Functional outcome in children with multiple trauma without significant head injury.

OBJECTIVE: To assess functional outcome and describe disability at discharge in children who have had trauma without significant head injury. DESIGN: Retrospective cohort. SETTING: National Pediatric Trauma Registry, 1988-1994. PARTICIPANTS: Patients of ages 7 to 18 years with Glasgow Coma Scale (GCS) 13 to 15 without significant anatomic head inJury. RESULTS: Functional Independence Measure (FIM) at discharge was used to assess patient outcome. There were 13,649 children meeting study criteria who had sustained 34,254 injuries. Fractures constituted 30% of all injuries. As measured by FIM, 1,522 (11.2%) patients had mild disability at discharge; 1,983 (14.5%) had moderate disability. After adjustment for age and injury severity, children with lower extremity fractures were more likely to be discharged with functional limitations than those without (relative risk, 5.43; 95% confidence interval: 5.06, 5.84). Of children with moderate disability at discharge, less than 50% were referred for rehabilitation evaluation and less than 25% for physical therapy. CONCLUSION: Functional dependence is present in a large proportion of injured children, even without significant head injury. Rehabilitation and other services may be underused in this population. Further study is required to fully assess the degree and duration of disability in these patients.

Written language production and neuropsychological function in children with traumatic brain injury.

OBJECTIVE: To establish the early consequences of traumatic brain injury (TBI) on spontaneous written language production in children by examining writing deficits as a function of injury severity and correlating written performance with neuropsychological data. DESIGN: Case-control cohort study. SETTING: Two regional medical centers. PATIENTS: Seventy-six children, aged 8 to 15 years, with mild, moderate, or severe closed head injury were compared with controls who were individually matched on the premorbid characteristics of age, gender, school grade, behavior, and academic performance. MAIN OUTCOME MEASURES: Assessment of written language production and neuropsychological function was undertaken approximately 1 month following resolution of posttraumatic amnesia. Case-control differences on 16 measures of spontaneous written narratives were computed. RESULTS: Factor analysis and conceptual similarities suggested that the measures of written language fell into five domains: Efficiency, Completeness, General Readability, Error, and Vocabulary. A highly significant, moderate correlation between these measures and severity of injury was found. The highest correlations were found for the written language domains of Efficiency and Completeness and the lowest for the Vocabulary domain. Moderate correlations were also found between measures of written language and neuropsychological function. CONCLUSIONS: At 1 month after resolution of posttraumatic amnesia, written language production in children with TBI is negatively correlated with severity of injury. Some aspects of written language production are affected to a greater extent than others. Considerable common ground was found between written language production and neuropsychological function.

Predictors of family functioning and change 3 years after traumatic brain injury in children.

OBJECTIVES: To examine changes in family functioning from injury to 3 years after pediatric traumatic brain injury; to determine factors most predictive of family outcomes at 3 years and variables that promote positive outcomes and changes over time. DESIGN: Prospective cohort study. SETTING: Two regional tertiary care centers: cases followed for 3 years into community. PARTICIPANTS: Families of 81 children, ages 6 to 15 years, who sustained closed head injury and loss of consciousness (mild = 43, moderate = 20, severe = 18), consecutively enrolled over 15 months. MAIN OUTCOME MEASURES: Family Environment Scale, Family Assessment Device, Family Inventory of Life Events, Health Insurance Survey-General Well-Being, NYU Problem Checklist for Significant Others, Family Interview Rating Scale, Family Global Assessment Scale. All were obtained initially and at 3 months, 1 year, and 3 years postinjury. Predictor variables were selected from the instruments above, as well as from the parent and teacher versions of the Child Behavior Checklist, socioeconomic status, and injury severity. RESULTS: Preinjury functioning was the best predictor of 3-year outcomes. Fewer changes in family functioning were reported over 3 years in the mild or moderate groups, whereas more deterioration occurred in the severe group. At 3 years, one third to one half of parents in either the moderate or severe groups reported medium to high strain in 19 of 34 problem areas. Low levels of family control and high levels of expressiveness correlated with better outcomes for severe group. Positive change for the severe group was marked by better preinjury levels of communication, expressiveness, problem solving, use of resources, role flexibility, greater activity orientation, and less conflict, control, and stress. Preinjury variables and severity explained from 26% to 69% of the variation in 3-year outcomes. CONCLUSIONS: Families at risk for poorer outcomes can be prospectively identified and should be supported and encouraged in their efforts to develop new coping resources.

Acute gastric dilatation in Duchenne muscular dystrophy: a case report and review of the literature.

Duchenne muscular dystrophy (DMD) is the most common neuromuscular disorder of childhood. Its clinical characteristics that derive from skeletal muscle involvement have been well described. Less well known is that visceral smooth muscle is affected in DMD. We report a case of a 19-year-old man with DMD who presented with severe nonradiating epigastric pain. He was initially sent home from the emergency department with a diagnosis of costochondritis. Acute gastric dilation was not considered in the differential diagnosis despite supportive history, physical examination findings, and radiographs. The case illustrates the lack of familiarity by clinicians of the gastrointestinal manifestations of DMD, including gastric dilatation and intestinal pseudoobstruction. Following a case discussion, the literature relevant to acute gastric atony is reviewed.

Neurobehavioral sequelae of severe pediatric traumatic brain injury: a cohort study.

OBJECTIVES: To determine: (1) the magnitude of neurobehavioral deficits following severe traumatic brain injury (TBI) in children, 3 weeks and 1 year after resolution of post-traumatic amnesia (PTA); (2) the relationship between deficits and injury severity; (3) the performance of cases compared to population norms versus individually matched controls. DESIGN: Prospective cohort study. SETTING: Two regional university medical centers. PARTICIPANTS: Cases were 30 children 6 to 15 years old with severe TBI, measured by initial Glasgow Coma Scale (GCS) score and days to reach a GCS score of 15. Controls were individually matched for age, gender, and premorbid academic achievement. MAIN OUTCOME MEASURES: Subjects received the same neurobehavioral tests three weeks and one year after resolution of PTA. Outcomes included individual test scores and variables summarizing results in eight domains. Correlations were calculated between deficits, expressed as case-control differences, and injury severity. RESULTS: Cases showed substantial deficits and performed significantly more poorly than controls at both initial and 1-year testing. At initial testing, cases had an overall score two standard deviations below controls. At 1-year testing their overall score was one standard deviation below controls. Greater impairment was found in those who reached a GCS score of 15 after 1 month or who had an initial GCS of 3 to 5. The proportion of cases with deficits and the magnitude of deficits at both testing times was underestimated by using population norms instead of controls. CONCLUSIONS: Severe TBI results in significant, persistent deficits related to the level of severity. Comparisons with population norms instead of controls underestimates deficits.

Amyoplasia, the most common type of arthrogryposis: the potential for good outcome.

BACKGROUND: Amyoplasia is the most commonly seen diagnostic subgroup of children with arthrogryposis. The natural history of these children has not been well described previously. METHODS: Review of the medical records of 38 children with amyoplasia enabled us to describe their birth characteristics, therapeutic interventions, and functional outcomes. RESULTS: Eighty-four percent of the children had symmetrical, four-limb involvement, which was similar to the original descriptions of amyoplasia, at birth. There was an average of 5.7 orthopedic procedures per child, and the children had multiple castings and splintings of their limbs and participated in physical and occupational therapy on a regular basis. By the age of 5 years, 85% were ambulatory, most were relatively or completely independent in their activities of daily living, and most were in regular classrooms at the appropriate grade level. CONCLUSION: Although children with amyoplasia have pronounced musculoskeletal involvement at birth, which requires orthopedic and rehabilitative interventions during their childhood, their functional outcome in both physical and educational areas is excellent.

Recovery trends over three years following pediatric traumatic brain injury.

This cohort study investigated the magnitude of neurobehavioral, academic, and "real world" deficits over the course of 3 years in children with mild, moderate, and severe traumatic brain injury (TBI), and their individually matched controls. This series of analyses addresses the history of recovery, tracing changes in performance over time. Data on 72 case-control pairs (mild, n = 40; moderate, n = 17; severe, n = 15) were available for three testing times: 3 weeks, 1 year, and 3 years after the resolution of post-traumatic amnesia. The same standardized battery of tests was used at all testing times. The dependent variables in these analyses included individual test results, a variable summarizing results within each of 10 neurobehavioral domains, and an overall score across all domains. Three statistics were calculated for each variable: (1) the "grand" mean across the three testing times; (2) the slope (expressing the linear trend in performance); and (3) the change in slope over time (expressing the change in the rate of recovery). Use of the differences between case and control scores controlled for premorbid factors, maturation, and test-retest effects. Results indicate the chronicity of neurobehavioral deficits across all 3 years for moderately and severely injured children. They show a strong improvement rate during the first year, but a negligible rate of change during the following 2 years postinjury in most domains. All three of the time components--grand mean, slope, and change in slope--have significant Spearman correlations with severity ranging up to rho = -.5. Over time, the recovery rate slows down more for those with greater brain injury severity. The greatest slowing of recovery occurs in Performance IQ, adaptive problem solving, memory, and motor skills, as well as on a summary score of overall performance. Given this "plateauing" of recovery, achievement of parity with peers by the moderately and severely injured seems unlikely. Mildly injured children, however, exhibit negligible deficits or change in performance over time.

Osteogenesis imperfecta: an overview of general pediatric rehabilitation.

The unique biological changes associated with Osteogenesis Imperfecta (OI) result in a dramatic reduction in a child's functional capacity. Successful adaptation and optimal functioning for the child and family, the over-arching goal of comprehensive rehabilitation, are dependent upon the complex interactions between biological processes and a host of behavioral, psychosocial, and environmental factors. This article reviews the premises underlying the need for rehabilitation; general rehabilitation strategies; the aims and outcomes to be achieved through the provision of rehabilitation; and the broad-based issues and variables that affect outcome. Because of the multifactorial and complex nature of the pediatric disability, advances in the rehabilitation of children with OI will require long-term, multivariant, and multicenter studies that will capture health-related, psychosocial, environmental, and functional variables.

Outcome of pediatric traumatic brain injury at three years: a cohort study.

This cohort study examined the neurobehavioral, academic, and "real world" consequences of mild, moderate, and severe traumatic brain injury in children at 3 years following the resolution of posttraumatic amnesia. Seventy-two children, aged 6 to 15 years at time of injury, were individually matched with controls on the basis of age, gender, school grade, and the classroom teacher's assessment of premorbid academic achievement and behavior. Both groups were assessed using the same standardized neuropsychological test battery and parent and teacher report measures as were used initially and at 1-year follow-up covering 10 cognitive, behavioral, and functional domains. The performance of both moderately and severely injured children was worse than their controls on 40 out of 53 variables. The association of outcome variables with injury severity was validated using school achievement tests and grades. Analyses of the impact of preinjury variables and study dropouts on outcome showed no threat to the validity of study findings. These results provide strong validation for the persisting and comprehensive nature of neuropsychological deficits in children and adolescents with moderate and severe traumatic brain injury.

Mild pediatric traumatic brain injury: adjusting significance levels for multiple comparisons.

The outcome following mild traumatic brain injury (TBI) is controversial. We addressed this topic in a study of neurobehavioural and 'real-world' functioning among 53 children with mild TBI and their matched controls, using statistical methods recently developed for multiple comparisons. Because the study involved calculation of 414 p-values, four methods of adjustment for multiple comparisons, including the Bonferroni method, were used to avoid 'false-positive' statistical significance. The additional three methods allowed greater insight into the data than provided by the standard Bonferroni adjustment. Results showed that at initial testing, three areas of 'real-world' functioning (eating, domestic and home/community living skills) had weak but statistically significant associations with mild injury. No other specific areas of neuro-behavioural or 'real-world' functioning had plausible associations with the injury either initially, at 1 year, or when changes over the year were considered. However, the adjustment for multiple comparisons provided additional results. There were statistical significant associations of the injury with the entire domain of neurobehavioural variables both initially and at 1 year. These results suggest that the injury affects a spectrum of neurobehavioural skills weakly, rather than a single area substantially. The gain from using multiple comparison methods is discussed.

Family functioning and children's academic performance and behavior problems in the year following traumatic brain injury.

This study examined the roles of preinjury family and child functioning and injury severity in predicting 1-year outcomes and changes in academic performance and behavioral problems following childhood traumatic brain injury (TBI). Families of 94 children (ages 6 to 15) with TBI (mild = 50, moderate = 25, severe = 19) were consecutively enrolled from emergency departments of two regional medical centers. Standardized measures of family and child functioning and interviewer ratings were completed within 3 weeks of injury (measuring preinjury status), at 3 months, and 1 year. Mean ratings of preinjury child functioning were within normal range. Whereas injury severity was associated with substantial declines in academic functioning, there was no association of injury severity with change in behavior problems. Interview ratings showed declines at all severity levels, however. Poor academic and cognitive outcomes at 1 year were associated with injury severity and, to a lesser degree, poor preinjury family and child functioning. In contrast, most of the variation in behavioral outcomes was explained by preinjury child or family factors. Preinjury functioning must be assessed and support services provided for optimal academic and behavioral outcomes following childhood TBI.

Comparison of indices of traumatic brain injury severity as predictors of neurobehavioral outcome in children.

This study examined the ability of early measures of traumatic brain injury (TBI) severity to predict neurobehavioral and functional skill outcomes shortly after injury and at 1 year postinjury. Ninety-eight children aged 6 to 15 years with TBI were consecutively identified on presentation to two regional medical centers. Ten measures of TBI severity were subsequently administered: initial Glasgow Coma Scale (motor, eye, verbal, and total GCS), duration of loss of consciousness, Abbreviated Injury Scale Head score, GCS motor score at 3 days postinjury, days to reach a total GCS score of 15, days to reach a GCS motor score of six, and duration of posttraumatic amnesia (days to reach a 75% performance on the Children's Orientation and Amnesia Test [COAT]). Cases were matched individually with controls on the basis of age, gender, school grade, the classroom teacher's assessment of pre-morbid level of academic performance in reading and arithmetic, and pre-morbid behavior. Both groups received intellectual, neuropsychologic, academic, and functional skill assessments three weeks after the case achieved full orientation and 1 year later. The indices of injury severity that were most predictive of both early and 1-year outcome across all neurobehavioral and functional measures were (1) days to an age-adjusted 75% performance on the COAT, (2) days to a GCS score of 15, and (3) initial total GCS score. For most outcome areas, a single measure of severity predicted outcome almost as well as multiple measures. However, early and 1-year academic performance and 1-year memory performance were best predicted by considering multiple indices of brain injury severity. The GCS verbal and motor scores were better predictors of outcome than the GCS eye score. However, consideration of individual GCS subscores did not improve upon prediction of outcome versus the GCS total score. These results provide strong validation for the use of duration of posttraumatic amnesia, measured by the COAT, as a measure of TBI severity and a significant indicator of neurobehavioral and functional outcome in children.

Family functioning and injury severity as predictors of child functioning one year following traumatic brain injury.

This study examined changes in children's functioning in the year following traumatic brain injury (TBI) and the preinjury family and injury factors most predictive of children's overall adaptive functioning and social competence at 1 year. Ninety-four children with TBI (mild = 50, moderate = 25, severe = 19) and their families were consecutively enrolled from two regional medical centers. The age range was from 6 years to 15 years. Interviewer ratings and standard measures of family and child functioning were completed within 3 weeks of injury (measuring preinjury status), at 3 months and 1 year. Mean preinjury parent and teacher ratings of child functioning were within normal range. Older children (> or = 12 years) had worse preinjury functioning than younger children. Declines in child functioning were significantly associated with injury severity. Mild and moderately injured children had few declines in overall functioning. Severely injured children had the most dramatic early declines and improved only slightly between 3 months and 1 year; however, older children from poorly functioning families deteriorated in the same period. Injury severity and preinjury family functioning explained from 25% to 39% of the variation in child functioning at 1 year and up to 57% when the child's preinjury status was included. Children at risk for poorer adaptation following TBI can be identified and for optimal recovery should receive appropriate support services for optimal recovery.

Mild pediatric traumatic brain injury: a cohort study.

Using a prospective, cohort design, we investigated whether children with mild traumatic brain injury (TBI) differed from individually matched controls on measures of intellectual, neuropsychological, academic, and "real world" functioning. Subjects included children between the ages of 6 and 15 years who sustained mild, moderate, and severe closed head injuries and were consecutively identified on presentation to the emergency departments of two regional, university medical centers. One hundred twenty-nine children were eligible for enrollment. Seventeen refused enrollment. Fifty-nine of the 112 enrolled children were classified as mildly injured. Six of these children dropped out, leaving 53 mildly injured cases for analysis. Individually matched controls from the classroom of the injured cases were identified based on age, gender, and premorbid academic achievement and behavior. Assessment measures included standardized intellectual, neuropsychological, and academic measures. Also, parent and teacher questionnaires, measuring social, educational, domestic, and community living skills were used. Among 51 outcome variables only five were significantly associated with injury at initial or 1-year testing after adjusting for multiple comparisons. However, these five associations were either very weak or implausible. Results from this study suggest that mild TBI produces virtually no clinically significant long-term deficits in intellectual, neuropsychological, academic, or "real world" functioning.

Pediatric traumatic brain injury: acute and rehabilitation costs.

Pediatric traumatic brain injury constitutes an enormous public health problem, but little is known about the economic costs of such injury. Using charges as a proxy for cost, we prospectively collected data on initial hospital charges and professional fees for emergency department services, acute inpatient care, and acute inpatient rehabilitation for 96 patients with mild, moderate, and severe traumatic brain injuries. We also examined the relationship between these costs and injury severity and etiology. Acute care and rehabilitation median costs were $5,233 per child, $11,478 for hospitalized children, and $230 for those only seen in the emergency department. Median costs for injuries due to motor vehicles, bicycles, and falls were $15,213, $6,311, and $792, respectively. Using Glasgow Coma Scale criteria, median cost of mild, moderate, and severe traumatic brain injuries were $598, $12,022, and $53,332, respectively. Injury etiology added modestly but significantly to the prediction of cost over and above that predicted by injury severity alone. Rehabilitation costs accounted for 37% of the total for all children, but 45% of those with the most severe injuries.

Severity of pediatric traumatic brain injury and neurobehavioral recovery at one year--a cohort study.

As part of an ongoing longitudinal cohort study of children with mild, moderate, and severe traumatic brain injury and their matched controls, the neurobehavioral status of 94 case-control pairs was assessed one year after initial postinjury testing. There was a statistically significant dose-response association of severity with performance in all six domains of neurobehavioral functioning (intelligence, adaptive problem solving, memory, academic performance, motor performance, and psychomotor problem solving) with Spearman correlation coefficients of up to -.35, p < .001. The strongest correlations between severity and outcome were in the domains of intelligence, academic performance, and motor performance. Recovery over the year was also dependent on the severity of brain injury. Because mildly injured cases had negligible initial deficits, recovery was not at issue. However, for moderately and severely injured children, the degree of initial impairment was related to the magnitude of both recovery and residual deficit. Results showed that the use of population normative values to evaluate impairment was misleading. Although the mean scores of all severity groups fell within the normal range of standardized tests, the means for the moderately and severely injured were substantially below those of their matched controls on many tests.

Traumatic brain injury as a risk factor for behavioral disorders in children.

The most common behavioral problems that are associated with traumatic brain injury in children are the same behaviors that prompt referral to special education for behavioral disorder. The purpose of this study was to determine whether there is an association between traumatic head injury in children and subsequent behavioral disorders for which special educational services are provided. A case-control design was used to compare occurrences of prior head injury in children receiving special educational services for behavioral disorders (cases) to similar occurrences in children in regular education (controls). Subjects included 170 case and 197 control students in grades 1 through 5 in a single large school district during 1988-1989. Data were collected by parent questionnaire and school record review. The odds ratio (OR) of a history of head injury among children with behavioral disorders relative to controls was 3.3 (95% confidence interval [CI] 1.3-8.3); the OR of a history of head injury sustained during the preschool years was 8.7 (95% CI 2.5-30.7) in cases relative to controls. Mean IQ scores were significantly lower for cases injured at two years of age or less in comparison with cases injured later. Full scale IQs (+/- SD) were 88 +/- 5 versus 107 +/- 14 (t = 3.5, p = .008), performance IQs 91 +/- 9 versus 108 +/- 12 (t = 3.0, p = .012), and verbal IQs 86 +/- 7 versus 106 +/- 15 (t = 3.2, p = .008). Achievement test results did not differ between cases with and those without histories of head injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Motor performance in children after traumatic brain injury.

Traumatic brain injury can result in persistent impairments of motor performance that interfere with functional activities. This study compared the gross and fine motor performance of 14 traumatically brain-injured children (five to 15 years old, with loss of consciousness for at least 24 hours) to 14 normal children group matched for age and sex. All subjects had normal intelligence and no prior history of cognitive or motor delays. Subjects were assessed with the Bruininks-Oseretsky Test of Motor Proficiency at least 16 months after injury. Results were compared using the Wilcoxon rank sum test. Highly significant differences were found between groups on the Gross Motor Composite. Although no significant differences were found on the Fine Motor Composite, a highly significant difference also was found on one of the fine motor sub-tests, Upper-Limb Speed and Dexterity. Subtest analysis revealed that when speed was a component of either fine or gross motor tasks, a pattern of significant differences was found. This is consistent with previous research in neuropsychology, which has demonstrated problems in speeded motor performance of children with brain injuries. These findings provide direction for further research, clinical assessment, and treatment of this at-risk population.