Service provision for children and young people with acquired brain injury: Practice recommendations.

BACKGROUND: Providing appropriate rehabilitation services for Acquired Brain Injury (ABI) in childhood presents a number of challenges for caregivers, health and education professionals and the young person as they develop. PRIMARY OBJECTIVE: To record the challenges and possible creative solutions generated by an international group of professionals to address the needs of children with ABI. Review of information: Recommendations were generated from children's special interest group meetings of the International Brain Injury Association (Turin, Italy, 2001; Stockholm, Sweden, 2003; Melbourne, Australia, 2005; Lisbon, Portugal, 2008) and through meetings of the International Paediatric Brain Injury Society (IPBIS), formed in 2009. Delegates participating in the workshops were representative of nations from around the world and included The Netherlands, New Zealand, Australia, the UK, Finland, Germany, South Africa, the US, Canada, Sweden, Brazil and Italy. OUTCOMES: The information presented is based on a retrospective review of those meetings and the summaries of the topics considered.

Traumatic brain injury recorded in the UK Joint Theatre Trauma Registry among the UK Armed Forces.

OBJECTIVES: To use the UK Joint Theatre Trauma Registry (UK-JTTR) to identify service personnel sustaining traumatic brain injury (TBI) in recent conflicts and to examine injury characteristics, outcomes, and severity measures predictive of survival. SETTING: Operations HERRICK (Afghanistan) and TELIC (Iraq). DESIGN: The UK-JTTR records data for every UK service person either killed on operations or treated by Defence Medical Services after a trauma call, including those evacuated for inpatient care following traumatic injury. UK-JTTR data were retrospectively analyzed to identify those who sustained TBI. MAIN MEASURES: The Mayo system was used to define TBI. Glasgow Coma Scale score, injury severity score, new injury severity score, trauma injury severity score, abbreviated injury scale, and a severity characterization of trauma were used to predict survival. RESULTS: In total, 464 UK service personnel sustained TBI, representing 19% of the 2440 casualties in Afghanistan and Iraq, recorded in the UK-JTTR. Most TBI casualties had moderate-severe TBI (402, 87%). There were 181 (39%) survivors, 56% of these received neurorehabilitation. Improvised explosive devices accounted for 55% of TBIs sustained in Afghanistan and 31% of TBIs in Iraq. Logistic regression analyses were performed using the 412 cases (149 survivors: 263 fatalities) with scores on all severity measures. The best-fitting model was based on trauma injury severity score. A trauma injury severity score more than 11.13 indicates a more than 95% probability of survival. CONCLUSION: This is the first study of UK combat TBIs between 2003 and 2011. Almost 1 in 5 UK service personnel recorded in the UK-JTTR had TBI; most were moderate-severe. However, mild TBI is likely to be underrepresented in the UK-JTTR. These findings may be used to plan future rehabilitation needs, as almost half the survivors did not receive neurorehabilitation.

Minor head injury in children: evaluating written discharge advice provided by Scottish emergency departments.

OBJECTIVES: Emergency departments (EDs) routinely provide written information when a child with head injury (HI) is discharged home. This usually contains advice about recognizing signs of serious complications such as intracranial bleeding. This study evaluated the quality of discharge leaflets currently provided by Scottish emergency departments (EDs) by comparing them against written discharge advice recommended by the Scottish Intercollegiate Guideline Network (SIGN). METHODS: All 35 EDs in Scotland which treat children were asked to send a copy of the advice leaflet provided when a child with HI is discharged. Leaflets were evaluated by awarding scores for the inclusion of specific aspects of health information as recommended by SIGN. The inclusion of serious warning symptoms (maximum 20 points) and other advice on observation and help-seeking (maximum 21 points) was assessed. RESULTS: 34 EDs provided leaflets. The median score for including serious warning symptoms was 10/20. The median score for including advice regarding observation and when to seek help was 6.5/21. Several leaflets contained unclear or contradictory advice. CONCLUSION: Many leaflets did not include important information recommended by SIGN guidelines. There was considerable variation in the quality and clarity of written discharge advice provided. This may reduce the ability of parents to recognize rare but serious complications. It is recommended that a standardized HI information leaflet based on SIGN guidelines be used across all Scottish EDs.

Self-esteem in children after traumatic brain injury: an exploratory study.

Children with a traumatic brain injury (TBI) often have difficulties in adjusting to their injury and altered abilities, and may be at risk of low self-esteem and loss of confidence. However, few studies have examined self-esteem in this client group. The current study measured the self-esteem of a group of children who were, on average, two years post-TBI and compared this to their performance on other psychometric measures. Participants were 96 children with TBI and 31 peer controls, their parents and teachers. Self-esteem was measured using the Coopersmith Self-esteem Inventory (CSEI). CSEI scores were compared with performance on Wechsler Intelligence Scales (WISC-III), Hospital Anxiety and Depression Scale (HADS); Children's Memory Scale (CMS), Vineland Adaptive Behaviour Scales (VABS) and Parental Stress Index (PSI). Self-esteem was highly correlated with IQ; HADS anxiety and depression; and parental stress (p< 0.001). Children with TBI had significantly lower self-esteem than controls and population norms (p=0.015). Many children with TBI demonstrate low self-esteem and this is closely linked with anxiety and depression. This may hamper academic performance and could lead to further psychosocial problems. It is recommended that self-esteem is routinely assessed after brain injury and rehabilitation strategies implemented to promote a sense of self-worth.

Minor head injury in the Republic of Ireland: evaluation of written information given at discharge from emergency departments.

Most patients presenting to the emergency department with minor head injuries are discharged with written information. Here the quality of minor head injury discharge leaflets in the Republic of Ireland is evaluated against a nationally accepted template. There was great variability in leaflet content. Most provided minimal information on emergency symptoms but 60% contained no information on post-concussional symptoms. No leaflet was available in audio-format or languages other than English. Information provided in minor head injury leaflets should be improved and standardised across Ireland.

Prediction of raised intracranial pressure complicating severe traumatic brain injury in children: implications for trial design.

OBJECTIVES: To describe current patterns of management of raised intracranial pressure (ICP) in traumatic brain injury relevant to clinician buy-in to possible randomized controlled trials of treatments of raised ICP. To examine the feasibility of early identification of children at sufficient risk of developing raised ICP to permit a uniform approach between centers to the initiation of ICP monitoring. This would permit quantification of ICP elevation and enrollment as appropriate to randomized controlled trials of raised ICP interventions. DESIGN: Logistic regression modeling of death before pediatric intensive care unit discharge and decision tree and logistic regression of development of raised ICP through analysis of a prospectively collected, standardized, national data set. SETTING: Pediatric intensive care units in the United Kingdom and Eire. PATIENTS: Patients were 501 children <16 yrs of age primarily admitted to intensive care unit for management of traumatic brain injury in the United Kingdom and Eire between February 2001 and August 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The data analyzed included demographic, acute physiologic, and cranial imaging variables. Death was associated with both raised ICP and the nonmeasurement of ICP. In a subset of 199 patients, an empirically derived decision rule predicted the development of raised ICP at any point during ICU admission with sensitivity of 73% and specificity of 74% (positive predictive value 82% and negative predictive value 63%). Logistic regression modeling performed comparably. The decision rule also predicted raised ICP in 20% of children not undergoing ICP monitoring. CONCLUSIONS: Simple models based on early clinical data may predict the development of raised ICP sufficiently well to encourage a consistent approach between centers to initiation of ICP monitoring. We estimate studies designed to detect reductions in ICU mortality will require >320 children per arm, although this figure may be higher if more conservative assumptions are made.

Predictors of positive growth after traumatic brain injury: a longitudinal study.

PRIMARY OBJECTIVE: To investigate long-term positive psychological growth in individuals with traumatic brain injury (TBI) and to relate growth to injury characteristics and early outcomes. RESEARCH DESIGN: Longitudinal study. METHOD AND PROCEDURE: Long-term follow-up of a group of TBI survivors recruited between 1991-1995. In 2004, 240 of the 563 original participants were invited to take part in a follow-up study. At follow-up, survivors completed the Positive Changes in Outlook Questionnaire (CiOP) along with a structured interview/questionnaire which permitted a Glasgow Outcome Scale (GOSE) score to be assigned. RESULTS: One hundred and sixty-five TBI survivors completed both questionnaire and CiOP. One hundred and three (62%) participants had suffered severe TBI, 24 (15%) moderate and 38 (23%) mild. Mean length of follow-up was 11.5 years post-injury (range 9-25 years). On the GOSE at follow-up, 43 (26%) had severe disability; 72 (44%) moderate disability; and 50 (30%) good recovery. Scores on the CiOP indicated positive psychological growth in over half of the sample, as evidenced by agreement with items such as 'I don't take life for granted anymore' and 'I value my relationships much more now'. CiOP total scores did not correlate with any injury or early outcome variables. However, at long-term follow-up there was a negative correlation between positive growth and anxiety and depression. CONCLUSION: Survivors of mild, moderate and severe TBI showed evidence of long-term positive changes in outlook.

Intracranial pressure complicating severe traumatic brain injury in children: monitoring and management.

OBJECTIVE: To identify factors associated with the use of intracranial pressure (ICP) monitoring and to establish which ICP-targetted therapies are being used in children with severe traumatic brain injury (TBI) in the United Kingdom. To evaluate current practice against recently published guidelines. DESIGN AND SETTING: Prospective data collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Ireland admitting children (< 16 years) with TBI between February 2001 and August 2003. RESULTS: Detailed clinical information was obtained for 501 children, with information on the use of ICP monitoring available in 445. ICP monitoring was used in only 59% (75/127) of children presenting with an emergency room Glasgow Coma Scale of 8 or below. Large between centre variation was seen in the use of ICP monitoring, independent of severity of injury. There were 86 children who received ICP-targetted therapies without ICP monitoring. Wide between centre variation was found in the use of ICP-targetted therapies and in general aspects of management, such as fluid restriction, the use of muscle relaxants and prophylactic anticonvulsants. Intra-ventricular catheters are rarely placed (6% of cases); therefore cerebrospinal fluid drainage is seldom used as a first-line therapy for raised ICP. Jugular venous bulb oximetry (4%), brain microdialysis (< 1%) and brain tissue oxygen monitoring (< 1%) are rarely used in current practice. Contrary to published guidelines, moderate to severe hyperventilation is being used without monitoring for cerebral ischaemia. CONCLUSIONS: There is an urgent need for greater standardisation of practice across UK centres admitting children with severe TBI.

Return to driving after traumatic brain injury: a British perspective.

PRIMARY OBJECTIVE: To identify the current legal situation and professional practice in assisting persons with traumatic brain injury (TBI) to return to safe driving after injury. METHODS AND PROCEDURES: A brief review of relevant literature, a description of the current statutory and quasi-statutory authorities regulating return to driving after TBI in the UK and a description of the nature and resolution of clinical and practical dilemmas facing professionals helping return to safe driving after TBI. Each of the 15 UK mobility centres was contacted and literature requested; in addition a representative of each centre responded to a structured telephone survey. MAIN OUTCOME AND RESULTS: The current situation in the UK is described, with a brief analysis of the strengths and weaknesses both of the current statutory situation, and also the practical situation (driving centres), with suggestions for improvements in practice. CONCLUSION: Although brain injury may cause serious limitations in driving ability, previous drivers are not routinely assessed or advised regarding return to driving after TBI.

Behaviour and school performance after brain injury.

PRIMARY OBJECTIVE: To examine the relationship between behavioural problems and school performance following traumatic brain injury (TBI). SUBJECTS: 67 school-age children with TBI (35 mild, 13 moderate, 19 severe) and 14 uninjured matched controls. Parents and children were interviewed at a mean of 2 years post-TBI. Teachers reported on academic performance and educational needs. Children were assessed using the Vineland Adaptive Behaviour Scales (VABS) and the Weschler Intelligence Scale for Children (WISC-III). MAIN OUTCOMES AND RESULTS: Two-thirds of children with TBI exhibited significant behavioural problems, significantly more than controls (p = 0.02). Children with behavioural problems had a mean IQ aproximately 15 points lower than those without (p = 0.001, 95% CI: 7-26.7). At school, 76%(19) of children with behavioural problems also had difficulties with schoolwork. Behavioural problems were associated with social deprivation and parental marital status (p < or = 0.01). CONCLUSIONS: Children with TBI are at risk of developing behavioural problems which may affect school performance. Children with TBI should be screened to identify significant behavioural problems before they return to school.

Mentally disordered offenders with a history of previous head injury: are they more difficult to discharge?

PRIMARY OBJECTIVES: To identify the incidence of head injury (HI) amongst mentally disordered offenders (MDOs) in UK medium secure units (MSUs) and test the hypothesis that patients with a history of HI are more difficult to discharge than patients without HI. DESIGN, METHODS AND PROCEDURES: One hundred and thirteen MDOs being discharged to community settings from five MSUs in England were recruited consecutively between 1 April 1999 and 31 December 2000. Data on previous HI, offending history and discharge planning were collected from clinical case notes, structured questionnaires and interviews with clinical staff. MAIN OUTCOMES AND RESULTS: More patients with HI (57.4%) than patients without HI (47%) had a violent index offence. Risk assessments carried out prior to discharge showed patients with HI to be at greater risk of violence to others and of self-harm than patients without HI (p < or = 0.05). All but two patients in the HI group were difficult to discharge (43, 95.6%), compared to 52 (82.5%) in the non-HI group. CONCLUSIONS: Information on previous HI should be collected on admission to MSUs and considered when planning for discharge.

Prevalence of traumatic brain injury amongst children admitted to hospital in one health district: a population-based study.

There is a dearth of information regarding the prevalence of brain injury, serious enough to require hospital admission, amongst children in UK. In North Staffordshire, a register of all children admitted with traumatic brain injury (TBI) has been maintained since 1992 presenting an opportunity to investigate the incidence of TBI within the region in terms of age, cause of injury, injury severity and social deprivation. The register contains details of 1553 children with TBI, two-thirds of whom are male. This population-based study shows that TBI is most prevalent amongst children from families living in more deprived areas, however, social deprivation was not related to the cause of injury. Each year, 280 per 100,000 children are admitted for >or=24h with a TBI, of these 232 will have a mild brain injury, 25 moderate, 17 severe, and 2 will die. The incidence of moderate and severe injuries is higher than previous estimates. Children under 2 years of age account for 18.5% of all TBIs, usually due to falls, being dropped or non-accidental injuries (NAIs). Falls account for 60% of TBIs in the under 5 years. In the 10-15 age group road traffic accidents (RTAs) were the most common cause (185, 36.7%). These findings will help to plan health services and target accident prevention initiatives more accurately.

Reported problems and their resolution following mild, moderate and severe traumatic brain injury amongst children and adolescents in the UK.

PRIMARY OBJECTIVES: To examine the problems reported by families of children who have suffered traumatic brain injury (TBI), and how these differ from problems reported by control families. To identify those problems most likely to resolve over time, and to examine information and follow-up requirements. DESIGN, METHODS AND PROCEDURES: The families of 97 children with mild (49), moderate (19) and severe (29) TBI, aged 5-15 at injury, were interviewed and assessed at a mean of 2.29 years post-injury and compared with 31 healthy controls. A structured questionnaire was used to collect information on problems pre- and post-TBI. Initially, respondents reported problems spontaneously, and were subsequently prompted using a checklist of problem categories. Problems of behaviour and emotion were measured using the Vineland Adaptive Behaviour Scales (VABS) and the Hospital Anxiety and Depression Scale (HADS). MAIN OUTCOMES AND RESULTS: Following the TBI, 83 children (85.6%) received no therapeutic input, 74 families (76.3%) had unmet information needs, particularly regarding long-term consequences. At first interview, 1097 problems were reported by the TBI group. Behavioural and school problems were frequently reported by all TBI groups, significantly more than controls (p < or = 0.001). On the VABS, approximately two thirds of children with TBI exhibited 'significant' maladaptive behaviours, significantly more than controls (p = 0.002). Children in the mild and moderate/severe groups were significantly more anxious than controls on the HADS (p = 0.04). At 12 month follow-up, there were no significant differences in problem resolution between the TBI groups: 498 (53.9%) problems remained unchanged and 75 (8.1%) had worsened. Physical problems were most likely to resolve. CONCLUSIONS: Parents should be given information and support following their child's TBI, children should be routinely followed-up by health professionals and their needs assessed. It was found that children with TBI may be at risk of anxiety, yet few parents reported this as a particular concern. Future research should examine the relationship between anxiety and TBI.

Parental stress and burden following traumatic brain injury amongst children and adolescents.

PRIMARY OBJECTIVES: To assess parental stress following paediatric traumatic brain injury (TBI), and examine the relationship between self-reported problems, parental stress and general health. RESEARCH DESIGN: Parents of 97 children admitted with a TBI (49 mild, 19 moderate, 29 severe) to North Staffordshire National Health Service Trust, and parents of 31 uninjured children were interviewed and assessed. METHODS AND PROCEDURES: Structured interviews were carried out with families, and parents assessed on the Parenting Stress Index (PSI/SF) and General Health Questionnaire (GHQ-12) at recruitment, and repeated 12 months later. MAIN OUTCOMES AND RESULTS: Forty parents (41.2%) of children with TBI exhibited clinically significant stress. Regardless of injury severity, parents of injured children suffered greater stress than control parents as measured by the PSI/SF (p = 0.001). There was a highly significant relationship between number of problems reported and level of parental stress (p = 0.001). Financial burden was related to severity of TBI. At follow-up, one third of parents of children with severe TBI scored > or =18 on the GHQ-12, signifying poor psychological health. CONCLUSIONS: The parents of a child with serious TBI should be screened for abnormal levels of stress. Parental stress and family burden may be alleviated by improved information, follow-up and support.

Children's brain injury: a postal follow-up of 525 children from one health region in the UK.

PRIMARY OBJECTIVES: To follow-up a population of children admitted to one Hospital Trust with traumatic brain injury (TBI), and compare outcomes following mild TBI with outcomes following moderate or severe TBI. RESEARCH DESIGN: Population-based postal questionnaire survey. METHODS AND PROCEDURES: Questionnaires were mailed to parents of all 974 surviving children on a register of paediatric TBI admissions, 525 completed questionnaires were returned (56.2%). Most children (419) had suffered mild TBI, 57 moderate, and 49 severe. MAIN OUTCOMES AND RESULTS: Thirty per cent of parents received no information on post-injury symptoms, and clinical follow-up was limited. Statistically significant differences were observed between mild and moderate/severe groups for cognitive, social, emotional, and mobility problems. Nevertheless, approximately 20% of the mild group suffered from poor concentration, personality change and educational problems post-injury. Few schools (20%) made special provision for children returning after injury. CONCLUSIONS: Children can have long-lasting and wide-ranging sequelae following TBI. Information should be routinely given to parents and schools after brain injury.