Ensured complete case ascertainment by using data from multiple overlapping sourcesDeveloped prospective TBI register and cross-checked with ACC, MOH, sports clubs, etc.
GENDER:Infant males and females have approximately the same level of risk, but in those over 5 years of age the incidence increases faster in males and results in prevalence rates over double that of females. This gender difference is most apparent during adolescence – increased risk-taking behaviourETHNICITY:Ethnic disparities even more pronounced in paediatric populationsPREVIOUS TBI: Lifestyle factors, temperament
Other variables: For example, Chadwick, Rutter, Brown, Shaffer & Traub (1981) conducted a 2-year 3-month prospective study of TBI which found that children with mild TBI consistently demonstrated impaired cognitive performance when compared to a matched cohort. Regardless of injury severity, children with TBI may have difficulties in retaining and retrieving newly learned information.(Levin & Eisenberg, 1979).Subtle impairments in a child’s performance and classroom conduct may not be identified as being related to TBI, as teachers are often not informed of a child’s injury, particularly when it is mild, and may not be aware of the possible long-term effects of TBI (Hawley, Ward, Magnay, & Mychalkiw, 2004).Methodological issues: few longitudinal studies lack of baseline data
WISC-IV – Vocabulary, Similarities (Verbal Comprehension), Matrix Reasoning (Perceptual Reasoning), Symbol Search (Processing Speed)Estimate of FSIQ (r=.94)The short forms were selected on the basis of Sattler’s(Sattler & Dumont, 2004; Sattler & Ryan, 2009) recommendation as being suitable for rapid screening. WCJ-II - Letter- Word Identification, Applied Problems, Spelling, Passage Comprehension, Calculation and Writing Samples
BRIEF Domains:Inhibit, Initiate, Organisation of Material, Shift, Working Memory, Monitoring and Emotional ControlSDQ subscales: Emotional Symptoms, Conduct Problems, Hyperactivity-Inattention, Peer Problems, ProsocialBehaviour, Total DifficultiesKINDL - Physical health, emotional health, family functioning, self-esteem, social functioning, school functioning and an injury specific scale and has been used following TBI.
Letters to PrincipalNewslet
Mean scores for emotional and peer problems, and total difficulties were significantly higher in TBI groupParents of children with TBI perceive their children have greater social and emotional problems, and a higher level of overall difficulties, than controls
The Impact of Traumatic Brain Injury on Developmental Functioning in Children: Mild TBI at Home and School
THE IMPACT OF TRAUMATIC BRAIN INJURY ON DEVELOPMENTALFUNCTIONING IN CHILDRENMILD TBI AT HOME AND SCHOOL Rosalind Case Clinical Psychologist / Research Officer School of Psychology, University of Waikato
BIONICBrain Injury Outcomes NZ in theCommunity Epidemiology and outcomes of TBI HamiltonCity and Waikato District March 2010 – March 2011 Funded by HRC Projects Grant; led by Valery Feigin (AUT) Approximately 1300 participants Developed prospective TBI register Multiple overlapping sources, cross-checking
COBIC:Consequences of Brain Injury inChildhood 12-month follow-up of children aged 5-11 years at time of injury Jun 2011 – Present More in-depth focus on intellectual, academic, social, emotional, and behavioural functioning Complemented by BIONIC data Overall study funded by Lotteries Grant and led by Dr Nicola Starkey (University of Waikato) HRC Clinical Research Fellowship
Traumatic Brain Injury (TBI) “An acute brain injury resulting from mechanical energy to the head from external forces.” (WHO, 2005)• Immediate post-injury symptoms include one or more of the following: 1. Confusion or disorientation 2. Loss of consciousness 3. Post-traumatic amnesia 4. Other neurological abnormalities (e.g. focal neurological signs, seizure, intracranial lesion)
Classification of Severity• Severity rated according to scores on the Glasgow Coma Scale (GCS) Mild Moderate Severe • 13-15 • 9-12 • 3-8
Mild TBI Categories (Servedei,2001) Mild – Low Risk Mild – Medium Risk Mild – High RiskGCS = 15 With possible: With skull fractureNo loss of consciousness Loss of consciousness And/orNo amnesia Amnesia Neurological deficitsNo vomiting VomitingNo diffuse headache OR Diffuse headacheRisk of haematoma = <0.1:100 Risk of haematoma = 1-3:100 Risk of haematoma = 6-10:100
Overall Prevalence of TBI Internationally - 200-300 per 100,000 annually NZ rates slightly higher (349 per 100,000) Maori males disproportionately represented Rates vary widely; case registration poor Irrespective of age, 70-90% of TBIs are mild
Prevalence in Children Incidence peaks between 15-24 Smaller peaks <5 years and older adults Varies between 100-300 per 100,000 per year However, difficult to establish accurate rates: Problems of definition Age ranges Reliance on hospital data
McKinlay et al. (2008)… Prevalence of traumatic brain injury among children, adolescents, and young adults: Prospective evidence from a birth cohort. 1265 individuals Average incidence 1.0-2.3% per year Overall prevalence 30% (0-25 years) 1/3 experienced multiple TBI
Preliminary BIONIC Data Per100,000annually Incidence of TBI in those aged 0-19 years – BIONIC 2010/2011
Mechanisms Cause of TBI in those aged 0-19 years – BIONIC 2010/2011
Consequences of mild TBI inchildren Most mild TBI results in no long-term impacts Conflicting data Persistent difficulties may be present after mild TBI Variables aside from injury severity may be important Methodological issues
Developmental ContextDifficulties maytake time toemergeImpact ondevelopmentaltrajectory Fig 2. Hypothetical developmental changes in acquired skills (a) and new skills (b) in children after TBI (solid line) and controls (dotted line) from Taylor & Alden, 1997.
Research Aims Examine developmental and, more specifically, cognitive and academic functioning12 months after the occurrence of TBI in primary-school- aged children. Identify factors related to both functional impairment and recovery from paediatric TBI.
Assessment Domains and Tools Intellectual Functioning WISC-IV Subscales WISC-IV Subscales Estimate of Full Scale IQ Academic Performance WCJ-II Test of Academic Achievement Six subscales Brief Achievement, Reading, Math, Writing scores Teacher Questionnaire
Assessment Domains and Tools Executive Functioning Behaviour Rating Inventory of Executive Function (Parent/Teacher) Inhibit, Initiate, Organisation of Material, Shift, Working Memory, Monitoring and Emotional Control Emotional/Behavioural Functioning Strengths and Difficulties Questionnaire (Parent/Teacher/Self- Report) Emotional Symptoms, Conduct Problems, Hyperactivity- Inattention, Peer Problems, Prosocial Behaviour, Total Difficulties Quality of Life Kindl (Parent/Self-Report) Physical health, emotional health, family functioning, self- esteem, social functioning, school functioning and an injury specific scale
Current status Where I‟m up to right now: Clinical group 33/40 families assessed Matched cohort 31/40 families assessed Majority of children assessed at school Expected Completion June 2012
Engaging Participants Multiple methods to support recruitment and reduce attrition Multiple contact options parents/grandparents/N.O.K/GP/school Emphasis on rapport-building with view to ongoing relationship Provision of information regarding study purpose and importance Financial incentives/rewards for children Offering „shortened‟ assessments Assessment feedback
Engaging Schools Majority of child assessments conducted at school Matched cohort recruited via local schools Communication Approaches: Open, transparent and ongoing communication Face-to-face meetings with Principals and Staff Flexibility Prioritising schools‟ needs over assessor‟s Relationship-building with key staff members
Ethnicity 30 25 Number of Children 20 15 Clinical Control 10 5 0 NZ Euro NZ Maori Samoan Niuean Chinese Other Childs Ethnic Group
Results - Cognitive Functioning• Children in the TBI group have significantly lower FSIQ scores
Results - Academic Functioning• Children in the TBI group have significantly lower scores in reading, maths and writing tests Mean Tests of Achievement Scores 110 105 Mean Scores 100 95 Clinical Control 90 85 WCJ Reading WCJ Math WCJ Reading WCJ Tests of Achievement Subscales
Ability/AchievementDiscrepancies Children with TBI are significantly more likely to present with learning disorders 100 Frequency of Learning Disorders 90 80 70 Percentage of Children 60 50 Clinical 40 Control 30 20 10 0 Evidence of Learning Disorder Achieving at Predicted Level
Strengths and Difficulties Scores• Parents of children with TBI perceive their children have greater social and emotional problems, and a higher level of overall difficulties, than controls 12 10 8 6 Clinical Control 4 2 0 Emotional Social Problems Total Difficulties Problems
(seriously tentative)Conclusions This data is VERY preliminary and to be interpreted with caution! Causation/correlation – difficult to untangle Does TBI act as a marker for other difficulties? Further analysis will explore: Executive Function BASC profiles Quality of Life Interaction between clinical and demographic factors
What might this data mean forclinicians? Mild TBI is common and a large proportion of your clients will experience it Consider the role of mild TBI in your assessments and formulations Remember, most children don‟t have ongoing problems after TBI - but some do. Avoid definitive, causal statements about the relationship between mild TBI and later difficulties Consider TBI (particularly multiple events) as an „indicator‟
References Accident Compensation Corporation. (2006). Traumatic Brain Injury (TBI): Rehabilitation issues in Mild TBI. Wellington: ACC Provider Development Unit. Agran, P. F., Winn, D., Anderson, C., Trent, R., & Walton-Haynes, L. (2003). Rates of pediatric injuries by 3-month intervals for children. Pediatrics, 111, 683-692.Carroll, L. J., Cassidy, J. D., Holm, L., Kraus, J., & Coronado, V. G. (2004). Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, 43, 113-125. Anderson, V., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. (2001). Outcome From Mild Head Injury in Young Children: A Prospective Study. [Article]. Journal of Clinical & Experimental Neuropsychology, 23(6), 705. Barker-Collo, S., Wilde, N. J., & Feigin, V. L. (2009). Trends in head injury incidence in New Zealand: A hospital- based study from 1997/1998 to 2003/2004. Neuroepidemiology, 32(1), 32-39. Bener, A., Omar, A. O., Ahmad, A. E., Al-Mulla, F. H., & Abdul Rahman, Y. S. (2010). The pattern of traumatic brain injuries: A country undergoing rapid development. Brain Injury, 24(2), 74-80. Bruns, J., & Hauser, W. A. (2003). The epidemiology of traumatic brain injury: A review. Epilepsia, 44(10), 2-10. Carroll, L. J., Cassidy, J. D., Peloso, P. M., Borg, J., Von Holst, H., & Holm, L. (2004). Prognosis for mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on MIld Traumatic Brain Injury. Journal of Rehabilitation Medicine, 43, 84-105. Ewing-Cobbs, L., Barnes, M., Fletcher, J. M., Levin, H. S., Swank, P. R., & Song, J. (2004). Modeling of Longitudinal Academic Achievement Scores After Pediatric Traumatic Brain Injury. Developmental Neuropsychology, 25(1-2), 107-133.
References Feigin, V. L., Barker-Collo, S., Krishnamurthis, R., Theadom, A., & Starkey, N. (2010). Epidemiology of ischaemic stroke and traumatic brain injury. Best Practice and Research Clinical Anaesthesiology, 24, 485- 494.Hsiang, J. N., Yeung, T., Yu, A. L., & Poon, W. S. (1997). High-risk mild head injury. Journal of Neurosurgery, 87(2), 234-238. Hall, R. C. W., Hall, R. C. W., & Chapman, M. J. (2005). Definition, Diagnosis, and Forensic Implications of Postconcussional Syndrome. Psychosomatics, 46(3), 195-202. Hawley, C. A., Ward, A. B., Magnay, A. R., & Mychalkiw, W. (2004). Return to school after brain injury. Archives of Disease in Childhood, 89(2), 136(137). Keenan, H. T., & Bratton, S. L. (2006). Epidemiology and Outcomes of Pediatric Traumatic Brain Injury. Developmental Neuroscience, 28(4-5), 256-263. Kinsella, G., Prior, M., Sawyer, M., Ong, B., Murtagh, D., Eisenmajer, R., et al. (1997). Predictors and indicators of academic outcome in children 2 years following traumatic brain injury. Journal of the International Neuropsychological Society, 3 (6), 608-616. Kirkwood, M. W., Yeates, K. O., Taylor, H. G., Randolph, C., McCrea, M., & Anderson, V. A. (2008). Management of pediatric mild traumatic brain injury: A neuropsychological review from injury through recovery. The Clinical Neuropsychologist, 22(5), 769-800. Kraus, J. F., & Chu, L. D. (2005). Epidemidology. In J. M. Silver, T. W. McAllister & S. C. Yudofsky (Eds.), Textbook of traumatic brain injury. (pp. 3-26). Arlington, VA: American Psychiatric Publishing, Inc. McAllister, T. W. (2005). Mild brain injury and the postconcussion syndrome. In J. M. Silver, T. W. McAllister & S. C. Yudofsky (Eds.), Textbook of Traumatic Brain Injury (pp. 279-308). Arlington, VA: American Psychiatric Publishing, Inc. National Center for Injury Prevention and Control. (2011). WISQAR. From http://www.cdc.gov/injury/wisqars/index.html
References New Zealand Guidelines Group. (2006). Traumatic brain injury: Diagnosis, acute management and rehabilitation. Wellington: New Zealand Guidelines Group. Rutland-Brown, W., Wallace, L. J. D., Faul, M. D., & Langlois, J. A. (2005). Traumatic brain injury hospitalizations among American Indians/Alaska Natives. Journal of Head Trauma Rehabilitation, 20(3), 205-214. Sadock, B. J., & Sadock, V. A. (2003). Synopsis of Psychiatry. New York: Lippincott Williams & Wilkins. Torner, J. C., Schootman, M., Rizzo, M., & Tranel, D. (1996). Epidemiology of closed head injury. head Injury and postconcussive syndrome. New York: Churchill Livingstone. Villalba-Cota, J., Trujilo-Hernandez, B., Vasquez, C., Coli-Cardenas, R., & Torres-Ornelas, P. (2004). Causes of accidents in children aged 0-14 yeras and risk factors related to the family environment. Annals of Tropical Paediatrics, 24, 53- 57. Winqvist, S., Luukinen, H., Jokelainen, J., Lehtilahti, M., Näyhä, S., & Hillbom, M. (2008). Recurrent traumatic brain injury is predicted by the index injury occurring under the influence of alcohol. Brain Injury, 22(10), 780-785. World Health Organisation. (2005). Injuries in the WHO European region: burden, challenges and policy response. Background paper for the 55th session of Head Trauma Rehabilitation. Yeates, K. O., & Taylor, H. G. (2005). Neurobehavioural outcomes of mild head injury in children and adolescents. Pediatric Rehabilitation, 8, 5-16.