Behavior Articles 2015

J Neurotrauma. 2015 Aug 15;32(16):1230-8. doi: 10.1089/neu.2014.3803. Epub 2015 Mar 31

Amantadine Effect on Perceptions of Irritability after Traumatic Brain Injury:
Results of the Amantadine Irritability Multisite Study

Hammond FM(1,)(2), Sherer M(3), Malec JF(1), Zafonte RD(4), Whitney M(2), Bell
K(5,)(6), Dikmen S(5), Bogner J(7), Mysiw J(7), Pershad R(2)

This study examines the effect of amantadine on irritability in persons in the
post-acute period after traumatic brain injury (TBI). There were 168 persons ≥6
months post-TBI with irritability who were enrolled in a parallel-group,
randomized, double-blind, placebo-controlled trial receiving either amantadine
100 mg twice daily or equivalent placebo for 60 days. Subjects were assessed at
baseline and days 28 (primary end-point) and 60 of treatment using observer-rated
and participant-rated Neuropsychiatric Inventory (NPI-I) Most Problematic item
(primary outcome), NPI Most Aberrant item, and NPI-I Distress Scores, as well as
physician-rated Clinical Global Impressions (CGI) scale. Observer ratings between
the two groups were not statistically significantly different at day 28 or 60;
however, observers rated the majority in both groups as having improved at both
intervals. Participant ratings for day 60 demonstrated improvements in both
groups with greater improvement in the amantadine group on NPI-I Most Problematic
(p<0.04) and NPI-I Distress (p<0.04). These results were not significant with
correction for multiple comparisons. CGI demonstrated greater improvement for
amantadine than the placebo group (p<0.04). Adverse event occurrence did not
differ between the two groups. While observers in both groups reported large
improvements, significant group differences were not found for the primary
outcome (observer ratings) at either day 28 or 60. This large placebo or
nonspecific effect may have masked detection of a treatment effect. The result of
this study of amantadine 100 mg every morning and noon to reduce irritability was
not positive from the observer perspective, although there are indications of
improvement at day 60 from the perspective of persons with TBI and clinicians
that may warrant further investigation.

Arch Phys Med Rehabil. 2015 Aug;96(8 Suppl):S274-S281.e4. doi:
10.1016/j.apmr.2015.04.020

Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic
Brain Injury

Bogner J(1), Barrett RS(2), Hammond FM(3), Horn SD(2), Corrigan JD(4), Rosenthal
J(4), Beaulieu CL(5), Waszkiewicz M(6), Shea T(4), Reddin CJ(7), Cullen N(8),
Giuffrida CG(6), Young J(6), Garmoe W(9)

OBJECTIVE: To identify predictors of the severity of agitated behavior during
inpatient traumatic brain injury (TBI) rehabilitation.
DESIGN: Prospective, longitudinal observational study.
SETTING: Inpatient rehabilitation centers.
PARTICIPANTS: Consecutive patients enrolled between 2008 and 2011, admitted for
inpatient rehabilitation after index TBI, who exhibited agitation during their
stay (n=555, N=2130).
INTERVENTIONS: Not applicable.
MAIN OUTCOME MEASURE: Daytime Agitated Behavior Scale scores.
RESULTS: Infection and lower FIM cognitive scores predicted more severe
agitation. The medication classes associated with more severe agitation included
sodium channel antagonist anticonvulsants, second-generation antipsychotics, and
gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated
with less severe agitation included antiasthmatics, statins, and
norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants.
CONCLUSIONS: Further support is provided for the importance of careful serial
monitoring of both agitation and cognition to provide early indicators of
possible beneficial or adverse effects of pharmacologic interventions used for
any purpose and for giving careful consideration to the effects of any
intervention on underlying cognition when attempting to control agitation.
Cognitive functioning was found to predict agitation, medications that have been
found in previous studies to enhance cognition were associated with less
agitation, and medications that can potentially suppress cognition were
associated with more agitation. There could be factors other than the
interventions that account for these relations. In addition, the study provides
support for treatment of underlying disorders as a possible first step in
management of agitation. Although the results of this study cannot be used to
draw causal inferences, the associations that were found can be used to generate
hypotheses about the most viable interventions that should be tested in future
controlled trials.

J Neuropsychiatry Clin Neurosci. 2015 Aug 10:appineuropsych15030045. [Epub ahead of print]

Pathological Laughter and Crying and Psychiatric Comorbidity After Traumatic
Brain Injury

Roy D(1), McCann U(1), Han D(1), Rao V(1)

There are limited data regarding the incidence of pathological laughter and
crying (PLC) after traumatic brain injury (TBI). This study aimed to identify the
occurrence of PLC in the first year after TBI and to determine whether there is a
relationship between PLC and other clinical features or demographics. Subjects
who sustained a first-time TBI were recruited from acute trauma units and were
assessed at 3, 6, and 12 months after TBI. Rates of PLC at 3, 6, and 12 months
after TBI were 21.4%, 17.5%, and 15.5%, respectively. Patients with PLC had
higher percentages of psychiatric diagnoses, including personality changes,
depressive disorders, and mood disorders secondary to a general medical
condition, as well as higher rates of posttraumatic stress disorder. Univariate
logistic and linear regression analyses indicated a significant association
between PLC and scores on the Clinical Anxiety Scale 3 months after TBI and on
the Hamilton Depression Rating Scale 12 months after TBI. Individuals who have
PLC during the first year after TBI are more likely to have any psychiatric
diagnosis as well as higher rates of mood and anxiety symptoms. In addition, PLC
in the early TBI period may serve as a predictor of depression and anxiety
symptoms at 12 months after TBI.

J Neurosurg. 2015 Aug 28:1-16. [Epub ahead of print]

Association of traumatic brain injury with subsequent neurological and
psychiatric disease: a meta-analysis

Perry DC(1), Sturm VE(1), Peterson MJ(2,)(3), Pieper CF(4), Bullock T(5), Boeve
BF(6), Miller BL(1), Guskiewicz KM(7), Berger MS(8), Kramer JH(1), Welsh-Bohmer
KA(9)

OBJECT Mild traumatic brain injury (TBI) has been proposed as a risk factor for
the development of Alzheimer's disease, Parkinson's disease, depression, and
other illnesses. This study's objective was to determine the association of prior
mild TBI with the subsequent diagnosis (that is, at least 1 year postinjury) of
neurological or psychiatric disease. METHODS All studies from January 1995 to
February 2012 reporting TBI as a risk factor for diagnoses of interest were
identified by searching PubMed, study references, and review articles. Reviewers
abstracted the data and assessed study designs and characteristics. RESULTS
Fifty-seven studies met the inclusion criteria. A random effects meta-analysis
revealed a significant association of prior TBI with subsequent neurological and
psychiatric diagnoses. The pooled odds ratio (OR) for the development of any
illness subsequent to prior TBI was 1.67 (95% CI 1.44-1.93, p < 0.0001). Prior
TBI was independently associated with both neurological (OR 1.55, 95% CI
1.31-1.83, p < 0.0001) and psychiatric (OR 2.00, 95% CI 1.50-2.66, p < 0.0001)
outcomes. Analyses of individual diagnoses revealed higher odds of Alzheimer's
disease, Parkinson's disease, mild cognitive impairment, depression, mixed
affective disorders, and bipolar disorder in individuals with previous TBI as
compared to those without TBI. This association was present when examining only
studies of mild TBI and when considering the influence of study design and
characteristics. Analysis of a subset of studies demonstrated no evidence that
multiple TBIs were associated with higher odds of disease than a single TBI.
CONCLUSIONS History of TBI, including mild TBI, is associated with the
development of neurological and psychiatric illness. This finding indicates that
either TBI is a risk factor for heterogeneous pathological processes or that TBI
may contribute to a common pathological mechanism.

CNS Spectr. 2015 Aug 28:1-3. [Epub ahead of print]

What do we know about obsessive-compulsive disorder following traumatic brain
injury?

Rydon-Grange M(1), Coetzer R(2)

In addition to the well-known cognitive impairment following traumatic brain
injury (TBI), neuropsychiatric sequelae are often reported as well. Although not
the most common neuropsychiatric consequence of TBI, obsessive-compulsive
disorder (OCD) has been associated with TBI. However, diagnosing new onset OCD
secondary to TBI is complicated by the potential for cognitive impairment
secondary to TBI masquerading as OCD. In particular, memory difficulties and
executive dysfunction may be confused as representing obsessions and compulsions.
Research in this area, which could guide clinical practice, remains limited. In
addition to using Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-V) criteria, neuropsychological testing and collateral interviews
may help clinicians when considering differential diagnoses in this complex area
of neuropsychiatry.

J Can Acad Child Adolesc Psychiatry. 2015 Fall;24(2):100-8. Epub 2015 Aug 31.

Mental Health Implications of Traumatic Brain Injury (TBI) in Children and Youth

Schachar RJ(1), Park LS(2), Dennis M(3)

OBJECTIVE: Traumatic brain injury (TBI) is the most common cause of death and
disability in children and adolescents. Psychopathology is an established risk
factor for, and a frequent consequence of, TBI. This paper reviews the literature
relating psychopathology and TBI.
METHOD: Selective literature review.
RESULTS: The risk of sustaining a TBI is increased by pre-existing
psychopathology (particularly ADHD and aggression) and psychosocial adversity.
Even among individuals with no psychopathology prior to the injury, TBI is
frequently followed by mental illness especially ADHD, personality change,
conduct disorder and, less frequently, by post-traumatic stress and anxiety
disorders. The outcome of TBI can be partially predicted by pre-injury adjustment
and injury severity, but less well by age at injury. Few individuals receive
treatment for mental illness following TBI.
CONCLUSION: TBI has substantial relevance to mental health professionals and
their clinical practice. Available evidence, while limited, indicates that the
risk for TBI in children and adolescents is increased in the presence of several,
potentially treatable mental health conditions and that the outcome of TBI
involves a range of mental health problems, many of which are treatable.
Prevention and management efforts targeting psychiatric risks and outcomes are an
urgent priority. Child and adolescent mental health professionals can play a
critical role in the prevention and treatment of TBI through advocacy, education,
policy development and clinical practice.

J Neurotrauma. 2015 Jul 1;32(13):967-75. doi: 10.1089/neu.2014.3684. Epub 2015
May 7.


Long-Term Behavioral Outcomes after a Randomized, Clinical Trial of
Counselor-Assisted Problem Solving for Adolescents with Complicated
Mild-to-Severe Traumatic Brain Injury.


Wade SL(1), Taylor HG(2), Cassedy A(1), Zhang N(1), Kirkwood MW(3), Brown TM(4),
Stancin T(5).

Author information:
(1)1 Division of Physical Medicine and Rehabilitation, Department of Pediatrics,
Cincinnati Children's Hospital Medical Center and University of Cincinnati
College of Medicine , Cincinnati, Ohio. (2)2 Division of Developmental and
Behavioral Pediatrics and Psychology, Department of Pediatrics, Case Western
Reserve University and Rainbow Babies and Children's Hospital , University
Hospitals Case Medical Center, Cleveland, Ohio. (3)3 Department of Physical
Medicine and Rehabilitation, Children's Hospital Colorado and University of
Colorado School of Medicine , Aurora, Colorado. (4)4 Department of Psychiatry and
Psychology, Mayo Clinic College of Medicine , Mayo Clinic, Rochester, Minnesota.
(5)5 Division of Pediatric Psychology, Department of Pediatrics, MetroHealth
Medical Center and Case Western Reserve University , Cleveland, Ohio.

Family problem-solving therapy (FPST) has been shown to reduce behavior problems
after pediatric traumatic brain injury (TBI). It is unclear whether treatment
gains are maintained. We sought to evaluate the maintenance of improvements in
behavior problems after a Web-based counselor-assisted FPST (CAPS) intervention
compared to an Internet resource comparison (IRC) intervention provided to
adolescents within the initial year post-TBI. We hypothesized that family
socioeconomic status, child educational status, and baseline levels of symptoms
would moderate the efficacy of the treatment over time. Participants included 132
adolescents ages 12-17 years who sustained a complicated mild-to-severe TBI 1-6
months before study enrollment. Primary outcomes were the Child Behavior
Checklist Internalizing and Externalizing Totals. Mixed-models analyses, using
random intercepts and slopes, were conducted to examine group differences over
time. There was a significant group×time×grade interaction (F(1,304)=4.42;
p=0.03) for internalizing problems, with high school-age participants in CAPS
reporting significantly lower symptoms at 18 months postbaseline than those in
the IRC. Post-hoc analyses to elucidate the nature of effects on internalizing
problems revealed significant group×time×grade interactions for the
anxious/depressed (p=0.03) and somatic complaints subscales (p=0.04). Results
also indicated significant improvement over time for CAPS participants who
reported elevated externalizing behavior problems at baseline (F(1, 310)=7.17;
p=0.008). Findings suggest that CAPS may lead to long-term improvements in
behavior problems among older adolescents and those with pretreatment symptoms.

J Neuropsychiatry Clin Neurosci. 2015 Summer;27(3):193-8. doi:
10.1176/appi.neuropsych.14060126. Epub 2015 May 11.


Areas of Brain Damage Underlying Increased Reports of Behavioral Disinhibition.

Knutson KM(1), Dal Monte O(1), Schintu S(1), Wassermann EM(1), Raymont V(1),
Grafman J(1), Krueger F(1).

Author information:
(1)From the Behavioral Neurology Unit, National Institute of Neurological
Disorders and Stroke, National Institutes of Health, Bethesda, MD (KMK, EMW);
Dept. of Neuropsychology, University of Turin, Turin, Italy (ODM); INSERM, U1028,
CNRS, UMR5292, Lyon Neuroscience Research Center, ImpAct Team, Lyon, France (SS);
University UCBL Lyon 1, Lyon, France (SS); Dept. of Medicine, Imperial College
London, London, United Kingdom (VR); Brain Injury Research, Rehabilitation
Institute of Chicago, Chicago, IL (JG); Dept. of Physical Medicine and
Rehabilitation, Psychiatry and Behavioral Sciences and Cognitive Neurology,
Northwestern University Medical School, Chicago, IL (JG); Molecular Neuroscience
Dept., George Mason University, Fairfax, VA (FK); and Dept. of Psychology, George
Mason University, Fairfax, VA (FK).

Disinhibition, the inability to inhibit inappropriate behavior, is seen in
frontal-temporal degeneration, Alzheimer's disease, and stroke. Behavioral
disinhibition leads to social and emotional impairments, including impulsive
behavior and disregard for social conventions. The authors investigated the
effects of lesions on behavioral disinhibition measured by the Neuropsychiatric
Inventory in 177 veterans with traumatic brain injuries. The authors performed
voxel-based lesion-symptom mapping using MEDx. Damage in the frontal and temporal
lobes, gyrus rectus, and insula was associated with greater behavioral
disinhibition, providing further evidence of the frontal lobe's involvement in
behavioral inhibition and suggesting that these regions are necessary to inhibit
improper behavior.

Proc Biol Sci. 2015 Jul 22;282(1811). pii: 20150711.

Modelling verbal aggression, physical aggression and inappropriate sexual
behaviour after acquired brain injury.


James AI(1), Böhnke JR(2), Young AW(3), Lewis GJ(3).

Author information:
(1)Brain Injury Rehabilitation Trust, Leeds LS25 2HA, UK Department of
Psychology, University of York, York YO10 5DD, UK andrewjames00@gmail.com.
(2)Mental Health and Addiction Research Group, Hull York Medical School,
University of York, York YO10 5DD, UK Department of Health Sciences, University
of York, York YO10 5DD, UK. (3)Department of Psychology, University of York, York
YO10 5DD, UK.

Understanding the underpinnings of behavioural disturbances following brain
injury is of considerable importance, but little at present is known about the
relationships between different types of behavioural disturbances. Here, we take
a novel approach to this issue by using confirmatory factor analysis to elucidate
the architecture of verbal aggression, physical aggression and inappropriate
sexual behaviour using systematic records made across an eight-week observation
period for a large sample (n = 301) of individuals with a range of brain
injuries. This approach offers a powerful test of the architecture of these
behavioural disturbances by testing the fit between observed behaviours and
different theoretical models. We chose models that reflected alternative
theoretical perspectives based on generalized disinhibition (Model 1), a
difference between aggression and inappropriate sexual behaviour (Model 2), or on
the idea that verbal aggression, physical aggression and inappropriate sexual
behaviour reflect broadly distinct but correlated clinical phenomena (Model 3).
Model 3 provided the best fit to the data indicating that these behaviours can be
viewed as distinct, but with substantial overlap. These data are important both
for developing models concerning the architecture of behaviour as well as for
clinical management in individuals with brain injury.

Neuropsychiatr Dis Treat. 2015 Jul 1;11:1601-7. doi: 10.2147/NDT.S80457.
eCollection 2015.


Diagnostic and treatment challenges in traumatic brain injury patients with
severe neuropsychiatric symptoms: insights into psychiatric practice.


Lauterbach MD(1), Notarangelo PL(1), Nichols SJ(2), Lane KS(1), Koliatsos VE(1).

Author information:
(1)The Neuropsychiatry Program at Sheppard Pratt, Sheppard Pratt Health System,
Baltimore, MD, USA. (2)Department of Emergency Medicine, The University of
Tennessee College of Medicine Chattanooga, Chattanooga, TN, USA.

Traumatic brain injury (TBI) causes a variety of neuropsychiatric problems that
pose diagnostic and treatment challenges for providers. In this report, we share
our experience as a referral neuropsychiatry program to assist the general
psychiatrist when adult TBI patients with psychiatric symptoms present for
evaluation and treatment. We completed a retrospective study of patients with
moderate-to-severe TBI and severe neuropsychiatric impairments. We collected
information on demographics, nature of injury, symptomatology, diagnoses, and
treatments. Data analysis indicates that mood stabilization was a key concern,
often requiring aggressive pharmacological management. Cognitive dysfunction was
a problem for the majority of patients, but was only medicated in a third, due to
poor efficacy or behavioral side effects. The co-occurrence of multiple
TBI-related symptoms and diagnoses in this patient cohort emphasizes the need for
individualized psychopharmacological approaches and interventions.

PLoS One. 2015 Jul 14;10(7):e0132558. doi: 10.1371/journal.pone.0132558.
eCollection 2015.


Does Traumatic Brain Injury Lead to Criminality? A Whole-Population Retrospective
Cohort Study Using Linked Data.


Schofield PW(1), Malacova E(2), Preen DB(2), D'Este C(3), Tate R(4), Reekie J(5),
Wand H(5), Butler T(5).

Author information:
(1)Neuropsychiatry Service, Hunter New England Local Health District, Newcastle,
NSW, Australia; Centre for Translational Neuroscience and Mental Health (CTNMH),
University of Newcastle, Newcastle, NSW, Australia. (2)Centre for Health Services
Research, School of Population Health, University of Western Australia, Perth,
WA, Australia. (3)National Centre for Epidemiology and Public Health, Australian
National University, Canberra, ACT, Australia. (4)Rehabilitation Studies Unit,
University of Sydney, Sydney, NSW, Australia. (5)Kirby Institute, UNSW Australia,
Sydney, NSW, Australia.

BACKGROUND: Traumatic brain injury (TBI) may be a risk factor for criminal
behaviour however multiple factors potentially confound the association.
METHODS: Record linkage and Cox proportional hazards regression analyses were
used to examine the association between hospital-recorded TBI (n = 7,694) and
subsequent first criminal conviction in a retrospective cohort matched 1:3 with
22,905 unaffected community controls and full-sibling controls (n = 2,397).
Aboriginality, substance abuse, social disadvantage, and mental illness were
included in analyses as potential confounders.
RESULTS: In multivariable models, relative to general population controls, TBI
was associated with any conviction (males: Hazard Ratio (HR) = 1·58 (95% CI 1·46
to 1·72); females: HR = 1·52 (95% CI 1·28 to 1·81)); and similar Hazard Ratios
were obtained for the sibling analyses in males (HR = 1.68 (95% CI 1.31-2.18))
and females (HR 1.27 (95% CI 0.71-2.29)). TBI was also associated with violent
convictions relative to the general population, (males: HR = 1.65 (95% CI 1.42 to
1.92); females HR = 1.73 (95% CI 1.21 to 2.47)), and in analyses with sibling
controls in men (HR = 1.89 (95% CI 1.20-3.00)), but not in women (HR 0.73, 95% CI
0.29-1.81)).
CONCLUSION: The results support a modest causal link between TBI and criminality
after comprehensive adjustment for confounding. Reducing the rate of TBI, a major
public health imperative, might have benefits in terms of crime reduction.

J Neuropsychiatry Clin Neurosci. 2015 Jul 17:appineuropsych15030073. [Epub ahead of print]

Personality Change Due to Traumatic Brain Injury in Children and Adolescents:
Neurocognitive Correlates.


Max JE(1), Wilde EA(1), Bigler ED(1), Hanten G(1), Dennis M(1), Schachar RJ(1),
Saunders AE(1), Ewing-Cobbs L(1), Chapman SB(1), Thompson WK(1), Yang TT(1),
Levin HS(1).

Author information:
(1)From the Dept. of Psychiatry, University of California, San Diego (JEM, WKT);
Rady Children's Hospital, San Diego, CA (JEM); the Depts. of Physical Medicine
and Rehabilitation (EAW, GH, HSL), Neurology (EAW), and Radiology (EAW), Baylor
College of Medicine, Houston, TX; the Depts. of Neuroscience and Psychology,
Brigham Young University, Provo, UT (EDB); the Dept. of Psychiatry, University of
Utah, Salt Lake City (EDB); the Program in Neurosciences and Mental Health (MD),
and the Brain and Behaviour Program, Dept. of Psychiatry, Research Institute
(RJS), The Hospital for Sick Children, Toronto, Canada; the Depts. of Psychiatry
(AES) and Pediatrics (LE-C), University of Texas Health Science Center, Houston;
the Center for BrainHealth, University of Texas, Dallas (SBC); and the Dept. of
Psychiatry, University of California, San Francisco (TTY).

Personality change due to traumatic brain injury (PC) in children is an important
psychiatric complication of injury and is a form of severe affective
dysregulation. This study aimed to examine neurocognitive correlates of PC. The
sample included 177 children 5-14 years old with traumatic brain injury who were
enrolled from consecutive admissions to five trauma centers. Patients were
followed up prospectively at baseline and at 6 months, and they were assessed
with semistructured psychiatric interviews. Injury severity, socioeconomic
status, and neurocognitive function (measures of attention, processing speed,
verbal memory, IQ, verbal working memory, executive function, naming/reading,
expressive language, motor speed, and motor inhibition) were assessed with
standardized instruments. Unremitted PC was present in 26 (18%) of 141
participants assessed at 6 months postinjury. Attention, processing speed, verbal
memory, IQ, and executive function were significantly associated with PC even
after socioeconomic status, injury severity, and preinjury attention deficit
hyperactivity disorder were controlled. These findings are a first step in
characterizing concomitant cognitive impairments associated with PC. The results
have implications beyond brain injury to potentially elucidate the neurocognitive
symptom complex associated with mood instability regardless of etiology.

 

Brain Inj. 2015 Jul 17:1-7. [Epub ahead of print]

Association between impulsivity, emotional/behavioural hyperactivation and
functional outcome one year after severe traumatic brain injury.


Rebetez MM(1), Rochat L, Ghisletta P, Walder B, Van der Linden M.

Author information:
(1)Cognitive Psychopathology and Neuropsychology Unit, University of Geneva ,
Switzerland .

OBJECTIVE: To examine impulsivity changes after a severe traumatic brain injury
(TBI) and to explore the relationships between impulsivity dimensions (urgency,
lack of premeditation, lack of perseverance, sensation seeking),
emotional/behavioural hyperactivation and 12-month outcome.
METHODS: Measures of emotional/behavioural hyperactivation and functional outcome
were administered to 60 patients with severe TBI 12 months after the trauma. A
scale designed to assess impulsivity changes after TBI was completed by the
patients' significant others at the same time.
RESULTS: Scores on urgency and lack of perseverance were higher after the trauma,
whereas the score on sensation seeking was lower and the score on lack of
premeditation remained stable. Urgency was the only dimension of impulsivity
related to both emotional/behavioural hyperactivation and functional outcome. The
relationship between urgency and functional outcome was mediated by
emotional/behavioural hyperactivation, suggesting that a high level of urgency
results in emotional/behavioural hyperactivation, which in turn impacts
functional outcome. Lack of perseverance was significantly associated with
functional outcome, indicating that the higher the lack of perseverance, the
lower the functional outcome.
CONCLUSION: The results contribute to a better understanding of the 12-month
outcome in patients with severe TBI. They also open interesting perspectives on
management strategies for implementing targeted psychological interventions to
decrease impulsive manifestations.

 

The Journal of Neuropsychiatry & Clinical Neurosciences, 2015 (ahead of pub)

Personality Change Due to Traumatic Brain Injury in Children and Adolescents: Neurocognitive Correlates

Jeffrey E. Max, M.B.B.Ch., Elisabeth A. Wilde, Ph.D., Erin D. Bigler, Ph.D., Gerri Hanten, Ph.D., Maureen Dennis, Ph.D., Russell J. Schachar, M.D., Ann E. Saunders, M.D., Linda Ewing-Cobbs, Ph.D., Sandra B. Chapman, Ph.D., Wesley K. Thompson, Ph.D., Tony T. Yang, M.D., Ph.D., Harvey S. Levin, Ph.D.

Personality change due to traumatic brain injury (PC) in children is an important psychiatric complication of injury and is a form of severe affective dysregulation. This study aimed to examine neurocognitive correlates of PC. The sample included 177 children 5–14 years old with traumatic brain injury who were enrolled from consecutive admissions to five trauma centers. Patients were followed up prospectively at baseline and at 6 months, and they were assessed with semistructured psychiatric interviews. Injury severity, socioeconomic status, and neurocognitive function (measures of attention, processing speed, verbal memory, IQ, verbal working memory, executive function, naming/reading, expressive language, motor speed, and motor inhibition) were assessed with standardized instruments. Unremitted PC was present in 26 (18%) of 141 participants assessed at 6 months postinjury. Attention, processing speed, verbal memory, IQ, and executive function were significantly associated with PC even after socioeconomic status, injury severity, and preinjury attention deficit hyperactivity disorder were controlled. These findings are a first step in characterizing concomitant cognitive impairments associated with PC. The results have implications beyond brain injury to potentially elucidate the neurocognitive symptom complex associated with mood instability regardless of etiology.

Continuum (Minneap Minn). 2015 Jun;21(3 Behavioral Neurology and
Neuropsychiatry):597-612. doi: 10.1212/01.CON.0000466655.51790.2f.

Neurobehavioral assessment

Kaufer DI.

PURPOSE OF REVIEW: This article presents a multidimensional, integrative approach
to clinical assessment and management of neurobehavioral disorders.
RECENT FINDINGS: Behavioral neurology and neuropsychiatry has grown as a
subspecialty along with increased recognition of two common brain disorders:
dementia and traumatic brain injury. Alzheimer disease is a highly prevalent
dementia and a prototypical memory disorder, which has led to a primary focus on
cognitive screening and assessment. By contrast, recent attention concerning
possible long-term sequelae of repetitive traumatic brain injury has emphasized
aberrant behavior (eg, depression, impulsivity, aggression). Clinical phenotyping
across cognitive and behavioral dimensions, in conjunction with advancements in
structural and functional neuroimaging, brain electrophysiologic techniques, and
molecular genetics, is essential to improve diagnostic precision and therapeutic
targeting along the spectrum of CNS disorders.
SUMMARY: All neurologists benefit from honing their clinical skills in
neurobehavioral assessment. A systematic approach to cognitive and behavioral
assessment increases differential diagnostic specificity, helps focus appropriate
therapeutic interventions, and improves the quality of life for patients and
their families. This article highlights practical approaches to neurobehavioral
assessment in support of differential diagnosis and therapeutic monitoring in
general neurology practice.

Radiology. 2015 Jun 16:142974. [Epub ahead of print]

Evaluation of White Matter Injury Patterns Underlying Neuropsychiatric Symptoms
after Mild Traumatic Brain Injury

Alhilali LM(1), Delic JA(1), Gumus S(1), Fakhran S(1).

Author information:
(1)From the Department of Radiology, Division of Neuroradiology, UPMC
Presbyterian Hospital, University of Pittsburgh Medical Center, 200 Lothrop St,
Presby South Tower, 3rd Floor, Suite 3950, Pittsburgh, PA 15213.

Purpose To determine if a central axonal injury underlies neuropsychiatric
symptoms after mild traumatic brain injury (mTBI) by using tract-based spatial
statistics analysis of diffusion-tensor images. Materials and Methods The
institutional review board approved this study, with waiver of informed consent.
Diffusion-tensor imaging and serial neurocognitive testing with the Immediate
Post-Concussion Assessment and Cognitive Testing evaluation were performed in 45
patients with mTBI (38 with irritability, 32 with depression, and 18 with
anxiety). Control subjects consisted of 29 patients with mTBI without
neuropsychiatric symptoms. Fractional anisotropy and diffusivity maps were
analyzed by using tract-based spatial statistics with a multivariate general
linear model. Diffusion-tensor imaging findings were correlated with symptom
severity, neurocognitive test scores, and time to recovery with the Pearson
correlation coefficient. Results Compared with control subjects, patients with
mTBI and depression had decreased fractional anisotropy in the superior
longitudinal fasciculus (P = .006), white matter around the nucleus accumbens (P
= .03), and anterior limb of the internal capsule (P = .02). Patients with
anxiety had diminished fractional anisotropy in the vermis (P = .04). No regions
of significantly decreased fractional anisotropy were seen in patients with
irritability relative to control subjects. Injury in the region of the nucleus
accumbens inversely correlated with recovery time in patients with depression (r
= -0.480, P = .005). Conclusion Unique white matter injury patterns were seen for
two major posttraumatic neuropsychiatric symptoms. Injury to the cerebellar
vermis in patients with mTBI and anxiety may indicate underlying dysfunction in
primitive fear conditioning circuits in the cerebellum. Involvement of the
nucleus accumbens in depression after mTBI may suggest an underlying
dysfunctional reward circuit that affects the prognosis in these patients.

West J Nurs Res. 2015 Jun 30. pii: 0193945915593180. [Epub ahead of print]

Effect of Preferred Music on Agitation After Traumatic Brain Injury

Park S, Williams RA, Lee D.

Agitation is a common behavioral problem after traumatic brain injury (TBI),
which threatens the safety of patients and caregivers and disrupts the
rehabilitation process. This study aimed to evaluate the effects of a preferred
music intervention on the reduction of agitation in TBI patients and to compare
the effects of preferred music with those of classical "relaxation" music. A
single group, within-subjects, randomized crossover trial design was formed,
consisting of 14 agitated patients with cognitive impairment after severe TBI.
Patients listened to preferred music and classical "relaxation" music, with a
wash-out period in between. Patients listening to the preferred music reported a
significantly greater reduction in agitation compared with the effect seen during
the classical "relaxation" music intervention (p = .046). These findings provide
preliminary evidence that the preferred music intervention may be effective as an
environmental therapeutic approach for reducing agitation after TBI.

Proceedings B. July 2015, Volume: 282 Issue: 1811.

Modelling verbal aggression, physical aggression and inappropriate sexual behaviour after acquired brain injury

Andrew I. W. James, Jan R. Böhnke, Andrew W. Young, Gary J. Lewis

Understanding the underpinnings of behavioural disturbances following brain injury is of considerable importance, but little at present is known about the relationships between different types of behavioural disturbances. Here, we take a novel approach to this issue by using confirmatory factor analysis to elucidate the architecture of verbal aggression, physical aggression and inappropriate sexual behaviour using systematic records made across an eight-week observation period for a large sample (n = 301) of individuals with a range of brain injuries. This approach offers a powerful test of the architecture of these behavioural disturbances by testing the fit between observed behaviours and different theoretical models. We chose models that reflected alternative theoretical perspectives based on generalized disinhibition (Model 1), a difference between aggression and inappropriate sexual behaviour (Model 2), or on the idea that verbal aggression, physical aggression and inappropriate sexual behaviour reflect broadly distinct but correlated clinical phenomena (Model 3). Model 3 provided the best fit to the data indicating that these behaviours can be viewed as distinct, but with substantial overlap. These data are important both for developing models concerning the architecture of behaviour as well as for clinical management in individuals with brain injury.

J Pediatr Psychol. 2015 May;40(4):391-397. Epub 2014 Oct 22.

Topical Review: Negative Behavioral and Cognitive Outcomes Following Traumatic
Brain Injury in Early Childhood.

Garcia D(1), Hungerford GM(1), Bagner DM(2).

Author information:
(1)Department of Psychology, Florida International University. (2)Department of
Psychology, Florida International University dbagner@fiu.edu.

OBJECTIVE: To summarize recent research on negative behavioral and cognitive
outcomes following early childhood traumatic brain injury (TBI). METHODS:
Topical review of the literature published since the year 2000 examining
behavioral and cognitive difficulties following TBI in early childhood. RESULTS:
Research findings from the reviewed studies demonstrate a variety of negative
behavioral and cognitive outcomes following TBI in childhood, particularly for
children <5 years of age. Negative outcomes include problems with externalizing
behaviors, attention, language, and cognitive functioning (e.g., IQ, executive
functioning). Furthermore, negative outcomes have been shown to persist up to 16
years following the injury. CONCLUSIONS: The empirical studies reviewed
demonstrate the increased risk for negative behavioral and cognitive outcomes
following early childhood TBI. Furthermore, the review highlights current
strengths and limitations of TBI research with young children and the need for
multidisciplinary work examining outcomes for this vulnerable pediatric
population.

Brain Inj. 2015 May 7:1-9

Psychological problems, self-esteem and body dissatisfaction in a sample of
adolescents with brain lesions: A comparison with a control group.

Pastore V(1), Colombo K, Maestroni D, Galbiati S, Villa F, Recla M, Locatelli F,
Strazzer S.

Author information:
(1)IRCCS Eugenio Medea, Associazione La Nostra Famiglia , Bosisio Parini, Lecco ,
Italy.

PRIMARY OBJECTIVES: This study aims to describe psychological problems,
self-esteem difficulties and body dissatisfaction in a sample of adolescents with
acquired brain lesions and to compare them with an age- and gender-matched
control group.
RESEARCH DESIGN: In an experimental design, the psychological profile of 26
adolescents with brain lesions of traumatic or vascular aetiology, aged 12-18
years, was compared with that of 18 typically-developing subjects. Moreover,
within the clinical group, patients with TBI were compared with patients with
vascular lesions.
METHODS AND PROCEDURES: The psychological and adaptive profile of the adolescents
was assessed by a specific protocol, including CBCL, VABS, RSES, EDI-2 and BES.
MAIN OUTCOME AND RESULTS: Adolescents with brain lesions showed more marked
psychological problems than their healthy peers; they also presented with a
greater impairment of adaptive skills and a lower self-esteem. No significant
differences were found between patients with traumatic lesions and patients with
vascular lesions.
CONCLUSIONS: Adolescents with acquired brain lesions were at higher risk to
develop psychological and behavioural difficulties. Furthermore, in the clinical
sample, some variables such as the long hospitalization and isolation from family
and peers were associated to a greater psychological burden than the aetiology of
the brain damage.

J Neuropsychiatry Clin Neurosci. 2015 May 11

Areas of Brain Damage Underlying Increased Reports of Behavioral Disinhibition.

Knutson KM(1), Dal Monte O, Schintu S, Wassermann EM, Raymont V, Grafman J,
Krueger F.

Author information:
(1)From the Behavioral Neurology Unit, National Institute of Neurological
Disorders and Stroke, National Institutes of Health, Bethesda, MD (KMK, EMW);
Dept. of Neuropsychology, University of Turin, Turin, Italy (ODM); INSERM, U1028,
CNRS, UMR5292, Lyon Neuroscience Research Center, ImpAct Team, Lyon, France (SS);
University UCBL Lyon 1, Lyon, France (SS); Dept. of Medicine, Imperial College
London, London, United Kingdom (VR); Brain Injury Research, Rehabilitation
Institute of Chicago, Chicago, IL (JG); Dept. of Physical Medicine and
Rehabilitation, Psychiatry and Behavioral Sciences and Cognitive Neurology,
Northwestern University Medical School, Chicago, IL (JG); Molecular Neuroscience
Dept., George Mason University, Fairfax, VA (FK); and Dept. of Psychology, George
Mason University, Fairfax, VA (FK).

Disinhibition, the inability to inhibit inappropriate behavior, is seen in
frontal-temporal degeneration, Alzheimer's disease, and stroke. Behavioral
disinhibition leads to social and emotional impairments, including impulsive
behavior and disregard for social conventions. The authors investigated the
effects of lesions on behavioral disinhibition measured by the Neuropsychiatric
Inventory in 177 veterans with traumatic brain injuries. The authors performed
voxel-based lesion-symptom mapping using MEDx. Damage in the frontal and temporal
lobes, gyrus rectus, and insula was associated with greater behavioral
disinhibition, providing further evidence of the frontal lobe's involvement in
behavioral inhibition and suggesting that these regions are necessary to inhibit
improper behavior.

Accid Anal Prev. 2015 Apr 29;81:1-7

Traumatic brain injury, driver aggression and motor vehicle collisions in
Canadian adults.

Ilie G(1), Mann RE(2), Ialomiteanu A(3), Adlaf EM(2), Hamilton H(2), Wickens
CM(2), Asbridge M(4), Rehm J(2), Cusimano MD(5).

Author information:
(1)Division of Neurosurgery and Injury Prevention Research Office, St. Michael's
Hospital, 30 Bond St., Toronto, Ontario M5B 1W8, Canada. Electronic address:
ilieg@smh.ca. (2)Social and Epidemiological Research, Center for Addiction and
Mental Health, 33 Russell Street, Toronto, Ontario M5S 2S1, Canada; Dalla Lana
School of Public Health, University of Toronto, 155 College Street, 6th floor,
Toronto, Ontario M5T 3M7, Canada. (3)Social and Epidemiological Research, Center
for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario M5S 2S1,
Canada. (4)Department of Community Health and Epidemiology, Dalhousie University,
Halifax, Nova Scotia B3H 4R2, Canada. (5)Division of Neurosurgery and Injury
Prevention Research Office, St. Michael's Hospital, 30 Bond St., Toronto, Ontario
M5B 1W8, Canada; Dalla Lana School of Public Health, University of Toronto, 155
College Street, 6th floor, Toronto, Ontario M5T 3M7, Canada.

OBJECTIVE: This study examines the associations between lifetime traumatic brain
injury (TBI), driver aggression, and motor vehicle collisions among a population
sample of adults who reside in the province of Ontario, Canada.
METHOD: A cross-sectional sample of 3993 Ontario adults, aged 18-97 were surveyed
by telephone in 2011 and 2012 as part of Center for Addiction and Mental Health's
ongoing representative survey of adult mental health and substance use in Canada.
TBI was defined as trauma to the head that resulted in loss of consciousness for
at least five minutes or overnight hospitalization.
RESULTS: An estimated 91% (95% CI: 90.0, 91.9) of individuals in this sample held
a valid Ontario driver's license at the time of testing. Among those, 16.7%
reported a history of lifetime TBI and 83.3% reported no TBI. The prevalence of
TBI was higher among men than women. Relative to licensed adults without TBI,
adults with a history of TBI had significantly higher odds of engaging in serious
driver aggression in the past 12 months, such as making threats to hurt another
driver, passenger or their vehicle (AOR=4.39). These individuals also reported
significantly higher odds (AOR=1.74) of being involved in a motor vehicle
collision that resulted in hurting themselves, their passenger(s) or their
vehicle.
CONCLUSION: This is the first population-based study to demonstrate a
relationship between a history of TBI and higher rates of serious driver
aggression and collision involvement. Given the large proportion of adult drivers
with a history of TBI, these individuals may account for a disproportion burden
of all traffic safety problems. Whether the increased road safety risk of adults
with a history of TBI is reflective of neurocognitive deficits or is merely
evidence of a cluster of unsafe activities produced by a higher risk lifestyles
requires further research attention.

Brain Inj. 2015 Apr 27:1-9. [Epub ahead of print]

The experience of challenging behaviours following severe TBI: A family
perspective.

Tam S(1), McKay A, Sloan S, Ponsford J.

Author information:
(1)School of Psychological Sciences, Monash University , Melbourne , Australia .

PRIMARY OBJECTIVE: Family caregivers play an important role in managing
challenging behaviours after TBI. The aims of this study were to understand how
family caregivers of individuals with TBI perceive challenging behaviours and
their impact on the TBI individual's community integration and family
functioning.
RESEARCH DESIGN: A qualitative research design was employed to capture the lived
experience of family caregivers of individuals with TBI.
METHODS AND PROCEDURES: Face-to-face interviews were conducted on six female
family caregivers of individuals with severe TBI (sustained an average of 17
years earlier) and long-standing challenging behaviours.
MAIN OUTCOMES AND RESULTS: The results revealed that family caregivers adopted a
broader definition of challenging behaviour than that used by professionals and
these behaviours impacted on the community integration of the individual with
TBI, most notably leading to poor social relationships. Challenging behaviours
were viewed as a key source of distress and burden for family caregivers and they
used many different strategies to manage the behaviours.
CONCLUSION: Greater understanding of challenging behaviours from the perspectives
of family caregivers may help provide more effective support and interventions to
improve quality-of-life for individuals with challenging behaviours after TBI and
their families.

Brain Inj. 2015 Mar 19:1-7. [Epub ahead of print]

Predictors of behavioural health service use and associated expenditures:
Individuals with TBI in Pinellas County.

Dillahunt-Aspillaga C(1), Becker M, Haynes D, Ehlke S, Jorgensen-Smith T,
Sosinski M, Austin A.

Author information:
(1)Department of Rehabilitation and Mental Health Counseling .

OBJECTIVE: Traumatic brain injury (TBI) is a major public health concern. Such
injuries often result in dramatic changes in the individual's life-course due to
the associated complex co-morbidities. Limited research exists on the use and
expenditures incurred for behavioural healthcare services post-TBI. This study
examined predictors of behavioural service use, incarceration and associated
expenditures for individuals with TBI.
METHODS: Emergency Medical Services and Medicaid Claims data were used to
identify individuals diagnosed with a TBI in Pinellas County, Florida, in FY
2005. Ten statewide and local administrative data sets from 2005-2008 were
employed to determine subject's demographic characteristics, criminal justice
encounters, behavioural health services use and associated expenditures. Average
annual expenditures and use of mental health, substance abuse and criminal
justice services over a 3-year period were determined.
RESULTS: A total of 1005 individuals diagnosed with TBI were identified and, of
these, 910 survived the 3-year period. Study participants were grouped into high
and low behavioural health expenditure groups. Those in the high expenditure
group were more likely to be male, white and to have received behavioural health
services.
CONCLUSIONS: This study provides new information about predictors of behavioural
health service use and Medicaid expenditures for Floridians with TBI.

J Neurotrauma. 2015 Mar 31. [Epub ahead of print]

Amantadine Effect on Perceptions of Irritability after Traumatic Brain Injury:
Results of the Amantadine Irritability Multisite Study.

Hammond FM(1), Sherer M, Malec JF, Zafonte RD, Whitney M, Bell K, Dikmen S,
Bogner J, Mysiw J, Pershad R.

Author information:
(1)1 Department of Physical Medicine and Rehabilitation, Indiana University
School of Medicine , and Rehabilitation Hospital of Indiana, Indianapolis,
Indiana.

This study examines the effect of amantadine on irritability in persons in the
post-acute period after traumatic brain injury (TBI). There were 168 persons ≥6
months post-TBI with irritability who were enrolled in a parallel-group,
randomized, double-blind, placebo-controlled trial receiving either amantadine
100 mg twice daily or equivalent placebo for 60 days. Subjects were assessed at
baseline and days 28 (primary end-point) and 60 of treatment using observer-rated
and participant-rated Neuropsychiatric Inventory (NPI-I) Most Problematic item
(primary outcome), NPI Most Aberrant item, and NPI-I Distress Scores, as well as
physician-rated Clinical Global Impressions (CGI) scale. Observer ratings between
the two groups were not statistically significantly different at day 28 or 60;
however, observers rated the majority in both groups as having improved at both
intervals. Participant ratings for day 60 demonstrated improvements in both
groups with greater improvement in the amantadine group on NPI-I Most Problematic
(p<0.04) and NPI-I Distress (p<0.04). These results were not significant with
correction for multiple comparisons. CGI demonstrated greater improvement for
amantadine than the placebo group (p<0.04). Adverse event occurrence did not
differ between the two groups. While observers in both groups reported large
improvements, significant group differences were not found for the primary
outcome (observer ratings) at either day 28 or 60. This large placebo or
nonspecific effect may have masked detection of a treatment effect. The result of
this study of amantadine 100 mg every morning and noon to reduce irritability was
not positive from the observer perspective, although there are indications of
improvement at day 60 from the perspective of persons with TBI and clinicians
that may warrant further investigation.

J Head Trauma Rehabil. 2015 Mar-Apr;30(2):106-15

Traumatic brain injury in juvenile offenders: findings from the comprehensive
health assessment tool study and the development of a specialist linkworker
service.

Chitsabesan P(1), Lennox C, Williams H, Tariq O, Shaw J.

Author information:
(1)Centre for Mental Health and Risk, Manchester Academic Health Science Centre,
University of Manchester, Manchester, United Kingdom (Drs Chitsabesan, Lennox,
and Shaw and Mr Tariq); Pennine Care NHS Foundation Trust, Manchester, United
Kingdom (Dr Chitsabesan); and Centre for Clinical Neuropsychology Research,
University of Exeter, Exeter, Devon, United Kingdom (Dr Williams).

BACKGROUND: Young people in contact with the youth juvenile justice system have
well-documented vulnerabilities including high rates of mental health and
neurodevelopmental disorders. Studies have suggested that they may also be at
increased risk of traumatic brain injury (TBI).
OBJECTIVE: (1) To describe the profile of a cohort of juvenile offenders with TBI
and associated comorbidity with other neurodevelopmental disorders, mental health
needs, and offending behavior. (2) To describe the development of a specialist
brain injury service for juvenile offenders with TBI within custody.
METHODS: Ninety-three male participants aged 15 to 18 years were consecutively
admitted to a custodial secure facility. They were evaluated using a range of
different neurocognitive and mental health measures including the Rivermead
Post-Concussion Symptoms Questionnaire and the Comprehensive Health Assessment
Tool.
RESULTS: Eight-two percent of those interviewed reported experiencing at least 1
TBI, and 44% reported ongoing neuropsychological symptoms. Eighteen percent of
those sustaining a TBI reported moderate-severe postconcussion symptoms.
CONCLUSIONS: There is a high prevalence of TBI in juvenile offenders in custody,
with many experiencing multiple episodes. This study highlights the need for
further research in this area. An example of a specialist brain injury linkworker
service is described as one example of a model of service delivery for this
group.

J Head Trauma Rehabil. 2015 Mar-Apr;30(2):94-105

The prevalence of traumatic brain injury among young offenders in custody: a
systematic review.

Hughes N(1), Williams WH, Chitsabesan P, Walesby RC, Mounce LT, Clasby B.

Author information:
(1)Centre for Adolescent Health, Murdoch Childrens Research Institute, Melbourne,
Australia (Dr Hughes); University of Birmingham, Birmingham, United Kingdom (Dr
Hughes); University of Melbourne, Melbourne, Victoria, Australia (Dr Hughes);
University of Exeter, Exeter, United Kingdom (Drs William, Walesby, and Mounce
and Ms Clasby); University of Manchester, Manchester, United Kingdom (Ms
Chitsabesan); and Pennine Care NHS Foundation Trust, Manchester, United Kingdom
(Dr Chitsabesan).

OBJECTIVES: To examine the prevalence of traumatic brain injury (TBI) among young
people in custody and to compare this with estimates within the general youth
population.
DESIGN: Systematic review of research from various national contexts. Included
studies were assessed for the relevance of the definition of TBI and the research
population, and the quality of the study design.
RESULTS: Ten studies were identified for inclusion in the review. Four of these
studies included control groups. No studies examining comorbidity of TBI and
other neurodevelopmental disorders among incarcerated young people were
identified.
CONCLUSION: Reported prevalence rates of brain injury among incarcerated youth
range from 16.5% to 72.1%, with a rate of 100% reported among a sample of young
people sentenced to death. This suggests considerable levels of need among
incarcerated young people. Where control groups or directly comparable studies
within the general population exist, there is strong and consistent evidence of a
prevalence of TBI among incarcerated youth that is substantially greater than
that in the general population. This disparity is seemingly more pronounced as
the severity of the injury increases.

J Head Trauma Rehabil. 2015 Mar-Apr;30(2):75-85

Prevalence and predictors of externalizing behavior in young adult survivors of
pediatric traumatic brain injury.

Ryan NP(1), Hughes N, Godfrey C, Rosema S, Catroppa C, Anderson VA.

Author information:
(1)Murdoch Children's Research Institute, Melbourne, Victoria, Australia (Mr Ryan
and Drs Hughes, Godfrey, Rosema, Catroppa, and Anderson); Melbourne School of
Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
(Mr Ryan and Drs Hughes, Godfrey, Catroppa, and Anderson); University of
Birmingham, UK (Dr Hughes); and The Royal Children's Hospital Melbourne,
Melbourne, Victoria, Australia (Drs Rosema, Catroppa, and Anderson).

OBJECTIVES: To investigate rates of clinically significant externalizing behavior
(EB) in young adult survivors of pediatric traumatic brain injury (TBI) and
evaluate the contribution of pre- and postinjury risk and resilience factors to
EB outcomes 16 years after injury.
SETTING: Melbourne, Australia.
PARTICIPANTS: Fifty-five young adults (mean age = 23.85 years; injury age: 1.0-12
years) admitted to an emergency department following TBI between 1993 and 1997.
DESIGN: Longitudinal prospective study with data collected at the acute, 10-year,
and 16-year postinjury time points.
MAIN MEASURES: Severity of TBI, adaptive functioning, family functioning,
full-scale IQ, executive functioning, social communication, and symptoms of EB.
RESULTS: One of every 4 young people with a history of pediatric TBI demonstrated
clinical or subthreshold levels of EB in young adulthood. More frequent EB was
associated with poorer preinjury adaptive functioning, lower full-scale IQ, and
more frequent pragmatic communication difficulty.
CONCLUSION: Pediatric TBI is associated with an elevated risk for externalizing
disorders in the transition to adulthood. Results underscore the need for
screening and assessment of TBI among young offenders and suggest that early and
long-term targeted interventions may be required to address risk factors for EB
in children and young people with TBI.

J Head Trauma Rehabil. 2015 Jan-Feb;30(1):12-20

The experience, expression, and control of anger following traumatic brain injury
in a military sample.

Bailie JM(1), Cole WR, Ivins B, Boyd C, Lewis S, Neff J, Schwab K.

Author information:
(1)Defense and Veteran's Brain Injury Center, Naval Medical Center San Diego, San
Diego, California, and The Henry M. Jackson Foundation for the Advancement of
Military Medicine, Inc, Bethesda, Maryland (Drs Bailie and Boyd); The Henry M.
Jackson Foundation for the Advancement of Military Medicine, Inc. and the Defense
and Veterans Brain Injury Center, Washington, District of Columbia (Ms Ivins);
Defense and Veteran's Brain Injury Center, Fort Bragg, North Carolina, and The
Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc,
Bethesda, Maryland (Dr Cole); Department of Traumatic Brain Injury Womack Army
Medical Center and Defense and Veteran's Brain Injury Center, Fort Bragg, North
Carolina (Dr Lewis); Rehabilitation Medicine, United States Navy, and Defense and
Veteran's Brain Injury Center, Naval Medical Center San Diego, San Diego,
California (Dr Neff); and Epidemiology & Research Support Services, Defense and
Veteran's Brain Injury Center, Washington, District of Columbia (Dr Schwab).

OBJECTIVE: To investigate the impact of traumatic brain injury (TBI) on the
experience and expression of anger in a military sample.
PARTICIPANTS: A total of 661 military personnel with a history of TBI and 1204
military personnel with no history of TBI.
DESIGN: Cross-sectional, between-group design, using multivariate analysis of
variance.
MAIN MEASURE: State-Trait Anger Expression Inventory-2 (STAXI-2).
RESULTS: Participants with a history of TBI had higher scores on the STAXI-2 than
controls and were 2 to 3 times more likely than the participants in the control
group to have at least 1 clinically significant elevation on the STAXI-2. Results
suggested that greater time since injury (ie, months between TBI and assessment)
was associated with lower scores on the STAXI-2 State Anger scale.