Psychiatric disorders in children and adolescents in the first six months after mild traumatic brain injury.

The objective was to assess the nature, rate, predictive factors, and neurocognitive correlates of novel psychiatric disorders (NPD) after mild traumatic brain injury (MTBI). Children age 5-14 years with MTBI (N=87) from consecutive admissions to five trauma centers were enrolled and studied with semistructured psychiatric interviews soon after injury (baseline), and 70 of these children were assessed again 6 months post-injury. Injury severity; lesion characteristics; pre-injury variables, including psychiatric disorder, family psychiatric history, family functioning, socioeconomic status, psychosocial adversity, and adaptive functioning; and post-injury neurocognitive and adaptive functioning measures were assessed with standardized instruments. NPD occurred in 25 of 70 participants (36%) in the first 6 months after injury. NPD at 6 months was predicted by the presence of frontal white-matter lesions on MRI at 3 months post-injury, and was associated with concurrent decrements on neurocognitive indices of processing speed, expressive language, and intellectual functioning. NPD was not predicted by other indices of severity, pre-injury psychosocial variables, estimated pre-injury academic functioning, or adaptive and executive function decrements 6 months post-injury. These findings suggest that short-term psychiatric morbidity associated with MTBI in children and adolescents may be more common than previously thought and may have readily identifiable neuroimaging and neurocognitive correlates.

Evaluation of the errorless learning technique in children with traumatic brain injury.

OBJECTIVE: To compare errorless learning with trial-and-error (T&E) learning of declarative facts in children with memory disorders secondary to traumatic brain injury (TBI). DESIGN: Retrospective within-subjects concurrent treatment design. SETTING: Participants' school or home. PARTICIPANTS: Thirty-four children, ages 6 to 18 years, with mild, moderate, or severe postacute TBI who met criteria for memory impairment. INTERVENTION: Conditions consisted of an errorless learning method and a T&E method. Within a session, half the items were taught with the errorless learning method and half with the T&E method. Each child received two 1-hour sessions a week for 7 weeks. MAIN OUTCOME MEASURES: Relative effectiveness of errorless learning and T&E methods for (1) initial learning and (2) retention over time for learned items. RESULTS: There was an advantage for T&E on initial learning. In children with mild, but not moderate or severe TBI, 2-day retention was better with the errorless learning technique; 7-day retention was better with errorless learning in young children with mild TBI. Seventy-seven-day retention revealed an advantage for errorless learning in younger children with severe TBI. CONCLUSIONS: Findings did not support errorless learning as a generalized intervention for learning difficulties after TBI or identify specific age- or injury-severity groups that benefited from this technique.

Predictors of personality change due to traumatic brain injury in children and adolescents six to twenty-four months after injury.

Phenomenology and predictive factors of personality change due to traumatic brain injury (TBI) 6 to 24 months after injury was investigated in children, ages 5 to 14 years, enrolled from consecutive admissions and followed prospectively for 2 years. Injury and preinjury psychosocial variables were assessed. Personality change occurred in 13% of participants between 6 and 12 months after injury and 12% in the second year after injury. Severity of injury consistently predicted personality change, and preinjury adaptive function predicted personality change only in the second year postinjury. Lesions of the superior frontal gyrus were associated with personality change between 6 and 12 months following injury, after controlling for severity of injury and the presence of other brain lesions. Only lesions in the frontal lobe white matter were significantly related to personality change in the second year after injury. After childhood TBI, neural correlates of personality change evolve between 6 and 12 months and 12 to 24 months after injury. The data implicate the dorsal prefrontal cortex and frontal lobe white matter in the emergence of personality change involving the effortful or conscious regulation of affective states.

Predictors of attention-deficit/hyperactivity disorder within 6 months after pediatric traumatic brain injury.

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively for 6 months (baseline and 6 months), with semistructured psychiatric interviews. Injury severity, lesion characteristics, and preinjury variables including psychiatric disorder, family psychiatric history, family psychiatric history of ADHD, family function, socioeconomic status, psychosocial adversity, and adaptive function were assessed with standardized instruments. RESULTS: SADHD in the first 6 months after injury occurred in 18 of 115 (16%) of returning participants. All subtypes of ADHD occurred. Socioeconomic status (p = .041) and orbitofrontal gyrus lesions (p = .005) independently significantly predicted SADHD. CONCLUSIONS: These findings are consistent with research on developmental ADHD that implicate psychosocial factors and prefrontal structural and functional differences between those with and without the disorder.

Predictors of secondary attention-deficit/hyperactivity disorder in children and adolescents 6 to 24 months after traumatic brain injury.

OBJECTIVE: To assess the phenomenology and predictive factors of attention-deficit/hyperactivity disorder (ADHD) after traumatic brain injury (TBI), also called secondary ADHD (SADHD). METHOD: Children without preinjury ADHD 5-14 years old with TBI from consecutive admissions (n = 143) to five trauma centers were observed prospectively from 6 to 12 months (12-month assessment) and from 12 to 24 months (24-month assessment) postinjury with semistructured psychiatric interviews. Injury and preinjury psychosocial variables were assessed. RESULTS: SADHD occurred in 15 of 103 (15%) of participants between 6 and 12 months after injury and 17 of 82 (21%) in the second year after injury. SADHD was significantly (p < .05) comorbid with personality change due to TBI and new-onset disruptive behavior disorders. Preinjury adaptive function was a consistent predictor of SADHD. Regression analyses revealed that preinjury psychosocial adversity was an independent predictor of SADHD in the second year after injury. Neither severity of injury nor lesion location predicted SADHD from 6 to 24 months postinjury. CONCLUSIONS: Determination of preinjury psychosocial adversity and the child's preinjury functioning during the index hospitalization would improve identification of children at highest risk of development of SADHD.

Predictors of personality change due to traumatic brain injury in children and adolescents in the first six months after injury.

OBJECTIVE: To assess the phenomenology and predictive factors of personality change due to traumatic brain injury. METHOD: Children (N = 177), aged 5 to 14 years with traumatic brain injury from consecutive admissions to five trauma centers, were followed prospectively at baseline and 6 months with semistructured psychiatric interviews. Injury severity, lesion characteristics, and preinjury variables including psychiatric disorder, family psychiatric history, family function, socioeconomic status, psychosocial adversity, and adaptive function were assessed with standardized instruments. RESULTS: Personality change occurred in 22% of participants in the first 6 months after injury. Severity of injury predicted personality change, whereas none of the psychosocial variables predicted personality change. Lesions of the dorsal prefrontal cortex, specifically the superior frontal gyrus, were associated with personality change after controlling for severity of injury or the presence of other lesions. CONCLUSIONS: These findings are consistent with models of affective dysregulation that implicate a dorsal prefrontal cortex system important for effortful regulation of affective states.

Psychosocial outcome of TBI in children with unilateral frontal lesions.

To evaluate effects of unilateral frontal lesions on psychosocial and global outcome of traumatic brain injury (TBI) in children, Study 1 compared matched groups of 22 school aged children who had sustained TBI either with or without unilateral frontal lesions. Study 2 evaluated effects of unilateral extrafrontal lesions in 18 TBI patients as compared with 18 nonlesional TBI patients. Communication, Daily Living, and Socialization domains and the Maladaptive Behavior Scale of the Vineland Adaptive Behavior Scales (VABS) were used to assess psychosocial outcome, and the Glasgow Outcome Scale (GOS) measured global outcome. All patients underwent magnetic resonance imaging at least 3 months post injury. Children with frontal lesions had worse scores on the Daily Living and Socialization domains and a higher frequency of maladaptive behavior than those without frontal lesions, but there was no difference in cognitive function. Disability was twice as common in the frontal lesion group relative to children without frontal lesions. Volume of frontal lesion was related to the Socialization domain. Side of lesion had no effect, nor did presence of an extrafrontal lesion (Study 2). Unilateral frontal lesions adversely affect late psychosocial outcome of TBI in children.