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Trauma brain injury (TBI) is a common, acquired childhood disability. Few studies have attempted to measure the impact of preinjury functions on postinjury behavior. More severe injury is associated with a decrease in functional ability at 6 months post-TBI.
Trauma brain injury (TBI) is a common, acquired childhood disability. Few studies have attempted to measure the impact of preinjury functions on postinjury behavior. More severe injury is associated with a decrease in functional ability at 6 months post-TBI.
Trauma brain injury (TBI) is a common, acquired childhood disability. Few studies have attempted to measure the impact of preinjury functions on postinjury behavior. More severe injury is associated with a decrease in functional ability at 6 months post-TBI.
2012 34 19 1639 1647 2012 Informa UK, Ltd. 10.3109/09638288.2012.656789 0963-8288 1464-5165 Disability & Rehabilitation, 2012; 34(19): 16391647 2012 Informa UK, Ltd. ISSN 0963-8288 print/ISSN 1464-5165 online DOI: 10.3109/09638288.2012.656789 14 June 2011 03 January 2012 09 January 2012 Context: Traumatic brain injury (TBI) is a common, acquired childhood disability, which has been shown to have a signicant impact on childrens cognitive and educational function. While behavioral problems are also noted, there is ongoing debate about the contribution of preinjury factors in this domain. Few studies have attempted to measure the impact of these preinjury functions on postinjury behavior. Objective: To compare pre and postinjury adaptive ability, behavior, executive function and quality of life (QOL) and to identify factors that contribute to outcomes in these domains including injury severity, socio-demographic and preinjury characteristics. Design: Consecutive recruitments to a prospective, longitudinal study, utilizing a between factor design, with injury severity as the independent variable. Participants and methods: Children admitted to hospital with a diagnosis of TBI aged between 6 and 14 years (n=205) were divided according to injury severity (mild, moderate and severe). Adaptive behavior (Vineland Adaptive Behavior Scales), child behavior (Child Behavior Checklist), everyday executive functions (Behavior Rating Inventory of Executive Function) and QOL (Child Health Questionnaire) assessed at 6 months post-TBI. Results and conclusions: Severity by time interactions were identied across a range of outcome domains demonstrating that more severe injury is associated with a decrease in functional ability at 6 months post-TBI. This eect was most pronounced for everyday executive skills, social function and internalizing aspects of child behavior. Preinjury function was a consistent predictor of postinjury status. Injury severity contributed little to the prediction of functional outcomes once preinjury functioning was accounted for in the model. Age at injury and family cohesion were relevant to specic outcome domains only. Socio-economic status did not contribute signicantly to outcome at 6 months. Preinjury functioning as reported by parents in the acute phase may be a useful predictive tool for identifying children who may be at risk of functioning diculties 6 months post-TBI. Keywords: Adaptive behavior, behavior, child, executive function, quality of life, traumatic brain injury Introduction Childhood traumatic brain injury (TBI) is the most frequent cause of interruption to normal development, with as many as 500:100,000 children experiencing a TBI in any 1 year, and with 1/30 newborns sustaining a TBI by age 16[1]. With advances in medical treatment, mortality rates are low and RESEARCH PAPER Adaptive ability, behavior and quality of life pre and posttraumatic brain injury in childhood Vicki Anderson 1,2,3 , Robyne Le Brocque 4 , Greg Iselin 4 , Senem Eren 1,3 , Rian Dob 5 , Timothy J. Davern 6 , Lynne McKinlay 7 & Justin Kenardy 4 1 Critical Care & Neuroscience, Murdoch Childrens Research Institute, Melbourne, Australia, 2 Department of Psychology, Royal Childrens Hospital, Melbourne, Australia, 3 Psychological Science, University of Melbourne, Melbourne Australia, 4 Centre for National Research on Disability and Rehabilitation Medicine, The School of Medicine, 5 School of Psychology, University of Queensland, Brisbane, Australia, 6 Psychological Medicine, Monash University, Melbourne, Australia, and 7 Queensland Paediatric Rehabilitation Service, Royal Childrens Hospital, Brisbane, Australia Correspondence: Vicki Anderson, PhD, Department of Psychology, Royal Childrens Hospital, Parkville, Victoria 3052, Australia. E-mail: vicki.anderson@rch.org.au Childhood traumatic brain injury Priorities for intervention: (i) more severe injury; (ii) presence of pre-injury impairment; (iii) younger age at injury and (iv) evidence of family dysfunction. Level of functional impairment postinjury rarely meets criteria for a frank diagnosis (e.g. intellectual impair- ment and psychiatric disorder) and thus children are frequently ineligible for routine community supports. Reduced executive skills and social competence and elevated behavioral disturbances indicate that evi- dence-based interventions addressing these domains are a priority. Implications for Rehabilitation (Accepted January 2012) 1640 V. Anderson etal. Disability & Rehabilitation there are ever-increasing numbers of survivors. Te acute and lasting efects of severe TBI are recognized by the National Institutes of Health Consensus Development Panel on reha- bilitation of persons with TBI, which has highlighted the dramatic change in the individuals life course, profound disruption of the family and costly lifetime expenses [2]. In school-aged survivors, residual impairments are reported in a range of areas including cognition, educational achieve- ment, behavior and quality of life (QOL) [39]. Tese defcits may impact on a childs capacity to interact with the environ- ment, causing lags in skill acquisition and peer interaction, and resulting in increasing gaps between injured children and their age-matched peers. Follow-up of survivors of childhood TBI demonstrates that, even with access to rehabilitation, sig- nifcant problems may persist [4,7,10,11]. Injury or biological factors appear to explain a propor- tion of the variance in outcomes post-TBI. Te best estab- lished of these is injury severity, where a dose-response relationship is frequently identifed [3,12,13], with more severe injury associated with greater impairment. However, this relationship alone has been insufcient to account for the wide variability in outcomes, particularly within the pediatric population [9] and for domains other than physical and intellectual abilities. Other potential predictors include the childs age at injury, and social context, including socio- economic status (SES) and family environment [1422]. A further consideration that is frequently noted, but infre- quently evaluated, is the contribution of premorbid factors, in particular, preinjury child adaptive functions and behavior and preinjury environment. In the TBI literature it is commonly argued that individuals who have sustained are likely to be diferent to the general population. Previous studies have reported that, within the child TBI population, there is a high incidence of behavioral difculties, including learning problems, attentional defcits and impulsivity [2325]. It has also been documented that TBI is more common in families where parents are socially dis- advantaged, unemployed or emotionally disturbed [3,26,27], and where parental neglect and poor supervision are evident [28]. If these characteristics are present in children with TBI, it may be difcult to diferentiate TBI-specifc sequelae from those present premorbidly. Te present study aimed to address early outcome from TBI, within the context of functional abilities including adap- tive skills, behavior, everyday executive function and QOL, using a prospective, longitudinal design and with attention to the infuences of multiple potential predictors of outcome. Based on previous fndings, it was predicted that: 1. Tere would be a signifcant diference between pre and postinjury function across the following domains: adap- tive skills, behavior, everyday executive function and QOL. 2. More severe TBI would be associated with poorer func- tion in these domains at 6 months postinjury. 3. Injury severity and preinjury function would be the best predictors of postinjury function, with age at injury, fam- ily and socio-demographic factors less critical. Method Participants Tis article reports on data relating to both preinjury function and function assessed at 6 months postinjury from a larger prospective, longitudinal study. Participants represented consecutive admissions to the Mater Childrens Hospital in Brisbane and the Royal Childrens Hospitals in Brisbane and Melbourne. Following admission, the research team was notifed of family details via hospital staf in either the emer- gency department or the neurosurgery ward of each hospital. Inclusion criteria were: (i) 614 years at time of injury; (ii) admission to hospital for TBI; and (iii) a documented period of altered consciousness. Exclusion criteria included: (i) par- ents level of English unsatisfactory for completion of ques- tionnaires; (ii) previous documented neurological, psychiatric or developmental disorder; (iii) TBI was a result of suspected child abuse. In total, 514 families were eligible for participa- tion in the study. However, 309 failed to respond to invitations to participate within the study timeframe, were unable to be contacted or declined participation due to time pressures. Te resultant sample comprised 205 families with children who had sustained a TBI. Children had a mean age of 10.75 years [standard deviation (SD)=2.51] at the time of their accident. Of the sample, 92 (45%) children were from Brisbane and 113 (55%) from Melbourne and 142 (69%) were male. Demographic and injury details were collected on recruit- ment to the study, and are presented in Tables I and II. Federal privacy regulations prevented the collection of these data for nonparticipating families. Medical records were accessed to determine injury severity. Using the method described by Anderson etal. (1997), injury severity was classifed based on the childs lowest Glasgow Coma Scale score (GCS) [29] in the frst 24 hours and the presence/absence of neurological or radio- logical abnormalities. Injury severity was classifed as follows: Table I. Demographics characteristics of sample. Mild TBI Moderate TBI Severe TBI No. participants, n (%) 130 (63.4) 55 (26.9) 20 (9.70) Gender (males), n (%) 94 (72.3) 34 (61.8) 14 (70.0) Age at injury, M (SD) 10.80 (2.42) 10.48 (2.60) 11.12 (2.93) Recruitment location Melbourne, n (%) 72 (55.4) 33 (60.0) 8 (40.0) Brisbane, n (%) 58 (44.6) 22 (40.0) 12 (60.0) Socio-economic status High 62 (64) 24 (25) 11 (11) Medium 52 (65) 23 (29) 5 (6) Low 9 (53) 6 (35) 2 (12) Preinjury function VABS: TOT M(SD) 96.56 (15.87) 96.67 (17.67) 100.06 (16.42) CBCL:TOT M (SD) 50.86 (9.56) 51.49 (10.18) 50.80 (9.66) BRIEF: GEC M (SD) 50.86 (10.04) 50.68 (8.70) 54.05 (12.55) CHQ:PHYS* M (SD) 47.64 (11.80) 42.70 (16.51) 34.93 (24.87) FSIQ: 3 months* M (SD) 104.77 (11.84) 99.36 (13.82) 91.78 (10.39) *p<0.001. VAB:TOT, Vineland Adaptive Behavior Scale: Composite Score; CBCL:TOT, Child Behavior Checklist: Total Behavior Problems; BRIEF:GEC, Behavior Rating Invento- ry of Executive Function: Global Executive Composite; FSIQ, Full Scale Intelligence Quotient; CHQ:PHYS, physical subscale; CHQ:PSYCHOL, psychosocial subscale; TBI, traumatic brain injury; SD, standard deviation. Pre- and post-TBI adaptive ability, behavior and QOL 1641 2012 Informa UK, Ltd. (i) mild TBI (n = 130, 63%): lowest GCS between 1315 and an absence of neurological and radiological abnormalities; (ii) moderate TBI (n = 55, 27%): lowest GCS between 912 and/ or presence of intracranial lesions or neurological abnormality and (ii) severe TBI (n=20, 10%): lowest GCS between 38 and/ or presence of intracranial lesions or neurological abnormality. Measures Demographic-medical interview Preinjury medical, developmental, social and educational history of each participant was documented through inter- views with the primary caregiver. Information regarding parental occupation, education level and family constella- tion was also collected. A modifed version of the Australian Standard Classifcation of Occupations [30] was used to determine SES. Tis information was collected during the initial interview with families and SES rankings were based on the higher ranking occupation of the mother and father. Injury data were collected from medical records. Baseline data on child adaptive function, behavior, execu- tive function and QOL were collected from parent ratings of their childs function before their injury using the instru- ments described below. Te degree of limitations in fam- ily activities (due to child ill health) and family cohesion were obtained from parent preinjury ratings from the Child Health Questionnaire (CHQ) [31]. Child function Intellectual ability Te Wechsler Abbreviated Scale of Intelligence [32] was administered to all children in the study at 3 months postinjury. Full Scale Intelligence Quotient (IQ) (M = 100, SD=15) was calculated and used as a sample descriptor. Adaptive functioning, behavior, executive functioning and QOL Parents completed a number of questionnaires, rating their childs function across several domains. Preinjury ratings were provided on recruitment to the study, and subsequent ratings were collected at 6 months postinjury, on the follow- ing measures: 1. Adaptive functioning: Te Vineland Adaptive Behavior Scale (VABS) [33] has a questionnaire format, which provides information on a childs level of adaptive function in the following domains: Communication (VABS:COMM), Daily Living Skills (VABS:DL), and Socialization (VABS:SOC). A Total Adaptive Behavior score (VABS:TOT) is also derived. For each of these areas standard scores were calculated (M=100, SD=15). 2. Behavior: Childrens pre and postinjury behavior was assessed via the Child Behavior Checklist (CBCL) [34]. Te three summary scales (internalizing: CBCL:INT; externalizing: CBCL:EXT; and total problems: CBCL: TOT; M=50, SD=10) were examined. 3. Executive function: Te Behavior Rating Inventory of Executive Function (BRIEF) [35] measures executive functioning in children in day-to-day settings. Te 86 items are scored on a 3-point scale (never, sometimes and ofen), yielding eight clinical scales and two validity scales (inconsistency and negativity). Inhibition, shif and emotional control scales comprise the Behavioural Regulation Index (BRI), and initiation, working mem- ory, planning, organization of materials and monitor- ing clinical scales comprise the Metacognition Index (MCI). Te BRI and MCI combine to yield an overall score: Global Executive Composite (GEC). T scores (M=50, SD=10) are calculated for each, with higher T scores indicating that the child is experiencing greater difculties. 4. Quality of life: Te Australian adaptation of the CHQ [31] assesses functional health status and well-being in children including physical (CHQ:PHYS) and psycho- social (CHQ:PSYCHOL) functioning and the impact of the childs functioning on the parent (CHQ:FC). T scores for Physical and Psychosocial subscales were computed (M = 50, SD = 10) acutely and at 6 months post-TBI. Ten standardized scores were also considered, relating to child behavior and mental health, child self-esteem, child functioning and the impact of the childs psychosocial health on the parent. Procedure Te study was approved by the Human Research Ethics Committees of the Mater Childrens Hospital in Brisbane and the Royal Childrens Hospitals in Brisbane and Melbourne and was conducted in compliance with national legislation and the Code of Ethical Principles for Medical Research Involving Human Subjects of the World Medical Table II. Injury and medical characteristics of sample. Mild TBI Moderate TBI Severe TBI Age at injury: years, M (SD) 10.80 (2.42) 10.48 (2.60) 11.12 (2.93) Glasgow coma scores GCS: admission* M (SD) 14.66 (0.57) 13.41 (2.14) 8.85 (4.10) GCS: lowest in 24 hrs* M (SD) 14.44 (0.68) 12.69 (2.36) 6.75 (3.18) Duration of coma * None, n (%) 52 (40.0) 21 (38.2) 2 (10.0) 05 mins, n (%) 49 (37.7) 18 (32.7) 9 (45.0) 5 min1 day, n (%) 1 (0.8) 3 (5.50) 3 (15.0) 17 days, n (%) - - 3 (15.0) Not recorded, n (%) 28 (21.50) 13 (23.60) 3 (15.0) Cause of injury* MVA passenger, n (%) 9 (6.9) 10 (18.20) 6 (30.0) MVA pedestrian, n (%) 3 (2.3) 8 (14.50) 5 (25.0) Fall, n (%) 80 (61.6) 23 (41.90) 8 (40.0) Blow/knock, n (%) 16 (12.30) 7 (12.70) 1 (5.0) Sport, n (%) 22 (16.90) 7 (12.70) - Neurological signs* n (%) 18 (34.0) 23 (43.40) 12 (22.6) CT/MRI pathology* None, n (%) 128 (100.00) 27 (49.10) 5 (25.0) Frontal, n (%) - 5 (9.10) 1 (5.0) Extrafrontal, n (%) - 6 (10.90) 2 (10.0) Multifocal/difuse, n (%) - 17 (30.9) 12 (60.0) *p<0.05. GCS, Glasgow Coma Score; MVA, motor vehicle accident;TBI, traumatic brain injury; SD, standard deviation; CT/MRI, computed tomography/magnetic resonance imaging. 1642 V. Anderson etal. Disability & Rehabilitation Association (Declaration of Helsinki). Children who met the selection criteria were identifed during hospital admis- sion or shortly afer discharge. Parents and primary caregiv- ers were approached, either in person or through written correspondence, to take part in the study. Consistent with ethical guidelines, participants were entered into the study once informed written consent was obtained. Within the frst 2 months postinjury, parents completed the demo- graphic interview and the assessments of child function- ing with respect to their childs preinjury functioning. At 3 months post-TBI children completed the IQ assessment. At 6 months postinjury, the parent/caregiver completed questionnaires relating to the childs current level of func- tioning and the child was assessed for neuropsychological functioning. Statistical analysis Quantitative analyses were conducted using SPSS (version 14.0). Item level missing data were treated according to standard scoring rules for each variable or mean substituted. Missing data due to noncompletion of questionnaires were deleted from analyses on a case by case basis. Analysis of data lost to attrition showed no signifcant diference between those who remained in the study and those who were lost to follow-up for the independent variables of injury severity, gender, age and socio-economic status. Initially the three injury severity groups were compared [analysis of variance (ANOVA)] to identify any demographic or injury-related diferences. To address hypotheses 1 and 2, that there would be a signifcant diference between pre and postinjury function, with more severe injury leading to greater impairment, ANOVA (severity by time) was conducted for each outcome domain (adaptive function, behavior, executive function and QOL). We were particularly interested in severity by time interaction efects which would indicate deterioration in parent ratings of child function for children with more severe injuries. Tukeys honestly signifcant diference analyses were conducted to identify group diferences. For Hypothesis 3, that injury severity and preinjury function would be the best predictors of postinjury function, hierachical regressions were employed for each outcome domain. Baseline variables, child variables (age at injury, gender and SES) CHQ:FC and injury severity (mild, moderate and severe) were included in each analysis. Results Demographic and injury characteristics of sample Analysis indicated no group diferences across TBI severity groups with respect to age at injury, gender, SES, preinjury adaptive abilities, behavior or executive function. For QOL, signifcant diferences were observed for the childs physical functioning at time 1 with children with severe TBI having signifcantly lower physical functioning compared to mild and moderate TBI. Not unexpectedly, intellectual ability at 3 months postinjury was signifcantly lower for children with more severe insults. Tere were also no systematic difer- ences identifed across the three recruitment sites (Table I). As illustrated in Table II, diferences were found for all measures of injury severity: GCS on admission, lowest GCS in the frst 24 hours, duration of coma, cause of injury, neuro- logical signs and computed tomography/magnetic resonance imaging (CT/MRI) pathology. Of the 205 children included in the study, 25 (12%) sustained injury as a motor vehicle pas- senger, 17 (8%) as a motor vehicle pedestrian, 111 (54%) from falls, 24 (12%) from knocks/blows, and 28 (14%) from sport- ing accidents. Presence of neurological signs (e.g., seizures, dysarthria, ataxia, blurred vision) was observed in 53 (26%) participants. CT/MRI was available on 124 (60%) participants. Abnormalities were detected on 44 (22%) of scans. Tere were 44 (22%) children who sustained skulls fractures and 20 (10%) of children required neurosurgical intervention. Pre and postinjury (6 months) outcomes across severity groups Adaptive function Analysis of pre and postinjury parent ratings of adaptive function revealed surprisingly few signifcant fndings (Table III). No signifcant time efects were evident for overall adaptive function, daily living skills or communica- tion skills. For socialization, a signifcant severity by time efect was found, F(2,106) = 6.31, p = 0.003, with children with severe TBI demonstrating signifcantly lower social- ization skills at 6 months postinjury compared with their preinjury functioning (p = 0.01). Children with mild and moderate TBI did not show signifcant changes over time in this domain. Child behavior No signifcant diference was observed for time efects for parent ratings of child behavior on the CBCL, however there was a signifcant severity by time interaction for CBCL:TOT, F(2,151) = 4.59, p = 0.01, and CBCL:INT, F(2,149) = 2.99, p = 0.05 (Table III). Post hoc analyses showed that parents rated their child as having signifcantly more total behavior problems at 6 months post severe TBI (p=0.01). Tere was no signifcant diference over time for total behavior problems for children with mild or moderate injuries. For internalizing behavior, children with mild TBI were found to have some improvement in their symptoms (p = 0.01). Tere were no signifcant group diferences for externalizing behavior. Executive skills Parent ratings of everyday executive skills on the BRIEF showed a consistent pattern of group diferences, both for time and for severity by time interaction (Table III). Diferences were observed for the BRIEF:GEC for both time, F(1,154)=25.88, p< 0.001, and interaction efects, F(2,154)=9.73, p<0.001. Children with moderate (p=0.03) and severe TBI (p<0.001) had signifcantly higher levels of dysfunction at 6 months postinjury compared to their preinjury functioning. A similar pattern was observed for both moderate and severe TBI groups for performance on the BRIEF:MCI [time: F(1,154)=23.69, p < 0.001; severity by time: F(2,154) = 8.23, p < 0.001]. Signifcant time and severity by time efects were also observed Pre- and post-TBI adaptive ability, behavior and QOL 1643 2012 Informa UK, Ltd. for the BRIEF:BRI [time: F(1,154)=18.45, p<0.001; severity by time: F(2,154)=7.55, p=0.001]. Post hoc analyses showed signifcantly poorer functioning for children with severe TBI (p<0.001), but no signifcant changes over time for children with mild and moderate TBI. Quality of life Signifcant main efects for time were observed for CHQ:PHYS, with poorer physical function acutely postin- jury, F(1,146)=7.04, p=0.01. No severity by time efect was observed. In contrast, no signifcant time efect was observed for CHQ:PSYCHOL, however a signifcant severity by time interaction was detected, F(2,146)=3.45, p=0.03. Although the overall model was signifcant, group level diferences just failed to meet signifcance. Children with mild TBI performed marginally better at 6 months TBI (p=0.06) while those with severe TBI had lower psychological performance at 6 months postinjury than at injury (p=0.06). Predictors of postinjury abilities Outcomes of regression analyses are presented for each of the four functional domains under investigation: adaptive func- tioning, child behavior, executive skills and QOL (TableIV). Variables entered into the regression models included the relevant preinjury baseline variable, child variables including child gender, age at injury and socio-economic status; family functioning and cohesion and injury severity. Adaptive functioning A signifcant regression model was found for adaptive behavior [VABS:TOT: F(7,71) = 7.58; p < 0.001]. Signifcant variables included preinjury VABS:TOT, and child age at injury. Te model accounted for 37% of the variance in adaptive behavior functioning. A signifcant model was also found for childrens communication skills at 6 months postinjury [VABS:COMM: F(7,113) = 10.50; p < 0.001]. Signifcant variables included preinjury VABS:COMM and child age at injury. Te model accounted for 36% of the variance in childs communication functioning at 6 months postinjury. A similar model was also found for the childs functioning in terms of daily living skills [VABS:DL: F(7,98) = 11.64; p < 0.001]. Again, signifcant variables included preinjury VABS:DL and child age at injury and accounted for 42% of the variance in functioning in daily living skills at 6 months. A signifcant model was also found for socialization skills at 6 months postinjury [VABS:SOC: F(7,88) = 9.68; p < 0.001]. For this model both preinjury VABS:SOC and injury severity contributed signifcantly to predicting VABS:SOC at 6 months. Te model accounted for 39% of the variance in childs socialization at 6 months postinjury. In summary, preinjury adaptive functioning pre- dicted postinjury functioning across each of the domains. Child age at injury was also signifcant in the models for total functioning, communication skills and daily living but not for socialization. Injury severity was not signifcant in the models except for predicting postinjury socialization, where children with more severe injury had poorer functioning. Child gen- der, SES and family cohesion were nonsignifcant in predict- ing adaptive functioning at 6 months. Child behavior Signifcant models were also obtained for child behavior problems at 6 months post TBI injury. For CBCL:TOT, [F(7,137) = 22.41, p < 0.001], preinjury CBCL:TOT and injury severity were signifcant and accounted for 51% of the Table III. Pre and postinjury (6 months) parent ratings of childrens adaptive function, behavior, executive functioning and quality of life by TBI severity.
Mild TBI Moderate TBI Severe TBI Pre Post Pre Post Pre Post Adaptive function VABS:TOT M (SD) 95.70 (14.01) 97.87 (14.47) 98.58 (20.71) 97.2 (13.07) 99.38 (16.54) 93.08 (16.97) VABS:COMM M (SD) 97.63 (14.85) 98.77 (14.16) 93.84 (18.00) 95.56 (15.28) 95.13 (17.72) 91.06 (15.05) VABS: DL M (SD) 92.70 (12.44) 92.76 (13.01) 95.39 (19.54) 98.26 (10.69) 95.12 (12.34) 93.94 (16.50) VABS:SOC M (SD)* a 101.30 (13.10) 103.82 (13.00) 100.38 (13.00) 100.48 (10.60) 105.23 (12.25) 95.85 (18.16) Behavior CBCL:TOT M (SD)* b 50.85 (9.52) 50.03 (9.94) 51.87 (10.07) 50.74 (12.54) 51.16 (9.79) 55.89 (10.74) CBCL:INT M (SD)*** c 51.37 (10.16) 49.24 (10.57) 51.00 (8.70) 52.19 (10.96) 53.00 (10.04) 51.26 (10.43) CBCL:EXT M (SD) 50.57 (9.75) 51.02 (10.47) 53.65 (9.79) 52.15 (11.08) 52.50 (10.51) 55.74 (11.65) Executive function BRIEF:GEC M (SD)** c, ** b 50.75 (9.96) 51.04 (10.39) 50.63 (8.90) 53.92 (11.97) 54.89 (12.30) 63.63 (12.43) BRIEF:BRI M (SD)** c, ** b 49.42 (9.56) 49.78 (10.33) 50.08 (10.25) 51.89 (11.79) 53.32 (12.42) 61.58 (12.89) BRIEF:MCI M (SD)** c, ** b 51.43 (10.07) 51.70 (10.58) 50.87 (8.30) 53.92 (11.97) 55.26 (11.38) 62.84 (11.41) Quality of Life CHQ:PHY M (SD)*** c 47.65 (11.81) 50.77 (9.46) 42.70 (16.51) 48.06 (12.55) 34.93 (24.87) 39.81 (14.23) CHQ:PSYCHOL M (SD) 47.76 (10.38) 49.86 (9.62) 46.77 (9.70) 46.39 (11.90) 43.45 (13.07) 38.54 (14.38) *p<0.01; **p<0.001; ***p<0.05. a Severity efect. b Severity by time interaction. c Time efect. VABS:TOT, Adaptive Composite Score; VABS:COMM, communication domain; VABS:DL, daily living domain; VABS:SOC, socialization domain; CBCL:TOT, total behav- ior problems; CBCL:INT, internalizing problems; CBCL:EXT, externalizing problems; BRIEF:GEC, Global Executive Composite; BRIEF:BRI, Behavioral Regulation Index; BRIEF:MCI, Metacognitive Index; CHQ:PHYS, physical Subscale; CHQ:PSYCHOL, psychosocial subscale; TBI, traumatic brain injury; SD, standard deviation. 1644 V. Anderson etal. Disability & Rehabilitation variance in child total behavior problems at 6 months. A sig- nifcant model was also obtained for internalizing behavior at 6 months postinjury [CBCL:INT: F(7,136)=17.59; p<0.001]. Preinjury CBCL:INT was the only signifcant variable in the model which accounted for 45% of the variance in internal- izing behavior scores at 6 months postinjury. A similar model was found for externalizing scores at 6 months (CBCL:EXT: F(7,134) = 0 21.78; p < 0.001. Once again, the only variable signifcant in the fnal model was preinjury CBCL:EXT. Te fnal accounted for 51% of the variance in externalizing behavior at 6 months. Executive functioning A signifcant model was also found for global executive func- tioning [BRIEF:GEC: F(7,138)=29.71; p<0.001]. Signifcant variables in the model included preinjury BRIEF:GEC, CHQ:FC and injury severity. Te model accounted for 58% of the variance in outcomes. For behavioral regulation, analyses resulted in a signifcant model [BRIEF:BRI: F(7,138)=25.40; p < 0.001] with signifcant variables including preinjury BRIEF:BRI and injury severity. Te model accounted for 54% of the variance in behavioral regulation at 6 months. A sig- nifcant model was also obtained predicting metacognition at 6 months [BRIEF:MCI: F(7,138)=31.40; p<0.001]. Once again, preinjury BRIEF:MCI, CHQ:FC, and injury severity were signifcant. Te model accounted for 60% of the variance in metacognitive outcome at 6 months postinjury. In sum- mary, preinjury executive functioning predicted functioning at 6 months post injury. Injury severity was also signifcant in predicting outcomes. Child age at injury, gender and SES were nonsignifcant. Family cohesion also signifcantly predicted GEC scores and metacognition at 6 months postinjury. Quality of life Regression analysis predicting physical functioning at 6 months was signifcant [CHQ:PHYS: F(7,133) = 4.28, p<0.001], however accounted for only 14% of the variance. Preinjury CHQ:PHYS and injury severity were the only variables that signifcantly predicted physical functioning at 6 months. For psychosocial functioning the model was also signifcant [CHQ:PSYCHOL: F(7,133)=11.01, p<0.001] and accounted for 33% of the variance in functioning at 6 months postinjury. Preinjury CHQ:PSYCHOL and injury severity were both signifcant variables in the model. In summary, only preinjury QOL and injury severity predicted QOL at 6 months postinjury. Table IV. Regression analyses predicting functioning outcomes at 6 months post-TBI injury. Outcome (postinjury ratings) Adjusted R 2 Test statistic Signifcant variables B SE B Beta p value Adaptive function VABS:TOT 0.37 F(7,71)=7.58; p<0.001 VABS:TOT Pre- 0.36 0.09 0.39 <0.001 Age 2.25 0.57 0.38 <0.001 VABS:COMM 0.36 F(7,113)=10.50; p<0.001 VABS:COMM Pre- 0.30 0.07 0.33 <0.001 Age 1.98 0.45 0.35 <0.001 CHQ:FA 0.11 0.05 0.17 0.03 VABS:DL 0.42 F(7,98)=11.64; p<0.001 VABS:DL: Pre- 0.32 0.07 0.34 <0.001 Age 2.54 0.45 0.45 <0.001 VABS:SOC 0.39 F(7,88)=9.68; p<0.001 VABS:SOC Pre- 0.64 0.09 0.58 <0.001 GCS 4.71 1.65 0.24 0.005 Behavior CBCL:TOT 0.51 F(7,137)=22.41; p<0.001 CBCL:TOT Pre- 0.76 0.08 0.68 <0.001 GCS 2.36 0.93 0.15 0.012 CBCL:INT 0.45 F(7,136)=17.59; p<0.001 CBCL:INT Pre- 0.70 0.77 0.66 <0.001 CBCL:EXT 0.51 F(7,134)=21.78; p<0.001 CBCL:EXT Pre- 0.73 0.08 0.66 <0.001 Executive function BRIEF:GEC 0.58 F(7,138)=29.71; p<0.001 BRIEF:GEC Pre- 0.73 0.07 0.62 <0.001 CHQ:FC 0.10 0.04 0.14 0.014 GCS 3.55 0.92 0.21 <0.001 BRIEF:BRI 0.54 F(7,138)=25.40; p<0.001 BRIEF:BRI Pre- 0.68 0.07 0.60 <0.001 Injury severity 3.13 0.95 0.19 0.001 BRIEF:MCI 0.60 F(7,138)=31.40; p<0.001 BRIEF:MCI Pre- 0.78 0.07 0.66 <0.001 CHQ:FC 0.11 0.04 0.15 0.007 Injury severity 3.19 0.89 0.19 000 Quality of life CHQ:PHYS 0.14 F(7,133)=4.28; p=0.000 CHQ:PHYS Pre- 0.16 0.08 21 0.049 injury severity 4.08 1.36 0.24 0.003 CHQ:PSYCHOL 0.33 F(7,133)=11.01; p=0.000 CHQ:PSYCHOL Pre- 0.40 0.09 0.37 0.000 injury severity 4.34 1.17 .26 0.000 VABS:TOT, Adaptive Composite Score; VABS:COMM, communication domain; VABS:DL, daily living domain; VABS:SOC, socialization domain; CBCL:TOT, total behav- ior problems; CBCL:INT, internalizing problems; CBCL:EXT, externalizing problems; BRIEF:GEC, Global Executive Composite; BRIEF:BRI, Behavioral Regulation Index; BRIEF:MCI, Metacognitive Index; CHQ:PHYS, physical subscale; CHQ:PSYCHOL, psychosocial subscale; CHQ:FC, family cohesion; VHQ:FA, family activities; Pre, preinjury scores; TBI, traumatic brain injury. Pre- and post-TBI adaptive ability, behavior and QOL 1645 2012 Informa UK, Ltd. Discussion Te present study examined sub-acute functional outcomes (adaptive ability, child behavior, everyday executive function and QOL) in school-aged children who had sustained a mild, moderate or severe TBI 6 months previously. Preinjury status and injury severity were explored to determine their contribu- tion to these outcomes. To assist in diferentiating postinjury problems specifc to TBI, we excluded children from this study with preexisting neurological, psychiatric or developmental disorders, previous TBI or nonaccidental injuries. We also established that there were no severity group diferences for demographic factors, which might confound outcomes (e.g. gender, SES and age at injury). Contrary to predictions, few changes were noted for adap- tive abilities from preinjury to 6 months postinjury, with little impact of injury severity. Of note, these fndings are in keep- ing with those reported by Anderson and colleagues [10,12] who found few diferences at 6 months postinjury, but with impairments in adaptive function emerging by 12 months and persisting to 30 months. Te exception to this pattern was for socialization, where the severe TBI group showed a sub- stantial decrease in social skills from preinjury to 6 months postinjury, possibly due to extended hospitalization and con- valescence and associated restrictions in social interactions. Child behavior problems were seen to increase postinjury, consistent with the work of others [6,36], although, group mean ratings remained well within the normal range for all TBI groups. Children with severe TBI were found to have greater overall behavior problems at 6 months following TBI than children with milder insults. No group or time diferences were identifed for externalizing behaviors. For internalizing behaviors, a small, but signifcant decrease in problems was detected specifc to children with mild TBI. By far the most dramatic results for the study were seen for everyday ratings of executive function. On the BRIEF, all summary measures indicated poorer function by 6 months post-TBI and this was also associated with more severe injury. Tese fndings suggest that executive dysfunction is present relatively early postinjury. As might be expected, in the physical domain, children with TBI showed signifcant improvement in the physical domain from the acute phase to 6 months post-TBI. Further, children with severe TBI demonstrated poorer function both acutely and 6 months postinjury, suggesting that physical defcits associated with TBI persist in this group. Consistent with the small literature on postinjury QOL [8], children with severe injury appeared to be most vulnerable to experience poorer QOL in the psychosocial domain. Parent ratings sug- gested poorer psychosocial QOL at 6 months for children with severe TBI. Taken together with poorer social adaptive outcomes, these results suggest specifc and increasing psy- chosocial problems post-TBI in the context of severe injury. Tese results, taken together with fndings from regres- sion analyses, highlight the importance of injury severity for sub-acute functional outcomes afer child TBI, a fnding that has been well established in the literature [11,13]. More severe injury, as measured by depth of coma in the 24 hours postinjury and abnormalities identifed by CT and MRI, con- tributed signifcantly to social skills, overall behavioral func- tion, executive abilities and QOL. In contrast, age at injury was less infuential, impacting only postinjury total adaptive function, communication and daily living skills. Tis lack of relationship may be explained by the age range under study, with previous research identifying greatest risk for children injures prior to age 5 years [13,14]. As expected, preinjury function also had a major impact on postinjury function for all domains under study. Investigation of environmental factors indicated that SES was not infuential at six months postinjury. While this fnding is in direct contradiction to those reported by other groups [22], it may be that, in this relatively early stage postinjury, the impact of psychosocial factors is yet to emerge. Further follow-up of this sample is needed to determine whether this is the case. Of note, the more proximal infuence of family cohesion did emerge as a predictor for parent ratings of everyday executive abilities. Study limitations Several methodological issues need to be considered when interpreting these fndings. Firstly, the study design does not include a noninjured control group. To minimize any con- founds associated with our design, we employed only mea- sures with robust psychometric properties with standardized scores. Secondly, preinjury evaluations have been criticized as potentially biased, with the possibility of a halo efect emerg- ing, where parents idealize their injured child. In response to this concern, we note that the total group and severity group preinjury means for all measures included in the study protocol indicate distributions similar to population expecta- tions. Further, as severity groups did not difer on any of these measures there is little evidence that such factors have had a signifcant impact on our fndings. Finally, our ratings of both pre and postinjury child function are primarily based on a single source parent-ratings. Tis may result in a reporting bias, and future studies should include multiple informants to reduce the possibility of this occurring. Clinical implications Study fndings have important implications for management and intervention, particularly as the timeframe for follow-up of this sample (that is to 6 months postinjury) is in keeping with the timing of intensive acute rehabilitation following childhood TBI. Te most consistent fnding was the critical importance of preinjury function in predicting abilities at 6 months postinjury. Tis suggests that allocation of manage- ment and intervention resources, as well as decisions relating to compensation payments, need to consider not only injury severity, but also preinjury risk factors. Specifcally, children with preinjury vulnerabilities may be at particular risk, with such impairments exacerbated following TBI. With respect to the relevance of injury severity, our results indicate the expected dose-response relationship between injury severity and outcome. Specifcally, where no preexist- ing problems were present, mild TBI was associated with few functional consequences at 6 months postinjury, and thus of lowest priority for intervention services. Similarly, children 1646 V. Anderson etal. Disability & Rehabilitation with moderate TBI were also at relatively low risk for functional impairments, with the exception of executive difculties, such as poor planning, problem solving and working memory. In contrast, more severe insult was associated with greatest risk of functional difculties across all domains assessed, and it follows that these children should be considered to have the highest priority for rehabilitation services. Other risk factors for poor outcome were earlier age at injury and lower levels of family cohesion. Taken together, these fndings suggest that the priorities for access to interventions focused on func- tional abilities should be: (i) more severe injury; (ii) presence of preinjury impairment; (iii) younger age at injury and (iv) evidence of family dysfunction. Study fndings also suggest some direction in terms of the nature and focus of intervention services for children post- TBI. Of note, our results, and those of others previously, indi- cate that the level of functional impairment present postinjury rarely meets criteria for a frank diagnosis (e.g. intellectual impairment and psychiatric disorder) and thus children are frequently ineligible for routine community supports. Despite this, the degree of functional impairment clearly impacts on QOL and community participation. Reduced executive skills and social competence and elevated risk of behavioral distur- bance would suggest that interventions that focus on these domains should be a priority. Recently, the availability of evidence-based interventions for these abilities has improved, both for child-directed and family-based approaches [3742], and a focus on such approaches should be considered as an addition to traditional physical and cognitive techniques. Conclusions In conclusion, reporting on a large and well character- ized sample of child survivors of TBI, our study has found evidence to support the deterioration of everyday executive skills, social function, and aspects of child behavior postinjury in association with signifcant TBI sustained in childhood. Preinjury functioning was the strongest predictor of function- ing at 6 months post TBI. Injury severity was also signifcant in the models tested and contributed to the prediction of dete- rioration in child behavior, executive ability and QOL. 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Ya'qūb Ibn Is Āq Al-Kindī, Alfred L. Ivry-Al-Kindi's Metaphysics - A Translation of Ya'qūb Ibn Is Āq Al-Kindī's Treatise On First Philosophy (Fī Al-Falsafah Al-Ūlā) - SUNY (1974) PDF