Service and support needs following pediatric brain injury: perspectives of children with mild traumatic brain injury and their parents

Psychosocial Factors Associated With Time to Recovery After Concussion in Adolescent Ice Hockey Players

OBJECTIVE

To investigate the association between psychosocial factors and physician clearance to return to play (RTP) in youth ice hockey players after sport-related concussion.

DESIGN

Prospective cohort study, Safe to Play (2013-2018).

SETTING

Youth hockey leagues in Alberta and British Columbia, Canada.

PARTICIPANTS

Three hundred fifty-three ice hockey players (aged 11-18 years) who sustained a total of 397 physician-diagnosed concussions.

INDEPENDENT VARIABLES

Psychosocial variables.

MAIN OUTCOME MEASURES

Players and parents completed psychosocial questionnaires preinjury. Players with a suspected concussion were referred for a study physician visit, during which they completed the Sport Concussion Assessment Tool (SCAT3/SCAT5) and single question ratings of distress and expectations of recovery. Time to recovery (TTR) was measured as days between concussion and physician clearance to RTP. Accelerated failure time models estimated the association of psychosocial factors with TTR, summarized with time ratios (TRs). Covariates included age, sex, body checking policy, days from concussion to the initial physician visit, and symptom severity at the initial physician visit.

RESULTS

Self-report of increased peer-related problems on the Strengths and Difficulties Questionnaire (TR, 1.10 [95% CI, 1.02-1.19]), higher ratings of distress about concussion outcomes by participants (TR, 1.06 [95% CI, 1.01-1.11]) and parents (TR, 1.05 [95% CI, 1.01-1.09]), and higher parent ratings of distress about their child's well-being at the time of injury (TR, 1.06 [95% CI, 1.02-1.09]) were associated with longer recovery.

CONCLUSIONS

Greater pre-existing peer-related problems and acute distress about concussion outcomes and youth well-being predicted longer TTR. Treatment targeting these psychosocial factors after concussion may promote recovery.

'Family first' - feasibility and pilot outcomes of a community intervention for families of children in recovery following brain injury

PURPOSE

Feasibility and pilot outcomes of a new community-based program for families of children with acquired brain injury (ABI) are presented. Interventions, delivered by home-visiting and teletherapy, were underpinned by problem-solving therapy, narrative meaning making, goal-directed interventions and community system psychoeducation.

METHODS

Eighty-three families of children, who had sustained an ABI before 12 years of age, had an average of 13 sessions of the 'Family First' (FF) intervention. A mixed-methods prospective design was employed. Feasibility was evaluated through measures of accessibility and acceptability. Goal attainment scaling and pre-post changes on standardized questionnaires assessed changes in psychosocial adjustment and quality of life.

RESULTS

Feasibility analyses suggested engagement and retention of often hard to reach families and children with high psychosocial needs. Qualitative analyses suggested themes related to the accessibility of a unique service ('Nothing else like this out there' and 'Accessible and flexible') which facilitated 'Empowerment' within a family context ('A family affair'). Promising changes on standardized scales of behavior problems, competencies and child and family quality of life were discerned. Increased goal attainment scores were observed.

CONCLUSION

The FF program showed feasibility and promise. It impacted positively on the lives of children and families and improved capacity in supporting systems.

Transactional processes matter: experiences between parents of children with acquired brain injury and health and education providers

PURPOSE

Little is known about how parents' transactions with health and educational professionals shape their experience of these systems, and impact on capacities to support their child with acquired brain injury (ABI). We explored experiences of specific transactions and perceptions of impact.

METHODS

A focus group and individual interviews were conducted with seven parents of children in the chronic phase of recovery following ABI. Thematic analysis was used to interpret the data.

RESULTS

Four superordinate themes were identified: "These Encounters Matter," "A Person not a Number-Interpersonal Skills that Count," "The Blind Leading the Blind," and "Becoming the Backbone." Findings highlighted that these transactions mattered to parents, promoting either distress or empowerment. Positive outcomes were characterized by transactions related to communication, empathy, trust, collaboration, and connection. However, there was a perception of the "blind leading the blind" and that ultimately parents needed to enter such transactions armed with knowledge and their own therapeutic goals.

CONCLUSIONS

Our findings unpack contextual and transactional elements of parents' experiences with health and education professionals which empower or distress. Understanding and improving these processes is important, given the central role families play in child outcomes following ABI. Implications for clinical practice are discussed.

School experiences following traumatic brain injury: A longitudinal qualitative study

BACKGROUND

This longitudinal qualitative study tracked students with traumatic brain injury (TBI) from hospital discharge through their return to school and then for an average of four years of school.

OBJECTIVE

To better understand the experiences of students and parents in the education system following TBI.

METHODS

Participants were parents and educators of 21 students with TBI. Interviews were conducted using open-ended questions and students were observed in the classroom.

RESULTS

From these data, three themes were identified: lack of student tracking year to year, lack of educator training, and conflicting views between educators and parents about students' needs. These factors ultimately led to parent frustration and eventually conflict and deteriorating relationships between parents and educators.

CONCLUSION

The results suggest that improving educator training could positively affect the factors identified and possibly mitigate parent frustration.

A 'Network of Understanding and Compassion': A Qualitative Study of Survivor Perspectives on Unmet Needs After Traumatic Brain Injury (TBI) in Regional Communities

OBJECTIVE

This qualitative study aimed to identify the service and support needs of people with a recent history of traumatic brain injury (TBI) living in the community.

METHODS

A postal survey was sent to 662 people 6-18 months after hospital admission for a mild-to-severe TBI. The survey included an open-ended item ('wish-basket') for collecting ideas about important unmet needs.

RESULTS

Responses from 53 individuals were coded and processed using thematic analysis. Five themes (n = 39) were identified, three of which were related to personal needs. These personal wishes were about being symptom-free, independent and emotionally supported by, and connected to, loved ones. The remaining themes were about the wished-for changes to the health system and society, such as wishing for health care continuity (as opposed to being abandoned), and for greater understanding and support by society.

CONCLUSIONS

There is scope to improve the services and support for people living with TBI in the community. This includes reconsidering the way that discharge occurs, addressing the personal needs that remain when living in the community and promoting greater social awareness of TBI to counteract disadvantage.

Re/producing the Pediatric Concussion Discourse in clinical rehabilitation practice

PURPOSE

In the field of pediatric concussion, little to no scholarship has examined how clinical practice is shaped by patterned ways of thinking, talking about, and coming to understand concussion and young people (or "discourses of concussion in young people"). In this paper, we examine the ways in which one such discourse, the Pediatric Concussion Discourse (PCD), shapes how young people with concussion, their parents, and clinicians can think about, act in relation to, and experience concussion.

MATERIALS AND METHODS

This critical rehabilitation research is informed by the post-structuralist theory of Michel Foucault (1926-1984), and the key concepts of power/knowledge, discourse, and the subject.

RESULTS

Circulating through clinical guidelines for the management of pediatric concussion, the PCD re/produces the expectation that young people with concussion and their parents will behave as "responsible" subjects who follow the recommendations of so-called experts without question. If recommendations are not implemented, the PCD has the potential to constitute these same groups as "nonadherent", re/producing problematic discourses of medical compliance.

CONCLUSIONS

By examining the effects of the PCD, it becomes possible to imagine how clinical practice and research might evolve in new ways that respect the knowledges and experiences of young people with concussion and their parents.Implications for RehabilitationEngaging in critical examination of clinical rehabilitative practice creates opportunity to imagine how we might approach commonly adopted clinical approaches, including the delivery of health education, differently.Implications for clinical rehabilitation practice include delivering health education in the context of supportive therapeutic relationships that respect the knowledges and experience of young people with concussion and their parents.Implications for rehabilitation research include engaging with critical scholarship within and beyond field and disciplinary boundaries, engaging in formal educational opportunities, and connecting with less formal but invaluable communities of practice.

Pediatric Trauma: What Hurts?

OBJECTIVES

Pediatric trauma patients are injured during crucial developmental years and require subsequent absence from school and activities. The impact of these changes on pediatric trauma patients is not well studied. We sought to assess the functional and emotional impact of pediatric trauma. In addition, the inpatient experience was evaluated for performance improvement purposes.

METHODS

A prospective survey was conducted at our trauma center (February 2019 to May 2019) of admitted trauma patients (<18 years). Patients who died before admission and nonaccidental trauma patients were excluded. Patients completed an inpatient survey and another at 3 months postdischarge.

RESULTS

Sixty patients were enrolled; 31 completed follow-up. Patients were 10 ± 5 years, 75% being male (n = 45), with an Injury Severity Score of 7 ± 6. A total of 13% were seen by behavioral medicine while inpatient; 18% of patients had preexisting anxiety. Preexisting functional limitations existed in 7% of the patients. At 3 months, 71% were back to preinjury academics, and 58% had returned to extracurriculars. At follow-up, 10% of patients felt withdrawn, and 32% felt emotional/distracted. Only 13% of patients were undergoing therapy compared with 7% preinjury. Patients communicated their best/worst experiences.

CONCLUSION

Pediatric trauma patients experience significant functional and emotional limitations after trauma. This suggests that all pediatric trauma patients should be evaluated by behavioral medicine during their admission with postdischarge support services offered. Performance improvement opportunities were identified in areas of pain control and communication.

"You Can't Fix Your Brain": Exploring concussion experiences of children and parents

PURPOSE

To explore the experiences, information needs and preferences of children who have had a concussion and their parents who have cared for them.

DESIGN

Qualitative description.

METHODS

Semi-structured qualitative interviews were conducted via Zoom with children who have had a concussion between ages 5 and 16 years and parents who have cared for a child with a concussion. Interviews were audio-recorded and transcribed.

RESULTS

Fourteen interviews were conducted with children and parents who have experiences with concussion. Four major themes were identified: (1) mechanism of injury and concussion symptoms experienced by children, (2) parent concerns, emotions, and health care experience with child's concussion, (3) concussions affect more than just your head and, (4) health information seeking, and preferences of parents and children related to concussion. Children and their parents have unique experiences, information needs and preferences regarding concussion.

PRACTICE IMPLICATIONS

This information offers valuable insights about developing resources about childhood concussion that parents and children will find useful and relevant. This research has direct relevance to healthcare professionals who may encounter children with concussion in their daily practice so they can ensure the needs of children and families are being met. Our findings will be used to create the content for an innovative knowledge translation tool about pediatric concussion.

Thinking Otherwise: Bringing Young People into Pediatric Concussion Clinical and Research Practice

Background:

As rates of pediatric concussion have steadily risen, and concerns regarding its consequences have emerged, pediatric concussion has received increased attention in research and clinical spheres. Accordingly, there has been a commitment to determine how best to prevent and manage this injury that so commonly affects young people. Despite this increased attention, and proliferation of research, pediatric concussion as a concept has rarely, if ever, been taken up and questioned. That is, little attention has been directed toward understanding what concussion ‘is’, or how young people are regarded in relation to it. As a result, pediatric concussion is understood in decidedly narrow terms, constructed as such by a biomedical way of knowing.

Aim:

We aim to demonstrate how conceptualizing concussion, and young people, ‘otherwise’, enabled the co-production of a more nuanced and complex understanding of the experience of pediatric concussion from the perspective of young people.

Approach:

Drawing on an illustrative case example from a critical qualitative arts-based study, we demonstrate how bringing young people into research as ‘knowers’ enabled us to generate much-needed knowledge about concussion in young people.

Implications:

The critical thinking put forward in this paper suggests a different approach to pediatric concussion, which is shared in the form of implications for clinical and research practice.

Early cognitive impairment is common in pediatric patients following mild traumatic brain injury

INTRODUCTION

The incidence and factors related to early cognitive impairment (ECI) after mild traumatic brain injury (mTBI) in pediatric trauma patients (PTPs) are unknown. Prior data in the adult population demonstrated an ECI incidence of 51% after mTBI and strong correlation with initial Glasgow Coma Scale (GCS) and Brain Injury Guidelines (BIG) category. Therefore, we hypothesized that ECI is common after mTBI in PTPs and associated with initial GCS and BIG category.

METHODS

A single-center, retrospective review of PTPs (age, 8-17 years) from 2015 to 2019 with intracranial hemorrhage and mTBI (GCS score, 13-15) was performed. Primary outcome was ECI, defined as Ranchos Los Amigos score less than 8. Comparisons between ECI and non-ECI groups regarding Injury Severity Score (ISS), demographics, and cognitive and clinical outcomes were evaluated using χ2 statistics and Wilcoxon rank sum tests. Odds of ECI were evaluated using multivariable logistic regression.

RESULTS

From 47 PTPs with mTBI, 18 (38.3%) had ECI. Early cognitive impairment patients had a higher ISS than non-ECI patients (19.7 vs. 12.6, p = 0.003). Injuries involving motor vehicles were more often related to ECI than non-auto-involved mechanisms (55% vs. 15%, p = 0.005). Lower GCS score (odds ratio [OR], 6.60; 95% confidence interval [CI], 1.34-32.51, p = 0.02), higher ISS (OR, 1.12; 95% CI, 1.01-1.24; p = 0.030), and auto-involved injuries (OR, 6.06; 95% CI, 1.15-31.94; p = 0.030) were all associated with increased risk of ECI. There was no association between BIG category and risk of ECI (p > 0.05).

CONCLUSION

Nearly 40% of PTPs with mTBI suffer from ECI. Lower initial GCS score, higher ISS, and autoinvolved mechanism of injury were associated with increased risk of ECI. Brain Injury Guidelines category was not associated with ECI in pediatric patients.

LEVEL OF EVIDENCE

Prognostic study, Level III.

Personality Traits and Social Supports in Adolescents With Persistent Postconcussion Symptoms

OBJECTIVES

To determine whether adolescents with persistent postconcussion symptoms (PPCS) differ from healthy peers in their personality traits and social supports.

SETTING

Specialty Concussion Clinic and Primary Care Clinic affiliated with an academic medical center.

PARTICIPANTS

Ninety-seven adolescents (42 with PPCS, 55 healthy peers; age: 15 ± 2 years).

DESIGN

Participants completed a web-based survey that included medical and demographic characteristics, mechanisms of concussion, 10-item Big Five Inventory, and Child and Adolescent Social Support Scale. A Student's 2-tailed t test with multiple testing corrections was used to compare the youths with PPCS to healthy peers.

MAIN MEASURES

The primary outcome was PPCS, defined by the presence of 2 or more concussion-related symptoms on the Post-Concussion Symptom Scale (PCSS), lasting for more than 4 weeks after initial injury. The secondary outcome was perceived personality traits and social support, based on the 10-item Big Five Inventory and the Child and Adolescent Social Support Scale, respectively.

RESULTS

The PPCS group had higher neuroticism scores on their Big Five Inventory than healthy peers. They also reported less social support from teachers and classmates than healthy peers.

CONCLUSION

Youths with PPCS report specific personality and social support characteristics that differ from their peers. These findings suggest that individual personality and school-based social supports may influence concussion recovery.

The impact of injury: The experiences of children and families after a child's traumatic injury

Objective:

To explore the experiences of children and families after a child’s traumatic injury (Injury Severity Score >8).

Design:

Qualitative interview study.

Setting:

Two children’s major trauma centres in England.

Participants:

32 participants: 13 children with traumatic injuries, their parents/guardians (n = 14) and five parents whose injured child did not participate.

Methods:

Semi-structured interviews exploring the emotional, social, practical and physical impacts of children’s injuries, analysed by thematic analysis.

Results:

Interviews were conducted a median of 8.5 months (IQR 9.3) post-injury. Injuries affected the head, chest, abdomen, spine, limbs or multiple body parts. Injured children struggled with changes to their appearance, physical activity restrictions and late onset physical symptoms, which developed after hospital discharge when activity levels increased. Social participation was affected by activity restrictions, concerns about their appearance and interruptions to friendships. Psychological impacts, particularly post-traumatic stress type symptoms often affected both children and parents. Parents’ responsibilities suddenly increased, which affected family relationships and roles, their ability to work and carry out daily tasks. Rapid hospital discharge was wanted, but participants often felt vulnerable on return home. They valued continued contact with a healthcare professional and practical supports from family and friends, which enabled resumption of their usual lives.

Conclusions:

Injured children experience changes to their appearance, friendships, physical activity levels and develop new physical and mental health symptoms after hospital discharge. Such challenges can be addressed by the provision of advice about potential symptoms, alternative activities during recovery, strategies to build resilience and how to access services after hospital discharge.

Qualitative study of the needs of injured children and their families after a child's traumatic injury

OBJECTIVE

To explore the needs of children and their families after a child's traumatic injury.

DESIGN

Semi-structured qualitative interviews with purposeful sampling for different types of injuries and a theoretical thematic analysis.

PARTICIPANTS

32 participants; 13 children living at home after a traumatic injury, their parents/guardians (n=14) and five parents whose injured child did not participate.

SETTING

Two Children's Major Trauma Centres (hospitals) in England.

RESULTS

Interviews were conducted a median 8.5 months (IQR 9.3) postinjury. Injuries affected the limbs, head, chest, abdomen, spine or multiple body parts. Participants highlighted needs throughout their recovery (during and after the hospital stay). Education and training were needed to help children and families understand and manage the injury, and prepare for discharge. Information delivery needed to be timely, clear, consistent and complete, include the injured child, but take into account individuals' capacity to absorb detail. Similarly, throughout recovery, services needed to be timely and easily accessible, with flexible protocols and eligibility criteria to include injured children. Treatment (particularly therapy) needed to be structured, goal directed and of sufficient frequency to return injured children to their full function. A central point of contact is required after hospital discharge for advice, reassurance and to coordinate ongoing care. Positive partnerships with professionals helped injured children and their families maintain a sense of hope and participate in joint decision making about their care.

CONCLUSION

Throughout the full trajectory of recovery injured children and their families need family centred, accessible, flexible, coordinated health services, with more effective harmonious, communication between professionals, the child and their family. There is a requirement for support from a single point of contact and a system that monitors the needs of the injured child and their family after hospital discharge.

Paediatric traumatic brain injury

PURPOSE OF REVIEW

To provide a summary of recent developments in the field of paediatric traumatic brain injury (TBI).

RECENT FINDINGS

The epidemiology of paediatric TBI with falling rates of severe TBI, and increasing presentations of apparently minor TBI. There is growing interest in the pathophysiology and outcomes of concussion in children, and detection of 'significant' injury, arising from concern about risks of long-term chronic traumatic encephalopathy. The role of decompressive craniectomy in children is still clarifying.

SUMMARY

Paediatric TBI remains a major public health issue.

Changes over time in family members of adults with mild traumatic brain injury

Objective:

The impact of traumatic brain injury (TBI) extends beyond the person who was injured. Family caregivers of adults with moderate to severe TBI frequently report increased burden, stress and depression. Few studies have examined the well-being of family members in the mild TBI population despite the latter representing up to 95% of all TBIs.

Methods:

Five areas of well-being were examined in 99 family members (including parents, partners, siblings, other relatives, adult children, friends or neighbours) of adults (aged ≥16 years) with mild TBI. At 6- and 12-month post-injury, family members completed the Bakas Caregiver Outcomes Scale, Short Form-36 Health Survey, EQ-5D-3L, Hospital Anxiety and Depression Scale and the Pittsburgh Sleep Quality Index. Outcomes and change over time and associated factors were examined.

Results:

At 6 months, group mean scores for health-related quality of life for mental and physical components and overall health status were similar to the New Zealand (NZ) population. Mean scores for sleep, anxiety and depression were below clinically significant thresholds. From 6 to 12 months, there were significant improvements in Bakas Caregiver Outcomes Scale scores by 2.61 (95% confidence interval: 0.72–4.49), health-related quality of life (mental component) and EQ-5D-3L overall health (P= 0.01). Minimally clinically important differences were observed in overall health, anxiety, health-related quality of life and depression at 12 months. Female family members reported significant improvements in physical health over time, and more positive life changes were reported by those caring for males with TBI.

Conclusions:

The findings suggest diminished burden over time for family members of adults with mild TBI.