White matter microstructure predicts longitudinal social cognitive outcomes after paediatric traumatic brain injury: a diffusion tensor imaging study.

BACKGROUND: Deficits in social cognition may be among the most profound and disabling sequelae of paediatric traumatic brain injury (TBI); however, the neuroanatomical correlates of longitudinal outcomes in this domain remain unexplored. This study aimed to characterize social cognitive outcomes longitudinally after paediatric TBI, and to evaluate the use of sub-acute diffusion tensor imaging (DTI) to predict these outcomes. METHODS: The sample included 52 children with mild complex-severe TBI who were assessed on cognitive theory of mind (ToM), pragmatic language and affective ToM at 6- and 24-months post-injury. For comparison, 43 typically developing controls (TDCs) of similar age and sex were recruited. DTI data were acquired sub-acutely (mean = 5.5 weeks post-injury) in a subset of 65 children (TBI = 35; TDC = 30) to evaluate longitudinal prospective relationships between white matter microstructure assessed using Tract-Based Spatial Statistics and social cognitive outcomes. RESULTS: Whole brain voxel-wise analysis revealed significantly higher mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) in the sub-acute TBI group compared with TDC, with differences observed predominantly in the splenium of the corpus callosum (sCC), sagittal stratum (SS), dorsal cingulum (DC), uncinate fasciculus (UF) and middle and superior cerebellar peduncles (MCP & SCP, respectively). Relative to TDCs, children with TBI showed poorer cognitive ToM, affective ToM and pragmatic language at 6-months post-insult, and those deficits were related to abnormal diffusivity of the sCC, SS, DC, UF, MCP and SCP. Moreover, children with TBI showed poorer affective ToM and pragmatic language at 24-months post-injury, and those outcomes were predicted by sub-acute alterations in diffusivity of the DC and MCP. CONCLUSIONS: Abnormal microstructure within frontal-temporal, limbic and cerebro-cerebellar white matter may be a risk factor for long-term social difficulties observed in children with TBI. DTI may have potential to unlock early prognostic markers of long-term social outcomes.

A preliminary investigation into psychosocial outcome and quality-of-life in adolescents following childhood traumatic brain injury.

OBJECTIVE: This study investigated the long-term psychosocial outcome and quality-of-life (QoL) of 15-18 year olds, sustaining childhood traumatic brain injury (TBI) between birth and 5 years. METHOD: Thirty-three participants (17 TBI parent-proxies, 16 control parent-proxies) were involved in the present study which compared parent-ratings for the TBI group and healthy controls on the Sydney Psychosocial Reintegration Scale-Child form (SPRS-C) and the Paediatric Quality of Life Inventory (PedsQL). RESULTS: Despite comparable overall psychosocial reintegration scores, parents reported that their teens with TBI were more likely to experience poor QoL compared to controls. On further analysis, some aspects of psychosocial outcome appear to be compromised following childhood TBI. CONCLUSIONS: Interventions targeting childhood TBI must consider QoL in addition to symptom reduction and be extended throughout adolescence. The limitations of the sample size are cause for concern; however, preliminary results do validate the need for future research efforts.

Social function assessment tools for children and adolescents: a systematic review from 1988 to 2010.

Advances in neuroscience have added to the understanding of social functioning which has become an increasing area of focus in the psychology and neuropsychology literature. Given importance of appropriate social functioning to everyday interactions, as well as psychological well-being, accurately identifying and documenting such functions constitute a critical undertaking for both researchers and clinicians in psychology and related health professions. This review aimed to identify available social function assessment tools for children and adolescents using a comprehensive search method. Eighty-six measures were identified. Information on the assessment tools including the theoretical model they are based on, age range, sample used in development, and psychometric information are described. Results will aid researchers, psychologists and other health professionals in the selection of an appropriate tool to assess social function.

Hippocampus, amygdala and global brain changes 10 years after childhood traumatic brain injury.

Traumatic brain injury (TBI) in children results in damage to the developing brain, particularly in severely injured individuals. Little is known, however, of the long-term structural aspects of the brain following childhood TBI. This study investigated the integrity of the brain 10 years post-TBI using magnetic resonance imaging volumetrics in a sample of 49 participants with mild, moderate and severe TBI, evaluated against a normative sample of 20 individuals from a pediatric database with comparable age and gender distribution. Structural integrity was investigated in gray and white matter, and by manually segmenting two regions of interest (hippocampus, amygdala), potentially vulnerable to the effects of childhood TBI. The results indicate that more severe injuries caused a reduction in gray and white brain matter, while all TBI severity levels resulted in increased volumes of cerebrospinal fluid and smaller hippocampal volumes. In addition, enlarged amygdala volumes were detected in severely injured patients compared to their mild and moderate counterparts, suggesting that childhood TBI may disrupt the development of certain brain regions through diffuse pathological changes. The findings highlight the lasting impact of childhood TBI on the brain and the importance of monitoring brain structure in the long-term after early injury.

Planning, problem-solving and organizational abilities in children following traumatic brain injury: intervention techniques.

Due to the mechanisms involved in traumatic brain injury (TBI), the frontal lobes are often impacted. As the frontal regions of the brain are believed to subsume executive functioning, then it follows that post-TBI deficits may be seen in this domain. Executive functioning broadly refers to a set of inter-related skills necessary to maintain an appropriate problem-solving set for the attainment of a future goal and may include areas such as attentional control, planning, problem-solving, cognitive flexibility, abstraction and information processing. The literature available on interventions for executive difficulties following TBI is minimal, with that focused on the paediatric population even more limited. From the few evaluation studies available, results tend to suggest that specific types of intervention lead to positive outcomes. However, as the interventions are few and often based on case studies, there is much need for more evaluation studies to be conducted.

Attentional and processing skills following traumatic brain injury in early childhood.

PRIMARY OBJECTIVE: Attentional deficits are common following TBI in adults. This study examined whether these skills are also vulnerable following early childhood injury, when such skills are rapidly developing. RESEARCH DESIGN: This study investigated attention 30 months post-TBI in pre-schoolers (n=56) and age-matched controls (n=26). TBI children were divided into mild, moderate and severe injury groups. METHODS AND PROCEDURE: Pre-injury data were collected at time of injury. Assessment of attention included the Continuous Performance Test, Wechsler Intelligence Scale and Personality Inventory for Children. MAIN OUTCOMES AND RESULTS: Severe TBI was associated with reduced accuracy and slowed processing, particularly on complex motor responses. Sustained attention was more intact. Parental reports indicate internalized behavioural problems and somatic complaints. CONCLUSIONS: Young children with severe TBI are at risk for severe, persisting attentional impairments. Children with mild and moderate TBI show better outcome, with pre-injury behaviour and age also predictive of attentional skills at 30 months post-injury.

Recovery of executive skills following paediatric traumatic brain injury (TBI): a 2 year follow-up.

PRIMARY OBJECTIVE: Disruptions to executive function (EF) may occur as a result of traumatic brain injury (TBI), in the context of direct damage to frontal regions or in association with disruption of connections between these areas and other brain regions. Little investigation of EF has occurred following TBI during childhood and there is little evidence of possible recovery trajectories in the years post-injury. The present study aimed to (i) examine whether a dose-response relationship exists between injury severity and EF; (ii) document recovery of EF in the 2 years post-injury and (iii) determine any additional predictors of outcome in the domain of EF. RESEARCH DESIGN: The study employed a prospective, longitudinal design, with participants recruited at time of injury and followed over a 2-year period. METHODS AND PROCEDURES: The study examined EF in a group of 69 children who had sustained a mild, moderate or severe TBI. Four components of EF were assessed: (i) attentional control; (ii) planning, goal setting and problem solving; (iii) cognitive flexibility; and (iv) abstract reasoning. OUTCOMES AND RESULTS: Results showed that, while children with severe TBI performed most poorly during the acute stage post-injury, they exhibited greatest recovery of EF over a 24-month period. Regardless, functional deficits remained most severe for this group 2 years post-injury. Results demonstrated the multi-dimensional nature of EF and the differential recovery of skills, following childhood TBI. Pre-injury ability and age at injury were identified as significant predictors of EF and functional skills. CONCLUSIONS: Children sustaining severe TBI at a young age are particularly vulnerable to impairments in EF. While these difficulties do show some recovery with time since injury, long-term deficits remain and may impact on ongoing development.

Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children.

OBJECTIVE: To examine the contributions of injury severity, physical and cognitive disability, child and family function to outcome 30 months after traumatic brain injury (TBI) in children. DESIGN: A prospective, longitudinal, between group design, comparing function before and after injury across three levels of injury severity. SUBJECTS: One hundred and fifty children, 3.0-12.11 years old, admitted to hospital with a diagnosis of TBI. The sample was divided according to injury severity: mild (n = 42), moderate (n = 70), severe (n = 38). Children with a history of neurological, developmental, and psychiatric disorders were excluded from participation. MAIN OUTCOME MEASURES: Post injury physical function, cognitive ability (incorporating intellect, memory, and attention), behavioural and family functioning, and level of family burden. RESULTS: A dose-response relation was identified for injury severity and physical and cognitive outcome, with significant recovery documented from acute to six months after TBI. Behavioural functioning was not related to injury severity, and where problems were identified, little recovery was noted over time. Family functioning remained unchanged from preinjury to post injury assessments. The level of family burden was high at both six and 30 months after injury, and was predicted by injury severity, functional impairment, and post injury child behavioural disturbance. CONCLUSIONS: These results suggest ongoing problems for the child and significant family burden 30 months after TBI. The nature and severity of the physical and cognitive problems are closely related to injury severity, with child and family function predicted by psychosocial and premorbid factors.

Predictors of acute child and family outcome following traumatic brain injury in children.

OBJECTIVE: To examine the relative contributions of injury severity, level of physical and cognitive disability, child behavior and family function to short-term outcome 6 months following traumatic brain injury (TBI) in children. DESIGN: Prospective, longitudinal, between-group design, comparing preinjury and postinjury measures of functional outcome across three levels of injury severity. SUBJECTS: One hundred and twelve children, aged 2-12 years admitted to the Royal Children's Hospital, Melbourne, with a diagnosis of TBI. The sample was divided into three groups, according to injury severity: mild TBI (n = 31), moderate TBI (n = 52) and severe TBI (n = 29). Children with a history of neurologic, developmental and psychiatric disorder were excluded from participation. MAIN OUTCOME MEASURES: Levels of postinjury functioning in the following domains: physical function, cognitive ability (incorporating intellect, memory and attention), behavioral and family functioning, and level of family burden. RESULTS: A clear dose-response relationship for physical and cognitive outcomes was found, with severe TBI associated with greater impairment of physical, intellectual, memory and attentional function. For psychosocial outcome, results were less clearly linked to injury severity. Preinjury behavioral and family functioning were closely related to postinjury function in these domains, with an interaction identified between family function and child behavior at 6 months postinjury. Family functioning remained unchanged postinjury, although level of burden was high, and predicted by injury severity, functional impairment and postinjury behavioral disturbance. CONCLUSIONS: These results suggest ongoing functional problems for the child and significant family burden 6 months following TBI. The nature and severity of physical and cognitive problems are most closely related to injury severity, with family functioning and child behavior better predicted by psychosocial and premorbid factors.

Development of executive functions through late childhood and adolescence in an Australian sample.

Although there have been significant theoretical advances in the field of child neuropsychology, developmental features of adolescence have received less attention. Progress in clinical practice is restricted due to a lack of well-standardized, developmentally appropriate assessment techniques. This article addresses these issues in relation to executive skills. These abilities are targeted for 2 reasons: first, because they are often considered to be mature during late childhood and adolescence, despite limited investigation in this age range; and second, because of their central importance to efficient day-to-day functioning. Using a normative sample of 138 children, aged 11.0 to 17.11 years, this article plots the development of executive skills through late childhood and early adolescence and interprets progress in these skills with reference to current neurological and cognitive theory.

Outcome from mild head injury in young children: a prospective study.

There is a lack of agreement regarding the long-term consequences of mild head injury (HI) at any age, with such effects rarely studied in early childhood. Given the rapid development occurring within the brain during this period, any disruption may have the potential to cause transient or permanent damage to brain structure and function. The present study sought to investigate the behavioral implications of such potential disruptions using a prospective, longitudinal design. Children aged 3-7 years at the time of injury, and suffering from mild HI, were evaluated acutely and at 6 and 30 months post-injury. Pre-injury data were collected with respect to communication, social skills, daily living skills and behavioral function. Results were compared to those from a non-injured control sample matched for age, gender, socioeconomic status, and pre-injury function. Findings showed few group differences. Children with mild HI performed similarly to controls on measures of intellectual ability, receptive language, and both everyday and spatial memory capacity. Group differences were identified for verbal fluency and story recall, with HI children failing to recover over time.

Recovery of intellectual ability following traumatic brain injury in childhood: impact of injury severity and age at injury.

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine the relationship between recovery, injury severity, age at injury and pre-injury ability. 124 children were divided according to (1) age at injury: 'young' (3-7 years) 'old' (8-12) and (2) injury severity (mild, moderate, severe). Children were evaluated acutely (T1) and at 12 months post-injury (T2), using standardized intellectual measures (IQ). Results showed a relationship between greater injury severity and poorer IQ. Age at injury was not predictive of outcome for children with mild/moderate TBI. For severe TBI, younger age at injury led to minimal recovery in IQ, while recovery from later injury was similar to that for adults. Findings suggest that children sustaining severe TBI in early childhood may be particularly at risk for residual problems post-injury.

Recovery of memory function following traumatic brain injury in pre-school children.

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre school period. Ninety-six children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 35). Children were evaluated acutely and at 6,12 and 18 months post-injury using intellectual and memory measures. Results showed a relationship between greater injury severity and poorer intellectual ability. This dose-response relationship was not clearly evident for memory function within the acute phase of recovery, but developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems. Findings are discussed in the context of theories of plasticity and recovery of function.

A prospective analysis of the recovery of attention following pediatric head injury.

Little is known about specific attentional sequelae following a closed head injury, their pattern of recovery or their interaction with ongoing development. The present study examined attentional abilities in a group of children who had sustained a mild, moderate, or severe head injury. Results showed that the severe head injury group exhibited greater deficits on a number of attentional measures at acute and 6 months postinjury phases, in comparison to children in the mild and moderate head injury groups. Specifically, deficits were most evident on timed tasks where speed of processing was an integral component. Difficulties persisted to at least 6 months postinjury and so may lead to cumulative deficits over time.

Attentional skills in the acute phase following pediatric traumatic brain injury.

Only a limited number of studies have investigated attention following pediatric head-injury. The present study examined sustained attention and processing speed in a group of children who had sustained a mild (n = 27), moderate (n = 33) or severe (n = 16) traumatic brain injury (TBI). No significant differences were evident between the TBI groups on reaction time measures. Results did show that the severe TBI group exhibited greater deficits in the area of sustained attention, in comparison to children with mild and moderate injuries, in the acute stage following traumatic brain injury. This difficulty may impact on the future development of skills dependent on intact attentional capacity.

Early effects of traumatic brain injury on young children's language performance: a preliminary linguistic analysis.

Language skills undergo rapid development during the early childhood years, so that by the time children start school they are competent communicators with well established syntactic, semantic and pragmatic abilities for their age. Little is known about the effects of traumatic brain injury (TBI) on the acquisition of these language skills during the early childhood years. This study used a prospective, cross-sectional design to compare the language abilities of young children following their head injury. Fifteen brain injured children, aged between 4-6 years, were divided into three injury groups depending on severity of injury, i.e. mild, moderate and severe, and compared with a matched community control group. They were assessed within 3 months of sustaining their injury on a range of expressive and receptive language tests, and free speech conversation samples, which were analysed pragmatically and syntactically. Results indicated that the severe group performed most poorly on language tasks. It is suggested that linguistic evaluation is an important component of follow up at least for the severe head injured population.

The development of pragmatic communication skills in head injured children.

This study investigated the developmental levels of pragmatic language skills in children following head injury (HI), in comparison to their uninjured peers. Participants were 30 head-injured and 19 healthy controls, classified into a 'young' age group, 8-9 years, and an 'old' age group, 11-12 years. Participants were administered the WISC- III, a negotiating requests task and a hint task, the latter two assessing verbal reasoning skills and abilities to be indirect, respectively. It was found that negotiation and hinting strategies were rapidly developing in these age groups, where abilities to hint were less mature for all groups. Results found a main effect for injury on cognitive and functional language tasks, reflected by lower performance levels and inflexibility in reasoning for the head-injured group. Injury sustained at an earlier age consistently predicted poorer performance on the language tasks, complicating the ongoing development of generalized and higher-order communicative skills. Severity of injury did not predict performance on either language task.

Recovery of educational skills following paediatric traumatic brain injury.

Academic success in the classroom is often dependent upon a child's ability in the areas of literacy, such as reading and spelling, and arithmetic. Following traumatic brain injury these skills are often compromised. The present study examined the recovery of educational skills (reading accuracy, reading comprehension, spelling and arithmetic) over 24 months post-injury, in a group of children who had sustained a mild, moderate or severe TBI. Results showed that the severe TBI group exhibited greater deficits on reading comprehension and arithmetic, while the moderate and severe TBI groups performed similarly in the areas of reading accuracy and spelling. Future research is required to further investigate predictors of educational outcome post-TBI.

Functional memory skills following traumatic brain injury in young children.

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre-school period. Forty-four children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 26). Children were evaluated acutely and at 12 months post-injury using the Rivermead Behavioural Memory Test for Children. Results failed to show a clear dose-response relationship between injury severity and memory function during the acute phase of recovery. However, this relationship developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems.

Childhood bacterial meningitis: impact of age at illness and acute medical complications on long term outcome.

This study compared postmeningitic children (N = 130) with grade and sex matched controls (N = 130) selected from target children's schools on measures of intellectual, linguistic, learning, and reading skills. Results showed that children with a history of meningitis are at greater risk for impairment in these areas, with experience of the disease prior to 12 months of age being an important risk factor. Within the postmeningitic sample presence of medical complications was associated with poorer verbal abilities. Finally, a significant relationship was identified between depressed language skills and later educational difficulty, with these findings interpreted with respect to both developmental and neuropsychological principles.