The McMaster family assessment device and clinical rating scale: questionnaire vs interview in childhood traumatic brain injury.

Two modalities of family assessment based on the McMaster Model of Family Functioning (MMFF), including a self-report questionairre (Family Assessment Device-FAD) and a clinical interview (McMaster Structured Interview For Families-McSIFF) as scored on the McMaster Clinical Rating Scale (MCRS) were compared in an attempt to explore the inter-changeability of the two. Significant correlations were hypothesized between the FAD and MCRS in both prospective and retrospective groups and that correlations would increase over three data points in the prospective study. The sample included 50 children and adolescents (ages 6-4) with traumatic brain injury (TBI) from a prospective study. In addition, 72 children and adolescents (ages 5-14), consisting of 24 patients with severe TBI, individually matched to a comparison group of 24 mild TBI patients and a control group of 24 orthopaedic patients were included from a retrospective study. Significant correlations between the FAD and MCRS were found across both studies, with increasing correlations at each successive data point in the prospective study. Agreement between the two measures regarding classification of families as clinical vs healthy was also statistically significant at the majority of assessment occasions; however, most specific indices of agreement were only modest. The clinical and research implications of these findings are discussed.

The phenomenology of personality change due to traumatic brain injury in children and adolescents.

The authors aimed to contribute a clinically rich description of personality change due to traumatic brain injury (PC) in children. The sample consisted of consecutively injured children. Ninety-four subjects ages 5 to 14 years were assessed at the time of hospitalization after a traumatic brain injury (TBI). A standardized psychiatric interview, the Neuropsychiatric Rating Schedule, was used to elicit symptoms of PC. PC occurred in 59% of severe (22/37) and 5% of mild/moderate (3/57) TBI subjects. Among the 37 severe TBI subjects, the labile subtype of PC was the most common (49%), followed by the aggressive and disinhibited subtypes (38% each), apathy (14%), and paranoia (5%). Also frequent in severe TBI was perseveration (35%). A detailed case example, numerous clinical vignettes of PC symptoms, and a tabulation of their frequencies provide clinicians a broader frame of reference for eliciting symptoms of PC.

Personality change disorder in children and adolescents following traumatic brain injury.

The occurrence of personality change due to traumatic brain injury (PC), and its clinical and neuroimaging correlates were investigated. Ninety-four children, ages 5 through 14 at the time of hospitalization following traumatic brain injury (TBI; severe TBI N = 37; mild-moderate TBI N = 57), were assessed. Standardized psychiatric, adaptive functioning, cognitive functioning, family functioning, family psychiatric history, severity of injury, and neuroimaging assessments were conducted. The Neuropsychiatric Rating Schedule (NPRS) was used to establish a diagnosis of PC. Approximately 40% of consecutively hospitalized severe TBI participants had ongoing persistent PC an average of 2 years postinjury. An additional approximately 20% had a history of a remitted and more transient PC. PC occurred in 5% of mild-moderate TBI but was always transient. Interrater reliability for the diagnosis of PC was good (Kappa = .70). In severe TBI participants, persistent PC was significantly associated with severity of injury, particularly impaired consciousness over 100 hr, adaptive and intellectual functioning decrements, and concurrent diagnosis of secondary attention deficit hyperactivity disorder, but was not significantly related to any psychosocial adversity variables. These findings suggest that PC is a frequent diagnosis following severe TBI in children and adolescents, but is much less common following mild-moderate TBI.

Cognitive outcome in children and adolescents following severe traumatic brain injury: influence of psychosocial, psychiatric, and injury-related variables.

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than psychiatric or psychosocial factors as correlates of cognitive outcomes. We addressed this concern by recruiting a consecutive series (N = 24) of children age 5 through 14 years who suffered a severe TBI, a matched group who sustained a mild TBI, and a second matched group who sustained an orthopedic injury. Standardized intellectual, memory, psychiatric, family functioning, family psychiatric history, neurological, and neuroimaging assessments were conducted at an average of 2 years following injury. Severe TBI, when compared to mild TBI and orthopedic injury, was associated with significant decrements in intellectual and memory function. A principal components analysis of independent variables that showed significant (p < .05) bivariate correlations with the outcome measures yielded a neuropsychiatric factor encompassing severity of TBI indices and postinjury psychiatric disorders and a psychosocial disadvantage factor. Both factors were independently and significantly related to intellectual and memory function outcome. Postinjury psychiatric disorders added significantly to severity indices and family functioning and family psychiatric history added significantly to socioeconomic status in explaining several specific cognitive outcomes. These results may help to define subgroups of children who will require more intensive services following their injuries.

Posttraumatic stress symptomatology after childhood traumatic brain injury.

The purpose of this study was to quantify and to identify predictors of posttraumatic stress disorder (PTSD) symptomatology after traumatic brain injury (TBI). Fifty children aged 6 to 14 years, hospitalized after TBI, were assessed soon after TBI regarding injury severity and preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; neuroimaging was also analyzed. Psychiatric assessments were repeated 3, 6, 12, and 24 months after TBI. Only 2 of 46 (4%) subjects with at least one follow-up assessment developed PTSD. However, the frequency with which subjects experienced at least one PTSD symptom ranged from 68% in the first 3 months to 12% at 2 years in assessed children. The presence of an internalizing disorder at time of injury followed by greater injury severity were the most consistent predictors of PTSD symptomatology. It is apparent, therefore, that PTSD and subsyndromal posttraumatic stress disturbances occur despite neurogenic amnesia. These problems should be treated, particularly if symptoms persist beyond 3 months.

Traumatic brain injury in children and adolescents: psychiatric disorders at one year.

Factors predictive of psychiatric outcome in the second 6 months following traumatic brain injury (TBI) in 43 children and adolescents were assessed prospectively. The outcome measure was the presence of a psychiatric disorder not present before the injury ("novel"). Out of six models tested, four were predictive of novel psychiatric disorder: preinjury family function, family psychiatric history, socioeconomic class/intellectual function, and behavior/adaptive function. Post hoc analyses suggested that preinjury family functioning measured by a structured interview was a significant predictive variable. Severity of injury, when reclassified as severe versus mild/moderate TBI, significantly predicted novel psychiatric disorders. These data suggest that some children, identifiable through clinical assessment, are at increased risk for psychiatric disorders following TBI.

Psychiatric disorders in children and adolescents after severe traumatic brain injury: a controlled study.

OBJECTIVE: To study psychiatric and behavioral morbidity associated with severe traumatic brain injury (TBI). METHOD: A consecutive series (n = 24) of children aged 5 through 14 years who suffered a severe TBI were matched to subjects who sustained a mild TBI and to a second matched group who sustained an orthopedic injury with no evidence of TBI. Standardized psychiatric, behavioral, and neuroimaging assessments were conducted on average 2 years after injury. RESULTS: Severe TBI was associated with a significantly higher rate of current "novel" psychiatric disorders (15/24; 63%) compared with children with mild TBI (5/24; 21%) and orthopedic injury (1/24; 4%). Higher effect sizes were evident for child and adolesent self-report of internalizing symptoms rather than externalizing symptoms, for parents' report of overall behavior and internalizing symptoms rather than externalizing symptoms, and for teachers' reports of overall behavior and externalizing symptoms rather than internalizing symptoms. CONCLUSIONS: Severe TBI is a profound risk factor for the development of a psychiatric disorder. Survivors should be assessed for organic personality syndrome, which is the most common psychiatric disorder after this type of injury.

Attention-deficit hyperactivity symptomatology after traumatic brain injury: a prospective study.

OBJECTIVE: To study prospectively the course of attention-deficit hyperactivity (ADH) symptomatology in children and adolescents after traumatic brain injury (TBI). It was hypothesized that ADH symptomatology would be significantly related to severity of injury. METHOD: Subjects were children (n = 50) aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, socioeconomic, family functioning, and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales, and neuroimaging was analyzed. RESULTS: The main finding of this study was that change in ADH symptomatology in the first 2 years after TBI in children and adolescents was significantly related to severity of injury. Overall ADH symptomatology during the study was significantly related to a measure of family dysfunction when family psychiatric history, socioeconomic status, and severity of injury were controlled. CONCLUSION: The presence of a positive "dose-response" relationship between severity of injury and change in ADH symptoms, present from the 3-month assessment, was consistent with an effect directly related to brain damage.

Adaptive functioning following traumatic brain injury and orthopedic injury: a controlled study.

OBJECTIVE: To study adaptive functioning after severe traumatic brain injury (TBI). DESIGN: Case-control study. SETTING: A university hospital and three regional and four community hospitals. SUBJECTS: A consecutive series (n=24) of children age 5 through 14 years who suffered severe TBI were individually matched to subjects who sustained a mild TBI and to a second group who sustained an orthopedic injury with no evidence of TBI. MAIN OUTCOME MEASURES: Standardized adaptive functioning, intellectual, psychiatric, and neuroimaging assessments were conducted on average 2 years after injury. RESULTS: Severe TBI was associated with significantly (p < .05) lower Vineland Adaptive Behavior composite, communication, and socialization standard scores and lower Child Behavior Checklist parent-rated social competence scores compared with children with orthopedic injury. Severe TBI and mild TBI subjects were significantly (p < .05) more impaired than orthopedic subjects on teacher-rated adaptive function. Family functioning, psychiatric disorder in the child, and IQ were significant variables, explaining between 22% and 47% of the variance in adaptive functioning outcomes. CONCLUSIONS: Severe TBI is associated with significant deficits in child adaptive functioning. This association appears to be mediated by family dysfunction, child psychiatric disorder, and intellectual deficits.

Oppositional defiant disorder symptomatology after traumatic brain injury: a prospective study.

Our goal was to prospectively study the course of oppositional defiant disorder (ODD) symptomatology in children and adolescents in the first 2 years after traumatic brain injury (TBI). Fifty children aged 6 to 14, hospitalized after TBI, were assessed soon after TBI regarding injury severity; preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; and neuroimaging was analyzed. ODD symptomatology in the first year after TBI was related to preinjury family function, social class, and preinjury ODD symptomatology. Increased severity of TBI predicted ODD symptomatology 2 years after injury. Change (from before TBI) in ODD symptomatology at 6, 12, and 24 months after TBI was influenced by socioeconomic status. Only at 2 years after injury was severity of injury a predictor of change in ODD symptomatology. The influence of psychosocial factors appears greater than severity of injury in accounting for ODD symptomatology and change in such symptomatology in the first but not the second year after TBI in children and adolescents. This appears related to persistence of new ODD symptomatology after more serious TBI.

Pediatric traumatic brain injury and burn patients in the civil justice system: the prevalence and impact of psychiatric symptomatology.

The goal of this research was to conduct an assessment of psychopathology in plaintiffs following pediatric traumatic brain injury (TBI) and burns and its relationship to awards of total compensatory damages. Childhood TBI (n = 43) and burn (n = 51) plaintiffs were ascertained through a survey of the U.S. civil justice system involving a review of judicial opinions and verdict reporters in cases that had resulted in an award of compensatory damages in all states from 1978 to 1988. Narrative summaries, drawn from these sources with supplemental information from counsel of record, where possible, were prepared. Psychiatric and disability ratings were made from the summaries, blind to award data. Outcome measures were the pattern and prevalence of psychiatric disorders and their correlation with the awards. It was found that psychiatric disorders, which were almost exclusively internalizing disorders (e.g., anxiety), were present in approximately 25 percent of the subjects in each group. Psychiatric symptoms were not related to the award amount. Significantly greater awards in the TBI group were accounted for by greater disability measures. Physical disability and total disability (including physical and quality of life limitations) were significantly and independently correlated with the award. It is concluded that the prevalence of psychiatric disorders in childhood TBI and burn plaintiffs is similar to that found in TBI and burn subjects in clinical studies. Distribution of disorders is atypical in that externalizing disorders (e.g., attention deficit/hyperactivity disorder) were not commonly reported for either class of injuries. Awards are strongly correlated with disability variables reflecting mainly the severity of physical injury. Internalizing psychopathology may be underappreciated in decisions involving magnitude of awards following selected childhood injuries.

The Neuropsychiatric Rating Schedule: reliability and validity.

OBJECTIVE: To evaluate reliability and validity for the Neuropsychiatric Rating Schedule (NPRS) interview designed to permit diagnosis of organic personality syndrome (OPS) or personality change due to a general medical condition (PC). METHOD: Subjects from prospective (n = 50) and retrospective (n = 72) studies of traumatic brain injury were aged 6 through 18 years. Parents and children were informants for the NPRS. Convergent and discriminant validity of subtypes of OPS/PC were assessed against standard scales completed by parents and teachers. Interrater reliability data (n = 20), test-retest reliability data (n = 42), as well as sensitivity-to-change data (n = 37) were collected. RESULTS: All subtypes of OPS/PC were diagnosed, but apathy and paranoia subtypes were rare. Rating scale data supported convergent validity of OPS/PC subtypes generated with the NPRS. Affective instability, rage/aggression, and inappropriate social judgment were moderately to highly correlated, but apathy and paranoia could be discriminated from each of these subtypes. Interrater agreement for NPRS items was fair to excellent for all but one item (paranoia). Test-retest reliability was fair to good, and sensitivity to change was demonstrated. CONCLUSION: The NPRS generated reliable and valid diagnoses of the common subtypes of OPS/PC.

Child and adolescent traumatic brain injury: correlates of disruptive behaviour disorders.

A record review focused on children and adolescents, with a history of traumatic brain injury (TBI), who were consecutively admitted to a brain injury clinic in which all new patients are psychiatrically evaluated. Correlates of post-injury oppositional defiant disorder/conduct disorder (ODD/CD) and post-injury attention deficit hyperactivity disorder (AHD) were investigated. Subjects who developed ODD/CD following TBI, when compared to subjects without a lifetime history of the disorder, had significantly more impaired family functioning, showed a trend toward a greater family history of alcohol dependence/abuse and suffered a milder TBI. In contrast, there were no variables which discriminated between subjects who developed ADHD following injury and those with no lifetime history of ADHD. It is difficult to determine whether ODD, CD and ADHD occurring after TBI in the patient is related to the TBI, directly or indirectly. Appropriate clinical assessment requires consideration of the important mediating role of family functioning, severity of injury and family psychiatric history.

Child and adolescent traumatic brain injury: correlates of injury severity.

A record review focused on children and adolescents, with a history of traumatic brain injury, who were consecutively admitted to a brain injury clinic in which all new patients are psychiatrically evaluated. Significant correlates of severity of injury in the cognitive, education and communication domains of functioning included Performance IQ but not Verbal IQ nor standardized ratings of language or learning disability. Current organic personality syndrome (OPS) but not attention deficit hyperactivity disorder or oppositional defiant disorder/conduct disorder diagnostic status was significantly related to severity. In conclusion, the findings in this referred sample are similar to prospective studies indicating that Performance IQ appears sensitive in reflecting brain damage. The finding linking OPS to severity of injury is not surprising. This is because OPS is a diagnosis which is dependent on the clinician's judgment of the likelihood that the organic factor is etiologically related to a defined behavioural syndrome. The diagnosis therefore requires a clinical judgment that the threshold of severity of a presumed organic etiological factor has been reached.

Predictors of family functioning after traumatic brain injury in children and adolescents.

OBJECTIVE: To assess factors predictive of family outcome in the first 2 years after traumatic brain injury (TBI) in children and adolescents. METHOD: Subjects were children aged 6 to 14 at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury factors (psychiatric family functioning, and family life events), injury factors (severity of injury), and postinjury factors (coping and development of a psychiatric disorder, never before present, i.e., "novel") were conducted using standard clinical scales. The outcome measure was family function as assessed with standardized family functioning interviews (at 12 and 24 months after TBI) and primary caretaker self-report questionnaires (at 3 and 6 months after TBI). RESULTS: Fifty subjects enrolled, and the analyses focused on 37, 41, 43, and 42 subjects assessed at the 3-, 6-, 12-, and 24-month follow-up evaluations, respectively. The strongest influences on family functioning after childhood TBI are preinjury family functioning, the development of a "novel" psychiatric disorder in the child, and preinjury family life events or stressors. CONCLUSIONS: These data suggest that there are families, identifiable through clinical assessment, at increased risk for family dysfunction after a child's TBI. Early identification and treatment of the child's psychopathology and family dysfunction may attenuate the associated morbidity.

Traumatic brain injury in a child psychiatry inpatient population: a controlled study.

OBJECTIVE: To extend our findings from child psychiatry outpatients to child psychiatry inpatients regarding the similarity of children with a history of traumatic brain injury (TBI), particularly mild TBI, to matched children without such a history. METHOD: This is a chart review of patients consecutively admitted to a child psychiatry inpatient unit over a 5-year period. Children with TBI were matched by age, sex, race, and social class to children with no history of TBI. Axis I and II diagnoses and diagnostic clusters and use of special education services and IQ scores were compared. RESULTS: Fifty-six (8.1%) of 694 consecutive patients admitted had a definite TBI. Not one of more than 50 variables compared between TBI and control subjects was significantly different. CONCLUSION: In a child psychiatry inpatient unit, patients with a history of TBI were virtually indistinguishable from matched children without TBI. Caution should be exercised before attributing the child's problems, especially long-term problems, to the TBI unless the injury was severe or the child is exhibiting related phobic or posttraumatic stress symptomatology.

Child and adolescent traumatic brain injury: psychiatric findings from a paediatric outpatient specialty clinic.

A record review focused on children and adolescents, with a history of traumatic brain injury, who were consecutively admitted to a brain injury clinic in which all new patients are psychiatrically evaluated. The development of a 'novel' psychiatric disorder (not present before injury) occurred in 76% (38/50) of the cohort and was correlated significantly with family psychiatric history and family function, but not with severity of injury, preinjury psychiatric status, intellectual/educational functioning, or socioeconomic status. Psychiatric consultation is often necessary in this paediatric population even though much of the psychopathology, particularly following mild injury, may not be directly related to brain trauma.

Traumatic brain injury in children and adolescents: psychiatric disorders at two years.

OBJECTIVE: To extend findings regarding predictive factors of psychiatric outcome from the first to the second year after traumatic brain injury (TBI) in children and adolescents. METHOD: Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the presence of a psychiatric disorder, not present before the injury ("novel"), during the second year after TBI. RESULTS: Fifty subjects enrolled, and the analyses focused on 42 subjects followed at 24 months. Severity of injury, preinjury family function, and preinjury lifetime psychiatric history predicted the development of a "novel" psychiatric disorder present in the second year. CONCLUSION: These data suggest that there are children, identifiable through clinical assessment, at increased risk for "novel" psychiatric disorders in the second year after TBI.

Traumatic brain injury in children and adolescents: psychiatric disorders in the second three months.

Psychiatric disorders may be common after traumatic brain injury (TBI) in children, yet there is a death of prospective studies examining this problem. Fifty children aged 6 to 14, hospitalized after TBI, were assessed soon after TBI regarding preinjury psychiatric, behavioral, adaptive, and family functioning, family psychiatric history status and injury severity. The outcome measure was the presence of a "novel" psychiatric disorder (not present before the injury) during the second 3 months after the injury. Forty-two subjects were reassessed at 6 months. Severity of injury, family psychiatric history, and family function predicted a novel psychiatric disorder. Among children suffering a mild/moderate injury, those with preinjury lifetime psychiatric disorders were no longer (as they had been in the first 3 months) at higher risk than those without such a lifetime history. Thus, there appeared to be children, identifiable through clinical assessment, at increased risk for novel psychiatric disorders after TBI.

Traumatic brain injury in a child psychiatry outpatient clinic: a controlled study.

OBJECTIVE: To demonstrate the similarity of children with a history of traumatic brain injury (TBI), particularly mild TBI, to matched children without such a history, within a child psychiatry outpatient clinic. METHOD: This is a chart review of patients presenting to a child psychiatry outpatient clinic over a 3-year period. Children with TBI were matched by age, sex, race, and social class to children with no history of TBI. Axis I and II diagnoses, use of special education services, and IQ scores were compared. RESULTS: Seventy-four (5.6%) of 1,333 consecutive clinic cases had a definite TBI. Of these, 64 were mild. Only 3 of 59 comparisons that were made between TBI and control subjects were significant. A developmental communication disorder cluster was significantly more frequent in the TBI group. Autism and a pervasive developmental disorder cluster were significantly more frequent in the control group. CONCLUSION: In a child psychiatry clinic, patients with a history of TBI are virtually indistinguishable from matched children without TBI. Caution should be exercised before attributing the child's problems, especially long-term problems, to the TBI unless the injury was severe or the child is exhibiting related phobic or posttraumatic stress symptomatology.