As Time Goes by: Understanding Child and Family Factors Shaping Behavioral Outcomes After Traumatic Brain Injury

Abstract

Objective: To model pre-injury child and family factors associated with the trajectory of internalizing and externalizing behavior problems across the first 3 years in children with pediatric traumatic brain injury (TBI) relative to children with orthopedic injuries (OI). Parent-reported emotional symptoms and conduct problems were expected to have unique and shared predictors. We hypothesized that TBI, female sex, greater pre-injury executive dysfunction, adjustment problems, lower income, and family dysfunction would be associated with less favorable outcomes.Methods: In a prospective longitudinal cohort study, we examined the level of behavior problems at 12 months after injury and rate of change from pre-injury to 12 months and from 12 to 36 months in children ages 4–15 years with mild to severe TBI relative to children with OI. A structural equation model framework incorporated injury characteristics, child demographic variables, as well as pre-injury child reserve and family attributes. Internalizing and externalizing behavior problems were indexed using the parent-rated Emotional Symptoms and Conduct Problems scales from the Strengths and Difficulties questionnaire.Results: The analysis cohort of 534 children [64% boys, M (SD) 8.8 (4.3) years of age] included 395 with mild to severe TBI and 139 with OI. Behavior ratings were higher after TBI than OI but did not differ by TBI severity. TBI, higher pre-injury executive dysfunction, and lower income predicted the level and trajectory of both Emotional Symptoms and Conduct Problems at 12 months. Female sex and poorer family functioning were vulnerability factors associated with greater increase and change in Emotional Symptoms by 12 months after injury; unique predictors of Conduct Problems included younger age and prior emotional/behavioral problems. Across the long-term follow-up from 12 to 36 months, Emotional Symptoms increased significantly and Conduct Problems stabilized. TBI was not a significant predictor of change during the chronic stage of recovery.Conclusions: After TBI, Emotional Symptoms and Conduct Problem scores were elevated, had different trajectories of change, increased or stayed elevated from 12 to 36 months after TBI, and did not return to pre-injury levels across the 3 year follow-up. These findings highlight the importance of addressing behavioral problems after TBI across an extended time frame.

Behavior problems 7 years after severe childhood traumatic brain injury: Results of the Traumatisme Grave de L’Enfant study.

“…There was a tendency for improvement between the first and second year, but this was only temporary, with a nonsignificant increase between the second and the seventh year in the proportion of participants above the clinical cutoff for internalizing and externalizing problems. These results support the continuity of behavioral problems over time and are in line with previous studies suggesting that behavioral problems emerge soon after injury and, once present, these difficulties tend to become persistent (Ewing-Cobbs et al, 2021;Schwartz, 2003).…”

A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury

“…The need to exclude the parental employment variable contrasts with findings in the literature indicating that SES has an impact on a child’s ability to recover from injury and post-injury therapy [ 62 ]. Lower family income has been associated with a higher percentage of pediatric TBI mortality [ 63 ] and higher levels of emotional difficulties and conduct problems at 12 months post-injury [ 64 ]. The lack of employment variability may explain why this variable was not included in the SEM model; the majority of households had at least one parent employed for more than 35 h a week (87.3% of households in our sample), compared to households where parents worked less (10.3%).…”

Executive functioning, behavior, and white matter microstructure in the chronic phase after pediatric mild traumatic brain injury: results from the adolescent brain cognitive development study

“…In line with our results, Jones et al (2021) report difficulties in executive, emotional, and behavioral domains 7 years following an mTBI. Another study reports psycho-emotional problems that persist up to 2 years following a TBI (Ewing-Cobbs et al, 2021). However, still other studies report behavioral difficulties that had either subsided 1 year after mTBI (Maillard-Wermelinger et al, 2009) or parent-rated executive functioning that showed an improving trajectory 2 years following TBI .…”

“…Further, persistent emotional problems have frequently been reported following mTBI in children (Emery et al, 2016;Ewing-Cobbs et al, 2021;Gagner, Landry-Roy, Bernier, Gravel, & Beauchamp, 2018;Jones et al, 2021). In addition to simply experiencing negative emotions, emotional problems may be due to impairments in cognitive control and subsequent difficulties in the regulation of such emotions.…”