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Original Investigation |

Social Environmental Moderators of Long-term Functional Outcomes of Early Childhood Brain Injury

Shari L. Wade, PhD1,2; Nanhua Zhang, PhD2,3; Keith Owen Yeates, PhD4,5,6; Terry Stancin, PhD7,8; H. Gerry Taylor, PhD9,10
[+] Author Affiliations
1Division of Physical Medicine and Rehabilitation, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
2University of Cincinnati College of Medicine, Cincinnati, Ohio
3Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
4Department of Psychology, University of Calgary, Calgary, Alberta, Canada
5Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
6Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
7Division of Child & Adolescent Psychiatry & Psychology, Department of Psychiatry, Case Western Reserve University, Cleveland, Ohio
8MetroHealth Medical Center, Cleveland, Ohio
9Division of Developmental and Behavioral Pediatrics and Psychology, Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
10Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, Cleveland, Ohio
JAMA Pediatr. 2016;170(4):343-349. doi:10.1001/jamapediatrics.2015.4485.
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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 environment.

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.

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Figure 1.
Adjusted Mean Levels of Functional Impairment by Group at Low/High Levels of Authoritarian Parenting

Significant group by authoritarian parenting interaction (F3,113 = 3.14; P = .03). Children with traumatic brain injury (TBI) revealed greater functional impairment ratings than children with orthopedic injury at high authoritarian parenting levels, but only children with severe TBI showed significantly greater functional impairment ratings than those with orthopedic injury at low levels of authoritarian parenting (difference = 21.35; P = .03). Error bars indicate ±1 SE.

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Figure 2.
Adjusted Mean Levels of Functional Impairment by Group at Low/High Levels of Permissive Parenting

Significant group by permissive parenting interaction (F3,113 = 5.74; P = .001). Children with complicated mild (difference = 33.55; P < .001) and severe (difference = 41.98; P < .001) traumatic brain injury (TBI) revealed greater functional impairment ratings than those with orthopedic injury at high permissive parenting levels, yet children with moderate TBI (difference = 31.64; P = .007) showed greater functional impairment ratings than children with orthopedic injury at low levels of permissive parenting. Error bars indicate ±1 SE.

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Place holder to copy figure label and caption
Figure 3.
Adjusted Mean Levels by Group at Low/High Levels of Facilitative Home Environments

Significant group by home environment interaction (F3,114 = 3.28; P = .02) revealed significantly poorer long-term functioning outcomes for children with a traumatic brain injury (TBI) than children with an orthopedic injury when the home environment had low enrichment, while high facilitative home environments revealed no significant group differences in functional impairment. EA HOME indicates the early adolescent version of the Home Observation for Measures of the Environment. Error bars indicate ±1 SE.

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