Impact of traumatic brain injury on the family: A critical review.

Presents a critical overview of the literature of family psychosocial outcome after traumatic brain injury (TBI). Thirty-seven family outcome studies were reviewed. Most of the data presented were on psychosocial outcome of primary caregivers, most often parents and spouses. A smaller amount of outcome literature on siblings and children of a parent with TBI was also considered. In the studies reviewed, 23 different standardized psychosocial outcome measures were used in addition to semistructured, in-depth interviews and indexes such as medication usage and counseling uptake. A clear bias was evident in the literature whereby family outcome was likely to be viewed by researchers in terms of stress and burden on relatives. Recommendations were made for future family outcome research to develop a more theoretically coherent framework of family adaptation post-TBI to expand our understanding of relatives' psychosocial outcome and to shift the research focus to the resilience of families and their ability to work toward positive outcomes. There is a need to use standardized, TBI-specific measures with cross-cultural validity to have less variability in outcome measurement and more consensus in operationalizing outcome in order to enhance comparability between studies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Caring for a family member with a traumatic brain injury

The responses to a questionnaire on subjective burden are reported for 52 primary caregivers of a group of persons with traumatic brain injuries sustained an average of 6 years previously. The aim of the study was to examine satisfaction with social support, perception of coping skills, and appraisal of symptoms as predictors of strain in the carers. A range of responses, both positive and negative, to the work of caring for a relative with a head injury was reported. A high prevalence rate of emotional and behavioural changes in the persons with head injuries was found and the amount of distress caused by these symptoms was found to be predictive of burden. The other factor important in predicting burden was the carers' ratings of their satisfaction with their ability to cope with the work of caregiving. Social support, injury severity, and the demographic characteristics of the persons with head injury and their carers were not significant predictors. Depression in the carers was also investigated and the variable most predictive of elevated depression scores was coping satisfaction. These findings reinforce the importance of strengthening carers coping resources in rehabilitation work with head injured persons and their families.     

Morris water maze deficits in rats following traumatic brain injury: lateral controlled cortical impact

This experiment utilized a laterally placed controlled cortical impact model of traumatic brain injury (TBI) to assess changes on spatial learning and memory in the Morris water maze (MWM). Adult rats were subjected to one of two different levels of cortical injury, mild (1 mm) or moderate (2 mm) deformation, and subsequently tested for their ability to learn (acquisition) or remember (retention) a spatial task, 7 or 14 days after injury. Results revealed an injury-dependent deficit for experimental animals compared to sham-operated controls. Not only did the TBI result in longer escape latencies, but also significant deficits in search time and relative target visits. Although the moderately injured animals demonstrated significant histopathology in the cortex and hippocampus, mildly injured subjects demonstrated no obvious tissue destruction, but did manifest significant behavioral change. These results demonstrate that a laterally placed controlled cortical impact is capable of producing significant cognitive deficits on both acquisition and retention paradigms utilizing the MWM.     

The relationship of caregiver coping to family outcomes during the initial year following pediatric traumatic injury.

This study identified coping strategies associated with caregiver outcomes following pediatric injury and examined injury type as a moderator of coping efficacy. Families of 103 children with traumatic brain injury (TBI) and 71 children with orthopedic injuries were followed prospectively during the initial year postinjury. The groups had comparable preinjury characteristics and hospitalization experiences but differed on neurological insult. In hierarchical regression analyses, acceptance was associated with lower burden and denial was associated with greater distress in both groups. Active coping resulted in higher distress following TBI but not orthopedic injuries. Conversely, the use of humor was related to diminishing distress following TBI but unrelated to distress following orthopedic injuries. Results are discussed in terms of the implications for intervention following TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinically significant behavior problems during the initial 18 months following early childhood traumatic brain injury.

Objective: This study looked at the emergence of clinically significant problems in behavior, executive function skills, and social competence during the initial 18 months following traumatic brain injury (TBI) in young children relative to a cohort of children with orthopedic injuries (OI) and the environmental factors that predict difficulties postinjury. Participants: Children, ages 3–7 years, hospitalized for severe TBI, moderate TBI, or OI were seen shortly after their injury (M = 40 days) and again 6 months, 12 months, and 18 months postinjury. Design: Behavioral parent self-reports, demographic data, family functioning reports, and home environment reports were collected at injury baseline and each time point postinjury. Results: Results suggest that, compared with the OI group, the severe TBI group developed significantly more externalizing behavior problems and executive function problems following injury that persisted through the 18-month follow-up. Minimal social competence difficulties appeared at the 18-month follow-up, suggesting a possible pattern of emerging deficits rather than a recovery over time. Conclusions: Predictors of the emergence of clinically significant problems included permissive parenting, family dysfunction, and low socioeconomic status. The findings are similar to those found in school-age children. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Blame attribution in intentional and unintentional traumatic brain injury: Longitudinal changes and impact on subjective well-being.

Objective: Examine longitudinal changes in attribution of blame to self and others, and concern over cause of injury, in both intentional (violence-related) and unintentional (accidental) traumatic brain injury (TBI); investigate the relation of these factors to subjective well-being outcomes at 1 year post-TBI. Study Design: Prospective, multicenter, observational study with longitudinal component. Participants: 99 men with unintentional TBI and 25 men with intentional TBI who sustained moderate to severe injuries, received inpatient rehabilitation, and provided data in both acute rehabilitation and 1-year follow-up. Measures: Blame Attribution Questionnaire, General Health Questionnaire-30, Neurobehavioral Functioning Inventory-Revised Depression Scale, Satisfaction With Life Scale, community participation measures. Results: At both time points, participants with intentional TBI blamed others more while those with unintentional TBI blamed themselves more (trend). Other-blame at 1 year predicted depression but not life satisfaction. Self-blame was not a significant predictor of depression or life satisfaction. Increasing concern over cause/blame for injury from acute rehabilitation to follow-up was associated with high levels of emotional distress. Conclusion: Blame attribution issues may be markers of TBI-related emotional distress regardless of injury etiology, particularly when others are blamed for the injury and/or concerns over cause of injury do not resolve over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Concordance of patients' and family members' ratings of neurobehavioral functioning after traumatic brain injury

OBJECTIVE: To examine differences in family and patient evaluation of neurobehavioral functioning in adults with traumatic brain injury (TBI). DESIGN: Differences were examined by conducting 70 paired sample t tests on scale items and 6 paired sample t tests on scale scores from a neurobehavioral inventory. SETTING: Medical center outpatient clinic. PARTICIPANTS: Three hundred one consecutive adult patients with TBI and 301 informants, primarily family members, completed the neurobehavioral inventory. MAIN OUTCOME MEASURE: Neurobehavioral Functioning Inventory (NFI) comprised of six scales with items describing symptoms and daily living problems. RESULTS: Paired t test analyses of the six scales indicated that patients reported a significantly greater level of communication problems than did their matched family members. No differences were found for the other five scales. Paired t test analyses of the 70 scale items revealed significant differences in patient and family ratings for only 13 items. In all 13 instances, patients reported greater levels of dysfunction than were reported by their family members. Analysis of variance (ANOVA) indicated a main effect of injury severity for only the Communication and Memory/Attention scales. CONCLUSIONS: Findings indicate general agreement between family members and patients regarding patients' everyday problems. Results do not support contentions that patients tend to underestimate difficulties. Agreement levels appear related to injury severity, item specificity, and item content. More research is needed to identify other variables relating to agreement levels, including age, injury severity, and amount of contact between patients and family members.     

Use of family focused therapy in rehabilitation for veterans with traumatic brain injury.

Objective: Military personnel returning from Iraq and Afghanistan with traumatic brain injury (TBI) present with a complex array of stressors encountered during combat as well as upon re-entry, often with additional physical and mental health comorbidities. This requires an intensive approach to treatment that includes family intervention as a part of rehabilitation. There is a small but growing literature addressing the needs of families when a family member has sustained a TBI. An established treatment intervention for individuals with serious mental illness, such as family focused therapy (FFT), is uniquely suited to address the complexity of issues presented by returning military personnel, and may be adapted for moderate to severe TBI populations. In this article, we discuss the rationale for adapting this family intervention for this population and present a case vignette illustrating adaptations for TBI. Conclusions: The adaptation of an existing family intervention for a chronic condition that focuses on enhancing both individual and family functioning is a useful starting point. With further research to modify FFT for this unique population and establish feasibility, this approach may supplement existing models of family intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can a Web-based family problem-solving intervention work for children with traumatic brain injury?

Objective: To examine the feasibility and efficacy of a Web-based intervention for children with traumatic brain injury (TBI). Participants: 6 families comprising 8 parents, 5 siblings, and 6 children with TBI (mean age=10.5 years). Intervention: Families received computers, Web cameras, and Internet access. Participants completed 7-11 online sessions and accompanying weekly videoconferences with the therapist. Main Outcome Measures: Outcomes included child behavior problems, social competence, executive function skills, and parent-child conflict. Results: Children with TBI rated Web site content as very to extremely helpful and reported high overall satisfaction. There was a trend for children with TBI to rate the videoconferences as less helpful than did other family members and relative to a face-to-face visit. Parents reported improvements in antisocial behaviors, and children with TBI reported reductions in conflict with parents regarding school. Conclusions: Web-based interventions hold promise for improving child outcomes following pediatric TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol abuse and traumatic brain injury: effect on event-related potentials

OBJECTIVE: To examine the individual and combined impact that traumatic brain injury (TBI) and heavy social use of alcohol have on electrophysiologic correlates of working memory and evaluation of task-relevant information. DESIGN: Case-control study. SETTING: University hospital brain injury rehabilitation unit. PARTICIPANTS: Forty male volunteers divided into four groups on the basis of their history of TBI and alcohol intake. Subjects with TBI had experienced a severe closed head injury at least 1 year before testing. MAIN OUTCOME MEASURE: Event-related potentials (ERPs) and neuropsychometric tests. RESULTS: Groups showed no significant differences in average age or neuropsychological tests. TBI groups did not differ in time postinjury or on severity measures. Alcohol use measures were significantly greater in the two alcohol groups. N200 latency and P300 amplitude were impaired in heavy social drinkers and in nondrinking subjects with TBI relative to controls, but were significantly impaired in subjects with TBI who were also heavy social drinkers. CONCLUSION: The results indicate that although alcohol use and TBI independently produce mile alterations in some aspects of late ERP components, the ERP changes are significantly greater when alcohol use and TBI are combined. This study provides evidence that heavy social drinking after TBI has a measurable impact on electrophysiologic correlates of cognition.     

Mild traumatic brain injury. A primer for understanding its impact on employee return to work

1. Mild head injuries are common occurrences in the United States. 2. If not properly understood and managed, mild head injuries can be unnecessarily costly in terms of lost work days, financial expenditures, and human suffering. 3. If properly understood and treated, most victims of mild head injuries can return to productive lifestyles. 4. Factors that place persons at high risk for more severe symptoms and/or more lengthy recovery periods are easy to conceptualize.     

The role of the family for behavioral outcome in children and adolescents following traumatic brain injury.

This study assessed the behavioral outcome of 51 children with traumatic brain injury (TBI) up to 2 years following injury. Children with severe injuries, but not those with mild or moderate injuries, were reported by parents to have a greater incidence of behavior problems following TBI. Regression analyses indicated that the presence of a partner for the primary caregiver of the child and the acute emotional reaction of the parent to the injury were both predictive of child behavioral outcome, although not by 2-year follow-up. These findings suggest that parental coping resources may impact on the development of child behavioral sequelae following TBI, emphasizing the role of the family in the child's response and the importance of supportive intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family burden following traumatic brain injury.

Investigated burden experienced by 60 spouses and 71 parents who served as primary caregivers to individuals with traumatic brain injury (BI). Burden levels, as assessed by the Questionnaire on Resources and Stress (QRS-SF), were compared for spouses and parents. Both parents and spouses exhibited high levels of burden. Relative to spouses, parents reported significantly greater burden related to lifespan care. Spouses reported significantly less personal reward than did parents. The presence of social aggression and cognitive disability in the individual with BI was found to have a greater association with subjective burden of caregivers than was the presence of physical disability or injury severity. Results of previous studies with QRS-SF scores show that the responsibility assumed by spouses and parents of persons with BI was as great as that experienced by families of people with severe chronic physical disabilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Delayed traumatic cerebral aneurysm after brain injury

Traumatic aneurysms (TAs) are an unusual etiology for late neurological deterioration after traumatic brain injury (TBI) and represent less than 1% of all cerebral aneurysms. TAs most often are diagnosed acutely but may be delayed in presentation. To increase awareness of this serious but treatable condition when diagnosed early, we report a delayed TA after a motor vehicle accident. The patient experienced a seizure on day 46 postinjury while in rehabilitation and demonstrated persistent lethargy and hemiparesis. Neuroimaging revealed a large, ruptured left pericallosal artery TA, which was surgically clipped. The patient completed his rehabilitation course and was eventually discharged home with family. Among TBIs, TAs are associated with penetrating injuries and skull base or anterior cranial fossa fractures. Associated mortality is high, especially if rupture has occurred. Although TAs are rare, the clinician should be vigilant in the at-risk patient.     

Rehabilitation after traumatic brain injury in adults

PURPOSE: Traumatic brain injury (TBI) stands as a major public health problem and one of the most important challenges for neurological rehabilitation. This review discusses advances that have occurred in the past 10 years in rehabilitation after severe TBI in adults. METHOD: First, theoretical concepts, goals of rehabilitation and organization of resources are reviewed. Then specific questions that arise in the rehabilitation of severe TBI patients are considered. RESULTS: Three phases are distinguished in post-traumatic evolution. Acute rehabilitation takes place during coma and arousal states. Specific aims are to prevent orthopaedic and visceral complications, and to provide sensory stimulations with the hope of accelerating arousal. Secondly subacute (generally inpatient) rehabilitation is designed to facilitate and accelerate recovery of impairments, and to compensate for disabilities. Motility, cognition, behaviour, personality and affect should be simultaneously addressed in an holistic approach. Physical as well as psychological independence and self-awareness are the major goals to emphasize. A third, post-acute rehabilitation phase includes outpatient therapy for achieving physical, domestic and social independence, reduction of handicaps and re-entry into the community. CONCLUSIONS: Problems with returning home, obtaining financial independence, driving, returning to work, participating in social relationships and leisure activities, and the importance of psychosocial adjustment and self-acceptance, are outlined. Questions about economic aspects and rehabilitation in the future are addressed.     

The management of severe traumatic brain injury

An approach to the initial evaluation, resuscitation, and treatment of the patient with severe traumatic brain injury is presented in terms of the underlying physiology and literature support. The primary importance of rapid and complete systemic resuscitation in terms of the "ABCs" is stressed, with the goal of optimizing cerebral perfusion and preventing secondary insults to the injured brain. The integration of brain-specific treatments and diagnostic maneuvers into resuscitation protocols is discussed, including the role of mannitol and hyperventilation as well as the prioritization of CT imaging of the brain.