Post-concussive symptoms in children with mild traumatic brain injury.

To investigate postconcussive symptoms (PCS) following pediatric mild traumatic brain injury (mTBI), 8- to 15-year-old children with mTBI (n = 186) and a comparison group with uncomplicated orthopedic injuries (OI, n = 99) were recruited from two emergency departments. Parent and child ratings of PCS and symptom counts were obtained within 3 weeks after injury (baseline) and at 1, 3, and 12 months postinjury. The mTBI group also completed magnetic resonance imaging at baseline. Group differences were examined using growth modeling, controlling for age at injury, sex, socioeconomic status, and (for parent-based measures) preinjury symptom levels. Relative to the OI group, the mTBI group had higher ratings of somatic PCS and parent counts of PCS at the initial assessments, but higher parent ratings of cognitive PCS and child counts of PCS throughout follow-up. Higher levels of PCS in the mTBI group were associated with motor-vehicle-related trauma, loss of consciousness, neuroimaging abnormalities, and hospitalization. The findings validate both transient and persistent PCS in children with mTBI and document associations of symptoms with injury and noninjury factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of short- and long-term outcomes after traumatic brain injury in children: Behavior and achievement.

Longitudinal behavior and achievement outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries not involving brain insult. Measures of preinjury child and family status and of postinjury achievement skills were administered shortly after injury. Assessments were repeated 3 times across a mean follow-up interval of 4 years. Results from mixed model analysis revealed persisting sequelae of TBI. Recovery of math skills was observed in the severe TBI group but only for children from less stressed families. Social disadvantage in children with TBI predicted more adverse behavioral sequelae and less favorable changes in some outcome measures. The findings suggest that pediatric TBI has long-term effects on behavior and achievement but that postinjury progress is influenced by the family environment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality and functional outcome following traumatic brain injury.

Objective: To investigate pre- to postinjury personality change in relation to outcomes following traumatic brain injury (TBI). Design: Prospective analysis of personality ratings, depression, and outcome using multiple regression analyses. Participants: Cohort of 3 clinical trauma groups (mild TBI, moderate-severe TBI, orthopedic injury) and their significant others (SO). Outcome Measures: Independent Living Scale, Vocational Independence Scale, and Mayo-Portland Adaptability Inventory, 1-2 years postinjury. Predictor Variables: Posttraumatic amnesia (PTA); patient and SO NEO Personality Inventory-Revised ratings of preinjury personality taken at 1-2 months postinjury. Results: Personality function was normal for all groups (regardless of rating source) and stable over time. Neuroticism, and specifically depression, accounted for small proportions of variance in functional outcome, beyond PTA. Conclusions: There is little empirical evidence for significant personality disturbance or change up to 2 years post-TBI. Personality and depression contribute modestly to functional outcomes. Results support a distinction between "personality change" and behavior change following TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of short- and long-term neuropsychological outcomes after traumatic brain injury in children.

Longitudinal neuropsychological outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries only. Neuropsychological functioning was assessed at baseline, at 6- and 12-month follow-ups, and at an extended follow-up (a mean of 4 years postinjury). Mixed model analyses revealed persistent neuropsychological sequelae of TBI that generally did not vary as a function of time postinjury. Some recovery occurred during the first year postinjury, but recovery reached a plateau after that time, and deficits were still apparent at the extended follow-up. Further recovery was uncommon after the first year postinjury. Family factors did not moderate neuropsychological outcomes, despite their demonstrated influence on behavior and academic achievement after childhood TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Age differences in a sample of state vocational rehabilitation clients with traumatic brain injury.

Objective: To examine the relations among age, neuropsychological functioning, and vocational rehabilitation following traumatic brain injury (TBI). Study Design and Participants: Prospective study of 78 adults (18-57 years) who qualified for services with the Missouri Division of Vocational Rehabilitation (DVR), based on a history of TBI followed from enrollment to case closure. Group differences based on age were examined for neuropsychological and vocational outcome with multivariate analysis of variance and nonparametric methods. Main Outcome Measures: Neuropsychological test data and DVR data regarding vocational placement. Results: Age-related differences were present for a measure of mental flexibility, isolated demographic characteristics, and 1 DVR service category. Contrary to hypotheses, there were no age-related differences in vocational outcome. Conclusions: In contrast to hospital-based samples, age does not appear to be a negative indicator for individuals admitted to a state DVR program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Executive functions and social competence in young children 6 months following traumatic brain injury.

Objective: This study examined the impact of traumatic brain injury (TBI) in young children on executive functions and social competence, and particularly on the role of executive functions as a predictor of social competence. Method: Data were drawn from a prospective, longitudinal study. Participants were children between the ages of 3 years 0 months and 6 years 11 months at time of injury. The initial sample included 23 with severe TBI, 64 with moderate TBI, and 119 with orthopedic injuries (OI). All participants were assessed at 3 and 6 months postinjury. Executive functions were assessed using neuropsychological tests (Delayed Alternation task and Shape School) and parent ratings on the Behavior Rating Inventory of Executive Function and Child Behavior Questionnaire. Parents rated children's social competence on the Adaptive Behavior Assessment System, Preschool and Kindergarten Behavior Scales, and Home and Community Social Behavior Scales. Results: Children with severe TBI displayed more negative outcomes than children with OI on neuropsychological tests, ratings of executive functions, and ratings of social competence (η2 ranged from .03 to .11). Neuropsychological tests of executive functions had significant but weak relationships with behavioral ratings of executive functions (ΔR2 ranged from .06 to .08). Behavioral ratings of executive functions were strongly related to social competence (ΔR2 ranged from .32 to .42), although shared rater and method variance likely contributed to these associations. Conclusions: Severe TBI in young children negatively impacts executive functions and social competence. Executive functions may be an important determinant of social competence following TBI. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Porteus maze performance following traumatic brain injury in children.

To investigate planning in traumatically brain injured children, the authors gave the Porteus Maze Test (PMT; S. D. Porteus, 1959) to 276 pediatric patients who had sustained a traumatic brain injury (TBI) at least 3 years previously. Sensitivity of the PMT to TBI severity, age at test, and volume of focal brain lesions detected by magnetic resonance imaging was also studied. The Peabody Picture Vocabulary Test-Revised (L. M. Dunn & L. M. Dunn, 1981) was also administered as a control measure. Results indicated that the PMT was highly sensitive to TBI severity and to volume of circumscribed prefrontal lesions. In contrast to the PMT data, receptive vocabulary was related to injury severity but not to discrete prefrontal lesions. Implications for mechanisms of cognitive deficit after TBI in children are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury.

Objective: The long-term consequences of traumatic brain injury affect millions of Americans, many of whom report using religion and spirituality to cope. Little research, however, has investigated how various elements of the religious and spiritual belief systems affect rehabilitation outcomes. The present study sought to assess the use of specifically defined elements of religion and spirituality as psychosocial resources in a sample of traumatically brain injured adults. Participants: The sample included 88 adults with brain injury from 1 to 20 years post injury and their knowledgeable significant others (SOs). The majority of the participants with brain injury were male (76%), African American (75%) and Christian (76%). Measures: Participants subjectively reported on their religious/spiritual beliefs and psychosocial resources as well as their current physical and psychological status. Significant others reported objective rehabilitation outcomes. Analyses: Hierarchical multiple regression analyses were used to determine the proportion of variance in outcomes accounted for by demographic, injury related, psychosocial and religious/spiritual variables. Results: The results indicate that religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability whereas public religious practice and existential well-being were not. Conclusions: The findings of this project indicate that specific facets of religious and spiritual belief systems do play direct and unique roles in predicting rehabilitation outcomes whereas religious activity does not. Notably, a self-reported individual connection to a higher power was an extremely robust predictor of both subjective and objective outcome. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children.

Objective: This study sought to determine whether the family environment moderates psychosocial outcomes after traumatic brain injury (TBI) in young children. Method: Participants were recruited prospectively from consecutive hospital admissions of 3- to 6-year-old children, and included 19 with severe TBI, 56 with complicated mild/moderate TBI, and 99 with orthopedic injuries (OI). They completed 4 assessments across the first 18 months postinjury. The initial assessment included measures of parenting style, family functioning, and the quality of the home. Children's behavioral adjustment, adaptive functioning, and social competence were assessed at each occasion. Mixed model analyses examined the relationship of the family environment to psychosocial outcomes across time. Results: The OI and TBI groups differed significantly in social competence, but the family environment did not moderate the group difference, which was of medium magnitude. In contrast, group differences in behavioral adjustment became more pronounced across time at high levels of authoritarian and permissive parenting; among children with severe TBI, however, even those with low levels of permissive parenting showed increases in behavioral problems. For adaptive functioning, better home environments provided some protection following TBI, but not over time for the severe TBI group. These 3-way interactions of group, family environment, and time postinjury were all of medium magnitude. Conclusion: The findings indicate that the family environment moderates the psychosocial outcomes of TBI in young children, but the moderating influence may wane with time among children with severe TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Construct validity of an attention rating scale for traumatic brain injury.

Attention deficits are nearly ubiquitous after traumatic brain injury (TBI). In the subacute phase of moderate to severe TBI, these deficits may be difficult to measure with the precision needed to predict outcomes, assess degree of recovery, and monitor treatment response. This article reports the findings of four studies, three observational and one a randomized, controlled treatment trial of methylphenidate (MP), designed to provide construct validation of the Moss Attention Rating Scale (MARS), an observational measure of attention dysfunction following TBI. One hundred seven participants with moderate to severe TBI were enrolled during treatment on an inpatient rehabilitation unit. MARS scores were provided independently by four rehabilitation disciplines (Physical, Occupational and Speech Therapies and Nursing). Results indicated that the MARS: (1) is more strongly related to concurrent measures of cognitive versus physical disability, supporting its validity as a measure of cognition, (2) is more strongly related to concurrent psychometric measures of attention versus measures thought to rely less on attention, supporting its validity as a measure of attention; and (3) predicts 1-year outcomes of TBI better than psychometric measures of attention. However, the MARS (4) was not differentially affected by MP versus placebo treatment. Results support the construct validity and utility of the MARS, with further research needed to clarify its role in treatment outcome assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting community integration following traumatic brain injury with health and cognitive status measures.

Objective: To examine measurement properties of the Community Integration Questionnaire (CIQ) and the Short-Form Health Survey (SF-36) and assets the contributions of cognitive functioning and health to community integration. Design: Rating scale analyses and regression analysis data on basic cognitive functioning and health collected from 289 individuals with traumatic brain injury. Results: Person reliabilities indicated substantial measurement error. Ceiling effects weakened the model (adjusted R2 = .143) specifying the contributions of age, gender, cognitive functioning, and health to community integration. Conclusions: Poor measurement properties and definitional problems associated with community integration weakened the results. The extent to which potential familial and environmental characteristics contributing to role fulfillment change across time requires further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of age on long-term cognitive function after traumatic brain injury.

Objective: To examine the association of age and time postinjury with cognitive outcome 5–22 years following traumatic brain injury (TBI), in relation to matched uninjured controls. Methods: One hundred twelve participants with mild to very severe TBI, aged 16–81 years at the time of injury, were cognitively assessed on measures of processing speed and attention, verbal and visual memory, executive function, and working memory. Results were compared with those of 112 healthy controls individually matched for current age, gender, education, and estimated IQ. Results: Older injured individuals performed worse than did younger injured individuals across all cognitive domains, after controlling for the performance of controls. In relation to matched controls, long-time survivors performed disproportionately worse than did more recently injured individuals, irrespective of age. Conclusions: After maximum spontaneous recovery from TBI, poorer cognitive functioning appears to be associated with both older age at the time of injury and increased time postinjury. These findings have implications for prognosis, early treatment recommendations, and long-term issues of differential diagnosis and management planning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The influence of memory beliefs in individuals with traumatic brain injury.

Objective: To explore metamemory (memory beliefs) and affective functioning in individuals with traumatic brain injury (TBI). Participants: Twenty-six individuals with mild TBI (MTBI), 16 individuals with severe TBI (STBI), and 42 uninjured adults. Outcome Measures: Metamemory in Adulthood questionnaire, Postconcussion Syndrome Checklist, Perceived Stress Scale, Beck Depression Inventory (2nd ed.), Beck Anxiety Inventory. Results: The control group endorsed higher memory self-efficacy, fewer depressive symptoms, fewer memory strategies, and fewer postconcussion symptoms than the MTBI or STBI group. The MTBI group placed high importance on success in memory tasks. Memory self-efficacy and memory-strategies use mediated the relation between TBI and depression. Conclusion: Individuals with brain injury hold negative beliefs about their memory functioning, and such beliefs contribute to depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of traumatic brain injury on working memory-related brain activation in adolescents.

Eight adolescents (ages 13-18 years) who sustained traumatic brain injury (TBI) and eight gender- and age-matched typically developing (TD) adolescents underwent event-related functional MRI (fMRI) while performing a Sternberg letter recognition task. Encoding, maintenance, and retrieval were examined with memory loads of one or four items during imaging. Both groups performed above a 70% accuracy criterion and did not differ in performance. TD adolescents showed greater increase in frontal and parietal activation during high-load relative to low-load maintenance than the TBI group. The TBI patients showed greater increase in activation during high-load relative to low-load encoding and retrieval than the TD group. Results from this preliminary study suggest that the capability to differentially allocate neural resources according to memory load is disrupted by TBI for the maintenance subcomponent of working memory. The overrecruitment of frontal and extrafrontal regions during encoding and retrieval following TBI may represent a compensatory process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Fatigue following traumatic brain injury: Frequency, characteristics, and associated factors.

Objectives: To document the frequency, characteristics, and factors associated with fatigue following traumatic brain injury (TBI). Design: Survey methodology and multivariate statistical design. Setting: Rehabilitation center and community. Participants: 452 participants aged 16 years and over with minor to severe TBI who answered a questionnaire measuring diverse aspects of fatigue as well as different dimensions of psychological distress, pain, and sleep quality. Measures: Proportion of participants reporting being significantly fatigued. Validated measures of fatigue, sleep quality, and psychological distress. Results of a logistic regression analysis. Results: Significant fatigue was reported by 68.5% of participants. Mental fatigue was the most prominent type of fatigue, followed by physical fatigue. Fatigue was present even several years following the accident and had many perceived impacts on day-to-day function. Factors associated with fatigue were a shorter time since injury; being on long-term disability leave; and higher levels of sleep problems, cognitive disturbances, and anxiety. Conclusion: Fatigue is a prevalent problem after TBI that requires more clinical and scientific attention because it probably has important repercussions on the quality of rehabilitation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Selective attention deficits and subjective fatigue following traumatic brain injury.

The present study aimed to investigate the relationship between subjective fatigue and selective attention deficits following traumatic brain injury (TBI). Forty-six participants with mild-severe TBI and 46 healthy controls completed fatigue scales (Visual Analogue Scale--Fatigue, Fatigue Severity Scale [FSS] and Causes of Fatigue Questionnaire [COF]), and attentional measures including subtests from the Test of Everyday Attention, and the Complex Selective Attention Task (C-SAT). TBI participants reported greater fatigue on the FSS and COF, performed more slowly on attentional measures, and made more errors on the C-SAT. After controlling for anxiety and depression, fatigue was significantly correlated with performance only on the C-SAT. Findings suggest a relationship between subjective fatigue and impairment on tasks requiring higher order attentional processes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Incentive effects on event-based prospective memory performance in children and adolescents with traumatic brain injury.

Prospective memory (PM) is the formation of an intention and remembering to perform this intention at a future time or in response to specific cues. PM tasks are a ubiquitous part of daily life. Currently, there is a paucity of information regarding PM impairments in children with traumatic brain injury (TBI) and less empirical evidence regarding effective remediation strategies to mitigate these impairments. The present study employed two levels of a motivational enhancement (i.e., a monetary incentive) to determine whether event-based PM could be improved in children with severe TBI. In a crossover design, children with orthopedic injuries and mild or severe TBI were compared on two levels of incentive (dollars vs. pennies) given in response to accurate performance. All three groups performed significantly better under the high- versus low-motivation conditions. However, the severe TBI group's high-motivation condition performance remained significantly below the low-motivation condition performance of the orthopedic injury group. PM scores were positively and significantly related to age-at-test, but there were no age-at-injury or time-postinjury effects. Overall, these results suggest that event-based PM can be significantly improved in children with severe TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive functioning ten years following traumatic brain injury and rehabilitation.

Many previous studies investigating long-term cognitive impairments following traumatic brain injury (TBI) have focused on extremely severely injured patients, relied on subjective reports of change and failed to use demographically relevant control data. The aim of this study was to investigate cognitive impairments 10 years following TBI and their association with injury severity. Sixty TBI and 43 control participants were assessed on tests of attention, processing speed, memory, and executive function. The TBI group demonstrated significant cognitive impairment on measures of processing speed (Symbol Digit Modalities Test [SDMT], Smith, 1973; Digit Symbol Coding, Wechsler, 1997), memory (Rey Auditory Verbal Learning Test [RAVLT]; Rey, 1958; Lezak, 1976), Doors and People tests; Baddeley, Emslie & Nimmo-Smith, 1994) and executive function (Hayling C [Burgess & Shallice, 1997] and SART errors, Robertson, Manly, Andrade, Baddeley & Yiend, 1997). Logistic Regression analyses indicated that the SDMT, Rey AVLT and Hayling C and SART errors most strongly differentiated the groups in the domains of attention/processing speed, memory and executive function, respectively. Greater injury severity was significantly correlated with poorer test performances across all domains. This study shows that cognitive impairments are present many years following TBI and are associated with injury severity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of the Neuropsychiatric Inventory in traumatic brain injury: A pilot investigation.

Objective: The goal of this investigation was to pilot the Neuropsychiatric Inventory (NPI) among individuals with traumatic brain injury (TBI) and their caregivers, assessing its screen-metric approach. Design and Participants: Using the NPI, caregivers rated neurobehavioral disturbances in 51 individuals with moderate-to-severe TBI. The NPI was completed 1 or 2 years after the individuals were injured. Results: Caregivers reported the highest symptom levels for participants on Irritability/Lability, Apathy, and Agitation/Aggression, and rated greater levels of distress tied to those domains and to Dysphoria. Caregivers endorsing domain screening items endorsed significantly more metric items (vs. screen non-endorsers) within that domain, as would be expected if the screen accurately measured the psychopathology under consideration. In addition, the screen-metric yielded extremely low false-positive rates, although 5 of the 12 domains had elevated false-negative rates. Conclusions: Findings provide preliminary support for the accuracy of the NPI's screen-metric in this population and are consistent with prior work detailing common problematic neurobehavioral consequences of TBI. These results lay groundwork for research and clinical use of this measure in populations with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Response to "Care continuum in traumatic brain injury rehabilitation".

Comments on the original article "Care continuum in traumatic brain injury rehabilitation," by J. M. Uomoto and A. McLean (see record 1990-02670-001). As someone working within the insurance industry with the responsibility for purchasing services for TBI patients, I think that the TBI care continuum, as presented by Uomoto and McLean, represents a sensible response to a critical need. It does not offer, however, any specific information on what is effective and simply restates what has already been recognized by many in the insurance industry: head trauma rehabilitation is long, complex, multidisciplinary, intensely individualistic, and enormously expensive. The insurance industry is aware that a continuum care approach is necessary. Clearly, no one can dispute that treatment has to be ongoing and multifaceted to address a disability that has such a colossal medical, social, vocational, and psychological impact. In addition, the need for acute hospitalization, acute rehabilitation, and a protective environment to provide care and address basic needs is readily accepted. The problem for the insurance industry is what constitutes effective treatment beyond the acute phase of trauma stabilization and maintenance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)