Further recommendations of the International Paediatric Brain Injury Society (IPBIS) for the post-acute rehabilitation of children with acquired brain injury.

BACKGROUND: Paediatric acquired brain injury is a life-long condition which impacts on all facets of the individual's lived experience. The existing evidence base continues to expand and new fields of enquiry are established as clinicians and researchers uncover the extent of these impacts. PRIMARY OBJECTIVE: To add to recommendations described in the International Paediatric Brain Injury Society's 2016 paper on post-acute care for children with acquired brain injury and highlight new areas of enquiry. REVIEW OF INFORMATION: Recommendations were made based on the opinions of a group of experienced international clinicians and researchers who are current or past members of the board of directors of the International Paediatric Brain Injury Society. The importance of each recommendation was agreed upon by means of group consensus. OUTCOMES: This update gives new consideration to areas of study including injuries which occur in pre-school children, young people in the military, medical referral, young offenders and the use of technology in rehabilitation.

Head injury among older adults and their clinical management: one year of emergency department attendances at a UK trauma center.

OBJECTIVES: Primary: describe characteristics of adults aged ≥65 attending the Emergency Department (ED) at one major trauma center. Secondary: examine co-morbidities and complications; identify use of anticoagulant/antiplatelet medication among older adults presenting with Head Injury (HI); assess clinical management against UK guidelines. METHODS: All ED admissions were screened prospectively to identify HI using case notes, hospital records and Trauma Audit Research Network data. Data were collected on demographics, cause and severity of injury, co-morbidities, anticoagulation/antiplatelet use, diagnostic imaging and discharge outcomes. RESULTS: Over 12 months, 697 patients aged ≥65 years attended the ED for HI, representing over a quarter of adult ED attendances for HI. Mean age was 78.5 years (range 65-106), 395 (56.7%) were female. Most HIs were mild (93.5%) and 86% caused by falls. Three-quarters were discharged without hospital admission. Most had a preexisting medical condition andtaking medications prior to HI. Of these 116 were taking anticoagulants/antiplatelets but only 37 (31.9%) received a head CT scan. Half the patients were given a written HI information sheet at ED discharge. CONCLUSIONS: Care of HI in older adults is challenging due to comorbidities. Practising evidence-based clinical management and following guidelines is important, but strict adherence is not common practice.

Risk of Motor Vehicle Collision or Driving Impairment After Traumatic Brain Injury: A Collaborative International Systematic Review and Meta-Analysis.

OBJECTIVE: To synthesize knowledge of the risk of motor vehicle collision (MVC) following a traumatic brain injury (TBI) and the associated risk of driving impairment, as measured by on-road tests, computerized simulators, and self-reported or state-recorded driving records. METHODS: Our international team searched 7 databases for studies published between 1990 and 2015 of people with TBI, controls, and data concerning either MVC or driving impairment. The included articles examined the risk of MVC among people with TBI; we excluded studies that examined the risk of having a TBI associated with being involved in an MVC. RESULTS: From 13 578 search results, we included 8 studies involving 1663 participants with TBI and 4796 controls. We found no significant difference in the risk of MVC (odds ratio = 1.24, 95% confidence interval = 0.80-1.91, P = .34). When we restricted the analysis to self-report, the risk of MVC was higher for those without a TBI (odds ratio = 1.63, 95% confidence interval = 1.21-2.22, P = .002). In contrast, participants with TBI consistently performed worse during on-road assessments and had more problems with vehicular control. CONCLUSION: Limitations of reviewed studies included small sample sizes, failure to specify TBI severity or time postinjury, and absence of objective measures of risk. Findings concerning the relationship between TBIs from non-MVC causes and crash risk are, therefore, inconclusive and do not provide evidence for major changes to existing clinical guidelines for driving with TBI.

Self-awareness following a traumatic brain injury in childhood: a developmental perspective.

Impaired self-awareness is a common consequence following a brain injury that affects engagement in rehabilitation and results in poor long term functional outcomes. Literature regarding self-awareness following a brain injury in childhood is lacking. The aim of this research study was to understand the self-awareness of deficits from a developmental perspective. METHODS: A multiple case study design with fully integrated mixed methodology (QUAN+QUAL). Fifteen children/young people (CYP) with traumatic brain injury (TBI) (5-17 years; 10 male) were recruited and data were collected from CYP, their parents and teachers. Self-report measures included Strengths and Difficulties Questionnaire and Harter Scales. Interview measures included Self-Understanding Interview and Knowledge Interview for Children. A novel method of analysis compared CYP report to parent/teacher report and to normative children's data. Three exemplars showcase this methodology. RESULTS: Within-case and cross-case analysis identified interrupted development of self-awareness following TBI. CYP ratings differed most from parent/teacher ratings in the social and behavioural domains. In relation to the school/learning and physical domains, CYP ratings differed most from normative children's data. The younger children had greater degree of ratings discrepancy across all domains. Seven key themes were aspirations, beliefs, being different, brain injuries, characteristics, participation, and interpersonal interactions and relationships. CONCLUSION: This study is among the first to describe the complexity of self-awareness across a range of functional domains following a brain injury in childhood. New theoretical and clinical perspectives are presented from understanding the importance of typical development and the child's age at injury.

Traumatic brain injuries in older adults-6 years of data for one UK trauma centre: retrospective analysis of prospectively collected data.

OBJECTIVES: Our aim was to determine the incidence of traumatic brain injury (TBI) in older adults and investigate the relationship between injury characteristics and outcomes. METHODS: Retrospective analysis of prospectively collected data submitted to Trauma Audit and Research Network (TARN) database for a major trauma centre in the West Midlands, UK, from 2008 to 2014. The Mayo Scale was used to categorise TBI. All patients were aged ≥65 years and were admitted with head or brain injuries meeting TARN inclusion criteria: injury resulting in immediate admission to hospital for 3 days, admitted to a high dependency area or death following trauma. We determined age, gender, mechanism of injury, Injury Severity Score, presenting Glasgow Coma Scale (GCS) and Mayo Score, and the association of outcome (Glasgow Outcome Scale (GOS)) with age and clinical presentation. RESULTS: 4413 patients were admitted with trauma meeting TARN criteria: 1389 were ≥65 years and 45% (624) had TBI. For patients ≥65 years with TBI, mean age was 79 (range 65-99); 56% were men. Falls accounted for 85% of all TBIs. Most TBIs were moderate/severe (80%) by the Mayo criteria. Of the 279 patients with subdural haematoma, 28% had neurosurgery. Most patients survived TBI (78%); 57% had a good outcome on GOS at discharge (not requiring care package). Mortality was associated with increased age (17% in ages 65-74 years, 19% in 75-84 years, 30% in ≥85 years, p=0.03). Outcome was significantly associated with injury severity (p=0.0001). CONCLUSIONS: Patients with TBI represented 45% of all trauma cases meeting TARN inclusion criteria. Falls at home accounted for most TBIs. Most had moderate/severe TBI, yet over half made a good recovery on GOS. Our data indicate that injury prevention initiatives should focus on home safety. Further research is needed to examine rehabilitation and follow-up after hospital discharge.

Technological aids for the rehabilitation of memory and executive functioning in children and adolescents with acquired brain injury.

BACKGROUND: The use of technology in healthcare settings is on the increase and may represent a cost-effective means of delivering rehabilitation. Reductions in treatment time, and delivery in the home, are also thought to be benefits of this approach. Children and adolescents with brain injury often experience deficits in memory and executive functioning that can negatively affect their school work, social lives, and future occupations. Effective interventions that can be delivered at home, without the need for high-cost clinical involvement, could provide a means to address a current lack of provision.We have systematically reviewed studies examining the effects of technology-based interventions for the rehabilitation of deficits in memory and executive functioning in children and adolescents with acquired brain injury. OBJECTIVES: To assess the effects of technology-based interventions compared to placebo intervention, no treatment, or other types of intervention, on the executive functioning and memory of children and adolescents with acquired brain injury. SEARCH METHODS: We ran the search on the 30 September 2015. We searched the Cochrane Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic + EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), CINAHL Plus (EBSCO), two other databases, and clinical trials registers. We also searched the internet, screened reference lists, and contacted authors of included studies. SELECTION CRITERIA: Randomised controlled trials comparing the use of a technological aid for the rehabilitation of children and adolescents with memory or executive-functioning deficits with placebo, no treatment, or another intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed titles and abstracts identified by the search strategy. Following retrieval of full-text manuscripts, two review authors independently performed data extraction and assessed the risk of bias. MAIN RESULTS: Four studies (involving 206 participants) met the inclusion criteria for this review.Three studies, involving 194 participants, assessed the effects of online interventions to target executive functioning (that is monitoring and changing behaviour, problem solving, planning, etc.). These studies, which were all conducted by the same research team, compared online interventions against a 'placebo' (participants were given internet resources on brain injury). The interventions were delivered in the family home with additional support or training, or both, from a psychologist or doctoral student. The fourth study investigated the use of a computer program to target memory in addition to components of executive functioning (that is attention, organisation, and problem solving). No information on the study setting was provided, however a speech-language pathologist, teacher, or occupational therapist accompanied participants.Two studies assessed adolescents and young adults with mild to severe traumatic brain injury (TBI), while the remaining two studies assessed children and adolescents with moderate to severe TBI. Risk of biasWe assessed the risk of selection bias as low for three studies and unclear for one study. Allocation bias was high in two studies, unclear in one study, and low in one study. Only one study (n = 120) was able to conceal allocation from participants, therefore overall selection bias was assessed as high.One study took steps to conceal assessors from allocation (low risk of detection bias), while the other three did not do so (high risk of detection bias). Primary outcome 1: Executive functioning: Technology-based intervention versus placeboResults from meta-analysis of three studies (n = 194) comparing online interventions with a placebo for children and adolescents with TBI, favoured the intervention immediately post-treatment (standardised mean difference (SMD) -0.37, 95% confidence interval (CI) -0.66 to -0.09; P = 0.62; I(2) = 0%). (As there is no 'gold standard' measure in the field, we have not translated the SMD back to any particular scale.) This result is thought to represent only a small to medium effect size (using Cohen's rule of thumb, where 0.2 is a small effect, 0.5 a medium one, and 0.8 or above is a large effect); this is unlikely to have a clinically important effect on the participant.The fourth study (n = 12) reported differences between the intervention and control groups on problem solving (an important component of executive functioning). No means or standard deviations were presented for this outcome, therefore an effect size could not be calculated.The quality of evidence for this outcome according to GRADE was very low. This means future research is highly likely to change the estimate of effect. Primary outcome 2: MemoryOne small study (n = 12) reported a statistically significant difference in improvement in sentence recall between the intervention and control group following an eight-week remediation programme. No means or standard deviations were presented for this outcome, therefore an effect size could not be calculated. Secondary outcomesTwo studies (n = 158) reported on anxiety/depression as measured by the Child Behavior Checklist (CBCL) and were included in a meta-analysis. We found no evidence of an effect with the intervention (mean difference -5.59, 95% CI -11.46 to 0.28; I(2) = 53%). The GRADE quality of evidence for this outcome was very low, meaning future research is likely to change the estimate of effect.A single study sought to record adverse events and reported none. Two studies reported on use of the intervention (range 0 to 13 and 1 to 24 sessions). One study reported on social functioning/social competence and found no effect. The included studies reported no data for other secondary outcomes (that is quality of life and academic achievement). AUTHORS' CONCLUSIONS: This review provides low-quality evidence for the use of technology-based interventions in the rehabilitation of executive functions and memory for children and adolescents with TBI. As all of the included studies contained relatively small numbers of participants (12 to 120), our findings should be interpreted with caution. The involvement of a clinician or therapist, rather than use of the technology, may have led to the success of these interventions. Future research should seek to replicate these findings with larger samples, in other regions, using ecologically valid outcome measures, and reduced clinician involvement.

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.

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.

Management of minor head injury in adults.

Head injury accounts for up to 20 per cent of emergency department (ED) attendances (Kay and Teasdale 2001), and approximately 800,000 patients attend U.K. EDs with head injuries every year (National Institute for Health and Clinical Excellence (NICE) 2007a, Scottish Intercollegiate Guidelines Network (SIGN) 2009). About 90 per cent of these patients have a mild or minor head injury and are managed in EDs before being discharged home (Swann and Teasdale 1999). NICE in England and Wales and SIGN in Scotland have issued guidelines for the early management of head injury in adults in an attempt to improve clinical practice. This article discusses the important role of emergency nurses, particularly with regard to discharge information and advice for patients, relatives and carers.

Early management of children with minor head injuries.

In the UK, about 260,000 children with head injuries attend emergency departments each year (National Institute for Health and Clinical Excellence (NICE) 2007, Scottish Intercollegiate Guidelines Network (SIGN) 2009). About 90 per cent of these injuries are minor and can be managed without admission to hospital (Swann and Teasdale 1999). Clinical guidelines for early management of head injury have recently been published by NICE in England and Wales, and by SIGN in Scotland, to standardise management across the UK. This article discusses the role of emergency nurses in implementing these guidelines.

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.

Epidemiology of paediatric minor head injury: Comparison of injury characteristics with Indices of Multiple Deprivation.

BACKGROUND: Head injury (HI) is a common presentation to Child Emergency Departments (CEDs), but the actual number of children attending with minor HI is unclear. Most research has focussed on admitted patients, often relying on hospital-coded admission data. We studied the incidence of minor HI presenting to the CED of a major teaching hospital in Coventry and Warwickshire. HI attendances were compared with population data to identify injury patterns relating to deprivation. METHODS: All CED admissions were screened by the research team, and data on minor head injuries (GCS 13-15) collected prospectively from 1st January until 31st August 2011. Information was collected on demographics, ethnicity, cause and severity of injury, injury location (in or outside the home), other injuries and mode of arrival. Deprivation data were obtained by cross-referencing postcodes with English Indices of Multiple Deprivation (IMD 2010). For comparison, the hospital audit department provided figures for coded head injuries during the same period. RESULTS: During the 8 month period, hand-searching identified 1747 children with minor HI, aged between 0 and 16 years. Of these 99% had minimal HI (GCS 15 or 'alert'). In the same period, hospital-coded minor HIs numbered only 1081. HIs formed 9% of all CED attendances. Thirteen children returned to the CED with worrying symptoms after discharge home. Approximately 3.4% of the local paediatric population attend the CED with HI per year (3419/100,000 population). Falls accounted for 62% of HIs overall, rising to 77% in children aged 0-5. Most in-home head injuries (81%) were the result of falls (p<0.0001). Significantly more injuries took place inside the home for 0-5 year olds (58%) than for older children (20%) (p<0.0001). Children living in the most deprived areas were more likely to attend the CED with HI (RR: 1.19; CI: 1.06-1.35, p=0.004), and arrive using emergency services (OR: 1.77; CI: 1.30-2.40, p<0.001). There were no significant differences between the deprived and non-deprived groups for location or cause of injury. CONCLUSIONS: Young children are particularly at risk of HI and parents should be offered information on injury prevention. More children from deprived areas attended with HI and these families may benefit most from targeted interventions.

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.

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.

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.