Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002-2006. Centers for Disease Control and Prevention ...
The impact of cognitive factors on the relationship between pediatric traumatic brain injury and adaptive functioning outcomes Emily Shultz 1, Kristen E. Robinson 1, Maureen Dennis 2, H. Gerry Taylor 3, Erin D. Bigler 4, Kenneth Rubin 5, Kathryn Vannatta 1, Cynthia A. Gerhardt 1, Terry Stancin 6, & Keith Owen Yeates 7 1 The
Research Institute at Nationwide Children’s Hospital and The Ohio State University, 2 The Hospital for Sick Kids, 3 Case Western Reserve University and University Hospitals Case Medical Center, 4 Brigham Young University, 5 University of Maryland, College Park, 6 MetroHealth Medical Center and Case Western Reserve University School of Medicine, 7 University of Calgary.
background
method (continued)
• In the U.S., over half a million children sustain a traumatic brain injury (TBI) annually. • TBI can cause long-lasting physical, cognitive, and emotional deficits, which may be reflected in the child’s ability to perform everyday tasks. • Adaptive functioning encompasses conceptual, practical, and social domains. • Executive function (EF), an integrative set of higher order abilities, and processing speed (PSpd), an estimate of the speed of neural transmission, are two cognitive skills that are vulnerable in TBI, relative to the severity of the injury. • Considering that adaptive functioning skills rely on planning and organization, as well as responding to complex and evolving stimuli, individuals who have impaired EF and slower PSpd may experience deficits in adaptive functioning. • We examined adaptive functioning skills that have been previously understudied. Hypothesis 1: Children with severe TBI (STBI) will exhibit deficits in adaptive functioning relative to children with orthopedic injury (OI) and mild-to-moderate TBI (MTBI). Hypothesis 2: EF and PSpd will account for significant variance in the relationship between injury severity and adaptive functioning.
results (continued)
Analyses Hypothesis 1: One-way ANOVAs and planned contrasts examined whether the injury groups differed on neurocognitive and adaptive functioning outcomes. Hypothesis 2: Multiple mediator models using ordinary least squares path analysis determined the relative contributions to adaptive functioning accounted for by injury severity, executive function, and processing speed. Figure 1: Conceptual mediation model Executive Function
• As expected, the STBI group performed significantly more poorly than the OI group on both EF (t[126]=-2.49, p =0.01, d =0.66), and PSpd (t[126]=-2.41, p =0.02, d =0.56). • Children with STBI were rated more poorly in leisure skills on the ABAS-II than both MTBI (t[109]=-2.64, p =0.01, d =0.73), and OI (t[109]=-2.18, p =0.03, d =0.58). • Parents of children with STBI rated their children’s functional communication more poorly than parents of both MTBI (t[103]=-2.07, p =0.04, d =0.58) and OI (t[103]=-2.44, p= 0.02, d= 0.69). • Teachers also rated children with STBI more poorly in functional communication relative to children with OI (t[85] = -2.72, p =0.01, d =1.00).
Hypothesis 2
(TEA-Ch)
Table 3: Significant indirect effects of severe TBI and mild-moderate TBI via executive function and processing speed on adaptive functioning
Severe TBI v OI
Adaptive functioning
CASP Social Participation
Parent BASC-2 Functional Communication
Teacher BASC-2 Functional Communication
Severe TBI v OI
Executive function Processing speed*
Executive function* Processing speed
Executive function* Processing speed
Mild-Moderate TBI v OI
Executive function Processing speed
Executive function Processing speed
Executive function Processing speed
(CASP, ABAS-II, Parent and Teacher BASC-2)
method
Mild-Moderate TBI v OI
Procedure • Participants included 129 children (ages 8-13) who were hospitalized for STBI (n=19, Glasgow Coma Score < 8), MTBI (n=50, Glasgow Coma Score 9 to 15), or OI (n=60, fracture with no brain injury) an average of 2.7 years post-injury (SD=1.1; range 1-5.3). • Children were recruited at three children’s hospitals as part of the larger Social Outcomes in Brain Injury in Kids (SOBIK) project. • After parental consent, children completed a neuropsychological assessment and parents completed ratings of adaptive functioning during home visits. Teachers (n=88) also completed ratings of the children’s adaptive functioning. Table 1: Demographics and injury variables
Age at testing (M, SD)
Severe TBI (n=19) 10.13 (1.60)
Mild-moderate TBI (n=50) 10.62 (1.39)
Orthopedic injury (n=60) 10.63 (1.68)
Age at injury (M, SD)
7.81 (2.1)
8.02 (1.94)
7.80 (1.82)
Sex (% boys)
63%
68%
60%
Race (% white)
88%
88%
90%
Measures Executive function (EF): Test of Everyday Attention for Children (TEA-Ch): Children completed tests of inhibitory control (Walk, Don’t Walk), auditory working memory (Code Transmission), and cognitive flexibility (Creature Counting). Processing speed (PSpd): Wechsler Intelligence Scales for Children-Fourth Edition, Processing Speed Index (WISC-PSI): Children completed Cancellation and Symbol Search subtests. Adaptive functioning: Adaptive Behavior Assessment System- Second Edition (ABAS-II): Parents rated children on Self-Care, Health/Safety, Community Use and Leisure subscales. Behavior Assessment for Children, Second Edition (BASC-2): Parents and teachers rated how often the children engage in adaptive and problem behaviors on the Functional Communication and Adaptability subscales. Parents also rated children on the Activities of Daily Living (ADLs) subscale. Child and Adolescent Social Participation (CASP): Parents rated children’s participation in activities at home, school, and the community. The highest possible score is 100, with higher scores indicating more social participation.
Processing Speed (WISC-PSI)
* Indicates that the indirect path of injury severity on a specified domain of adaptive functioning was significant according to bootstrapping analyses, CI 95%.
results Hypothesis 1 Table 2: Group differences on executive function, processing speed and adaptive functioning outcomes Severe TBI
TEA-Ch WISC-PSI CASP
ABAS-II
Parent BASC-2
Teacher BASC-2
Mild-Moderate TBI Orthopedic Injury
M (SD)
M (SD)
M (SD)
Executive Function*
86.40 (13.00)
91.93 (13.21)
94.78 (12.39)
Processing Speed*
96.47 (16.03)
101.62 (11.07)
105.15 (14.83)
Social Participation**
93.64 (8.80)
96.87 (6.19)
98.53 (3.70)
Self-Care
8.35 (3.45)
10.10 (2.89)
9.25 (2.97)
Home Living
7.06 (4.74)
8.18 (4.03)
7.43 (4.13)
Health/ Safety
9.35 (3.30)
10.18 (2.96)
10.07 (2.30)
Community Use
8.80 (3.05)
10.21 (3.11)
9.73 (3.18)
Leisure*
8.94 (3.09)
11.08 (2.80)
10.63 (2.69)
Activities of Daily Living
45.71 (11.68)
48.89 (10.79)
49.38 (9.04)
Functional Communication †
45.69 (10.27)
51.50 (9.90)
52.27 (8.78)
Adaptability
49.24 (12.59)
51.87 (10.36)
52.04 (9.01)
Functional Communication*
43.85 (8.29)
49.23 (11.33)
52.75 (9.31)
Adaptability
Note: †p < .10, * p < .05, ** p< .01
50.38 (9.91)
50.31 (8.60)
53.33 (9.56)
• Test of overall indirect effects (Both EF and PSpd included in model): • Social participation: Significant for the STBI group, c =-4.89, t =-3.27, p < .01, but not the MTBI group. • Parent-reported functional communication: Significant for the STBI group, c =6.58, t =-2.44, p < .05, but not the MTBI group. • Teacher-reported functional communication: significant for the STBI group, c =7.68, t =-2.38, p
