Brain Injury In Young Children Research Articles

More to the story than executive function: Effortful control soon after injury predicts long-term functional and social outcomes following pediatric traumatic brain injury in young children.

To examine the impact of early traumatic brain injury (TBI) on effortful control (EC) over time and the relationship of EC and executive functioning (EF) to long-term functional and social outcomes. Parents of children (N = 206, ages 3-7) with moderate-to-severe TBI or orthopedic injuries (OIs) rated EC using the Child Behavior Questionnaire at 1 (pre-injury), 6, 12, and 18 months post-injury. Child functioning and social competence were assessed at 7 years post-injury. Mixed models examined the effects of injury, time since injury, and their interaction on EC. General linear models examined the associations of pre-injury EC and EC at 18 months with long-term functional and social outcomes. Models controlled for EF to assess the unique contribution of EC to outcomes. Children with severe TBI had significantly lower EC than both the OI and moderate TBI groups at each post-injury time point. Both pre-injury and 18-month EC were associated with long-term outcomes. Among those with low EC at baseline, children with moderate and severe TBI had more functional impairment than those with OI; however, no group differences were noted at high levels of EC. EC had main effects on parent-reported social competence that did not vary by injury type. Findings suggest that EC is sensitive to TBI effects and is a unique predictor of functional outcomes, independent of EF. High EC could serve as a protective factor, and as such measures of EC could be used to identify children for more intensive intervention.

Computed tomography of traumatic brain injury in infants and young children (a literature review)

Objective . To analyze recent studies related to the use of computed tomography in traumatic brain injury in young children. Results . Traumatic brain injury (TBI) is one of the most common causes of death and disability in children. Pediatric TBI has a number of characteristics different of adults. This is due to age-related anatomical and physiological differences depending on patient's physical condition and on problems with his/her neurological assessment. Young children demonstrate specific pathological reactions to TBI with clear concomitant neurological manifestations. The authors present an important information on current aspects of CT application for all types of isolated blunt TBI in children aged from birth to 3 years with consideration of age-appropriate characteristics and emergency condition. Although TBI mechanisms are similar in young children and adults, visual manifestations of head injury in children have their own specific features due to the developing brain and cranial vault. Radiologist's primary role is to identify and characterize the type and severity of head injury so as to assist the correct management of the patient. Using the information obtained from CT examination and knowing TBI mechanisms in infants and young children, a radiologist can play a key role both in diagnostics and in selection of effective care, thus improving clinical outcomes. Conclusion . Head CT with multifaceted and 3D reconstructions has now replaced X-ray examination of the skull in suspected TBI and has become the most important diagnostic technique in patients with TBI at emergency settings. Radiographs do not provide with additional diagnostic information and may be excluded from the examination, if CT with 3D reconstruction are planned to perform or has already been performed.

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

To evaluate the association between cumulative visits for care of minor injuries and risk of traumatic brain injuries in children aged ≤36months. 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 0-36months 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 ≤36months. A total of 91011 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 0-36months were significantly associated with traumatic brain injuries by 36months of age, with an odds ratio of 2.12 (95% confidence interval: 1.68-2.68) for multiple visits. Cumulative visits for treatment of minor injuries during the first 36months of life were associated with increased risk of traumatic brain injuries by 36months of age.

Traumatic Brain Injury in Young Children: A Scoping Review.

To review the evidence available on early childhood (i.e., 0-5 years 11 months) traumatic brain injury (TBI) and identify clinical implications and future directions for speech-language pathology (SLP) practice and research, a scoping review of the literature was conducted following the 2018 Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRSIMA-ScR) guidelines. A total of 44 peer-reviewed articles were included for review. Included studies were assigned one or more of the following thematic labels related to early childhood TBI: etiology, assessment, treatment, outcomes, contributing factors. Most of the studies were nonexperimental studies and addressed outcomes following early childhood TBI. We conclude, based on this scoping review, that children who experience a TBI before 6 years of age are at risk for persistent long-term difficulties in academic and social functioning. SLPs are among the group of clinicians most appropriate to assess and treat these children; yet, the evidence for assessment, treatment, and identification of factors contributing to the recovery of young children with TBI is particularly lacking. Rigorous research is needed to improve the evidence base for SLPs.

Traumatic brain injury in young children with isolated scalp haematoma

ObjectiveDespite high-quality paediatric head trauma clinical prediction rules, the management of otherwise asymptomatic young children with scalp haematomas (SH) can be difficult. We determined the risk of intracranial injury when...

Longitudinal Developmental Outcomes after Traumatic Brain Injury in Young Children: Are Infants More Vulnerable Than Toddlers?

Children under 4 years of age have the highest incidence of traumatic brain injury (TBI) among the non-elderly and may be at high risk of poor developmental outcomes. We prospectively enrolled a cohort of children injured before 31 months old with TBI or orthopedic injury (OI), from 2013 to 2015 at two pediatric level 1 trauma centers to study very young children's developmental outcomes after injury. We used Ages & Stages-3 and Ages & Stages: Social-Emotional screening tools to measure children's development at pre-injury and 3 and 12 months post-injury. The cohort included 123 children with TBI categorized as mild (n = 48), complicated-mild or moderate (n = 54), and severe (n = 21) and 45 children with OI. Generalized linear models examined effects of injury severity and age at injury controlling for pre-injury ratings. Children with mild or complicated-mild/moderate TBI generally remained on developmental track. Compared to OI, children with severe TBI tended to have a negative developmental trajectory with decrements in communication (-7.07; 95% confidence interval [CI], -13.7, -0.48), gross motor (-15.2; 95% CI, -21.1, -9.19), problem solving (-11.6; 95% CI, -17.9, -5.29), personal-social (-16.8; 95% CI, -22.8, -10.8), and social-emotional (21.0; 95% CI, 7.32, 34.7) domains 12 months post-injury. Developmental effects from TBI differed by age at injury: Infants had more difficulties than older children in communication and problem-solving domains. Despite low developmental scores in 28% of the cohort, only 5% were receiving Early Childhood Intervention (ECI) services 12 months after injury. Early age at injury is a vulnerability factor after TBI. Young age and severe injury should prompt evaluation for ECI.

Rehabilitation and school services following traumatic brain injury in young children.

Preschool children have the highest incidence of emergency department visits for traumatic brain injury (TBI) with the majority discharged home without a single point of entry into follow-up services. This paper describes families' experience with service access following TBI. To describe parent reported service utilization following preschool TBI and examine predictors of service access. Participants (N = 80) were drawn from the first visit of a longitudinal study examining elementary school outcomes following TBI. Parents were interviewed about their service history. Descriptive statistics analyzed sample demographics. Logistic regression examined associations between injury related factors and service utilization. TBI participants had mild injuries (83%) and were either discharged to home or spent less than a week in the hospital. No TBI participants received inpatient rehabilitation and only a portion of the sample (26%) received outpatient treatment. Length of hospital stay was a significant predictor of service access (Wald = 4.33, df = 1, p = 0.040). All children were enrolled in preschool without accommodations. Currently no systematic continuum of care exists for children with TBI injured prior to elementary school, despite availability of healthcare, education and state based resources. Healthcare professionals in contact with young children can help with follow-up by educating parents about TBI effects on learning.

Observed parent behaviors as time-varying moderators of problem behaviors following traumatic brain injury in young children.

Parent behaviors moderate the adverse consequences of pediatric traumatic brain injury (TBI); however, it is unknown how these moderating effects change over time. This study examined the moderating effect of observed parent behaviors over time since injury on the relation between TBI and behavioral outcomes. Participants included children, ages 3-7 years, hospitalized for moderate (n = 52) or severe (n = 20) TBI or orthopedic injury (OI; n = 95). Parent-child dyads were videotaped during structured task and free play conditions, and parents completed child behavior ratings. Linear mixed models using a lagged, time-varying moderator analysis examined the relationship of observed parent behaviors at the baseline, 6-month, and 12-month assessments to child behavior problems at 6 months, 12 months, and 18 months postinjury, after controlling for preinjury levels of child behavior problems. The effect of TBI on behavior was exacerbated by less favorable parent behaviors, and buffered by more favorable parent behaviors, in children with severe TBI over the first 12 months postinjury. By 18 months postinjury, however, the moderating effect of parent behaviors diminished, such that children with severe TBI showed more behavior problems relative to children with moderate TBI or OI regardless of parent behaviors or in response to parent behaviors that were initially protective. The results suggest that the moderating effects of the family environment are complex and likely vary in relation to both recovery and developmental factors, with potentially important implications for targets and timing of intervention. (PsycINFO Database Record

Supplemental Material for Observed Parent Behaviors as Time-Varying Moderators of Problem Behaviors Following Traumatic Brain Injury in Young Children

Supplemental Material for Observed Parent Behaviors as Time-Varying Moderators of Problem Behaviors Following Traumatic Brain Injury in Young Children

Predicting Abusive Head Trauma

Abusive head trauma (previously termed “shaken baby syndrome”) is a tragic source of traumatic brain injury in young children, especially in those <2

Utilization of Behavioral Therapy Services Long-Term After Traumatic Brain Injury in Young Children

ObjectiveTo examine associations of clinical need, defined by elevated parent ratings of child behavior problems and utilization of behavioral health services in young children with traumatic brain injury (TBI) and an orthopedic injury (OI) comparison group. DesignParents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months postinjury. SettingChildren's hospitals and a general hospital. ParticipantsParticipants included parents of 3 groups of children injured between 3 and 7 years of age (N=139): 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI. InterventionsNot applicable. Main Outcome MeasuresParents completed ratings of child behavior, mental health symptomology, and family functioning at both visits; at the extended follow-up, they reported utilization of behavior therapy or counseling services since the 18-month follow-up visit. ResultsChildren with TBI had more behavior problems than those with OI. Although clinical need at both follow-ups was associated with greater service utilization at the extended follow-up, all groups had unmet needs as defined by a clinical need in the absence of services. Lower socioeconomic status was associated with higher rates of unmet need across groups. ConclusionsThe results document unmet long-term behavioral health needs after both TBI and OI in children and underscore the importance of monitoring and treatment of postinjury behavior problems.

Maternal warm responsiveness and negativity following traumatic brain injury in young children.

To understand how traumatic brain injury (TBI) affects maternal warm responsiveness and negativity over the first 12 months following injury. We used a concurrent cohort research design to examine dyadic interactions in young children with a TBI (n = 78) and a comparison group of young children with orthopedic injuries (OI; n = 112) and their families during the initial weeks following injury (i.e., baseline) and at two follow-up periods (approximately 6 and 12 months later). Trained raters coded videotaped interactions during a free play and structured teaching task for maternal warm responsiveness and negativity. Mothers in the complicated mild/moderate TBI group, but not those in the severe TBI group, exhibited significantly lower levels of maternal warm responsiveness than mothers in the OI group. However, these differences were observed only at baseline during free play and only at baseline and 6 months postinjury during the structured teaching task, suggesting diminishing adverse effects of complicated mild/moderate TBI on parenting over time postinjury. Analysis failed to reveal group differences in maternal negativity at any of the assessments. Across groups, lower socioeconomic status (SES) was associated with lower levels of warm responsiveness and higher levels of negativity. These findings, though preliminary, indicate possible alterations in mother-child interactions in the months following a TBI.

Acute and chronic management of traumatic brain injury

Traumatic brain injury is recognized as the biggest cause of death and acquired disability after infancy. Its importance, especially in children, has been re-emphasized by a recent population based study, the first of its kind, which found a much higher incidence than previously reported: 790 per 100 000 person years.1 This was chiefly due to the detection of more cases of mild injury, which accounted for 95% overall. Children under 5 had the highest incidence and 70% of all cases were in children and young adults. Falls were the biggest cause, except in the 15-34 year age group where transport accidents were more frequent and injuries more likely to be moderate or severe. These data add to previous studies, especially in informing policies aimed at prevention, which are already showing benefits in many countries. However, once a child or adult has had a severe brain injury it is still uncertain how best to help them. Prompt effective resuscitation and subsequent intensive care are beneficial, but what next? Much attention has been devoted to the management of raised intracranial pressure, which occurs due to the brain swelling inside a fixed compartment (the skull) and can lead to impaired blood supply and cerebral herniation. In adults, observational studies have suggested that measurement of intracranial pressure and decompression by various different craniectomy procedures improves outcome. However, more recent controlled studies indicate that this may not be correct. The DECRA trial in Australia and New Zealand randomized 155 adults to receive bifrontotemporoparietal decompressive craniectomy, with dural opening, or standard care.2 Those in the craniectomy group had a lower intracranial pressure and duration of intensive care stay, more immediate complications especially hydrocephalus, and a poorer outcome at 6 months follow-up. Another major study in South America randomized 324 adults and adolescents to intracranial pressure assessment either by clinical and imaging criteria or by direct measurement.3 The first group received significantly more brain specific interventions such as hyperventilation, mannitol and hypertonic saline, although not more cerebrospinal fluid drainage or craniectomy, but there was no difference in mortality or other outcome measures. The DECRA trial also illustrates the difficulties of such studies: over 3000 patients were assessed for eligibility, one unit contributed over a third of the data, and it took 12 years to enrol enough patients to meet even a revised statistical threshold. The trial has been criticized from various aspects including the entry criteria.4 Another international trial, RESCUEicp, using the same surgical technique but different entry criteria in patients aged 10 to 65 years, is currently in progress.4 Finally, decompression is only one possible tool in acute management: others such as hypothermia, hyperventilation, and hyperosmolar and pharmacological agents also lack strong supportive evidence for their use.5 From a paediatric perspective, despite the high incidence of traumatic brain injury in young children, not to mention their greater life expectancy, there has been a marked paucity of any similar studies. The biggest was a pilot study published over a decade ago in 27 children aged 12 months or older admitted over a 7-year period which used a different technique, bitemporal craniectomy, and found that outcome at 6 months might be improved.6 No long-term follow-up has been published and no similar studies have been performed since.4 While it might be reasonable to await results of studies in adults, it can also be argued that a young child's brain may respond differently to injury for both anatomical and physiological reasons.4 Although the effects of acute management strategies often remain unproven, some evidence is available for adults, and to a much lesser extent for children, showing benefit from rehabilitation.5, 7 At present then in a logical world as much research should be devoted to methods of rehabilitation as to perhaps more glamorous acute interventions. Finally, the outcome of severe injury is well documented but the possible effects of mild head injuries in young children remain less clear and in view of their newly recognized high incidence this needs more work too.

Age at injury and long-term behavior problems after traumatic brain injury in young children.

This study examined the effects of age at injury on the persistence of behavior problems and social skill deficits in young children with complicated mild to severe traumatic brain injury (TBI). A concurrent cohort/prospective research design was used with repeated assessments of children with TBI (n = 82) or Orthopedic Injury (OI) (n = 114). Parents completed the Child Behavior Checklist, the Behavior Rating Inventory of Executive Functions, and the Preschool and Kindergarten Behavior Scales or the Home and Community Social and Behavior Scales shortly after injury to assess preinjury functioning, and at an extended follow-up an average of 38 months postinjury. Generalized linear modeling was used to examine the relationship of age at injury to the maintenance of behavior problems, and logistic regression was used to examine the persistence of clinically significant behavior problems. At the extended follow-up, severe TBI was associated with significantly greater anxiety problems relative to the Group OI. With increasing time since injury, children who sustained a severe TBI at an earlier age had significantly higher levels of parent-reported symptoms of ADHD and anxiety than children who were older at injury. Findings suggest that longer-term treatment for behavior problems may be needed after severe TBI, particularly for those injured at an earlier age.

Predictors of Cognitive Function and Recovery 10 Years after Traumatic Brain Injury in Young Children: Anderson V, Godfrey C, Rosenfeld JV, et al. Pediatrics 2012;129:254–61.

Predictors of Cognitive Function and Recovery 10 Years after Traumatic Brain Injury in Young Children: Anderson V, Godfrey C, Rosenfeld JV, et al. Pediatrics 2012;129:254–61.

Long-term Intellectual Outcome of Traumatic Brain Injury in Children: Limits to Neuroplasticity of the Young Brain?

Trauma is the most frequent cause of acquired brain injury in young children, but few studies of long-term intellectual outcome have been published. With a high incidence of inflicted injury in young children, long-term outcome data on accidental traumatic brain injury (TBI) in young children is especially sparse. In these 2 reports from the same children's hospital, there are noteworthy differences in the intellectual outcomes. Crowe et al1 followed up 53 children who had sustained TBI (20 mild, 33 moderate to severe) before age 3 years and tested 27 healthy children with similar demographic features for comparison. Two-thirds of the children who had sustained moderate to severe TBI were injured in falls. Socioeconomic level of the family at the time of injury was the strongest predictor of intellectual level at follow-up when the children were 4 to 6 years old. The nonsignificant effect of acute TBI severity and the generally average range of intellectual function are unexpected findings. However, the classification … Address correspondence to Harvey S. Levin, PhD, Baylor College of Medicine, 1709 Dryden Rd, Suite 1200, Houston, TX 77030. E-mail: hlevin{at}bcm.edu

Predictors of Cognitive Function and Recovery 10 Years After Traumatic Brain Injury in Young Children

Childhood traumatic brain injury (TBI) has implications for functional outcomes, but few studies have documented long-term outcomes. The purpose of this study was to plot recovery of cognitive and functional skills after early childhood TBI to 10 years postinjury and to identify the contribution of injury, environment, preinjury characteristics, and acute functional recovery. Subjects were recruited consecutively to this prospective, longitudinal study, which used a between-factor design, with injury severity as the independent variable. Forty children with TBI aged 2 and 7 years were recruited on admission to a tertiary pediatric hospital, divided according to injury severity, and compared with 16 healthy controls acutely and 12 and 30 months and 10 years postinjury. Cognition, adaptive ability, executive function, and social/behavioral skills were examined. Children with severe TBI had poorest outcomes, with deficits greatest for cognition. Recovery trajectories were similar across severity groups but with significant gains in verbal skills from 12 and 30 months to 12 months and 10 years. Predictors of outcome included preinjury ability (for adaptive function) and family function (social/behavioral skills). Results confirm a high risk of persisting deficits after severe TBI in early childhood. Children with less severe TBI appear to recover to function normally. Contrary to speculation about "growing into deficits," after protracted recovery to 30 months, young children make age-appropriate progress at least to 10 years postinsult. Environmental factors were found to contribute to adaptive and social/behavioral recovery.

Predictors of Cognitive Function and Recovery 10 Years After Traumatic Brain Injury in Young Children

Predictors of Cognitive Function and Recovery 10 Years After Traumatic Brain Injury in Young Children

The relationship of parental warm responsiveness and negativity to emerging behavior problems following traumatic brain injury in young children.

Parenting behaviors play a critical role in the child's behavioral development, particularly for children with neurological deficits. This study examined the relationship of parental warm responsiveness and negativity to changes in behavior following traumatic brain injury (TBI) in young children relative to an age-matched cohort of children with orthopedic injuries (OI). It was hypothesized that responsive parenting would buffer the adverse effects of TBI on child behavior, whereas parental negativity would exacerbate these effects. Children, ages 3-7 years, hospitalized for TBI (n = 80) or OI (n = 113), were seen acutely and again 6 months later. Parent-child dyads were videotaped during free play. Parents completed behavior ratings (Child Behavior Checklist; T. M. Achenbach & L. A. Rescorla, 2001) at both visits, with baseline ratings reflecting preinjury behavior. Hypotheses were tested using multiple regression, with preinjury behavior ratings, race, income, child IQ, family functioning, and acute parental distress serving as covariates. Parental responsiveness and negativity had stronger associations with emerging externalizing behaviors and attention-deficit/hyperactivity disorder symptoms among children with severe TBI. Findings suggest that parenting quality may facilitate or impede behavioral recovery following early TBI. Interventions that increase positive parenting may partially ameliorate emerging behavior problems.

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

This study sought to determine whether the family environment moderates psychosocial outcomes after traumatic brain injury (TBI) in young children. 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. 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. 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.