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.

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.

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.