Our study demonstrated that indeed children managed for TBI in MNRH do experience psychosocial deficits when assessed 1-2 years after injury. The findings are in concert with many previous studies carried out in different settings that report continued deficits in various domains of quality of life long after TBI (4, 6, 10, 11) The overall psychosocial functioning in our study was good with a mean score of 82, with only 14.3% of children being at-risk status for a poor psychosocial outcome (9).
Of the different domains of psychosocial functioning, we found that social functioning was the most favorable outcome in our children. This compared closely with a previous study done earlier by Vaca et al. in Mulago Hospital, who found that 91% of pediatric TBI patients reported being friendly at 1-year post-injury(8). We postulate that the good social outcome may be explained by the strong family and society ties that are still present in African settings. Besides, the parenting style practices in the Ugandan setting may foster recovery and adaptive functioning following TBI. Studies have demonstrated that authoritative parenting facilitates functional recovery following TBI compared to permissive parenting(12, 13).
Our study also established that TBI greatly affected the school functioning of children with about 15.5% of the children in this study population being unable to resume school following the TBI. About 18.1% of our study population reported poor school functioning with forgetfulness being the most cited complaint by parents. Previous studies have also demonstrated that TBI impacts negatively on the school performance of children (14, 15). Anderson et al. noted a decline in general intellectual functioning following TBI in children, up to 5 and 10 years post-injury (16). In South Africa, Dollman et al. examined the academic performance of children following TBI and found that there was a threefold increase in the use of educational services following TBI (17). Unfortunately, we did not assess the pre-injury school performance of children in our study, and hence our results were only based on the opinion of parents of their children at the time of the interviews. Our study found three factors that significantly affected the psychosocial outcomes of children following TBI. They included length of time post-injury, the severity of TBI, and the presence of associated injuries.
We found that children that had sustained TBI 2 years ago were more likely to have a favorable outcome compared to those who had sustained injury only 1 year ago. Our study, therefore, shows that recovery of psychosocial functioning following TBI continues even after 1-year post-injury. While most studies, like ours, show a trend towards improvement of psychosocial domains with time, a few show conflicting trends(14, 18). Stocchetti et al. noted that a significant proportion of patients will show significant and continuous improvement in functional outcome during the first 6 months after injury, and then stabilizing thereafter (19). However, evidence is accumulating that outcomes continue to change over long periods post-injury (19-21). A meta-analysis by Babikian et al. examined the impact of time post-injury on functional outcomes in children following TBI (22). They noted about 0-5 months post-injury represent a post-acute period, where greatest functional impairments are observed; 6-23 months post-injury represent the time of maximum recovery, and 24 and more months post-injury represent a time of minimal change of the established outcome. Furthermore, the severe injury was noted to have the least recovery, and moderate TBI had the greatest recovery of functional outcomes (22). These findings support the notion that adaptive outcomes continue to improve over time post-injury.
Our study also established the impact of severity of injury on the long term outcomes following TBI. We noted that patients with moderate and severe TBI were more likely to suffer from psychosocial deficits long after the injury. The negative effects of more severe forms of TBI have been exhaustively documented by other authors (6, 8, 16, 21, 23, 24). Babikian et al. in their meta-analysis reported that psychosocial functioning in children with severe TBI continued to deviate so greatly from an uninjured control at more than 2 years post-injury (22).
Notably, severe injury in children is associated with poorer physical, social, psychological, and academic outcomes as compared to mild TBI. Dollman et al. reported that more than two-thirds of South African children managed for severe TBI reported significant academic deficits requiring special needs education services (17). Even if our study didn’t assess the use of special educational services post TBI, we established that the impact of severity of injury on school functioning of children was significant. Age at injury is another important factor that has been cited by various authors to contribute significantly to long term psychosocial outcomes following TBI in children (5, 14, 24). Younger age at injury, especially below 5 years, has been reported to be associated with poorer long term psychosocial outcomes. It is postulated that disruption of a rapidly developing brain at an early age leads to an arrest in the development and attainment of new knowledge and skill (3, 25). However, despite the above postulations, our study did not find age at the injury to be significantly associated with long-term psychosocial outcomes. The lack of association between age at injury and long term outcomes may be explained by the fact that our study did not include children below 4 years of age at the time of injury. We found that children that had sustained associated injuries had poorer psychosocial outcomes in comparison to those with no associated injury. Children with associated injuries also reported poorer physical outcomes in comparison to their counterparts without associated injuries. Patients that have multiple injuries are at a higher risk of physical deficits in comparison to those with a single injury; this has been reported to be associated with worse long term physical and psychological outcomes(26).There was a strong correlation between physical functioning and psychosocial outcome of children with TBI (rho = 0.45) at p-value ≤ 0.001.
Indeed, we acknowledge that the consecutive sampling method used in our study did not provide an adequate proportion of children with severe TBI, probably due to the associated higher rate of mortality. Our study setting receives patients from all over the country especially during the acute phase management of TBI, and some of the potential participants might have been lost to follow-up if they stay far from the capital city, or they did not have a working phone number to be called. It is likely that these results therefore do not give a true representation of outcomes in children with TBI, especially the severe TBI pattern. However, it might have adequately covered a good representation for mild and moderate TBI pediatric patients.