Nicolay Chertkoff Walz

The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children.

OBJECTIVE This study sought to determine whether the family environment moderates psychosocial outcomes after traumatic brain injury (TBI) in young children. METHOD Participants were recruited prospectively from consecutive hospital admissions of 3- to 6-year-old children, and included 19 with severe TBI, 56 with complicated mild/moderate TBI, and 99 with orthopedic injuries (OI). They completed 4 assessments across the first 18 months postinjury. The initial assessment included measures of parenting style, family functioning, and the quality of the home. Childrens behavioral adjustment, adaptive functioning, and social competence were assessed at each occasion. Mixed model analyses examined the relationship of the family environment to psychosocial outcomes across time. RESULTS The OI and TBI groups differed significantly in social competence, but the family environment did not moderate the group difference, which was of medium magnitude. In contrast, group differences in behavioral adjustment became more pronounced across time at high levels of authoritarian and permissive parenting; among children with severe TBI, however, even those with low levels of permissive parenting showed increases in behavioral problems. For adaptive functioning, better home environments provided some protection following TBI, but not over time for the severe TBI group. These 3-way interactions of group, family environment, and time postinjury were all of medium magnitude. CONCLUSION The findings indicate that the family environment moderates the psychosocial outcomes of TBI in young children, but the moderating influence may wane with time among children with severe TBI.

Diffusion Tensor MR Imaging Reveals Persistent White Matter Alteration after Traumatic Brain Injury Experienced during Early Childhood

BACKGROUND AND PURPOSE: Diffusion tensor imaging (DTI) can noninvasively quantify white matter (WM) integrity. Although its application in adult traumatic brain injury (TBI) is common, few studies in children have been reported. The purposes of this study were to examine the alteration of fractional anisotropy (FA) in children with TBI experienced during early childhood and to quantify the association between FA and injury severity. MATERIALS AND METHODS: FA was assessed in 9 children with TBI (age = 7.89 ± 1.00 years; Glasgow Coma Scale [GCS] = 10.11 ± 4.68) and a control group of 12 children with orthopedic injuries without central nervous system involvement (age = 7.51 ± 0.95 years). All of the subjects were at minimum 12 months after injury. We examined group differences in a series of predetermined WM regions of interest with t test analysis. We subsequently conducted a voxel-wise comparison with Spearman partial correlation analysis. Correlations between FA and injury severity were also calculated on a voxel-wise basis. RESULTS: FA values were significantly reduced in the TBI group in genu of corpus callosum (CC), posterior limb of internal capsule (PLIC), superior longitudinal fasciculus (SLF), superior fronto-occipital fasciculus (SFO), and centrum semiovale (CS). GCS scores were positively correlated with FA in several WM areas including CC, PLIC, SLF, CS, SFO, and inferior fronto-occipital fasciculus (IFO). CONCLUSION: This DTI study provides evidence that WM integrity remains abnormal in children with moderate-to-severe TBI experienced during early childhood and that injury severity correlated strongly with FA.

Executive Functions and Social Competence in Young Children 6 Months Following Traumatic Brain Injury

OBJECTIVE This study examined the impact of traumatic brain injury (TBI) in young children on executive functions and social competence, and particularly on the role of executive functions as a predictor of social competence. METHOD Data were drawn from a prospective, longitudinal study. Participants were children between the ages of 3 years 0 months and 6 years 11 months at time of injury. The initial sample included 23 with severe TBI, 64 with moderate TBI, and 119 with orthopedic injuries (OI). All participants were assessed at 3 and 6 months postinjury. Executive functions were assessed using neuropsychological tests (Delayed Alternation task and Shape School) and parent ratings on the Behavior Rating Inventory of Executive Function and Child Behavior Questionnaire. Parents rated childrens social competence on the Adaptive Behavior Assessment System, Preschool and Kindergarten Behavior Scales, and Home and Community Social Behavior Scales. RESULTS Children with severe TBI displayed more negative outcomes than children with OI on neuropsychological tests, ratings of executive functions, and ratings of social competence (η² ranged from .03 to .11). Neuropsychological tests of executive functions had significant but weak relationships with behavioral ratings of executive functions (ΔR² ranged from .06 to .08). Behavioral ratings of executive functions were strongly related to social competence (ΔR² ranged from .32 to .42), although shared rater and method variance likely contributed to these associations. CONCLUSIONS Severe TBI in young children negatively impacts executive functions and social competence. Executive functions may be an important determinant of social competence following TBI.

Clinically significant behavior problems during the initial 18 months following early childhood traumatic brain injury.

OBJECTIVE This study looked at the emergence of clinically significant problems in behavior, executive function skills, and social competence during the initial 18 months following traumatic brain injury (TBI) in young children relative to a cohort of children with orthopedic injuries (OI) and the environmental factors that predict difficulties postinjury. PARTICIPANTS Children, ages 3-7 years, hospitalized for severe TBI, moderate TBI, or OI were seen shortly after their injury (M = 40 days) and again 6 months, 12 months, and 18 months postinjury. DESIGN Behavioral parent self-reports, demographic data, family functioning reports, and home environment reports were collected at injury baseline and each time point postinjury. RESULTS Results suggest that, compared with the OI group, the severe TBI group developed significantly more externalizing behavior problems and executive function problems following injury that persisted through the 18-month follow-up. Minimal social competence difficulties appeared at the 18-month follow-up, suggesting a possible pattern of emerging deficits rather than a recovery over time. CONCLUSIONS Predictors of the emergence of clinically significant problems included permissive parenting, family dysfunction, and low socioeconomic status. The findings are similar to those found in school-age children.

Traumatic brain injury in young children: Postacute effects on cognitive and school readiness skills

Previous studies have documented weaknesses in cognitive ability and early academic readiness in young children with traumatic brain injury (TBI). However, few of these studies have rigorously controlled for demographic characteristics, examined the effects of TBI severity on a wide range of skills, or explored moderating influences of environmental factors on outcomes. To meet these objectives, each of three groups of children with TBI (20 with severe, 64 with moderate, and 15 with mild) were compared with a group of 117 children with orthopedic injuries (OI group). The children were hospitalized for their injuries between 3 and 6 years of age and were assessed an average of 1 1/2 months post injury. Analysis revealed generalized weaknesses in cognitive and school readiness skills in the severe TBI group and less pervasive effects of moderate TBI. Indices of TBI severity predicted outcomes within the TBI sample and environmental factors moderated the effects of TBI on some measures. The findings document adverse effects of TBI in early childhood on postacute cognitive and school readiness skills and indicate that these effects are related to both injury severity and the family environment.

A randomized trial of teen online problem solving for improving executive function deficits following pediatric traumatic brain injury.

Objective:To examine the efficacy of teen online problem solving (TOPS) in improving executive function (EF) deficits following traumatic brain injury (TBI) in adolescence. Methods:Families of adolescents (aged 11–18 years) with moderate to severe TBI were recruited from the trauma registry of 2 tertiary-care childrens hospitals and then randomly assigned to receive TOPS (n = 20), a cognitive-behavioral, skill-building intervention, or access to online resources regarding TBI (Internet resource comparison; n = 21). Parent and teen reports of EF were assessed at baseline and a posttreatment follow-up (mean = 7.88 months later). Results:Improvements in self-reported EF skills were moderated by TBI severity, with teens with severe TBI in the TOPS treatment reporting significantly greater improvements than did those with severe TBI in the Internet resource comparison. The treatment groups did not differ on parent ratings of EF at the follow up. Conclusions:Findings suggest that TOPS may be effective in improving EF skills among teens with severe TBI.

Preliminary efficacy of a Web-based family problem-solving treatment program for adolescents with traumatic brain injury.

ObjectivePreliminary report of the efficacy of a Web-based treatment program to improve adolescent and family psychosocial functioning following traumatic brain injury (TBI). ParticipantsFamilies of 9 adolescents with TBI (2 severe and 7 moderate) injured less than 24 months ago participated in this study. InterventionA Web-based family treatment program designed to enhance family problem solving and adjustment, as well as reduce adolescent behavioral and social problems that are common sequelae of moderate-to-severe TBI was used as intervention. The program consisted of 10 core sessions and up to 4 supplemental sessions, each consisting of self-guided Web exercises followed by a videoconference therapy session. ResultsSignificant improvements were found in parent-reported adolescent internalizing behaviors, self-reported adolescent depressive symptoms, parental depression, and parent-adolescent conflict. Effect sizes were in the medium-to-high range for these same contrasts. Exploratory analyses suggested that providing audio with the Web site may enhance some outcomes. ConclusionsThis study provides preliminary evidence of the feasibility and efficacy of family-centered online intervention for improving adolescent and family adaptation following pediatric TBI.

The relationship of parental warm responsiveness and negativity to emerging behavior problems following traumatic brain injury in young children

Parenting behaviors play a critical role in the childs behavioral development, particularly for children with neurological deficits. This study examined the relationship of parental warm responsiveness and negativity to changes in behavior following traumatic brain injury (TBI) in young children relative to an age-matched cohort of children with orthopedic injuries (OI). It was hypothesized that responsive parenting would buffer the adverse effects of TBI on child behavior, whereas parental negativity would exacerbate these effects. Children, ages 3-7 years, hospitalized for TBI (n = 80) or OI (n = 113), were seen acutely and again 6 months later. Parent-child dyads were videotaped during free play. Parents completed behavior ratings (Child Behavior Checklist; T. M. Achenbach & L. A. Rescorla, 2001) at both visits, with baseline ratings reflecting preinjury behavior. Hypotheses were tested using multiple regression, with preinjury behavior ratings, race, income, child IQ, family functioning, and acute parental distress serving as covariates. Parental responsiveness and negativity had stronger associations with emerging externalizing behaviors and attention-deficit/hyperactivity disorder symptoms among children with severe TBI. Findings suggest that parenting quality may facilitate or impede behavioral recovery following early TBI. Interventions that increase positive parenting may partially ameliorate emerging behavior problems.

Cognitive development after traumatic brain injury in young children

The primary aims of this study were to examine post-injury cognitive development in young children with traumatic brain injury (TBI) and to investigate the role of the proximal family environment in predicting cognitive outcomes. Age at injury was 3-6 years, and TBI was classified as severe (n = 23), moderate (n = 21), and complicated mild (n = 43). A comparison group of children who sustained orthopedic injuries (OI, n = 117) was also recruited. Child cognitive assessments were administered at a post-acute baseline evaluation and repeated at 6, 12, and 18 months post-injury. Assessment of the family environment consisted of baseline measures of learning support and stimulation in the home and of parenting characteristics observed during videotaped parent-child interactions. Relative to the OI group, children with severe TBI group had generalized cognitive deficiencies and those with less severe TBI had weaknesses in visual memory and executive function. Although deficits persisted or emerged across follow-up, more optimal family environments were associated with higher scores for all injury groups. The findings confirm other reports of poor recovery of cognitive skills following early childhood TBI and suggest environmental influences on outcomes.

Traumatic Brain Injuries in Early Childhood: Initial Impact on the Family

Objective: The purpose of this study was to examine factors that affect parental burden and distress during the first few months following a traumatic brain injury (TBI) in young children. Methods: Participants were consecutively enrolled children ages 3 through 6 years with either a TBI (n = 89; 21 severe, 22 moderate, and 45 complicated mild) or orthopedic injury (OI; n = 119) requiring hospitalization. During the post-acute period, parents provided information regarding the preinjury family environment and current caregiver functioning and injury-related burden. Results: Compared with parents of young children with OI, parents of children with TBI reported greater overall caregiver burden and greater burden related to the injury. Parents of children with severe TBI also reported more stress with spouses and siblings and higher levels of parental depression and global distress relative to the OI comparison group. Parents of 5- to 6-year-old children reported significantly higher levels of both injury-related burden and distress than parents of 3- to 4-year-old children. Parents of children with mild TBI based on the Glasgow Coma Scale (GCS) who also had positive neuroimaging findings reported greater injury-related burden than parents of children with moderate TBI. Parents reported using a variety of coping strategies, with higher levels of denial and disengagement corresponding with greater injury-related burden and distress. Conclusions: Consistent with previous research on family adaptation to TBI in school-age children, chronic life stresses and interpersonal resources accounted for significant variance in measures of acute injury-related burden and parental distress in parents of younger children, although differences were small. TBI severity defined by GCS scores alone may not be sufficient to identify families at risk of increased burden. Findings suggest that services aimed at facilitating family adjustment following TBI in young children may need to consider a broader definition of risk factors when identifying families who would benefit from interventions.