IMPORTANCE: After traumatic brain injury (TBI), children often experience impairment when faced with tasks and situations of increasing complexity. Studies have failed to consider the potential for ...attention problems to develop many years after TBI or factors that may predict the development of secondary attention-deficit/hyperactivity disorder (SADHD). Understanding these patterns will aid in timely identification of clinically significant problems and appropriate initiation of treatment with the hope of limiting additional functional impairment. OBJECTIVE: To examine the development of SADHD during the 5 to 10 years after TBI and individual (sex, age at injury, and injury characteristics) and environmental (socioeconomic status and family functioning) factors that may be associated with SADHD. DESIGN, SETTING, AND PARTICIPANTS: Concurrent cohort/prospective study of children aged 3 to 7 years hospitalized overnight for TBI or orthopedic injury (OI; used as control group) who were screened at 3 tertiary care children’s hospitals and 1 general hospital in Ohio from January 2003 to June 2008. Parents completed assessments at baseline (0-3 months), 6 months, 12 months, 18 months, 3.4 years, and 6.8 years after injury. A total of 187 children and adolescents were included in the analyses: 81 in the TBI group and 106 in the OI group. MAIN OUTCOMES AND MEASURES: Diagnosis of SADHD was the primary outcome. Assessments were all completed by parents. Secondary ADHD was defined as an elevated T score on the DSM-Oriented Attention-Deficit/Hyperactivity Problems Scale of the parent-reported Child Behavior Checklist, report of an ADHD diagnosis, and/or current treatment with stimulant medication not present at the baseline assessment. The Family Assessment Device–Global Functioning measurement was used to assess family functioning; scores ranged from 1 to 4, with greater scores indicating poorer family functioning. RESULTS: The analyzed sample included 187 children with no preinjury ADHD. Mean (SD) age was 5.1 (1.1) years; 108 (57.8%) were male, and 50 (26.7%) were of nonwhite race/ethnicity. Of the 187 children, 48 (25.7%) met our definition of SADHD. Severe TBI (hazard ratio HR, 3.62; 95% CI, 1.59-8.26) was associated with SADHD compared with the OI group. Higher levels of maternal education (HR, 0.33; 95% CI, 0.17-0.62) were associated with a lower risk of SADHD. Family dysfunction was associated with increased risk of SADHD within the TBI group (HR, 4.24; 95% CI, 1.91-9.43), with minimal association within the OI group (HR, 1.32; 95% CI, 0.36-4.91). CONCLUSIONS AND RELEVANCE: Early childhood TBI was associated with increased risk for SADHD. This finding supports the need for postinjury monitoring for attention problems. Consideration of factors that may interact with injury characteristics, such as family functioning, will be important in planning clinical follow-up of children with TBI.
Traumatic brain injury (TBI) is the leading cause of acquired disability in children, and attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental sources of ...disability.1,2 The association between TBI and ADHD has been a topic of controversy, which Asarnowet al3 address in their systematic review and meta-analysis in this issue of JAMA Pediatrics. They focus on whether the risk of ADHD increases after TBI, but also present data bearing on the question of whether ADHD is itself a risk factor for TBI. Importantly, their analysis shows a "dose-related" association between TBI severity and postinjury ADHD, with a significantly elevated risk of ADHD among children with severe TBI compared with an other injured control (OIC) group of children and children with mild TBI within 1 year postinjury, and with a noninjured control (NIC) group, OIC, and children with mild TBI more than 1 year postinjury. In addition, their analyses show no increase in postinjury ADHD in children with concussion, mild TBI, or moderate TBI compared with the rate in the NICs or OICs. They also note that the rate of preinjury ADHD was higher in children with TBI than in the general population, although not higher than among samples of the NIC or OIC groups. These findings have important clinical implications, highlighting the need to assess for ADHD in children with TBI, especially those with severe injuries, but also to take a careful history to determine whether symptoms of ADHD predate the injury.
Parent-teacher agreement on attention-deficit/hyperactivity disorder (ADHD) symptom ratings ranges from low to moderate. Most studies evaluating parent-teacher agreement have not assessed measurement ...invariance across raters. Hence, it is unclear whether discordance across raters is due to differing ADHD constructs across raters or other factors (e.g., subjective differences across raters). Additionally, the effect of development on parent-teacher agreement is relatively unknown. To address these limitations, the present study used parent and teacher ADHD ratings from a large (N = 6,659) developmentally diverse (ages 4-17) sample. Using exploratory structural equation modeling on half the sample, and then confirmatory factor analysis (CFA) on the other half of the sample, confirmed a 2-factor structure with significant cross-loadings for the 18 ADHD symptoms. CFA invariance analyses demonstrated that the 2-factor symptom structure was similar across raters and age groups. After confirming measurement invariance, the correlation between latent factors within and across raters was examined for each age group as well as across age groups. Parents reported greater severity of ADHD symptoms than did teachers, and both parents and teachers reported higher levels of hyperactivity/impulsivity in younger children than in older children and consistent levels of inattention across development. Finally, correlations between parent-teacher ratings of like factors were weak for inattention and moderate-strong for hyperactivity/impulsivity, and the magnitude of parent-teacher agreement did not vary across development. In conclusion, while parent and teacher ratings of ADHD behaviors are only weakly to moderately correlated, each reporter provides unique and valid clinical information as it relates to ADHD symptom presentation.
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For the past decade, intra-individual variability in reaction times on computerized tasks has become a central focus of cognitive research on Attention-Deficit/Hyperactivity Disorder (ADHD). Numerous ...studies document increased reaction time variability among children and adults with ADHD, relative to typically developing controls. However, direct comparisons with other disorders with heightened reaction time variability are virtually nonexistent, despite their potential to inform our understanding of the phenomenon. A growing literature examines the sensitivity of reaction time variability to theoretically and clinically relevant manipulations. There is strong evidence that stimulus treatment reduces reaction time variability during a range of cognitive tasks, but the literature is mixed regarding the impact of motivational incentives and variation in stimulus event rate. Most studies of reaction time variability implicitly assume that heightened reaction time variability reflects occasional lapses in attention, and the dominant neurophysiological interpretation suggests this variability is linked to intrusions of task-negative brain network activity during task performance. Work examining the behavioral and neurophysiological correlates of reaction time variability provides some support for these hypotheses, but considerably more work is needed in this area. Finally, because conclusions from each of domains reviewed are limited by the wide range of measures used to measure reaction time variability, this review highlights the need for increased attention to the cognitive and motivational context in which variability is assessed and recommends that future work always supplement macro-level variability indices with metrics that isolate particular components of reaction time variability.
To identify latent trajectories of executive functioning (EF) recovery overtime after childhood traumatic brain injury (TBI) and examine the predictive value of known risk factors within and across ...recovery trajectories using latent class growth modeling (LCGM).
A total of 206 children between the ages of 3 and 7 years with a moderate to severe TBI or orthopedic injury (OI) were included. LCGM was applied to identify longitudinal trajectories of postinjury EF as assessed by the Behavior Rating Inventory of Executive Functioning General Executive Composite (GEC). Separate models were estimated for the TBI and OI groups.
Two TBI trajectories-normal limits (70.8%) and clinically elevated (29.2%)-and 3 OI trajectories-normal limits (20.9%), subclinical (49.0%), and clinically elevated (30.17%)-were identified. Baseline GEC was the only predictor of class membership for all models. Both TBI trajectories demonstrated an increase in GEC over time, whereas only 1 of the 3 OI classes demonstrated this pattern. Family variables were associated with GEC across trajectories.
The lack of association of injury characteristics with trajectory class membership highlights the heterogeneity in recovery after pediatric TBI. Associations of EF trajectories with family factors underscore the importance of involving the family in interventions for children with traumatic injuries.
To explore teacher-rated trajectories of executive functioning (EF) after early childhood traumatic brain injury (TBI) and to identify injury-related, academic, and family factors associated with ...growth trajectories using latent class growth analysis.
A total of 121 children who sustained a TBI or orthopedic injury (OI) between the ages of 3 and 7 years were recruited from 3 tertiary care children's hospitals and a general hospital in Ohio, including 57 with moderate or severe TBI and 64 with OI.
Assessments were completed at baseline (0-3 months postinjury) and an average of 6, 12, 18, and 81 months postinjury. Changes in teacher-rated EF were modeled across time and heterogeneity in recovery and moderating factors was examined.
Study variables included participant demographics, teacher-rated EF (Behavior Rating Inventory of Executive Function), family functioning (McMaster Family Assessment Device), and parenting style (Parenting Practices Questionnaire).
Analysis of teacher-rated EF yielded 2 trajectories: Normative (64.71%) and At-Risk (35.29%). Traumatic brain injury was a weak predictor of membership in the At-Risk trajectory ( P = .05). Membership in the At-Risk trajectory (compared with Normative category) was associated with a higher incidence of Individualized Education Programs, higher baseline EF concerns, increased endorsement of authoritarian parenting, lower socioeconomic status, and non-White race.
Teacher-rated EF after pediatric TBI differs from OI. Increased EF concerns over time were associated with increased baseline EF and characteristics of the home and school environment. These findings extend previous research on recovery of EF to educational settings and outline potentially modifiable risk factors that can maximize success in the school settings for children who experience early-childhood traumatic injury.
To identify latent trajectories of IQ over time after pediatric traumatic brain injury (TBI) and examine the predictive value of risk factors within and across recovery trajectories.
206 children ...ages 3-7 years at injury were included: 87 TBI (23 severe, 21 moderate, 43 complicated mild) and 119 orthopedic injury (OI). We administered intelligence tests shortly after injury (1½ months), 12 months, and 6.8 years postinjury. Latent class growth modeling was used to identify latent subgroups. Separate models examined verbal and nonverbal IQ recovery trajectories following TBI versus OI. Variables included: age at injury, sex, race, socioeconomic status, injury severity, quality of the home environment, family functioning, and parenting style.
Both the TBI and OI analyses yielded different growth models for nonverbal (
= 3) and verbal IQ (
= 3). Although all models resulted in 3 latent classes (below average, average, and aboveaverage performance); trajectory shapes, contributors to class membership, and performance within each class varied by injury group and IQ domain. TBI severity was associated with class membership for nonverbal IQ, with less severe injuries associated with higher IQ scores; however, TBI severity did not influence verbal IQ class membership. Parenting style had a more prominent effect on verbal and nonverbal IQ within the TBI than OI trajectories.
Findings suggest TBI severity is related to recovery trajectories for nonverbal but not verbal IQ and parenting style has stronger effects on recovery in TBI than OI. Results highlight the importance of parental factors on long-term recovery after TBI.
To examine the prevalence of academic need, academic service utilization, and unmet need as well as factors associated with academic service utilization 6.8 years after traumatic brain injury (TBI) ...in early childhood.
Fifty-eight (16 severe, 14 moderate, 28 complicated mild) children with TBI and 72 children with orthopedic injury (OI) completed the long-term follow-up 6.8 years after injury in early childhood (ages 3-7 years). Injury group differences in rates of need for academic services, academic service utilization, and unmet need as well as factors associated with service utilization and unmet need were examined.
Students with moderate and severe TBI had significantly greater rates of need than those with OI. A greater proportion of the severe TBI sample was receiving academic services at long-term follow-up than the OI and complicated mild groups however, among those with an identified need, injury group did not affect academic service utilization. Below average IQ/achievement scores was the only area of need predictive of academic service utilization. Rates of unmet need were high and similar across injury groups (46.2%-63.6%).
The need for academic services among patients who sustained a TBI during early childhood remains high 6.8 years post injury. Findings underscore the importance of continued monitoring of behaviors and academic performance in students with a history of early childhood TBI. This may be especially true among children with less severe injuries who are at risk for being underserved.
Purpose/Objective: Our goal was to examine the feasibility and preliminary efficacy of an app-based coaching intervention (Social Participation and Navigation; SPAN) to help survivors of acquired ...brain injury attain social participation goals. Research Method/Design: This is a nonrandomized pilot trial of SPAN, including 15 adolescents (9 with traumatic brain injury, 6 with brain tumor) between the ages of 14-22. The SPAN intervention consisted of a mobile app to support the development and implementation of social participation goals, weekly video-conference coaching sessions to identify goals and step-by-step action plans, and online didactic materials. Assessments were completed pre- and postintervention. Satisfaction with the intervention, confidence in the adolescents' ability to participate in and plan social activities and manage their emotions and behaviors, and frequency and satisfaction with social participation were assessed via self- and parent-report questionnaires developed for this project. Behavior problems, social competence, and social problems were measured by using the Child Behavior Checklist and the Youth Self-Report. Results: High levels of participant and parent satisfaction were reported. Increases in parent-reported frequency of social participation and teen-reported confidence in their ability to participate and develop social participation goals and plans were observed. A decline in parent-reported total problems, internalizing problems, externalizing problems, and social problems was noted. Conclusion/Implications: Results support the feasibility of the program, because participants were able to successfully meet with their coaches and use the app to develop and accomplish social participation goals. Further research will be needed to refine the app and program, particularly when reaching out to populations beyond traumatic brain injury.
Impact and Implications
This study describes the refined Social Participation and Navigation (SPAN) program; discusses the feasibility, utility, and satisfaction with the program; and presents preliminary outcome data. The study confirms the acceptability of the app based coaching intervention to set and achieve social participation goals. Further development of content and materials is needed to make the intervention more applicable/tailored for additional acquired brain injury populations.
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To examine the impact of early traumatic brain injury (TBI) on effortful control (EC) over time and the relationship of EC and executive functioning (EF) to long-term functional and social outcomes.
...Parents of children (
= 206, ages 3-7) with moderate-to-severe TBI or orthopedic injuries (OIs) rated EC using the Child Behavior Questionnaire at 1 (pre-injury), 6, 12, and 18 months post-injury. Child functioning and social competence were assessed at 7 years post-injury. Mixed models examined the effects of injury, time since injury, and their interaction on EC. General linear models examined the associations of pre-injury EC and EC at 18 months with long-term functional and social outcomes. Models controlled for EF to assess the unique contribution of EC to outcomes.
Children with severe TBI had significantly lower EC than both the OI and moderate TBI groups at each post-injury time point. Both pre-injury and 18-month EC were associated with long-term outcomes. Among those with low EC at baseline, children with moderate and severe TBI had more functional impairment than those with OI; however, no group differences were noted at high levels of EC. EC had main effects on parent-reported social competence that did not vary by injury type.
Findings suggest that EC is sensitive to TBI effects and is a unique predictor of functional outcomes, independent of EF. High EC could serve as a protective factor, and as such measures of EC could be used to identify children for more intensive intervention.
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