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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