Martha Wright

Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status

OBJECTIVE. We examined whether mild traumatic brain injuries in children and adolescents, especially when associated with acute clinical features reflecting more severe injury, result in different postinjury trajectories of postconcussive symptoms compared with mild orthopedic injuries. PARTICIPANTS AND METHODS. Participants in this prospective and longitudinal cohort study were 8- to 15-year-old children, 186 with mild traumatic brain injuries and 99 with mild orthopedic injuries, who were recruited from consecutive admissions to emergency departments in 2 large childrens hospitals. Parents rated current postconcussive symptoms within 3 weeks of injury and at 1, 3, and 12 months after injury. At the initial assessment, parents also provided retrospective ratings of preinjury symptoms, and children with mild traumatic brain injuries received MRI of the brain. Clinical features examined as predictors of postconcussive symptoms included loss of consciousness, Glasgow Coma Scale score below 15, other injuries, acute symptoms of concussion, and intracranial abnormalities on the MRI. RESULTS. Finite mixture modeling identified 4 longitudinal trajectories of postconcussive symptoms (ie, no postconcussive symptoms, moderate persistent postconcussive symptoms, high acute/resolved postconcussive symptoms, high acute/persistent postconcussive symptoms). The mild traumatic brain injuries and orthopedic injuries groups demonstrated a different distribution of trajectories. Children with mild traumatic brain injuries were more likely than those with orthopedic injuries to demonstrate high acute/resolved and high acute/persistent trajectories relative to the no postconcussive symptoms group. The 2 trajectories with high acute levels of postconcussive symptoms were especially likely among children with mild traumatic brain injuries whose acute clinical presentation reflected more severe injury. CONCLUSIONS. Mild traumatic brain injuries, particularly those that are more severe, are more likely than orthopedic injuries to result in transient or persistent increases in postconcussive symptoms in the first year after injury. Additional research is needed to elucidate the range of factors, both injury related and non–injury related, that place some children with mild traumatic brain injuries at risk for postconcussive symptoms.

Post-Concussive Symptoms in Children with Mild Traumatic Brain Injury

To investigate postconcussive symptoms (PCS) following pediatric mild traumatic brain injury (mTBI), 8- to 15-year-old children with mTBI (n = 186) and a comparison group with uncomplicated orthopedic injuries (OI, n = 99) were recruited from two emergency departments. Parent and child ratings of PCS and symptom counts were obtained within 3 weeks after injury (baseline) and at 1, 3, and 12 months postinjury. The mTBI group also completed magnetic resonance imaging at baseline. Group differences were examined using growth modeling, controlling for age at injury, sex, socioeconomic status, and (for parent-based measures) preinjury symptom levels. Relative to the OI group, the mTBI group had higher ratings of somatic PCS and parent counts of PCS at the initial assessments, but higher parent ratings of cognitive PCS and child counts of PCS throughout follow-up. Higher levels of PCS in the mTBI group were associated with motor-vehicle-related trauma, loss of consciousness, neuroimaging abnormalities, and hospitalization. The findings validate both transient and persistent PCS in children with mTBI and document associations of symptoms with injury and noninjury factors.

Cognitive reserve as a moderator of postconcussive symptoms in children with complicated and uncomplicated mild traumatic brain injury

The occurrence of postconcussive symptoms (PCS) following mild traumatic brain injury (TBI) in children may depend on cognitive reserve capacity. This prospective, longitudinal study examined whether the relationship between mild TBI and PCS is moderated by cognitive ability, which served as a proxy for cognitive reserve. Participants included 182 children with mild TBI and 99 children with orthopedic injuries (OI), ranging from 8 to 15 years of age when injured. Mild TBI were classified as complicated (n = 32) or uncomplicated (n = 150) depending on whether they were associated with trauma-related intracranial abnormalities on magnetic resonance imaging. PCS were assessed initially within 3 weeks of injury, and again at 1, 3, and 12 months post injury. The initial assessment also included standardized tests of childrens cognitive skills and retrospective parent ratings of pre-injury symptoms. Hierarchical linear modeling indicated that ratings of PCS were moderated jointly by cognitive ability and injury severity. Children of lower cognitive ability with a complicated mild TBI were especially prone to cognitive symptoms across time according to parents and to high acute levels of PCS according to childrens self-ratings. Cognitive reserve is an important moderator of the outcomes of mild TBI in children and adolescents.

Injury versus noninjury factors as predictors of postconcussive symptoms following mild traumatic brain injury in children

OBJECTIVE To examine the relative contributions of injury characteristics and noninjury child and family factors as predictors of postconcussive symptoms (PCS) following mild traumatic brain injury (TBI) in children. METHOD Participants were 8- to 15-year-old children, 186 with mild TBI and 99 with mild orthopedic injuries (OI). Parents and children rated PCS shortly after injury and at 1, 3, and 12 months postinjury. Hierarchical regression analyses were conducted to predict PCS from (1) demographic variables; (2) premorbid child factors (WASI IQ; WRAT-3 Reading; Child Behavior Checklist; ratings of preinjury PCS); (3) family factors (Family Assessment Device General Functioning Scale; Brief Symptom Inventory; and Life Stressors and Social Resources Inventory); and (4) injury group (OI, mild TBI with loss of consciousness [LOC] and associated injuries [AI], mild TBI with LOC but without AI, mild TBI without LOC but with AI, and mild TBI without LOC or AI). RESULTS Injury group predicted parent and child ratings of PCS but showed a decreasing contribution over time. Demographic variables consistently predicted symptom ratings across time. Premorbid child factors, especially retrospective ratings of premorbid symptoms, accounted for the most variance in symptom ratings. Family factors, particularly parent adjustment, consistently predicted parent, but not child, ratings of PCS. CONCLUSIONS Injury characteristics predict PCS in the first months following mild TBI but show a decreasing contribution over time. In contrast, noninjury factors are more consistently related to persistent PCS.

Apolipoprotein E4 as a Predictor of Outcomes in Pediatric Mild Traumatic Brain Injury

The epsilon4 allele of the apolipoprotein E (APOE) gene has been linked to negative outcomes among adults with traumatic brain injury (TBI) across the spectrum of severity, with preliminary evidence suggesting a similar pattern among children. This study investigated the relationship of the APOE epsilon4 allele to outcomes in children with mild TBI. Participants in this prospective, longitudinal study included 99 children with mild TBI between the ages of 8 and 15 recruited from consecutive admissions to Emergency Departments at two large childrens hospitals. Outcomes were assessed acutely in the Emergency Department and at follow-ups at 2 weeks, 3 months, and 12 months post-injury. Among the 99 participants, 28 had at least one epsilon4 allele. Children with and without an epsilon4 allele did not differ demographically. Children with an epsilon4 allele were significantly more likely than those without an epsilon4 allele to have a Glasgow Coma Scale score of less than 15, but the groups did not differ on any other measures of injury severity. Those with an epsilon4 allele exhibited better performance than children without an epsilon4 allele on a test of constructional skill, but the groups did not differ on any other neuropsychological tests. Children with and without an epsilon4 allele also did not differ on measures of post-concussive symptoms. Overall, the findings suggest that the APOE epsilon4 allele is not consistently related to the outcomes of mild TBI in children.

Premorbid child and family functioning as predictors of post-concussive symptoms in children with mild traumatic brain injuries

This study sought to determine whether premorbid child and family functioning accounts for or moderates group differences in post‐concussive symptoms following mild traumatic brain injury (TBI) in childhood.

Agreement between Parents and Children on Ratings of Post-Concussive Symptoms Following Mild Traumatic Brain Injury

The level of parent-child agreement on post-concussive symptoms (PCS) was examined in children following mild traumatic brain injuries (TBI). As part of a larger longitudinal study, 186 children with mild TBI and 99 with orthopedic injuries (OI), from 8 to 15 years of age, were recruited prospectively. Parents and children completed the PCS Interview (PCS-I) and the Health and Behavior Inventory (HBI) at 2 weeks, 1 month, 3 months, and 12 months postinjury. Item-level correlations between child and parent ratings on both measures of PCS were significant but modest in both groups. Parent-child correlations for composite scales on the HBI and the total score on the PCS-I were significant in both groups, but somewhat higher in the OI group than in the mild TBI group. Mean symptom ratings tended to be significantly higher for children as compared to parents, especially for somatic symptoms. Parents and children display modest agreement when reporting PCS; their ratings correlate significantly, but children report higher mean levels of symptoms than parents.

Mild traumatic brain injury and executive functions in school-aged children

Objective: This study sought to examine the effects of mild traumatic brain injury (TBI) on executive functions in school-aged children. Participants and method: The prospective, longitudinal study involved 8–15 year old children, 186 with mild TBI and 99 with mild orthopaedic injuries (OI). They were administered the Stockings of Cambridge and Spatial Working Memory sub-tests from the Cambridge Neuropsychological Testing Automated Battery (CANTAB) ∼10 days, 3 months and 12 months post-injury. Parents completed the Behavior Rating Inventory of Executive Functions (BRIEF) on each occasion, with ratings at the initial assessment intended to assess pre-morbid functioning retrospectively. Results: On the CANTAB, the groups did not differ on the Stockings of Cambridge and the mild TBI group unexpectedly performed better than the OI group on Spatial Working Memory. On the BRIEF, children with mild TBI showed a marginally significant trend toward more problems than the OI group on the Metacognition Index composite. The only BRIEF sub-scale on which they demonstrated significantly more problems was Organization of Materials. The presence of intracranial abnormalities on MRI was associated with more problems on the BRIEF Organization of Materials sub-scale at 3 months, but other findings were not consistent with hypothesized effects of TBI severity. The CANTAB sub-tests were significant predictors of later ratings on the BRIEF, but accounted for modest variance. Discussion: Children with mild TBI show limited evidence of deficits in executive functions, either cognitively or behaviourally, irrespective of injury characteristics. Cognitive tests of executive functions are modest predictors of ratings of executive functions in everyday life, for children both with and without mild TBI.

Coping strategies as a predictor of post-concussive symptoms in children with mild traumatic brain injury versus mild orthopedic injury.

This study examined whether childrens coping strategies are related to post-concussive symptoms following mild traumatic brain injury (TBI) versus orthopedic injury (OI). Participants were 8- to 15-year-old children with mild TBI (n = 167) or OI (n = 84). They rated their current preferred coping strategies and post-injury symptoms at 2 weeks (baseline) and 1, 3, and 12 months post-injury. Childrens reported use of coping strategies did not vary significantly over time, so their baseline coping ratings were examined as predictors of post-concussive symptoms across time. Self-ratings of symptoms were positively related to emotion-focused strategies and negatively related to problem-focused engagement after both mild TBI and OI. Higher problem-focused disengagement predicted larger group differences in childrens ratings of symptoms, suggesting that problem-focused disengagement moderates the effects of mild TBI. Coping strategies collectively accounted for approximately 10-15% of the variance in childrens post-concussive symptoms over time. The findings suggest that coping may play an important role in accounting for childrens perceptions of post-concussive symptoms after mild TBI.

Relationships among post-concussive symptoms and symptoms of PTSD in children following mild traumatic brain injury

Primary objective: To investigate the occurrence of post-concussive symptoms (PCS) and symptoms of post-traumatic stress disorder (PTSD) in children following mild traumatic brain injuries (TBI). Research design: Longitudinal study comparing the outcomes of mild TBI and orthopaedic injuries (OI) in children aged 8–15. Methods and procedures: One hundred and eighty-six children with mild TBI and 99 with OI were recruited prospectively. Parents rated childrens PCS and symptoms of PTSD at 2 weeks, 3 months and 12 months post-injury. One hundred and sixty-seven with mild TBI and 84 with OI completed all assessments. Main outcomes and results: Controlling for symptoms of PTSD, the mild TBI group demonstrated more PCS than the OI group, although the magnitude of group differences diminished with time. Controlling for PCS, the OI group displayed more symptoms of PTSD than the mild TBI group at baseline, but not thereafter. Symptoms of PTSD and PCS were correlated significantly, but more highly in the OI group than the mild TBI group. Conclusions: Although PCS and symptoms of PTSD are correlated, children with mild TBI are more distinguishable from children with OI based on PCS than on symptoms of PTSD. The latter symptoms, moreover, do not account for increased PCS following mild TBI in children.