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Child head injuries could harm relationship with parents

Monday 18 April 2016

"A simple bang on the head can alter a child's relationship with their parents claim academics," the Daily Mail reports.

A Canadian study found children who had experienced even a mild traumatic head injury, may have developed changes to their mood and behaviour.

Mild head injuries are common in younger children and may carry a risk to their developing brains. The study team were concerned that the psychological effects of head injuries may be underestimated.

The study aimed to assess the social and developmental effects of a mild head injury on 47 young children aged under five years. The group was compared to groups of children who'd had an orthopaedic injury (e.g. a fractured bone) or no injury.

Six months after the injury, researchers observed the child and their parents during 45 minutes of play or other activities, and rated the interactions among the head injury group as significantly poorer than the no injury group. There were no differences from the orthopaedic group.

There are several limitations to this study, including lack of observation prior to the accident to compare against. We also do not know whether these score differences have any meaningful implications for the child's long-term development, particularly given that the parent's reported no change in their interactions with their child.

Parents should not be overly concerned by these findings. However, they know their child best and if they think a head injury could be having longer-term effects on their child, they should seek medical advice.

Where did the story come from?

The study was carried out by researchers from Ste-Justine Research Centre and the University of Montreal, Quebec, in Canada, and was published in the peer-reviewed Journal of Neuropsychology. No sources of financial support are reported.

The Daily Mail's coverage may cause undue concern to parents and would have benefited from noting some of the limitations of this research, such as the lack of long-term follow-up assessments.

What kind of research was this?

This was a cohort study to observe the quality of the parent-child relationship for young children (18 months to five years) who had experienced a mild traumatic brain injury (TBI), caused by, for example, a fall or accident that results in a blow or jolt to the head.

The researchers say that mild TBI, or concussion only, where there are no signs of brain damage on imaging scans, accounts for the vast majority of all TBIs. In children under the age of five, TBIs are said to affect nearly 2 in 100 children every year.

The size and weight of the child's head in relation to the rest of their body reduces the control they have when trying to minimise the impact of a force/blow to the head. Furthermore, as the child's brain is still developing, they are thought to be particularly vulnerable to the effects of trauma. 

The researchers considered that because parent-child relationships form the centre of the child's social environment, they are the ideal setting to observe the possible adverse effects of mild TBI on a child's functioning.

What did the research involve?

The study recruited 130 children from an emergency department. They were aged 18 to 60 months and comprised three groups:

  • 47 who'd had an accidental mild TBI
  • 27 who'd had an accidental orthopaedic injury, such as a bone fracture
  • a control group of 56 children who'd had no injury

They excluded children with other confounding characteristics that could influence the results, such as those born premature, diagnosed with other significant physical or psychological conditions (including congenital), or previous head injury. 

Requirements for mild TBI were that the head trauma involved:

  • acceleration-deceleration (e.g. falling and hitting your head)
  • their Glasgow Coma Scale (GCS) score was 13-15 (15 is the maximum and equates to full normal response); the GCS is a well-validated scoring system for assessing neurological damage resulting from brain injury
  • they'd experienced at least one symptom such as loss of consciousness, confusion, irritability, drowsiness, poor balance or vomiting  
  • there were no signs of damage on brain imaging

Parents completed questionnaires on the child's pre-injury behaviour and environment. Six months after injury the researchers collected follow-up information via questionnaires, and also conducted a three-hour observation assessment with the child and their parent.

The assessments used numerous validated scales. There were two main outcome measures – the Mutually Responsive Orientation (MRO) scale and the Parental-Stress Index. The former measures the quality of child-parent interactions over 45 minutes when involved in different activities, such as playing with toys or eating a snack. The Parental-Stress Index is a self-reported questionnaire on parental distress, parent–child dysfunctional interaction and child characteristics, with a higher score indicating a poor bond.

The researchers followed up 94% of the original sample.

What were the basic results?

The main results reported relate to the MRO score, which focuses on parent-child exchanges. Children in the mild TBI group scored significantly lower at follow-up than children in the non-injured control group for all three subscales of the MRO score – communication, co-operation and emotion. There was no difference between the orthopaedic injury group and the other two groups.

There were reportedly no differences between groups in self-reported parent-child interaction on the Parental-Stress Index. The researchers interpret this to mean that observational measures may be more sensitive.

How did the researchers interpret the results?

The researchers conclude that their findings, "have implications for children's post-injury social development and highlight the importance of monitoring social outcomes even after minor head injuries."


This observational study comparing groups of young children in Canada who'd experienced mild TBI, orthopaedic injury or no injury finds that the MRO scores were lower after injury in the TBI group than the uninjured group.

However, before leaping to the conclusion that children who have suffered a mild head injury are going to have impaired development and poor social interactions, there are several important points to bear in mind:

  • Though parents were said to have reported the child's pre-injury function, we have no observational assessments from before the injury, so don't know that they significantly differed from before.
  • There was no difference in the parents' report of their interactions with their child on the Parental-Stress Index. The researchers interpret this to mean that observational measures on the MRO may be more sensitive, but it could be debateable what clinical significance the between-group differences on the MRO actually have. For example, the TBI group had lower scores than the no injury group. Does that mean there's going to be any meaningful difference in their development or social interactions? It would be useful to follow these children up a year or a few years down the line, to see if these apparent differences at six months persisted.    
  • There was a relatively small number of children in the different groups. The same differences may not have been observed if there were a larger selection of children or they had been recruited in different ways. For example, this sample of children with mild TBI had all presented to the emergency department. There may be many more children who experience a mild knock to the head, but their parents don't take them to hospital. Therefore, it is difficult to know which children this group can be generalised to.

Overall, the study is a useful addition to the literature on the possible effects of mild TBI in young children. However, it does not provide good evidence that suffering a mild brain injury affects the quality of the child's relationship with their parents.

If you are concerned that your child's behaviour, mood and attitude may have changed after a recent head injury, you should contact your GP for advice as a precaution.

Analysis by Bazian
Edited by NHS Website

Links to the headlines

A simple bang on the head can alter a child's relationship with their parents claim academics

Daily Mail, 18 April 2016

Links to the science

Lalonde G, Bernier A, Beaudoin C, et al.

Investigating social functioning after early mild TBI: the quality of parent-child interactions

Journal of Neuropsychology. Published online March 24 2016