Melbourne School of Psychological Sciences - Theses
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ItemReconceptualising paediatric traumatic brain injury as a disorder of the ‘social brain’: a longitudinal prospective study of brain-behaviour relationships( 2017)Background: Childhood and adolescence coincide with rapid maturation of distributed neural systems implicated in complex socio-emotional behaviours; however, little is known about the impact of early traumatic brain injury on the acquisition and establishment of these skills. This longitudinal prospective study evaluates the influence of paediatric traumatic brain injury (TBI) on social cognitive and sociobehavioural functioning, and examines factors associated with long-term outcome and recovery of these skills. Method: High resolution T1, susceptibility-weighted and diffusion-weighted MRI sequences were acquired sub-acutely in 112 children and adolescents with mild-severe TBI. For comparison, 43 typically developing children of similar age and sex were scanned. Formal child outcome assessments and parent ratings of social behaviour were completed at both 6- and 24-months post-injury. Results: Findings reveal that social cognitive and sociobehavioural skills are vulnerable to long-term disruption from TBI, with evidence for a time-dependent emergence of social cognitive impairment in younger children for whom skills were emerging or not yet established at the time of injury. Poorer long-term social outcomes were documented in association with diffuse cerebral microbleeds, lower family affective responsiveness, poorer parent mental health, and grey and white matter neuroanatomical differences in large-scale neural systems implicated in social behaviour. Poorer post-acute social cognition mediated the prospective impact of sub-acute neuroanatomical abnormalities on chronic sociobehavioural problems. Conclusions: Evidence for robust brain-behaviour relationships accord with a network paradigm of sociocognitive disturbance, and should prompt clinicians to consider structural connectivity when interpreting impairments in children with TBI, especially in the domain of social cognition. Results suggest that, although high resolution MRI has potential to unlock prognostic markers associated with poorer social outcomes, neuroanatomical differences in large scale neural systems represent one of several factors that contribute to the emergence and persistence of social difficulties after child TBI. Clinicians should monitor the presence of broad range of injury, child-related, and modifiable family environmental risk factors, and incorporate these indicators into clinical management and rehabilitation planning.
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ItemFatigue after child brain injury( 2016)Objective: Traumatic brain injury (TBI) is one of the most frequent causes of childhood disability. Fatigue is commonly reported during the acute and chronic phases of TBI recovery. Fatigue is defined as reduced performance in response to prolonged or unusual exertion and leads to reduced quality of life and school participation in children. Despite the prevalence of fatigue following TBI, there is little examining its nature and course. In particular, patterns of fatigue over time and predictors of longitudinal outcome after child TBI are unclear. The aim of this thesis is to address identified gaps in the existing research within the field of fatigue after child TBI. Throughout, we adopt a model of fatigue that is developmentally sensitive and multidimensional – including physical, sleep/rest, and cognitive elements. First, through systematic review of the literature we identify a psychometrically robust fatigue assessment instrument for use in child TBI. We then use this multidimensional fatigue measure to assess fatigue at three time-points after child TBI: 6 weeks, 6- and 12-months in order to meet the following study aims. First, we aim to compare fatigue in our TBI sample to published control data (at 6-weeks and 12-months post-injury), by TBI severity. Second, we examine fatigue over time (6- to 12-months post-injury) within our sample. Fourth, we explore factors predictive of worse fatigue on the fatigue measure at 6-weeks (child and parent perspectives) and 12-months (parent perspectives) post-injury. Our hypotheses were that fatigue following child TBI (a) would be higher than reported in published healthy children control data, (b) would reduce over time post-injury and (c) would be associated with more severe TBI and other hypothesised risk factors (such as sociodemographic characteristics). Method: Phase 1: A systematic review of fatigue assessment instruments used in children was conducted using key academic databases. Study quality and the psychometric properties of the instruments were assessed. Phase 2: We included participants already recruited to a larger prospective longitudinal study comprising 159 children (0-17 years at injury) with mild, moderate or severe TBI, presenting to one of three participating sites (two Canadian, one Australia). From the larger cohort, a subsample of 47 adolescents (8-18 years at injury) also participated in follow-up- 6-weeks post-injury. As part of the larger study protocol, at the time of child TBI, parents provided pre-injury child data based on retrospective report, including report of pre-injury fatigue and sleep difficulties. Healthy control data published from an American sample of children age 2-19 years was used for group comparisons (Panepinto et al., 2014). Results: Phase 1: Systematic Review identified twenty fatigue instruments, and two demonstrated strong measurement properties. Phase 2: Fatigue was rated by 35 participants (parents and adolescents) 6-weeks post-injury. At 6-weeks post-injury, fatigue in child TBI was significantly worse relative to control data (47 per cent and 29 per cent rated severe fatigue respectively). Between 6- and 12-months post-injury there was no detectable improvement in fatigue. Rather, cognitive fatigue worsened over time. Fatigue 12-months post-injury was again worse relative to control data (parent ratings). Fatigue was predicted by multiple variables, including pre-injury sociodemographic factors (female sex), psychological well-being (general fatigue) and pre-injury fatigue (sleep/rest fatigue). Symptoms after injury in multiple domains (physical/motor, pain, sleep psychological or inattention) additionally predicted fatigue 12 months post-injury. Conclusions: Fatigue is a complex, severe and persistent complaint after child TBI. Interventions are required to help reduce fatigue after child TBI.
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ItemAdjustment in life after traumatic brain injury: the impact of cognition, employment, and perceived sense of purpose in life( 2013)Traumatic brain injury (TBI) affects the most wide-ranging domains of survivors’ lives, markedly reducing emotional health and quality of life. The primary objective of this study was to explore the widely proclaimed therapeutic effect of employment on psychological wellbeing (PWB) and quality of life (QoL) relative to perceived sense of purpose in life (PIL). An additional aim was to examine the influence of factors involving cognitive function, injury severity, age at time of injury, gender, and preinjury education, on survivors’ work ability and return to work (RTW). A mixed methods design was used for an in-depth and comprehensive understanding about adjustment in life post-TBI. Method: Participants (N=40; 10-18 months post-TBI) were grouped according to age: 18-39 years (younger group), 40-55 years (older group) and injury severity (Glasgow Coma Scale scores): mild TBI (n=25), moderate-severe TBI (n=15). Quantitative Component: Neuropsychological testing and questionnaire surveys were performed to evaluate participants’ cognitive function, levels of perceived work gainfulness, PIL, PWB, and QoL. Data was analysed using bivariate and multivariate analyses of variance, aided by SPSS computer software. Qualitative Component: 12 participants (6 from each severity group) were randomly selected for digitally recorded semi-structured interviews, predominantly concerning the impact of work and life meaningfulness on adjustment process. Interviews were analysed using grounded theory methodology, aided by NVivo 10 computer package. Results and Discussion: PIL, in comparison to employment, cognitive function, and injury severity, made the strongest unique contribution in explaining PWB and QoL (p < 0.001). Employment potential was largely affected by memory and injury severity, with increased memory deficits (p < 0.01) and injury severity (p < 0.05) respectively associated with deteriorated employment potential. Main Conclusion: Having a strong sense of life as purposeful, notwithstanding employment, cognitive function, and injury severity, encourages survivors to focus on their lives and important life goals and to ultimately, achieve a promising life with healthy wellbeing.
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ItemMeasurement invariance testing of the MMPI-2 when used with patients suffering a traumatic brain injury( 2013)The MMPI-2 is one of the most widely used tests of personality and psychopathology in both clinical and research settings (Archer & Newsom, 2000; Butcher, Rouse & Steven, 1996; Smith, Gorske, Wiggins & Little, 2010). It is suggested the neurological damage from a traumatic brain injury (TBI) can falsely inflate MMPI-2 profiles. Following this theory, the Gass (1991) correction procedure removes 14 items from the MMPI-2. Widespread use of the correction procedure continues despite conflicting results from replication studies. In this study measurement invariance analysis was completed separately on MMPI-2 scales Hs1, Hy3 and Sc8 to assess the Gass correction procedure. A TBI sample (n=254) and a sample generated from the MMPI-2 normative data (n=2600) was used for measurement invariance testing. In measurement invariance Test 1 (baseline model test) all residuals and one item loading for each factor were held to equality. In Test 2 (strict invariance test), all parameters were held to equality across groups. The requirement of invariance is that CFI decrease by equal to or less than .002 (Meade, Johnson and Braddy, 2008). If a model failed the test of strict invariance then a partial invariance model was defined using the backwards elimination procedure. Practical impact analysis was completed using the Millsap and Kwok (2004) procedure to assess the clinical effect from a failure to establish strict invariance. Prior to measurement invariance testing, exploratory factor analysis and confirmatory factor analysis were employed to define a factor model in Hs1, Hy3 and Sc8. A 4-Factor model was selected as best representing the 32 items from Hs1. In Test 1 the model produced reasonable fit indices (RMSEA = .023, CFI = .947, TLI = .943). In Test 2 the decrease in CFI was above the threshold of invariance (RMSEA = .025, CFI = .932, TLI = .930). A partial invariance model was defined with the parameters for four items freed (RMSEA = .023, CFI = .946, TLI = .945). All items passed the tests of no practical impact. In Hy3 a 4-Factor model was selected as best representing the 40 items from this scale not previously analysed in Hs1. In Test 1 the model produced reasonable fit indices (RMSEA .026, CFI = .921, TLI =.915). In Test 2 the decrease in CFI was above the threshold of invariance (RMSEA .043, CFI = .767, TLI =.761). A partial invariance model was defined with the parameters for 20 items freed (RMSEA .026, CFI = .919, TLI =.915). Items 161 and 185 failed the tests of no practical impact. In Sc8 a 5-factor model was selected as best representing the 68 items not previously analysed in Hs1 or Hy3. In Test 1 the model produced reasonable fit indices (RMSEA .015, CFI = .934, TLI = .932). In Test 2 the decrease in CFI was above the threshold of invariance (RMSEA .023, CFI = .838, TLI = .837). A partial invariance model was defined with the parameters for 28 items freed (RMSEA .015, CFI = .932, TLI = .930). Items 17, 92, 190, 278, 281, 291 and 303 failed the tests of no practical impact. Eleven of the 14 items from the Gass correction procedure passed the test of strict invariance, with the other three passing the tests of no practical impact. This finding fails to support continued use of the Gass correction procedure. Additionally the finding is contrary to the hypothesis that neurological content will bias MMPI-2 profiles in specific populations, such as the traumatic brain injury. However, some items were failed the tests of no practical impact and were identified as concerning. The implications from these findings are discussed.
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ItemSpeaking for themselves: how do adolescents define their quality of life after a traumatic brain injury?( 2013)Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young people (Yeates et al., 2002). The status of quality of life (QoL) in paediatric TBI is mixed. Our recent meta-analysis of paediatric QoL (Di Battista et al., 2012) found that good QoL outcomes are contingent on milder injuries, proxy reporting and early assessment whereas poor outcomes reflect more severe injuries and later assessment. Available paediatric QoL data is largely based on the health-related quality of life (HRQoL) paradigm; where a good outcome is contingent on what one can accomplish or achieve, as assessed by proxies. Information on the subjective well-being (SWB) component of QoL is limited. When estimating the HRQOL in adolescents, the presence of anxiety and depression and the quality of social relationships are important considerations, because adolescents are entrenched in social development during this phase of maturation. The influence of anxiety, depression and loneliness on HRQOL in adolescent survivors of TBI has not been documented. The goal of this study was to explore the adolescent experience of quality of life, anxiety, depression and loneliness after a traumatic brain injury. This study is a mixed-methods assessment of the impact of mood states and loneliness on quality of life (QoL) in adolescents who have survived a traumatic brain injury (TBI). METHOD: mixed method/cohort pilot study (11 adolescents, mild to severe TBI; 9 parents), using self-report (anxiety, depression, HRQoL, loneliness) and proxy-report measures (anxiety, depression and HRQoL) and clinical psychiatric interviews (adolescent only). The adolescent experience of these states is not accurately reflected by parental proxy. Self-reported depression and age at injury were associated with health-related quality of life outcomes, while anxiety was not. Severity of injury was not related to secondary outcomes. Adolescent narratives revealed that having experienced a TBI does not a priori impact upon perceived QoL. The impact of a TBI on QoL could be positive or negative. Post-injury changes in ability were not always attributed to the injury, but rather to a sense of normal age-related changes as identified by the adolescent. Changes as a result of the injury were not always considered important to the adolescent’s view on QoL. Adolescents identified social and inter-personal discrepancies and the emotional consequences of these discrepancies. Ultimately, the individual’s appraisal of their identity from pre to post injury life related to their current sense of well-being. Friendships were very important considerations for post-injury well-being. Processes of post-traumatic growth were identified in the adolescent narrative. The findings of this study are novel and have important implications for both research study design and clinical care settings involving adolescent survivors of a TBI.