Predictors and outcomes of sleep problems following childhood traumatic brain injury: A prospective cohort study

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BACKGROUND: Sleep problems are a relatively common and disabling consequence of childhood traumatic brain injury (TBI). However, few studies have evaluated factors associated with persistent sleep problems or their effects on subsequent behavioral difficulties. Understanding these associations can inform the focus and timing of post-injury interventions and monitoring. OBJECTIVES: This study aimed to identify early risk factors associated with sleep problems 1 year after childhood TBI, and the prospective associations between such sleep problems and subsequent internalizing and externalizing behavioral difficulties 2 years post-injury. METHODS: This longitudinal observational cohort study included children aged 5-15 who received emergency department care for TBI and matched community controls. Baseline measures of pre-injury child functioning were administered within 1 week of injury. Post-injury sleep problems were assessed after 1 year, and internalizing/externalizing behavioral difficulties after 2 years, using well-validated symptom rating scales, including the Child Behavior Checklist sleep problems composite and internalizing/externalizing broadband scales. RESULTS: The cohort comprised 144 children, categorized into three groups: 63 with mild TBI, 38 with moderate-to-severe TBI, and 43 community controls. The moderate-to-severe TBI group displayed higher levels of sleep problems compared to controls (mean difference, M diff, 0.68; 95 % CI 0.34-1.33) and children with mild TBI (M diff 0.72; 95 % CI 0.13-1.31). In multivariable adjusted models, lower family functioning (B 0.18; 95 % CI 0.05-0.32) and increased TBI severity (B -0.02; 95 % CI -0.03 to -0.01) were predictive of elevated sleep problems at 1-year post-injury. Furthermore, increased sleep problems at 1-year post-injury predicted higher internalizing and externalizing behavioral difficulties at 2 years post-injury after controlling for baseline sleep scores, pre-injury behavioral problems, age, sex, TBI severity, socioeconomic status, and family functioning. CONCLUSIONS: This study underscores the need to address sleep problems in routine clinical screening, post-injury surveillance, and early preventive interventions after childhood TBI. Further research is warranted to evaluate whether family-centered, sleep-focused interventions can mitigate these problems and prevent the onset of later behavioral difficulties in children with TBI.

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