Ohio researchers examine childhood brain trauma
Who recovers from mild injuries, and who suffers?
Rehab professionals have noted for some time that the majority of head injuries are mild, but even these can become a major health problem, causing victims persistent problems.
It’s estimated that mild head injuries or concussions account for more than 80% of all childhood head injuries, and these types of injuries might be on the rise.
"I haven’t seen anything in epidemiology about an increase in concussions children suffer, but there is an increase in major sports injuries from soccer, skateboarding, and scooters," notes Keith Yeates, PhD, associate professor of pediatrics and psychology at The Ohio State University and associate director for the Center for Injury Research and Policy at the Children’s Research Institute of Columbus, OH. Yeates also is the director of pediatric neuropsychology at the Children’s Hospital in Columbus.
"The controversy about concussions, and it’s been going on for some time, is that there seem to be a sort of small but definite group of people who report a variety of persistent problems, including inattention, forgetfulness, increased fatigue, headaches, and more irritability and personality changes," Yeates says. "So there doesn’t seem to be much question that there are some folks who after a mild concussion have those kinds of problems, but the controversy is, why do they have those problems?"
Some experts say this is a psychological phenomenon and not a result of the brain injury, while others say it reflects some underlying brain dysfunction, Yeates says.
The latter theory has some support from other research findings that children have persistent problems following mild brain injuries, and that is what Yeates and fellow investigators intend to study: What are the effects of mild brain injuries or concussions on children and adolescents?
The Center for Injury Research and Policy has been awarded a $3.5 million grant from the National Institute of Child Health and Human Development to study the long-term effects of mild brain injuries in children. Yeates will lead the five-year study and work in conjunction with Case Western Reserve University and Rainbow Babies and Children’s Hospital in Cleveland.
"Our goal is to get an idea of how those problems occur and to get a better handle on how injury-related factors and non-injury related factors predict occurrences of problems after a concussion," Yeates says.
"Adults have been shown to be slower to go back to work with more work-related disability. For whatever reason, they have the symptoms and they have some significant disability or problems in day-to-day life as a result or consequence of those problems," Yeates adds. "We don’t know if children miss more school or go to the doctor more often."
The research might lend support to one of the theories regarding mild brain injury, although Yeates hypothesizes that the two schools of thought are not mutually exclusive.
"At different times, some symptoms may be more physiological and others may be psychological," Yeates says. "My theory is that post-concussion symptoms, particularly the physical and some cognitive, are more likely to have a physiological basis soon after the injury occurred, and that some emotional and behavioral symptoms that occur later after the injury may have more psychological components."
Since there likely are multiple causes for the symptoms, they aren’t simple to treat and also present a challenge for research.
With adults who have had minor brain injuries, there is the problem of secondary gain that may make it difficult to determine the basis for persistent problems, and this is another reason why researchers are particularly interested in studying a population of children, Yeates says.
For example, adults may be suing someone over the brain injury, so there is some motivation to claim disability, Yeates says.
"Kids can be a topic of litigation as well, and I’ve been involved in these cases, but I think when that happens it’s the parents and adults who are motivated financially and not the kids," Yeates adds. "So I do think perhaps the children will provide a clearer test to the answer of these questions."
One of the questions families will be asked during the mild brain injury study will be whether the family is involved in litigation because of the injury. This will help investigators determine whether there is a difference in problems reported by children who are involved in litigation and those who are not, Yeates adds.
Here are some details about how the study will work:
- Recruiting: Plans are to recruit 200 children, ages 8 to 15, who have had mild concussions and 100 children in the same age range who have had minor orthopedic injuries that do not involve head injury. The orthopedic injury subjects will be the comparison group.
"One of the questions is whether there are any specific issues with head injury vs. other sorts of injury," Yeates says.
Children will be recruited from both the Children’s Hospital in Columbus and the Rainbow Babies and Children’s Hospital in Cleveland.
All of the children included in the study group will have had an injury of blunt trauma to the head that resulted in the loss of consciousness and a Glasgow coma score that ranges from 13-15, which is the mildest of brain injuries. If the Glasgow coma score is 15 by the time the child is seen in the emergency room, then the child will be included in the study only if the child had symptoms of vomiting, amnesia, vertigo, dizziness, or another alteration of mental status or functioning, Yeates says.
"We’re trying to avoid recruiting children who’ve just had bumps to the head," he adds.
Recruitment began late last year and will continue over the next 2.5 years, with a goal of having all subjects recruited within three years, Yeates says.
The only children who will be eliminated from the study because of the cause of their injuries are those whose injury was a result of their ingesting alcohol and those who were physically abused. "There’s good literature to suggest that alcohol would affect the outcome of traumatic brain injury," Yeates says.
"We don’t want other injuries that might have an effect on the central nervous system, like shock or hypertension, and we want the injury to be a concussion and not a real serious injury otherwise," Yeates explains.
Also, children with severe psychiatric disorders will be excluded from the study, and all children in the study will need to have use of their preferred arm because the study will test that function.
- Baseline assessment: Children will receive a baseline assessment within two weeks of the injury. All children will receive an MRI that will look for brain lesions. About 20% of children are expected to have brain lesions, and that’s one of the injury-related factors investigators are interested in studying, Yeates says.
"We are interested to see if they’re more likely to have post-concussion symptoms and worse outcomes than those without lesions," he explains.
Parents will be asked for background data about the family environment, social environment, resources available in the community, and stresses that affect the family. They’ll be assessed for their own psychological functioning and their attitudes toward illness.
Some parents may reinforce sick behavior
"We’re interested in how these types of factors either lessen an injury or heighten it," Yeates says. "We have a measure called the illness behavioral encouragement scale, which is based on the notion that some parents — not necessarily consciously, but indirectly — may reinforce sick behavior."
By using this scale, investigators might determine whether parents who are more likely to reinforce ill behavior from their children will report more symptoms and whether parents with greater resources and fewer stresses report fewer effects from the injury.
- Ongoing assessments: Children will be followed for a year after their injuries, with symptom assessments conducted at one month and full assessments at three and 12 months post-injury.
"We’re interested in both the children’s outcomes and how the family and parenting functioning might affect the outcomes of mild head injury," Yeates says.
Both children and their families will be asked about persistent problems that may relate to the brain injury, including the incidence of headaches.
"Headaches are more commonly reported after mild head injury than severe injury, and that raises the question of how much of it is psychological," Yeates says. "No one can tell whether someone is having a headache — it’s only reported."
Investigators will study whether children who report headaches are less interested in everyday activities, such as riding bikes, playing with other children, etc. Also, researchers will observe whether children who report persistent problems miss more school or see their doctors more frequently.
Parents are not being asked to keep journals because the study will use measurement tools that are more objective so as to minimize reporting bias.
The study will continue through 2006 and possibly longer if additional funding is found.
Need More Information?
- Keith Yeates, PhD, Associate Professor of Pediatrics and Psychology, The Ohio State University; Associate Director for the Center for Injury Research and Policy, Children’s Research Institute; Director of Pediatric Neuropsychology at the Children’s Hospital, Department of Psychology, 700 Children’s Drive, Columbus, OH 43205. Telephone: (614) 722-4700.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content