[Show abstract][Hide abstract] ABSTRACT: To examine associations of clinical need, defined by elevated parent ratings of child behavior problems, and utilization of behavioral health services in young children with TBI and in an orthopedic injury (OI) comparison group.
Parents completed outcome measures 18 months after injury and at an extended follow-up conducted an average of 38 months post injury.
Recruitment was conducted at Level 1 Trauma Centers at three children's hospitals and one general hospital.
Participants included parents of three groups of children injured between 3 and 7 years of age: 47 children with complicated mild to moderate TBI, 18 with severe TBI, and 74 with OI.
Parents 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 visit.
Children 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.
The results document unmet long-term behavioral health needs following both TBI and OI in children and underscore the importance of monitoring and treatment of post-injury behavior problems.
Archives of physical medicine and rehabilitation 04/2014; · 2.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examined the impact of traumatic brain injury (TBI) in young children on sleep problems and the relationship of sleep problems to neuropsychological and psychosocial functioning. Participants were drawn from an ongoing longitudinal study of injury in young children recruited from 3 to 6 years of age. They constituted three groups: orthopedic injury (n = 92), complicated mild/moderate TBI (n = 55), and severe TBI (n = 20). Caregivers completed the Children's Sleep Habits Questionnaire (CSHQ), as well as ratings of behavioral adjustment, adaptive functioning, and everyday executive function at 1, 6, 12, and 18 months post-injury. Retrospective ratings of pre-injury sleep and psychosocial functioning were obtained at the initial assessment. Children completed neuropsychological testing at all occasions. Children with complicated mild/moderate TBI demonstrated more total sleep problems than children with OI at 6 months post-injury, but not at 12 or 18 months. Children with severe TBI displayed more bedtime resistance and shorter sleep duration than those with complicated mild/moderate TBI or OI at several occasions. Across groups, total sleep problems predicted more emotional and behavioral problems and worse everyday executive function as rated by parents across follow-up occasions. In contrast, sleep problems were generally not related to neuropsychological test performance. The results suggest that young children with TBI demonstrate more sleep problems than children with injuries not involving the head. Sleep problems, in turn, significantly increase the risk of poor psychosocial outcomes across time, but are not associated with worse neuropsychological test performance. Keywords: Traumatic brain injury; sleep; preschool; cognitive ability; behavior.
Journal of neurotrauma 03/2014; · 4.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To test the hypothesis that international adoption of Chinese and Eastern European girls after 9 months of age results in long-term changes in the neural circuitry supporting monolingual English in later childhood.
Functional magnetic resonance imaging was used to test this hypothesis by comparison with a control group of American-born English speakers (n = 13). Girls now aged 6-10 years adopted from China (n = 13) and Eastern Europe (n = 12) by English-speaking families were recruited through a pediatric hospital-based international adoption center after spending more than 6 months in an orphanage or other institution, a measure of early environmental deprivation. Functional magnetic resonance imaging scans were performed on a 3 Tesla MRI scanner using a verb generation language fluency task. Composite activation maps were computed for each group using a general linear model with random effects analysis.
Chinese born adoptees demonstrate atypical lateralization of language function with an apparent shift of temporal-parietal and frontal areas of brain activity toward the right hemisphere. Eastern European adoptees exhibited a rightward shift relative to controls in both frontal and temporal-parietal brain regions.
Significant differences in lateralization between the Chinese and American-born groups in temporal-parietal language areas highlight the possible impact of early tonal Asian language exposure on neural circuitry. Findings suggest that exposure to an Asian language during infancy can leave a long-term imprint on the neural circuitry supporting English language development.
The Journal of pediatrics 07/2013; · 4.02 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective: 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). Method: 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. Results: 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. Conclusions: Findings suggest that longer-term treatment for behavior problems may be needed after severe TBI, particularly for those injured at an earlier age. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
[Show abstract][Hide abstract] ABSTRACT: Objective: To examine the results of a randomized clinical trial (RCT) of Teen Online Problem Solving (TOPS), an online problem solving therapy model, in increasing problem-solving skills and decreasing depressive symptoms and global distress for caregivers of adolescents with traumatic brain injury (TBI). Method: Families of adolescents aged 11-18 who sustained a moderate to severe TBI between 3 and 19 months earlier were recruited from hospital trauma registries. Participants were assigned to receive a web-based, problem-solving intervention (TOPS, n = 20), or access to online resources pertaining to TBI (Internet Resource Comparison; IRC; n = 21). Parent report of problem solving skills, depressive symptoms, global distress, utilization, and satisfaction were assessed pre- and posttreatment. Groups were compared on follow-up scores after controlling for pretreatment levels. Family income was examined as a potential moderator of treatment efficacy. Improvement in problem solving was examined as a mediator of reductions in depression and distress. Results: Forty-one participants provided consent and completed baseline assessments, with follow-up assessments completed on 35 participants (16 TOPS and 19 IRC). Parents in both groups reported a high level of satisfaction with both interventions. Improvements in problem solving skills and depression were moderated by family income, with caregivers of lower income in TOPS reporting greater improvements. Increases in problem solving partially mediated reductions in global distress. Conclusions: Findings suggest that TOPS may be effective in improving problem solving skills and reducing depressive symptoms for certain subsets of caregivers in families of adolescents with TBI. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
[Show abstract][Hide abstract] ABSTRACT: To examine cognitive predictors of academic achievement in young children with traumatic brain injury (TBI) and orthopedic injury (OI) shortly after injury and 1 year postinjury.
Participants included 3- to 6-year-old children, 63 with TBI (46 with moderate TBI and 17 with severe TBI) and a comparison group of 80 children with OI. Academic achievement was assessed approximately 1 and 12 months postinjury using three subtests from the Woodcock-Johnson Tests of Achievement-Third Edition and the School Readiness Composite from the Bracken Basic Concepts Scale-Revised. General intellectual functioning, memory, and executive functions were measured at the initial assessment using standardized tests.
Hierarchical linear regression was used to predict academic achievement at the initial and 1-year follow-up assessments. Memory and executive functions were significant predictors of academic achievement at both assessments after controlling for group membership and demographic variables. Executive function remained a significant predictor of some outcomes after taking general intellectual functioning into account. Predictive relationships did not vary across the TBI and OI groups. Similar results were obtained when regression analyses were completed with only TBI participants using the Glasgow Coma Scale score as a predictor, although memory and executive functioning were somewhat less robust in predicting academic achievement than before.
Memory and executive function predict academic achievement after TBI in preschool children, although some of the associations may be accounted for by general intellectual functioning.
[Show abstract][Hide abstract] ABSTRACT: We studied risky decision making (RDM) in 8 healthy adolescents (TC) and 11 adolescents with mild to moderate traumatic brain injuries (TBI) using the Balloon Analog Risk Task (BART) and functional magnetic resonance imaging (fMRI). Participants inflated simulated balloons (with more points awarded to bigger balloons), which might burst at any time. Increasing brain activation levels were associated with increasing balloon size in a largely bilateral network, including cerebellar, inferior parietal, limbic, and frontal areas. Both groups performed similarly and activated similar networks.
[Show abstract][Hide abstract] ABSTRACT: This study examined the longer term effect of traumatic brain injury (TBI), approximately 18 months post-injury, on emerging narrative discourse skills of 85 children with orthopaedic injury (OI), 43 children with moderate TBI, and 19 children with severe TBI who were between 3 years and 6 years 11 months at injury. Children with TBI performed worse than children with OI on most discourse indices. Children with severe TBI were less proficient than children with moderate TBI at identifying unimportant story information. Age and pragmatic skills were predictors of discourse performance.
Journal of Neuropsychology 11/2011; 6(2):143-160. · 3.82 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A growing body of literature has documented evidence for emotion labeling (EL) deficits after traumatic brain injury (TBI); however, long-term effects of TBI on EL abilities, particularly among young children, are unclear. We investigated EL abilities and socio-emotional outcomes in 32 children with moderate-severe TBI, 23 with complicated-mild TBI, and 82 children with orthopedic injuries (OI), shortly after injury and at 18 months post-injury. All children were between 3:0 and 6:11 years of age at the time of injury. Repeated measures analyses indicated that all groups showed improved EL performance between acute and 18-month assessments, but that the moderate-severe TBI group improved at a slower rate than the OI group, so that the two groups showed significantly different performance at 18 months. Emotion labeling ability did not significantly contribute to the prediction of socio-emotional outcomes after controlling for pre-injury functioning. These results provide preliminary evidence of emerging EL deficits after early childhood TBI that are related to injury severity but that do not predict social and behavioral outcomes.
Journal of the International Neuropsychological Society 09/2011; 17(6):1132-42. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The goal of this study was to examine how parenting style (authoritarian, authoritative, permissive) and family functioning are related to behavioral aspects of executive function following traumatic brain injury (TBI) in young children.
Participants included 75 children with TBI and 97 children with orthopedic injuries (OI), ages 3-7 years at injury. Pre-injury parenting behavior and family functioning were assessed shortly after injury, and postinjury executive functions were assessed using the Behavior Rating Inventory of Executive Functioning (BRIEF; Gioia & Isquith, 2004) at 6, 12, and 18 months postinjury. Mixed model analyses, using pre-injury executive functioning (assessed by the BRIEF at baseline) as a covariate, examined the relationship of parenting style and family characteristics to executive functioning in children with moderate and severe TBI compared to OI.
Among children with moderate TBI, higher levels of authoritarian parenting were associated with greater executive difficulties at 12 and 18 months following injury. Permissive and authoritative parenting styles were not significantly associated with postinjury executive skills. Finally, fewer family resources predicted more executive deficits across all of the groups, regardless of injury type.
These findings provide additional evidence regarding the role of the social and familial environment in emerging behavior problems following childhood TBI.
[Show abstract][Hide abstract] ABSTRACT: To report the results of a randomized clinical trial of teen online problem-solving (TOPS) meant to improve behavioral outcomes of adolescents with traumatic brain injury (TBI).
A randomized clinical trial was conducted to compare the efficacy of TOPS with access to Internet resources in teenagers with TBI in improving parent and self-reported behavior problems and parent-teen conflicts. Participants included 41 adolescents aged 11 to 18 years (range: 11.47-17.90 years) who had sustained a moderate-to-severe TBI between 3 and 19 months earlier. Teens in the TOPS group received 10 to 14 online sessions that provided training in problem-solving, communication skills, and self-regulation. Outcomes were assessed before treatment and at a follow-up assessment an average of 8 months later. Groups were compared on follow-up scores after we controlled for pretreatment levels. Injury severity and socioeconomic status were examined as potential moderators of treatment efficacy.
Forty-one participants provided consent and completed baseline assessments, and follow-up assessments were completed for 35 participants (16 TOPS, 19 Internet resource comparison). The TOPS group reported significantly less parent-teen conflict at follow-up than did the Internet-resource-comparison group. Improvements in teen behavior after TOPS were moderated by injury severity; there were greater improvements in the teens' internalizing symptoms after TOPS among adolescents with severe TBI. Family socioeconomic status also moderated the efficacy of TOPS in improving behavior problems reported by both parents and teens, although the nature of the moderation effects varied.
Our findings suggest that TOPS contributes to improvements in parent-teen conflict generally and parent and self-reported teen behavior problems for certain subsets of participants.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the relationship of family and parenting factors to long-term executive dysfunction and attention problems after early childhood traumatic brain injury (TBI). We hypothesized that the magnitude of executive dysfunction and attention problems would be moderated by family and parenting factors.
A multicenter, prospective cohort study that included an orthopedic injury (OI) reference group.
Three tertiary academic children's hospital medical centers and one general medical center.
Children, ages 3-7 years, hospitalized for OI, moderate TBI, or severe TBI. METHODS AND OUTCOME MEASUREMENTS: Parental ratings of family functioning and parenting styles were obtained 18 months after the injury occurred. The main outcome measurements, which were parental ratings of children's executive function and attention, were performed at least 24 months after the injury occurred (mean, 39 months; range, 25-63 months).
Group comparisons were conducted with use of t-tests, χ(2) analysis, analysis of variance, and Pearson and Spearman correlations. Regression analysis was used to examine associations of the outcomes with family functioning and parenting styles and to test moderating effects of these factors on group differences.
Participants with severe TBI demonstrated increased executive dysfunction and attention problems compared with those who sustained moderate TBI or OI. Lower levels of family dysfunction were associated with better executive function and attention across groups but did not moderate group differences. However, attention deficits after severe TBI were exacerbated under conditions of more permissive parenting relative to attention deficits after OIs.
Executive function and attention problems persisted on a long-term basis (>24 months) after early childhood TBI, and positive global family functioning and nonpermissive parenting were associated with better outcomes. Better characterization of the optimal family environment for recovery from early childhood TBI could help target future interventions.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
Severe TBI in young children negatively impacts executive functions and social competence. Executive functions may be an important determinant of social competence following TBI.
[Show abstract][Hide abstract] ABSTRACT: Difficulty in inhibition or cognitive control is a common and significant sequela of pediatric traumatic brain injury (TBI). The present study used functional MRI to examine one specific inhibitory function, interference control, in 11 adolescents, aged 12-16 years, (mean age, 15.7 years) with TBI who were at least 1 year postinjury and 11 age-matched typically developing control participants (TC) (mean age, 15.2 years). Participants completed a Counting Stroop task with 2 main conditions: (1) a neutral condition requiring the counting of animal words and (2) an interference condition in which mismatched number words were counted. Both TBI and TC adolescents activated similar networks of brain regions relevant to interference control, but the TBI group showed higher levels of activation relative to the TC group in multiple brain areas within this network, including predominantly right frontal and parietal regions. Findings of greater activation of the relevant neural network in the TBI group are consistent with recent fMRI findings using other interference control paradigms with individuals with a history of TBI.
Journal of the International Neuropsychological Society 01/2011; 17(1):181-9. · 2.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to examine family adaptation to a traumatic brain injury (TBI) in young children during the first 18-month postinjury, when compared with children who had an orthopedic injury.
A concurrent cohort/prospective research design was used with repeated assessments of children aged 3 to 6 years with TBI or orthopedic injury requiring hospitalization and their families. Shortly after injury and at 6-, 12-, and 18-month postinjury, parents of 99 children with TBI (20 severe, 64 moderate, 15 mild) and 117 with orthopedic injury completed standardized assessments of family functioning, parental distress and coping, injury-related burden, and noninjury-related parent stressors and resources. Mixed models analyses examined group differences in parental burden and distress adjusted for race and social demographic factors.
Both moderate and severe TBI were associated with higher levels of injury-related stress than orthopedic injury, with stress levels diminishing over time in all groups. Severe TBI was also associated with greater psychological distress on the Brief Symptom Inventory but not with more depressive symptoms. Family functioning and social resources moderated the relationship of TBI severity to injury-related burden and caregiver distress, respectively. Lower child adaptive skills were associated with poorer family outcome but group differences remained even when controlling for this effect.
Severe TBI in young children has adverse consequences for parents and families during the first 18-month postinjury. The consequences lessen over time for many families and vary as a function of social resources.
Journal of developmental and behavioral pediatrics: JDBP 05/2010; 31(4):317-25. · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: This study examined the longer-term effects of traumatic brain injury (TBI) on theory of mind (ToM) skills of children who were between the ages of 5 and 7 years at the time of injury. Fifty-two children with orthopaedic injury, 30 children with moderate TBI, and 12 children with severe TBI were evaluated approximately 1 year post-injury (mean age=6.98 years, SD=0.59, range=6.02-8.26). Children with severe TBI did not engage in representation of first- and second-order mental states at a developmental level comparable to their peers, suggesting stagnation or lack of development, as well as regression of putatively existing ToM skills. Age, task-specific cognitive demands, and verbal abilities were strong predictors of ToM performance. However, even after taking those factors into account, children with severe TBI had poorer ToM performance than children with orthopaedic injuries.
Journal of Neuropsychology 03/2010; 4(Pt 2):181-95. · 3.82 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
Behavioral parent self-reports, demographic data, family functioning reports, and home environment reports were collected at injury baseline and each time point postinjury.
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.
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.
[Show abstract][Hide abstract] ABSTRACT: Research suggests that pediatric TBI results in injury-related stress and burden and psychological distress for parents. However, existing studies have focused almost exclusively on mothers, so that we know relatively little about the impact of childhood TBI on fathers.
The aims were to prospectively examine differences in maternal and paternal response to early childhood TBI over time relative to a comparison cohort of mothers and fathers of children with orthopedic injuries (OI).
The concurrent cohort/prospective research design involved repeated assessments of children aged 3-6 years with TBI or OI requiring hospitalization and their families. Shortly after injury and at 6, 12, and 18 months post injury, parents of 48 children with TBI (11 severe and 37 moderate) and 89 with OI completed standardized assessments of injury-related stress and burden, parental distress, and coping strategies. Mixed models analyses and Generalized Estimating Equations examined differences in maternal versus paternal burden, distress, and coping over time. The analyses included interactions of parent sex with group (severe TBI, moderate TBI, OI) and time since injury, to examine the moderating effects of injury severity on parental response to injury over time.
Fathers were more likely than mothers to use denial to cope following moderate and severe TBI, but not OI. Conversely, mothers were more likely to prefer acceptance and emotion-focused strategies than fathers regardless of the type of injury. The use of active coping strategies varied as a function of injury type, parent sex, and time since injury. Fathers reported greater injury-related stress and distress than mothers over time, with pronounced differences in the severe TBI and OI groups.
Mothers and fathers appear to respond differently following TBI. The different types of responses may serve to exacerbate emerging family dysfunction.