset. Education was not an individual predictor. These preliminary findings suggest that CR may forestall the clinical manifestation of CTE.

Differential effects of minocycline on microglial activation and neurodegeneration following closed head injury in the neonate rat

The role of microglia in the pathophysiology of injury to the developing brain has been extensively studied. In children under the age of 4 who have sustained a traumatic brain injury (TBI), markers of microglial/macrophage activation were increased in the cerebrospinal fluid and were associated with worse neurologic outcome. Minocycline is an antibiotic that decreases microglial/macrophage activation following hypoxic-ischemia in neonatal rodents and TBI in adult rodents thereby reducing neurodegeneration and behavioral deficits. In study 1, 11-day-old rats received an impact to the intact skull and were treated for 3days with minocycline. Immediately following termination of minocycline administration, microglial reactivity was reduced in the cortex and hippocampus (p<0.001) and was accompanied by an increase in the number of fluoro-Jade B profiles (p<0.001) suggestive of a reduced clearance of degenerating cells; however, this effect was not sustained at 7days post-injury. Although microglial reactivity was reduced in the white matter tracts (p<0.001), minocycline treatment did not reduce axonal injury or degeneration. In the thalamus, minocycline treatment did not affect microglial reactivity, axonal injury and degeneration, and neurodegeneration. Injury-induced spatial learning and memory deficits were also not affected by minocycline. In study 2, to test whether extended dosing of minocycline may be necessary to reduce the ongoing pathologic alterations, a separate group of animals received minocycline for 9days. Immediately following termination of treatment, microglial reactivity and neurodegeneration in all regions examined were exacerbated in minocycline-treated brain-injured animals compared to brain-injured animals that received vehicle (p<0.001), an effect that was only sustained in the cortex and hippocampus up to 15days post-injury (p<0.001). Whereas injury-induced spatial learning deficits remained unaffected by minocycline treatment, memory deficits appeared to be significantly worse (p<0.05). Sex had minimal effects on either injury-induced alterations or the efficacy of minocycline treatment. Collectively, these data demonstrate the differential effects of minocycline in the immature brain following impact trauma and suggest that minocycline may not be an effective therapeutic strategy for TBI in the immature brain.

Aging with Traumatic Brain Injury: Effects of Age at Injury on Behavioral Outcome following Diffuse Brain Injury in Rats

Development and aging are influenced by external factors with the potential to impact health throughout the life span. Traumatic brain injury (TBI) can initiate and sustain a lifetime of physical and mental health symptoms. Over 1.7 million TBIs occur annually in the USA alone, with epidemiology suggesting a higher incidence for young age groups. Additionally, increasing life spans mean more years to age with TBI. While there is ongoing research of experimental pediatric and adult TBI, few studies to date have incorporated animal models of pediatric, adolescent, and adult TBI to understand the role of age at injury across the life span. Here, we explore repeated behavioral performance between rats exposed to diffuse TBI at five different ages. Our aim was to follow neurological morbidities across the rodent life span with respect to age at injury. A single cohort of male Sprague-Dawley rats (n = 69) was received at postnatal day (PND) 10. Subgroups of this cohort (n = 11-12/group) were subjected to a single moderate midline fluid percussion injury at age PND 17, PND 35, 2 months, 4 months, or 6 months. A control group of naïve rats (n = 12) was assembled from this cohort. The entire cohort was assessed for motor function by beam walk at 1.5, 3, 5, and 7 months of age. Anxiety-like behavior was assessed with the open field test at 8 months of age. Cognitive performance was assessed using the novel object location task at 8, 9, and 10 months of age. Depression-like behavior was assessed using the forced swim test at 10 months of age. Age at injury and time since injury differentially influenced motor, cognitive, and affective behavioral outcomes. Motor and cognitive deficits occurred in rats injured at earlier developmental time points, but not in rats injured in adulthood. In contrast, rats injured during adulthood showed increased anxiety-like behavior compared to uninjured control rats. A single diffuse TBI did not result in chronic depression-like behaviors or changes in body weight among any groups. The interplay of age at injury and aging with an injury are translationally important factors that influence behavioral performance as a quality of life metric. More complete understanding of these factors can direct rehabilitative efforts and personalized medicine for TBI survivors.

The accuracy of adult recall for early mild traumatic brain injury

BACKGROUND

Childhood mild traumatic brain injury (mTBI) has been associated with negative adult outcomes. Effective interventions require identification of the injury event. There is currently little information regarding the accuracy of adult recall of childhood mTBI.

METHOD

Prospectively collected information from a large birth cohort was used to examine adult recall accuracy at age 25 for 161 childhood mTBI events occurring before age 10.

RESULTS

At age 25 cohort members recalled 11 outpatient injuries and 16 inpatient injuries. Recall accuracy increased with age. Logistic regression analysis distinguished between respondents who reported and did not report a childhood mTBI event correctly classifying 84.5% of cases. Age at injury, injury severity and loss of consciousness (LoC) made a unique statistically significant contribution to the model.

CONCLUSIONS

Most childhood mTBI events are not recalled in adulthood. Age at injury, injury severity and LoC significantly increase likelihood of recall and should be used in measures that evaluate whether injury has occurred. Implications for rehabilitation Traumatic brain injury occurs frequently and often results in ongoing deficits in attention, concentration, executive function and later mental health problems. Identification of a history of traumatic brain injury is essential to ensure that appropriate rehabilitative input is provided. Rehabilitation professionals need to be aware that mental health problems may be secondary to a prior traumatic brain injury. It is important for rehabilitation professionals elicit an accurate history of traumatic brain injury to ensure that their treatment plans are tailored to the needs of this group.

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

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

Neurobehavioral Outcomes in Children After Out-of-Hospital Cardiac Arrest

OBJECTIVE

This study examined 12-month neurobehavioral outcomes in children who survived out-of-hospital cardiac arrest (OH-CA), were comatose after resuscitation, and were enrolled in a clinical trial to evaluate targeted temperature management to hypothermia (33.0°C) or normothermia (36.8°C) (Therapeutic Hypothermia after Pediatric Cardiac Arrest, Out-of-Hopsital [THAPCA-OH]; NCT00878644).

METHODS

Baseline functioning was assessed by caregiver responses on the Vineland Adaptive Behavior Scales-Second Edition (VABS-II) soon after OH-CA (based on functioning before OH-CA); children with broadly normal baseline functioning (VABS-II ≥70) were included in the THAPCA-OH primary outcome. VABS-II was completed again 12 months later. Then, face-to-face cognitive evaluations were completed. Analyses evaluated changes in VABS-II composite, domain, and subdomain scores and cognitive functioning at follow-up.

RESULTS

Ninety-six of 295 enrolled children were alive at 12 months; 87 of 96 had broadly normal baseline functioning (VABS-II ≥70). Follow-up was obtained on 85/87. Forty-two of 85 had VABS-II ≥70 at 12 months. VABS-II composite, domain, and subdomain scores declined significantly between baseline and 12-month follow-up (P < .001). Declines were greatest in older children. Most children displayed well below average cognitive functioning. Older age at cardiac arrest and higher baseline VABS-II scores were predictive of greater decline in neurobehavioral function. Treatment with hypothermia did not influence neurobehavioral outcomes.

CONCLUSIONS

This is the largest study exploring long-term neurobehavioral outcomes in children surviving OH-CA who were comatose after resuscitation. Results revealed significant neurobehavioral morbidity across multiple functional domains, based both on caregiver reports and performance on objective cognitive measures, in survivors 1 year later.

Factors influencing attrition in a multisite, randomized, clinical trial following traumatic brain injury in adolescence

BACKGROUND

Attrition in longitudinal research negatively affects statistical power, disrupts statistical stability, and can produce unwanted bias.

OBJECTIVE

To investigate factors associated with shorter length of study participation and lower rates of study completion (ie, attrition) in a large, multisite, longitudinal, randomized, clinical trial examining the efficacy of a Web-based family problem-solving treatment following traumatic brain injury (TBI) in adolescence.

SETTING

Five major trauma centers in the central and western regions of the United States.

PARTICIPANTS

Children (N = 132) aged 12 to 17 years hospitalized for complicated mild to severe TBI within the previous 6 months.

RESULTS

Completers had a higher primary caregiver education and higher family income than noncompleters, whereas ethnicity, latency to baseline assessment, and intervention group were not significantly associated with study completion.

CONCLUSION

This is the first study that has specifically examined factors of attrition in a pediatric TBI population. The results suggest that research on pediatric TBI populations may be biased toward higher-income families and highlights the importance of designing studies with increased awareness of the impact of participant demographic factors.