Social Environmental Moderators of Long-term Functional Outcomes of Early Childhood Brain Injury

IMPORTANCE Pediatric traumatic brain injury (TBI) contributes to impairments in behavior and academic performance. However, the long-term effects of early childhood TBI on functioning across settings remain poorly understood. OBJECTIVE To examine the long-term functional outcomes of early childhood TBI relative to early childhood orthopedic injuries (OIs). We also examine the moderating role of the social environment as defined by parent report and observational measures of family functioning, parenting practices, and home environment. DESIGN, SETTING, AND PARTICIPANTS A prospective, longitudinal, observational cohort study conducted at each child's home, school, and hospital, including 3 children's hospitals and 1 general hospital in the Midwest. Patients were enrolled in the initial study between January 2003 and October 2006. Follow-ups were completed between January 2010 and April 2015. Fifty-eight children who sustained a TBI (67% of original enrolled cohort) and 72 children who sustained an OI (61% of the original enrolled cohort) were prospectively followed up from shortly after injury (between the ages of 3 and 7 years at enrollment) to an average of 6.7 years after injury, with assessments occurring at multiple points. MAIN OUTCOMES AND MEASURES Long-term functional outcomes in everyday settings, as assessed through the Child and Adolescent Functional Assessment Scale (CAFAS). RESULTS Of the 130 children included, the median age for those with OIs was 11.72 years and 11.97, 12.21, and 11.72 years for those with complicated mild, moderate, and severe TBIs, respectively. Children with moderate and severe TBI were rated as having more functional impairments in multiple domains than those with OIs (P <.05). Children with complicated mild TBI had greater impairments in school (odds ratio = 2.93; 95% CI = 1.10-7.82) and with thinking (odds ratio = 15.72; 95% CI = 3.31-74.73) than those with OIs. Functional impairments in children with TBI were more pronounced among children from families with higher levels of permissive (mean CAFAS of 49.71, 35.74, 58.14, and 16.16 for severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with significant difference between severe TBI and OI [difference = 33.55; P <.001] and complicated mild TBI and OI [difference = 41.98; P <.001]) or authoritarian (mean CAFAS of 56.45, 41.80, 54.90, and 17.12 for severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with significant difference between severe TBI and OI [difference = 39.33; P <.001], moderate TBI and OI [difference = 24.68; P =.003], and complicated mild TBI and OI [difference = 37.78; P <.001]) parenting or with fewer home resources (mean CAFAS of 69.57, 47.45, 49.00, and 23.81 for severe TBI, moderate TBI, complicated mild TBI, and OI, respectively, with significant difference between severe TBI and OI [difference = 45.77; P <.001], moderate TBI and OI [difference = 23.64; P <.001], and complicated mild TBI and OI [difference = 25.20; P <.001]). CONCLUSIONS AND RELEVANCE Even children with relatively mild early TBI experience long-term functional impairments, particularly in the context of less favorable home environments. These findings suggest that improving parenting skills and the quality of the home environment may promote functional recovery following early TBI.