Abstract

Traumatic brain injury (TBI) is associated with complaints including headaches, restlessness, memory problems, or irritability, which are assumed to be a consequence of the TBI. The current study is a first attempt to establish the prevalence of common TBI complaints reported by non-brain-injured children aged 11–13. In a 38-item self-report questionnaire, 124 children reported high base rates for symptoms over the past year, especially “grumpy/cross” (79.4%), “frustration” (74.0%), and “fatigue (mental or physical)” (72.2%). This was comparable with base rate information reported by Lees-Haley and Brown (1993) for non-brain-injured adults for a longer period (24-month period). Approximately 20% of children reported five or more symptoms on a daily or weekly basis. They were most likely to be in behavioral and emotional rather than somatic or cognitive domains. Therefore, further research is needed to establish base rate information in order to clarify the true significance of symptom reporting and caution is recommended in interpretation of these symptoms in neuropsychological assessment of TBI in children.

Introduction

Traumatic brain injury in children

Head injuries in children occur frequently and are one of the most common injuries that children receive. Kraus (1995) found that the incidence of brain injury in children was 180 per 100,000 children per year across all severities. While early research into the effects of traumatic brain injury (TBI) in children was based on knowledge of the effects of TBI in adults, more recent research has shown that the effects of brain injury in children must be studied in their own right. There are issues that are unique to damage in the developing brains of children and adolescents that must be considered (Anderson, Fenwick, Manly, & Robertson, 1998; Anderson, Northam, Hendy, & Wrennell, 2001) and the effects of injury to the brain will differ according to what age the child is at the time of injury (Dennis, Wilkinson, Koski, & Humphreys, 1995). Unlike previously thought, the immature brain of children does not offer some protection in a brain injury because of the “plasticity” of the young brain, but rather, young children are more sensitive to some types of brain injury than adults and show less recovery (Anderson et al., 2001; Dennis et al., 1995).

Brain injuries in children are often followed by impairments in a wide range of domains and the more severe the brain injury the greater the deficits (Catroppa & Anderson, 1999; Ewing-Cobbs, Fletcher, Levin, Iovino, & Miner, 1998). These domains include intelligence and academic achievement (Anderson et al., 2001; Kinsella et al., 1997), attention (Anderson & Pentland, 1998; Yeates, 2000), language (Blosser & DePompei, 2003; Ewing-Cobbs, Levin, & Fletcher, 1998), motor skills (Barlow, Thomson, Johnson, & Minns, 2005; Chaplin, Deitz, & Jaffe, 1993), memory (Anderson, Catroppa, Rosenfeld, Haritou, & Morse, 2000; Levin, Ewing-Cobbs, Eisenberg, 1995), executive function (Dennis et al., 1995; Todd, Anderson, & Lawrence, 1996), and behavioral and social functioning (Andrews, Rose, & Johnson, 1998; Deaton & Waaland, 1994; Schwartz et al., 2003).

There are reasonably accurate assessment processes available for determining post-injury functioning for the child as long as the assessment is multidimensional (Baron, 2004; Beers, Hammond, & Ryan 2006). However, pre-injury functioning is usually assessed based on the reports from significant others and this can be susceptible to biases in reporting (Hartlage, 1995). Research with adults who have received a TBI has shown that their reports of the degree of impairment do not always match the reports of significant others (Fischer, Trexler, & Gauggel, 2004; Sawchyn, Mateer, & Suffield, 2005) and this has also been shown with children (Leathem & Body, 1997).

The use of base rates in psychological assessment

Retrospective self-reported data are affected by recall that may be selective and unreliable and this has been reported in witness testimonies (Loftus, 1982), self-reports of estimations of injury rates (Harel et al., 1994), recalling attitudes of beliefs from the past (Visser, Krosnick, & Lavrakas, 2000), and recalling emotions (Thomas & Diener, 1990). Self and informant ratings of everyday functioning comparing patients with TBI to people without TBI tended to over report the premorbid functioning of the person with the TBI (Leathem, Murphy, & Flett, 1998; Thomas & Diener, 1990). Since these biases make the validity of self-reported data questionable (Murphy & Davidshofer, 2001), more robust methods are needed and one way to do this is to use base rates in clinical decision-making.

Meehl and Rosen (1955) first drew attention to the importance of using base rates in psychological assessment and despite others supporting this (Gouvier, 1999; McCaffrey, Palav, O'Bryant, & Labarge, 2003), base rates still seem to be under utilized in clinical judgments about diagnosis (Chan, 2001; Elwood, 1993; Gouvier, Hayes, & Smiroldo, 1998; Lees-Haley & Brown, 1993). The purpose of psychological assessment in clinical psychology is to discriminate those with a target disorder and those without and psychometric tests are often used to aid in these decisions, but an over-reliance on these tests without consideration of base rates can increase the error in clinical judgments (Meehl & Rosen, 1955). However, base rates should guide clinical practice and not rule it (Gouvier, Pinkston, Santa Maria, & Cherry, 2002) and, overall, there is a need for actuarial and clinical decision-making to be integrated in their use, as they are complementary. When used together, they can achieve the highest degree of accuracy for neuropsychological diagnosis (Willis, 1988).

Lees-Haley and Brown (1993) reported base rates for symptoms related to neuropsychological injury in personal injury claimants. In their study, 170 adult claimant patients reported much higher frequency of self-reported symptoms associated with neuropsychological impairment (about half of the symptoms were reported as being a problem for more than 50% of the claimants) than 50 control participants, that is, not involved in personal injury complaints. Participants were asked whether they had suffered from any of the complaints since the injury (for personal injury claimants) or over the previous 24 months (for controls). Since the Lees-Haley and Brown (1993) study was able to establish base rates for symptoms of TBI in adults, the idea to investigate base rates of symptoms for TBI in children provided impetus for the current study. While there are some studies of symptom base rates as they apply to adults with TBI (McCaffrey et al., 2003), a search of the literature found no studies that had established symptom base rates of childhood TBI.

The current study

The current study was a first attempt to consider base rates of TBI symptoms in children. While the Lees-Haley and Brown study included both claimants who had a TBI and controls, this study, initially, aimed to only study non-head injured children. (In the event, however, there were a number of children with reported head injury. Whether this equated to brain injury is unclear and is discussed in the “Results” section.) In addition, data were gathered over a shorter timeframe than the Lees-Haley and Brown study, and children were asked to rate how often these complaints occurred (i.e., once a year, month, week, or day) in order to better determine the frequency of problems and to provide more clinically meaningful data. The aim of the study was to assess the prevalence of common symptoms of TBI in children aged 11–13 who had not had a head injury and these results would be compared with the base rates reported by adults in the Lees-Haley and Brown study. It was hypothesized that there would be no noticeable gender differences as this had been observed in studies with adults.

Method

Participants

The participants in this study were students, aged 11–13, from two full primary schools (with children from year 1 to year 8) from a broad cross section of the local population. Information was distributed to 142 children. Five parents did not give consent for their children to participate, then on the day the questionnaire was administered, ten children were absent and another chose not to participate. Of the 126 children who did participate, 2 did not complete the demographic data on the back page of the questionnaire and their responses were excluded from the results. Of the remaining 124 children, who made up the sample, 27 (10 girls and 17 boys), mean age 11.9 years (SD = 0.7), indicated that they had been to the doctor or hospital due to an injury to the head or concussion. The remaining 97 children (43 girls and 54 boys), mean age 11.8 years (SD = 0.8), indicated that they had not received a head injury.

Measure

The 38-item questionnaire used in this study was aimed to assess the common health complaints of children. Items were taken from the list of complaints in the Lees-Haley and Brown (1993) study and then worded in child appropriate language (questionnaire is available from author on request). Some items were removed because they were inappropriate (sexual problems, impotence) or might cause embarrassment for the children filling them out in the classroom setting (diarrhea, constipation). Items 30 (frustration) and 35 (getting into many fights) were added as they have been shown to be common sequelae of TBI in children (Leathem & Body, 1997). Most items began with a stem of “I have trouble with … .” For some items, it was necessary to have a different stem as they read better and were more easily understood in another format (e.g., item 2 “I feel very unhappy, sad, or depressed,” or item 17 “I am not able to do everyday tasks easily and well”). The questionnaire also included eight distracter items that are not commonly associated with head injury so that if a child had suffered a head injury they would be able to complete the questionnaire without checking off every item as being a problem for them (the rationale for using these, as well as the particular choice of items, was exactly the same as the process used by Lees-Haley and Brown). A 5-point Likert scale was used and response options were “Never or less than once a year,” “Once a year,” “Once a month,” “Once a week,” and “Every day.” The final three items gathered demographic information and whether or not they had been to the doctor or hospital for head injury.

Procedure

Information Sheets and Consent Forms were provided for parents and consent was gained from the Board of Trustees from each school. An oral explanation of the research was provided for the children as well as providing simplified Children's Information Sheets. It was stressed to the children that participation was completely voluntary. The questionnaires were administered to each class separately and the nature of the research as well as the voluntary participation was re-explained to the children. The children completed the questionnaires anonymously before returning them to the researcher.

Results

Collated results of the questionnaire are presented in Table 1, with symptoms ranked in descending order of frequency of symptoms that occur on a daily basis. When compared with the rates of occurrence reported by adult controls in the Lees-Haley and Brown (1993) study, who reported symptoms over the previous 24 months, the children reported comparable rates of these symptoms within the previous year.

Table 1.

Total percentage positive responses from participants

Symptoms Daily Weekly Monthly Yearly Never Adult controlsa 
Concentration and attention difficulties 13.5 11.5 12.5 22.9 39.6 26 
Impatience 12.4 9.3 11.3 29.9 37.1 36 
Word finding problems 11.5 9.4 17.7 26.0 35.4 20 
Fatigue (mental or physical) 10.3 22.7 16.5 22.7 27.8 58 
Sleeping problems 9.4 17.7 12.5 26.0 34.4 52 
Memory problems 8.3 8.3 17.7 14.6 51.1 20 
Frustration 7.3 17.7 16.7 32.3 26.0 – 
Difficulty with planning or organization 7.3 17.7 13.5 25.0 36.5 24 
Restlessness 7.3 16.7 15.7 12.5 47.8 18 
Reading problems 7.3 8.3 7.3 11.5 65.6 22 
Grumpy or cross 6.2 18.6 30.9 23.7 20.6 38 
Depressed, unhappy, sad 6.2 11.3 25.8 26.8 29.9 32 
Bumping into things 5.2 7.3 11.5 12.5 63.5 20 
Foot painb 4.2 12.5 20.8 18.7 43.8 22 
Headaches 4.1 9.3 29.9 24.7 32.0 62 
Aggression, getting into fights 4.1 5.2 7.3 27.1 56.3 – 
Speech problems 4.1 1.0 15.5 26.8 52.6 16 
Hearing problems 3.1 15.6 14.6 21.9 44.8 18 
Worried about healthb 3.1 9.3 14.4 17.5 55.7 36 
Difficulty with everyday tasks 3.1 8.3 14.6 17.7 56.3 16 
Lack of interest in things 3.1 5.2 11.5 16.7 63.5 30 
Bleedingb 3.1 4.2 9.4 26.0 57.3 12 
Nervousness, anxiety 2.1 12.5 31.3 25.0 29.1 54 
Numbness 2.1 4.2 7.3 14.6 71.8 12 
Broken bonesb 2.1 4.2 4.2 7.3 82.2 
Nausea, sore tummy 1.1 9.5 18.9 34.7 35.8 34 
Vision problems 1.1 4.2 10.5 13.7 70.5 22 
Confusion 1.0 13.5 22.9 22.9 39.7 16 
Neck painb 1.0 9.3 19.6 22.7 47.4 30 
Dizziness 1.0 8.3 15.6 22.9 52.2 26 
Back painb 1.0 4.1 22.7 21.6 50.6 48 
Shoulder painb 1.0 4.2 14.6 18.8 61.4 14 
Trembling 1.0 4.1 7.2 9.3 78.4 
Seizures 1.0 1.0 2.1 4.2 91.7 
Elbow painb 0.0 2.1 5.2 13.4 79.3 12 
Symptoms Daily Weekly Monthly Yearly Never Adult controlsa 
Concentration and attention difficulties 13.5 11.5 12.5 22.9 39.6 26 
Impatience 12.4 9.3 11.3 29.9 37.1 36 
Word finding problems 11.5 9.4 17.7 26.0 35.4 20 
Fatigue (mental or physical) 10.3 22.7 16.5 22.7 27.8 58 
Sleeping problems 9.4 17.7 12.5 26.0 34.4 52 
Memory problems 8.3 8.3 17.7 14.6 51.1 20 
Frustration 7.3 17.7 16.7 32.3 26.0 – 
Difficulty with planning or organization 7.3 17.7 13.5 25.0 36.5 24 
Restlessness 7.3 16.7 15.7 12.5 47.8 18 
Reading problems 7.3 8.3 7.3 11.5 65.6 22 
Grumpy or cross 6.2 18.6 30.9 23.7 20.6 38 
Depressed, unhappy, sad 6.2 11.3 25.8 26.8 29.9 32 
Bumping into things 5.2 7.3 11.5 12.5 63.5 20 
Foot painb 4.2 12.5 20.8 18.7 43.8 22 
Headaches 4.1 9.3 29.9 24.7 32.0 62 
Aggression, getting into fights 4.1 5.2 7.3 27.1 56.3 – 
Speech problems 4.1 1.0 15.5 26.8 52.6 16 
Hearing problems 3.1 15.6 14.6 21.9 44.8 18 
Worried about healthb 3.1 9.3 14.4 17.5 55.7 36 
Difficulty with everyday tasks 3.1 8.3 14.6 17.7 56.3 16 
Lack of interest in things 3.1 5.2 11.5 16.7 63.5 30 
Bleedingb 3.1 4.2 9.4 26.0 57.3 12 
Nervousness, anxiety 2.1 12.5 31.3 25.0 29.1 54 
Numbness 2.1 4.2 7.3 14.6 71.8 12 
Broken bonesb 2.1 4.2 4.2 7.3 82.2 
Nausea, sore tummy 1.1 9.5 18.9 34.7 35.8 34 
Vision problems 1.1 4.2 10.5 13.7 70.5 22 
Confusion 1.0 13.5 22.9 22.9 39.7 16 
Neck painb 1.0 9.3 19.6 22.7 47.4 30 
Dizziness 1.0 8.3 15.6 22.9 52.2 26 
Back painb 1.0 4.1 22.7 21.6 50.6 48 
Shoulder painb 1.0 4.2 14.6 18.8 61.4 14 
Trembling 1.0 4.1 7.2 9.3 78.4 
Seizures 1.0 1.0 2.1 4.2 91.7 
Elbow painb 0.0 2.1 5.2 13.4 79.3 12 

Notes: dash indicates that items not included because of differences between child and adult experiences of traumatic brain injury.

aAdult “Controls” (i.e., non-personal injury claimants) from Lees-Haley and Brown (1993).

bItems included as distracters.

An unexpected result of this study was that 27 children (10 girls and 17 boys) responded that they had been to the doctor or hospital to attend to a head injury or concussion. Statistical analysis using the Mann–Whitney (U) test indicated only a few items in which there was a statistically significant difference in reporting between the head-injured and the non-head-injured groups (i.e., elbow pain, back pain, seizures, and vision problems). However, as there did not appear to be a pattern in this reporting (two of the items were distracter items) and since the severity of the reported injury could not be corroborated by adult report, no meaningful comparison could be made between the groups, and the results of the whole sample of children were considered in the results analysis. Analysis with the Mann–Whitney test indicated that there was no statistical difference between reporting by boys and girls on any item.

Results indicate that there were four items with which 10% of the children reported having difficulty on a daily basis and nine items with which 20% of the children reported difficulty on a daily or weekly basis.  Approximately 8% of children reported difficulty with seizures; however, this may be due to misunderstanding of the item, which said “I have trouble with seizures. I have fits or spasms when my body jolts or shakes and can't stop it.” Some children may have reported concern over normal body movements and twitches (e.g., hypnagogic jerks at sleep onset).

In addition, for each participant, it was calculated how many symptoms were reported on a daily or weekly basis. Table 2 shows the frequency that children reported multiple symptoms and indicates that 9% of the children reported ten or more symptoms as occurring at least weekly and 2.5% reported ten or more or more symptoms as occurring at least daily. This indicates that 30% of the participants reported five or more symptoms as occurring weekly and 13% reported five or more symptoms as occurring daily. In other words, 70% of the children reported fewer than five symptoms on a weekly basis and 87% reported fewer than five symptoms on a daily basis.  In fact, 52.4% of the children reported no symptoms on a daily basis and 25% of the children reported no symptoms on a weekly basis.

Table 2.

Frequency that children reported multiple symptoms

No of endorsed items Weekly (%) Daily (%) 
25.0 52.4 
1 to 4 44.4 34.7 
5 to 9 21.8 10.5 
10 to 14 8.1 1.6 
15 to 19 0.8 
20 or more 0.8 
No of endorsed items Weekly (%) Daily (%) 
25.0 52.4 
1 to 4 44.4 34.7 
5 to 9 21.8 10.5 
10 to 14 8.1 1.6 
15 to 19 0.8 
20 or more 0.8 

Discussion

The current study aimed to assess the prevalence of common symptoms of TBI in children, aged 11–13, who had not incurred a head injury and the results were compared with the rates reported by adults in the Lees-Haley and Brown (1993) study with adults. The findings of this study indicate that the most frequently reported problems were endorsed by over 70% of the children (“Grumpy or cross” 79.4%; “Frustration” 74.0%; and “Fatigue [mental or physical]” 72.2%) when reporting over the previous year. These were comparable with the rates reported by adults in the previously mentioned study; however, no direct statistical comparison of children and adult symptom base rates was attempted.

In addition, the current study asked the children to report the frequency of these complaints over shorter time periods, which indicated that there were only four items in which 10% or more of the children reported having trouble on a daily basis and only eight items in which 20% or more of the children reported having trouble on a daily or weekly basis. Furthermore, 30% of the children reported five or more symptoms as occurring weekly and only 13% reported five or more symptoms as occurring daily. Therefore, multiple, frequent symptoms are not especially common in most children (70% reported fewer than five symptoms occurring weekly and 87% reported fewer than five symptoms on a daily basis), suggesting that reports of many symptoms occurring on a daily basis may be clinically significant. While there is no indication of the severity of these complaints, it could be concluded that if one in five children report having “trouble” with multiple symptoms on a daily or weekly basis, they may well be impacting on their everyday functioning. These results suggest that base rate information definitely needs to be considered when making clinical judgments in neuropsychological assessment of TBI in children to enhance decision-making.

Compared with studies with adults where no difference was found between reporting rates for men and women, it was hypothesized that no difference would be seen between boys and girls in the current study. As suggested, there was no statistically significant difference in reporting between boys and girls and future research with larger numbers would be necessary to explore further any differences in responding by boys and girls.

Previous studies with adults who have not incurred a head injury have shown that they report high base rates of common symptoms of head injury (Chan, 2001; Lees-Haley & Brown, 1993). In the current study, the rates at which the children reported complaints over the previous year (which is more consistent with the reporting period in the adult studies which asked over the previous 24 months) were also high. The most frequently reported symptoms for non-head-injured children in the current study were reported by 70%–80% of the participants. In the study by Chan, 5 of the 16 items were endorsed by more than 50% of the participants and the most frequently reported item, “Longer time to think,” was reported by 65.9% of the participants. In the Lees-Haley study, the participants reported at slightly lower frequencies: only 4 of the 37 items were endorsed by more than 50% of the non-head-injured participants and the most frequently reported item was “Headaches” (62%). However, making direct comparisons across these studies is difficult due to different response options and reporting timeframes across the studies.

The most commonly reported symptoms for children were related to behavioral and emotional functioning. These symptoms may not be the most indicative of brain injury and symptoms that are more indicative (cognitive and somatic complaints) were less endorsed by the children. While behavioral and emotional symptoms may be more prevalent for children, generally (as indicated in this study), this base rate information may help inform diagnostic decision-making for children with possible brain injury. That is, it is not only the number of symptoms that a child reports that needs to be considered but also the kind of symptoms. If there are multiple complaints of cognitive and somatic complaints occurring on a daily basis, then the likelihood of brain injury could be indicated.

While some studies have shown that psychosocial problems are more persistent than cognitive or physical problems after brain injury (Deaton & Waaland, 1994), this research suggests that these domains of interest also cause concern for children who have not incurred a TBI. The studies with adults did not show such a strong predominance of behavioral items in the most frequently reported symptoms (Chan, 2001; Lees-Haley & Brown, 1993). These results are an indication of support for previous evidence that the experiences of children and adults need to be considered in their own right (Anderson et al., 2001). Further research that identified these constructs of interest in a more robust manner would be needed to clarify these issues.

In order to be comparable with adult studies, the current study used a questionnaire response format that asked children whether they had difficulties with symptoms over the previous year. However, this format might have over inflated the children's responses because in order to recall over a period of a year the children were more likely to have used estimation strategies and recall would have been worse (Harel et al., 1994; Schwarz, 1999) than for a shorter timeframe. Therefore, collecting results over a shorter period (daily/weekly/monthly) not only provided more clinically meaningful data, but may have contributed to less use of these estimation strategies. Furthermore, inclusion of a rating of the severity, as well as the frequency of symptoms, would be a valuable addition to future studies.

One limitation of the current study is that it did not address how cultural factors may have influenced responding and this could be an area in need of further research. Also, this study did not identify other neurological or psychiatric diagnoses, whose symptoms might overlap those seen in TBI, and gathering this information (maybe through collateral information) would be useful in future studies. Including children with confirmed TBI to compare with those without head injury would also be a valuable addition for future research.

This study has provided a starting point and justification for further research to collect base rate information for TBI symptoms in children with a larger group of children. This study has supported evidence that the effects of TBI in children need to be studied in their own right because there are differences in the way that children report compared with the patterns of response seen by adults in other studies. It would be useful for future research to include larger samples that include children with and without a head injury using robust selection criteria. Collection of this base rate information will help to improve the neuropsychological assessment of children post-injury, which will assist in assessing entitlement to compensation and realistic rehabilitation planning.

Funding

This research was funded by Massey University.

Conflict of Interest

None declared.

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