This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroup's recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Characteristic features of inflicted TBI included acute computed tomography/magnetic resonance imaging findings of preexisting brain injury, extraaxial hemorrhages, seizures, retinal hemorrhages, and significantly impaired cognitive function without prolonged impairment of consciousness.

Object-Although long-term neurological outcomes after traumatic brain injury (TBI) sustained early in life are generally unfavorable, the effect of TBI on the development of academic competencies is unknown. The present study characterizes intelligence quotient (IQ) and academic outcomes an average of 5.7 years after injury in children who sustained moderate to severe TBI prior to 6 years of age.Methods-Twenty-three children who suffered inflicted or noninflicted TBI between the ages of 4 and 71 months were enrolled in a prospective, longitudinal cohort study. Their mean age at injury was 21 months; their mean age at assessment was 89 months. The authors used general linear modeling approaches to compare IQ and standardized academic achievement test scores from the TBI group and a community comparison group (21 children).Children who sustained early TBI scored significantly lower than children in the comparison group on intelligence tests and in the reading, mathematical, and language domains of achievement tests. Forty-eight percent of the TBI group had IQs below the 10th percentile. During the approximately 5-year follow-up period, longitudinal IQ testing revealed continuing deficits and no recovery of function. Both IQ and academic achievement test scores were significantly related to the number of intracranial lesions and the lowest postresuscitation Glasgow Coma Scale score but not to age at the time of injury. Nearly 50 % of the TBI group failed a school grade and/or required placement in selfcontained special education classrooms; the odds of unfavorable academic performance were 18 times higher for the TBI group than the comparison group.Conclusions-Traumatic brain injury sustained early in life has significant and persistent consequences for the development of intellectual and academic functions and deleterious effects on academic performance. Keywords traumatic brain injury; shaken baby syndrome; academic performance; cognitive outcome; pediatric neurosurgery Pediatric TBI represents a major public health problem. Authors of recent studies of TBI in the US from 1995 to 2001 have determined that infants and children 4 years of age or younger have higher rates of TBI-related mortality, hospitalization, and emergency department visits NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript than children 5 to 9 or 10 to 14 years of age. 40 The external cause of TBI in young children varies with age. 8 Inflicted neurotrauma is the most common cause in infants younger than 24 months of age; approximately 90% of cases of significant TBI in this age group are caused by physical abuse. 13,19,39 The most frequent external causes of injury in preschoolers include falls and motor vehicle accidents. 39 Despite the high incidence of serious TBI in infants and young children, very little is known about long-term developmental outcomes and academic course in these cases. Retrospective follow-up studies have identified persistent neurological and cognitive sequelae in children who sustained i...

Chronic pediatric traumatic brain injury (TBI) is associated with significant and persistent neurobehavioral deficits. Using diffusion tensor imaging (DTI), we examined area, fractional anisotropy (FA), radial diffusion, and axial diffusion from six regions of the corpus callosum (CC) in 41 children and adolescents with TBI and 31 comparison children. Midsagittal cross-sectional area of the posterior body and isthmus was similar in younger children irrespective of injury status; however, increased area was evident in the older comparison children but was obviated in older children with TBI, suggesting arrested development. Similarly, age was correlated significantly with indices of tissue microstructure only for the comparison group. TBI was associated with significant reduction in FA and increased radial diffusivity in the posterior third of the CC and in the genu. The axial diffusivity did not differ by either age or group. Logistic regression analyses revealed that FA and radial diffusivity were equally sensitive to post-traumatic changes in 4 of 6 callosal regions; radial diffusivity was more sensitive for the rostral midbody and splenium. IQ, working memory, motor, and academic skills were correlated significantly with radial diffusion and/or FA from the isthmus and splenium only in the TBI group. Reduced size and microstructural changes in posterior callosal regions after TBI suggest arrested development, decreased organization, and disrupted myelination. Increased radial diffusivity was the most sensitive DTI-based surrogate marker of the extent of neuronal damage following TBI; FA was most strongly correlated with neuropsychological outcomes.

Acute CT/MRI findings were examined in a prospective, longitudinal study of 60 children 0-6 years of age hospitalized for moderate to severe traumatic brain injury (TBI). TBI was categorized as either inflicted (n = 31) or noninflicted (n = 29). Glasgow Coma Scale scores and perinatal history were comparable in both groups. Acute CT/MRI studies were visually inspected by a radiologist blind to group membership. Compared with the noninflicted TBI group, the inflicted TBI group had significantly elevated rates of subdural interhemispheric and convexity hemorrhages as well as signs of pre-existing brain abnormality, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly. Intraparenchymal hemorrhage, shear injury, and skull fractures were more frequent after non-inflicted TBI. Subarachnoid hemorrhage and infarct/edema occurred with comparable frequency in both groups. Characteristic acute neuroimaging findings of inflicted TBI included multiple extraaxial hemorrhages in addition to the mild atrophy, subdural hygromas, and ventriculomegaly that suggest prior brain abnormality.

To examine executive processes in young children with traumatic brain injury (TBI), we evaluated performance of 44 children who sustained moderate-to-severe TBI prior to age 6 and to 39 comparison children on delayed response (DR), stationary boxes, and spatial reversal (SR) tasks. The tasks have different requirements for holding mental representations in working memory (WM) over a delay, inhibiting prepotent responses, and shifting response set. Age at the time of testing was divided into 10- to 35- and 36- to 85-month ranges. In relation to the community comparison group, children with moderate-to-severe TBI scored significantly lower on indexes of WM/inhibitory control (IC) on DR and stationary boxes tasks. On the latter task, the Age x Group interaction indicated that performance efficiency was significantly reduced in the older children with TBI relative to the older comparison group; performance was similar in younger children irrespective of injury status. The TBI and comparison groups did not differ on the SR task, suggesting that shifting response set was not significantly altered by TBI. In both the TBI and comparison groups, performance improved with age on the DR and stationary boxes tasks. Age at testing was not significantly related to scores on the SR task. The rate of acquisition of working memory (WM) and IC increases steeply during preschool years, but the abilities involved in shifting response set show less increase across age groups (Espy, Kaufmann, & Glisky, 2001; Luciana & Nelson, 1998). The findings of our study are consistent with the rapid development hypothesis, which predicts that skills in a rapid stage of development will be vulnerable to disruption by brain injury.

Objective-To better understand the impact of age at injury, severity of injury, and time since injury on long-term school outcomes of children with traumatic brain injury (TBI).Participants-Four groups of children: complicated mild/moderate TBI (n=23), severe TBI (n=56), orthopedic injury (n=35), and healthy controls (n=42). Children with TBI were either two years post injury or six years post injury. Design-Cross-sectional designMeasures-School records as well as parental ratings of functional academic skills and school competency.Results-Children with severe TBI had consistently high usage of school services and low school competency ratings than children with orthopedic injuries and healthy controls. In contrast, children with complicated-mild/moderate TBI were significantly more likely to receive school support services and have lower competence ratings at six years than at two years post injury. Students injured at younger ages had lower functional academic skill ratings than those injured at older ages.Conclusions-These findings highlight the increasing academic challenges faced over time by students with complicated-mild/moderate TBI and the vulnerability of younger children to poorer development of functional academic skills.Keywords traumatic brain injury; children; school outcomes; special education Traumatic brain injury (TBI) is a leading cause of death and disability in childhood. Each year in the United States, approximately 475,000 children under the age of 14 years sustain a TBI 1 and approximately 30,000 have long-term disabilities 2 . TBI is viewed as a chronic disease process that initiates ongoing and possibly lifelong changes that affect multiple Address correspondence to: Mary Prasad, Children's Learning Institute, UT Health, 7000 Fannin, Houston, Texas 77030, Mary.R.Prasad@uth.tmc.edu, 713-500-3888. Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. Conflict of Interest:The authors have no conflict of interests to disclose. HHS Public AccessAuthor manuscript J Head Trauma Rehabil. Author manuscript; available in PMC 2018 January 01. Author Manuscript Author ManuscriptAuthor ManuscriptAuthor Manuscript organ systems 3 . Common consequences of moderate to severe pediatric TBI include chronic, often lifelong, impairments in cognition, psychological health, adaptive behavior, and academic functioning. Academic functioning is particularly important to health related quality of life because mastering the school curriculum is one of the major developmental tasks of childhood. Functional academic deficits often emerge long-term following significant TBI and are characterized by poor school performance, high rates of grade retention, and receipt of special academic support services 4,5 . In this paper, we examine long-term academic outcomes in children with a range of TBI severity using a prospective, multidimensional approach. Time Since Injury, Severity of TBI, and Age at InjuryAcademic deficits, which are among the most significant an...

The relationship between clinical and neuroimaging variables and multiple outcome measures was examined in a longitudinal, prospective study of 60 children less than 6 years of age who sustained either inflicted or noninflicted traumatic brain injury. Hierarchical multiple regression indicated that the modified Glasgow Coma Scale score, the duration of impaired consciousness and the number of intracranial lesions visualized on CT/MRI accounted for a significant amount of the variance in the Glasgow Outcome Scale (GOS), cognitive and motor scores at baseline, 3- and 12-month evaluations. Inflicted brain injury adversely affected both GOS and cognitive outcomes. Pupillary abnormalities were associated with poorer motor outcome. Neither age at injury nor the Injury Severity Score accounted for significant variability in outcomes.