What do we know about improving later outcomes following early brain injury?

Transcription

1 What do we know about improving later outcomes following early brain injury? Liam Dorris Consultant Paediatric Neuropsychologist Royal Hospital for Sick Children Glasgow CBIT Conference Edinburgh 2013

2 Aims To consider what factors can influence longerterm outcomes after early brain injury. To review recent scientific literature relevant to outcomes. To consider what we can change and how we can best use available resources.

3 Moderators (covariates) Moderators change the strength of an effect or relationship between two variables They indicate when or under what conditions an effect can be expected Relationship using multiple regression ranges from 1 to +1 where 0 is a non significant effect e.g. TBI (predictor variable) & IQ at 10 year FU(criterion variable), injury severity may moderate the relationship

4 10 Year IQ data Full IQ Verbal IQ Performance IQ Mild Moderate Severe

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6 What have we learned from genome wide association studies? The biggest effect sizes for associations between genes and traits both for common disorders and quantitative dimensions are much smaller than anyone expected. For example, in a GWA meta-analysis of IQ for nearly 18,000 children, the largest effect size accounts for 0.2% of the variance (Benyamin et al., 2013). If the largest effects are so small, the smallest effects will be infinitesimal, which means that they will be difficult to detect in GWA studies and even harder to replicate. Missing heritability problem- See Plomin (2013) JCPP 54:10, pp

7 Mediators In behavioural sciences, mediators are theoretical constructs that describe dynamic properties of individuals such as beliefs, emotions or behaviours Baron & Kenny (1986) suggest that mediators explain how external events assume internal psychological significance Key to the utility/validity of moderators and mediators is that they are testable

8 Mediator

9 Parenting style

10 Family environment Children who do better at school tend to come from homes that are quieter, more organised and have a predictable routine, regardless of SES (Evans, 2006) Children living in environmental confusion and unpredictability of high levels of family chaos (noise, disorder and human traffic) have lower expectations, lack of persistence and a tendency to withdraw from challenge (Brown & Low, 2008). Level of parent reported family chaos directly effects early reading level (Johnson et al 2008), behaviour disorder & IQ (Coldwell et al, 2006; Hart et al, 2007), and poor sleep cycles (Sharif & Sargent 2010).

11 Bearsden Primary s magnificent seven head off to Cambridge University Bearsden Herald

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14 post acute rehabilitation

15 Nithianantharajah & Hannan (2006) Nature Reviews

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17 Sleep Significant literature emphasising the importance of sleep for learning & emotional adjustment in children Mild TBI e.g. Milroy, Dorris, & McMillan (2008) Sleep Disturbances following Mild Traumatic Brain Injury in Childhood. Ped Psychol, 33(3): Moderate severe TBI e.g Sumpter, Dorris & McMillan (2013) Sleep disturbance after severe traumatic brain injury in childhood. Journal of the International Neuropsychological Society, 19,1 6; Sumpter R, Dorris L, Kelly T & McMillan TM. (2013) Sleep disorders in children with traumatic brain injury: a case of severe neglect. Developmental Medicine & Child Neurology (in press) Early adversity e.g. Cuddihy C, Dorris L, Kocovska E, & Minnis H. (2013) Sleep disturbance in children with a history of maltreatment. Adoption & Fostering (in press).

18 Measures Sleep Daytime Function Parent Report: Children s Sleep Habits Questionnaire (CSHQ) Self Report: Sleep Self Report (SSR) Questionnaire Objective Correlate:Actigraphy FiveNights Pediatric Quality of Life Inventory (PedsQL) Core Scales Strengths and Difficulties Questionnaire Wechsler Abbreviated Scale of Intelligence (WASI) Two Subtest Form Digit Symbol Coding Subtest, Wechsler Intelligence Scale for Children IV (WISC IV)

19 Actigraphy Accelerometer Worn on the non dominant wrist 5 days and nights

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21 Evidence for psychological rehabilitation

22 Programs produced reliable short term improvements in working memory skills. For verbal working memory, effects were not sustained at follow up. More importantly, there was no convincing evidence of the generalisation of working memory training to other skills (nonverbal and verbal ability, inhibitory processes in attention, word decoding, and arithmetic). The authors conclude that memory training programs appear to produce short term, specific training effects that do not generalize. Findings cast doubt on both the clinical relevance of working memory training programs and their utility as methods of enhancing cognitive functioning in typically developing children and healthy adults.

23 A systematic review of interventions alleviating cognitive and psychosocial problems in children following acquired brain injury. Ross, Dorris, & McMillan (2011) Dev Med & Child Neurology, 53(8), In terms of cognitive outcomes, there is limited evidence for effective interventions for attention, memory and learning difficulties. In terms of psychosocial outcomes, there is evidence that interventions can alleviate internalising symptoms. Importance of involving families, and providing intensive interventions emphasised

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26 Friendship, loneliness and psychosocial functioning in children with traumatic brain injury Kimberley A. Ross1, Liam Dorris1,3,Tom McMillan1, Tom Kelly2, & Ruth Sumpter1. Brain Injury 2011;25(12), Academic Unit for Mental Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, Scotland, UK, 2.Department of Neuropsychology, Royal Victoria Infirmary, Newcastle upon Tyne, UK, and 3.Fraser of Allander Neurosciences Unit, Royal Hospital for Sick Children, Glasgow, Scotland, UK

27 Background: Childhood and adolescence is a time of rapid social development, when friendships are of particular importance for emotional welfare [1]. There is evidence of social cognitive deficits following paediatric traumatic brain injury (TBI) including deficits in emotional recognition, social problem solving and theory of mind [2]. There is a need for more research examining the impact that childhood TBI can have on general psychosocial functioning and moreover friendship quality [2]. This study compares friendship quality, rates of loneliness and general psychosocial functioning in children who have sustained a (TBI) with non injured controls.

28 Methods: A between subjects design with 14 participants in the TBI group and 14 in the non injured control group, aged between 7 13 years and matched for age, gender, receptive vocabulary and socio economic status. Children completed measures of: Receptive vocabulary (British Picture Vocabulary Scale II; BPVS II), Friendship quality (Friendship Quality Questionnaire Revised; FQQ R) Loneliness (Loneliness and Social Dissatisfaction Scale; LSDS). The main caregiver was asked to assess: Social skills and social withdrawal (Personality Inventory for Children II; PIC 2) General psychosocial and behavioural functioning (Strengths and Difficulties Questionnaire; SDQ).

29 Results: Significant differences were not found on measures completed by children (FQQ R, LSDQ) or on the PIC 2. On the SDQ, total difficulties were rated as much greater by caregivers in the TBI group (z= 2.6, p=0.009) and these were mainly associated with sub scales relating to emotional problems and hyperactivity.

30 Table 1: Means and Standard Deviations of Scores by Group Variable TBI (n=14) Median (Range) Control (n=14) Median (Range) Effect size (r) FQQ Validation and caring^ 2.9 (2.4) 2.9 (2.3) 0.04 (small) FQQ Conflict and Betrayal 0.9 (3.1) 0.6 (2.9) 0.11 (small) FQQ Companionship and Recreation^ 2.8 (1.8) 2.8 (2.4) 0.13 (small) FQQ Help an Guidance^ 2.8 (3.6) 2.7 (3.1) 0.10 (small) FQQ Intimate Exchange^ 2.6 (3.8) 2.5 (3.5) 0.10 (small) FQQ Conflict resolution^ 2.7 (3.0) 3.0 (3.0) 0.13 (small) LSDQ Total Score 4.0 (12) 2.5 (12) 0.11 (small) PIC-2 SSK 48.0 (50) 46.0 (18) 0.11 (small) PIC-2 WDL 51.5 (50) 45.0 (29) 0.15 (small) SDQ Total Difficulties 12 (30) 4.5 (13)** 0.51 (large) SDQ Emotional Symptoms 3.5 (10) 0.5 (5.0)* 0.46 (medium) SDQ - Hyperactivity 5.5 (10) 1.0 (6.0)** 0.65 (large) SDQ Peer Problems 1.0 (8.0) 1.0 (5.0) 0.15 (small) SDQ Conduct Problems 2.0 (6.0) 1.0 (6.0) 0.34 (medium) SDQ Prosocial Behaviour^ 8.0 (8.0) 8.0 (6.0) 0.00 (small) ^Higher scores indicate less difficulty, *p <0.05, **p<0.01 Effect sizes r < 0.3 small, r = medium, r > 0.5 large

31 Table 2: SDQ variables by group percentage in the normal, borderline and abnormal ranges for each domain Normal Borderline Abnormal TBI (n=14) Control (n=14) TBI (n=14) Control (n=14) TBI (n=14) Control (n=14) Total Difficulties Emotional Symptoms Conduct Problems Hyperactivity Peer Problems Prosocial Behaviour 57% 100% % 0 64% 100% 29% 0 7% 0 57% 93% 21.5% % 7% 50% 93% 7% 7% 43% 0 79% 93% 0 7% 21% 0 86% 86% 7% 7% 7% 7%

32 Conclusions: Whilst evidence for friendship problems was not found in children with TBI, evidence for emotional and behavioural difficulties that may lead to social vulnerabilities later in life were found. This indicates a need for prospective longitudinal research to explore whether peer relationship difficulties become more apparent in adolescent years and to identify which risk factors predict poorer social outcomes. There are recent reviews of the effectiveness of psychological interventions on cognitive and psychosocial outcomes following paediatric TBI [3], which may be important in terms of early intervention to moderate the risk of poor psychosocial outcomes consistently reported in adults with TBI [4].

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34 Anderson et al (2012) Methods Consecutive prospective longitudinal design N=76 (48m/28f) 45% acute sample Age at injury 2 12 years Documented TBI inc. LoC Able to complete cognitive exam Exclusion Penetrating/NAI

35 Pre injury Adaptive Behaviour VABS Family Function FFQ Injury & Demographics 10 yr FU MRI (1.5t) IQ Adaptive Behaviour ABAS BRIEF FFQ & FBII Service use Q Measures

36 Results Severity was predictor of IQ change Family burden also predicted by severity Univariate analyses identified consistent group differences in adaptive behaviour and processing speed.

37 10 Year IQ data Full IQ Verbal IQ Performance IQ Mild Moderate Severe

38 Percentage impaired (>1sd) by injury severity at 10 yr FU Mild Moderate Severe 10 0 FSIQ Proc Speed WM ABAS Brief Social Skills

39 Discussion Overall, groups fell within low average to average ranges on measures of cognitive, adaptive, executive or social skills. Rates of impairment were significantly higher than population estimates. In contrast to 5 year outcomes, injury factors (depth of coma, white matter volumes) were not sig predictors of outcome. Most predictive of outcome were pre injury functioning and family function. Cognitive/adaptive outcomes and social consequences may have different bases.

40 Summary Injury variables are less predictive of psychosocial, emotional and behavioural outcomes the more distal the injury. Family functioning and premorbid functioning more predictive of long term cognitive and psychosocial outcomes. Interventions improving parenting and family environment most likely to improve QoL, academic attainment, employment and relationship status, in turn these predict mental health outcomes.

41 So, what does help? Family narrative is important in helping parents and children to adjust to changes Increasing self efficacy and reducing avoidant coping Avoid over pathologising Increasing positive coping and skills based approaches to achieving goals Providing intensive psychological therapy where needed and consultation to wider systems particularly school Use the resources available to increase social participation & raise academic attainment