Research Reports - Social environmental moderators of long-term functional outcomes of early childhood brain injury
JAMA Pediatr. 2016 Apr 1;170(4):343-9. doi: 10.1001/jamapediatrics.2015.4485.
Wade SL(1), Zhang N(2), Yeates KO(3), Stancin T(4), Taylor HG(5).
IMPORTANCE: Pediatric traumatic brain injury (TBI) contributes to impairments in
behavior and academic performance. However, the long-term effects of early
childhood TBI on functioning across settings remain poorly understood.
OBJECTIVE: To examine the long-term functional outcomes of early childhood TBI
relative to early childhood orthopedic injuries (OIs). We also examine the
moderating role of the social environment as defined by parent report and
observational measures of family functioning, parenting practices, and home
DESIGN, SETTING, AND PARTICIPANTS: A prospective, longitudinal, observational
cohort study conducted at each child's home, school, and hospital, including 3
children's hospitals and 1 general hospital in the Midwest. Patients were
enrolled in the initial study between January 2003 and October 2006. Follow-ups
were completed between January 2010 and April 2015. Fifty-eight children who
sustained a TBI (67% of original enrolled cohort) and 72 children who sustained
an OI (61% of the original enrolled cohort) were prospectively followed up from
shortly after injury (between the ages of 3 and 7 years at enrollment) to an
average of 6.7 years after injury, with assessments occurring at multiple points.
MAIN OUTCOMES AND MEASURES: Long-term functional outcomes in everyday settings,
as assessed through the Child and Adolescent Functional Assessment Scale (CAFAS).
RESULTS: Of the 130 children included, the median age for those with OIs was
11.72 years and 11.97, 12.21, and 11.72 years for those with complicated mild,
moderate, and severe TBIs, respectively. Children with moderate and severe TBI
were rated as having more functional impairments in multiple domains than those
with OIs (P < .05). Children with complicated mild TBI had greater impairments in
school (odds ratio = 2.93; 95% CI = 1.10-7.82) and with thinking (odds
ratio = 15.72; 95% CI = 3.31-74.73) than those with OIs. Functional impairments
in children with TBI were more pronounced among children from families with
higher levels of permissive (mean CAFAS of 49.71, 35.74, 58.14, and 16.16 for
severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with
significant difference between severe TBI and OI [difference = 33.55; P < .001]
and complicated mild TBI and OI [difference = 41.98; P < .001]) or authoritarian
(mean CAFAS of 56.45, 41.80, 54.90, and 17.12 for severe TBI, moderate TBI,
complicated mild TBI, and OI, respectively, with significant difference between
severe TBI and OI [difference = 39.33; P < .001], moderate TBI and OI
[difference = 24.68; P = .003], and complicated mild TBI and OI
[difference = 37.78; P < .001]) parenting or with fewer home resources (mean
CAFAS of 69.57, 47.45, 49.00, and 23.81 for severe TBI, moderate TBI, complicated
mild TBI, and OI, respectively, with significant difference between severe TBI
and OI [difference = 45.77; P < .001], moderate TBI and OI [difference = 23.64;
P < .001], and complicated mild TBI and OI [difference = 25.20; P < .001]).
CONCLUSIONS AND RELEVANCE: Even children with relatively mild early TBI
experience long-term functional impairments, particularly in the context of less
favorable home environments. These findings suggest that improving parenting
skills and the quality of the home environment may promote functional recovery
following early TBI.