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.

Adolescent quality of life following family problem-solving treatment for brain injury.

OBJECTIVE: To examine changes in quality of life (QoL) in adolescents receiving family problem-solving therapy (F-PST) following traumatic brain injury (TBI). METHOD: Adolescents hospitalized for moderate-to-severe TBI were randomized to 1 of 3 ten-session, 6-month long treatments: face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Participants included 96 boys and 54 girls, of whom 124 were White and 6 were Hispanic. Outcomes were assessed pretreatment and 6 and 9 months later. Adolescents and parents rated adolescent QoL and TBI-related symptoms on the PedsQL and Health and Behavior Inventory (HBI), respectively. We used mixed modeling to examine changes over time and moderators of treatment efficacy. RESULTS: Therapist- and self-guided online groups demonstrated improvements in parent-proxy QoL from baseline to 9 months, Cohen's d = 0.75; p = .004 and Cohen's d = 1.30; p < .001, respectively. The face-to-face group had poorer parent-proxy QoL at 6 months (M = 62, SE = 3.4) than either the therapist- (M = 70.9, SE = 2.8) or self-guided online group (M = 71.1, SE = 2.6). There were no changes or group differences in self-reported QoL over time. Similar findings were observed on the HBI. Differential treatment effects on parent-proxy outcomes were found in boys versus girls and in those from single versus 2-parent households. Improvements in parent-proxy HBI ratings mediated QoL improvements. CONCLUSIONS: Both online treatments, but not face-to-face F-PST, were associated with clinical improvements, raising questions about our current delivery paradigm. Individual and family moderators of treatment efficacy underscore the potential of personalized treatment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A Randomized Comparative Effectiveness Trial of Family-Problem-Solving Treatment for Adolescent Brain Injury: Parent Outcomes From the Coping with Head Injury through Problem Solving (CHIPS) Study.

OBJECTIVE: To examine changes in depression and distress in parents of adolescents receiving family-problem-solving therapy (F-PST) following traumatic brain injury. METHOD: Families of adolescents hospitalized for moderate to severe traumatic brain injury were randomized to face-to-face F-PST (34), therapist-guided online F-PST (56), or self-guided online F-PST (60). Outcomes were assessed pretreatment and 6 and 9 months later. Parents rated depression and distress on the Center for Epidemiological Studies Depression Scale and the Brief Symptom Inventory, respectively. Mixed modeling was used to examine changes over time and treatment moderators. RESULTS: The therapist-guided online group had significant reductions in parental depression over time. Analyses of slopes of recovery revealed differential improvement on the Center for Epidemiological Studies Depression Scale between the 2 online groups, with no significant change in depressive symptoms following self-guided F-PST. On the Brief Symptom Inventory Global Severity Index, the therapist-guided online group reported significant improvement from baseline to 6 months that was maintained at 9 months. The face-to-face and self-guided online groups reported significant reductions in distress between 6 and 9 months with corresponding large effect sizes. Differences on the Center for Epidemiological Studies Depression Scale between therapist-guided and self-guided online groups at the 9-month follow-up were more pronounced in families of lower socioeconomic status, t103 = -2.87; P = .005. CONCLUSIONS: Findings provide further support for the utility of therapist-guided online F-PST in reducing parental depression and distress following pediatric traumatic brain injury and offer limited evidence of the efficacy of self-guided online treatment for these outcomes. Families of lower socioeconomic status may benefit more from therapist involvement.

The Relationship of Adolescent and Parent Preferences for Treatment Modality With Satisfaction, Attrition, Adherence, and Efficacy: The Coping With Head Injury Through Problem-Solving (CHIPS) Study.

OBJECTIVE: To characterize treatment preferences for delivery of family problem-solving treatment (F-PST) to adolescents with behavioral challenges following traumatic brain injury (TBI) and to examine associations with attrition, adherence, satisfaction, and efficacy. METHOD: Adolescents who had been hospitalized for moderate to severe TBI were randomized to face-to-face F-PST (n = 34), therapist-guided online F-PST (n = 56), and self-guided online F-PST (n = 60). Adolescents and parents rated treatment convenience and anticipated benefit before group assignment. Sessions completed served as an index of adherence. Satisfaction was rated posttreatment. The Behavior Rating Inventory of Executive Function and Strengths and Difficulties Questionnaire were used to assess parent-reported behavioral concerns. RESULTS: Both parents and adolescents were more likely to agree or strongly agree that they anticipated self-guided online F-PST to be the most convenient relative to either of the therapist-involved approaches. Parents were also less likely to anticipate face-to-face treatment as most beneficial, relative to the two online treatments. Adolescent preferences were significantly related to attrition with 27% versus 13% dropout rates for those assigned to nonpreferred and preferred treatments, respectively. Parent and adolescent preferences before treatment were unrelated to post-intervention satisfaction, adherence, or improvements in parent-reported child behavior problems. CONCLUSIONS: Online treatments are perceived favorably among adolescents with TBI and their parents. For adolescents, these pretreatment preferences influenced treatment completion. Poor correspondence between initial preferences and posttreatment satisfaction and benefit suggests that therapeutic experience more strongly influences ultimate satisfaction.

A Comparison of 2 Online Parent Skills Training Interventions for Early Childhood Brain Injury: Improvements in Internalizing and Executive Function Behaviors.

OBJECTIVE: To examine the effectiveness of a web-based parenting intervention (Internet-Based Interacting Together Everyday: Recovery After Childhood TBI [I-InTERACT]) and an abbreviated version (Express) in reducing executive dysfunction and internalizing problems among young children following traumatic brain injury (TBI). METHOD: Parents of 113 children (ages 3-9 years) who had sustained a TBI were randomized to 1 of 3 treatment groups: I-InTERACT, Express, or an Internet Resource Comparison (IRC) group. Parents who participated in either I-InTERACT or Express completed self-guided web sessions and received live coaching of their parenting skills via videoconferencing with a therapist. I-InTERACT included additional psychoeducation, stress management, and family communication skills (eg, marriage, grief, pain, and sleep). Analyses of covariance were utilized to compare the groups on parent-reported executive function behaviors (ie, Behavior Rating Inventory of Executive Function) and internalizing symptoms (ie, Child Behavior Checklist) at baseline and 6 months. RESULTS: Parents who participated in Express reported significantly lower levels of executive dysfunction than those in I-InTERACT, ß = -0.49; t(2, 73) = -2.47, P = .048, and significantly lower levels of withdrawal than those in the IRC group, ß = -0.44; t(2, 74) = -2.22, P = .03. The Express group did not significantly differ from the IRC group on executive function behaviors or the I-InTERACT group on internalizing problems, all P > .05. Children with more problems at baseline, families with lower education levels, and parents with more symptoms of depression benefited most. CONCLUSION: A brief, online parent training intervention may be efficacious in improving executive dysfunction and internalizing problems following early TBI, particularly among children of lower socioeconomic status or with existing behavioral concerns.

Impaired cerebral autoregulation and elevation in plasma glial fibrillary acidic protein level during cardiopulmonary bypass surgery for CHD.

BACKGROUND: Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level. METHODS: We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient's autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure. RESULTS: A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual's peak autoregulation and biomarker values (p=0.01). CONCLUSIONS: Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.

Randomized Clinical Trial of Online Parent Training for Behavior Problems After Early Brain Injury.

OBJECTIVE: To evaluate the effectiveness of Internet-based Interacting Together Everyday: Recovery After Childhood TBI (I-InTERACT) versus abbreviated parent training (Express) or access to online resources (internet resources comparison [IRC]) in improving parenting skills and decreasing behavior problems after early traumatic brain injury (TBI). METHOD: In this randomized, controlled, clinical trial, 113 children 3 to 9 years old previously hospitalized for moderate to severe TBI were randomly assigned to receive Express (n = 36), I-InTERACT (n = 39), or IRC (n = 38). Express included 7 online parent skills sessions, and I-InTERACT delivered 10 to 14 sessions addressing parenting skills, TBI education, stress, and anger management. The 2 interventions coupled online modules with therapist coaching through a Health Insurance Portability and Accountability Act-compliant Skype link. The IRC group received access to online TBI and parent skills resources. Co-primary outcomes were blinded ratings of parenting skills and parent report of behavior problems and problem intensity on the Eyberg Child Behavior Inventory (ECBI). Outcomes were assessed before treatment and 3 and 6 months after treatment, with the latter constituting the primary endpoint. RESULTS: The Express and I-InTERACT groups displayed higher levels of positive parenting at follow-up. Only the I-InTERACT group had lower levels of negative parenting at 6 months. The Express group had lower ECBI intensity scores than the IRC group. Baseline symptom levels moderated improvements; children in the Express and I-InTERACT groups with higher baseline symptoms demonstrated greater improvements than those in the IRC group. Changes in parenting skills mediated improvements in behavior in those with higher baseline symptoms. CONCLUSION: Brief online parent skills training can effectively decrease behavior problems after early TBI in children with existing behavioral symptoms. Clinical trial registration information-Internet-based Interacting Together Everyday, Recovery After Childhood TBI (I-InTERACT)-RRTC; http://clinicaltrials.gov/; NCT01214694.

Problem-Solving After Traumatic Brain Injury in Adolescence: Associations With Functional Outcomes.

OBJECTIVE: To examine the association of problem-solving with functioning in youth with traumatic brain injury (TBI). DESIGN: Cross-sectional evaluation of pretreatment data from a randomized controlled trial. SETTING: Four children's hospitals and 1 general hospital, with level 1 trauma units. PARTICIPANTS: Youth, ages 11 to 18 years, who sustained moderate or severe TBI in the last 18 months (N=153). MAIN OUTCOME MEASURES: Problem-solving skills were assessed using the Social Problem-Solving Inventory (SPSI) and the Dodge Social Information Processing Short Stories. Everyday functioning was assessed based on a structured clinical interview using the Child and Adolescent Functional Assessment Scale (CAFAS) and via adolescent ratings on the Youth Self Report (YSR). Correlations and multiple regression analyses were used to examine associations among measures. RESULTS: The TBI group endorsed lower levels of maladaptive problem-solving (negative problem orientation, careless/impulsive responding, and avoidant style) and lower levels of rational problem-solving, resulting in higher total problem-solving scores for the TBI group compared with a normative sample (P<.001). Dodge Social Information Processing Short Stories dimensions were correlated (r=.23-.37) with SPSI subscales in the anticipated direction. Although both maladaptive (P<.001) and adaptive (P=.006) problem-solving composites were associated with overall functioning on the CAFAS, only maladaptive problem-solving (P<.001) was related to the YSR total when outcomes were continuous. For the both CAFAS and YSR logistic models, maladaptive style was significantly associated with greater risk of impairment (P=.001). CONCLUSIONS: Problem-solving after TBI differs from normative samples and is associated with functional impairments. The relation of problem-solving deficits after TBI with global functioning merits further investigation, with consideration of the potential effects of problem-solving interventions on functional outcomes.

Quality of Life of Pediatric Patients With Long QT Syndrome.

Children with long QT syndrome (LQTS) live with the risk of sudden death, activity restrictions, and the need for daily medications. We sought to evaluate the quality of life (QOL), self-perception, and behavior of patients with LQTS as perceived by both patients and their parents and identify predictors of lower QOL. QOL (Pediatric QOL Inventory [PedsQL] and Pediatric Cardiac Quality of Life Inventory [PCQLI]), self-perception, and behavioral inventories were completed by patients with LQTS and their parents. Comparison of PedsQL scores was made to published data for healthy children using t tests, and PCQLI scores were compared with those of patients with differing complexity of congenital heart disease. Mixed modeling was used for multivariable analysis. Sixty-one patients with LQTS were evaluated (age 13.6 ± 3.0 years; male 49%). Compared with healthy children, the PedsQL Total, Psychosocial, and Physical Health Summary scores were significantly lower for patients with LQTS and parent proxy reports (p ≤0.001). In general, PCQLI scores of patients with LQTS and parents were similar to those of patients with tetralogy of Fallot (p ≥0.2), lower than those of patients with bicuspid aortic valve (p ≤0.02), and higher than those of patients with single ventricle (p ≤0.03). Lower patient and parent PCQLI scores were associated with internalizing problems. For parents, the presence of a cardiac device and medication side effects were additionally associated with lower PCQLI scores. In conclusion, patients with LQTS and their parents report lower QOL than normal children secondary to physical and psychosocial factors. Increasing focus on the psychological well-being of these patients is needed in an effort to improve their QOL.

Quality of life in pediatric patients affected by electrophysiologic disease.

BACKGROUND: Treatment of electrophysiologic (EP) disease in pediatric patients has improved; however, the effects on quality of life (QOL) are unknown. OBJECTIVE: The purpose of this study was to compare QOL within EP disease groups and to other congenital heart diseases, to evaluate the effects of cardiac rhythm devices on QOL, and to identify drivers of QOL in EP disease. METHODS: Cross-sectional study of patient/parent proxy-reported Pediatric Cardiac Quality of Life Inventory scores (Total, Disease Impact, Psychosocial Impact) in subjects aged 8 to 18 years from 11 centers with congenital complete heart block (CCHB), ventricular tachycardia (VT), supraventricular tachycardia (SVT), and long QT syndrome (LQTS). QOL was compared between EP disease groups and congenital heart disease groups [bicuspid aortic valve (BAV), tetralogy of Fallot (TOF), and Fontan]. General linear modeling was used to perform group comparisons and to identify predictors of QOL variation. RESULTS: Among 288 patient-parent pairs, mean age was 12.8 ± 3.0 years. CCHB (µ = 83) showed higher patient Total QOL than other EP disease cohorts (P ≤ .02; LQTS µ = 73; SVT µ = 74). SVT (µ = 75) and LQTS (µ = 75) had lower patient Total scores than BAV (µ = 81; P ≤ .008). Patient/parent-proxy QOL scores for all EP disease groups were not different than TOF and higher than Fontan. The presence of a cardiac rhythm device was associated with lower QOL scores in LQTS (µ = 66 vs µ = 76; P < .01). Predictors of lower patient/parent-proxy QOL included EP disease type (P ≤ .03), increased medical care utilization (P ≤ .04), and no parental college degree (P ≤ .001). CONCLUSION: Given the significant variation in QOL in EP disease type, stratification by EP disease type and increased medical care utilization may allow for targeted interventions to improve QOL.

Reliability of grading retinal hemorrhages in abusive head trauma.

PURPOSE: To study the intra- and inter-observer reliability of pediatric ophthalmologists in grading retinal hemorrhages in abusive head trauma. METHODS: Pediatric ophthalmologists attending the 2009 annual meeting of the American Association for Pediatric Ophthalmology and Strabismus participated in an onsite survey. The participants were required to compare a collection of fundus photographs of patients with abusive head trauma to two standardized photographs, A and B. Participants graded photographs as normal (no retinal hemorrhages), better than A but not normal, same as A, between A and B, same as B, or worse than B. The survey was divided into four parts: part 1 consisted of 20 photographs to be graded; part 2 was a questionnaire about participant's professional experience; part 3 consisted of 20 photographs to be graded (including 15 graded in part 1 but reordered); and part 4 asked about the criteria used to grade the photographs. RESULTS: Of the 95 participants, 92 (97%) were licensed physicians with a mean of 14 years in practice. The intra-rater reliability was found to be high, with overall average of 85% pre- and post-agreement on the common pictures. Kendall's coefficient of concordance was used as the statistical measure of inter-rater reliability and had a high value (0.82). CONCLUSIONS: Pediatric ophthalmologists showed high intra- and inter-observer reliability in grading retinal hemorrhages in abusive head trauma.

Diabetes self-management profile short form: a preliminary report.

Effective family management of type 1 diabetes in childhood is critical to maintaining optimal glycemic control. The purpose of this study was to provide preliminary evidence for a reduced form of the Diabetes Self-Management Profile (DSMP) using Rasch modeling techniques. The study was a secondary analysis of DSMP data drawn from a previous study on patterns of self-management from 239 preadolescents with type 1 diabetes. Rasch modeling strategies were used to identify the most informative items and then a reduced score composite was correlated with hemoglobin A1c (A1c) and blood glucose monitoring (BGM) frequency. A short form of the DSMP was obtained using seven items that comprised all five subscales of the DSMP. The DSMP Short-Form (DSMP-SF) composite score correlated significantly with child's HbA1c and BGM frequency. The DSMP-SF may be considered a valid and effective screening interview alternative to the longer, original, DSMP, particularly when attempting to identify high-risk patients.

Trajectories of adherence to airway clearance therapy for patients with cystic fibrosis.

OBJECTIVE: Although cross-sectional studies have demonstrated poor adherence to airway clearance therapy (ACT) for patients with cystic fibrosis (CF), no studies have identified longitudinal patterns of adherence. The objective was to characterize and identify predictors of ACT adherence trajectories for individuals with CF. METHODS: Secondary data analyses were conducted for a randomized clinical trial examining differences in three ACTs. Participants (n = 153; M = 14.3 years, 55% male, 86% Caucasian, baseline FEV(1)% predicted: M = 86.7)/primary caregivers completed Daily Phone Diaries, an empirically supported adherence measure, every 4 months. RESULTS: Group-based trajectory modeling revealed the best-fitting solution was a three-group model: low-adherence (14%), medium-adherence (49%), and high-adherence (37%) groups. ACT type was the only significant predictor of adherence trajectories. DISCUSSION: Three trajectories of adherence to ACT for patients with CF were found. With the identification of trajectories, adherence interventions can be targeted for the subgroup at highest risk in order to prevent poor health outcomes.

Adherence to treatment among children with cardiac disease.

OBJECTIVE: Our purpose was to review the literature with respect to issues of adherence to treatment among children with congenital and acquired cardiac disease. MATERIALS AND METHODS: Databases used for this review included MEDLINE, Pub Med's Single Citation Manager, Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, and Google Scholar. We did not use any restrictions on date when locating peer-reviewed articles published worldwide through December of 2008. RESULTS: There exists a lack of published research regarding adherence to medical treatment for children with cardiac conditions. Of the few published studies, rates of adherence for children with congenital and acquired cardiac disease ranged from a high of 96% for an in-patient exercise programme, to a low of 33% among those who made all of their medical appointments. Risk factors for nonadherence included older age, one as opposed to two parents in the home, lack of emotional availability of parents, smoking, sedentary lifestyle, use of illicit drugs, presence of tattoos, and multiple body piercings. Clinical outcomes associated with non adherence in the population of children undergoing transplantation included mortality, acute episodes of rejection, lower levels of Cyclosporine A, and lower values for the International Normalised Ratio of prothrombin. CONCLUSIONS: For children with congenital and acquired heart disease, the challenges of adherence to treatment can often be overwhelming. Recommendations designed to maximize the impact and scientific rigour of future studies include obtaining quantitative and qualitative measures of adherence, identifying primary and secondary endpoints, emphasizing factors of interest, planning studies with sufficient power to impact on the adherence to treatment, and developing epidemiologic foundations.