Linda Ewing-Cobbs

Neuroimaging, Physical, and Developmental Findings After Inflicted and Noninflicted Traumatic Brain Injury in Young Children

Objective. To characterize neuroimaging, physical, neurobehavioral, and developmental findings in children with inflicted and noninflicted traumatic brain injury (TBI) and to identify characteristic features of inflicted TBI. Methods and Patients. Forty children, 0 to 6 years of age, hospitalized for TBI who had no documented history of previous brain injury were enrolled in a prospective longitudinal study. TBI was categorized as either inflicted (n = 20) or noninflicted (n = 20) based on the assessment of hospital and county protective services. Glasgow Coma Scale scores and neonatal history were comparable in both groups. Outcome Measures. Acute computed tomography/magnetic resonance imaging studies and physical findings were evaluated. Glasgow Outcome Scale scores, cognitive development, and motor functioning were assessed an average of 1.3 months after TBI. χ2 analyses assessed differences in the distribution of findings in the inflicted and noninflicted TBI groups. Results. Signs of preexisting brain injury, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly, were present in 45% of children with inflicted TBI and in none of the children with noninflicted TBI. Subdural hematomas and seizures occurred significantly more often in children with inflicted TBI. Intraparenchymal hemorrhage, edema, skull fractures, and cephalohematomas were similar in both groups. Retinal hemorrhage was only identified in the inflicted TBI group. Glasgow Outcome Scale scores indicated a significantly less favorable outcome after inflicted than noninflicted TBI. Mental deficiency was present in 45% of the inflicted and 5% of the noninflicted TBI groups. Conclusions. Characteristic features of inflicted TBI included acute computed tomography/magnetic resonance imaging findings of preexisting brain injury, extraaxial hemorrhages, seizures, retinal hemorrhages, and significantly impaired cognitive function without prolonged impairment of consciousness.

Behavioral Changes After Closed Head Injury in Children

This study provides a longitudinal follow-up of the behavioral adjustment of 45 children with mild, moderate, and severe closed head injuries. Two measures of behavioral adjustment, the Child Behavior Checklist (CBCL) and the Vineland Adaptive Behavior Scales (VABS), were obtained from a parent at the time of injury and at 6 and 12 months postinjury. The severely injured children obtained significantly poorer VABS scores than children with mild and moderate injuries over the year-long follow-up. In addition, on the CBCL, severely injured children had more school problems and engaged in fewer social activities than mild and moderately injured children. These results show that severe head injury in children was associated with declines in adaptive functioning, whereas scores for children with mild and moderate injuries did not differ, nor did they deviate from average levels at any follow-up interval. Language: en

Modeling of longitudinal academic achievement scores after pediatric traumatic brain injury

In a prospective longitudinal study, academic achievement scores were obtained from youth 5 to 15 years of age who sustained mild-moderate (n = 34) or severe (n = 43) traumatic brain injuries (TBI). Achievement scores were collected from baseline to 5 years following TBI and were subjected to individual growth curve analysis. The models fitted age at injury, years since injury, duration of impaired consciousness, and interaction effects to Reading Decoding, Reading Comprehension, Spelling, and Arithmetic standard scores. Although scores improved significantly over the follow-up relative to normative data from the standardization sample of the tests, children with severe TBI showed persistent deficits on all achievement scores in comparison to children with mild-moderate TBI. Interactions of the slope and age parameters for the Arithmetic and Reading Decoding scores indicated greater increases over time in achievement scores of the children injured at an older age, but deceleration in growth curves for the younger children with both mild-moderate and severe TBI. These results are compatible with the hypothesis that early brain injuries disrupt the acquisition of some academic skills. Hierarchical regression models revealed that indexes of academic achievement obtained 2 years following TBI had weak relations with the duration of impaired consciousness and socioeconomic status. In contrast, concurrent cognitive variables such as phonological processing and verbal memory accounted for more variability in academic scores. Given the significant and persistent decrement in basic academic skills in youth with severe TBI, it is clear that head-injured youth require intensive, long-term remediation and intervention not only of the academic skills themselves, but also of those cognitive abilities that support the development and maintenance of reading and math.

Narrative Discourse after Closed Head Injury in Children and Adolescents

This study examined narrative discourse in 20 children and adolescents at least 1 year after sustaining a head injury. Narratives were analyzed along the dimensions of language structure, information structure, and flow of information. Severity of impaired consciousness was associated with a significant reduction in the amount of language and information. The most important finding which emerged was the disruption in information structure. This pattern confirms the impression of disorganized discourse in severely injured children. Explanations for the disruption in information structure are explored in terms of the role of vocabulary, memory, and localization of lesion according to magnetic resonance imaging. In view of recent evidence that frontal lobe damage is associated with discourse formulation deficits in adults and is the most common site of focal lesion in closed head injury, we examined discourse patterns in individual patients with frontal lobe lesions. Preliminary data from our single-case studies suggest discourse patterns similar to those reported for adults with frontal lobe injuries.

Language Functions Following Closed-Head Injury in Children and Adolescents

Fifty-six children and adolescents who sustained a closed-head injury were divided into two groups based on neurological criteria. Language performance was assessed using the Neurosensory Center Comprehensive Examination for Aphasia during the subacute stage of recovery. Naming, expressive, and written language were more impaired than receptive-language functions. At least 20% of the sample exhibited deficits on measures of describing the function of objects, sentence repetition, verbal associative fluency, writing to dictation, and copying sentences. No sparing of function was observed in children relative to adolescents. Moreover, written-language performance was more depressed in children than adolescents. Results were discussed in terms of acquired aphasia in children and posttraumatic linguistic deficits in adults.

The Children's Orientation and Amnesia Test: Relationship to Severity of Acute Head Injury and to Recovery of Memory

The Childrens Orientation and Amnesia Test (COAT) was developed to assess cognition serially during the early stage of recovery from traumatic brain injury in children and adolescents. The norms for the COAT, which is composed of 16 items evaluating general orientation, temporal orientation, and memory, were defined from data obtained from 146 children aged 3 to 15 years. In 37 patients with head injuries, the duration of posttraumatic amnesia, as indicated by the number of days COAT scores were in the impaired range, was significantly related to both verbal and nonverbal memory at the baseline and 6 and 12 months after injury. COAT scores were a better predictor of verbal and nonverbal memory performance than the Glasgow Coma Scale score at 6 and 12 months after the injury. This study shows that the COAT has adequate reliability and validity as a measure of the duration of posttraumatic amnesia in children and adolescents.

Arrested development and disrupted callosal microstructure following pediatric traumatic brain injury: relation to neurobehavioral outcomes.

Chronic pediatric traumatic brain injury (TBI) is associated with significant and persistent neurobehavioral deficits. Using diffusion tensor imaging (DTI), we examined area, fractional anisotropy (FA), radial diffusion, and axial diffusion from six regions of the corpus callosum (CC) in 41 children and adolescents with TBI and 31 comparison children. Midsagittal cross-sectional area of the posterior body and isthmus was similar in younger children irrespective of injury status; however, increased area was evident in the older comparison children but was obviated in older children with TBI, suggesting arrested development. Similarly, age was correlated significantly with indices of tissue microstructure only for the comparison group. TBI was associated with significant reduction in FA and increased radial diffusivity in the posterior third of the CC and in the genu. The axial diffusivity did not differ by either age or group. Logistic regression analyses revealed that FA and radial diffusivity were equally sensitive to post-traumatic changes in 4 of 6 callosal regions; radial diffusivity was more sensitive for the rostral midbody and splenium. IQ, working memory, motor, and academic skills were correlated significantly with radial diffusion and/or FA from the isthmus and splenium only in the TBI group. Reduced size and microstructural changes in posterior callosal regions after TBI suggest arrested development, decreased organization, and disrupted myelination. Increased radial diffusivity was the most sensitive DTI-based surrogate marker of the extent of neuronal damage following TBI; FA was most strongly correlated with neuropsychological outcomes.

Lifetime and novel psychiatric disorders after pediatric traumatic brain injury.

OBJECTIVE To assess lifetime and current psychiatric disorders at least 1 year after traumatic brain injury (TBI) in children and adolescents. METHOD Forty-six youths who sustained a TBI between the ages of 6 through 15 years were evaluated at least 1 year post-TBI to identify the presence of lifetime and/or novel psychiatric disorders. Semistructured interviews of the parent and child and standardized parent self-report rating instruments were used. RESULTS Attention-deficit/hyperactivity disorder and depressive disorders were the most common lifetime and novel diagnoses. A wide variety and high rate of novel psychiatric disorders were identified; 74% of these disorders persisted in 48% of the injured children. Internalizing disorders were more likely to resolve than externalizing disorders. Both interviews and parent ratings were sensitive to current externalizing behaviors; interviews more often detected internalizing disorders, whereas parent ratings also identified cognitive difficulties. CONCLUSIONS Findings were generally consistent with previous research demonstrating the high rate of novel psychiatric disorders following pediatric TBI. Psychiatric interviews were sensitive in identifying both lifetime and novel disorders.

Executive functions following traumatic brain injury in young children: A preliminary analysis

To examine executive processes in young children with traumatic brain injury (TBI), we evaluated performance of 44 children who sustained moderate-to-severe TBI prior to age 6 and to 39 comparison children on delayed response (DR), stationary boxes, and spatial reversal (SR) tasks. The tasks have different requirements for holding mental representations in working memory (WM) over a delay, inhibiting prepotent responses, and shifting response set. Age at the time of testing was divided into 10- to 35- and 36- to 85-month ranges. In relation to the community comparison group, children with moderate-to-severe TBI scored significantly lower on indexes of WM/inhibitory control (IC) on DR and stationary boxes tasks. On the latter task, the Age × Group interaction indicated that performance efficiency was significantly reduced in the older children with TBI relative to the older comparison group; performance was similar in younger children irrespective of injury status. The TBI and comparison groups did not differ on the SR task, suggesting that shifting response set was not significantly altered by TBI. In both the TBI and comparison groups, performance improved with age on the DR and stationary boxes tasks. Age at testing was not significantly related to scores on the SR task. The rate of acquisition of working memory (WM) and IC increases steeply during preschool years, but the abilities involved in shifting response set show less increase across age groups (Espy, Kaufmann, & Glisky, 2001; Luciana & Nelson, 1998). The findings of our study are consistent with the rapid development hypothesis, which predicts that skills in a rapid stage of development will be vulnerable to disruption by brain injury.

Acute neuroradiologic findings in young children with inflicted or noninflicted traumatic brain injury

Abstract Acute CT/MRI findings were examined in a prospective, longitudinal study of 60 children 0–6 years of age hospitalized for moderate to severe traumatic brain injury (TBI). TBI was categorized as either inflicted (n=31) or noninflicted (n=29). Glasgow Coma Scale scores and perinatal history were comparable in both groups. Acute CT/MRI studies were visually inspected by a radiologist blind to group membership. Compared with the noninflicted TBI group, the inflicted TBI group had significantly elevated rates of subdural interhemispheric and convexity hemorrhages as well as signs of pre-existing brain abnormality, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly. Intraparenchymal hemorrhage, shear injury, and skull fractures were more frequent after noninflicted TBI. Subarachnoid hemorrhage and infarct/edema occurred with comparable frequency in both groups. Characteristic acute neuroimaging findings of inflicted TBI included multiple extraaxial hemorrhages in addition to the mild atrophy, subdural hygromas, and ventriculomegaly that suggest prior brain abnormality.