Paediatrics (RCH) - Theses
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ItemAnosmia in paediatric traumatic brain injury( 2015)Objective: Paediatric traumatic brain injury (TBI) is a leading cause of childhood disability, and is associated with significant physical, sensory, psychosocial and neuropsychological sequelae. While our knowledge of outcomes after paediatric TBI has expanded over the past 20-30 years little is known about olfactory function outcomes. This is despite the fact that olfactory dysfunction (OD) is known to be common after adult TBI, has poor prognosis for recovery and is associated with significant functional implications in health, safety, and activities of daily living. In adults with TBI, OD has been linked to injury variables including severity, site of impact, neuropathology and skull fracture and to deficits in executive function (EF), with OD suggested as a potential marker of EF deficits following TBI, though little is known about these relationships in paediatric TBI. The overall aim of this thesis was to address the dearth of research in paediatric OD. The study investigated the frequency with which OD occurs following paediatric TBI, and the relationship between OD and injury variables such as severity, fracture, and injury impact. The relationship between olfactory function and EF was examined and recovery of OD documented up to 18 months post injury. Overall, it was hypothesised that children with moderate/severe TBI would demonstrate poorer olfactory function than those with mild TBI and that children with TBI and OD would perform more poorly on measures of EF than those without OD. Method: Thirty-seven children aged 8-16 years with TBI were recruited to our prospective longitudinal study. Olfactory assessment using the University of Pennsylvania Smell Identification Test was conducted at 0-3 months (T1), 8 months (T2) and 18 months (T3) post injury. Children completed EF tests at T2 and parents completed ratings of behavioural EF at T2 and T3. Results: At T1 19% of participants demonstrated impaired olfaction, with 5% classified as anosmic. OD was significantly related to injury severity at T1, with those with moderate/severe TBI showing poorer olfactory function than those with mild TBI. Longitudinal follow-up indicated evidence of recovery in olfactory function at T2, however, only 16% of those with the most severe OD showed recovery to normal olfactory function, with the remainder demonstrating ongoing OD at T3. Occipital site of impact was a significant predictor of olfactory performance at T3. Children with OD showed significantly poorer performance on a single EF measure of fluency at T2 compared to those with normal olfaction. Acute olfactory function did not significantly predict EF outcomes at either 8 or 18 months post injury. Conclusions: OD appears to be relatively common after paediatric TBI, with limited prospects for recovery, consistent with previous adult research. Acute OD was significantly related to injury severity, though those children at greatest risk of poor later olfactory function were those with an occipital site of impact. Evidence for a link between OD and EF was limited and in particular, acute olfactory function did not appear to be an accurate predictor of later EF deficits. Our findings indicate the need for a focus on OD in clinical practice with routine screening and implementation of education and management strategies recommended. There is a need for further longitudinal research in larger cohorts to elucidate further the links between OD and injury variables, identify clinical predictors of OD, and investigate the functional implications for children and adolescents with TBI.
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ItemLong-term psychosocial outcomes following childhood traumatic brain injury( 2014)Introduction: Childhood traumatic brain injury (CTBI) is one of the most common causes of mortality and impairments in children, impacting on the development of neuropsychological, social and psychological functioning. A disruption in these areas often results in long-term impairments with interpersonal relationships, participation in leisure and social activities and quality of life. Background: Available literature has shown that children and adolescents with a CTBI demonstrate greater social and psychological dysfunction than typically developing children and adolescents. They often show lower self-esteem, have fewer friends, express more maladaptive, aggressive and antisocial behaviour in a social environment and have poorer emotional and behavioural regulation. These symptoms may become more severe and develop into a clinical disorder, with children and adolescents with a CTBI having a 49% risk of developing any kind of psychiatric disorder compared to 13% risk for healthy developing children and adolescents. Most research in this field has investigated these outcomes up to 5 years post-injury, although less is known about the long-term outcomes after CTBI into adulthood. Aim: The aim of this thesis was to investigate the development of long-term psychosocial outcomes over a period of 16 years following CTBI. The participants were recruited from a prospective, longitudinal sample ascertained between 1993-1997 and aged 1-7 years at time of injury. Children were included in the study if there was sufficient information regarding their CTBI to classify illness severity, if they were able to speak English and complete the protocol. They were excluded in cases of a non-accidental, penetrating or previous brain injury or if there was evidence of a pre-existing neurological or developmental disorder. A healthy control group was also recruited during the same period, matched for age, gender and socio-economic status (SES) with the CTBI sample. Both groups were followed up several times, with this thesis utilising data from the acute, 6 month, 5 year and 16 year post injury time points. Results: The results showed that young adult survivors of CTBI reported more depressive, anxious and withdrawn symptoms then their healthy peers. Ratings on psychosocial measures rated by the young adults with CTBI were compared with the ratings of their significant other, with analyses indicating fair to excellent agreement on the obvious and noticeable behaviours, such as communication, and alcohol and drug use. In contrast, there was poor agreement on the more internalising symptoms such as depressed/anxious and withdrawn symptoms. With regard to the developmental trajectory of social skills, and internalising and externalising symptoms, the CTBI and control group did not differ. However, there was a trend for the CTBI group to be rated higher on internalising symptoms by the parent at every time point. Conclusion: In summary, young adults with a CTBI experience more internalising symptoms than their healthy peers, and are at higher risk of developing more severe symptoms and even clinical disorders. Appropriate screening by health professionals and early intervention should be considered to prevent the development of any significant social or psychological symptoms later in life.