1. THE IMPACT OF TRAUMATIC
BRAIN INJURY ON
DEVELOPMENTAL
FUNCTIONING IN CHILDREN
MILD TBI AT HOME AND SCHOOL
Rosalind Case
Clinical Psychologist / Research Officer
School of Psychology, University of Waikato

2. BIONIC
Brain Injury Outcomes NZ in the
Community
 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

3. COBIC:
Consequences of Brain Injury in
Childhood
 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

4. 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)

5. Classification of Severity
• Severity rated according to
scores on the Glasgow Coma
Scale (GCS)
Mild Moderate Severe
• 13-15 • 9-12 • 3-8

6. Mild TBI Categories (Servedei,
2001)
Mild – Low Risk Mild – Medium Risk Mild – High Risk
GCS = 15 With possible: With skull fracture
No loss of consciousness Loss of consciousness And/or
No amnesia Amnesia Neurological deficits
No vomiting Vomiting
No diffuse headache OR
Diffuse headache
Risk of haematoma = <0.1:100 Risk of haematoma = 1-3:100 Risk of haematoma = 6-10:100

7. 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

8. 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

9. 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

10. Preliminary BIONIC Data
Per
100,000
annually
Incidence of TBI in those aged 0-19 years – BIONIC 2010/2011

11. Mechanisms
Cause of TBI in those aged 0-19 years – BIONIC 2010/2011

12. Risk Factors
Gender Alcohol
Disparity increases
Parental misuse
with age
Increased
Risk
Ethnicity Previous TBI
Maori over-represented 1 injury = 3x risk
Poorer outcomes
Higher Mortality 2+ injuries = 9x risk

13. Correlates of Multiple TBI

14. Consequences of mild TBI in
children
 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

15. Developmental Context
Difficulties may
take time to
emerge
Impact on
developmental
trajectory
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.

16. 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.

17. Method
 Participants
 Clinical group
 BIONIC participants aged 6-12
 Hamilton/Waikato region
 Matched cohort
 Age/Gender/Socio-economic Status
 Procedure
 12-month follow-up
 Parents
 Child
 Teacher

18. 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

19. 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

20. 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

21. 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

22. 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

23. Demographics
Ages Min-Max x
(years:month
s)
Clinical 6.4-12.7 8.97
Group
Control 6.0-12.8 8.57
Group
Gender Male (N) % Female (N) %
Clinical 15 45.5 18 54.5
Controls 13 43.3 17 56.7
Injury Mild % Mild % Mild % Missin
Severity Low Moderate High g
Clinical 4 12.1 15 45.5 10 30.3 4

24. Ethnicity
30
25
Number of Children
20
15 Clinical
Control
10
5
0
NZ Euro NZ Maori Samoan Niuean Chinese Other
Child's Ethnic Group

25. Results - Cognitive Functioning
• Children in the TBI group have significantly lower FSIQ
scores

26. 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

27. Ability/Achievement
Discrepancies
 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

28. 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

29. (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

30. What might this data mean for
clinicians?
 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‟

31. References
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