http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2014; 28(7): 906–914 ! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.888762

ORIGINAL ARTICLE

Psychosocial adjustment following acquired brain injury in childhood and adolescence: Executive, behavioural and emotional contributions Cheryl Soo1,2, Robyn Tate2,3, & Naomi Brookes4 1

Australian Centre for Child Neuropsychology Studies, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Australia, Rehabilitation Studies Unit, Sydney Medical School, University of Sydney, Australia, 3Royal Rehabilitation Centre, Sydney, Australia, and 4 Brain Injury Rehabilitation Program, Sydney Children’s Hospital, Randwick, Australia 2

Abstract

Keywords

Background: A large literature documents psychosocial difficulties affecting participation in everyday activities following acquired brain injury (ABI). This study examined executive, behavioural and emotional contributions to psychosocial outcome in children with ABI. Method: Participants with ABI (n ¼ 35; aged 7–18 years) were recruited from a rehabilitation department. Psychosocial functioning was assessed using the Sydney Psychosocial Reintegration Scale for Children (SPRS-C). Executive, emotional and behavioural variables were examined using self and parent-report measures. Results: Thirty-eight per cent of the sample was classified as having good psychosocial functioning, with 54% classified as limited and 8% as poor. The sample was dichotomized on executive, behavioural and emotional functioning comparing those with and without difficulties. Participants classified without behavioural difficulties had better functioning on SPRS-C compared to those with difficulties (p50.01). In contrast, for executive and emotional functioning, hardly any SPRS-C variable showed significant group differences. Of the total group, 15–21% had elevated levels on emotional outcome measures. This was, however, dependent on age, with 22–44% of the older sample reporting elevated levels on at least one emotional variable compared to 4–16% of the younger sample. Discussion: The pattern of results highlight the contribution of behavioural functioning to psychosocial outcome post-childhood ABI.

Acquired brain injury, behavioural, emotional, executive, outcome, psychosocial

Introduction It is estimated that 20 000 children under the age of 15 years in Australia have a disability related to an acquired brain injury (ABI) such as traumatic brain injury (TBI), stroke, hypoxia and brain tumour [1]. A number of studies have found that more severe degrees of childhood ABI cause a complex array of difficulties in the areas of cognition [2, 3], such as attention and executive functioning [4]; behaviour [5, 6]; emotion [7–10], social [11–15] and physical functioning [16]. Several studies have also examined psychosocial functioning following childhood ABI [17–23]. The International Classification of Functioning, Disability and Health (ICF) [24] outlines three levels of functioning in terms of a person’s impairments (i.e. difficulties in body functions), activity limitation (i.e. the execution of a task or action by a person) and participation restriction (i.e. involvement in life situation) in the context of environmental and personal factors. Within this conceptualization, psychosocial difficulties may be Correspondence: Cheryl Soo, PhD, Research Fellow, Australian Centre for Child Neuropsychology Studies, Murdoch Children’s Research Institute, Department of Psychology, Royal Children’s Hospital, Flemington Rd, Parkville, Victoria 3052, Australia. Tel: +61 3 99366761. Email: [email protected]

History Received 19 August 2013 Revised 25 November 2013 Accepted 25 January 2014 Published online 5 March 2014

viewed on the levels of activity limitation and participation restriction affecting how a person takes part in everyday routines, such as in school, social, domestic, leisure and sporting activities. Children with ABI have been reported to experience psychosocial difficulties in a number of the above areas [17–23]. A large recent prospective longitudinal study of consecutive recruitments (n ¼ 209) by Anderson et al. [17] demonstrated more severe injury is associated with a decrease in psychosocial functioning at 6 months post-TBI. This association was most pronounced for everyday executive skills, social function and internalizing behaviour. Other recent studies confirm these findings, reporting that children with TBI experience difficulties in social, emotional and behavioural (e.g. inattention/hyperactivity) domains [25, 26]. Such difficulties in turn affect the child’s ability to participate in everyday activities [18] and their quality-of-life [27, 28]. Unfortunately, there is no clear framework, such as the ICF, for defining psychosocial outcome post-childhood ABI in the literature. Indeed, comparison across studies in the area is hindered by the broad way in which the term psychosocial is conceptualized and measured. For example, some studies have used broad behavioural rating scales [20] or hyperactivity/inattention scales [22] as measures of psychosocial

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outcome, whereas other studies have defined psychosocial functioning specifically as adaptive functioning [21] or a combination of adaptive and other (e.g. social, behavioural) functioning [23]. Additionally, the terms used to describe the same constructs under the umbrella of psychosocial functioning differ across studies. For example, one study may define psychosocial outcome as adaptive, behavioural and academic functioning, while another study may refer to these same constructs as functional outcome. Several studies have examined the relationship between a range of psychosocial variables with factors such as demographic, injury, cognitive, behavioural and environmental domains [23, 29, 30]. Yeates et al. [23] examined the relationship between psychosocial outcomes and family environment in young children with TBI aged between 3–6 years. They defined psychosocial outcomes as comprising three components: behavioural adjustment as measured by the Child Behaviour Checklist (CBCL), adaptive functioning as measured by the Adaptive Behavior Assessment System (ABAS) and social competence as measured by the Preschool and Kindergarten Behavior Scales and the Home and Community Social and Behavior Scales. They reported that family environment was a significant moderator in psychosocial outcomes of TBI; in particular, family environment rather than social competence moderated group differences in behavioural adjustment and adaptive functioning. Catroppa et al. [31] examined predictors of outcome in the areas of adaptive abilities, behaviour, educational and family functioning in a sample of children with TBI (n ¼ 48) and a healthy control group (n ¼ 17). They reported that pre-injury levels of adaptive and behavioural functioning best predicted 5 year outcomes in adaptive and behavioural domains, respectively. In their regression analyses, Max et al. [30] found adaptive functioning was predicted by family functioning, psychiatric disorder in the child and IQ, explaining 22–47% of the variance. Not only has past research shown that there are differences in definition of psychosocial functioning, but also difference in factors that predict the psychosocial outcome defined. The Sydney Psychosocial Reintegration Scale (SPRS) [32] was developed to measure psychosocial outcome consistent with assessment of the ICF (WHO) [24] domains of activity limitation and participation restriction. The scale was originally developed for adults with TBI and its reliability and validity for a brain injury population has been established [33–35]. The scale measures post-injury functioning in three domains: (1) occupational activities (e.g. school and leisure), (2) interpersonal relationships (e.g. with family members and friends) and (3) daily living skills (e.g. personal hygiene activities and transport in the community). The newly developed SPRS-C (SPRS for Children) has been adapted from the SPRS to measure psychosocial functioning in children and adolescents with ABI [36], with preliminary evidence to support its use in adolescents with TBI [37, 38]. In particular, good agreement has been found between adolescents with TBI (n ¼ 17) and their parents (n ¼ 16) across most SPRS-C domains, with ICCs ranging from 0.65–0.97, with the one exception being the daily living skills domain where the ICC was 0.26 [38]. The current literature indicates that psychosocial functioning is reduced following ABI, resulting in lowered participation in everyday activities and quality-of-life. More studies

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which examine psychosocial adjustment in the context of ICF model are needed. In the present study, the ICF was used as a framework to conceptualize psychosocial functioning following childhood ABI. This study investigates post-injury activity limitation and participation restriction across the SPRS-C domains of: (i) occupational activities, (ii) interpersonal relationships and (iii) daily living skills. The aim is to: (1) examine psychosocial outcome following childhood ABI, (2) document the occurrence of cognitive (executive), behavioural and emotional difficulties in the sample and (3) investigate the relationship between psychosocial outcome and impairment factors. It is anticipated that those with better levels of cognitive, behavioural and emotional functioning will have better psychosocial outcome.

Method Participants Thirty-five participants and their caregivers were recruited from the Brain Injury Rehabilitation Programme (BIRP) of Sydney Children’s Hospital, Australia. Children who satisfied the following criteria were included in the study: (1) a history of an ABI (e.g. encephalitis, stroke or hypoxia) or TBI where there was head trauma and loss of or altered consciousness as defined by Glasgow Coma Score (GCS), post-traumatic amnesia (PTA) or intra-cranial abnormalities on brain scan, (2) aged between 7–18 years at time of the interview and (3) were admitted to the BIRP at Sydney Children’s Hospital during the 12 months from June 2005 to May 2006. Exclusion criteria were: (1) caregiver or child non-fluent in English and (2) child history of developmental disability or pre-injury neurological disorder (e.g. intellectual disabilities, cerebral palsy, attention deficit hyperactivity disorder and learning disabilities). Measures Socioeconomic status (SES) The Daniel Scale of Occupational Prestige [39] was used to measure socioeconomic status. The scale is based on occupation and provides a 6-point rating scale (1 ¼ high to 6 ¼ low SES). Psychosocial functioning The Sydney Psychosocial Reintegration Scale for Children (SPRS-C) [36] was used to measure psychosocial function. It is a 12-item questionnaire designed for children and adolescents with brain injury and contains three domains: (1) occupational activities (i.e. school and leisure and for older participants this includes work), (2) interpersonal relationships and (3) daily living skills (e.g. personal hygiene, use of transport). Parent, self and clinician report versions are available. The SPRS-C is an adapted version of the Sydney Psychosocial Reintegration Scale (SPRS) [32] with slight modifications in order to suit children and adolescents aged between 5–18 years. For example, occupational activities focused on school rather than work and living skills focused on performing regular chores rather than living independently in the community. The psychometric properties of the SPRS have been studied extensively, yielding evidence of good

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reliability and validity [32, 35]. Items are rated on a 5-point scale, with the total score ranging from 0–48; higher scores represent better levels of psychosocial reintegration. Scores on the SPRS-C were grouped into three categories: (i) Good, which includes scores reflecting ‘Good’ and ‘A little difficulty’ (scores 36–48), (ii) Limited, which includes scores reflecting ‘Some difficulty’ and ‘a lot of difficulty’ (scores 24–35) and (iii) Poor, which includes scores reflecting a ‘poor’ level of functioning (scores 0–23). Executive functioning The Delis-Kaplan Executive Function Scale (D-KEFS) [40] was used to measure executive functioning. The D-KEFS is designed for children and adults aged 8–89 years and comprises sub-tests focusing on domains such as flexibility of thinking, inhibition, problem-solving, planning, impulse control, concept formation, abstract thinking and creativity. Children aged 7 years did not complete this test given it is not suitable for this age group. All other participants were asked to complete the following sub-tests: the Trail Making Test (TMT)—number letter switching measure (cognitive flexibility) and Verbal Fluency Test (VFT)— number correctly generated for letter (verbal fluency). Moderate-to-high split-half reliabilities have been reported for these sub-tests (0.50–0.90) [41]. Studies have indicated that the D-KEFS tests have reasonable sensitivity in distinguishing among several different types of clinical groups [42]. Behavioural functioning The Child Behaviour Checklist (CBCL/6-18) [43] was used to measure behaviour as assessed through parent report. It is a 118-item questionnaire for 6–18 year olds focusing on children’s competencies and behavioural/emotional problems. Parents were asked to provide information on their child’s activities, social relations and school performance. CBCL sub-scale and total scores were used with analyses based on normalized T-scores (scores less than 60 considered to be within the normal range, scores between 60–63 in the borderline clinical range and scores above 63 indicating clinical range). Reliability of the CBCL is good, with test– re-test coefficients for the empirically based indices ranging from r ¼ 0.82–0.94 and alpha coefficients ranging from r ¼ 0.78–0.97, p50.001. Validity is evidenced by association of CBCL with Conners Rating Scales (r ¼ 0.71–0.89) and Behavior Assessment System for Children (BASC) scales (r ¼ 0.38–0.89, p50.01) [43]. Emotional functioning Emotional functioning was measured using self-report in order to take into account the internal subjective nature of the constructs in this domain. Assessment of emotional functioning required two sets of instruments to cater for the age-span of the participants, there being no single set of instruments that spanned the 7–18 year age groups represented in the present study. Younger participants (less than 15 years of age) were administered the suite of sub-scales of the Beck Youth Inventory (BYI) and participants 15 years of age and older were administered separate instruments measuring the same emotional constructs as the BYI.

Brain Inj, 2014; 28(7): 906–914

Participants younger than 15 years of age. The Beck Youth

Inventories (BYI) [44] is a self-report scale assessing emotional and social impairment in children and youth aged 7–14 years. It comprises the following sub-scales: (1) Beck Depression Inventory–Youth (BDI-Y), (2) Beck Anxiety Inventory–Youth (BAI-Y), (3) Beck Anger Inventory–Youth (BANI-Y), (4) Beck Disruptive Behaviour Inventory–Youth (BDBI-Y) and (5) Beck Self-concept Inventory (BSCI-Y). Each sub-scale contains 20 items. Cronbach’s alpha coefficients indicate high internal consistency ranging from 0.87–0.91 for ages 7–10 and from 0.89–0.92 for ages 11–14 years. Convergent validity has been demonstrated [44], for example, a moderate and significant correlation coefficient has been found between BAI-Y and the Revised Children’s Manifest Anxiety Scale (RCMAS) [45] (r ¼ 0.70; p50.001). The Multidimensional Anxiety Scale for Children (MASC) [46] was used to evaluate anxiety. It is a 39-item self-report scale designed to assess various dimensions of anxiety in children and adolescents, including the following scales: (1) Physical Symptoms, (2) Harm Avoidance, (3) Social Anxiety and (4) Total score. Cronbach’s alpha internal reliability coefficient across subscales range from 0.50–0.88 for children aged between 8–19 years [46]. Test–re-test reliabilities across 3 month intervals for sub-scales are good-to-excellent, with intra-class correlation coefficients ranging from 0.69–0.93. Evidence has been shown for factorial, convergent and discriminant validity of the MASC [46]. The Children’s Depression Inventory (CDI) [47]) was used to assess depression. It is a 27-item self-report scale designed to measure the extent and severity of symptoms of depression for youth. The CDI has the following five sub-scales in addition to the total score: (1) Negative mood, (2) Interpersonal Problems, (3) Ineffectiveness, (4) Anhedonia and (5) Negative self-esteem. Cronbach’s alpha for the CDI in normative and clinical samples range from 0.71–0.89 providing support for internal consistency reliability [47]. Various forms of validity of the CDI have been documented; for example, discriminant validity between groups of clinical vs non-referred (control) children [48]. The Adolescent Anger Rating Scale (AARS) [49] was used to measure anger. It is a 41-item self-report scale for youth aged 11–19 years. It yields three domains scores: (1) instrumental anger, (2) reactive anger and (3) anger control. Cronbach alpha coefficients for the total standardization sample range from 0.81–0.92 [49]. Evidence of validity has been documented; for example, convergent validity coefficient of the reactive anger sub-scale of the AARS and anger control problems of the Conners-Wells Self Report Scales–Long (CWSRS-L) [50] was 0.61 and between AARS instrumental anger and CWSRS-L conduct problems sub-scales was 0.57. The Self-Description Questionnaire II (SDQ-II) [51] was used to examine self-concept. It is a 102-item self-report measure which assesses three areas of academic self-concept, seven areas of non-academic self-concept and general selfconcept. The general self-concept sub-scale (GSC) was used in this study. Items within the GSC sub-scale include: ‘I can do things as well as most people’ and ‘Nothing I do ever

Participants 15 years of age and older.

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seems to turn out right’. Evidence of reliability and validity is provided by Marsh [51]. Alpha reliability coefficient for each SDQ-II sub-scale is generally high, ranging from 0.83–0.91, with coefficient for the general self-concept sub-scale at 0.88. Construct validity of the SDQ-II is supported by factor analysis studies, with responses on the SDQ-II systematically related to external criteria in a way that is consistent with theory of self-concept. Given younger and older children completed different tests to measure emotional functioning, standard scores on a given emotional domain were combined across tests for younger and older children to yield one measure of that emotional construct. For example, standard score on the MASC–Total (for 15–18 years) or BAI-Y (for 7–14 years) provided scores for ‘anxiety’ variable. Although a degree of measurement inaccuracy may be associated with these summarized measures, this method was adopted because very few standardized measures of emotional functioning have been developed for the age span of participants in this study. Procedure Approval to conduct the study was obtained from the ethics committee of the South East Sydney Area Health Service, Australia. All children and adolescents admitted to the BIRP at the Sydney Children’s Hospital during the 1-year period between June 2005 and May 2006, aged between 7–18 years and meeting the study selection criteria were invited to participate through invitation by letter. The total pool of eligible participants was 76. Families interested in participating in the study were asked to contact the hospital. A follow-up phone call was made for those who did not respond to the letter to ask if they would like to participate. For those who agreed to participate, an appointment time for an interview with the parent and child was scheduled at either the hospital or in the family home. Children and parents attended an interview on one occasion which lasted 2 hours. Signed informed consent was obtained prior to completing the interview with the parent and child/adolescent. Parents were asked to complete the CBCL and a semi-structured questionnaire focusing on the child’s background and injury details. The child/adolescent was asked to complete: (i) subtests of the DKEFS if age appropriate and (ii) questionnaires focusing on emotional functioning. Adolescents aged between 15–18 years were asked to complete the CDI to assess depressive symptoms, MASC to assess anxiety symptoms, AARS to assess anger and SDQ-II to assess self-concept. The younger group, children aged between 7–14 years, completed the BYI to assess all of the above domains of emotional functioning. Following completion of the interview, the clinical researcher (CS), who interviewed all families in this study, rated the children on the SPRS-C by combining all questionnaire and interview information provided by parents and children. Statistical analyses Screening of the data using Kolmogorov-Smirnov tests revealed that a number of variables, including SPRS-C occupational activities and interpersonal relationships subscales, differed significantly from normal distribution; thus,

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non-parametric statistical tests were used for all analyses. Three sets of statistical analyses were conducted: (1) Psychosocial adjustment across SPRS-C domains: The percentage of participants classified in good, limited and poor categories on the SPRS-C domains (occupational living, interpersonal relationships and daily living skills) and total score were calculated. Chi-square tests were used to determine if there were differences between younger vs older children classified in Good vs Limited/ poor categories. (2) Executive, behavioural and emotional functioning according to age groups: In order to classify participants as having difficulties in executive, behavioural and emotional functioning, a standard score equal to or greater than 1.0 SD above the mean was used. Chi-square tests were then used to compare the proportion of younger vs older children classified with difficulties on the executive, behavioural and emotional variables. (3) Relationship between psychosocial and impairment variables: Three dichotomized summary variables, one for each of the domains of executive, behavioural and emotional functioning were constructed. For the executive summary variable, participants were classified as having overall difficulties if they had difficulties on either the D-KEFS Trail making test or D-KEFS Verbal fluency test. Respectively, these tests measure (i) cognitive flexibility on a visual-motor sequencing task and (ii) verbal behavioural productivity and cognitive flexibility. For the emotional summary variable, participants were classified as having overall difficulties if they had difficulties on any one of anxiety, depression, anger or self-concept domains. The behavioural summary variable was based on difficulties on the CBCL-total score. For each of these summary variables, Mann-Whitney U-tests were conducted using SPRS-C scores as dependent variables, with Bonferroni corrections applied to control for multiple comparisons (critical alpha level, p50.01).

Results Table I shows the demographic and injury information of the total sample (aged 7–18 years) according to injury severity. Mean age at assessment for the total sample was 12.6 years, with mean age at onset and time post-onset being 10.3 years and 26.2 months, respectively. Over two-thirds of the total group were males (71.4%). No significant differences were found between mild injury and moderate/severe injury groups for age at assessment, age of onset, socio-economic status and proportion of males. Time post-injury for participants in the mild group, however, was longer compared to the moderate/severe group (p50.05). Psychosocial functioning The percentage of participants classified in good, limited and poor categories on the SPRS-C domains and total score are presented in Figure 1. In terms of the overall psychosocial functioning, 37.8% was classified as good, whereas 54.1% were classified as limited and 8.1% as poor. A similar pattern of finding was also reflected in the three SPRS domains. In the occupational activities domain, 32.4% were classified

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Table I. Demographic data and injury information for mild, moderate/severe injury and total groups. Mild injurya (GCS 13–15) M (SD) (n ¼ 17) Age at assessment (years) Age at injury/onset (years) Time post-injury/onset (months) Socio-economic statusb Sex Males Females Cause of injury Non-TBI TBI-total MVA Fall Bicycle/sports Assault

12.2 (3.4) 9.7 (3.1) 28.6 (6.2) 4.0 (1.4) n (%) 12 (70.1) 5 (29.4) 17 6 6 4 1

– (100.0) (35.3) (35.3) (23.5) (5.8)

Moderate/severe injurya (GCS 3–12) M (SD) (n ¼ 11)

Total group M (SD) (n ¼ 35)

12.7 (2.8) 10.6 (2.9) 23.1 (6.7) 3.4 (0.7) n (%)

12.6 (3.2) 10.3 (3.1) 26.2 (6.7) 3.8 (1.2) n (%)

9 (81.8) 2 (18.2)

25 (71.4) 10 (28.6)

– 11 (100.0) 3 (27.2) 6 (54.5) 2 (18.2) 0

4 31 10 14 6 1

(11.4) (88.6) (28.6) (40.0) (14.7) (2.9)

GCS, Glasgow coma scale; MVA, Motor vehicle accident. a Data are available for n ¼ 28. b According to the Daniel Scale of Occupational Prestige. Table II. Percentage of participants classified with executive, behavioural and emotional difficulties in younger (7–14 years), older (15–18 years) and total age groups. 7–14 years, 15–18 years, Total group, % (n ¼ 26) % (n ¼ 9) % (n ¼ 35)

Figure 1. Percentage of participants classified in the good, limited and poor categories for occupational activities (OA), interpersonal relationships (IR) and daily living skills (DLS).

as good, 56.8% were classified as limited and 10.8% as poor. For interpersonal relationships, 30.8% were classified as good, 46.2% were classified as limited and 23% as poor. A somewhat lower number were classified as having good daily living skills (27%), with 62.2% classified as limited and 10.8% as poor. When comparing Good vs Limited/poor categories on SPRS-C total and domain scores, no significant differences were found between younger and older participants (2 ¼ 0.01–1.6, p40.01, ns). Executive, behavioural and emotional functioning Table II presents data on the presence of executive, behavioural and emotional difficulties in younger (7–14 years), older (15–18 years) and total groups. In terms of the total group, the majority of the group displayed behavioural (31.4–62.9%) compared to executive (27.2–35.7%) or emotional difficulties (14.7–21.2%). However, these figures mask age-related differences. In the behavioural domain, a significantly larger number of younger children had scores

Executive Cognitive flexibility/inhibition DKEFS-TMT number/letter switchinga Verbal Fluency DKEFS-Letterb Behavioural CBCL-Anxious/depressed CBCL-Withdrawal CBCL-Somatic CBCL-Social problems* CBCL-Thought problems* CBCL-Attention CBCL-Rule breaking CBCL-Aggressive behaviour CBCL-Internalising CBCL-Externalising CBCL-Total Emotionalc Anxiety** Depression Anger Self-concept

35.0

11.1

27.6

36.8

33.3

35.7

50.0 50.0 69.2 53.8 53.8 46.2 34.6 38.5 57.7 38.5 50.0

22.2 44.4 44.4 11.1 11.1 22.2 22.2 11.1 33.3 22.2 33.3

42.9 48.6 62.9 42.9 42.9 40.0 31.4 31.4 48.6 34.3 45.7

4.0 12.0 12.0 16.0

44.4 22.2 33.3 37.5

14.7 14.7 17.6 21.2

DKEFS, Delis Kaplan Executive Function System; TMT, Trail Making Test; CBCL, Child Behavior Checklist. a n ¼ 6 missing data; bn ¼ 5 missing data; cn ¼ 1–2 missing data. *p50.05; **p50.01.

indicating difficulties on the CBCL social (2 ¼ 4.99, p50.05) and thought problems (2 ¼ 4.99, p50.05) compared to older participants. In the emotional domain, a significantly larger number of participants in the older group had scores indicating difficulties on the anxiety sub-scale compared to the younger group (2 ¼ 8.63, p50.01). No other significant differences were found between younger and older participants for any other executive, behavioural or emotional variable.

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Comparison of SPRS-C scores for those with and without executive, behavioural and emotional difficulties Table III presents data for the total group of participants aged 7–18 years. It displays SPRS-C scores for those classified with or without difficulties on the executive functioning scale. Participants with executive functioning difficulties scored lower SPRS-C scores on the daily living skills domain indicating poorer psychosocial functioning (p50.01). No other significant differences were found on the other SPRS-C variables (p40.01). As shown in Table III, a number of SPRS-C variables were able to discriminate between those with and without behavioural difficulties, including occupational activities (p50.01), interpersonal relationships (p50.01) and total scores (p50.01). Specifically this indicates that children with poor behavioural functioning have significantly more psychosocial difficulties compared to those without behavioural difficulties. In contrast, no SPRS-C variable was able to distinguish between participants classified with and without difficulties in emotional functioning (p40.01; Table III).

Discussion This study aimed to investigate psychosocial adjustment in a sample of children with ABI who were admitted to a tertiary Brain Injury Rehabilitation Unit in Sydney, Australia during the 12 months from June 2005 to May 2006. These findings indicate that, following childhood ABI, approximately onethird of this sample was rated as having ‘good’ psychosocial Table III. Median SPRS-C scores for individuals classified with or without executive function difficulties, behavioural difficulties and emotional difficulties. Median (range) Low High Mann-Whitney functioning functioning U (z) Executive functioninga n SPRS-C Occupational activities Interpersonal relationships Daily living skills Total Behavioural functioningb n SPRS-C Occupational activities Interpersonal relationships Daily living skills Total Emotional functioningc n SPRS-C Occupational activities Interpersonal relationships Daily living skills Total a

16 9.5 10.5 9.5 30.5

14 (4–13) (5–16) (6–12) (15–39)

19 9.0 10.0 9.0 27.0

(8–16) (4–15) (8–16) (22–44)

2.22* 0.50 2.82** 1.88

(6–16) (7–16) (8–16) (24–44)

3.12** 2.84** 2.13* 3.63**

(4–16) (5–15) (6–16) (15–44)

0.19 0.19 0.26 0.15

16 (4–12) (4–13) (5–15) (15–36)

23 10.0 11.0 10.0 31.0

11.5 11.5 12.0 36.0

13.0 12.0 10.0 36.0 9

(6–16) (4–16) (8–15) (22–43)

10.0 11.0 10.0 33.0

Standard score of 1 SD on either Delis Kaplan Executive Function System Trail Making or Verbal Fluency tests. Standard score of 1 SD on Child Behavior Checklist (total score). c Standard score of 1 SD on any one of the following variables: anxiety, depression, self-concept, anger. *p50.05; **p50.01. b

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adjustment—reflecting the SPRS-C categories of ‘good’ or ‘a little difficulty’. A similar figure was found for specific domains of functioning, with 32% of the sample rated as good in the occupational activities domain, 31% rated as having good interpersonal relationships and a slightly lower figure of 27% rated as good in daily living skills. In all the domains, most of the sample was rated as ‘limited’ (46.2–62.2%), corresponding to ratings of ‘some difficulty’ or ‘a lot of difficulty’. A lower proportion of the sample were rated in the ‘poor’ category across psychosocial domains (10.8–23%). No significant differences were found for younger vs older groups in terms of psychosocial functioning scores. The findings relating to behavioural, executive and emotional functioning suggest that difficulties in these areas may be related to age of the participant. Relatively higher proportions of younger children (34–69%) showed behavioural difficulties compared to the older group (11–44%). Conversely, higher proportions of older children (22–44%) reported emotional difficulties compared to younger children (4–16%). Indeed, this study found that a significantly greater number of older children reported anxiety-related difficulties compared to younger children (44% compared to 4%). A number of reasons could account for this. It is possible that older participants with ABI have greater awareness of their emotional difficulties and, hence, are better able to report them. These findings, however, are in contrast to findings in a recent study by Max et al. [52], who found younger children were at greatest risk for developing a novel anxiety disorder after TBI using DSM-IV diagnosis. It is likely that the differences in these findings may be due to the way anxiety was measured (self-report in this study vs clinical diagnosis in the Max et al. study) as well as inclusion of older adolescents (aged 15–18 years) in this sample. It is emphasized that the way emotional functioning is assessed in ABI may be a key factor underlying the discrepancy between findings across ABI studies. For example, the scales used in this study to measure anxiety (MASC and BYI-A) were not designed for ABI populations. These standardized measures were used in this study because limited alternatives were available for children with brain injury. Some of the anxietyrelated physiological signs tapped into by some of the items of these scales accompany the medical symptoms relating to ABI, thus contributing to the inaccurate assessment of anxiety in this population. Although the foregoing should be taken into account when interpreting these findings, it is also noted that this sample comprised fewer numbers of participants in the older group (n ¼ 9) compared to the younger group (n ¼ 26) and, thus, these findings should be confirmed using a larger sample. The present findings are consistent with other studies which have found evidence of psychosocial difficulties in adolescents with TBI using the SPRS-C [37, 38]. For example, Green et al. [37] reported differences for SPRS-C domains scores according to TBI severity, with those in the severe TBI group rated more poorly on the occupational activities and daily living skills domains than a non-TBI control group. In addition, these findings suggest that behavioural functioning has the strongest relationship with psychosocial outcome. These findings are consistent

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with results using adult samples, suggesting challenging behaviour is one of the best predictors of a person’s level of community integration following brain injury [53]. In contrast, these results did not find a direct relationship between psychosocial outcome and emotional functioning. It may be that other factors in combination with emotional variables may contribute to outcome. For example, factors such as family support and coping skills may mediate the impact of anxiety or depression on psychosocial outcome. Given the sample size, it was not possible to conduct a regression analysis to examine the relative contribution of predictors of psychosocial outcome. Future research could partial out these issues by examining the relationship between emotional functioning and psychosocial outcome while controlling for such mediating variables. Self-report was used for emotional and parent report for behavioural constructs in this study and, thus, the results may have been influenced by the person providing the information. Future studies could also investigate these domains as a function of the type of informant for both domains. It is likely that agreement between parent and child ratings will depend on a number of factors including the nature of the construct being assessed, the instrument used and the age of the child. For example, a recent study found high levels of agreement between parents and adolescents for psychosocial outcome as measured by the SPRS-C [38]. Yet, a large literature also documents differences between parent and self-report of behavioural symptoms [54, 55]. Given much less research in this area has focused on emotional functioning, examining the pattern of informant ratings for emotional outcome post-ABI may provide unique information on symptoms for internalizing conditions such as anxiety and depression which may not be so readily observable by others. A detailed investigation comparing ratings of emotional functioning from different informants is particularly pertinent given the literature documenting reduced self-awareness of deficit following TBI [56–58]. Additionally, note that in this sample time post-injury for the mild group was longer than that for the moderate/severe group. It is acknowledged that this variable is likely to play an important role in psychosocial recovery; for example, a child’s ability to interact with others may improve or worsen over time. A more homogeneous group would be ideal for future studies. The present research extends one’s understanding about the psychosocial adjustment experienced by children and adolescents with ABI on average 2 years post-injury. Approximately two thirds of the sample continued to experience difficulties in participating in school and leisure activities, getting along with others and engaging in day-today living skills. The study contributes to the literature suggesting that, consistent with studies using adult samples, behavioural symptoms contribute most to psychosocial outcome. The clinical implications of these findings include the need to increase resources for interventions that manage behaviour post-ABI. Such interventions may include parentbased programmes for managing behaviour [59] or childbased cognitive behavioural therapies involving family members and school personnel [60]. In addition to replication of the findings from this study, this research highlights a need for prospective research to investigate the range of predictors

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of psychosocial outcome following childhood ABI, including investigation of the networks of mediating and moderating variables involved.

Acknowledgements We would like to thank all participants and their families who participated in this study.

Declaration of interest This study was supported by funding to the Rehabilitation Studies Unit by the Motor Accidents Authority of NSW. The authors report no conflicts of interest.

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Psychosocial adjustment following acquired brain injury in childhood and adolescence: executive, behavioural and emotional contributions.

A large literature documents psychosocial difficulties affecting participation in everyday activities following acquired brain injury (ABI). This stud...
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