Diffusion tensor MR imaging reveals persistent white matter alteration after traumatic brain injury experienced during early childhood.

BACKGROUND AND PURPOSE: Diffusion tensor imaging (DTI) can noninvasively quantify white matter (WM) integrity. Although its application in adult traumatic brain injury (TBI) is common, few studies in children have been reported. The purposes of this study were to examine the alteration of fractional anisotropy (FA) in children with TBI experienced during early childhood and to quantify the association between FA and injury severity. MATERIALS AND METHODS: FA was assessed in 9 children with TBI (age = 7.89 +/- 1.00 years; Glasgow Coma Scale [GCS] = 10.11 +/- 4.68) and a control group of 12 children with orthopedic injuries without central nervous system involvement (age = 7.51 +/- 0.95 years). All of the subjects were at minimum 12 months after injury. We examined group differences in a series of predetermined WM regions of interest with t test analysis. We subsequently conducted a voxel-wise comparison with Spearman partial correlation analysis. Correlations between FA and injury severity were also calculated on a voxel-wise basis. RESULTS: FA values were significantly reduced in the TBI group in genu of corpus callosum (CC), posterior limb of internal capsule (PLIC), superior longitudinal fasciculus (SLF), superior fronto-occipital fasciculus (SFO), and centrum semiovale (CS). GCS scores were positively correlated with FA in several WM areas including CC, PLIC, SLF, CS, SFO, and inferior fronto-occipital fasciculus (IFO). CONCLUSION: This DTI study provides evidence that WM integrity remains abnormal in children with moderate-to-severe TBI experienced during early childhood and that injury severity correlated strongly with FA.

Bidirectional child-family influences on outcomes of traumatic brain injury in children.

Child behavior problems, injury-related family burden, and parent psychological distress were assessed longitudinally over the first year post injury in 40 children with severe traumatic brain injury (TBI), 52 with moderate TBI, and 55 with orthopedic injuries not involving brain insult. Parents rated children's preinjury behavior soon after injury. Postinjury child behavior and family outcomes were assessed at 6- and 12-month follow-ups. Findings from path analysis revealed both direct and indirect effects of TBI on child behavior and family outcomes, as well as cross-lagged child-family associations. Higher parent distress at 6 months predicted more child behavior problems at 12 months, controlling for earlier behavior problems; and more behavior problems at 6 months predicted poorer family outcomes at 12 months, controlling for earlier family outcomes. Support for bidirectional influences is tentative given that limited sample size precluded use of structural equation modeling. The findings nevertheless provide impetus for considering the influences of person-environment interactions on outcomes of TBI.

The relationship of caregiver coping to family outcomes during the initial year following pediatric traumatic injury.

This study identified coping strategies associated with caregiver outcomes following pediatric injury and examined injury type as a moderator of coping efficacy. Families of 103 children with traumatic brain injury (TBI) and 71 children with orthopedic injuries were followed prospectively during the initial year postinjury. The groups had comparable preinjury characteristics and hospitalization experiences but differed on neurological insult. In hierarchical regression analyses, acceptance was associated with lower burden and denial was associated with greater distress in both groups. Active coping resulted in higher distress following TBI but not orthopedic injuries. Conversely, the use of humor was related to diminishing distress following TBI but unrelated to distress following orthopedic injuries. Results are discussed in terms of the implications for intervention following TBI.

Child and family functioning 6 and 12 months after a serious pediatric fracture.

BACKGROUND: Previous findings indicate that pediatric fractures can have adverse consequences for child adjustment and family functioning immediately after injury. However, longer term effects of the fractures are unknown. The purposes of the present prospective study were to examine the child and family outcomes of pediatric traumatic fractures at 6 months and 1 year after injury, and to identify injury and treatment factors associated with these outcomes. METHODS: We evaluated 57 children 6 to 12 years of age with traumatic fractures requiring hospitalization. Using standardized measures and parent interview, we obtained measures of pre- and postinjury child and family functioning. RESULTS: Although outcomes were primarily positive at 1 year after injury, child functional limitations and family stress were observed up to 6 months after injury. Lower extremity fractures had a more negative impact on families across all three assessment points. Children with fracture interventions that involved prolonged immobilization had more functional limitations at 6 months than children who were ambulatory. Family burden was higher at 1 month for the immobilized children, but not at later follow-up. CONCLUSION: Some children and families experience adverse effects during the year after a serious pediatric fracture, especially if sustained in a lower extremity. Fracture stabilization that allows for greater ambulation may offer some benefits related to functional outcomes and family impact.

Cognitive-behavioral predictors of asthma morbidity in inner-city children.

Asthma is a growing health problem among children in the United States, particularly in urban, inner-city areas. This article examines the relationship between cognitive-behavioral aspects of asthma management (caretaker asthma knowledge, expectations, and problem-solving) and asthma morbidity in a sample of 1,376 inner-city children with physician-diagnosed asthma. In the analyses, baseline symptom severity served as a covariate, and the average of the 3-, 6-, and 9-month follow-up data served as the outcome measure. Children of caregivers with ineffective problem-solving strategies had significantly more days of wheezing over a 14-day period. Ineffective problem-solving capabilities were also associated with poorer functional status; however, positive caregiver expectations were associated with better functional status. Of the cognitive-behavioral factors studied in a high-risk urban population, caregiver problem-solving skills and expectations emerged as meriting further investigation and possible intervention.

Prevalence and correlates of depressive symptoms following traumatic brain injuries in children.

The prevalence and correlates of depressive symptoms following childhood traumatic brain injuries (TBI) were examined using data drawn from a prospective longitudinal study. Participants included 38 children with severe TBI, 51 with moderate TBI, and 55 with orthopedic injuries (OI). Assessments occurred shortly after injury (baseline) and at 6- and 12-month follow-ups. Children completed the Child Depression Inventory (CDI). Parents rated depressive symptoms using the Child Behavior Checklist (CBC), with baseline ratings reflecting premorbid status. Assessments also included measures of children's neurocognitive functioning and the family environment. The three groups did not differ overall in self-reported symptoms on the CDI, but did display different trends over time. The three groups did not differ on parent ratings of premorbid depressive symptoms on the CBC, but parents reported more depressive symptoms in the TBI groups than in the OI group at 6- and 12-month follow-ups. Child and parent reports were correlated for children in the TBI groups, but not for those in the OI group. Depressive symptoms were related to socioeconomic status in all groups. Socioeconomic status also was a significant moderator of group differences, such that the effects of TBI were exacerbated in children from more disadvantaged homes. Although self-reports of depressive symptoms were related inconsistently to children's verbal memory, parent reports of depressive symptoms were unrelated to IQ or verbal memory. The findings suggest that TBI increases the risk of depressive symptoms, especially among more socially disadvantaged children, and that depressive symptoms are not strongly related to post-injury neurocognitive deficits.

The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma.

OBJECTIVE: Children living in the inner city are affected disproportionately by asthma morbidity and mortality. Previous research has shown that behavioral and psychosocial factors affect asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated the factors that contribute to asthma morbidity among inner-city children. This article examines the relationship between psychosocial factors and asthma morbidity in this population. METHODS: A total of 1528 English- and Spanish-speaking children 4 to 9 years of age with asthma and their primary caretakers were recruited from 8 research centers in 7 metropolitan inner-city areas in the United States. Psychosocial variables were assessed at baseline and included measures of child and caretaker mental health, caretaker's problems with alcohol, life stress, social support, and parenting style. Morbidity measures were evaluated at baseline and at 3-, 6-, and 9-month follow-up intervals. These included number of hospitalizations and unscheduled visits for asthma in the past 3 months and number of days of wheeze and functional status in the previous 2-week period. RESULTS: Of the psychosocial variables assessed, mental health had the strongest relationship to children's asthma morbidity. Children whose caretakers had clinically significant levels of mental health problems were hospitalized for asthma at almost twice the rate as children whose caretakers did not have significant mental health problems. Children with clinically significant behavior problems had significantly more days of wheeze and poorer functional status in the follow-up period. CONCLUSION: Psychosocial factors, particularly the mental health of children and caretakers, are significant factors in predicting asthma morbidity. They may need to be included in intervention programs aimed at decreasing asthma morbidity in inner-city children with asthma in order for these programs to be successful.

Division of responsibility for asthma management tasks between caregivers and children in the inner city.

This investigation examined caregiver and child perceptions of the division of responsibility for asthma management tasks in families. The study sample included 789 children with asthma, aged 6 to 9 years, who lived in the inner city. These children and their primary caregivers completed the Asthma Responsibility Interview. The correlation between the caregiver's and child's ratings of the child's responsibility was low (.19), with children rating themselves as more responsible than their caregivers rated them. Caregiver and child ratings of the child's responsibility increased with the child's age; however, caregivers' ratings of their own responsibility remained constant over the age range studied. Kappa statistics ranged from -.03 to .12, with up to 16% of children reporting less responsibility for self-care than was indicated by the caregiver. More than one third of families reported four or more asthma caregivers. The discrepancy between the caregiver's and child's perceptions and the involvement of multiple caregivers raise the possibility of unintentional nonadherence.

Influences on first-year recovery from traumatic brain injury in children.

This study examined recovery over the first year following traumatic brain injury (TBI) in children 6-12 years of age. Forty-two children with severe TBI and 52 with moderate TBI were compared to 58 children with orthopedic injuries. The children and their families were evaluated at a baseline assessment and at 6- and 12-month follow-ups. Findings documented cognitive, achievement, and behavioral sequelae of TBI, with only limited evidence for recovery over the first year postinjury. Outcomes were predicted by preinjury factors, TBI severity, and measures of the postinjury family environment. Some of the sequelae of severe TBI were more marked in the context of higher compared with lower levels of family burden or dysfunction. The findings confirm the need to consider environmental contributions to outcomes of TBI in children.

Family burden and adaptation during the initial year after traumatic brain injury in children.

OBJECTIVE: Traumatic brain injury (TBI) often leads to long-term behavioral and cognitive deficits in children. However, little is known about the burden and psychosocial morbidity of pediatric TBI for families. The purpose of this study was to test the hypothesis that moderate and severe TBI in children has more adverse consequences than orthopedic trauma. DESIGN: The sample was comprised of children between the ages of 6 and 12 recruited from hospital trauma and inpatient units including 53 with severe TBI, 56 with moderate TBI, and 80 with orthopedic injuries not involving central nervous system insult. Measures of injury-related burden, parental distress, and family functioning were administered to the child's primary caregiver at baseline assessment conducted soon after injury and at 6- and 12-month follow-ups. Multivariate repeated measures analysis of covariance was used to examine group differences in these outcomes over time. RESULTS: Caregivers in the severe TBI group reported significantly higher levels of family burden, injury-related stress, and parental psychological symptoms than caregivers in the orthopedic injury group (ORTHO). The groups did not differ with respect to marital distress. Caregivers in the severe TBI group were significantly more likely than caregivers in the ORTHO group to exceed the clinical cutoff on the Brief Symptom Inventory and to report clinically significant levels of family dysfunction at follow-up. CONCLUSIONS: The findings suggest that severe TBI is a source of considerable caregiver morbidity, even when compared with other traumatic injuries. Caregivers in the severe TBI group had persistent stress associated with the child's injury, as well as the reactions of other family members, and a relative risk of clinically significant psychological symptoms nearly twice that of the ORTHO comparison group. These findings underscore the need for interventions that facilitate family adaptation after pediatric TBI.

Self-reported adherence, management behavior, and barriers to care after an emergency department visit by inner city children with asthma.

OBJECTIVE: The inability to adhere to a prescribed therapeutic program for the treatment of a chronic disease may be responsible in part for continued disease activity. This problem may be more of an issue in the treatment of asthma, a common, potentially lethal chronic condition in which the lack of symptoms may be interpreted as remission. Adherence was one of the key areas of interest for the National Cooperative Inner-City Asthma Study. The focus of this study was to identify those issues reported by families that could adversely affect their adherence to an asthma care program. The identification of barriers to adherence could then form the basis of a successful intervention program. This study describes barriers to adherence, asthma management behavior, and self-reported adherence. METHODS: Patients presenting during an acute attack of asthma at an emergency department (ED) were recruited for this study. The medical record of the ED encounter was abstracted and compared with information that was obtained during a baseline interview 3 to 5 weeks later. During the baseline interview, parents were asked about health care behaviors related to adherence. RESULTS: There were 344 children 4 to 9 years of age living in inner city census tracts in the study. Four areas of adherence (medicine use, appointment-keeping, emergency actions, and asthma attack prevention) were investigated. The parental report of medications prescribed at the ED and the information on the abstracted ED report agreed 94.9% of the time for the beta-agonists, 86.8% for steroids, and 69.4% for cromolyn. Among respondents, 85.4% of parents reported that they are able to follow the ED recommendations almost all of the time; side effects of medicines were a concern for 81.1% of caretakers who were adherent and for 89.5% of caretakers who were nonadherent. Doubts regarding the usefulness of medications occurred in 34.4% of those considered adherent and 54.2% who admitted nonadherence. Medications were forgotten some of the time by 45.2% of the children, and 52.8% tried to get out of taking medicine. Appointments for follow-up care were kept by 69% of those given an appointment in the ED, by an estimated 60.0% of those who were told specifically to call for an appointment, and by an estimated 25.2% of those who were neither given an appointment nor told specifically to make one. Only one third of parents report that they were able to keep the child away from known asthma triggers nearly all of the time. Approximately half avoided allergens; however, only 37.5% reported avoidance of cigarette smoke. The use of preventive medicines occurred in 23.5%. Using a medicine and taking the child to a physician were reported as the first or second action during an acute attack of asthma by 72.1% of respondents. CONCLUSIONS: Adherence to an asthma-management program involves a number of areas: medication, appointment-keeping, prevention, and applying an emergency plan of action. Barriers to adherence may exist in one or all four of these areas, leading to ineffective control of asthma. Recommendations are made for improving the patient-physician partnership to improve adherence.

Preinjury family environment as a determinant of recovery from traumatic brain injuries in school-age children.

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than environmental factors as predictors of recovery. We addressed this concern using data collected during a prospective study of children with either TBI or orthopedic injuries (OI) and their families. Participants included 53 children with severe TBI, 56 with moderate TBI, and 80 with OI, all from 6 to 12 years of age at the time of injury. Measures of the preinjury family environment were collected shortly after the injury (baseline). Child cognitive and behavioral outcomes were assessed at baseline and at 6- and 12-month follow-ups. Individual growth curve analyses showed that measures of the preinjury family environment consistently predicted both the level of cognitive and behavioral functioning at 12 months postinjury and the rate of intraindividual change during the 12-month follow-up period, even after taking into account group membership and injury severity. In some cases, the preinjury family environment was a significant moderator of the effect of TBI, buffering its impact in high-functioning families and exacerbating it in low-functioning families. Thus, preinjury environmental factors predict recovery following TBI in children, even after accounting for injury-related variables.

Childhood traumatic brain injury: initial impact on the family.

Traumatic brain injury (TBI) is a significant source of morbidity and mortality in children, resulting in a wide range of cognitive and behavioral sequelae. However, little is known about the effects of pediatric TBI and its aftermath on families. The current investigation examined the impact of TBI on families during the first month following injury. Children with orthopedic injuries requiring hospitalization served as a control group. The sample consisted of 44 families of children of severe TBI, 52 families of children with moderate TBI, and 69 families of children with orthopedic injuries not involving the central nervous system (CNS). Families of children with severe TBI experienced significantly more injury-related stress than the other two groups of families. Parents of children with TBI also reported higher levels of psychological symptoms than parents of children with orthopedic injuries. Findings from regression analyses suggested that families facing multiple stressors in addition to the injury and those who cope poorly may be at greatest risk for adverse consequences. Future interventions could provide anticipatory guidance and support to at-risk families.

Chronic life stress and treatment outcome in agoraphobia with panic attacks.

OBJECTIVE: Factors associated with response to treatment for agoraphobia are as of yet poorly understood. The authors investigated the relationship between chronic forms of life stress and clinical improvement and recovery in subjects with agoraphobia. METHOD: Subjects meeting the DSM-III criteria for agoraphobia with panic attacks (N = 73) completed measures of life stress, agoraphobic symptoms, and depressive symptoms at the initiation and completion of the 12-week treatment protocol. Chronic stressors were assessed during intensive structured interviews 3-5 years after the completion of treatment and were rated by using a reliable, and previously validated, contextual rating system. The contextual life stress interview was completed by 54 subjects. The relationship of chronic forms of stress to treatment response was assessed by comparing symptomatic improvement in the subjects who had and had not experienced chronic stressors. RESULTS: Of the 54 subjects, 23 (43%) reported chronic stressors of marked or moderate severity. Subjects experiencing chronic stressors evidenced less improvement after treatment on both self-report and objective indexes of agoraphobic symptoms. Additionally, more subjects identified as nonrecovered experienced chronic stressors than did recovered subjects. CONCLUSIONS: Chronic stressors appear to predict a relatively unfavorable treatment outcome, as defined by higher levels of symptoms after treatment, less improvement, and less likelihood of recovery. These results have important implications for enhancing psychotherapeutic outcomes.

Skin changes and diseases associated with pregnancy.

During the gestational period, the skin is among the many organs undergoing changes. Various endocrine changes occurring in pregnancy are thought to give rise to certain skin changes such as pigmentary alterations, abnormalities in hair growth, vascular anomalies, and striae. Also, there are several skin diseases unique to the pregnant woman. Whereas the physiologic skin changes are mainly of cosmetic importance, the various pregnancy-unique skin diseases have associated symptoms, and an increase in both fetal and/or maternal morbidity and mortality is associated with several of these skin diseases.