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

Dec 04, 2022 •313 likes •457 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

  1. 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 Prevalence of TBI • Evidence from a birth cohort 1

  2. 4/12/17 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 Cumulative Proportion experiencing a TBI Years Male Female 2

  3. 4/12/17 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 Birth Cohort Groups n = 1265 MTBI Reference 0-5 years n = 814 Inpatient Outpatient n = 22 n = 57 Requiring brief Not requiring hospital admission hospital admission ≤ 2 days 3

  4. 4/12/17 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 0-5 Year Group 14 Inattention / Hyperactivity 13 12 11 10 9 8 7 8 9 10 11 12 13 Year Reference Outpatient Inpatient Group Group Group mTBI vs reference - Conduct 0-5 Year Group 31 30 29 Conduct 28 27 26 25 24 7 8 9 10 11 12 13 Year Reference Outpatient Inpatient Group Group Group 4

  5. 4/12/17 mTBI vs fractures and reference group - Inattention / Hyperactivity 0-5 Year Group 14 Inattention / Hyperactivity 13 12 11 10 9 8 7 8 9 10 11 12 13 Year Reference Other Injury Outpatient Inpatient Group Group Group Group MTBI vs fractures and reference group - Conduct 0-5 Year Group 31 30 29 Conduct 28 27 26 25 24 7 8 9 10 11 12 13 Year Reference Other Injury Outpatient Inpatient Group Group Group 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. 5

  6. 4/12/17 What if we matched behaviour at age 7 years? 3 for 1 match of psychosocial rating at age 7 Reference Group Reference Inpatient Subgroup Group 0-5 n = 66 n = 22 • 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 Combined mother & teacher ratings of inattention / hyperactivity & conduct matched at age 7 years 0-5 Year Group 0-5 Year Group 31 14 Inattention / Hyperactivity 30 13 29 12 Conduct 28 11 27 10 26 9 25 8 24 7 8 9 10 11 12 13 7 8 9 10 11 12 13 Year Year Reference Inpatient Subgroup 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 • One or two very high scoring children in the Mild TBI group may have biased the findings 6

  7. 4/12/17 Combined ratings of inattention / hyperactivity & conduct matched at age 7 years, median split 0-5 Year Group 0-5 Year Group 31 14 Inattention / Hyperactivity 30 13 29 12 Conduct 28 11 27 10 26 9 25 8 24 7 8 9 10 11 12 13 7 8 9 10 11 12 13 Year Year Lower Injury Lower Ref Upper Injury Upper Ref Group Group Group Group Both Mothers and Teachers • Rated more inattentive behaviours over years 7-13 • Rated more conduct disordered behaviours over years 7-13 Psychiatric symptoms at ages 14-16 years based on DSM-III-R 4.2 * 6.2 ** * P< 0.05 ** P< 0.01 7

  8. 4/12/17 Psychiatric symptoms at ages 14-16 years based on DSM-III-R 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 4.2 * 6.2 ** 3.6 * 1.4 2.4 * P< 0.05 ** P< 0.01 Association between TBI and Reported Alcohol and Drug Dependence Evaluated Over Years 16-25 Percent Reporting Alcohol and Drug Dependence 36% Odds Ratios 3.05 * * p <0.05 30% ** p <0.01 2.90 * 24% 18% 1.41 1.28 12% 6% 0% Alcohol Dependence Drug Dependence Reference Outpatient Inpatient 8

  9. 4/12/17 Association between Reported Arrests, and Property and Violent Offences Evaluated Over Years 16-25 3.68 ** 15.0 Relative Risk Ratios Mean Number of Reported Events * p <0.05 12.5 ** p <0.01 3.43 ** 10.0 7.5 1.63 ** 1.68 ** 5.0 5.46 ** 2.5 1.63 * 0 Arrests Property Offences Violent Offences Reference Outpatient Inpatient Summary and Conclusions • 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? Possible contributors to long-term outcomes • Early vulnerability • Identification • Symptoms 9

  10. 4/12/17 Early Vulnerability • Critical stages of development • Solution – early intervention Identification- Parent report • Language ability of young children • Relies on parent identification • What of symptoms are reported? Differences in symptoms Internal External 36 Rate of Concussive Symptoms 30 24 18 12 6 0 Dizziness Blurred Vision Loss of Memory Headaches LOC Vomiting 2-5 Years Old ( n =39) 6-12 Years Old ( n =41) • Solution – Appropriate screening instrument 10

  11. 4/12/17 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 McKinlay et al. Public knowledge Public Perception Study of ‘concussion’ …. 2011, Brain Injury, 25(7–8): 761–766 1. Sometimes symptoms can take hours to show-up. True 2. Someone with a concussion should be kept awake. False 3. A concussion occurs only as a result of a blow directly to the head. False 4. Young children will recover better from concussion than adults. False 5. Being knocked-out is not necessary for concussion. True 6. Temporary confusion is not concussion if it clears within 5 minutes. False 7. The symptoms of concussion are apparent at the time of injury. False 8. An injury is a concussion only when there is a loss of consciousness. False 9. There are no long-term effects of concussion. False 10. It is safe to return to playing sport as soon as the confusion clears. False Correct answer (true/false) Rate answer certainty out of 100 11

  12. 4/12/17 Public response to questions 1. Sometimes symptoms can take hours to show-up False 2. Someone with a concussion should be kept awake True 3. A concussion occurs only as a result of a blow directly to the head True 4. Young children will recover better from concussion than adults False 5. Being knocked-out is not necessary for concussion True 6. Temporary confusion is not concussion if it clears within 5 minutes False 7. The symptoms of concussion are apparent at the time of injury False 8. An injury is a concussion only when there is a loss of consciousness False 9. There are no long term effects of concussion False 10. It is safe to return playing sport as soon as the confusion clears False McKinlay et al. Public knowledge of ‘concussion’ …. 2011, Mean 0 10 20 30 40 50 60 70 80 90 100 Brain Injury, 25(7–8): 761–766 Response Response Certainty 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 12

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