the impact of traumatic brain injury on developmental functioning in children: mild tbi at home and...
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THE IMPACT OF TRAUMATIC BRAIN INJURY ON DEVELOPMENTAL FUNCTIONING IN CHILDREN
MILD TBI AT HOME AND SCHOOL
Rosalind Case
Clinical Psychologist / Research Officer
School of Psychology, University of Waikato
BIONICBrain Injury Outcomes NZ in the Community
Epidemiology and outcomes of TBI Hamilton City and Waikato District March 2010 – March 2011 Funded by HRC Projects Grant; led by Valery
Feigin (AUT) Approximately 1300 participants
Developed prospective TBI register Multiple overlapping sources, cross-checking
COBIC: Consequences of Brain Injury in Childhood
12-month follow-up of children aged 5-11 years at time of injury
Jun 2011 – Present
More in-depth focus on intellectual, academic, social, emotional, and behavioural functioning
Complemented by BIONIC data Overall study funded by Lotteries Grant and led
by Dr Nicola Starkey (University of Waikato) HRC Clinical Research Fellowship
Traumatic Brain Injury (TBI)
“An acute brain injury resulting from mechanical energy to the head from external forces.” (WHO, 2005)
• Immediate post-injury symptoms include one or more of the following:
1. Confusion or disorientation2. Loss of consciousness3. Post-traumatic amnesia4. Other neurological abnormalities (e.g.
focal neurological signs, seizure, intracranial lesion)
Classification of Severity
• Severity rated according to scores on the Glasgow Coma Scale (GCS)
Mild• 13-15
Moderate• 9-12
Severe• 3-8
Mild TBI Categories (Servedei, 2001)
Mild – Low Risk Mild – Medium Risk Mild – High Risk
GCS = 15
No loss of consciousness
No amnesia
No vomiting
No diffuse headache
Risk of haematoma = <0.1:100
With possible:
Loss of consciousness
Amnesia
Vomiting
OR
Diffuse headache
Risk of haematoma = 1-3:100
With skull fracture
And/or
Neurological deficits
Risk of haematoma = 6-10:100
Overall Prevalence of TBI
Internationally - 200-300 per 100,000 annually
NZ rates slightly higher (349 per 100,000)
Maori males disproportionately represented
Rates vary widely; case registration poor
Irrespective of age, 70-90% of TBIs are mild
Prevalence in Children
Incidence peaks between 15-24
Smaller peaks <5 years and older adults
Varies between 100-300 per 100,000 per year
However, difficult to establish accurate rates: Problems of definition
Age ranges
Reliance on hospital data
McKinlay et al. (2008)…
Prevalence of traumatic brain injury among
children, adolescents, and young adults:
Prospective evidence from a birth cohort.
1265 individuals
Average incidence 1.0-2.3% per year
Overall prevalence 30% (0-25 years)
1/3 experienced multiple TBI
Preliminary BIONIC Data
Incidence of TBI in those aged 0-19 years – BIONIC 2010/2011
Per 100,000 annually
Mechanisms
Cause of TBI in those aged 0-19 years – BIONIC 2010/2011
Risk Factors
GenderDisparity increases with age
AlcoholParental misuse
EthnicityMaori over-represented
Poorer outcomesHigher Mortality
Previous TBI1 injury = 3x risk2+ injuries = 9x risk
Increased Risk
Correlates of Multiple TBI
Multiple Injuries
Lower SES
Alcohol
abuse
Individual
Factors
Neglect
Consequences of mild TBI in children
Most mild TBI results in no long-term
impacts
Conflicting data
Persistent difficulties may be present after mild TBI
Variables aside from injury severity may be
important
Methodological issues
Developmental Context
Difficulties may take time to emerge
Impact on developmental trajectory
Fig 2. Hypothetical developmental changes in acquired skills (a) and new skills (b) in children after TBI (solid line) and controls (dotted line) from Taylor & Alden, 1997.
Research Aims
Examine developmental and, more specifically, cognitive and academic functioning12 months after the occurrence of TBI in primary-school-aged children.
Identify factors related to both functional impairment and recovery from paediatric TBI.
Method
Participants Clinical group
BIONIC participants aged 6-12 Hamilton/Waikato region
Matched cohort Age/Gender/Socio-economic Status
Procedure 12-month follow-up Parents Child Teacher
Assessment Domains and Tools
Intellectual Functioning WISC-IV Subscales
WISC-IV Subscales Estimate of Full Scale IQ
Academic Performance WCJ-II Test of Academic Achievement
Six subscales Brief Achievement, Reading, Math, Writing
scores
Teacher Questionnaire
Assessment Domains and Tools
Executive Functioning Behaviour Rating Inventory of Executive Function (Parent/Teacher)
Inhibit, Initiate, Organisation of Material, Shift, Working Memory, Monitoring and Emotional Control
Emotional/Behavioural Functioning Strengths and Difficulties Questionnaire (Parent/Teacher/Self-
Report) Emotional Symptoms, Conduct Problems, Hyperactivity-Inattention,
Peer Problems, Prosocial Behaviour, Total Difficulties
Quality of Life Kindl (Parent/Self-Report)
Physical health, emotional health, family functioning, self-esteem, social functioning, school functioning and an injury specific scale
Current status
Where I’m up to right now: Clinical group
33/40 families assessed Matched cohort
31/40 families assessed
Majority of children assessed at school Expected Completion June 2012
Engaging Participants
Multiple methods to support recruitment and reduce attrition
Multiple contact options parents/grandparents/N.O.K/GP/school
Emphasis on rapport-building with view to ongoing relationship
Provision of information regarding study purpose and importance
Financial incentives/rewards for children Offering ‘shortened’ assessments Assessment feedback
Engaging Schools
Majority of child assessments conducted at school
Matched cohort recruited via local schools
Communication Approaches: Open, transparent and ongoing communication Face-to-face meetings with Principals and Staff Flexibility Prioritising schools’ needs over assessor’s Relationship-building with key staff members
Demographics
Ages Min-Max (years:month
s)
x
Clinical Group
6.4-12.7 8.97
Control Group
6.0-12.8 8.57
Gender Male (N)
% Female (N)
%
Clinical 15 45.5
18 54.5
Controls 13 43.3
17 56.7
Injury Severity
MildLow
% MildModerate
% MildHigh
% Missing
Clinical 4 12.1
15 45.5
10 30.3 4
Ethnicity
NZ Euro NZ Maori Samoan Niuean Chinese Other 0
5
10
15
20
25
30
ClinicalControl
Child's Ethnic Group
Num
ber
of
Childre
n
Results - Cognitive Functioning
• Children in the TBI group have significantly lower FSIQ scores
Results - Academic Functioning
• Children in the TBI group have significantly lower scores in reading, maths and writing tests
WCJ Reading WCJ Math WCJ Reading85
90
95
100
105
110
115
Mean Tests of Achievement Scores
ClinicalControl
WCJ Tests of Achievement Subscales
Mea
n Sc
ores
Ability/Achievement Discrepancies
Children with TBI are significantly more likely to present with learning disorders
Evidence of Learning Disorder Achieving at Predicted Level0
10
20
30
40
50
60
70
80
90
100Frequency of Learning Disorders
ClinicalControl
Perc
enta
ge o
f Chi
ldre
n
Strengths and Difficulties Scores
Emotional Prob-lems
Social Problems Total Difficulties0
2
4
6
8
10
12
ClinicalControl
• Parents of children with TBI perceive their children have greater social and emotional problems, and a higher level of overall difficulties, than controls
(seriously tentative) Conclusions This data is VERY preliminary and to be
interpreted with caution! Causation/correlation – difficult to
untangle Does TBI act as a marker for other
difficulties? Further analysis will explore:
Executive Function BASC profiles Quality of Life Interaction between clinical and demographic
factors
What might this data mean for clinicians?
Mild TBI is common and a large proportion of your clients will experience it Consider the role of mild TBI in your
assessments and formulations Remember, most children don’t have ongoing
problems after TBI - but some do. Avoid definitive, causal statements about the
relationship between mild TBI and later difficulties
Consider TBI (particularly multiple events) as an ‘indicator’
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