4/12/17 Childhood MTBI Adult outcomes? Dr Audrey McKinlay - - PDF document

▶
4 12 17
SMART_READER_LITE
LIVE PREVIEW

4/12/17 Childhood MTBI Adult outcomes? Dr Audrey McKinlay - - PDF document

Dec 04, 2022 313 likes •460 views

4/12/17 Childhood MTBI Adult outcomes? Dr Audrey McKinlay University of Melbourne, Australia Webinar Objectives Prevalence Long-term outcomes Possible contributors to long-term outcomes Public Understanding of mTBI

slide-1
SLIDE 1

4/12/17 1

Childhood MTBI – Adult outcomes?

Dr Audrey McKinlay University of Melbourne, Australia

Webinar Objectives

  • Prevalence
  • Long-term outcomes
  • Possible contributors to long-term outcomes
  • Public Understanding of mTBI

Prevalence of TBI

  • Evidence from a birth cohort
slide-2
SLIDE 2

4/12/17 2

Method

  • Large birth cohort (n = 1265)

(Christchurch Heath and Development Study, initiated in 1977)

  • Information prospectively gathered (0-25 years)
  • Information collected from a number of sources

Overall Statistics

  • 318 individuals accounted for 458 TBI events

– 307 (67% dealt with in outpatient setting) – 151 (33.0% of TBI events admitted to hospital) – 11% met criteria for moderate-severe injury

(motor vehicle 37.5%; falls 34.4%; sports related 18.8%; fights 9.4%)

  • Extrapolated average yearly incidence rate of

1750 per 100000

  • Prevalence 31.6% for 0-25 year olds

– 12.4% hospitalised for TBI 0-25 years

TBI years 0 - 25

Years

Cumulative Proportion experiencing a TBI Male Female

slide-3
SLIDE 3

4/12/17 3

Long term outcomes of mTBI

  • Evidence from a birth cohort

mTBI and psychosocial outcomes

  • Design: Longitudinal, birth cohort.

(Christchurch Heath and Development Study, initiated in 1977)

  • Aim: Evaluate MTBI effects in terms of:
  • 1. Severity of MTBI
  • 2. Early injury
  • 3. Control for pre-injury factors

Groups

Birth Cohort

n = 1265

MTBI

0-5 years

Reference

n = 814

Outpatient

n = 57

Inpatient

n = 22

Not requiring hospital admission Requiring brief hospital admission ≤ 2 days

slide-4
SLIDE 4

4/12/17 4

Inclusion - Exclusion criteria

  • MTBI inclusions

– Diagnosis of concussion – LOC ≤ 20 minutes – PTA ≤ 60 minutes

  • Exclusions

– Skull fractures – Moderate or severe head injury – Evidence of child abuse (pre or post injury) mTBI vs reference - Inattention / Hyperactivity

Reference Group Outpatient Group Inpatient Group

14 13 12 11 10 9 8 7 8 9 10 11 12 13

Year Inattention / Hyperactivity

0-5 Year Group

mTBI vs reference - Conduct

Reference Group Outpatient Group Inpatient Group

31 30 29 28 26 25 24 7 8 9 10 11 12 13

Year Conduct

0-5 Year Group

27

slide-5
SLIDE 5

4/12/17 5

mTBI vs fractures and reference group

  • Inattention / Hyperactivity

Reference Group Outpatient Group Inpatient Group

14 13 12 11 10 9 8 7 8 9 10 11 12 13

Year Inattention / Hyperactivity

0-5 Year Group

Other Injury Group

MTBI vs fractures and reference group

  • Conduct

31 30 29 28 26 25 24 7 8 9 10 11 12 13

Year Conduct

0-5 Year Group

27

Reference Group Outpatient Group Inpatient Group Other Injury Group

Answers to frequently asked questions using descriptive data

  • Children who have accidents may have greater

behavioural problems than other children.

  • There may be other variables that you were

unable to control for.

slide-6
SLIDE 6

4/12/17 6

  • For each inpatient group child:

– Gender matched with 3 children from the reference group – Identical combined mother and teacher scores – Randomly selected

  • Separately for attention and conduct

What if we matched behaviour at age 7 years?

Inpatient Group 0-5 n = 22 Reference Subgroup n = 66

3 for 1 match of psychosocial rating at age 7 Reference Group

31 30 29 28 26 25 24 7 8 9 10 11 12 13

Year Conduct

0-5 Year Group

27 7 8 9 10 11 12 13

Year

0-5 Year Group

Combined mother & teacher ratings of inattention / hyperactivity & conduct matched at age 7 years

14 13 12 11 10 9 8

Inattention / Hyperactivity Reference Subgroup Inpatient Group

  • Children who have accidents may have greater

behavioural problems than other children

  • There may be other variables that you were

unable to control for

  • One or two very high scoring children in the Mild

TBI group may have biased the findings Answers to frequently asked questions using descriptive data

slide-7
SLIDE 7

4/12/17 7

7 8 9 10 11 12 13

Year

0-5 Year Group

31 30 29 28 26 25 24 7 8 9 10 11 12 13

Year Conduct

0-5 Year Group

27

Upper Injury Group Upper Ref Group Lower Injury Group Lower Ref Group

Combined ratings of inattention / hyperactivity & conduct matched at age 7 years, median split

14 13 12 11 10 9 8

Inattention / Hyperactivity

Both Mothers and Teachers

  • Rated more inattentive behaviours over

years 7-13

  • Rated more conduct disordered

behaviours over years 7-13

* P< 0.05 ** P< 0.01

Psychiatric symptoms at ages 14-16 years based on DSM-III-R

4.2* 6.2**

slide-8
SLIDE 8

4/12/17 8

1.4 2.4 * P< 0.05 ** P< 0.01

Psychiatric symptoms at ages 14-16 years based on DSM-III-R

4.2* 6.2** 3.6* 4.2* 6.2** 3.6* 1.4 2.4

* P< 0.05 ** P< 0.01

Psychiatric symptoms at ages 14-16 years based on DSM-III-R

36% Alcohol Dependence 30% 24% 18% 12% 6% 0% Drug Dependence Percent Reporting Alcohol and Drug Dependence 2.90* 1.41 3.05* 1.28

Reference Outpatient Inpatient

Association between TBI and Reported Alcohol and Drug Dependence

Evaluated Over Years 16-25 Odds Ratios * p<0.05 ** p<0.01

slide-9
SLIDE 9

4/12/17 9

15.0 Arrests 12.5 10.0 7.5 5.0 2.5 Property Offences Violent Offences Mean Number of Reported Events

Reference Outpatient Inpatient

5.46** 1.63*

Relative Risk Ratios * p<0.05 ** p<0.01

3.43** 1.68** 3.68** 1.63**

Evaluated Over Years 16-25

Association between Reported Arrests, and Property and Violent Offences

  • Controlled for pre-injury factors
  • Adverse psychosocial / psychiatric outcomes
  • Clearly, there is a lower level of MTBI for which there

are no long-term outcomes

  • Conversely, more severe cases of MTBI in

preschool children have an increased likelihood of some and psychiatric outcomes

  • But Why?

Summary and Conclusions

Possible contributors to long-term outcomes

  • Early vulnerability
  • Identification
  • Symptoms
slide-10
SLIDE 10

4/12/17 10

  • Critical stages of development
  • Solution – early intervention

Early Vulnerability Identification- Parent report

  • Language ability of young children
  • Relies on parent identification
  • What of symptoms are reported?

Differences in symptoms

  • Solution – Appropriate screening instrument

Dizziness 36 30 18 12 6 Rate of Concussive Symptoms 2-5 Years Old (n=39) 6-12 Years Old (n=41) 24 Blurred Vision Loss of Memory Headaches LOC Vomiting

Internal External

slide-11
SLIDE 11

4/12/17 11

Symptoms

  • Chapman & Hudson (2010)

– Public – 17 T/F many endorsed incorrect beliefs, underestimated

problems

  • Bloodgood et al. (2013)

– Adolescent - 13-18 yrs 4/5 had heard about ¼ reported basic

understanding

  • Ernst et al (2016)

– Educators – 33% endorsed Don’t Know to the statement: – “When children are knocked unconscious most wake up quickly with

no lasting effects”

Misunderstanding

  • Study of 103 participants randomly selected from the

community – 29 (28.3%) endorsed having experienced a concussion – Later they were asked if they had experienced a mHI or mTBI,

17/29 (58.5%) said no

Concussion – Head Injury – Brain Injury Increasing Severity

Public Perception Study

1. Sometimes symptoms can take hours to show-up. 2. Someone with a concussion should be kept awake. 3. A concussion occurs only as a result of a blow directly to the head. 4. Young children will recover better from concussion than adults. 5. Being knocked-out is not necessary for concussion. 6. Temporary confusion is not concussion if it clears within 5 minutes. 7. The symptoms of concussion are apparent at the time of injury. 8. An injury is a concussion only when there is a loss of consciousness. 9. There are no long-term effects of concussion.

  • 10. It is safe to return to playing sport as soon as the confusion clears.

Correct answer (true/false) Rate answer certainty out of 100

True False False False True False False False False False

McKinlay et al. Public knowledge

  • f ‘concussion’ …. 2011,

Brain Injury, 25(7–8): 761–766

slide-12
SLIDE 12

4/12/17 12

Public response to questions

1. Sometimes symptoms can take hours to show-up 2. Someone with a concussion should be kept awake 3. A concussion occurs only as a result of a blow directly to the head 4. Young children will recover better from concussion than adults 5. Being knocked-out is not necessary for concussion 6. Temporary confusion is not concussion if it clears within 5 minutes 7. The symptoms of concussion are apparent at the time of injury 8. An injury is a concussion only when there is a loss of consciousness 9. There are no long term effects of concussion

  • 10. It is safe to return playing sport as soon as the confusion clears

False True True False True False False False False False

10 20 30 40 50 60 70 80 90 100

Response Certainty McKinlay et al. Public knowledge of ‘concussion’ …. 2011, Brain Injury, 25(7–8): 761–766 Mean Response

Athletes vs Public?

  • Not significantly more accurate
  • Athletes were:

– More confident – More likely to watch sports

– not associated with accuracy

– More likely to have friend with concussion

– not associated with accuracy

– Not more likely to attend briefing sessions – Attendance at a briefing session not associated with higher

accuracy.

– Accuracy was associated with care seeking behaviour

Terminology

  • Hospital based study 365

consecutive patients

  • Terms Used:

– Minor head injury – Concussion – Mild head injury – Mild concussion – Closed head injury – Traumatic brain injury – Stable head injury

slide-13
SLIDE 13

4/12/17 13

Information

  • 96 hospitals (27 different pamphlets)
  • One complied with CDC guidelines
  • Only one close to ideal readability level
  • None included only correct information

Lack of understanding

  • Use of correct terminology and Information
  • Early intervention
  • Provision for follow-up
  • McKinlay A., Dalrymple-Alford J.C., Horwood L.J., & Fergusson D. M. (2002) Long term psychosocial outcomes after mild

head injury in early childhood. Journal of Neurology, Neurosurgery, and Psychiatry, 73, 281-288.

  • McKinlay A., Grace R.C., Horwood L.J., Fergusson D.M., Ridder E.M., MacFarlane M. (2008) Prevalence of traumatic brain

injury among children, adolescents and young adults: prospective evidence from a birth cohort. Brain Injury 22 (2), 175-181

  • McKinlay A., Grace R., Horwood J., Fergusson D., MacFarlane M. (2009) Adolescent psychiatric symptoms following

preschool childhood mild traumatic brain injury: Evidence from a birth cohort. Journal of Head Trauma Rehabilitation, 24, 3, 221-227.

  • McKinlay A., Grace R.C., Horwood L.J., Fergusson D.M., MacFarlane M.R. (2010) Long term behavioral outcomes of

preschool mild traumatic brain injury. Child Health Care and Development, 36, 1, 22-30.

  • McKinlay A., Corrigan J., Horwood L.J., Fergusson D.M. (2013) Substance abuse and criminal activities following traumatic

brain injury in childhood, adolescence and early adulthood. Journal of Head Trauma Rehabilitation. doi: 10.1097/HTR.

  • Coullie C., McKinlay A., McLellan T., Britt E., Grace R., MacFarlane M. (2014) A Comparison of Adult Outcomes for Males

Compared to Females Following Paediatric Traumatic Brain Injury. Neuropsychology, 29 (4), 501.

Key Publications