Adaptive ability, behavior and quality of life pre and posttraumatic brain injury in childhood.

CONTEXT: Traumatic brain injury (TBI) is a common, acquired childhood disability, which has been shown to have a significant impact on children's cognitive and educational function. While behavioral problems are also noted, there is ongoing debate about the contribution of preinjury factors in this domain. Few studies have attempted to measure the impact of these preinjury functions on postinjury behavior. OBJECTIVE: To compare pre and postinjury adaptive ability, behavior, executive function and quality of life (QOL) and to identify factors that contribute to outcomes in these domains including injury severity, socio-demographic and preinjury characteristics. DESIGN: Consecutive recruitments to a prospective, longitudinal study, utilizing a between factor design, with injury severity as the independent variable. PARTICIPANTS AND METHODS: Children admitted to hospital with a diagnosis of TBI aged between 6 and 14 years (n = 205) were divided according to injury severity (mild, moderate and severe). Adaptive behavior (Vineland Adaptive Behavior Scales), child behavior (Child Behavior Checklist), everyday executive functions (Behavior Rating Inventory of Executive Function) and QOL (Child Health Questionnaire) assessed at 6 months post-TBI. RESULTS AND CONCLUSIONS: Severity by time interactions were identified across a range of outcome domains demonstrating that more severe injury is associated with a decrease in functional ability at 6 months post-TBI. This effect was most pronounced for everyday executive skills, social function and internalizing aspects of child behavior. Preinjury function was a consistent predictor of postinjury status. Injury severity contributed little to the prediction of functional outcomes once preinjury functioning was accounted for in the model. Age at injury and family cohesion were relevant to specific outcome domains only. Socio-economic status did not contribute significantly to outcome at 6 months. Preinjury functioning as reported by parents in the acute phase may be a useful predictive tool for identifying children who may be at risk of functioning difficulties 6 months post-TBI.

Impact of posttraumatic stress disorder and injury severity on recovery in children with traumatic brain injury.

The adverse impact on recovery of posttraumatic stress disorder (PTSD) in mild traumatic brain injury (TBI) has been demonstrated in returned veterans. The study assessed this effect in children's health outcomes following TBI and extended previous work by including a full range of TBI severity, and improved assessment of PTSD within a longitudinal design. There were 205 children and adolescents (6 to 15 years of age) who experienced a TBI that were assessed at 2, 3, 6, 12, and 18 months following the TBI. Severity of TBI was classified as mild, moderate, or severe. After controlling for the impact of the severity of TBI, premorbid behavioral and emotional problems and executive function, children with TBI and PTSD did not experience as much psychosocial recovery as those without PTSD. Furthermore the level of psychosocial function was no better than that experienced by children with a severe TBI. In contrast, severe TBI was predictive of a poorer physical recovery in the first 6 months, after which recovery was equivalent across all severity levels.

Early attention impairment and recovery profiles after childhood traumatic brain injury.

OBJECTIVES: To examine recovery of attention from 3 to 6 months postinjury; to identify effects of injury severity and time since injury on performance; to explore whether complex attention skills (eg, shifting, divided attention, attentional control) are more vulnerable to traumatic brain injury (TBI), and slower to recover than simple attention skills (eg, attentional capacity, selective attention, sustained attention). DESIGN: Prospective longitudinal investigation. PARTICIPANTS: A total of 205 school-aged children with TBI were divided into groups according to injury severity (mild = 63%, moderate = 27%, severe = 10%). SETTING: Emergency departments of 3 metropolitan children's hospitals across Australia. MAIN MEASURES: Standardized clinical measures of both simple and complex attention were administered at 3 months and 6 months postinjury. RESULTS: Attention skills were vulnerable to the impact of TBI. More severe injury affected attention skills most negatively. Significant recovery was observed over time. There were few interaction effects, with severity groups exhibiting similar levels of recovery over the 6 months post-TBI. No differences in recovery trajectories were detected for simple and complex attention. CONCLUSIONS: These findings have important clinical and educational implications, suggesting that children with TBI, and particularly those with more serious injuries, are most vulnerable to attention deficits in the acute stages postinjury. It is important that schools and families are aware of these limitations and structure expectations accordingly. For example, gradual return to school should be considered, and in the early stages of recovery, children should be provided with sufficient rest time, with reduced expectations for tasks such as homework.

Which method of posttraumatic stress disorder classification best predicts psychosocial function in children with traumatic brain injury?

Controversy surrounds the classification of posttraumatic stress disorder (PTSD), particularly in children and adolescents with traumatic brain injury (TBI). In these populations, it is difficult to differentiate TBI-related organic memory loss from dissociative amnesia. Several alternative PTSD classification algorithms have been proposed for use with children. This paper investigates DSM-IV-TR and alternative PTSD classification algorithms, including and excluding the dissociative amnesia item, in terms of their ability to predict psychosocial function following pediatric TBI. A sample of 184 children aged 6-14 years were recruited following emergency department presentation and/or hospital admission for TBI. PTSD was assessed via semi-structured clinical interview (CAPS-CA) with the child at 3 months post-injury. Psychosocial function was assessed using the parent report CHQ-PF50. Two alternative classification algorithms, the PTSD-AA and 2 of 3 algorithms, reached statistical significance. While the inclusion of the dissociative amnesia item increased prevalence rates across algorithms, it generally resulted in weaker associations with psychosocial function. The PTSD-AA algorithm appears to have the strongest association with psychosocial function following TBI in children and adolescents. Removing the dissociative amnesia item from the diagnostic algorithm generally results in improved validity.

Solution focused nursing: an evaluation of current practice.

This Australian study explored the extent to which solution focused nursing (SFN), a new philosophy of care underpinning a Bachelor of Nursing Programme, was understood by students and staff. Students and faculty perceptions of teaching and learning were explored using survey and semi-structured interview methods. The results showed that students did not have strong views about whether solutions or problems contribute best to a definition of nursing knowledge, but there were some differences between the year groups. This was hypothesised to be related to the way SFN is or is not being taught. Teachers were generally positive about SFN but perceived that they needed more education on the philosophy to ensure it could be translated into their teaching. A teaching and learning package is recommended to be produced and made available to all teachers within the program.

'Closing the loop': the role of health care leaders in integrating research and practice.

The study reported here examines what health care leaders do to implement the routine integration of information into clinical practice decision making. Clinical leaders of a major Australian tertiary teaching hospital were interviewed. The study found that there is wide variation in the extent to which information is routinely used to inform practice. Those leaders who successfully integrated information used some common strategies. The ownership of information may be the single most powerful factor in clinical leaders' ability to encourage its use. A lack of trust, inappropriate systems and a fear of unfavourable consequences were identified as issues. The findings have implications for policy makers, hospital administrators and clinical leaders and question the effectiveness of centralised approaches to driving clinical change.