Effectiveness of the Brains Ahead! Intervention: 6 Months Results of a Randomized Controlled Trial in School-Aged Children With Mild Traumatic Brain Injury.

OBJECTIVE: To examine the effectiveness of Brains Ahead!, a psychoeducational intervention aimed to prevent long-term problems with activities and participation in children after mild traumatic brain injury (mTBI). PARTICIPANTS: In total, 124 children, aged 6 to 18 years, diagnosed with mTBI and their caregivers. METHOD: After randomization, participants in the intervention group received a face-to-face psychoeducational session with written take-home information and follow-up telephone call(s). Participants in the control group received usual care, consisting of a concise information brochure. PRIMARY OUTCOME MEASURES: Activities and participation (Child and Adolescent Scale of Participation [CASP]). SECONDARY OUTCOMES: fatigue, postconcussive symptoms (PCSs), posttraumatic stress symptoms (PTSSs), and quality of life (QOL). RESULTS: Generalized Estimated Equation analyses showed that both groups improved over the first 6 months post-mTBI, but the intervention group did not differ significantly on the CASP. Mann-Whitney U tests showed that the intervention group reported significantly less fatigue, PCSs, and PTSSs and better QOL compared with the control group at 6 months post-MTBI. CONCLUSIONS: The Brains Ahead! intervention resulted in significant improvements compared with usual care in reducing fatigue, PCSs, and PTSSs and improving QOL. Lack of an effect on activities and participation may be due to the ceiling effect of the CASP.

Activities and Participation in the First 6 Months After Mild Traumatic Brain Injury in Children and Adolescents.

OBJECTIVE: To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI). METHODS: A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers. MAIN MEASURES: Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning. RESULTS: Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level. DISCUSSION: Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents.

OBJECTIVE: This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI). METHODS: A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors. RESULTS: Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045). DISCUSSION: Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Neurological outcome in children and youth with acquired brain injury 2-year post-injury.

OBJECTIVE: To determine neurological outcome in children and youth with acquired brain injury (ABI) and explore associated factors. DESIGN: Cross-sectional study, two-years post-injury. PATIENTS: Hospital-based sample (n=112) aged 6-22 years. METHODS: Neurological outcome and participation were assessed with a multidimensional neurological examination and the Child and Adolescent Scale of Participation. Logistic regression analyses were used to explore the relationships. RESULTS: Both sensorimotor and cognitive deficits were found in 30-31%, language deficits and behavioural deficits in 10-17%. Non-traumatic injury had a negative impact on neurological outcome, specifically regarding sensorimotor and language deficits. Lower education level showed a significantly poorer neurological outcome. High levels of age-expected participation were reported, with a significant relation between deficits and participation restrictions, especially at school. CONCLUSION: One out of three have a poor neurological outcome, related to type of injury and lower level of education. The amount of deficits is associated with participation restrictions.

Health-related quality of life in children and youth with acquired brain injury: Two years after injury.

OBJECTIVE: To determine health-related quality of life (HRQoL) in children and youth with acquired brain injury (ABI) two years post-injury and explore associated factors. DESIGN: Cross-sectional. SUBJECTS: Children and youth (n = 72; aged 6-22 years) with mild to severe ABI (87% mild). METHODS: The primary outcome measures self-reported and parent-reported HRQoL were assessed with the Paediatric Quality of Life Inventory (PedsQL) and compared with age-appropriate reference values of the Dutch population. Spearman correlation coefficients (Rs) were used to explore relationships between HRQoL and sociodemographic and ABI characteristics, severity of impairments and presence of post-injury problems. RESULTS: Children and youth with ABI and the reference population had similar self-reported HRQoL. However, as reported by parents, children with ABI aged 6-7 years and youth aged 13-18 years had poorer HRQoL regarding psychosocial health. Children's post-injury cognitive, behavioural and social problems were moderately associated with poorer HRQoL, especially psychosocial health (Rs ≥ 0.40). Severity nor type of injury were associated with children's HRQoL. CONCLUSION: Two years post-injury, in children and youth with mild to severe ABI, reported HRQoL is similar to that in the general population, whereas parents reported less favourable outcomes. Post-injury cognitive, behavioural and social problems require ongoing attention during long-term follow-up.

Activities and participation of children and adolescents after mild traumatic brain injury and the effectiveness of an early intervention (Brains Ahead!): study protocol for a cohort study with a nested randomised controlled trial.

BACKGROUND: Approximately 20 % of children and adolescents who have sustained mild traumatic brain injuries may experience long-term consequences, including cognitive problems, post-traumatic stress symptoms and reduced load-bearing capacity. The underestimation and belated recognition of these long-term consequences may lead to chronic and disruptive problems, such as participation problems in school and in social relationships. The aim of this study is to examine the level of activities and participation of children and adolescents up to 6 months after a mild traumatic brain injury and to identify possible outcome predictors. Another aim is to investigate the effectiveness of an early psychoeducational intervention and compare the results with those obtained with usual care. METHODS/DESIGN: This paper presents the Brains Ahead! study design, a randomised controlled trial nested within a multicentre, longitudinal, prospective cohort study. The eligible participants include children and adolescents between 6 and 18 years of age who have experienced a mild traumatic brain injury within the last 2 weeks. The cohort study will include 500 children and adolescents with a mild traumatic brain injury and their caregivers. A subset of 140 participants and their caregivers will be included in the randomised controlled trial. Participants in the randomised controlled trial will be randomly assigned to either the psychoeducational intervention group or the usual care control group. The psychoeducational intervention involves one face-to-face contact and one phone contact with the interventionist, during which the consequences of mild traumatic brain injury and advice for coping with these consequences to prevent long-term problems will be discussed. Information will be provided both verbally and in a booklet. The primary outcome domain is activities and participation, which will be evaluated using the Child and Adolescent Scale of Participation. Participants are evaluated 2 weeks, 3 months and 6 months after the mild traumatic brain injury. DISCUSSION: The results of this study will provide insight into which children with mild traumatic brain injury are at risk for long-term participation problems and may benefit from a psychoeducational intervention. TRIAL REGISTRATION: Netherlands Trial Register identifier NTR5153 . Registered on 17 Apr 2015.

Family impact of acquired brain injury in children and youth.

OBJECTIVE: To assess the parental view on the impact of pediatric traumatic brain injury (TBI) and nontraumatic brain injury (NTBI) on the family and its determinants. METHODS: Follow-up study including parents of children with a hospital-based diagnosis of acquired brain injury (ABI) aged 4-20 years at onset of ABI. Parents completed the Pediatric Quality of Life Inventory Family Impact Module (PedsQL FIM), which measures Parent Health-Related Quality of Life, Family Functioning, Communication, and Worry. Additional assessments included the Pediatric Stroke Outcome Measure (PSOM), the Child & Family Follow-up Survey (CFFS), PedsQL General Core and Multiple Fatigue Scales, and sociodemographic and disease characteristics. RESULTS: Parents of 108 patients, median age 13 years (range 5-22), completed the questionnaires 24-30 months after diagnosis. There were 81 patients with TBI of whom 11 (14%) with moderate/severe TBI and 27 patients with NTBI of whom 5 (19%) with moderate/severe NTBI. The median PedsQL FIM Total Scale was 80.4 (SD 16.1). The PedsQL FIM Total Scale and 4 out of 5 Subscale Scores were statistically significantly better in the TBI group than in the NTBI group and in patients with severe NTBI than with mild/moderate NTBI. Moreover, in the total group, there were significant univariate associations between the FIM Total Scale and/or one or more Subscale Scores and age, preinjury patient health problems, and the PSOM, CFFS, PedsQL General Core, and Multiple Fatigue Scales. In the multivariable analysis, the FIM Total Scale was significantly associated with type and severity of injury and preinjury patient health problems. CONCLUSIONS: Two years after onset, the parent-reported that impact of ABI on the family as measured by the PedsQL FIM was considerable especially in patients with moderate/severe NTBI.