Early Childhood Traumatic Brain Injury Research Articles

Trajectories of Executive Functions After Early Childhood Traumatic Brain Injury: Teacher Ratings in the Initial 81 Months Postinjury.

To explore teacher-rated trajectories of executive functioning (EF) after early childhood traumatic brain injury (TBI) and to identify injury-related, academic, and family factors associated with growth trajectories using latent class growth analysis. A total of 121 children who sustained a TBI or orthopedic injury (OI) between the ages of 3 and 7 years were recruited from 3 tertiary care children's hospitals and a general hospital in Ohio, including 57 with moderate or severe TBI and 64 with OI. Assessments were completed at baseline (0-3 months postinjury) and an average of 6, 12, 18, and 81 months postinjury. Changes in teacher-rated EF were modeled across time and heterogeneity in recovery and moderating factors was examined. Study variables included participant demographics, teacher-rated EF (Behavior Rating Inventory of Executive Function), family functioning (McMaster Family Assessment Device), and parenting style (Parenting Practices Questionnaire). Analysis of teacher-rated EF yielded 2 trajectories: Normative (64.71%) and At-Risk (35.29%). Traumatic brain injury was a weak predictor of membership in the At-Risk trajectory ( P = .05). Membership in the At-Risk trajectory (compared with Normative category) was associated with a higher incidence of Individualized Education Programs, higher baseline EF concerns, increased endorsement of authoritarian parenting, lower socioeconomic status, and non-White race. Teacher-rated EF after pediatric TBI differs from OI. Increased EF concerns over time were associated with increased baseline EF and characteristics of the home and school environment. These findings extend previous research on recovery of EF to educational settings and outline potentially modifiable risk factors that can maximize success in the school settings for children who experience early-childhood traumatic injury.

Brain-derived neurotrophic factor Val66Met and neuropsychological functioning after early childhood traumatic brain injury.

The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on neuropsychological functioning in children with traumatic brain injury (TBI) relative to orthopedic injury (OI). Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Children completed a battery of neuropsychological measures targeting attention, memory, and executive functions at four timepoints spanning the immediate post-acute period to 18 months post-injury. Children also completed a comparable age-appropriate battery of measures approximately 7 years post-injury. Parents rated children's dysexecutive behaviors at all timepoints. Longitudinal mixed models revealed a significant allele status × injury group interaction with a medium effect size for verbal fluency. Cross-sectional models at 7 years post-injury revealed non-significant but medium effect sizes for the allele status x injury group interaction for fluid reasoning and immediate and delayed verbal memory. Post hoc stratified analyses revealed a consistent pattern of poorer neuropsychological functioning in Met carriers relative to Val/Val homozygotes in the TBI group, with small effect sizes; the opposite trend or no appreciable effect was observed in the OI group. The results suggest a differential effect of the BDNF Val66Met polymorphism on verbal fluency, and possibly fluid reasoning and immediate and delayed verbal memory, in children with early TBI relative to OI. The Met allele-associated with reduced activity-dependent secretion of BDNF-may confer risk for poorer neuropsychological functioning in children with TBI.

A Preliminary DTI Tractography Study of Developmental Neuroplasticity 5-15 Years After Early Childhood Traumatic Brain Injury.

Plasticity is often implicated as a reparative mechanism when addressing structural and functional brain development in young children following traumatic brain injury (TBI); however, conventional imaging methods may not capture the complexities of post-trauma development. The present study examined the cingulum bundles and perforant pathways using diffusion tensor imaging (DTI) in 21 children and adolescents (ages 10–18 years) 5–15 years after sustaining early childhood TBI in comparison with 19 demographically-matched typically-developing children. Verbal memory and executive functioning were also evaluated and analyzed in relation to DTI metrics. Beyond the expected direction of quantitative DTI metrics in the TBI group, we also found qualitative differences in the streamline density of both pathways generated from DTI tractography in over half of those with early TBI. These children exhibited hypertrophic cingulum bundles relative to the comparison group, and the number of tract streamlines negatively correlated with age at injury, particularly in the late-developing anterior regions of the cingulum; however, streamline density did not relate to executive functioning. Although streamline density of the perforant pathway was not related to age at injury, streamline density of the left perforant pathway was significantly and positively related to verbal memory scores in those with TBI, and a moderate effect size was found in the right hemisphere. DTI tractography may provide insight into developmental plasticity in children post-injury. While traditional DTI metrics demonstrate expected relations to cognitive performance in group-based analyses, altered growth is reflected in the white matter structures themselves in some children several years post-injury. Whether this plasticity is adaptive or maladaptive, and whether the alterations are structure-specific, warrants further investigation.

Language performance within three months of early childhood traumatic brain injury.

To examine language outcomes in the short-term stage (i.e., within three months) of early childhood traumatic brain injury (TBI). A retrospective chart review over a 10-year period (January 1, 2007 to December 31, 2016) was completed at a single-site inpatient rehabilitation hospital. Inclusion criteria were children aged 15 months to five years 11 months with a diagnosis of closed TBI. Twenty-four charts were included in the descriptive analysis of language; there were fewer children with expressive language scores (n = 18) than receptive language scores (n = 24), likely due to word retrieval difficulties as per clinical documentation. Effects of TBI on language performance were more pronounced in receptive than expressive language. For children with scores in both receptive and expressive language areas (n = 18), five children had below average scores. These children were described as having language delays pre-injury (n = 2), lower exposure to English (n = 1), information processing difficulties (n = 1), and difficulties with formulation and organization of language (n = 1). This study represents an initial step in understanding expressive and receptive language performance shortly after early childhood TBI. Challenges with assessment as well as directions for future research are discussed.

A-5 Brain-Derived Neurotrophic Factor Val66Met and Neuropsychological Functioning Following Early Childhood Traumatic Brain Injury

Abstract Objective The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on neuropsychological functioning in children with traumatic brain injury (TBI) relative to children with orthopedic injury (OI). Method Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Children completed a battery of neuropsychological measures targeting attention, memory, and executive functions at four time points spanning the immediate post-acute period to 18 months post-injury. Children also completed a comparable age-appropriate battery of measures approximately 7 years post-injury. Parents rated children’s executive functioning at all time points. Results Longitudinal mixed models revealed a significant allele status x injury group interaction for verbal fluency (p = 0.007) and a non-significant trend for parent-rated dysexecutive behaviors (p = 0.069), and cross-sectional models at 7 years post-injury revealed a non-significant trend for the allele status x injury group interaction for fluid reasoning skills (p = 0.074). Post hoc analyses suggested a consistent pattern of poorer neuropsychological functioning in Met carriers relative to Val/Val homozygotes in the TBI group; in contrast, the opposite trend was observed in the OI group. Conclusions The results suggest a differential effect of the BDNF Val66Met polymorphism on verbal fluency, dysexecutive behaviors, and fluid reasoning skills in children with early TBI relative to OI, and that the Met allele—associated with reduced activity-dependent secretion of BDNF—confers risk for poorer neuropsychological functioning in children with TBI.

Brain-Derived Neurotrophic Factor Val66Met and Behavioral Adjustment after Early Childhood Traumatic Brain Injury.

The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on behavioral adjustment in children with traumatic brain injury (TBI) relative to children with orthopedic injury (OI). Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Parents completed the Child Behavior Checklist (CBCL) at the immediate post-acute period, 6, 12, and 18 months after injury, and an average of 3.5 and 7 years after injury. Longitudinal mixed models examined the BDNF Val66Met allele status (Met carriers vs. Val/Val homozygotes) × injury group (TBI vs. OI) interaction in association with behavioral adjustment. After adjusting for continental ancestry, socioeconomic status, time post-injury, and pre-injury functioning, the allele status × injury group interaction was statistically significant for Internalizing, Externalizing, and Total Behavior problems. Post hoc within-group analysis suggested a consistent trend of poorer behavioral adjustment in Met carriers relative to Val/Val homozygotes in the TBI group; in contrast, the opposite trend was observed in the OI group. These within-group differences, however, did not reach statistical significance. The results support a differential effect of the BDNF Val66Met polymorphism on behavioral adjustment in children with early TBI relative to OI, and suggest that the Met allele associated with reduced activity-dependent secretion of BDNF may impart risk for poorer long-term behavioral adjustment in children with TBI.

Understanding the relationship between family functioning and health-related quality of life in very young children with moderate-to-severe TBI

Objective: To investigate the relationship of pre-injury and concurrent family functioning with health-related quality of life (HR QoL) following traumatic brain injury (TBI) or orthopedic injury (OI) in very young children. Method: Prospective enrollment of children ages 0–4 years who presented to the emergency department after sustaining either acute TBI or OI. This is a sub-analysis of children who completed at least one post-injury follow-up visit. At time of study enrollment, parents rated pre-injury family functioning (Family Assessment Device—General Functioning Scale) and the child’s HR QoL (Pediatric Quality of Life InventoryTM). Family functioning and HR QoL were assessed at one and six months post-injury. Mixed models were used to examine family functioning as a moderator of a child’s HR QoL following injury. Results: Data were analyzed for 42 children with TBI and 24 children with OI. For both groups, better pre-injury family functioning was significantly associated with better HR QoL over time. A triple interaction of injury type by time since injury by concurrent family functioning indicated that children with TBI and poor family functioning had significantly worse HR QoL at six months post-injury relative to other groups. Conclusion: Despite a small sample size, current results underscore the importance of family functioning to recovery following early childhood TBI and support the need for continued research and development of interventions to improve outcomes in this population.

The clinical utility of the Children’s Communication Checklist-2 in children with early childhood traumatic brain injury

Objective Pediatric traumatic brain injury (TBI) is associated with long-term cognitive and behavioral deficits. Social communication impairments are common and impact functional outcomes, such as social engagement and academic performance. There are many barriers to identifying social communication deficits following TBI, including the absence of a standardized parent-reported communication measure for use in this population. The Children’s Communication Checklist—Second Edition (CCC-2) has demonstrated utility in identifying communication deficits in diagnoses other than TBI. This study investigated the clinical utility of the CCC-2’s social communication scales in children with TBI. Method: 203 children who sustained TBI or orthopedic injuries between the ages of 36 and 83 months were recruited as part of a larger, longitudinal study. We analyzed social communication subscale scores from the CCC-2 an average of 3.5 years postinjury. We used binary logistic regression analyses to examine the measure’s accuracy in classifying children with and without social communication deficits on other measures of pragmatic language and social competence. Correlation analyses and linear mixed models were used to examine the construct validity of the CCC-2. Results: The CCC-2 was able to accurately classify those with and without pragmatic language impairments on the Comprehensive Assessment of Spoken Language 92% of the time (sensitivity = 55%) and 96% of the time on the Home and Community Social Behavior scale (sensitivity = 72%). The CCC-2 demonstrated strong correlations with and predictive validity for measures of social communication and competence. Conclusions: The findings offer support for the clinical utility of the CCC-2 in the pediatric TBI population.

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

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. 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. Longitudinal, single-site, case-control study. 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. 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. 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.

From Early Childhood to Adolescence: Lessons About Traumatic Brain Injury From the Ohio Head Injury Outcomes Study.

The Ohio Head Injury Outcomes study was a 12-year longitudinal study of early childhood traumatic brain injury (TBI). This article reviewed the findings pertaining to caregiver and family functioning and child cognition, behavior, social competence, emotional functioning, and academics. We further considered individual and social-environmental influences on recovery and interventions. Recruitment was completed at 3 children's hospitals and 1 general hospital. Children aged 3 to 7 years at the time of injury with complicated mild to moderate and severe TBI or orthopedic injury requiring hospitalization were included. A concurrent cohort/prospective research design was used. A baseline assessment was completed shortly after the injury. Follow-up assessments were completed at 6, 12, and 18 months and at an average of 38 and 82 months postinjury. At baseline, parents/guardians completed retrospective ratings of their child's behavioral, emotional, and social functioning preinjury. At the subsequent assessments, ratings reflected current functioning. Information about current family and caregiver functioning was collected at each time point and cognitive testing was completed at selected time points. Recovery after TBI is complex, varies over time, and involves injury-related and premorbid influences, cognition, genetics, and caregiver and family functioning. A sizable number of children with TBI have persisting unmet clinical needs.

Impact of Secondary ADHD on Long-Term Outcomes After Early Childhood Traumatic Brain Injury.

To examine the impact of secondary attention-deficit/hyperactivity disorder (SADHD) on long-term global and executive functioning in adolescents after traumatic brain injury (TBI). Three tertiary cared children's hospitals and 1 general hospital. One hundred twenty children (TBI: n = 54; orthopedic injury: n = 66) without preinjury ADHD evaluated approximately 6.8 years postinjury. Cross-sectional data analysis from a prospective, longitudinal study. Outcomes included functional impairment (Child and Adolescent Functional Assessment Scale) and executive functioning (Behavior Rating Inventory of Executive Function [BRIEF]). SADHD moderated the association of injury type with the BRIEF-Behavioral Regulation Index (F1,113 = 4.42, P = .04) and the Child and Adolescent Functional Assessment Scale (F1,112 = 8.95, P = .003). TBI was only associated with poorer outcomes in the context of SADHD. SADHD was also associated with poorer outcomes on the BRIEF-Global Executive Composite (F1,113 = 52.92, P < .0001) and BRIEF-Metacognitive Index scores (F1,113 = 48.64, P < .0001) across groups. Adolescents with TBI had greater BRIEF-Global Executive Composite scores than those with orthopedic injury (F1,113 = 5.00, P = .03). Although SADHD was associated with poorer functioning across groups, its adverse effects on behavioral regulation and overall functioning were amplified following TBI. TBI + SADHD may confer an elevated risk for significant impairments in early adolescence.

Cumulative Influence of Inflammatory Response Genetic Variation on Long-Term Neurobehavioral Outcomes after Pediatric Traumatic Brain Injury Relative to Orthopedic Injury: An Exploratory Polygenic Risk Score.

The addition of genetic factors to prognostic models of neurobehavioral recovery following pediatric traumatic brain injury (TBI) may account for unexplained heterogeneity in outcomes. The present study examined the cumulative influence of candidate genes involved in the inflammatory response on long-term neurobehavioral recovery in children with early childhood TBI relative to children with orthopedic injuries (OI). Participants were drawn from a prospective, longitudinal study evaluating outcomes of children who sustained TBI (n = 67) or OI (n = 68) between the ages of 3 and 7 years. Parents completed ratings of child executive function and behavior at an average of 6.8 years after injury. Exploratory unweighted and weighted polygenic risk scores (PRS) were constructed from single nucleotide polymorphisms (SNPs) across candidate inflammatory response genes (i.e., angiotensin converting enzyme [ACE], brain-derived neurotrophic factor [BDNF], interleukin-1 receptor antagonist [IL1RN], and 5'-ectonucleotidase [NT5E]) that showed nominal (p ≤ 0.20) associations with outcomes in the TBI group. Linear regression models tested the PRS × injury group (TBI vs. OI) interaction term and post-hoc analyses examined the effect of PRS within each injury group. Higher inflammatory response PRS were associated with more executive dysfunction and behavior problems in children with TBI but not in children with OI. The cumulative influence of inflammatory response genes as measured by PRS explained additional variance in long-term neurobehavioral outcomes, over and above well-established predictors and single candidate SNPs tested individually. The results suggest that some of the unexplained heterogeneity in long-term neurobehavioral outcomes following pediatric TBI may be attributable to a child's genetic predisposition to a greater or lesser inflammatory response to TBI.

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.

Genetic Influences on Behavioral Outcomes After Childhood TBI: A Novel Systems Biology-Informed Approach.

Objectives: To test whether genetic associations with behavioral outcomes after early childhood traumatic brain injury (TBI) are enriched for biologic pathways underpinning neurocognitive and behavioral networks.Design: Cross-sectional evaluation of the association of genetic factors with early (~ 6 months) and long-term (~ 7 years) post-TBI behavioral outcomes. We combined systems biology and genetic association testing methodologies to identify biologic pathways associated with neurocognitive and behavior outcomes after TBI. We then evaluated whether genes/single nucleotide polymorphism (SNPs) associated with these biologic pathways were more likely to demonstrate a relationship (i.e., enrichment) with short and long-term behavioral outcomes after early childhood TBI compared to genes/SNPs not associated with these biologic pathways.Setting: Outpatient research setting.Participants:140 children, ages 3–6:11 years at time of injury, admitted for a TBI or orthopedic injury (OI).Interventions: Not Applicable.Main Outcome Measures: Child behavior checklist total problems T score.Results: Systems biology methodology identified neuronal systems and neurotransmitter signaling (Glutamate receptor, dopamine, serotonin, and calcium signaling), inflammatory response, cell death, immune systems, and brain development as important biologic pathways to neurocognitive and behavioral outcomes after TBI. At 6 months post injury, the group (TBI versus OI) by polymorphism interaction was significant when the aggregate signal from the highest ranked 40% of case gene associations was compared to the control set of genes. At ~ 7 years post injury, the selected polymorphisms had a significant main effect after controlling for injury type when the aggregate signal from the highest ranked 10% of the case genes were compared to the control set of genesConclusions: Findings demonstrate the promise of applying a genomics approach, informed by systems biology, to understanding behavioral recovery after pediatric TBI. A mixture of biologic pathways and processes are associated with behavioral recovery, specifically genes associated with cell death, inflammatory response, neurotransmitter signaling, and brain development. These results provide insights into the complex biology of TBI recovery.

Long term effects of early childhood traumatic brain injury on narrative discourse gist and psychosocial functioning

Purpose: To examine the long-term consequences of early childhood traumatic brain injury (TBI), approximately 6.8 years post-injury, on cognitive communication competency within a complex interplay of individual, contextual, and psychosocial factors. Additionally, we were interested in looking at the association of communication competence with social competence and overall functioning.Methods: 64 children with orthopedic injury, 40 children with moderate traumatic brain injury, and 14 children with severe traumatic brain injury who were between 3 years and 6 years 11 months at injury completed a narrative discourse task and clinical measures in a single visit at a longer term follow up in early adolescence, an average of 6.8 years post injury. Analyses of covariance were conducted to compare groups on the discourse task, and hierarchical linear regressions were conducted to examine the association of discourse measures with clinical measures of cognitive and psychosocial functioning.Results: Children with severe traumatic brain injury performed worse than children with moderate traumatic brain injury and orthopedic injury on all discourse indices and clinical measures. Injury severity, pragmatic skills, and socioeconomic status were associated with discourse gist. Discourse gist was the most sensitive measure of communication competence, and it was significantly associated with psychosocial outcomes independent of group.Conclusion: Children who sustain a severe traumatic brain injury in early childhood are at risk for long-term cognitive communication impairments that may be related to a complex interplay of injury, individual, and social factors.Implications for rehabilitationThe assessment and treatment of cognitive communication impairments after traumatic brain injury are complex and require consideration of individual, contextual, and psychosocial factors.Discourse, in general, and gist reasoning specifically, is a sensitive measure for detecting cognitive communication competence several years after pediatric traumatic brain injury.Treatments to address gist reasoning deficits may support improvements in global and social functioning.

Factors contributing to parent-child interaction quality following mild traumatic brain injury in early childhood.

There is emerging evidence that parent-child interactions are affected by early childhood traumatic brain injury (TBI). These findings are of functional importance when considering the high prevalence of TBI in early childhood alongside evidence that young children exposed to positive relationships with their parents early in life exhibit better social functioning concurrently and longitudinally. Given that the overall quality of parent-child interactions is the result of both parent and child emotional and behavioural dispositions, it remains unclear which parental or child-related factors contribute to the quality of interactions post-TBI. The aim of this study was to investigate the factors that contribute to the quality of parent-child interactions following early childhood TBI. The sample included 68 children (18-60months at recruitment) with accidental, uncomplicated mild TBI (mTBI). The quality of parent-child interactions was assessed 6months post-injury using the Mutually Responsive Orientation scale, an observational measure of the dyadic quality of parent-child exchanges. Potential contributing factors were assessed among parental factors (e.g., age, socioeconomic status, family burden, parental stress, marital satisfaction) and child-related factors (e.g., age, sex, symptoms, fatigue, adaptive/behavioural skills). Socioeconomic status, child post-concussive symptoms, and child sleep problems were found to be significant independent contributing factors to parent-child interactions six months post-injury. This study provides the first evidence that both parental and child factors relate to the quality of parent-child interactions following mTBI, thus contributing to a better understanding of the scope and complexity of factors that play a role in childrens' recovery.

Genetic Influences On Behavioral Outcomes After Childhood TBI: A Novel System Biology-Informed Approach

To test whether genetic associations with behavioral outcomes after early childhood traumatic brain injury (TBI) will be enriched for biologic pathways underpinning neurocognitive and behavioral networks.

Traumatic Brain Injury in Early Childhood and Risk of Attention-Deficit/Hyperactivity Disorder and Autism Spectrum Disorder

Early childhood (< 3 years of age) is a critical period for neurodevelopment. This study investigated the correlation between early childhood traumatic brain injury (TBI) and subsequent risk of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and developmental delay (DD) by analyzing a national-scale cohort. Data from the National Health Insurance Research Database, which comprises health care information from > 99% of the Taiwanese population, were analyzed. Children with TBI in their early childhood were enrolled from 1998-2008, and the incidence of subsequent ADHD, ASD, or DD (according to ICD-9 criteria) was assessed and compared with controls without TBI. Patients' age, number of TBI events, and TBI severity were investigated for the risk of ADHD, ASD, or DD. A total of 7,801 and 31,204 children were enrolled in the TBI and control cohorts, respectively. The TBI cohort exhibited a higher incidence of subsequent ADHD, ASD, or DD than the controls (all P < .001). Diagnoses of ADHD, ASD, or DD in the TBI cohort were made at a younger age compared with the controls. Cox regression demonstrated the highest hazard ratios (HRs) of ADHD, ASD, or DD with repeated TBI events, severe TBI, and TBI events before 1 year of age, with the exception that the HR of ASD did not significantly increase after repeated TBI (P = .335). In addition, cumulative HRs (> 10 years) of ADHD, ASD, or DD were increased after TBI (all P < .001). Data from this study suggest that the incidence of ADHD, ASD, and DD significantly increased after TBI events in early childhood (< 3 years of age). The risk factors include severe TBI, repeated TBI events, and TBI at a younger age. The long-term follow-up demonstrated an increased cumulative risk of ADHD, ASD, and DD after TBI.

Secondary Attention-Deficit/Hyperactivity Disorder in Children and Adolescents 5 to 10 Years After Traumatic Brain Injury

After traumatic brain injury (TBI), children often experience impairment when faced with tasks and situations of increasing complexity. Studies have failed to consider the potential for attention problems to develop many years after TBI or factors that may predict the development of secondary attention-deficit/hyperactivity disorder (SADHD). Understanding these patterns will aid in timely identification of clinically significant problems and appropriate initiation of treatment with the hope of limiting additional functional impairment. To examine the development of SADHD during the 5 to 10 years after TBI and individual (sex, age at injury, and injury characteristics) and environmental (socioeconomic status and family functioning) factors that may be associated with SADHD. Concurrent cohort/prospective study of children aged 3 to 7 years hospitalized overnight for TBI or orthopedic injury (OI; used as control group) who were screened at 3 tertiary care children's hospitals and 1 general hospital in Ohio from January 2003 to June 2008. Parents completed assessments at baseline (0-3 months), 6 months, 12 months, 18 months, 3.4 years, and 6.8 years after injury. A total of 187 children and adolescents were included in the analyses: 81 in the TBI group and 106 in the OI group. Diagnosis of SADHD was the primary outcome. Assessments were all completed by parents. Secondary ADHD was defined as an elevated T score on the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale of the parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or current treatment with stimulant medication not present at the baseline assessment. The Family Assessment Device-Global Functioning measurement was used to assess family functioning; scores ranged from 1 to 4, with greater scores indicating poorer family functioning. The analyzed sample included 187 children with no preinjury ADHD. Mean (SD) age was 5.1 (1.1) years; 108 (57.8%) were male, and 50 (26.7%) were of nonwhite race/ethnicity. Of the 187 children, 48 (25.7%) met our definition of SADHD. Severe TBI (hazard ratio [HR], 3.62; 95% CI, 1.59-8.26) was associated with SADHD compared with the OI group. Higher levels of maternal education (HR, 0.33; 95% CI, 0.17-0.62) were associated with a lower risk of SADHD. Family dysfunction was associated with increased risk of SADHD within the TBI group (HR, 4.24; 95% CI, 1.91-9.43), with minimal association within the OI group (HR, 1.32; 95% CI, 0.36-4.91). Early childhood TBI was associated with increased risk for SADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with TBI.

Early Childhood Traumatic Brain Injury and Later Academic Struggles

Prior studies in children with traumatic brain injury (TBI) show that postinjury academic problems persist or worsen with time, but long-term data are