Fitting back in: Adolescents returning to school after severe acquired brain injury

Adapting TeachABI to the local needs of Australian educators - a critical step for successful implementation

Background The present study is the foundational project of TeachABI-Australia , which aims to develop and implement an accessible, nation-wide digital resource for educators to address their unmet acquired brain injury (ABI)-related professional learning needs. The aim of the present study was to identify the adaptations required to improve the suitability and acceptability of the TeachABI professional development module within the Australian education system from the perspectives of Australian educators. Methods The research design employed an integrated knowledge translation approach and followed the ADAPT Guidance for undertaking adaptability research. A purposive sample of eight educators eligible to teach primary school in Australia provided feedback on the module through a quantitative post-module feedback questionnaire and a qualitative semi-structured interview. Results Participants rated the acceptability of the module as 'Completely Acceptable ' (Mdn  = 5, IQR = 1), and reported 'only Minor' changes were required (Mdn  = 2, IQR = 0.25) to improve the suitability to the Australian context. Qualitative analysis of transcripts revealed three broad categories: (1) the usefulness of TeachABI , (2) the local fit of TeachABI , and (3) pathways for implementing TeachABI in the local setting. Recommended adaptations to the module collated from participant feedback included changes to language, expansion of content, and inclusion of Australian resources, legislation, and videos. Conclusions TeachABI is acceptable to Australian educators but requires modifications to tailor the resource to align with the unique schooling systems, needs, and culture of the local setting. The systematic methodological approach to adaptation outlined in this study will serve as a guide for future international iterations of TeachABI .

Predictors of High School and College Graduation After Sustaining a Moderate-to-Severe Traumatic Brain Injury

OBJECTIVE

To identify early predictors of US high school and college graduation after moderate-to-severe traumatic brain injury (TBI).

SETTING

Inpatient rehabilitation and community.

PARTICIPANTS

TBI Model Systems participants, aged 16 to 24 years, enrolled as high school or college students at time of injury.

DESIGN

Prospective cohort study.

MAIN MEASURES

Successful graduation was defined as having a diploma (high school) or an associate/bachelor's degree (college) at 1-, 2-, or 5-year follow-up. Predictors were sex, race/ethnicity, urbanicity, preinjury substance abuse, primary rehabilitation payer, and functional independence at inpatient rehabilitation discharge.

METHOD

We descriptively characterized differences between those who did and did not graduate high school and college within the first 5 years postinjury and identified early predictors of successful high school and college graduation using 2 binomial logistic regressions.

RESULTS

Of those with known graduation status, 81.2% of high school and 41.8% of college students successfully graduated. Graduates in both groups were more often White than Black and had more functional independence at discharge. Among high school students, preinjury substance abuse was also a risk factor for not graduating, as was identifying as Hispanic or "other" race.

CONCLUSIONS

Sociodemographic factors and disability influence graduation outcomes, requiring structural, institutional, and personal interventions for success.

Ableism among children and youth with acquired brain injury and their caregivers: a systematic review

PURPOSE

Children and youth with acquired brain injury (ABI) experience persistent discrimination and ableism. The purpose of this systematic review was to understand the experiences and impact of ableism among children and youth with ABI.

METHOD

Six international databases were systematically searched for articles from 2002-2022. Studies were screened independently by four researchers who performed the data extraction. Study quality was appraised using the Standard quality assessment criteria for evaluating primary research.

RESULTS

Of the 2085 studies identified in the search, 15 met the inclusion criteria, which involved 1442 children and youth with brain injuries or caregivers representing them. Studies in the review showed the following key trends: (1) incidence of ableism among children and youth with ABI; (2) experiences of ableism at the individual and institutional levels, (3) impact of ableism (i.e., mental health, social relationships, quality of life) and (4) coping strategies (i.e., resources, supports).

CONCLUSIONS

Our findings reveal the alarming incidence of ableism among youth with ABI. Therefore, there is a critical need for more research to explore youth's lived experiences of ableism, especially from their perspectives along with the co-development of solutions to help enhance their social inclusion and well-being.

The process of identity change following ABI from the perspectives of adolescents and their mothers: A relational grounded theory approach

This study explored the process of identity adjustment following adolescent brain injury, within the systemic context of the parent-adolescent dyad. Six young people with an ABI (mean age 16.5 years, range 15-18 years; TBI: n = 3) were individually interviewed, and six respective mothers (mean age 45 years, range 37-50 years). A novel relational qualitative grounded theory approach was used, with analyses of dyads linked in an attempt to capture the shared process of adaptation post-injury for young people and their parents. Shared themes emerged for adolescents and mothers regarding "continuity and change" and "acknowledging or rejecting" experiences of change post injury. Adolescents experienced change as an, at times, distressing sense of being "not normal". While mothers turned towards their child, working hard to try to "fix everything", adolescents sought continuity of identity in the context of peer relationships, withdrawing socially to avoid feeling abnormal, reframing or finding new relationships. Some mothers sought to fill social losses through family or disability-specific activity. This study provides a relational understanding of the process of identity adjustment post adolescent BI. Future research and clinical practice should recognize the significant work of mothers, and significance of social relationships to adolescents' emerging post-injury identity.

A mapping review of adolescent identity after TBI: what clinicians need to know

ABSTRACTAdolescence is a critical period for developing a sense of identity, an iterative process that relies on the development of skills such as self-reflection and self-appraisal. Outcomes of identity development include personal ethics, knowledge of one's strengths and challenges, and, ultimately, independence. Traumatic brain injury (TBI) affects these outcomes in adults, when identity has been established and may need to be redefined; but what happens when an injury occurs while identity is being formed? To answer this question, we used mapping review methodology to explore TBI effects on adolescent identity formation, mapping the evidence onto a biopsychosocial framework for rehabilitation. We reviewed studies on identity in adolescents with mild to severe TBI ages 13-18 years, published from inception to 2021, with a focus on outpatient rehabilitation settings. Key findings of the mapping review noted adolescents post-TBI are likely to: (1) question their identity considering dissonance between the current self and their pre-injury self; and (2) seek to establish new, adaptive meanings and identities. All studies drew conclusions regarding identity and participation of adolescents post-TBI. Results provided insight into the importance of considering individualized rehabilitation interventions for adolescents, given their unique developmental path towards identity formation.

Developing a model of return to school: A Traumatic Brain Injury Model Systems study

OBJECTIVE

A common goal for those recovering from moderate to severe brain injury is to reengage in education or employment. There is significant overlap between the skills relevant for successful job and academic performance in high school and college, and many deficits reported after brain injury are consistent across young adults and adults. This study utilized a return to work (RTW) model framework to develop a model of return to school (RTS).

METHOD

Days of post-traumatic amnesia (PTA), length of stay (LOS), rehabilitation discharge Disability Rating Scale (DRS) scores, presence of pre-injury learning limitation, and educational level were used to predict RTS one-year post-injury in a student sample (N = 158, 58.8% white, 69.6% male) within the Traumatic Brain Injury Model Systems National Database.

RESULTS

The overall RTS rate for this sample was 62%. Logistic regression indicated that lower DRS discharge scores and being in high school pre-injury resulted in the best outcome.

CONCLUSION

Results showed partial support for the translation of RTW factors to a student sample; however, results may also favor the conceptual distinction in RTS versus RTW, which are elaborated. More outreach for college students may improve awareness of disability services, thereby heightening the future return rate.

You only get one brain. Adult reflections on acute and ongoing symptom experiences after traumatic brain injury in adolescence

BACKGROUND

This research adds to the scarce literature regarding adolescent experiences of traumatic brain injury (TBI). It uses a qualitative methodology to explore the symptoms experienced after sustaining a TBI at this unique stage of development including their persistence into adulthood.

METHODS

Thirteen adults (aged 20-25 years; mean 23 years) who sustained a mild-moderate TBI during adolescence (aged 13-17 years at injury), approximately 7.7 years (range = 6.7-8.0 years) prior, participated in the research. Semi-structured individual interviews, analyzed using thematic analysis, explored participants' experiences surrounding and following their TBIs.

RESULTS

TBI during adolescence can result in significant acute symptoms, particularly headaches, fatigue, and difficulties in thinking. Participants' descriptions of the extent and impact of these symptoms reflected feelings of frustration and often anxiety and/or depression. Difficulties could persist for years post-TBI and sometimes had not resolved at all.

CONCLUSIONS

Even mild TBI during adolescence can result in significant acute and ongoing symptoms, which can contribute to emotional distress in the long term.

The student journey: Living and learning following traumatic brain injury

Primary objective: In this research we set out to gain further understanding of the experiences of students participating in secondary and tertiary education following TBI: exploring academic and non-academic factors, as well as changes in experiences over time.Methods and procedures: A longitudinal, qualitative investigation was completed. 12 students (17-32 years) completed up to three in-depth interviews over a period of 4-15 months, capturing atotal of 30 time points. Data were analyzed using grounded theory methods.Main outcomes and results: Students' participation experiences were unique and varied with different timelines and outcomes, however they shared many similar critical points. We interpreted their experiences as a student journey traveling through four significant landscapes, "Choosing to study", "Studying", "Deciding what to do", "Making the next step." Journeys involved complex processes of living and learning. Moving along the pathway was not always smooth or straightforward.Conclusions: Students' experiences of returning to study following TBI can be interpreted as a complex journey of living and learning. Four important stages of the journey provide clinicians and educators with landscape features that can provide a structure for exploring supports to address both academic and non-academic factors to assist students in their study journey.

A Service User Perspective Informing the Role of Occupational Therapy in School Transition Practice for High School Learners with TBI: An African Perspective

Background

In the South African context, there are no specific guidelines regarding how to prepare and support adolescents for the transition from a health care to a high school setting post TBI. This raises questions about the relevance and responsiveness of the current transition practices in occupational therapy in terms of adequately preparing and supporting these adolescents to participate in school and hence exercise their right to a quality education.

Method

This study explored adolescents and other key role players' perspectives on and experiences of the high school transition (i.e., school reentry and continued school participation) post TBI. It was anticipated that this would provide an increased understanding of the enablers and barriers to high school reentry and participation post TBI. This served as a basis to explore the main aim of this study which was to help occupational therapists identify where efforts in terms of service delivery are needed. This study was situated in the interpretivist qualitative paradigm and used a multicase study design, which included semistructured interviews with eight adolescent learners with TBI, their primary caregivers, teachers, and principals as well as observations and documentation review.

Results

This paper will focus on a central theme in the research, namely, the nature and extent of support needed to facilitate the high school transition of adolescents with TBI within a developing context. Similar to the findings of studies conducted in developed contexts, participants highlighted that they felt that adolescents need support at various stages of the school transition. Participants further alluded to support that should be collaborative, coordinated, flexible, and monitored to ensure it is relevant and responsive to these adolescents' changing needs.

Conclusion

The study findings conclude that occupational therapists have a crucial role in fostering an enabling environment (directly and indirectly) through fulfilling various roles including that of a facilitator, intermediary, coach, collaborator, supporter, and advocator.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Researching experiences of childhood brain injury: co-constructing knowledge with children through arts-based research methods

Objective: In the knowledge base examining experiences of childhood brain injury, the perspectives of children with brain injury are notably lacking. This failure to represent the voices of pediatric clients has resulted in an incomplete knowledge base from which to inform evidence-based rehabilitation practice. In this paper, we examine why the perspectives of children with brain injury are rarely sought and propose a new way forward.Methods: We draw upon current evidence and practices in related fields and present an exemplar from an in-progress qualitative arts-based research project with children with brain injury.Results: Assumptions ingrained in research practices, particularly those surrounding the capacity of 'doubly vulnerable' children with brain injury to produce knowledge, have resulted in the relative exclusion of this group from research that concerns them. For the field to evolve, research practices must value children's first-hand accounts, engage them in co-constructing knowledge about their lives, and invite methods that meet their interests and abilities.Conclusion: By reframing how we think about the capacities of children with disabilities and shifting our research practices to include children with brain injury as knowledgeable participants, it becomes possible to expand the knowledge base upon which clinical rehabilitation practices are built.Implications for RehabilitationCurrent research practices preclude 'doubly vulnerable' pediatric populations, including children with brain injury, from actively contributing to research that concerns them.As a result, the perspectives of children with brain injury are virtually absent from research, rendering the evidence base upon which rehabilitative practices are built incomplete.Reframing how we think about the capacities of children with brain injury can shift how we engage with them, both in research and clinic, and may subsequently impact the knowledge available to us.Implications for client-centred rehabilitation are discussed, including the need to understand children as capable of insight into their own experience, as able to contribute to a more complete understanding of the health phenomena that affect them, and as invaluable and active participants in research and clinical care.

Social Participation and Navigation (SPAN): Description and usability of app-based coaching intervention for adolescents with TBI

BACKGROUND

Adolescents with brain injury (BI) often experience impairment in participation, which is an important predictor of outcomes.

OBJECTIVE

Describe the Social Participation and Navigation (SPAN) program, and report participant feedback and preliminary outcomes.

METHOD

Four adolescents and four coaches participated. SPAN included a mobile app, online didactic information, and peer coaching. Adolescents met weekly with coaches via video-conference, developed participation goals, and plans to achieve goals. Social and behavioral functioning before and after was assessed, and feedback about SPAN was collected.

RESULTS

SPAN was well received. Participants used the app to define and achieve goals. Medium to large effect sizes were found on adolescent self-reported measures, with negligible effects on parent-report measures. Positive and critical feedback is described.

CONCLUSIONS

Findings support the usability of SPAN, which has the potential to improve social participation of adolescents with a history of TBI through an innovative use of technology and peer coaching.

Social Participation and Navigation (SPAN) program for adolescents with acquired brain injury: Pilot findings

PURPOSE/OBJECTIVE

Our goal was to examine the feasibility and preliminary efficacy of an app-based coaching intervention (Social Participation and Navigation; SPAN) to help survivors of acquired brain injury attain social participation goals. Research Method/Design: This is a nonrandomized pilot trial of SPAN, including 15 adolescents (9 with traumatic brain injury, 6 with brain tumor) between the ages of 14-22. The SPAN intervention consisted of a mobile app to support the development and implementation of social participation goals, weekly video-conference coaching sessions to identify goals and step-by-step action plans, and online didactic materials. Assessments were completed pre- and postintervention. Satisfaction with the intervention, confidence in the adolescents' ability to participate in and plan social activities and manage their emotions and behaviors, and frequency and satisfaction with social participation were assessed via self- and parent-report questionnaires developed for this project. Behavior problems, social competence, and social problems were measured by using the Child Behavior Checklist and the Youth Self-Report.

RESULTS

High levels of participant and parent satisfaction were reported. Increases in parent-reported frequency of social participation and teen-reported confidence in their ability to participate and develop social participation goals and plans were observed. A decline in parent-reported total problems, internalizing problems, externalizing problems, and social problems was noted.

CONCLUSION/IMPLICATIONS

Results support the feasibility of the program, because participants were able to successfully meet with their coaches and use the app to develop and accomplish social participation goals. Further research will be needed to refine the app and program, particularly when reaching out to populations beyond traumatic brain injury. (PsycINFO Database Record

Examining a Statewide Educational Consulting Program for Pediatric Brain Injury

This study describes characteristics of students with acquired brain injury enrolled in a statewide educational consultation program and the program's support activities. Utilizing deidentified data from a statewide brain injury school consultation program, descriptive analyses of demographic and injury characteristics, including medical diagnosis (concussion/mild traumatic brain injury [TBI], moderate-severe TBI, and non-TBI), referral characteristics, educational placement, and the types of program activities were undertaken. 70% of students were referred for concussions/mild TBI and students were infrequently referred by medical professionals. Most students with concussion/mild TBI experienced recreational injuries (59%), while students with moderate/severe TBI commonly experienced road traffic injuries (48%). The greatest proportion of program team members' time was spent in consultation with school personnel (24%), communication with families (20%), and communication with school personnel (16%). Results suggest that the program addresses important communication and coordination needs among families, medical professionals, and educators and identifies opportunities to enhance program utilization.

Psychological and behavioural difficulties following severe TBI in adolescence: a comparison with a sample of peers with brain lesions of other origin and with a control group

OBJECTIVE

To describe behavioural and adjustment problems in a group of 57 adolescents with severe traumatic brain injury (TBI) and compare them with a clinical group of peers with brain lesions of other origin (N = 33) and a control group of healthy adolescents (N = 48).

METHODS

All subjects received an age-appropriate assessment, including the child behaviour checklist (CBCL) 4/18, the strengths and difficulties questionnaire (SDQ) and the vineland adaptive behaviour scales (VABS).

RESULTS

Compared with healthy peers, adolescents with TBI presented with more marked behavioural problems on most CBCL scales (Internalization and Externalization domains were both affected) and on the SDQ Hyperactivity and Peer problems scales. They also showed a more impaired functioning in most VABS domains. Compared with adolescents with brain lesions of other aetiology, patients with TBI showed more conduct problems on the SDQ scale, but no significant differences were found on the CBCL scales. Regarding the VABS, patients with other lesions presented with the worst outcome in the Motor and Daily Living Skills domains.

CONCLUSIONS

Adolescents with TBI are exposed at a very high risk to develop behavioural and psychological disturbances with the potential to severely affect their social re-entry. Further knowledge is needed to plan early and well-timed interventions.

Informing design of an app-based coaching intervention to promote social participation of teenagers with traumatic brain injury

OBJECTIVE

To examine perspectives of multiple stakeholders to inform the design of an app-based coaching intervention to promote social participation in teenagers with traumatic brain injury (TBI).

METHODS

Teenagers and college students with and without TBI and parents of teenagers with TBI were recruited from two children's hospitals and two universities in the USA (n = 39). Data were collected via interviews, focus groups, and surveys and examined using descriptive statistics and content analyses.

RESULTS

Teenagers with TBI reported more social participation barriers and fewer strategies for addressing these barriers than teenagers without TBI. There was consensus across groups about the value of college student coaches and use of smartphones and apps. Participants expressed mixed views on the use of chat rooms and degree of parent involvement.

CONCLUSION

Results provided insights about the possible benefits of the intervention, and informed its initial design (e.g., desired coach qualities, and type of coach training and supervision).

Beyond academic performance: Practice implications for working with students following traumatic brain injury

PURPOSE

Speech-language pathologists (SLPs) have a key role in supporting educational participation for secondary and tertiary students with traumatic brain injury (TBI). This article aims to (i) explore issues identified by students with TBI that affect educational participation beyond their academic performance, (ii) offer a framework based on research evidence to guide the practice of SLPs and (iii) explore strategies that may expand the traditional roles of SLPs to support students beyond academic performance.

METHOD

Data were drawn from an earlier qualitative research project in which three adolescent males were interviewed about their experiences of returning to education after severe TBI. Interviews were recorded, transcribed verbatim and analysed using a grounded theory approach.

RESULT

Six themes were identified that had a substantial impact beyond academic performance: poor community awareness of TBI, the invisible nature of TBI, getting back to everyday life, planning to return to education, being accepted and adjusting to long-term changes. Incorporating these factors, a clinical framework is put forward to guide SLPs in developing strategies for promoting positive educational participation.

CONCLUSION

By considering factors beyond academic performance and addressing these in intervention, SLPs may significantly improve the overall educational success and wellbeing of students living with TBI.

Children's and teachers' perspectives on adjustments needed in school settings after acquired brain injury

BACKGROUND

Children with acquired brain injury (ABI) often present with functional deficits that influence their societal participation and well-being. Successful reintegration into school calls for individual support to meet each child's adjustment needs. The adjustment needs of children with ABI in school settings have not previously been explored.

AIM

The objectives of the present study were (a) to describe adjustment needs in school settings for children with ABI and (b) to explore differences and similarities between reports from the children and their teachers.

METHODS

In this cross-sectional study, 20 children with ABI (mean age 12.8 ± 3.4 years; class grade 1-10) and their teachers were interviewed individually, using the School Setting Interview (SSI). Data were analyzed with descriptive and with non-parametric statistics.

RESULTS

(a) In the overall group, children rated that 55.6% of the 16 activities in the SSI needed no adjustment. The corresponding percentage for teachers was 48.4%. (b) In the child-teacher pairs, there was a positive relationship between teachers' and children's responses only in 3 out of 16 school activities and agreement varied strongly according to the activity in question.

CONCLUSIONS AND SIGNIFICANCE

It is important for occupational therapists and other professionals to specifically consider adjustment needs relating to school activities from various perspectives when aiming to provide individualized interventions.

Case Management for Children and Adolescents with Acquired Brain Injury in Community Settings: A Scoping Review

Background: Acquired brain injury is the leading cause of death and disability in children after infancy. Childhood brain injury has long-term consequences for children and parents, including challenges with returning to school, ongoing health and behaviour concerns, family functioning and demands on carers. Community-based case management interventions are a vital contribution to community supports.

Aims: This scoping study aims to scope and map the literature on case management, to identify how case management is described in the literature for children and adolescents with acquired brain injury (0–17 years).

Methods: A scoping review was completed of published articles on case management from four major databases (CINAHL, MEDLINE, PUBMed and Embase) between 2005 and 2015. Articles were selected against inclusion criteria and reviewed.

Results: Eight articles of 2688 records met the inclusion criteria and were reviewed. Case management was provided by case managers and other health professionals. The case management interventions described were mapped to the International Classification of Health Interventions and the Brain Injury Case Management Taxonomy (BICM-T). Case management addressed a range of needs including return to school, family issues and ongoing medical needs. There were anecdotal reports of effectiveness of case management during the return to school process.

Conclusion: This scoping study reveals a lack of information on this topic. Improved reporting of case management interventions and more research on case management is needed for children and adolescents with brain injury.

The One or the Many: Quantified Subjectivity and Aggregated Uniqueness in Qualitative Rehabilitation Research

This article aims to identify and critically assess qualitative intervention studies of rehabilitation processes that target young adults. By applying a meta-epistemological approach inspired by the works of Michel Foucault and Julia Kristeva, we examine how the included studies present qualitative knowledge and whether they adhere to their own stated principles of qualitative knowledge. Through their stated aims and theoretical framing, the articles draw attention to individual processes of meaning making. Nonetheless, we find that the articles to a great extent emphasize frequencies of the qualitative data they present. Individual processes and experiences are subject to subdivisions and categorization and transformed into manageable objects of knowledge. In conclusion, these studies, with one important exception, contribute to self-marginalization of the knowledge they themselves promote: They undermine the uniqueness of the qualitative knowledge they proclaim by focusing on frequency and the general patterns and categories encompassing the unique.

Social and Behavioral Outcomes following Childhood Traumatic Brain Injury: What Predicts Outcome at 12 Months Post-Insult?

This study sought to investigate social and behavioral outcomes 12 months following childhood traumatic brain injury (TBI) and to identify predictors of these outcomes. The study also compared rates of impairment in social and behavioral outcomes at 12 months post-injury between children with TBI and a typically developing (TD) control group. The study comprised 114 children ages 5.5 to 16.0 years, 79 with mild, moderate, or severe TBI and 35 TD children, group-matched for age, sex and socio-economic status. Children with TBI were recruited via consecutive hospital admissions and TD children from the community. Social and behavioral outcomes were measured via parent-rated questionnaires. Analysis of covariance models identified a significant mean difference between the mild and moderate groups for social problems only, but the moderate and severe TBI groups showed a higher rate of impairment, particularly in externalizing problems. Pre-injury function, injury severity, parent mental health, and child self-esteem all contributed significantly to predicting social and behavioral outcomes. Both injury and non-injury factors should be considered when identifying children at risk for long-term difficulties in social and behavioral domains.

Assessing psychosocial functioning following childhood acquired brain injury: The Sydney Psychosocial Reintegration Scale for Children

OBJECTIVE

The Sydney Psychosocial Reintegration Scale for Children (SPRS-C) assesses psychosocial functioning in children with acquired brain injury (ABI). This article aims to: (1) describe normative data for the parent-rated SPRS-C and, (2) evaluate the discriminant validity of the SPRS-C.

METHODS

For Aim 1, participants were parents of typically developing children (TDC) aged 5-14 years (N = 200). For Aim 2, participants with ABI were aged 5-14 years (n = 26). A matched group of TDC was sampled from the larger normative sample to serve as a control group (n = 26).

RESULTS

For Aim 1, SPRS-C scores across the 10 age-bands were in the higher ranges. Correlation coefficients of SPRS-C total score with child's age and parent occupational skill level were not statistically significant. For Aim 2, SPRS-C scores for the ABI group were significantly lower than the control group.

CONCLUSIONS

These data provide a guide for clinical interpretation of the SPRS-C for measuring psychosocial functioning in children with ABI.

Substance Use and Related Harms Among Adolescents With and Without Traumatic Brain Injury

OBJECTIVE

The relationship between self-reported lifetime traumatic brain injury (TBI) and drug and alcohol use and associated harms was examined using an epidemiological sample of Canadian adolescents.

SETTINGS AND DESIGN

Data were derived from a 2011 population-based cross-sectional school survey, which included 6383 Ontario 9th-12th graders who self-completed anonymous self-administered questionnaires in classrooms. Traumatic brain injury was defined as loss of consciousness for at least 5 minutes or a minimum 1-night hospital stay due to symptoms.

RESULTS

Relative to high schoolers without a history of TBI, those who acknowledged having a TBI in their lifetime had odds 2 times greater for binge drinking (5+ drinks per occasion in the past 4 weeks), 2.5 times greater for daily cigarette smoking, 2.9 times greater for nonmedical use of prescription drugs, and 2.7 times greater for consuming illegal drug in the past 12 months. Adolescents with a history of TBI had greater odds for experiencing hazardous/harmful drinking (adjusted odds ratio [aOR] = 2.3), cannabis problems (aOR = 2.4), and drug problems (aOR = 2.1), compared with adolescents who were never injured.

CONCLUSION

There are strong and demographically stable associations between TBI and substance use. These associations may not only increase the odds of injury but impair the quality of postinjury recovery.

A Qualitative Synthesis of Families' and Students' Hospital-to-School Transition Experiences Following Acquired Brain Injury

Acquired brain injury (ABI) is one of the greatest causes of death and disability among children in Canada. Following ABI, children are required to transition back to school and adapt to the physical, cognitive, behavioral, social, and emotional demands of the school environment. We conducted a qualitative systematic review of students' and parents' experiences of the transition back to school following ABI. We identified 20 articles that met our inclusion criteria. Six themes emerged: (a) lack of ABI-specific education for families and professionals, (b) communication-related factors as a facilitator and/or barrier to transition, (c) emotional focus, (d) peer relationships, (e) supports, and (f) ABI sequelae in the classroom. Students' and families' personal motivations and abilities and the support they receive in their environment affect their experiences of transitioning back to school and the disrupted occupations they face.

The association between traumatic brain injury and ADHD in a Canadian adult sample

OBJECTIVE

This study describes the association between lifetime traumatic brain injury (TBI) and attention deficit and hyperactivity disorder (ADHD) among Canadian adults.

METHOD

A cross-sectional sample of 3993 Ontario adults aged 18 or older were surveyed by Computer Assisted Telephone Interviewing (CATI) throughout 2011 and 2012 as part of the CAMH Monitor, a rolling survey assessing the health, mental health and substance use of Ontario adults. TBI was defined as trauma to the head that resulted in loss of consciousness for at least five minutes or overnight hospitalization. ADHD was measured by the 6-item ASRS screener for adult ADHD, and self-reported history of diagnosed ADHD.

RESULTS

Among adults with a history of TBI, 6.6% (95% CI: 4.7, 9.4) screened ADHD positive, and 5.9% (95% CI: 3.6, 9.5) reported having been diagnosed with ADHD in their lifetime. Adults with lifetime TBI had significantly greater odds of scoring positive on the ADHD/ASRS screen (OR = 2.49, 95% CI: 1.54, 4.04), and of reporting a history of diagnosed ADHD (OR = 2.64, 95% CI: 1.40, 4.98) than without TBI, when holding values of sex, age, and education constant.

CONCLUSION

Significant positive associations between lifetime TBI and both current and past ADHD were observed among adults in this population. More research to understand these associations, and their significance for the etiology and management of TBI and ADHD, is needed.

Supporting parents following childhood traumatic brain injury: a qualitative study to examine information and emotional support needs across key care transitions

INTRODUCTION

Traumatic brain injury (TBI) is the leading cause of death and acquired disability in childhood. Research has demonstrated that TBI can lead to long-term physical, cognitive, emotional and behavioural difficulties for children and parental stress. Less is known about how parents experience a childhood brain injury and their information and support needs. This study aimed to examine parents' experiences and support needs following a childhood TBI from the time of the accident to their child's discharge home.

METHODS

Qualitative semi-structured interviews were conducted with 29 parents/carers of children who had experienced a severe TBI. Participants were recruited from one children's tertiary centre in the UK. Data were analysed using the Framework approach.

RESULTS

Parents had unmet information and emotional support needs across the care trajectory from the time of the accident to their child's return home. Information needs related to the impact of the TBI on their child; current and future treatment/rehabilitation plans; helping their child and managing their behaviour; accessing services/support. They lacked information and support for care transitions. In different settings parents faced particular barriers to having their information needs met. Parents' felt they needed emotional support in coming to terms with witnessing the accident and the loss of their former child. Lack of community support related not only to service availability but to a general lack of understanding of the impact of TBI on children, particularly when this was invisible. Overall parents felt unsupported in coping with children's behavioural and psychological difficulties.

DISCUSSION

Taking a holistic approach to examining parents' experiences and support needs has enabled their changing needs to be highlighted across key care transitions within hospital and community settings and the service implications identified. Improvements in care co-ordination across care transitions are needed to ensure continuity of care and integration of support.

Parent management of the school reintegration needs of children and youth following moderate or severe traumatic brain injury

PURPOSE

School reintegration following children's traumatic brain injury (TBI) is still poorly understood from families' perspectives. We aimed to understand how both unique and common experiences during children's school reintegration were explained by parents to influence the family.

METHODS

Data came from an investigation using descriptive phenomenology (2005-2007) to understand parents' experiences in the first five years following children's moderate to severe TBI. Parents (N = 42 from 37 families in the United States) participated in two 90-min interviews (first M = 15 months; second M = 27 months). Two investigators independently coded parents' discussions of school reintegration using content analysis to understand the unique and common factors that parents perceived affected the family.

RESULTS

Parents' school negotiation themes included the following: (1) legal versus moral basis for helping the child; (2) inappropriate state and local services that did not consider needs specific to TBI; and (3) involvement in planning, implementing and evaluating the child's education plan. Parents perceived that coordinated and collaboration leadership with school personnel lessened families' workload. Families who home-schooled had unique challenges.

CONCLUSIONS

School reintegration can add to family workload by changing roles and relationships and by adding to parents' perceived stress in managing of the child's condition.

IMPLICATIONS FOR REHABILITATION

Moderate to severe traumatic brain injury is assumed to be the primary cause of children's morbidities post-injury. Despite laws in the United States meant to facilitate children's school reintegration needs, parents often perceived that policies and practices differed from the intentions of laws and added to the family workload and stress. The school environment of the child (physical, cultural or psychological setting) plays an important long-term role in shaping family roles, relationships and management of the child's condition.

Suicidality, bullying and other conduct and mental health correlates of traumatic brain injury in adolescents

Objective

Our knowledge on the adverse correlates of traumatic brain injuries (TBI), including non-hospitalized cases, among adolescents is limited to case studies. We report lifetime TBI and adverse mental health and conduct behaviours associated with TBI among adolescents from a population-based sample in Ontario.

Method and Findings

Data were derived from 4,685 surveys administered to adolescents in grades 7 through 12 as part of the 2011 population-based cross-sectional Ontario Student Drug Use and Health Survey (OSDUHS). Lifetime TBI was defined as head injury that resulted in being unconscious for at least 5 minutes or being retained in the hospital for at least one night, and was reported by 19.5% (95%CI:17.3,21.9) of students. When holding constant sex, grade, and complex sample design, students with TBI had significantly greater odds of reporting elevated psychological distress (AOR = 1.52), attempting suicide (AOR = 3.39), seeking counselling through a crisis help-line (AOR = 2.10), and being prescribed medication for anxiety, depression, or both (AOR = 2.45). Moreover, students with TBI had higher odds of being victimized through bullying at school (AOR = 1.70), being cyber-bullied (AOR = 2.05), and being threatened with a weapon at school (AOR = 2.90), compared with students who did not report TBI. Students with TBI also had higher odds of victimizing others and engaging in numerous violent as well as nonviolent conduct behaviours.

Conclusions

Significant associations between TBI and adverse internalizing and externalizing behaviours were found in this large population-based study of adolescents. Those who reported lifetime TBI were at a high risk for experiencing mental and physical health harms in the past year than peers who never had a head injury. Primary physicians should be vigilant and screen for potential mental heath and behavioural harms in adolescent patients with TBI. Efforts to prevent TBI during adolescence and intervene at an early stage may reduce injuries and comorbid problems in this age group.

‘School's a big part of your life …’: Adolescent Perspectives of Their School Participation Following Traumatic Brain Injury

Sustaining a traumatic brain injury (TBI) as an adolescent has a significant impact on life roles and most notably on that of school participation. In the literature there is a wide range of studies that provide clinicians with information regarding recommendations for assisting students in their return to school. However this information has predominantly been provided from the perspectives of educators and rehabilitation staff. The aim of this preliminary project was to hear the stories of three male adolescent students as they reflected on their own experiences of what it was like to go back to school after sustaining a severe TBI. Using a qualitative research design and in-depth interviews, the students' stories were transcribed and coded using grounded theory principles. Despite persisting communication difficulties, the students were able to provide rich stories indicative of their personal experiences. Three key themes emerged from the interviews: theadolescent student's sense of self, changesthe students noted; andsupportsthe students identified. A tentative model illustrating the relationship between these areas was developed. It is anticipated that this model will assist clinicians and educators to develop a holistic picture of a student's school participation from transition to ongoing school life.

Assessing Care and Support Needs for Children With Acquired Brain Injury: Normative Data for the Paediatric Care and Needs Scale (PCANS)

Introduction:The Paediatric Care and Needs Scale (PCANS) was developed to address the dearth of scales currently available for measuring support needs of children with acquired brain injury (ABI). The scale assesses environmental supports (both supervision and physical assistance) across 14 domains of everyday activities from support for personal hygiene to participation in leisure and social activities. This study aimed to determine support needs in typically developing children using the PCANS in a normative sample of Australian children.Methods:Participants were parents of typically developing children aged 5–14 years (N= 300) recruited from a range of schools in metropolitan Melbourne. Children with ABI, diagnosis of a neurological or developmental disorder, or significant medical condition were excluded. Thirty parents of children in each of 10 age levels, with approximately equal sex ratio were recruited.Results:Findings suggest that support needs vary according to age of the child (p< .01) but not sex of child or occupational status of the parent. Additionally, children were found to have significantly higher support needs for supervision compared with physical assistance across most of the domains of the PCANS (p< .01). A greater number of age differences across PCANS domains were also found in younger children (5 to 7 and 8 to 11 years) compared to the older age group (age 12–14 years).Conclusions:This study reports normative data for the PCANS using a sample of children stratified by age. Findings will provide an essential point of reference to help guide clinical interpretation of the PCANS for assessing support needs of children with ABI.

A case study on the communication of older adolescents

This study compared the communication of two older male adolescents (aged 17 and 19 years) with each other (peer interaction) and with a teacher (non-peer interaction) in three different types of activity (casual conversation, providing/listening to a recount and collaborative problem-solving). Conversation analysis, selected analyses from the perspective of systemic functional linguistics and social psychology (communication accommodation theory) were applied in data analysis. Peer interaction showed fewer questions, fewer challenging moves and the absence of divergent accommodation strategies. In the non-peer interaction, the teacher's higher number of turns, questions and interruptions appeared to influence the opportunity for adolescent contribution to the interactions. Some aspects of language use by each adolescent - mean turn length, use of one-word utterances and sarcasm - were consistent across communication partner and activity. The methodology is suggested to provide a suitable procedure for use in similar research with older adolescents who have traumatic brain injury.

Parents' experiences following children's moderate to severe traumatic brain injury: a clash of cultures

Little is understood about parents' experiences following children's moderate to severe traumatic brain injury (TBI). Using descriptive phenomenology, we explored common experiences of parents whose children were diagnosed with moderate to severe TBI. Parents from across the United States (N = 42, from 37 families) participated in two semistructured interviews (~ 90 minutes in length and 12 to 15 months apart) in the first 5 years following children's TBI. First interviews were in person. Second interviews, done in person or by phone, facilitated updating parents' experiences and garnering their critique of the descriptive model. Parent themes were (a) grateful to still have my child, (b) grieving for the child I knew, (c) running on nerves, and (d) grappling to get what my child and family need. Parents reported cultural barriers because of others' misunderstandings. More qualitative inquiry is needed to understand how the knowledge, attitudes, beliefs, and culture-based expectations of others influence parents' interactions and the family's adjustment and well-being.

Community integration interventions for youth with acquired brain injuries: a review

OBJECTIVE

To identify and summarize published literature that examined the effectiveness of social and community integration interventions for children and adolescents with ABI in order to provide recommendations regarding future research on this topic.

METHODS

A literature review was conducted to identify studies that focused on social and community integration interventions for youth with ABI. Further manual searching of relevant journals with a paediatric rehabilitation focus was also carried out.

RESULTS

Currently, limited research has been published evaluating such interventions. The lack of research may stem largely from issues relating to how to measure community integration. Recommendations regarding intervention settings and structure are discussed.

CONCLUSION

Additional studies investigating social and community integration interventions are necessary, including those with measures tailored specifically to community integration, larger samples, as are better controls and recruitment of youth with varying severities of brain injuries.

Executive skills and their functional implications: Approaches to rehabilitation after childhood TBI

BACKGROUND

It is widely acknowledged that children recover differently from adults following traumatic brain injury. The impact of neurological injury in the context of developing skills and changing expectations of behaviour requires a developmental approach to rehabilitation that considers children's abilities across home, school and community environments.

METHODS

This article aims to provide an overview of the impact of executive deficits on everyday functioning and to review information about intervention strategies that support long term development of skills.

RESULTS AND CONCLUSIONS

While individual disciplines are not directly referred to in this paper, input from a comprehensive and co-ordinated interdisciplinary team is crucial to understanding and reducing the impact of executive deficits on functional performance.

Further validation of the Child and Adolescent Scale of Participation (CASP)

PRIMARY OBJECTIVE

To further validate the Child and Adolescent Scale of Participation (CASP) for children and youth with acquired brain injuries and other disabling conditions.

RESEARCH DESIGN AND METHODS

A cross-sectional design was used. Data were collected on 313 children and youth, aged 3-22, with and without disabling conditions. Children with acquired brain injuries (ABI) were the largest group (56%). Cronbach's alpha, factor analyses and Rasch analyses were used to examine internal scale consistency and structure. Correlation analyses were conducted to examine associations between CASP scores and scores that reflect extent of impairment and impact of environmental barriers. Independent t-tests or analyses of variance were used to examine mean differences in CASP scores in relation to sex, age and disability groups.

MAIN OUTCOMES AND RESULTS

Children without disabilities had significantly greater extent of participation (higher CASP scores) than children with disabilities. Greater extent of participation was associated with lesser extent of impairment and environmental barriers. Evidence of internal consistency and internal structure validity was demonstrated. Factor analyses showed that items from similar domains loaded onto one of three factors and a large (63%) proportion of variance was explained. Rasch analyses revealed essentially one unidimensional construct. The item difficulty order closely matched the expected pattern of life situations that children would find more to less challenging to participate in.

CONCLUSIONS

Findings were similar to prior research and suggested that the CASP is a promising new measure of participation. However, study design features limit generalizations and definitive conclusions that can be made. Future research is needed to assess the ability of the CASP to detect change over time and to include a larger and more diverse sample.