Journal of Psychopathology and Clinical Psychology / Revista de Psicopatología y Psicología Clínica, 27 (1), 13-24, 2022

htpps://doi.org/10.5944/rppc.27891 J. Psychopathol. Clin. Psychol. / Rev. Psicopatol. Psicol. Clin.

https://www.aepcp.net ISSN 1136-5420
http://revistas.uned.es/index.php/rppc © Asociación Española de Psicología Clínica y Psicopatología

Differences in health-related quality of life, neuropsychological

functions and emotional state between children and adolescents with
mild traumatic brain injury and healthy controls
Karol Gutiérrez-Ruiz, Diana L. Audivet and Yoissy Mosquera-Valoy

Universidad Tecnológica de Bolívar, Cartagena, Colombia

Abstract: Little is known about the impact of mild traumatic brain injury (TBI) on the functioning of children in Latin America,
especially regarding a broad construct called health-related quality of life (HRQoL). The objective of this study was to analyze
the differences in HRQoL, neuropsychological functions and emotional state between a group of children and adolescents with
mild TBI and a healthy control group. A case-control study was conducted in which 30 children and adolescents with mild TBI
and their parents and a group of 30 healthy subjects participated. The results showed that participants with mild TBI had an
HRQoL similar to the one of the general population of the same age and sex. At the cognitive level, the group with mild TBI had
a lower processing speed and less work done in selective and sustained attention tasks; at the emotional and behavioral level,
they exhibited more symptoms of anxiety, depression, withdrawal and social problems.
Keywords: Traumatic brain injury; health-related quality of life; neuropsychological functions; emotional state.

Diferencias en la calidad de vida relacionada con la salud, las funciones neuropsicológicas y el estado
emocional entre niños y adolescentes con daño cerebral traumático leve y controles sanos
Resumen: Se sabe poco sobre el impacto del trauma craneoencefálico (TCE) leve en el funcionamiento de los niños en Latinoa-
mérica, especialmente en un constructo amplio denominado calidad de vida relacionada con la salud (CVRS). El objetivo de este
estudio fue analizar las diferencias en la CVRS, las funciones neuropsicológicas y el estado emocional de un grupo de niños y
adolescentes con TCE leve y un grupo control sano. Participaron 30 niños y adolescentes con TCE leve y sus padres, y un grupo
de 30 sujetos sanos. Los resultados evidenciaron que participantes con TCE leve percibieron una CVRS similar a la población
general de la misma edad y sexo. A nivel cognitivo el grupo con TCE leve tuvo una menor velocidad de procesamiento y canti-
dad de trabajo realizado en tareas de atención selectiva y sostenida; y a nivel emocional y conductual presentó mayor nivel de
síntomas de ansiedad, depresión, retraimiento y problemas sociales.
Palabras clave: trauma craneoencefálico; calidad de vida relacionada con la salud; funciones neuropsicológicas; estado emo-
cional.

Introduction common cause of acquired disability in childhood (Arango-

Lasprilla et al., 2012; Arango-Lasprilla et al., 2007; Au &
Traumatic brain injury (TBI) is one of the main causes Clark, 2017; Petersen et al., 2008). The incidence of TBI
of pediatric morbidity and mortality and is the most has increased in the last 10 years in Colombia; it is often a

Received: July 13, 2020; accepted: August 24, 2021. Acknowledgements: The authors thank the Napoleón Franco Pareja
Correspondence: Karol Gutiérrez-Ruiz, Faculty of Social and Human Children’s Hospital and the Barú Clinic in the city of Cartagena, Co-
Sciences, Technological University of Bolívar, Industrial and Techno- lombia, for their collaboration in data collection. This research was
logical Park Carlos Vélez Pombo, PC: 130014, Cartagena, Colombia. supported by Technological University of Bolívar through project
Email: [email protected] FCS1602T2002.

Journal of Psychopathology and Clinical Psychology / Revista de Psicopatología y Psicología Clínica 2022, Vol. 27 (1), 13-24
14 K. Gutiérrez-Ruiz, D. L. Audivet and Y. Mosquera-Valoy

result of automobile accidents and of social factors specific They inform persisting behavioral sequelae, most often
to the country (Quijano et al., 2010). hyperactivity/inattention, in the 12 months after mild
In general, there is consensus that the consequences TBI and beyond.
of brain damage caused by TBI in childhood are very There is a growing concern about neurodegenerative
broad (Au & Clark, 2017) and that those who survive changes that may occur chronically following mild TBI
moderate and severe TBI often have to cope with long- (Barkhoudarian et al., 2016; Mayer et al., 2017). The
term physical and psychological sequelae (Kotch & management of this condition, especially in children, can
Allen, 2019; Resch et al., 2019). However, the specific be challenging due to the lack of validated biomarkers
long-term problems that mild TBI can cause have only that clinicians can use to objectively diagnose patients
been addressed recently, and the results of these studies and also to predict cases with a worse prognosis (Mannix
are contradictory (Duhaime et al., 2012; Jones et al., et al., 2020; Mayer et al., 2018). Computed tomography
2019; Shultz et al., 2016; Staab & Powell, 2019). (CT) scans are not sensitive to the most probable
Studies on patients with mild TBI suggest that some pathological features of mild TBI (e.g., diffuse neural
recover quickly and can return to daily activities, while injuries, edema), neither structural magnetic resonance
there are people who continue to exhibit problems imaging (MRI), which also has a high-cost. Evidence
(Duhaime et al., 2012; Fineblit et al., 2016; Jones et al., from both routine-care and research-based studies
2019; Lambregts et al., 2018; Shultz et al., 2016). In suggest that the incidence of lesions on structural MRI
the case of children and adolescents, recovery may take scans is relatively low following pediatric mild TBI
longer than in adults; some experience persistent residual (Mayer et al., 2018). Unlike these structural biomarkers,
symptoms for more than 1 to 3 months and are diagnosed functional magnetic resonance imaging (fMRI),
with postconcussion syndrome (Cancelliere et al., 2014; electroencephalogram (EEG), magnetoencephalography
Hung et al., 2014). The sequelae of TBI can manifest (MEG) and functional near-infrared spectroscopy
at multiple levels, causing a variety of deficits that are (NIR) offer great promise for directly correlating the
different for each individual and can affect functionality neurobehavioral sequelae (e.g., poor attention) of acute/
in daily life, academic, social and/or work activities (Au sub-acute mild TBI with perturbed physiology (Mayer
& Clark, 2017; Duhaime et al., 2012; Jones et al., 2019; et al., 2017). The clinical use of S100B, a protein found
Shultz et al., 2016). in glial cells, has been studied as serum biomarker for
A systematic review of 30 studies published between pediatric mild TBI. This may be used as a supplementary
1990 to 2014 of psychological, psychiatric and behavioral tool to identify patients at risk for intracerebral lesions
outcomes of children following mild TBI compared (Calcagnile et al., 2012; Oris et al., 2018).
to a control group conclude that while the evidence is Health-related quality of life (HRQoL) is considered
mixed, the vast majority of children recovery quickly the subjective well-being perceived by individuals
with a small proportion of children displaying persistent relative to different aspects of their lives, such as physical,
problems. The problems most commonly described mental (emotional) and social aspects. It corresponds to
in the reviewed papers after mild TBI were attention the patient’s outlook about their disease and its impact on
problems and behavioral and emotional problems (i.e., their life (González et al., 2012; Sherer et al., 2020). Little
hyperactivity, disruptive behaviors, oppositional defiant is known about the course of HRQoL and the parameters
disorders, depression, anxiety, post-traumatic stress of functional outcomes in children and adolescents with
disorder) [Emery et al., 2016]. TBI. Compared to adults, pediatric HRQoL assessment
A cross-sectional study of 73 young persons (aged is a more recent field of study; however, the analysis of
6–22 years) with mild TBI revealed 7–15% had cognitive research conducted in the pediatric population, mainly in
impairments at two years after injury (Lambregts et al., English-speaking countries, has shown that the severity
2018). The cognitive processes affected were visuospatial of TBI significantly affects quality of life: mild TBIs have
constructional ability, visuospatial memory and executive been associated with a good prognosis, while moderate
functions (i.e., cognitive flexibility, processing speed and and severe TBIs have been associated with low HRQoL
inhibitory control). Phillips et al. (2017) also reported (Di Battista et al., 2012; Ryan et al., 2019).
deficits in working memory, especially in the central A systematic review of pediatric HRQoL following
executive component and phonological loop, in pediatric mild TBI concluded that a small proportion of children
TBI. Longitudinal studies such as the one carried out continue to experience diminished HRQoL up to a year
by Jones et al. (2019) have shown improvements in or longer post injury. This prolonged recovery may have
overall neurocognitive function over the year following implications on academic performance or psychosocial
injury, but not between 12 and 48 months after injury. wellbeing (i.e., social isolation, increased risk of

© Asociación Española de Psicología Clínica y Psicopatología

 Quality of life, neuropsychological functions and emotional state in pediatric TBI 15

developing adverse psychiatric outcomes) [Fineblit et al., the strata to which citizens with fewer resources belong.
2016]. Jones et al (2019) found thar parents of children Regarding the caregivers, 85% were parents of the
with mild TBI reported child’s HRQoL significantly children, often the mother (88%), and lived with them.
deteriorated between 12- and 48-months post-injury, The children of the clinical group were selected
particularly in relation to social functioning and school. through nonprobabilistic convenience sampling,
Although HRQoL is a very important outcome identifying the children and adolescents in the databases
parameter, there are currently no studies on the HRQoL of two private health institutions using one of the
of Colombian children with TBI, although it has been following ICD-10 codes (World Health Organization,
studied in adults with moderate and severe TBI (Arango- 1993): S06.2 (Diffuse traumatic brain injury), S06.3
Lasprilla et al., 2012). This is worrisome because patients (Focal traumatic brain injury), S06.8 (Other specified
often face obstacles after the trauma to satisfactorily intracranial injuries) and S06.9 (Unspecified intracranial
reintegrate into their social, family and work life, which injury). Additionally, they were required to meet the
could affect their quality of life (Howell et al., 2019; Ryan following inclusion criteria: 1) Age between 8 and 16
et al., 2019). There are limitations for the study of TBI in years. 2) Have diagnosis of mild TBI at the time of
Colombia; for example, the variability in the definitions evaluation confirmed by their medical history. 3) Age at
used and the population being studied, the underreporting time of trauma between 8 and 16 years. 4) Have had the
of information in medical records, which makes it difficult trauma for at least 6 months prior to the study. 5) Have
to estimate TBI severity, and the variability of the time no documented history of TBI, neurological disorders,
of follow-up of patients. All this constitutes obstacles psychiatric problems, substance and/or alcohol use,
to the real estimation of epidemiological data and to the autism spectrum disorder, intellectual disability or
understanding of the sequelae and complications that TBI learning difficulties prior to the TBI. Due to personal
can produce over time. data protection guidelines, the authors were not allowed
HRQoL is an important outcome parameter in to review the medical records of the minors, and the
clinical practice and also in research. However, the process was carried out by the staff of the health centers.
available measures should be used in conjunction with The children of the comparison group were selected
other measures, integrating the evaluation of cognitive from the general population using nonprobabilistic
or behavioral problems, to obtain a complete picture convenience sampling that took into account the
of the well-being of an individual. In the population following inclusion criteria: 1) Age between 8 and
of children with mild TBI, more information is needed 16 years. 2) Have no documented history of TBI,
regarding the neuropsychological sequelae of the brain neurological disorders, psychiatric problems, substance
damage. Taking into account that the assessment of and/or alcohol use, autism spectrum disorder, intellectual
HRQoL would provide additional information for the disability or learning difficulties.
optimization of treatment or comprehensive intervention The groups were similar in age, sex and socioeconomic
in pediatric TBI, the purpose of this study was to analyze status (p > .05). Mild TBI was confirmed through medical
the differences in HRQoL, neuropsychological functions records kept by the health centers, taking into account
and emotional state between a group of children and three criteria: altered level of consciousness (0 - 30
adolescents with mild TBI and a healthy control group. minutes), anterograde amnesia (< 24 hours) and a score
on the Glasgow coma scale between 13 and 15 points in
Method the first 24 hours. For five of the clinical cases, there was
loss of consciousness lasting less than 30 minutes; for
Participants the remaining cases, there was no loss of consciousness.
In all cases, the initial score on the Glasgow coma scale
A nonexperimental case-control cross-sectional was between 13 and 15 points.
study was conducted with a sample of 60 children and
adolescents, 16 females (Mage = 12.5 years, SD = 2.3 Instruments
years) and 44 males (Mage = 12.5 years, SD = 2.5 years),
and their primary caregiver. Thirty children with a Health Questionnaire for Children and Young People
history of mild TBI belonged to the clinical group (KIDSCREEN-27; The KIDSCREEN Group, 2004).
(Mage = 12.7 years, SD = 2.6 years), and 30 healthy The KIDSCREEN-27 assesses the health and subjective
children comprised the control group (Mage = 12.6 years, well-being of children and adolescents aged 8 to 18
SD = 2.5 years). Eighty-three percent of children with years. It is a cross-cultural instrument developed as a
TBI belonged to socioeconomic strata 1 and 2, that is, measure of self-perceived health applicable to children

Journal of Psychopathology and Clinical Psychology / Revista de Psicopatología y Psicología Clínica 2022, Vol. 27 (1), 13-24
16 K. Gutiérrez-Ruiz, D. L. Audivet and Y. Mosquera-Valoy

and adolescents who are healthy and to those who have Rey–Osterrieth complex figure test (Rey-Osterrieth,
chronic diseases. It has five dimensions: physical well- 1997). It is a test that evaluates perceptual organization
being, psychological well-being, autonomy and parents, and visual memory by reproducing a figure from
peer and social support, and school environment. The memory after a period of distraction. This test also allows
instrument requires only 10-15 minutes to complete, evaluation of organizational skills and strategic planning
there is a version for children and one for parents, and for problem solving and visual-constructional ability.
it was validated in the Colombian population with an The instrument has normative data for a Colombian
internal consistency estimated with the Cronbach’s alpha population of children aged 6 and 17 years, it has a
greater than 0.7 in all dimensions (Quintero et al., 2011). good reliability estimated with the Cronbach’s alpha in
the copy (a = 0.77) and recovery (a = 0.66) of the figure
Pediatric neuropsychological assessment protocol (Arango-Lasprilla et al., 2017).
Childs Behavior Checklist (CBCL) for parents
Trail Making Test (TMT; Reitan, 1992). Consists of (Achenbach & Rescorla, 2001). This questionnaire
a paper and pencil task that requires the subject to draw evaluates the presence of psychological disorders
lines to connect a series of circles in ascending order. It in children and adolescents aged 6 to 18 years. It is
requires visuospatial skills, motor speed and dexterity; it completed by the parents or caregivers of the children
is also considered a measure of cognitive flexibility and and is composed of two parts: the first allows us to assess
alternating attention. The instrument has normative data sports, social and academic skills or competencies, and
for the Colombian population of children between 6 and the second evaluates the main behavioral and affective
17 years of age, with an internal consistency estimated problems of children aged 6 to 18 years. The internal
with Cronbach’s alpha of 0.96 for TMT-A and 0.98 for consistency estimated with the Cronbach’s alpha is
TMT-B (Reynolds, 2002 cited in Arango-Lasprilla et al., greater than 0.7 in all questionnaire dimensions.
2017).
d2 Test of Attention (Brickenkamp, 2002). Consists of Procedure
a paper and pencil cancellation test. The task requires the
subject to cross out as many target letters as possible («d» Patients who were admitted to the outpatient clinic for
with two marks), moving from left to right, with a time TBI in two pediatric care centers in the city of Cartagena,
limit of 20 s/test. The instrument has normative data for a Colombia, between 2012 and 2018 were identified,
Colombian population of children aged between 6 and 17 compliance with the inclusion criteria was determined
years, and the scores obtained in this test are expressed in through the medical records of the health care centers,
percentiles (Arango-Lasprilla et al., 2017). According to and the parents of those who met the criteria to participate
the Spanish version of the test (Seisdedos, 2002), in most in the study were contacted by telephone. The control
studies, the scores are very reliable (r > .90). group was recruited from educational centers in the city.
Neuropsychological assessment of children battery First, medical history data was gathered for the
(Matute et al., 2007). It is a battery of tests designed to children participating in the experiment and the caregivers
characterize cognitive and behavioral skills in Spanish- completed the parent version KIDSCREEN 27; then,
speaking children between 5 and 16 years of age. The children’s version of the instrument was completed. Next,
following battery domains were administered: auditory the pediatric neuropsychological evaluation protocol
memory and visual memory, both the encoding and was administered to the children, and the process lasted
delayed recall processes. The scores obtained in these tests approximately 2.5 hours. Parents of minors also completed
are expressed in percentiles. The test-retest reliability of a questionnaire aimed at identifying the behavioral and
the administered tasks is between 0.59 and 0.68. socioemotional characteristics of their children.
Modified Wisconsin Card Sorting Test (M-WCST; All procedures performed in this study involving
Nelson, 1976). It is used for the evaluation of executive human participants were in accordance with ethical
functions. The abbreviated version of the test consists of standards of institutional and national research committee
48 response cards and 4 stimulus cards. This task is used and with the 1964 Helsinki declaration and its later
to evaluate perseverance, and conceptualization skills. amendments or comparable ethical standards.
The instrument has normative data for the Colombian The research ethics committee of the Universidad
population of children between 6 and 17 years of age, Tecnológica de Bolívar approved the research protocol
it has a good reliability estimated with the Cronbach’s and assigned the code FCS1602T2002.
alpha (a = 0.83) in the indicators of completed categories Informed consent was given to all participants in
and perseverative errors (Arango-Lasprilla et al., 2017). order to get their allowance for this study. They were

© Asociación Española de Psicología Clínica y Psicopatología

 Quality of life, neuropsychological functions and emotional state in pediatric TBI 17

informed that they could withdraw their participation at Of the patients, 93.33% were not under
any time. Moreover, all subjects were informed that the pharmacological treatment because of the injury, and
data would be coded by numbers to avoid identifying only 6.66% were given analgesics to treat recurrent
the participants and to maintain the confidentiality of the headaches. After the injury, 73.33% of the children did
data. not receive any type of therapeutic care, while 26.66%
received at least one of the following therapies in order
Data analysis of frequency: psychological care, psychiatric care,
neuropsychological rehabilitation, physical therapy,
The data corresponding to the qualitative variables speech-language therapy, occupational therapy and
such as sociodemographic factors and relevant clinical special education.
information were analyzed using measures of absolute Among the main sequelae associated with pediatric
and relative frequencies expressed as percentages; TBI, there is a prevalence of headaches, followed by
those corresponding to the quantitative variables were dizziness and pain in the extremities. Less commonly,
analyzed using measures of central tendency. echolalia, loss of vision, psychomotor agitation, sleep
To compare data between the clinical and control disorders, motor deficits, specific learning difficulties, and
groups regarding the different dimensions of HRQoL, behavioral and emotional disorders were observed. After
the Mann-Whitney U test statistic was used. Additionally, the trauma, 43.33% exhibited the following limitations
a group comparison analysis was performed using in order of frequency: doing homework, planning and
Student’s t-statistic based on the scores obtained by organization, increased time spent performing household
the participants in the pediatric neuropsychological tasks, difficulty interacting with family members in
assessment protocol. The analyses were performed with different spaces, performing recreational activities
the statistical package for social sciences (SPSS) version outside the home, and interacting with peers in different
24.0 for Windows (IBM, 2016). environments. Caregivers of 30% of children reported
that their school performance worsened after TBI.
Results
HRQoL perceived by children and adolescents with
Clinical characteristics of the group with mild TBI mild TBI, controls and caregivers

The average time elapsed since the TBI was 18 Children and adolescents with mild TBI, their
months, with a range of 7–60 months. Twenty-six percent caregivers and children without TBI report an HRQoL
of children suffered TBI due to a motor vehicle accident, that is similar to that of the general population of the
26.6% due to falls, 23.33% due to a traffic accident as same age and sex in the dimensions of physical well-
a pedestrian, 13.33% as a consequence of a recreational being, psychological well-being, autonomy and parents,
activity, and 3.33% as a result of being hit by an object peers and social support, and school environment (see
and 3.33% due to being hit by a person. Table 1).
Table 1. Description of the HRQoL dimensions perceived by each subgroup

Physical Psychological Autonomy and Peers and School

well–being well–being Parents Social support environment
M (SD) M (SD) M (SD) M (SD) M (SD)
Children with TBI 49.6 (7.9) 49.5 (6.9) 46.5 (9.0) 51.5 (8.9) 48.0 (12.4)
Caregivers of children with TBI 55.9 (13.6) 49.4 (11.8) 56.0 (12.1) 59.6 (10.6) 51.4 (14.2)
Controls 52.4 (10.6) 50.6 (8.7) 47.2 (8.1) 46.9 (8.1) 51.1 (9.4)
Note: M = mean; SD = standard deviation. The median T–score was taken for each of the HRQoL dimensions of the KIDSCREEN–27 for
Children and Adolescents and the one for parents. The scores are standardized with a median of 50 and standard deviation of 10, and ≤ 40
was used as a cut–off point to indicate a low HRQoL.

The HRQoL perceived by children and adolescents significant differences between the perception of the
with mild TBI was compared to that reported by the children and their caregivers in the majority of the
caregivers in the different dimensions of the HRQoL evaluated dimensions of HRQoL. Significant differences
evaluated by the KIDSCREEN 27. There were no were only found in the Autonomy and parents dimension

Journal of Psychopathology and Clinical Psychology / Revista de Psicopatología y Psicología Clínica 2022, Vol. 27 (1), 13-24
18 K. Gutiérrez-Ruiz, D. L. Audivet and Y. Mosquera-Valoy

(U = 60.0, p = .029, PSest = 0.26), so that parents had Neuropsychological performance and emotional state
higher HRQoL scores in this dimension compared to
children; however, the size of the effect is small. Table 2 shows the analysis of the mean difference
Finally, the HRQoL perceived by children and between subjects with mild TBI and controls on cognitive
adolescents with and without a history of TBI in the measures. The results show that there are statistically
different dimensions of the HRQoL was evaluated by significant differences between the clinical and control
the KIDSCREEN 27 and compared, finding that there groups in the TR rate (total of elements attempted) and
is no significant difference between the groups in four CON (concentration index) of the d2 test of attention.
of the five dimensions of HRQoL evaluated, except The TR index measures processing speed, amount of
the dimension peers and social support (U = 259.0, work performed and total productivity in the attention
p = .004, PSest = 0.29). In this dimension, the group task. It is a measure of selective and sustained attention
with TBI reports a higher HRQoL compared to the in which the control group showed a significantly higher
group without TBI; however, the size of the effect is performance than the clinical group. Additionally, the
small. clinical group did not achieve a good balance between

Table 2. Comparison of cognitive measures between clinical and control groups

Clinical group Control group

M (SD) M (SD) t p–value d
Graphic skills
Rey–Osterrieth complex figure test 25.8 (9.4) 24.9 (7.8) –.275 .785 —
Attention
TMT part A (time) 60.4 (45.3) 44.5 (23.3) –1.208 .237 —
d2 TR 52.3 (31.0) 70.5 (27.8) –1.990 .046* 0.30
d2 TA 38.0 (32.8) 51.3 (30.8) –1.123 .271 —
d2 O 31.9 (28.7) 31.2 (29.3) .061 .952 —
d2 C 15.4 (25.7) 11.7 (9.1) .506 .617 —
d2 TOT 68.2 (94.4) 60.4 (32.2) .295 .770 —
d2 CON 25.5 (33.1) 43.2 (27.3) –2.070 .038* 0.30
d2 VAR 51.6 (33.9) 50.1 (36.7) .111 .912 —
Verbal–auditory memory (encoding)
List of words 29.4 (22.1) 23.0 (24.7) –.752 .458 —
Story recall 23.1 (20.1) 25.9 (24.6) .349 .729 —
Visual memory (encoding)
List of figures 34.5 (21.4) 42.1 (26.6) .867 .393 —
Verbal–auditory memory (delayed recall)
Spontaneous retrieval of word list 30.8 (24.7) 28.1 (19.3) –.329 .745 —
Retrieval by word list key 25.7 (20.6) 36.7 (25.3) 1.284 .210 —
Verbal–auditory recognition 34.4 (29.5) 44.7 (22.5) 1.084 .288 —
Story recall 18.1 (21.9) 24.1 (26.1) .679 .503 —
Visual memory (delayed recall)
Spontaneous retrieval of figure list 43.6 (31.3) 36.6 (29.4) –.636 .530 —
Retrieval by figure list key 37.7 (32.2) 41.0 (22.9) .327 .746 —
Visual recognition 33.9 (26.1) 48.3 (20.1) –2.576 .104 —
Rey-Osterrieth complex figure retrieval 16.2 (9.0) 16.4 (7.4) .062 .951 —
Executive functions
Cognitive flexibility
No. of perseverative responses M–WCST 10.3 (5.7) 9.3 (5.5) .421 .627 —
Categorization
No. of categories M–WCST 2.0 (.9) 2.2 (.8) –.642 .526 —
Note: *p<.05; M = mean; SD = standard deviation.

© Asociación Española de Psicología Clínica y Psicopatología

 Quality of life, neuropsychological functions and emotional state in pediatric TBI 19

speed and accuracy in the execution of the test compared characteristics of the CBCL questionnaire. Significant
to the control group, with a lower concentration index. differences were found between the clinical and
However, the size of the effect is small. control groups in the anxiety/depression, withdrawal
No significant differences were found between and depression, and social problems subscales, with a
children with mild TBI and controls in graphic skills, medium effect size. In the anxiety/depression subscale,
auditory-verbal memory (encoding and delayed 13.3% of children with mild TBI are within the clinical
recall), visual memory (encoding and delayed recall), range, according to the parents’ report, and 13.3% are
and executive functioning (cognitive flexibility and at risk. Similarly, in the withdrawal and depression
conceptualization). subscale, 13.3% of children with mild TBI are at risk. On
Table 3 shows the comparison between subjects with the social problems subscale, 6.6% of children with mild
TBI and controls in the ten behavioral and emotional TBI are within the clinical range, while 13.3% are at risk.

Table 3. Comparison of CBCL between clinical and control groups

Clinical group Control group

M (SD) M (SD) t p–value d
Anxiety/depression 55.1 (15.9) 45.2 (6.7) –2.23 .038* 0.46
Withdrawal and depression 53.3 (9.6) 46.0 (9.3) –2.11 .044* 0.37
Somatization 58.9 (12.7) 49.9 (14) –1.84 .077 –
Social problems 55.7 (12.5) 47.0 (6.8) –2.37 .027* 0.41
Thought problems 50.0 (10.9) 45.6 (5.0) –1.37 .185 —
Attention problems 57.3 (12.0) 48.9 (12.6) –1.89 .070 —
Delinquent behavior 57.3 (16.1) 51.5 (8.9) –1.21 .240 —
Aggressive behaviors 53.6 (10.7) 47.9 (6.9) –1.73 .094 —
Internalizing 56.6 (12.8) 46.6 (7.8) –2.59 .015* 0.44
Externalizing 53.5 (11.2) 49.4 (8.3) –1.15 .260 —
Note: *p<.05; M = mean; SD = standard deviation.

In the clinical group, there were mainly internalization (Alted et al., 2009; Denis et al., 2011; De Villegas &
problems (withdrawal, somatic complaints, anxiety and Salazar, 2008). In our study, there was a greater number
depression) rather than externalization problems, and of cases of mild TBI in the lowest socioeconomic levels,
these difficulties were significantly greater compared to with 83% of the subjects evaluated being grouped in
the control group, with a medium effect size. levels 1 and 2 1. In relation to this, it has been found that
socioeconomic status constitutes a risk factor that affects
Discussion the quality of life of children, with families from lower
socioeconomic strata being prone to acquire these injuries
Mild TBI has been less understood and studied due to the conditions of their environment, such as the
compared to moderate and severe TBI, despite being state of their housing, marginalization, violence, among
an issue that generates significant public health concern others (Fiorentino et al., 2015; Quintero et al., 2011).
worldwide since it represents the majority of TBI cases Falls and motor vehicle accidents were the main
(Yeates et al., 2009). Similarly, the impact of mild TBI in mechanisms causing TBI, which supports that proposed
children and adolescents has received less attention than by Avilés et al. (2016), Fiorentino et al. (2015), García
in adults, especially in Latin America. Considering the et al. (2009), and Petersen et al. (2008). Previous studies
physical, cognitive and socioemotional difficulties that that have explored the sequelae associated with TBI
(Folleco, 2015; Gutiérrez-Ruiz et al., 2017; Pacheco,
can arise after TBI, this study explores the effect of mild
2014; Peralta et al., 2014) highlight the development
TBI on HRQoL in the pediatric population.
Regarding the characteristics of the sample, mild 1
The Colombian government bases the socioeconomic status of indi-
TBI is more common in males than in females, which viduals on their income and address of residence, and ranges from 1
agrees with the findings reported in previous studies (low) to 6 (high).

Journal of Psychopathology and Clinical Psychology / Revista de Psicopatología y Psicología Clínica 2022, Vol. 27 (1), 13-24
20 K. Gutiérrez-Ruiz, D. L. Audivet and Y. Mosquera-Valoy

of cognitive, social and behavioral difficulties after impact of mild TBI (Fineblit et al., 2016; Gilbert & Johnson,
the trauma that are related to low school performance. 2011; Mayer et al., 2018; Van Kampen et al., 2006).
According to the parents or caregivers, 30% of the When comparing in our study the perceptions about
children in the present study had worse academic the HRQoL reported by parents and children with mild
performance after the brain injury; in addition, they TBI, the parents had a tendency to report slightly higher
had more limitations in performing school tasks and scores in the majority of the dimensions of the HRQoL;
activities such as organizing their things and their time, however, these differences were only statistically
which can have an impact on academic performance. significant for the Autonomy and parents dimension,
In this study, 43.33% of children with mild TBI although the size of the effect is small. The perception
exhibited physical sequelae such as headache and that parents had of HRQoL in the study by Souza et al.
dizziness. There were also, to a lesser extent, cases of pain (2007) did not agree with the HRQoL self-reported by
in the extremities, loss of vision, psychomotor agitation, the children, with slightly higher scores by the parents.
sleep disorders, specific learning difficulties and Similarly, Pieper and Bear (2011) and Fineblit et al.
behavioral-emotional disorders. However, these sequelae (2016) found a discrepancy between the perception of
do not negatively impact HRQoL in mild TBI cases. children and parents of HRQoL after the TBI, parents
A large number of children do not require therapeutic rated HRQoL higher than their children.
care immediately after mild TBI. Authors assert that the In many cases, after the trauma, children experienced
majority of cases exhibit good recovery in motor areas a change in the way they perceived situations and
and functional independence for daily activities (Soto life problems, exhibiting positive coping with life
et al., 2014); however, long-term medical checks are circumstances. Thus, in the dimension of peers and
necessary to continue with the evaluation process. This social support, there was an atypical finding because,
would explain the fact that 73.33% of the participants contrary to expectations, children with mild TBI
in our study did not receive any type of therapeutic showed higher HRQoL in this dimension than children
treatment after medical discharge, and many of them did without TBI. In comparison to the control group, all
not continue with the follow-up medical checks, so there children with a history of mild TBI were within the
was no follow-up of the case progression that would have normal category. This finding suggests that after the
allowed the determination of possible therapeutic needs. trauma, the process of socialization was positive for
According to the results of this study, children and these children, which could be explained by their social
adolescents perceive the different dimensions of HRQoL and family environment because among the common
as normal after mild TBI. When comparing the HRQoL of characteristics of the participants is that they are part of
children with mild TBI and children without a history of large families and are frequently surrounded by friends,
TBI, there are no significant differences between the groups, which facilitates interaction and social inclusion. Family
which suggests that there is no important association between environment and social support are important predictors
mild TBI and HRQoL in our sample. These results are of psychosocial outcomes and overall functioning after
associated with the findings of Petersen et al. (2008), who a TBI, considering aspects such as severity, time elapsed
conducted an investigation to describe HRQoL, health status, after the injury and parenting style (Peralta et al., 2014).
behavioral problems and neuropsychological functioning in In this study, few significant differences were
a sample of children and adolescents after mild TBI through found between children with mild TBI and controls in
a longitudinal study, and found only small differences standardized cognitive and behavioral measures. Of all
throughout the study period and no difference in HRQoL the cognitive variables analyzed, only the scores for TR
compared to the control group. Souza et al. (2007) detected and CON of the d2 Test of Attention were significantly
that after four years of having suffered a TBI, most of the associated with mild TBI; however, the size of the effect
children evaluated returned to normal daily activities, and is small. There are studies in which no lasting cognitive
there were no significant differences between the quality of difficulties have been found in children with mild TBI;
life of these patients and the comparison group. It remains although they experience headaches, dizziness and
to be determined in this study whether or not the nature of fatigue, they do not show cognitive alterations, even
children’s HRQoL has returned to pre-injury levels and cannot one week after the trauma (Arciniegas & Wortzel,
be definitively answered this issue by the current analyzes 2014; García et al., 2003; Horn et al., 2013; Theeler
given the absence of information about children’s HRQoL et al., 2012). It has been documented that persistent
prior to mild TBI. Further, it has been suggested that younger problems after mild TBI are more common in children
pediatric mild TBI patients are less likely to accurately self- with a past TBI, learning difficulties, neurological or
report symptoms, which leads them to underestimate the psychiatric problems, or family stressors (Thompson &

© Asociación Española de Psicología Clínica y Psicopatología

 Quality of life, neuropsychological functions and emotional state in pediatric TBI 21

Irby, 2003). This suggests that these antecedents make et al., 2021). Although in this study the clinical group
children more vulnerable to the effects of mild TBI or showed externalizing symptoms, no statistically significant
that the information reported by the caregivers is based differences were found with the comparison group.
on the previous deficit. The possible effect of treatment This finding contradicts previous literature (Connolly &
by the clinical group should be considered in explaining McCormick, 2019; Emery et al., 2016); however, it must
these findings and also the neuroplasticity capacity in be taken into account that Jones et al. (2019) have reported
childhood (Kolb & Gibb, 2011; Taylor et al., 2013). improvements in child behavior informed by parents in the
There have been few studies on the long-term 12 months post-injury. The average age of the participants
consequences of mild TBI in the emotional state and in this study was 12 years, so they were in the adolescence
behavioral adjustment of children, and the findings are life period and often in this stage a significant proportion
often inconsistent (Keightley et al., 2014). Although of adolescents (including those without history of brain
some studies have not demonstrated persistent effects of injury) engage in externalizing behaviors (e.g., aggression,
mild pediatric TBI on behavior (Anderson et al., 2001), substance use, and delinquency) [Modecki et al., 2017]. It
other studies have documented that children suffering should also be considered that psychological and psychiatric
from mild TBI have higher indicators of psychiatric problems in children with a history of mild TBI are more
disorders (behavioral problems, social problems, prevalent when mild TBI is associated with hospitalization,
internalization and externalization problems) and higher when there are multiple previous mild TBIs and in individuals
levels of hyperactivity compared to controls (McKinlay with preexisting psychiatric illness (Emery et al., 2016).
et al., 2002; Massagli et al., 2004; Taylor et al., 2015). There are limitations of this study. First, it should be
When exploring in our study the effect of mild TBI clarified that being an exploratory study, these results
on daily functioning, particularly in the development are based on a small number of participants, which does
of social skills and behavioral problems, we found not exclude the possibility that there are individuals who
statistically significant differences with a medium effect experience persistent and chronic effects of mild TBI.
size in four of the ten subscales of the CBCL questionnaire: Second, this study utilized data from a geographically-
the anxiety/depression, withdrawal/depression, social limited sample of children and adolescents in Cartagena,
problems and internalization subscales. For the anxiety/ Colombia and its metropolitan area, therefore limiting
depression and withdrawal scales, the scores were within the generalizability of the findings. Third, due to the
significant clinical levels. Anxiety is part of a wide analytic strategy used in the present study, the evolution
spectrum of emotional problems after TBI in childhood of HRQoL, neuropsychological functions and the
and is associated with damage to the dorsal frontal lobe emotional state of children and adolescents with mild
and the frontal white-matter systems (Max et al., 2011). TBI were not follow up.
It is also possible to develop depressive disorder after As recommendations for future studies, it is
TBI, which may or may not be accompanied by anxiety. necessary to develop research with larger samples and
Depressive disorder has been associated with older with participants from different regions of the country
age at injury, family history of anxiety disorders, right in multicenter studies that allow us to better characterize
frontal white matter lesions and left inferior frontal gyrus the nature of mild TBI and to monitor the patient
lesions (Max et al., 2012). Recent findings examining progress to accurately determine the progression of the
the relationship between mild TBI and psychopathology neuropsychological clinical condition to better manage
showed a significant relation between childhood mild this condition in childhood. Future research should
TBI and increases in anxiety/depression symptomology attempt to replicate these findings and further analyze
later in adolescence (Connolly & McCormick, 2019). the trajectories of emotional and behavioral symptoms
The results of this exploratory study agree with related to mild TBI across the lifespan.
previous studies conducted in other countries and that
was found that mild TBI does not produce significant Conflicts of interest
long-term deficits in neuropsychological functioning,
whereas behavioral and emotional problems tend to The authors have no conflicts of interest to declare.
be more persistent over time. Our findings are also
consistent with studies conducted in adults (Keightley et References
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