This study demonstrated that children with inflicted TBI had worse outcomes than did children with noninflicted TBI when the study population was restricted to children <2 years of age at the time of injury. As might be expected from the worse outcomes, children with inflicted TBI also exhibited greater use of ancillary medical resources, such as occupational and physical therapies. Families caring for children after TBI were remarkably similar in terms of social and financial capital.
The poorer outcomes seen in this study seemed to be related most strongly to a requirement for CPR and/or seizures, either at presentation or at some time during the child’s hospitalization. Early posttraumatic seizures were associated with worse neurodevelopmental outcomes, at 3 years after injury, among children with inflicted TBI in a series reported from Scotland.19
Other possible reasons for the worse outcomes might include the mechanism of injury, the increased frequency of repeated injuries among children with inflicted injuries versus noninflicted injuries, and the possibility that children with inflicted injuries present later after their injury event. We showed previously that children with inflicted TBI were more likely to present with seizures than were children whose TBI was not inflicted.10
Approximately 35% of the children in the inflicted TBI group had evidence of previous neurologic injury, compared with none of the children with noninflicted injuries,10
which is consistent with findings from other studies of children with inflicted TBI.20,21
Although children with inflicted injuries seemed to fare worse overall than did children with noninflicted injuries, slightly more than 50% of them were faring well, as scored on the POPC, and the upper 25th percentile had scores in the well range on the FSII(R). This differs somewhat from earlier reports that indicated that the majority of children with inflicted TBI tended to fare poorly.22
This is also somewhat more hopeful than the results reported by Ewing-Cobbs et al.20
They reported on the outcomes of 40 children with TBI (20 with inflicted TBI and 20 with noninflicted TBI), who ranged in age from birth to 6 years, at ~1.3 months after recovery from traumatic amnesia. In that study, only 20% of the children with inflicted TBI were faring well, as measured with the Glasgow Outcome Scale23
adapted for children, compared with 55% of children with noninflicted TBI. The differences in outcomes between our study and the study by Ewing-Cobbs et al20
might be related to follow-up periods, sample sizes, or ages at the time of injury or might reflect the wider variation in initial severity related to complete population-based recruitment of participants, compared with recruitment from a single specialized center. Skills that are in a rapid stage of development might be more vulnerable to disruption by trauma than skills that have already been acquired,4
and children with inflicted TBI tend to be younger than children with noninflicted TBI. Age at injury has been shown to account for some of the variance in recovery of executive functioning among children with TBI who are <6 years of age.2
It is not known how this group of young children will perform in acquiring new skills as cognitive tasks and behavioral skills become more demanding. It is possible that more-subtle deficits caused by the brain injury are not well recognized by caregivers or measured with psychological testing at this early age.
Neither GCS scores nor injury severity scores were sufficiently sensitive and specific for use in definitively predicting longer-term outcomes. The injury severity score, with a specificity of 96%, is the most useful of the injury severity scoring systems. Very few children with an injury severity score indicating severe injury fared well; however, the scale is not sensitive.
Surprisingly, the sensitivity and specificity of GCS scores with the traditional cutoff value of ≤8 versus a cutoff value of ≤12 were not much different in this population. This might be because lesser injuries have more profound consequences among very young children, compared with older children and adults. Previous research showed that GCS scores have limitations in predicting outcomes among children.24
Use of ancillary medical resources was frequent for all children, with ~40% requiring some type of therapy weekly or more frequently. Children with inflicted injuries were somewhat more likely to be high users of services, on the basis of the severity of injury. Most families of children with moderate/severe disability outcomes were able to access therapy for their children, and most had a primary care physician. These results were encouraging, because ability to access health care has been shown to differ according to race and socioeconomic status.25
A previous qualitative study of children with TBI performed in Arkansas also found that children were able to access rehabilitative resources.26
However, most of the children in that study were injured at an older age and accessed resources through the school system. Children in our study were not yet old enough to be in the public school system, which could have made resources less accessible for families.
The families of the children with inflicted and noninflicted TBI seemed remarkably similar. The main differences in these families were the age of the maternal caregiver and the proportion of caregivers who were foster parents. This is not surprising, because many of the foster parents were grandparents. One year after injury, almost 50% of children with inflicted TBI were still in some type of foster care (family or unrelated). For both groups of children, the majority of maternal caregivers were from a minority group, unmarried, and employed. Caregivers did not differ in measures of social capital. It is possible that some children with inflicted TBI had their social capital enhanced, because families providing foster care are more likely to be older and are screened by DSS. Social outcomes of pediatric TBI survivors have been shown to be affected by family environments, including family resources.27
Severe TBI among older children has been shown to cause greater family stress, compared with other injury types.28
It is possible that enhanced social capital might have a moderating effect on stress created by caring for a child with a brain injury; however, many of these families might be stressed already because of adverse social circumstances, which could affect longer-term outcomes for these children. Also, although the necessity of providing complete care for an infant is expected, it is possible that the stresses of care would increase as the children reach an age at which families expect the child to be capable of more independence. Because families caring for children with TBI seem to be similar regardless of the injury mechanism, interventions designed to improve outcomes of children with early TBI may be applicable to both groups of children.
This study has limitations. Not all families enrolled in the follow-up portion of the study. Although families that participated or did not participate seemed similar to the entire cohort, they might have been different in ways that were not measured, which would create bias. In addition, families might differ in the way they function, which was not measured in this study. The child outcome portion of this study was performed through telephone interviews and not direct measurement of the child’s abilities, which might reduce its sensitivity. However, this approach allowed us to maintain a larger cohort of children, because there were no geographic restrictions on follow-up monitoring. It is not known whether foster mothers might assess children differently, compared with biological mothers who knew the child before injury. In addition, most children were still very young at the time of this assessment; therefore, delays might be less apparent to caregivers than they would be for children at a later stage of development.
The strengths of this study include the fact that the children’s age at injury was limited to <2 years. Because recovery from injury is partly age dependent, this allows a more-equal comparison of the inflicted and noninflicted children’s outcomes. We used several measures of child outcomes, and the FSII(R) and POPC identified the same group of children with poor outcomes, which adds validity to our ability to measure child outcomes through maternal caregiver interviews. In addition, this study was able to characterize the families caring for this group of children.