Service Delivery in the Healthcare and Educational Systems for Children Following Traumatic Brain Injury: Gaps in Care

Parent-Reported Academic Outcomes After a Mild Traumatic Brain Injury in the Pediatric Population

BACKGROUND

Millions of children are diagnosed with a traumatic brain injury (TBI) each year, most being mild TBI (mTBI). The effect of mTBIs on academic performance is of significant importance. We investigate mTBI's impact on parent-reported academic outcomes in school-aged pediatric participants.

METHODS

This cross-sectional survey study queried parents (N = 285) regarding letter grade performance and the presence or absence of academic accommodations before and after an mTBI, including complicated mTBI (c-mTBI, or mTBI with radiographic abnormality).

RESULTS

We found a parent-reported decline in letter grades following c-mTBI (p < .001), with no significant change following uncomplicated mTBIs. Degree and length of recovery were also associated with grade changes (p < .05). Those with no academic accommodations prior to the injury showed significant decreases in grades after injury regardless of post-injury accommodation status (p < .05).

IMPLICATIONS OF SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

This study underscores the need for an improved framework of support to maximize academic performance of children following mTBI, especially in those with a c-mTBI and still recovering from their injury.

CONCLUSION

Our study identifies children who are at risk for adverse academic outcomes following mTBI. We encourage efforts to better support school nurses in this effort, including improved communication between health care teams and school teams.

Exploring the care coordination experiences of professionals and caregivers of youth with acquired brain injuries in rural areas

PURPOSE

Acquired brain injuries (ABIs) can have devastating effects on children and their families. Families living in rural communities experience unique barriers to receiving and coordinating care for complex medical needs, but little research has examined those barriers for rural youth with ABIs.

MATERIALS AND METHODS

This qualitative study explored the experiences of rural adults caring for children with ABIs through interviews with six caregivers, three school staff members, and three medical professionals who had treated at least one child with an ABI.

RESULTS

Themes in their accounts include difficulty navigating complex situations, support from small communities, isolation and loneliness, the need for more professional education about ABI, and feelings of hope. Barriers to quality care coordination include navigating complex situations, access to transportation, and a lack of communication and education from healthcare agencies. Facilitators of rural care coordination include support from small communities and interagency communication.

CONCLUSIONS

The results support the need for more comprehensive coordination among rural agencies involved in ABI care. Suggestions for care improvement include providing flexibility due to transportation barriers, capitalizing on the benefits of a small and caring community, and providing healthcare and education professionals with more education about ABI interventions.

Traumatic brain injuries in paediatric patients: individual vs. team sports-related hospitalizations

Paediatric sport participation continues to increase in the United States, with a corresponding increase in sports-related concussions or traumatic brain injuries (TBIs). It is important to recognize which sports are at elevated risk and identify risk factors for hospital admission and length of stay (LOS). Paediatric patients (ages 5-18) from 2008 to 2014 were identified from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Eight hundred and ninety-four patients included those who were hospitalized with a TBI resulting from participation in an individual (451 patients) or team (443 patients) sport. We evaluated the differences in LOS and total charges between individual and team sports and found that compared to team sports, TBI patients in individual sports had significantly longer hospital stays compared to team sports (1.75 days versus 1.34 days, p < 0.001) and costlier ($27,333 versus $19,069, p < 0.001) hospital stays. This may be due to reduced awareness and reduced compliance with return-to-play protocols in individual sports. Safety education information at a young age, increased awareness of TBIs, and additional medical support for individual sports as well as team sports may help mitigate these findings.

The Importance of Identifying Children With Brain Injury in Schools: Speech-Language Pathologists as Crucial Partners

PURPOSE

The purpose of this article is to describe the importance of and strategies to identify traumatic brain injury (TBI) and associated cognitive-communication disorders (CCDs) in children, a priority identified by the attendees at the Fourth International Cognitive-Communication Disorders Conference. Childhood TBI is associated with a range of difficulties, including CCDs, that can adversely impact functioning and participation into adulthood. Identifying a history of TBI in children in schools is the crucial first step to then monitor, assess, and provide evidence-based intervention and accommodations in collaboration with families and medical and educational professionals.

CONCLUSION

Given that CCDs are treatable, effective identification, assessment, and management of students with TBI and resulting CCDs can reduce adverse outcomes in adult survivors of childhood TBI. Speech-language pathologists must be aware of their expertise in assessing and treating CCDs in children with TBI and advocate for programmatic and policy changes to better identify and support children with TBI.

Sport and Recreation Related Concussion in Children: National Concussion Surveillance System

INTRODUCTION

Concussions sustained during sports and recreational activities are a concern for young athletes. The purpose of this study was to estimate past 12-month sport- and recreation-related (SRR) traumatic brain injuries (TBIs) among a sample of children.

METHODS

Pilot data from the Centers for Disease Control and Prevention's National Concussion Surveillance System were analyzed. National Concussion Surveillance System utilized a cross-sectional random-digit-dial telephone survey using computer-assisted telephone interviewing to collect self/proxy-reported data from 2018 to 2019. Adults with children aged 5-17 in the household were asked about head injuries sustained by their children. Estimates were stratified by sociodemographic and injury circumstance characteristics. Data analysis occurred from April 2022 to July 2023.

RESULTS

Utilizing a tiered case definition developed by the Centers for Disease Control and Prevention, an estimated 6.9% (95% confidence interval [CI], 6.0%-7.8%) of the sample's 5-17-year-old children sustained at least one probable or possible SRR-TBI in the previous 12 months; 3.3% (95% CI, 2.7%-4.0%) of the children sustained at least one probable SRR-TBI. An estimated 63.6% (95% CI, 58.1%-69.0%) of all reported TBIs were attributed to SRR activities. Of the SRR-TBIs reported, 41.1% (95% CI, 33.0%-49.2%) were experienced while playing contact sports. Symptoms did not resolve for 8 or more days or had not resolved at the time of the interview for 18.1% (95% CI, 13.0%-23.1%) of the children's most recent SRR-TBI.

CONCLUSIONS

Many proxy-reported TBIs among children aged 5-17 years were due to sports and recreational activities. Athletic trainers and healthcare providers can play a role in the prevention, identification, and management of SRR-TBIs in their respective environments.

Unmet health care needs over the first 2 years after pediatric traumatic brain injury

AIM

Few studies have addressed how children and adolescents with traumatic brain injuries (TBIs) access health care and educational services. This study aimed to investigate the course of symptoms during the first two years after TBI, whether symptoms implied a need for health care and/or educational services, and the extent of unmet needs. The association between unmet needs and health-related quality of life was also explored.

METHODS

This prospective cohort study was conducted at Oslo University Hospital, Norway, from 2015 to 2018. Forty-nine patients aged 1-15 years hospitalized due to TBI were included and followed for 24 months. Registration of symptoms and identification of unmet needs was based on clinical assessment, self-reports and interviews with patients and parents during the acute phase and at 6 and 24 months postinjury.

RESULTS

Twenty-five percent of the sample presented with unmet needs at 24 months. Compared to the group with no needs and met needs, these patients reported lasting cognitive and emotional symptoms affecting school and social interaction and scored lower on health-related quality of life.

CONCLUSION

Pediatric patients with TBI may have long-term symptom burden affecting school and social functioning, leading to unmet needs if targeted services are not provided.

Effects of inpatient rehabilitation after acute care on motor, neuropsychological and behavioral outcomes in children with severe traumatic brain injury

PURPOSE

An observational study of children with severe traumatic brain injury (TBI) (Approaches and Decisions in Acute Pediatric TBI [ADAPT] Trial) demonstrated the benefits of inpatient rehabilitation on functional outcomes for those with more severely impaired consciousness when medically stable. We conducted a secondary analysis to assess whether using an inpatient rehabilitation or skilled nursing facility after acute hospitalization was associated with better motor, neuropsychological, and behavioral outcomes compared to receiving only non-inpatient rehabilitation among children with severe TBI.

MATERIALS AND METHODS

We included 180 children who used an inpatient rehabilitation or skilled nursing facility and 74 children who only received non-inpatient rehabilitation from the ADAPT trial. At 12 months post-injury, children underwent tests of motor skills, intellectual functioning, verbal learning, memory, processing speed, and cognitive flexibility. Parents/guardians rated children's executive function and behaviors. We performed inverse probability weighting to adjust for potential confounders.

RESULTS

No significant differences were found in any motor, neuropsychological, or behavioral measures between children receiving inpatient rehabilitation and children receiving only non-inpatient rehabilitation.

CONCLUSIONS

Analyses of comprehensive outcomes did not show differences between children receiving inpatient rehabilitation and children receiving only non-inpatient rehabilitation, suggesting a need for more research on specific components of the rehabilitation process.

Bilingual randomized controlled trial design, of a telephone-based intervention to promote rehabilitation adherence; A study focus on recruitment of Hispanic children with traumatic brain injury

BACKGROUND

While Hispanic children experience large long-term disparities in disability after traumatic Brain Injury (TBI), there is a gap in evidenced-based interventions to improve outcomes among this rapidly growing and at high-risk population. We developed and pilot tested a bilingual/bicultural intervention informed by Hispanic families consisting of Brain Injury Education and outpatient Navigation (1st BIEN). It integrates bilingual in-person education enriched by video content delivered through mobile phone devices, with outpatient navigation by bilingual and bicultural navigators during transitions of care and school return.

METHODS

Randomized controlled trial to test the efficacy of 1st BIEN to maintain long-term adherence to rehabilitation and determine its effect on children's functional outcomes. The primary outcome is treatment adherence at 6 months post-discharge at centralized acute facilities and community providers. Secondary outcomes are functional status of the child using PROMIS parental report measures and parental health literacy, self-efficacy, and mental health; measured at baseline (pre-injury and discharge) 3-,6- and 12- months post discharge. Children's academic performance is assessed using school records the year before and the year after injury.

DISCUSSION

Our study evaluates a novel, flexible and scalable approach using mobile phone devices to aid transitions of care, increase treatment adherence and improve TBI outcomes. It addresses the needs of an understudied population and builds upon their strengths. It is implemented by a bilingual and bicultural team with a deep understanding of the study population. It can serve as a model for TBI family centered interventions for at risk groups.

TRIAL REGISTRATION

ClinicalTrials.govNCT05261477. Registered on March 2, 2022.

The Influence of the Family Functioning and Social Relationships on Child Participation After Traumatic Brain Injury

PURPOSE

To describe the relationship amongst child and family characteristics (e.g. social relationships, family functioning) and child participation after traumatic brain injury (TBI) an average of 2.65 years post-TBI (SD = 2.12).

METHOD

Cross-sectional, secondary analysis of data collected as part of a larger research project.

RESULTS

N = 44 children with TBI. Analysis revealed statistically significant correlations between child participation, family functioning, and child characteristics.

CONCLUSIONS

School-aged children with TBI might experience chronic participation restrictions, associated with challenges in family functioning. Professionals can support children with TBI and their families through follow-up services that include a focus on family-based interventions to better support long-term outcomes for this population.

Factors impacting educational outcomes for students with traumatic brain injury in BrainSTEPS

Purpose: To describe child pre-injury and injury factors impacting post-injury educational outcomes for students with traumatic brain injury (TBI) participating in a state-wide, school-based, school re-entry consultation program, BrainSTEPS in Pennsylvania.Method: Retrospective analysis of a BrainSTEPS annual follow-up survey.Result: A total of 296 parent surveys were completed. Analysis revealed a significant difference between levels of severity of TBI and current educational placement (p < 0.001), receipt of current therapy (p < 0.05) and need for additional consult (p < 0.05). Severity of TBI was not related to other examined educational outcome variables (i.e. school performance, current symptoms). History of TBI, symptoms and treatment were not found to be associated with educational outcomes.Conclusion: These results both support findings from previous studies, and extend previous work by highlighting ongoing needs, including continued, individualised support, of children who sustain a moderate-severe TBI during childhood, and are currently in the chronic stages of injury, with consideration of pre- and post- injury factors. Programs such as BrainSTEPS provide identification of educational needs and provide needed services and supports for children with TBI. Sensitive, validated measures are needed to further understand the role of pre-injury and injury factors on educational outcomes, particularly in programs like BrainSTEPS.

Traumatic Brain Injuries Impact on School One Month and One Year After Injury

Traumatic brain injury (TBI) is a major cause of death and disability among the American population, but the impact TBIs have on the school experience of high school, and post-secondary students, is poorly understood. In this study, a cohort of 79 students, ages 15-22, with mild-to-severe TBIs, were retrospectively identified from the University of Washington Traumatic Brain Injury Database and Sample Repository. The Sickness Impact Profile (SIP) was used to determine the frequency at which schooling was impacted by a TBI and identify the most common self-reported issues students faced in their return to school. At 1 month post-injury, 70% of students either had not returned to school as a result of their TBI or had returned to school but experienced issues related to their TBI. The most-reported issues at 1 month were a difficulty keeping up with school work as a result of it taking longer to complete assignments, tiring easily, having to take frequent rests, and grades that were not as good as they used to be. At 1 year post-injury, the number of students whose TBIs were affecting their school situation dropped 20 percentage points to 49%. The most reported issues at 1 year were forgetting more quickly what was learned in class and having more difficulty understanding new concepts and material. These findings indicate that TBIs have a profound effect on a student's school experiences up to at least 1 year post-injury.

Return to School After Traumatic Brain Injury: Description of Implementation Settings

OBJECTIVE

Children who experience traumatic brain injury (TBI) of any severity may need accommodations when they return to school-the setting that manages academic achievement and learning. However, variations exist in current return to school (RTS) programs that address a child's transition to school following TBI. This article describes some of these return to school (RTS) programs and how they vary by setting.

DESIGN

This article provides insights from a modified evaluability assessment that examined RTS programs and their readiness for rigorous evaluation. A secondary analysis was conducted to better describe the types and location of programs examined.

RESULTS

Differences exist in program structure, access, and how care for children is monitored over time. RTS programs that serve children following TBI are located in healthcare settings, schools, and state agencies and vary in models of care due to their location and organizational structure.

CONCLUSIONS

Children who experience TBI benefit from a healthcare assessment and follow-up upon RTS that includes parental involvement. Models of care for this process vary based on program location and organizational structure. Further research and program evaluation are needed to better understand effectiveness and how to optimally monitor and care for children returning to school after a concussion or TBI.

Stakeholder Perspectives on the School Experiences of Students With Traumatic Brain Injury: The Effects of COVID-19 Pandemic on Service Delivery

BACKGROUND

For students with traumatic brain injury (TBI), the COVID-19 pandemic exacerbated challenges they were already experiencing at school.

METHODS

This qualitative study employed focus groups and interviews with students, parents, school, and medical personnel to explore the school experiences of students with TBI. Thematic qualitative analyses were used.

RESULTS

Key themes from the analysis include (a) incidence of brain injuries decreased; (b) screen time for students with TBI exacerbated symptoms; (c) COVID protocols at school made it difficult for educators to identify and provide accommodations for students with TBI; (d) COVID protocols at school could inadvertently exacerbate mental health difficulties after a TBI; and (e) COVID-related logistics increased the time between an injury and return to school or return to play.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

The results from this study suggest that professional development for teachers supporting students with TBI is needed, especially for online learning environments. Additionally, because mental/behavioral health concerns may arise for students with TBI in online learning environments, school health care providers can work with families to assess a student's mental health, making referrals to appropriate supports.

CONCLUSIONS

There is a significant need for professional development and school-wide infrastructure supportive of students with TBI.

Speech-Language Pathology Treatment of Cognitive-Communication Deficits in School-Aged Children With Traumatic Brain Injury: A Scoping Review

PURPOSE

The purpose of this scoping review was to synthesize the current evidence-based treatment practices used with school-aged children with any severity of traumatic brain injury (TBI) that could benefit the practice of speech-language pathologists (SLPs).

METHOD

A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Included studies were assigned thematic labels based on a modified version of the Rehabilitation Treatment Specification System.

RESULTS

A total of 27 articles that covered 16 different treatment approaches met inclusion criteria for this study. Most studies included adolescent or teenage participants with moderate-severe TBIs. Treatment targets included executive functioning (n = 15), social competence (n = 6), postconcussive symptoms (n = 5), behavior (n = 3), family functioning (n = 1), and health-related quality of life (n = 1). The majority of current interventions for school-aged children with TBI include a multidisciplinary approach and components of family involvement education.

CONCLUSIONS

Further research is needed on interventions that are specifically implemented by SLPs as well as protocols that include more heterogeneous samples (e.g., varied sociodemographic factors and injury severity) to allow for the development and testing of ecologically valid intervention practice. SLPs can use the results of this scoping review to individualize treatment based on the child's areas of need while considering individual characteristics and to provide person-centered intervention for children with school-aged TBI.

Cognitive, social, and health functioning of children with TBI engaged in a formal support program

BACKGROUND

Students with traumatic brain injury (TBI) often demonstrate difficulties that impact their successful return to school (RTS).

OBJECTIVE

To explore injury severity, age at injury, and time since injury as predictors for performance on measures of cognitive, social and health functioning for students' participating in a formal RTS cohort at the time of their enrollment in the School Transition After Traumatic Brain Injury (STATBI) research project.

METHODS

Outcome measures across cognitive, social, and health domains were analyzed for association with the explanatory variables of interest using quantile regressions and ordinary least squares regression, as appropriate.

RESULTS

Students (N = 91) injured after age 13 showed significantly lower cognitive outcomes than students whose injury occurred earlier. Additionally, students more than one-year post-injury demonstrated poorer social outcome on one measure compared to students whose injury occurred more recently. Health outcomes showed no significant association to any predictors.

CONCLUSION

The results of this analysis provide a baseline for a group of students with TBI as they enter a RTS research study. This data can now be paired with longitudinal measures and qualitative data collected simultaneously to gain a deeper understanding of how students with TBI present for RTS.

Perspectives on care coordination for youth with TBI: Moving forward to provide better care

BACKGROUND

Care coordination aligns services and optimizes outcomes for children with traumatic brain injury (TBI), yet numerous obstacles can impede effective care coordination following a TBI.

OBJECTIVE

The goal of this work is to identify barriers and facilitators to care coordination from the perspective of individuals who care for young people impacted by TBI (e.g., medical providers, educators, caregivers).

METHODS

Twenty-one care providers participated in semi-structured interviews to gather their perspectives on systems of care coordination for youth with TBI and potential areas for improvement. Using reflexive thematic analysis, researchers identified key themes across interviews.

RESULTS

Three themes were identified: 1) gaps in knowledge; 2) poor collaboration and communication between systems and care providers; and 3) inadequate legislative and policy frameworks that fund and support pediatric TBI. Across themes, participants shared their experiences and ideas to improve each of these areas.

CONCLUSION

A structured, consistent, and coordinated system of care for pediatric TBI is critical to ensure optimal outcomes. Protocols that emphasize intentional and productive collaboration between healthcare settings and schools and education for all care providers are cornerstones in improving outcomes for children. Top-down action that develops policy and funding initiatives is needed to ensure equitable, consistent access to appropriate healthcare and educational supports.

The role of social determinants of health in the receipt of school services after\\ traumatic brain injury: A focus review on underserved pediatric populations

BACKGROUND

Return to school is key for community re-integration after a traumatic brain injury (TBI). School support facilitates and ensure a successful transition back to school. However, access to school services is not uniform among U.S. children.

OBJECTIVE

To describe school services for children with TBI from minoritized backgrounds and highlight population-specific risk factors and facilitators for accessing services.

METHODS

Narrative review of the literature including studies on return to school after a mild-complicated, moderate, or severe TBI, among children enrolled in the U.S. school system. We describe receipt of services, enabling and risk factors, and outcomes, for minority children.

RESULTS

There is a gap in knowledge regarding return to school among minoritized children with TBIs. Studies have few participants from racial and ethnic minority backgrounds, or low income or rural communities. Transgender and non-binary youth are not represented in present research efforts. Studies highlight larger barriers to receipt of school services among minority children and additional barriers associated with their minority status.

CONCLUSION

Diversity in the U.S pediatric population is increasing. Minoritized populations are at increased risk for TBI and poor outcomes. Research focused on the needs of these populations is required to optimize school return after TBI hospitalization and overall post-discharge care.

School professionals' knowledge about pediatric traumatic brain injury: an international study

OBJECTIVE

To determine Spanish-speaking school professionals' level of knowledge and attitudes regarding pediatric TBI.

METHODS

School professionals(n = 2,238) from 19 countries completed an online-survey regarding their training, knowledge and misconceptions, attitudes and perceptions about TBI.

RESULTS

Of the full sample 75% (n = 1689) knew what TBI was, though only 18% (n = 350) reported having experience with a student with TBI. Only 7.7% (n = 143) and 3% (n = 55) of participants could identify all of the common short- and long-term TBI sequelae, respectively. Special education professionals, those with experience with a student with TBI, and those who had received training regarding TBI showed greater knowledge in these areas. Although participants showed high levels of knowledge in 6/24 misconceptions of TBI, they endorsed others. Group, sex, experience with students with TBI, training in TBI, and number of years working were significantly linked to some misconceptions about TBI; however, the effect sizes were small.

CONCLUSION

The knowledge and experience that Spanish-speaking school professionals have regarding childhood TBI are minimal. It is therefore critical that these professionals receive a more comprehensive education during their academic training and the practice of their profession about TBI.

Education on the consequences of traumatic brain injury for children and adolescents with TBI and families/caregivers: a systematic scoping review

OBJECTIVE(S)

To examine the breadth of education or training on the consequences of traumatic brain injury (TBI) for children and adolescents with TBI and their families/caregivers.

METHODS

Systematic scoping review of literature published through July 2018 using eight databases and education, training, instruction, and pediatric search terms. Only studies including pediatric participants (age <18) with TBI or their families/caregivers were included. Six independent reviewers worked in pairs to review abstracts and full-text articles independently, and abstracted data using a REDCap database.

RESULTS

Forty-two unique studies were included in the review. Based on TBI injury severity, 24 studies included persons with mild TBI (mTBI) and 18 studies focused on moderate/severe TBI. Six studies targeted the education or training provided to children or adolescents with TBI. TBI education was provided primarily in the emergency department or outpatient/community setting. Most studies described TBI education as the main topic of the study or intervention. Educational topics varied, such as managing TBI-related symptoms and behaviors, when to seek care, family issues, and returning to work, school, or play.

CONCLUSIONS

The results of this scoping review may guide future research and intervention development to promote the recovery of children and adolescents with TBI.

Attitudes and practices of specialty physicians regarding the return to school process after pediatric acquired brain injury

PURPOSE

More than 50,000 children are hospitalized yearly in the U.S. for acquired brain injury (ABI) with no established standards or protocols for school re-entry and limited resources for hospital-school communication. While ultimately the school has autonomy over curricula and services, specialty physicians were asked about their participation and perception of barriers in the school re-entry process.

METHODS

Approximately 545 specialty physicians were sent an electronic survey.

RESULTS

84 responses (43% neurologists and 37% physiatrists) were obtained with a response rate of ∼15%. Thirty-five percent reported that specialty clinicians currently make the plan for school re-entry. The biggest challenge for school re-entry noted by physicians was cognitive difficulties (63%). The biggest gaps perceived by physicians were a lack of hospital-school liaisons to help design and implement a school re-entry plan (27%), schools' inability to implement a school re-entry plan (26%), and an evidence-based cognitive rehab curriculum (26%). Forty-seven percent of physicians reported that they did not have adequate medical personnel to support school re-entry. The most commonly used outcome measure was family satisfaction. Ideal outcome measures included satisfaction (33%) and formal assessment of quality of life (26%).

CONCLUSION

These data suggest that specialty physicians identify a lack of school liaisons in the medical setting as an important gap in hospital-school communication. Satisfaction and formal assessment of quality of life are meaningful outcomes for this provider group.

Using guided credible history interviews to establish special education eligibility for students with traumatic brain injury

BACKGROUND

In Oregon in 2019, only 261 students were eligible for special education under the traumatic brain injury (TBI) category. Many students with TBIs are not treated by a medical provider, so the requirement for a medical statement could prevent eligible youth from receiving special education services.

OBJECTIVE

This study investigated barriers to using a medical statement to establish special education eligibility for TBI, support for using a guided credible history interview (GCHI), and training needs around GCHI.

RESULTS

Among participants, 84% reported difficulty obtaining a medical statement for TBI eligibility determination, and 87% favored the GCHI as an alternative, though they reported a need for training in TBI and GCHI.

CONCLUSION

The results support the use of GCHI to establish special education eligibility for TBI and informed Oregon's addition of GCHI to TBI special education eligibility determination.

Stakeholder perspectives on navigating the pediatric concussion experience: Exploring the needs for improved communication across the care continuum

BACKGROUND

For children, the post-concussion return to school process is a critical step towards achieving positive health outcomes. The process requires integration between healthcare professionals, parents, and school personnel.

OBJECTIVE

This research team conducted focus groups with stakeholders including parents, education personnel, school nurses, external healthcare providers (nurses) and athletic trainers to identify communication patterns between healthcare providers outside of the school setting and school personnel.

METHODS

Data from focus groups were analyzed using a Thematic Analysis approach. Researchers used an inductive (bottom-up) coding process to describe semantic themes and utilized a critical realist epistemology.

RESULTS

We identified four key themes within focus group data: (1) lack of effective communication between hospital and outpatient healthcare providers to school personnel; (2) parents who were strong advocates had improved communication with healthcare professionals and garnered more accommodations for their children; (3) non-school professionals and families were often confused about who the point of contact was at a given school; and (4) differing experiences for athletes vs. non-athletes.

CONCLUSION

This study suggests gaps in communication between healthcare and school professionals when children return to school following a concussion. Improving communication between healthcare providers and school staff will require a multi-faceted approach.

An Exploratory Study on Disparities in Service Provision and Long-Term Need After Early Childhood Acquired Brain Injury

PURPOSE

While health care and educational disparities are known to impact minoritized groups, few research studies have been conducted to examine disparities after childhood acquired brain injury (ABI). The purpose of this study was to explore child and injury factors (i.e., race, socioeconomic status, and length of hospital stay) associated with referral, parent education, and long-term need for children who experienced an early childhood ABI.

METHOD

This study was a secondary analysis of data collected through retrospective cohort chart review and prospective caregiver phone surveys.

RESULTS

Exploratory logistic regressions indicated a statistically significant association between child and injury factors and (a) referral to rehabilitation or educational services at hospital discharge (p < .001) and (b) caregiver-reported long-term needs (including both met and unmet needs) for special education services (p = .009). The models for caregiver-reported receipt of education on ABI and caregiver-reported unmet need for special education were not significant. For both significant models, there were no significant individual predictors.

CONCLUSIONS

Differences in acute and long-term service provision and need after childhood ABI are likely influenced by a complex interaction of individual, injury, and social-environmental factors. Future research should consider how health care and education practice and policy might account for these interactions to support more equitable access to and utilization of services to improve long-term outcomes for all children with ABI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21158878.

Effects of inpatient rehabilitation after acute care on functional and quality-of-life outcomes in children with severe traumatic brain injury

OBJECTIVE

Few studies have assessed the effectiveness of the rehabilitation process in children surviving severe traumatic brain injury (TBI). We evaluated whether receiving inpatient rehabilitation after acute hospitalization was associated with better functional outcomes compared to receiving only non-inpatient rehabilitation in children with severe TBI and explored an effect modification for Glasgow Coma Scale (GCS) score at hospital discharge.

METHODS

We included 254 children who received rehabilitation following severe TBI from a multinational observational study. The Pediatric Glasgow Outcome Scale - Extended (GOS-E Peds), parent/guardian-reported and child-reported Pediatric Quality of Life Inventory (PedsQL) at 12 months post-injury were assessed and described using summary statistics. Unadjusted and propensity score-weighted linear/ordinal logistic regression modeling were also performed.

RESULTS

180 children received inpatient rehabilitation and 74 children received only non-inpatient rehabilitation after acute hospitalization. Among children with a GCS<13 at discharge, those receiving inpatient rehabilitation had a more favorable GOS-E Peds score (OR = 0.12, p = 0.045). However, no such association was observed in children with a higher GCS. We found no differences in PedsQL scores between rehabilitation groups.

CONCLUSIONS

Future studies are warranted to confirm the benefits of inpatient rehabilitation for children with more severely impaired consciousness when medically stable.

Speech-Language Pathology Assessment of School-Age Children With Traumatic Brain Injury: A Scoping Review

PURPOSE

The purpose of this study was to describe evidenced-based assessment practices for school-age children with any severity of traumatic brain injury (TBI) that could inform the practice of speech-language pathologists (SLPs).

METHOD

A scoping review of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Included studies were assigned thematic labels related to the International Classification of Functioning, Disability and Health framework.

RESULTS

A total of 30 articles met inclusion criteria for this study. Most studies included adolescent or teenage participants with mild TBIs in the acute stages of recovery. Twenty-two different assessments were reported on for children with TBI addressing body structure/function (n = 19 assessments), activities and participation (n = 1 assessment), and contextual factors (n = 3 assessments).

CONCLUSIONS

Current assessments have a clear focus on body structure/function for adolescents after childhood TBI, with little research evidence to address activities and participation or contextual factors. The limited amount of functional assessments directly related to the SLP scope of practice stresses the need for additional research on ecologically valid and comprehensive assessment approaches for school-age children with TBI. The results of this review could be utilized as a resource in providing theoretical, evidence-based, and person-centered evaluation methods for children with TBI.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20422170.

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.

Factors that Influence Follow-Up Care for Families of Children with Acquired Brain Injury: A Scoping Review

PURPOSE

To describe factors that contribute to medical/rehabilitation service access following pediatric acquired brain injury (ABI) and identify gaps in the literature to guide future research.

MATERIALS & METHODS

The PRISMA framework for scoping reviews guided this process. Peer-reviewed journal databases were searched for articles published between 1/2008 and 12/2020, identifying 400 unique articles. For full inclusion, articles had to examine a variable related to the receipt or initiation of medical/rehabilitative services for children with ABI. Review articles and non-English articles were excluded.

RESULTS

Nine studies met full inclusion criteria. Included studies identified factors focused on four primary areas: understanding brain injury education/recommendations and ease of implementing recommendations, ease of scheduling and attending appointments, age/injury factors, and sociocultural factors. Well-scheduled appointments and simple strategies facilitated families' access to care and implementation of recommendations. An overwhelming number of recommendations, socioeconomic variables, and transportation challenges served as barriers for families and schools.

CONCLUSIONS

This scoping review offers several directions on which researchers can build to improve access to care and recommendation-implementation for families who have a child with an ABI. Enhanced understanding of these factors may lead to better service access, reduction of unmet needs, and enhanced long-term outcomes for children with ABI.

Application of the RE-AIM Framework for the Pediatric Mild Traumatic Brain Injury Evaluation and Management Intervention: A Study Protocol for Program Evaluation

Background

Children who experience a mild Traumatic Brain Injury (mTBI) may encounter cognitive and behavioral changes that often negatively impact school performance. Communication linkages between the various healthcare systems and school systems are rarely well-coordinated, placing children with an mTBI at risk for prolonged recovery, adverse impact on learning, and mTBI re-exposure. The objective of this study is to rigorously appraise the pediatric Mild Traumatic Brain Injury Evaluation and Management (TEaM) Intervention that was designed to enhance diagnosis and management of pediatric mTBI through enhanced patient discharge instructions and communication linkages between school and primary care providers.

Methods

This is a combined randomized and 2 × 2 quasi-experimental study design with educational and technology interventions occurring at the clinician level with patient and school outcomes as key endpoints. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework will be utilized as a mix methods approach to appraise a multi-disciplinary, multi-setting intervention with the intent of improving outcomes for children who have experienced mTBI.

Discussion

Utilization of the RE-AIM framework complemented with qualitative inquiry is suitable for evaluating effectiveness of the TEaM Intervention with the aim of emphasizing priorities regarding pediatric mTBI. This program evaluation has the potential to support the knowledge needed to critically appraise the impact of mTBI recovery interventions across multiple settings, enabling uptake of the best-available evidence within clinical practice.

Gaps in concussion management across school-aged children

OBJECTIVE

Examine how demographic and injury factors impact identification and management of concussion in students.

METHODS

Prospective observational cohort. Pre-K - 12th grade students within a large, urban school district reported to school with concussion during 2015-2019. Participants were grouped into Elementary/Middle School (E/MS) and High School (HS) and compared by sex, concussion history, injury setting and mechanism, time to medical evaluation and clearance, absences, and recommended accommodations.

RESULTS

154 E/MS and 230 HS students reported to school with physician-diagnosed concussion. E/MS students experienced fewer concussions at school and from sports than HS. More E/MS males than females sustained concussions, while this difference was reversed for HS. Time-to-evaluation was longer for E/MS, specifically female E/MS students and those injured outside of school. E/MS males were cleared more quickly than females. In contrast, no differences were found between sexes for HS by injury setting, mechanism of injury, or management factors.

CONCLUSION

Differences observed in E/MS students by demographic and injury factors are not observed in HS students. Younger students, particularly females or those not injured in school or sports, may be at risk for delayed identification and prolonged time to clearance. Future research should further characterize concussion management in E/MS children.

A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination tools

Introduction & importance

Children with traumatic brain injury (TBI) report unmet needs several years after their injury and may require long-term care. However, this chronic health condition is often only treated and monitored in the short-term. Care for young persons with TBI often relies on parents to manage their child's complex care network. Effective care coordination can close these gaps and facilitate continuity of care for children with TBI. The purpose of this scoping review was to develop a better understanding of tools that improve care coordination for Children with Special Health Care Needs (CSHCN). This, in turn, can inform care for children with TBI.

Methods

A scoping review was conducted following the PRISMA framework and methodology. OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination tools used with CSHCN.

Results

21 articles met the criteria for inclusion in the review, and 6 major categories of care coordination tools were identified: telehealth, online health records and tools, care plans, inpatient discharge protocols, family training, and reminders.

Discussion

Studies examining telehealth, online tools, care plans, and family training care coordination interventions for CSHCN have shown positive outcomes and would be relevant strategies to improve the care of children with TBI. Future prospective research should investigate these tools to explore whether they might improve communication, reduce unmet needs, increase service access, and improve long-term outcomes for children with TBI.

First-Line Health Care Providers' Reported Knowledge of and Referrals to Speech-Language Pathologists for Clients With Mild Traumatic Brain Injury

Purpose People with mild traumatic brain injury (mTBI) may experience deficits in cognition or communication that go unnoticed by first-line health care providers (FHPs). Speech-language pathologists (SLPs) assess and treat these domains yet are often underrepresented on mTBI multidisciplinary teams. This study's aim was to evaluate FHPs' reported knowledge of and referral practices to SLPs for individuals across the life span with mTBI. Method Physicians, physician assistants, nurse practitioners, nurses, and athletic trainers (n = 126) completed an online survey, including two Likert scale questions and one free response question relating to SLPs' role in mTBI. Results More than half of FHPs rate their knowledge of the SLP's role in mTBI management as low (somewhat knowledgeable, 29%; not very knowledgeable, 23%). Similarly, nearly two thirds of FHPs indicated rarely (19%) or never (44%), referring to SLPs for management of patients with mTBI. The majority of FHPs' open responses on the role of the SLP in mTBI management were incomplete, with many including domains that were not relevant to an SLP's role in the management of mTBI (e.g., dysphagia). Within the article, we provide results overall and according to individual profession. Conclusions Results suggest a majority of FHPs lack knowledge in the role of the SLP in the management of mTBI, which may underpin the low referral patterns reported by FHPs for SLP services. Future educational efforts for FHPs regarding the role of SLPs in mTBI care are necessary.

Nonstandardized Assessment of Cognitive-Communication Abilities Following Pediatric Traumatic Brain Injury: A Scoping Review

Purpose The purpose of this study is to describe and synthesize existing research on nonstandardized assessment of cognitive-communication abilities in children with traumatic brain injury (TBI) in order to improve the detection, diagnosis, and tracking of injury sequelae and guide appropriate service provision. Materials and Method A search of peer-reviewed journal databases revealed 504 unique articles published between January 2000 and August 2019. For full inclusion, articles had to report on empirical studies examining variables related to the nonstandardized assessment of cognitive-communication skills following TBI in children. Review articles, expert opinion pieces, and non-English language articles were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guided this process. Results Results were tabulated for each of the 14 articles that met full inclusion criteria. Included studies presented five different types of nonstandardized assessment: discourse analysis (n = 3), systematic observation of child's performance during an instrumental activity of daily living (n = 4), virtual reality tasks (n = 3), structured cognitive tasks (n = 2), and functional rating scales (n = 2). The majority of included studies compared the outcomes of nonstandardized assessment against subtest scores and checklists drawn from a variety of existing standardized and criterion-referenced assessments. Targeted cognitive-communication skills included attention, working memory, self-regulation, planning, multitasking, social problem-solving, inferencing, and macrolevel discourse. Conclusions Preliminary research suggests that a well-designed and systematically implemented nonstandardized assessment can yield essential information about children's cognitive-communication abilities in real-world contexts. Further research is needed to validate these assessments and to determine in which settings and situations they may prove most effective. Supplemental Material https://doi.org/10.23641/asha.15079026.

Met and unmet rehabilitative needs among pediatric patients with moderate to severe TBI

OBJECTIVE

Estimate the probability of met and unmet post-acute rehabilitative needs among pediatric patients with moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

One hundred and thirty children who received acute and post-acute rehabilitative services at a hospital for children.

METHODS

Prospective, observational study. Recommended service needs (1. Medical, 2. Psychological, 3. Cognitive/Educational, 4. Medically Based Therapies, 5. Community/Caregiver/Family Support) were collected at discharge and 1, 6, 12, and 18 months post-injury. Probabilities were estimated using nonlinear logistic regression models. The impact of age at discharge was also assessed.

RESULTS

Over time, the estimated probability of need for Medical, Medically Based Therapies, and Cognitive/Educational services were consistently high. Whereas unmet need for Medical and Medically Based Therapies were low, unmet need for Cognitive/Educational services were relatively high. Need for Psychological and Community/Caregiver/Family Support services increased in the months post-discharge, as did the probability of unmet need. Older age at discharge was associated with need for Psychological and Community/Caregiver Family Support services.

CONCLUSIONS

Findings support the long-term monitoring of need for Psychological and Community/Caregiver/Family Support services among children with moderate to severe TBI. Future research to explore the etiology of unmet needs is warranted.

Community reintegration needs following paediatric brain injury: perspectives of caregivers and service providers

PURPOSE

To explore the processes of community reintegration of children and families at least one year following a paediatric brain injury from the perspective of caregivers and outpatient/community service providers.

MATERIALS AND METHODS

A qualitative analysis of semi-structured interviews from outpatient or community service providers (N = 14; occupational, physical, and speech and language therapists, neuropsychologists, school counsellors, recreational providers) and caregivers of six children (N = 8) at least one year after their injury. Interviews were transcribed and thematically coded using deductive (employing Bronfenbrenner's ecological systems theory) and inductive approaches.

RESULTS

Themes from both providers and caregivers indicated additional supports needed at all levels of Bronfenbrenner's ecological systems theory (i.e., individual, microsystem, mesosystem/exosystem, macrosystem, chronosystem). Participants felt that several characteristics would be needed in an ideal service system following paediatric brain injury including: community solutions ("it takes a village"), long-term approaches to care, and new financial approaches.

CONCLUSIONS

The results suggest that children and families have substantial community reintegration needs following paediatric brain injury. Multi-system interventions are needed to support long-term community reintegration, especially those that increase communication and support transitions. There is also a strong need for alternative funding to support these efforts.Implications for RehabilitationFamilies with a child with a moderate to severe brain injury face challenges with community reintegration a year or more after their child's injury.Effort should be put into helping families navigate the complex medical, insurance, and school systems with a navigator service and step-down care to ensure a continuum of care and to support community reintegration.Special support should be provided during transitions, such as transitions from hospital care to outpatient care, and across school transitions.

Changing Healthcare and School Needs in the First Year After Traumatic Brain Injury

OBJECTIVE

To examine children's unmet and unrecognized healthcare and school needs following traumatic brain injury (TBI).

SETTING

Two pediatric trauma centers.

PARTICIPANTS

Children with all severity of TBI aged 4 to 15 years.

DESIGN

Prospective cohort.

MAIN MEASURES

Caregivers provided child health and school service use 3 and 12 months postinjury. Unmet and unrecognized needs were categorized compared with norms on standardized physical, cognitive, socioemotional health, or academic competence measures in conjunction with caregiver report of needs and services. Modified Poisson models examined child and family predictors of unmet and unrecognized needs.

RESULTS

Of 322 children, 28% had unmet or unrecognized healthcare or school needs at 3 months, decreasing to 24% at 12 months. Unmet healthcare needs changed from primarily physical (79%) at 3 months to cognitive (47%) and/or socioemotional needs (68%) at 12 months. At 3 months, low social capital, preexisting psychological diagnoses, and 6 to 11 years of age predicted higher healthcare needs and severe TBI predicted higher school needs. Twelve months postinjury, prior inpatient rehabilitation, low income, and preexisting psychological diagnoses were associated with higher healthcare needs; family function was important for school and healthcare needs.

CONCLUSIONS

Targeted interventions to provide family supports may increase children's access to services.

Healthcare Providers' Self-Reported Pediatric Mild Traumatic Brain Injury Diagnosis, Prognosis, and Management Practices: Findings From the 2019 DocStyles Survey

OBJECTIVE

To assess adherence to 5 key recommendations in the Centers for Disease Control and Prevention evidence-based guideline on pediatric mild traumatic brain injury, this article presents results from the 2019 DocStyles survey.

STUDY DESIGN

Cross-sectional, web-based survey of 653 healthcare providers.

RESULTS

Most healthcare providers reported adhering to the recommendations regarding the use of computed tomography and providing education and reassurance to patients and their families. However, less than half reported routinely examining their patients with mild traumatic brain injury (mTBI) using age-appropriate, validated symptom scales, assessing for risk factors for prolonged recovery, and advising patients to return to noncontact, light aerobic activities within 2 to 3 days. Self-reported mTBI diagnosis, prognosis, and management practices varied by specialty. Only 3.8% of healthcare providers answered all 7 questions in a way that is most consistent with the 5 recommendations examined from the Centers for Disease Control and Prevention Pediatric mTBI Guideline.

CONCLUSION

This study highlights several important information gaps regarding pediatric mTBI diagnosis and management. Further efforts to improve adoption of guideline recommendations may be beneficial to ensure optimal outcomes for children following an mTBI.

The Cognitive-Communication Checklist for Acquired Brain Injury: A Means of Identifying, Recording, and Tracking Communication Impairments

Purpose The communication service needs of individuals with acquired brain injuries (ABIs) are frequently overlooked, leading to delays, denials, or premature discharge from communication interventions. This is particularly true for those with subtle cognitive-communication deficits, which may not be apparent until sufficiently challenged at work, in school, or in the community. The purpose of this study was to evaluate a referral tool that could promote understanding of the broad range of communication impairments that occur following ABI and lead to improved identification and referral. Method This study evaluated the Cognitive-Communication Checklist for Acquired Brain Injury (CCCABI) through a survey. The CCCABI is a referral tool that summarizes 45 communication difficulties in 10 areas of cognitive-communication functioning. One hundred sixteen speech-language pathologists, 34 multidisciplinary referral sources, and 41 individuals with lived experience of brain injury were surveyed to evaluate the utility of this referral tool. Results The need for such a referral tool was endorsed by 96% of speech-language pathology respondents, 91% of multidisciplinary respondents, and 100% of respondents with lived experience of brain injury. Responses supported the CCCABI as a clear, comprehensive, and accessible tool for education and identification of the communication impairments that can occur after ABI. Conclusion The CCCABI is a means of increasing understanding of communication service needs following ABI in a manner that is accessible to individuals, families, program designers, funding sources, administrators, and multidisciplinary referral sources.

Understanding Cognitive Communication Needs in Pediatric Traumatic Brain Injury: Issues Identified at the 2020 International Cognitive-Communication Disorders Conference

Purpose In early 2020, the second International Cognitive-Communication Disorders Conference was held to provide an opportunity for researchers and clinician-scientists to discuss the most recent advances and pressing issues in the care of individuals with cognitive-communication disorders (CCDs). Presentations and discussions resulted in the identification of four areas in need of attention: (a) terminology, (b) training, (c) interdisciplinary teams, and (d) pediatrics. We will explore the four themes identified at ICCDC, specifically expanding on how terminology, training, and teams intersect in pediatric traumatic brain injury care. Additionally, we will provide two case studies to highlight the integration of these themes and suggest ways to advance clinical service provision across medical and educational settings for persons with CCDs through the lens of pediatrics. Conclusion While speech-language pathology has come a long way since the original discussion of CCD over 30 years ago, clinicians and researchers have ongoing opportunities to help advance the ways in which speech-language pathologists offer support to persons, specifically children, with CCDs and to continue to advance the profession.

Acute and Long-Term Services for Elementary and Middle School Children With Early Childhood Brain Injury

Purpose The purpose of this study was to investigate the rates of referral to and receipt of acute and long-term services and identify factors that could impact these rates for children who experienced an acquired brain injury (ABI) during early childhood who are now in elementary and middle school. Method This was a retrospective chart review and prospective phone survey of 29 caregivers of children with ABIs. Results Acutely, two thirds of this sample received hospital-based rehabilitation services, but only 44.8% of families reported receiving ABI-specific education or a referral to educational or rehabilitation services at the time of discharge. At an average of 8.5 years postinjury, children in this sample were largely reported to be performing positively in school. While special education rates did not change significantly over time, 20.7% of the sample reported having unmet educational needs. Additionally, service receipt decreased over time. Various injury and educational factors influenced rates of long-term special education and service receipt. Conclusions This study contributes to the emerging literature focusing on long-term outcomes of children with ABI. The results reinforce that children who experience an ABI in early childhood are unlikely to receive ABI-specific education or referrals to educational and rehabilitation services during their acute-care stay and, in the chronic stages of recovery, present with educational and therapy needs that can go unmet. To improve long-term service access for children who experience an early ABI, pathways need to be established within the acute-care setting for education and referrals that connect the child and family to treatment within early intervention and educational systems. Maintaining these pathways long term, particularly for potential social-behavioral and cognitive-communication concerns, could increase access to appropriate services and, thus, decrease unmet needs for children with ABI.

Sports- and Physical Activity-Related Concussion and Risk for Youth Violence

INTRODUCTION

Sports and physical activities are an important cause of traumatic brain injury among adolescents. Childhood traumatic brain injury has been associated with cognitive impairment, emotional problems, and impaired behavior control, and these neuropsychological changes may place these youth at increased risk for engagement in violence-related behaviors.

METHODS

Data from the 2017 National Youth Risk Behavior Survey (N=14,765), a nationally representative survey of U.S. high school students, were analyzed in 2019 to examine the associations between sports- and physical activity-related concussion and violence-related behaviors occurring in the community and at school. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, athlete status, impaired cognitive functioning, feeling sad/hopeless, and current substance use) prevalence ratios. Prevalence ratios were considered statistically significant if p<0.05.

RESULTS

Male students (17.1%) were more likely than female students (13.0%) to experience a sports- and physical activity-related concussion during the 12 months preceding the survey. Compared with students who did not have a concussion, those who experienced ≥1 sports- and physical activity-related concussion were more likely to be in a physical fight (male students, adjusted prevalence ratio=1.45; female students, adjusted prevalence ratio=1.55), carry a weapon (male students, adjusted prevalence ratio=1.24; female students, adjusted prevalence ratio=1.79), and fight at school (male students, adjusted prevalence ratio=1.40; female students, adjusted prevalence ratio=1.77). In addition, male students were more likely to carry a gun (adjusted prevalence ratio=1.62) and carry a weapon at school (adjusted prevalence ratio=1.73).

CONCLUSIONS

Although the direction of these associations is unknown, return-to-school programs may benefit from inclusion of assessment and counseling around issues of psychological and social functioning, conflict resolution, and coordination with violence prevention programs.

Return to School Following TBI: Educational Services Received 1 Year After Injury

BACKGROUND

Many children who experience a traumatic brain injury (TBI) return to school without receiving needed support services.

OBJECTIVE

To identify services received and predictors of formal special education services (ie, Individualized Education Plan [IEP]) for students with TBI 1 year after returning to school.

SETTING AND PARTICIPANTS

A total of 74 students with TBI recruited from children's hospitals in Colorado, Ohio, and Oregon.

DESIGN

Secondary analysis of previously reported randomized control trials with surveys completed by caregivers when students returned to school (T1) and 1 year later (T2). This study reports data collected at T2.

RESULTS

While 45% of students with TBI reported an IEP 1 year after returning to school, nearly 50% of students received informal or no services. Male students, those who sustained a severe TBI, and students whose parents reported domain-specific concerns were more likely to receive special education services at 1 year. In a multivariate model, sex remained the only significant predictor of IEP services at T2.

CONCLUSIONS

Females and students with less severe or less visible deficits were less likely to receive special education services. While transition services may help students obtain special education for the first year after TBI, identifying students with TBI who have subtle or later-developing deficits remains a challenge.

Addressing Key Clinical Care and Clinical Research Needs in Severe Pediatric Traumatic Brain Injury: Perspectives From a Focused International Conference

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Survivors of severe TBI are more prone to functional deficits, resulting in poorer school performance, poor health-related quality of life (HRQoL), and increased risk of mental health problems. Critical gaps in knowledge of pathophysiological differences between children and adults concerning TBI outcomes, the paucity of pediatric trials and prognostic models and the uncertain extrapolation of adult data to pediatrics pose significant challenges and demand global efforts. Here, we explore the clinical and research unmet needs focusing on severe pediatric TBI to identify best practices in pathways of care and optimize both inpatient and outpatient management of children following TBI.

Management of Return to School Following Brain Injury: An Evaluation Model

Traumatic brain injury (TBI) affects children's ability to succeed at school. Few educators have the necessary training and knowledge needed to adequately monitor and treat students with a TBI, despite schools regularly serving as the long-term service provider. In this article, we describe a return to school model used in Oregon that implements best practices indicated by the extant literature, as well as our research protocol for evaluating this model. We discuss project aims and our planned procedures, including the measures used, our quasi-experimental design using matched controls, statistical power, and impact analyses. This project will provide the evidential base for implementation of a return to school model at scale.

Early Brain Injury and Adaptive Functioning in Middle Childhood: The Mediating Role of Pragmatic Language

OBJECTIVE

Traumatic brain injuries (TBIs) often adversely affect adaptive functioning (AF). However, the cognitive mechanisms by which AF is disrupted are not well understood in young children who sustain TBI. This study examined pragmatic language (PL) and executive functioning (EF) as potential mechanisms for AF disruption in children with early, predominantly mild-complicated, TBI.

METHOD

The sample consisted of 76 children between the ages of 6 and 10 years old who sustained a TBI (n = 36) or orthopedic injury (OI; n = 40) before 6 years of age and at least 1 year prior to testing (M = 4.86 years, SD = 1.59). Children's performance on a PL and an expressive vocabulary task (which served as a control task), and parent report of child's EF and AF were examined at two time points 1 year apart (i.e., at age 8 and at age 9 years).

RESULTS

Injury type (TBI vs. OI) significantly predicted child's social and conceptual, but not practical, AF. Results indicated that PL, and not expressive vocabulary or EF at time 1, mediated the relationship between injury type and both social and conceptual AF at time 2.

CONCLUSIONS

A TBI during early childhood appears to subtly, but uniquely, disrupt complex language skills (i.e., PL), which in turn may disrupt subsequent social and conceptual AF in middle childhood. Additional longitudinal research that examines different aspects of PL and adaptive outcomes into adolescence is warranted.

Transitions to Outpatient Care After Traumatic Brain Injury for Hispanic Children

BACKGROUND AND OBJECTIVES

Rehabilitation after a child's traumatic brain injury (TBI) occurs in hospital, community, and school settings, requiring coordination of care and advocacy by parents. Our objective was to explore Hispanic parents' experiences during child's transitions of care after TBI.

METHODS

We conducted this qualitative study using semistructured interviews. We used a convenient sample of Hispanic parents of children hospitalized for a TBI in a single level I trauma center. Thematic content analysis using iterative deductive coding and triangulation with clinical data was conducted to identify barriers and facilitators for transitions of care.

RESULTS

Fifteen mothers, mostly from rural areas and with limited English proficiency, participated in the study. Obtaining outpatient rehabilitation was difficult. Barriers included lack of therapists and clinical providers close to home, worsened by insufficient transportation and other support resources; poor understanding of child's illness and treatments; and suboptimal communication with clinicians and school administrators. Facilitators included interpreter use, availability of Spanish written information, and receipt of inpatient rehabilitation. Parents of patients discharged to inpatient rehabilitation reported that observing therapies, receiving school discharge plans by hospital-teachers, and coordination of care were facilitators to access outpatient treatments and to support school return. Parents of children discharged from the hospital from acute care reported need of legal services to obtain school services.

CONCLUSIONS

Hispanic parents, especially those with limited English proficiency, can face significant challenges accessing TBI outpatient rehabilitation and school resources for their children. Although barriers are multifactorial, efforts to improve communication, parent's TBI education, and care coordination during transitions of care may facilitate a child's reintegration to the community and school.

Attending Follow-up Appointments After Pediatric Traumatic Brain Injury: Caregiver-Perceived Barriers and Facilitators

OBJECTIVE

To examine barriers and facilitators for follow-up care of children with traumatic brain injury (TBI).

SETTING

Urban children's hospital.

PARTICIPANTS

Caregivers of children (aged 2-18 years) discharged from an inpatient unit with a TBI diagnosis in 2014-2015.

DESIGN

Survey of caregivers.

MAIN MEASURES

Caregiver-reported barriers and facilitators to follow-up appointment attendance.

RESULTS

The sample included 159 caregivers who completed the survey. The top 3 barriers were "no need" (38.5%), "schedule conflicts" (14.1%), and "lack of resources" (10.3%). The top 5 identified facilitators were "good hospital experience" (68.6%), "need" (37.8%), "sufficient resources" (35.8%), "well-coordinated appointments" (31.1%), and "provision of counseling and support" (27.6%). Caregivers with higher income were more likely to report "no need" as a barrier; females were less likely to do so. Nonwhite caregivers and those without private insurance were more likely to report "lack of resources" as a barrier. Females were more likely to report "good hospital experience" and "provision of counseling and support" as a facilitator. Nonwhite caregivers were more likely to report "need" but less likely to report "sufficient resources" as facilitators.

CONCLUSIONS

Care coordination, assistance with resources, and improvements in communication and the hospital experience are ways that adherence might be enhanced.

Microstructural and Fluency Characteristics of Narrative and Expository Discourse in Adolescents With Traumatic Brain Injury

Purpose The purpose of this exploratory study was to identify specific microstructural and fluency differences in expository and narrative summaries produced by students with a traumatic brain injury (TBI) compared to students with typical development (TD). Method Five adolescents with TBI and 5 matched peers with TD verbally summarized 1 narrative and 2 expository (compare-contrast, cause-effect) lectures, creating 30 summaries. Researchers transcribed summaries and used paired t tests to analyze between-group differences in microstructural measures (productivity, lexical diversity, syntactic complexity), mazing behaviors, and pausing patterns. Results Youth with TBI produced significantly fewer utterances than teens with TD in both expository contexts, whereas youth with TD produced a significantly greater mean length of C-unit than teens with TBI in the narrative summary only. Youth with TBI produced significantly fewer filled pauses per utterance than did youth with TD during the cause-effect summary only and significantly more pauses per utterance and within-clause pauses per utterance during the compare-contrast summary. Where findings were statistically significant, effect sizes were large. There were no statistically significant between-group differences in mazing or pausing behaviors during narrative summary production. Conclusions This study is the 1st to compare microstructural and fluency characteristics in teens with TBI and those without when producing verbal summaries of a narrative and 2 types of expository passages. Findings from this study reinforce the need to expand research focusing on expository discourse tasks and identify variables that may be prone to disruption following TBI. Future work is needed to confirm whether identified differences correspond to true discourse difficulties. Supplemental Material https://doi.org/10.23641/asha.9807812.

The impact of driving time on pediatric TBI follow-up visit attendance

Objective: Examine the effect of driving time on follow-up visit attendance for children hospitalized with a traumatic brain injury (TBI). We hypothesized that families who lived further from the hospital would show poorer follow-up attendance.Participants: 368 children admitted to the hospital with TBI.Design & Outcome Measures: Using a retrospective chart review, we calculated driving time from patients' homes. The primary outcome was attendance at the first appointment post-discharge. We used logistic regression to examine the effect of driving time on attendance, including an analysis of the effects of injury and sociodemographic covariates on the model.Results: Majority of children attended their first appointment. Patients living 30-60 min from the hospital were most likely to attend, and those living 15 min away were least likely to attend. After adjusting for patient characteristics, families with driving time of 30-60 min had significantly higher odds of returning for follow-up than those with driving time <15 min, though the significance of this relationship disappeared after specific socioeconomic (SES) factors were included.Conclusions: Distance plays a significant role on follow-up attendance for pediatric patients with TBI. However, neighborhood SES may be an additional factor that influences the significance of the distance effect.Abbreviations: TBI: Traumatic brain injury; SES: socioeconomic status; ISS: Injury severity scale; AIS: Abbreviated injury scale.

The consequences of traumatic brain injury from the classroom to the courtroom: understanding pathways through structural equation modelling

Purpose: Paediatric traumatic brain injury (TBI) can have resultant ongoing significant impairments which can impact life outcomes. The primary aim of this research was to explore whether TBI contributes to the relationship between poor educational outcomes and offending trajectories.Materials and methods: Through analysis of a dataset consisting of self-reported health, educational, and offending histories of 70 incarcerated young males, structural equation modelling was used to explore the mediation of educational outcomes and patterns in offending behaviour by chronic symptoms following TBI.Results: Symptoms related to TBI significantly mediated the relationship between decreased educational attainment and more frequent convictions. It did not mediate any relationships involving age at first conviction.Conclusions: Traumatic brain injury appears to have more influence over frequency of offending patterns than age at first conviction. However, TBI remains a pervasive factor in both higher rates of offending and poorer educational attainment. In order to tackle this effect on adverse social outcomes, greater attention to the impact of TBI is required in education and criminal justice systems.IMPLICATIONS FOR REHABILITATIONHighlights traumatic brain injury as a contributory factor in some education to offending pathways, suggesting that greater focus on rehabilitation within the education and criminal justice systems is required.Reinforces that greater understanding of educational pathways post-injury is needed to better facilitate rehabilitation within the school system.