The occurrence of personality change due to traumatic brain injury (PC), and its clinical and neuroimaging correlates were investigated. Ninety-four children, ages 5 through 14 at the time of hospitalization following traumatic brain injury (TBI; severe TBI N = 37; mild-moderate TBI N = 57), were assessed. Standardized psychiatric, adaptive functioning, cognitive functioning, family functioning, family psychiatric history, severity of injury, and neuroimaging assessments were conducted. The Neuropsychiatric Rating Schedule (NPRS) was used to establish a diagnosis of PC. Approximately 40% of consecutively hospitalized severe TBI participants had ongoing persistent PC an average of 2 years postinjury. An additional approximately 20% had a history of a remitted and more transient PC. PC occurred in 5% of mild-moderate TBI but was always transient. Interrater reliability for the diagnosis of PC was good (Kappa = .70). In severe TBI participants, persistent PC was significantly associated with severity of injury, particularly impaired consciousness over 100 hr, adaptive and intellectual functioning decrements, and concurrent diagnosis of secondary attention deficit hyperactivity disorder, but was not significantly related to any psychosocial adversity variables. These findings suggest that PC is a frequent diagnosis following severe TBI in children and adolescents, but is much less common following mild-moderate TBI.

Previous studies of childhood traumatic brain injury (TBI) have emphasized injury-related variables rather than psychiatric or psychosocial factors as correlates of cognitive outcomes. We addressed this concern by recruiting a consecutive series (N = 24) of children age 5 through 14 years who suffered a severe TBI, a matched group who sustained a mild TBI, and a second matched group who sustained an orthopedic injury. Standardized intellectual, memory, psychiatric, family functioning, family psychiatric history, neurological, and neuroimaging assessments were conducted at an average of 2 years following injury. Severe TBI, when compared to mild TBI and orthopedic injury, was associated with significant decrements in intellectual and memory function. A principal components analysis of independent variables that showed significant (p < .05) bivariate correlations with the outcome measures yielded a neuropsychiatric factor encompassing severity of TBI indices and postinjury psychiatric disorders and a psychosocial disadvantage factor. Both factors were independently and significantly related to intellectual and memory function outcome. Postinjury psychiatric disorders added significantly to severity indices and family functioning and family psychiatric history added significantly to socioeconomic status in explaining several specific cognitive outcomes. These results may help to define subgroups of children who will require more intensive services following their injuries. (JINS, 1999, 5, 58–68.)

Extracranial magnetic resonance angiography (MRA) was performed in 20 children to evaluate for various arterial and venous conditions. Time-of-flight and phase-contrast angiograms were constructed using a maximal-intensity-projection algorithm. The accuracy of MRA was comparable to Doppler ultrasound (n = 12) and conventional angiography (n = 3). MRA could provide an excellent mapping of patent (including collaterals) versus thrombosed vessels at sites not evaluated or inaccessible by sonography. Limitations included assessment of small and/or tortuous vessels, severely stenotic lesions, and very slow flow.

OBJECTIVE:To study psychiatric and behavioral morbidity associated with severe traumatic brain injury (TBI).METHOD:A consecutive series (n = 24) of children aged 5 through 14 years who suffered a severe TBI were matched to subjects who sustained a mild TBI and to a second matched group who sustained an orthopedic injury with no evidence of TBI. Standardized psychiatric, behavioral, and neuroimaging assessments were conducted on average 2 years after injury.RESULTS:Severe TBI was associated with a significantly higher rate of current "novel" psychiatric disorders (15/24; 63%) compared with children with mild TBI (5/24; 21%) and orthopedic injury (1/24; 4%). Higher effect sizes were evident for child and adolesent self-report of internalizing symptoms rather than externalizing symptoms, for parents' report of overall behavior and internalizing symptoms rather than externalizing symptoms, and for teachers' reports of overall behavior and externalizing symptoms rather than internalizing symptoms.CONCLUSIONS:Severe TBI is a profound risk factor for the development of a psychiatric disorder. Survivors should be assessed for organic personality syndrome, which is the most common psychiatric disorder after this type of injury.

OBJECTIVE:To study prospectively the course of attention-deficit hyperactivity (ADH) symptomatology in children and adolescents after traumatic brain injury (TBI). It was hypothesized that ADH symptomatology would be significantly related to severity of injury.METHOD:Subjects were children (n = 50) aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, socioeconomic, family functioning, and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales, and neuroimaging was analyzed.RESULTS:The main finding of this study was that change in ADH symptomatology in the first 2 years after TBI in children and adolescents was significantly related to severity of injury. Overall ADH symptomatology during the study was significantly related to a measure of family dysfunction when family psychiatric history, socioeconomic status, and severity of injury were controlled.CONCLUSION:The presence of a positive "dose-response" relationship between severity of injury and change in ADH symptoms, present from the 3-month assessment, was consistent with an effect directly related to brain damage.

OBJECTIVE To assess factors predictive of family outcome in the first 2 years after traumatic brain injury (TBI) in children and adolescents. METHOD Subjects were children aged 6 to 14 at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury factors (psychiatric family functioning, and family life events), injury factors (severity of injury), and postinjury factors (coping and development of a psychiatric disorder, never before present, i.e., "novel") were conducted using standard clinical scales. The outcome measure was family function as assessed with standardized family functioning interviews (at 12 and 24 months after TBI) and primary caretaker self-report questionnaires (at 3 and 6 months after TBI). RESULTS Fifty subjects enrolled, and the analyses focused on 37, 41, 43, and 42 subjects assessed at the 3-, 6-, 12-, and 24-month follow-up evaluations, respectively. The strongest influences on family functioning after childhood TBI are preinjury family functioning, the development of a "novel" psychiatric disorder in the child, and preinjury family life events or stressors. CONCLUSIONS These data suggest that there are families, identifiable through clinical assessment, at increased risk for family dysfunction after a child's TBI. Early identification and treatment of the child's psychopathology and family dysfunction may attenuate the associated morbidity.

Rationale and Objectives. The purpose of this study was to determine the length of time over which previous radiologic reports were useful during current interpretations and the types of information gathered from the old reports.Materials and Methods. The authors directly observed the use of 209 old reports by radiologists during current radiologic interpretation. They recorded the date of the old report, modality used, and type of information sought. The interpreting radiologists then rated the value of the information in the old report on a Likert scale of 1 (high value) to 4 (minimal value).Results. In 85% of cases, the most valuable information obtained was found in reports that were less than 2 years old. The most frequently sought types of information were clinical history or the previous radiologist's interpretation.Conclusion. Old reports add value to current interpretation by providing a form of "second reading" and providing clinical history. Two years is sufficient old report access in 85% of situations.

Factors predictive of psychiatric outcome in the second 6 months following traumatic brain injury (TBI) in 43 children and adolescents were assessed prospectively. The outcome measure was the presence of a psychiatric disorder not present before the injury ("novel"). Out of six models tested, four were predictive of novel psychiatric disorder: preinjury family function, family psychiatric history, socioeconomic class/intellectual function, and behavior/adaptive function. Post hoc analyses suggested that preinjury family functioning measured by a structured interview was a significant predictive variable. Severity of injury, when reclassified as severe versus mild/moderate TBI, significantly predicted novel psychiatric disorders. These data suggest that some children, identifiable through clinical assessment, are at increased risk for psychiatric disorders following TBI.

The purpose of this study was to quantify and to identify predictors of posttraumatic stress disorder (PTSD) symptomatology after traumatic brain injury (TBI). Fifty children aged 6 to 14 years, hospitalized after TBI, were assessed soon after TBI regarding injury severity and preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; neuroimaging was also analyzed. Psychiatric assessments were repeated 3, 6, 12, and 24 months after TBI. Only 2 of 46 (4%) subjects with at least one follow-up assessment developed PTSD. However, the frequency with which subjects experienced at least one PTSD symptom ranged from 68% in the first 3 months to 12% at 2 years in assessed children. The presence of an internalizing disorder at time of injury followed by greater injury severity were the most consistent predictors of PTSD symptomatology. It is apparent, therefore, that PTSD and subsyndromal posttraumatic stress disturbances occur despite neurogenic amnesia. These problems should be treated, particularly if symptoms persist beyond 3 months.

Our goal was to prospectively study the course of oppositional defiant disorder (ODD) symptomatology in children and adolescents in the first 2 years after traumatic brain injury (TBI). Fifty children aged 6 to 14, hospitalized after TBI, were assessed soon after TBI regarding injury severity; preinjury psychiatric, socioeconomic, family functioning, and family psychiatric history status; and neuroimaging was analyzed. ODD symptomatology in the first year after TBI was related to preinjury family function, social class, and preinjury ODD symptomatology. Increased severity of TBI predicted ODD symptomatology 2 years after injury. Change (from before TBI) in ODD symptomatology at 6, 12, and 24 months after TBI was influenced by socioeconomic status. Only at 2 years after injury was severity of injury a predictor of change in ODD symptomatology. The influence of psychosocial factors appears greater than severity of injury in accounting for ODD symptomatology and change in such symptomatology in the first but not the second year after TBI in children and adolescents. This appears related to persistence of new ODD symptomatology after more serious TBI.

OBJECTIVE. We performed this study to determine whether applicants to the body and breast/body imaging fellowship programs at our institution misrepresented their publications in their applications or curricula vitae, as has been reported recently regarding applicants for gas troenterology fellowships. We also wanted to alert program directors to this issue.MATERIALS AND METHODS. For each applicant in 1992-1995, every article cited on an application form or curriculum vitae as published or in press was cross-referenced with computer databases or the actual journals.RESULTS. Of 201 applicants, 87 (43%) listed at least one article citation (total citations, 261; mean number of citations, 3.0; maximum number of citations, 20). Of 261 citations, 39 (15%) could not be verified. Seven articles (listed by six applicants) did not appear in print 16-30 months after being listed as in press; six citations (by six applicants) put the applicant's name higher on the authorship list than was actually true; two articles (by two applicants) were not in the location cited or elsewhere; and 24 articles (by 14 applicants) were listed as appearing in journals that could not be found. The first three categories were judged as misrepresentations of publications; the fourth category was judged indeterminate for misrepresentation.CONCLUSION. A minimum of 16% (14/87) of applicants to the body and breast/body imaging fellowship programs at our institution who cited publications, or 7% of all 201 applicants in the time studied, appear to have misrepresented their publication record. Program directors should be aware of the possible means for prevention of this problem.

The first series of secondary mania reported in children and adolescents is described. Four of 50 subjects (8%) from a prospective study of consecutive children hospitalized following traumatic brain injury developed mania or hypomania. The phenomenology is discussed regarding the overlapping diagnoses of mania, attention-deficit hyperactivity disorder, organic personality syndrome and the 'frontal lobe syndrome'. Severity of injury, lesion location and family history of major mood disorder may be implicated in the etiology of secondary mania. Lengthy episodes and similar frequency of irritability and elation may be characteristic.

We present a case focusing on the surprising paucity of changes in behavior and executive functioning following accidental gunshot injury in an adolescent. Detailed image analysis revealed lesions in the right frontopolar, anterior orbitofrontal, temporal polar, anterior inferior temporal cortices and amygdala. It is possible that partial sparing of the orbitofrontal area and the fact that the lesion was unilateral, in addition to the subject's superior preinjury intellectual status, premorbid psychiatric health and healthy family functioning, are relevant factors in his excellent overall short-term outcome. Neuropsychiatric aspects of major depression in the subject are also reviewed. The subject's lesion is consistent with a depressive symptom complex, described previously following focal right frontal lesions in children and adolescents as well as in adult studies of penetrating brain injury. The case is unique in that extensive baseline data are available from 16, 13 and 4 months before the penetrating brain injury as well as follow-up data at 8 months following this injury.

Objective To assess predictive factors of psychiatric outcome in the first 3 months after traumatic brain injury (TBI) in children and adolescents. Method Subjects were children aged 6 to 14 years at the time they were hospitalized after TBI. The study used a prospective follow-up design. Assessments of preinjury psychiatric, behavioral, adaptive functioning, family functioning, and family psychiatric history status were conducted. Severity of injury was assessed by standard clinical scales and neuroimaging was analyzed. The outcome measure was the development of a psychiatric disorder, never before present ("novel") in a subject during the first 3 months after the TBI. Results Fifty subjects enrolled, and the analyses focused on 37 subjects followed up at 3 months. Increasing severity of injury, presence of a lifetime psychiatric disorder, family psychiatric history, family dysfunction, and lower socioeconomic class/preinjury intellectual function predicted the development of a "novel" psychiatric disorder in the first 3 months of follow-up. Conclusions These data suggest that there are children, identifiable through clinical assessment, at increased risk for development of psychiatric disorders in the first 3 months after TBI.

Psychiatric disorders may be common after traumatic brain injury (TBI) in children, yet there is a dearth of prospective studies examining this problem. Fifty children aged 6 to 14, hospitalized after TBI, were assessed soon after TBI regarding preinjury psychiatric, behavioral, adaptive, and family functioning, family psychiatric history status and injury severity. The outcome measure was the presence of a ''novel'' psychiatric disorder (not present before the injury) during the second 3 months after the injury. Forty-two subjects were reassessed at 6 months. Severity of injury, family psychiatric history, and family function predicted a novel psychiatric disorder. Among children suffering a mild/moderate injury, those with preinjury lifetime psychiatric disorders were no longer (as they had been in the first 3 months) at higher risk than those without such a lifetime history. Thus, there appeared to be children, identifiable through clinical assessment, at increased risk for novel psychiatric disorders after TBI.

OBJECTIVE:We performed a field study and subsequent laboratory investigation of pediatric radiology at a small rural hospital. Our investigation had three components: to describe the characteristics of pediatric radiology in a rural primary care facility, to test the diagnostic accuracy of interpretation of pediatric images transmitted by teleradiology, and to compare relative diagnostic accuracy of general and pediatric radiologists who interpreted pediatric images at a rural institution.MATERIALS AND METHODS:All 196 pediatric radiographs obtained during a 4-month period comprised the database from which we determined practice characteristics. Reports of 153 unselected cases interpreted by general radiologists using teleradiology were compared with interpretation of the same cases by a pediatric radiologist who interpreted the original radiographs. Discrepant cases were further investigated by a receiver-operating-characteristic curve experiment in which general and pediatric radiologists interpreted each case twice: once viewing teleradiologic images and once viewing the original radiographs at another setting. We then compared interpretive accuracy of observers and techniques.RESULTS:The pediatric radiographs were predominantly simple examinations for common acute disease, particularly pneumonia and fractures. Discrepancies of interpretation between teleradiology and original radiographs, which occurred in 13% of images, showed no significant difference in accuracy of interpretation for either teleradiologic images or original radiographs. Likewise, we found no significant advantage for accuracy of interpretation by general or pediatric radiologists. Receiver-operating-characteristic analysis of 18 discrepant cases showed slightly increased accuracy for interpretation of original radiographs by pediatric subspecialists.CONCLUSION:Simple pediatric radiographs obtained at a rural primary care institution and transmitted by teleradiology can be adequately interpreted by general radiologists.