Disparities in disability after traumatic brain injury among Hispanic children and adolescents

Exploring racial disparities and inequalities among children and youth with acquired brain injury: a systematic review

PURPOSE

Racial minoritized children and youth with acquired brain injury (ABI) often experience multiple forms of discrimination. The purpose of this systematic review was to understand the racial disparities in health care among children and youth with ABI and their caregivers.

METHOD

Six international databases (Ovid Medline, Embase, Healthstar, Psychinfo, Scopus, and Web of Science) were systematically searched for peer-reviewed articles. Studies were screened by two researchers who also conducted the data extraction and quality appraisal. A narrative synthesis approach was used to analyze the data.

RESULTS

Of the 8081 studies identified in the search, 34 met the inclusion criteria, which involved 838,052 children and youth with brain injuries (or caregivers representing them) across two countries. The following themes were noted in the studies in our review: (1) racial disparities in accessing care (i.e., diagnosis, hospital admission, length of stay, rehabilitation treatment); (2) racial disparities in ABI-related health outcomes (i.e., functional outcomes and mortality rates); and (3) factors affecting racial disparities (i.e., sources in injury, insurance and expenditures, and intersectionality).

CONCLUSIONS

Our findings reveal the concerning racial disparities among children and youth with ABI. Further research should explore solutions for addressing such racial disparities and solutions to address them.

Pediatric Traumatic Brain Injury Outcomes and Disparities During the COVID-19 Pandemic

BACKGROUND

To study the impact of the COVID-19 pandemic on traumatic brain injury (TBI) patient demographic, clinical and trauma related characteristics, and outcomes.

METHODS

Retrospective chart review was conducted on pediatric TBI patients admitted to a Level I Pediatric Trauma Center between January 2015 and June 2022. The pre-COVID era was defined as January 1, 2015, through March 12, 2020. The COVID-19 era was defined as March 13, 2020, through June 30, 2022. Bivariate analysis and logistic regression were performed.

RESULTS

Four hundred-thirty patients were treated for pediatric TBI in the pre-COVID-19 period, and 166 patients during COVID-19. In bivariate analyses, the racial/ethnic makeup, age, and sex varied significantly across the two time periods (p < 0.05). Unwitnessed TBI events increased during the COVID-19 era. Logistic regression analyses also demonstrated significantly increased odds of death, severe disability, or vegetative state during COVID-19 (AOR 7.23; 95 % CI 1.43, 36.41).

CONCLUSION

During the COVID-19 pandemic, patients admitted with pediatric TBI had significantly different demographics with regards to age, sex, and race/ethnicity when compared to patients prior to the pandemic. There was an increase in unwitnessed events. In the COVID period, patients had a higher odds ratio of severe morbidity and mortality despite adjustment for confounding factors.

LEVEL OF EVIDENCE AND STUDY TYPE

Level II, Prognosis.

Mild Traumatic Brain Injuries and Risk for Affective and Behavioral Disorders

OBJECTIVES

Recent studies document an association between mild traumatic brain injuries (mTBIs) in children and postinjury psychiatric disorders. However. these studies were subject to limitations in the design, lack of long-term follow-up, and poorly defined psychiatric outcomes. This study determines the incidence and relative risk of postinjury new affective and behavior disorders 4 years after mTBIs.

METHODS

A cohort study of mTBI cases and matched comparisons within an integrated health care system. The mTBI group included patients ≤17 years of age, diagnosed with mTBI from 2000 to 2014 (N = 18 917). Comparisons included 2 unexposed patients (N = 37 834) per each mTBI-exposed patient, randomly selected and matched for age, sex, race/ethnicity, and date of medical visit (reference date to mTBI injury). Outcomes included a diagnosis of affective or behavioral disorders in the 4 years after mTBI or the reference date.

RESULTS

Adjusted risks for affective disorders were significantly higher across the first 3 years after injury for the mTBI group, especially during the second year, with a 34% increase in risk. Adjusted risks for behavioral disorders were significant at years 2 and 4, with up to a 37% increase in risk. The age group with the highest risk for postinjury affective and behavioral disorders was 10- to 13-year-old patients.

CONCLUSIONS

Sustaining an mTBI significantly increased the risks of having a new affective or behavioral disorder up to 4 years after injury. Initial and ongoing screening for affective and behavior disorders following an mTBI can identify persistent conditions that may pose barriers to recovery.

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.

Social Determinants of Health in Pediatric Rehabilitation for Children with Traumatic Injury: A Systematic Review

OBJECTIVE

To examine the current evidence regarding health care disparities in pediatric rehabilitation after hospitalization with traumatic injury.

STUDY DESIGN

This systematic review utilized both PubMed and EMBASE, and each was searched with key MESH terms. Studies were included in the systematic review if they (1) addressed social determinants of health including, but not limited to, race, ethnicity, insurance status, and income level; (2) focused on inpatient and outpatient rehabilitation services posthospital stay; (3) were based in the pediatric population; and (4) addressed traumatic injury requiring hospitalization. Only studies from within the US were included.

RESULTS

From 10 169 studies identified, 455 abstracts were examined for full-text review, and 24 studies were chosen for data extraction. Synthesis of the 24 studies revealed 3 major themes: (1) access to services; (2) outcomes from rehabilitation; and (3) service provision. Patients with public insurance had decreased availability of service providers and had longer outpatient wait times. Non-Hispanic Black and Hispanic children were more likely to have greater injury severity and decreased functional independence after discharge. Lack of interpreter services was associated with decreased utilization of outpatient services.

CONCLUSIONS

This systematic review identified significant effects of health care disparities on the rehabilitation process in pediatric traumatic injury. Social determinants of health must be thoughtfully addressed to identify key areas of improvement for the provision of equitable health care.

Rehabilitation Care of the Child with an Acute Severe Traumatic Brain Injury

Children with traumatic brain injury (TBI) represent a unique and evolving population. Recovery and long-term prognosis are variable given the heterogeneity of ages, developmental stages, and types of injuries. This article summarizes important information regarding severe TBI epidemiology, pathophysiology, classification, and acute management. Early and longitudinal involvement of rehabilitation experts, such as pediatric physiatrists, is critical in managing complications and optimizing outcomes.

U.S. vs. Foreign Nativity and 10-Year Trajectories of Mental Health after Traumatic Brain Injury: A Model Systems Study

BACKGROUND

Previous research has found racial and ethnic disparities in life satisfaction, depression, and anxiety after traumatic brain injury (TBI). However, limited studies have examined differences in these variables between U.S.- and foreign-born individuals with TBI. The purpose of this study was to examine whether differences exist in mental health outcomes between U.S.- and foreign-born individuals with TBI at 1, 2, 5, and 10 years after injury, as well as examine whether demographic and injury-related characteristics account for these differences.

METHOD

Participants were 8289 individuals with TBI who identified as U.S.-born and 944 who identified as born outside the U.S. in the TBI Model Systems study. Participants completed measures of mental health outcomes at 1, 2, 5, and 10 years after injury.

RESULTS

Foreign-born individuals with TBI had comparable levels of depression and anxiety trajectories to U.S.-born individuals, yet higher life satisfaction trajectories, even after controlling for demographic and injury-related variables.

CONCLUSION

Rehabilitation professionals should consider in their clinical work the mechanisms that likely influence mental health outcomes among foreign-born individuals, including family-based values that increase resilience, as well as the possible under-reporting of mental health symptoms along the lines of cultural norms.

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.

Exploring the measurement of pediatric cognitive-communication disorders in traumatic brain injury research: A scoping review

OBJECTIVE

To synthesize information about the constructs measured, measurement instruments used, and the timing of assessment of cognitive-communication disorders (CCDs) in pediatric traumatic brain injury (TBI) research.

METHODS AND PROCEDURES

Scoping review conducted in alignment with Arksey and O'Malley's five-stage methodological framework and reported per the PRISMA extension for Scoping Reviews. Inclusion criteria: (a) cohort description, case-control, and treatment studies; (b) participants with TBI aged 5-18 years; (c) communication or psychosocial outcomes; and (d) English full-text journal articles. The first author reviewed all titles, abstracts, and full-text articles; 10% were independently reviewed.

OUTCOMES AND RESULTS

Following screening, a total of 687 articles were included and 919 measurement instruments, measuring 2134 unique constructs, were extracted. The Child Behavior Checklist was the most used measurement instrument and 'Global Outcomes/Recovery' was the construct most frequently measured. The length of longitudinal monitoring ranged between ≤3 months and 16 years.

CONCLUSIONS AND IMPLICATIONS

We found considerable heterogeneity in the constructs measured, the measurement instruments used, and the timing of CCD assessment in pediatric TBI research. A consistent approach to measurement may support clinical decision-making and the efficient use of data beyond individual studies in systematic reviews and meta-analyses.

School Discipline as a Consequence of Violent Victimization in Adolescence: Understanding the Mediating Roles of Head Injury and Behavior

Pathways from violence to head injury and poor long-term outcomes have been found among numerous populations, however, have not yet been widely examined with youth exposed to violence. Traumatic brain injuries (TBIs) are linked to a range of consequences salient to adolescent development and well-being, such as impulsivity, academic abilities, and emotional processing. This gap in research has led to a missed opportunity to understand the consequences of youth victimization, particularly within the academic setting. The current study examined whether head injury and problem behaviors mediate the relationships between victimization and suspension/expulsion using data from the Pathways to Desistance Study, a multi-site, longitudinal study of serious adolescent offenders age 14-18. A sample of male youth who had witnessed violence (n = 1,094) reported a total score of victimization, number of early behavior problems (i.e., cheating, fighting, etc.), ever having a head injury (32.9%), and number of times suspended (adjusted M = 13.13; SD = 19.31) or expelled (adjusted M = 0.65; SD = 0.99). Structural equation modeling was used to examine direct and indirect pathways from victimization to suspension and expulsion through head injury and behavior. Direct pathways from victimization to school discipline were significant; indirect pathways mediated by only head injury were not significant, but indirect pathways through only problem behavior and through TBI and problem behavior were significant for both expulsion and suspension. Results suggest that youth who have been victimized are at higher risk for both suspension and expulsion and that this risk may be, in part, explained through increased head injury and problem behaviors. TBI screenings/services for violence-exposed youth and trauma-informed school-based services may help to deter trajectories toward suspension and expulsion but should be developed with attention to the influence of racial bias on pathways to school discipline.

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.

Intensive Parent-Child Interaction Therapy for Children with Traumatic Brain Injury: Feasibility Study

OBJECTIVE

This study examined the feasibility and initial outcome of a time-limited and intensive format of Parent-Child Interaction Therapy (PCIT) for families of young children who have sustained a traumatic brain injury (TBI).

METHODS

The nonrandomized open trial included 15 families with a child aged 2-5 years who had sustained a TBI and displayed clinically elevated levels of externalizing behavior problems. Families received clinic-based PCIT twice per week over an average of 6 weeks, with the exception of two families that received the same intensity and format of PCIT in the home.

RESULTS

Ten of the 14 families who completed the baseline assessment (71%) completed the intervention and post and follow-up assessments. On average, caregivers completed homework practice on 52% of the days in between sessions. Caregivers reported high acceptability and satisfaction following the intervention, as well as decreases in child externalizing and internalizing behavior problems at the post-assessment and 2-month follow-up.

CONCLUSIONS

Results of this open trial provide preliminary support for the feasibility of a time-limited and intensive format of PCIT for families of young children who have sustained a TBI and have elevated levels of behavior problems. This study highlights a promising intervention approach for improving domains commonly affected by early childhood TBI and preventing the development of more severe and persistent problems.

Feasibility and Acceptability of a Telephone-Based Intervention for Hispanic Children to Promote Treatment Adherence After Traumatic Brain Injury: A Pilot Study

OBJECTIVE

To assess the feasibility and acceptability of a telephone-based education and navigation program for Hispanic parents of children hospitalized with traumatic brain injury (TBI).

SETTING

Level I trauma hospital and pediatric inpatient rehabilitation unit in the Northwestern United States.

PARTICIPANTS

Fourteen Hispanic parent-child dyads. Parents were 85% female, with a mean age of 35 years. Children were 58% male, with a mean age of 9.7 years, and had been hospitalized for complicated mild/moderate (n = 5) or severe (n = 9) TBI.

DESIGN

Pilot prospective cohort design.

MAIN MEASURES

Feasibility measures include recruitment, retention, and intervention adherence rates. Acceptability of intervention was measured by parents' use of educational materials and satisfaction with navigation program. We also evaluated study processes, including completion of baseline, 3, 6, and 12 months functional assessments of the child; assessment of parental health literacy and self-efficacy; and adherence to follow-up rehabilitation appointments.

RESULTS

Eighty-two percent of approached potential participants were recruited into the study. One hundred percent of participants completed the intervention, and 85% had 1-year follow-up. Intervention acceptability was high: 90% reported satisfaction with navigator, and 92% used the educational manual. Assessments demonstrated significant improvement in parents' TBI caregiving and community self-efficacy; 92% attendance to follow-up rehabilitation appointments; and improvement in the child's functional measures, except communication skills.

CONCLUSIONS

Findings support feasibility and acceptability of a culturally relevant program to facilitate transitions of care for Hispanic children with TBI. A future randomized trial is warranted to determine the efficacy of the intervention on long-term treatment adherence and the child's post-TBI function.

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.

Disparities in Use of Subspecialty Concussion Care Based on Ethnicity

Concussion is common and subspecialty care can be essential to ensure recovery. However, barriers may exist to accessing care. This study aimed to assess disparities in subspecialty concussion care related to ethnicity, limited English proficiency (LEP), and insurance status. We utilized logistic regression to analyze 2010-2015 administrative data from four Sports Medicine clinics, comparing odds of being seen for concussion to odds of being seen for fracture by ethnicity, insurance type, and interpreter usage, controlling for demographic factors. ICD-9 codes were used to identify concussion and fracture. Our final sample contained 25,294 subjects: 5621 with concussion and 19,673 with fracture. In bivariate analysis, youth seen for concussion had 83% lower odds of being Hispanic compared with youth seen for fracture (95%CI: 75-92%). Due to interactions between ethnicity and interpreter use, we utilized a stratified multivariate model as our final model. Youth with concussion had 1.8× greater odds of having private insurance compared with youth with fracture (Hispanic OR 1.8, 95% CI 1.5-2.3; Non-Hispanic OR 1.8, 95% CI 1.7-2.0). Youth with concussion also had greater odds of not using an interpreter, though the strength of this association was weaker for Hispanic youth compared with non-Hispanic youth (Hispanic OR 1.68, 95% CI 1.30-2.17; Non-Hispanic OR 4.36, 95% CI 3.00-6.35). Age and sex were included as covariates. In conclusion, our analysis suggests disparities in subspecialty concussion care for Hispanic youth, as well as for individuals with LEP and non-private insurance. Further research should explore means for improving access to concussion care for all youth.

Research on Injury Disparities: A Scoping Review

Background: Research on disparities in traumatic injury has not been well characterized, limiting understanding of gaps in research and development of successful interventions. We conducted a scoping review to identify and synthesize research on disparities in intentional and unintentional traumatic injuries.

Methods: The review was guided by PRISMA Extension for Scoping Reviews. PubMed, PsycINFO, Web of Science, and CINAHL and systematic reviews from 2007 to 2017 were searched. Eligible articles were peer reviewed; conducted in the United States; and reported on clearly defined physical trauma and disparity, defined by Cochrane PROGRESS-Plus criteria. One reviewer assessed article titles and a second reviewer validated the inclusion with a random sample. Abstract and full-text review by two reviewers determined final inclusion.

Results: Of 7382 unique articles screened, 653 articles were included; inter-rater agreement was high (K=0.995). Studies reported on disparities in the acute hospital setting (104) or postacute/rehabilitation (86), with fewer focused on prevention (57) and policy development (6). Research methods used were quantitative (593) with 25 intervention studies, qualitative (45), qualitative/quantitative (7), and community-based participatory research (8). Age ranges of included studies were all ages (124), adults (318), pediatric/youth/adolescents (172), and older adults (40). Racial disparities were most commonly measured (439 studies); 38 created a white/nonwhite binary. Other commonly measured disparities were place of residence (122), insurance (111 studies), gender (89), age (75), and socioeconomic status measures (61). Disparities were noted in all of the categories. Studies commonly aggregated all types of traumatic injuries (129) or all types of violence (105).

Conclusions: The extant injury literature lacks research on prevention and policy to address disparities. Many studies aggregated types of trauma and patient groups, preventing an understanding of distinctions between groups and potential interventions. Intervention and community-based research strategies were limited. Future research can better specify measurement of understudied equity categories, trauma types and intent, and racial groups.

Racial Disparities in Outpatient Mental Health Service Use Among Children Hospitalized for Traumatic Brain Injury

OBJECTIVE

To examine racial differences in mental health service utilization after hospitalization for traumatic brain injury (TBI) among children with Medicaid insurance.

DESIGN AND MAIN MEASURES

Retrospective analysis of the MarketScan Multi-State Medicaid database from 2007 to 2012 was performed. Outpatient mental health service utilization (psychiatric and psychological individual and group services) was compared at TBI hospitalization, from discharge to 3 months and from 4 to 12 months after discharge, between children of non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, and "Other" racial groups. Multivariable mixed-effects Poisson regression models with robust standard errors were utilized.

RESULTS

A total of 5674 children (aged <21 years) were included in the study. There were no differences by race/ethnicity in mental health service utilization during hospitalization. At 3 months postdischarge, NHB children and children in the "Other" racial category were significantly less likely to receive outpatient mental health services than NHW children (NHB relative risk [RR] = 0.84; 95% confidence interval [CI], 0.72-0.98; Other RR = 0.72; 95% CI, 0.57-0.90). At 12 months, all racial minority children were significantly less likely to receive outpatient mental health services than NHW children (NHB RR = 0.84; 95% CI, 0.75-0.94; Hispanic RR = 0.72; 95% CI, 0.55-0.94; Other RR = 0.71; 95% CI, 0.60-0.84).

CONCLUSIONS

Racial disparities in utilization of outpatient mental health services exist for minority children hospitalized for TBI and insured by Medicaid. Future research should focus on improving transitions of care from inpatient to outpatient services for these children.

Assessment of executive function in bilingual adults with history of mild traumatic brain injury

Background and objective:

Adults with a history of traumatic brain injury (TBI) often show deficits in executive function (EF), including the ability to inhibit, switch, and attend to task relevant information. Although performances differences between bilinguals and monolinguals have been observed in EF tasks, there is little research on the effect of TBI on EF in bilinguals. In this study, an ecologically valid standardized measure and experimental computerized tasks of EF were administered to Spanish-English bilingual adults with and without history of mild traumatic brain injury (mTBI).

Method:

Twenty-two bilinguals with a history of mTBI [mean age=20.1 years, SD=3.7; education=13.4 years, SD=0.7] and 20 control bilinguals [mean age=20.8 years, SD=3.6; education=13.7 years, SD=1.1], matched for age and education, completed language proficiency questionnaires, the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES), English and Spanish language assessments, and a Flanker task (a test of inhibition).

Results:

Performance was analyzed using analyses of covariance. The results revealed that bilinguals with a history of mTBI performed worse on both the standardized assessment (FAVRES) and inhibition task. Interestingly, self-reported EF deficits were consistent with performance on these measures.

Conclusion:

The findings of this study provide useful information regarding assessment of EF deficits in bilinguals with a history mTBI. Computerized experimental tasks of EF may also prove useful in the assessment of EF in individuals with mTBI.

Effect of School Services on Academic Performance After Traumatic Brain Injury in Hispanic and Non-Hispanic Students

BACKGROUND

School reintegration after traumatic brain injuries (TBI) requires school support; however, implementation of services is complex. This study evaluates disparities in receipt of school services for Hispanic children and its effect on academic performance.

METHODS

Secondary analyses of school data on receipt of pre- and post-TBI school services. A logistic regression compared receipt of services between Hispanic and non-Hispanic white (NHW) children, and a linear regression evaluated services' effect on academic performance.

RESULTS

The study includes 419 children; 46 Hispanic, 373 NHW. For NHW children there were no differences in receipt of pre- and post-TBI services; Hispanic children had significant increase in receipt of services from 5% to 27% (p < .001). Compared to NHWs, Hispanics had lower grade point average (GPA) at baseline (2.3 [confidence interval, CI: 1.9-2.7] vs 2.9 [CI: 2.8-3.0]). No differences in GPA were found between groups after injury among students who received post-TBI services.

CONCLUSIONS

Students who receive post-TBI school services benefit academically. NHW students maintain their academic performance and Hispanics increase their performance to their NHW peers' level. This highlights the importance of providing post-TBI school services to ensure better outcomes for all children.

Putting the person in person-centered care: Stakeholder experiences in pediatric traumatic brain injury

PURPOSE

This pilot study sought to describe the perspectives and experiences of survivors of pediatric traumatic brain injury (pTBI), their caregivers, and the medical professionals who serve them.

METHODS

Thirteen people participated in semi-structured interviews: five survivors of pTBI, their primary caregivers, and three medical professionals who work with persons who have sustained pTBI. The study involved a prospective, qualitative, participatory action research model with convenience sampling. All interviews were transcribed and thematic analysis identified central concepts within and between groups. Additionally, the Consolidated Criteria for Reporting Qualitative Research (COREG) were applied.

RESULTS

This study found that survivors of pTBI and their caregivers commonly noted later developing issues, social challenges, and difficulty in post-rehabilitation transitions. In addition, both caregivers and medical professionals reported the need for improved follow-up with survivors, evidence-based research, and medical and therapy providers with specific training on pTBI.

CONCLUSIONS

The perspectives provided by key stakeholders in this pilot study identify common themes that should be central to driving innovation in rehabilitation research and clinical care.

Persistent Postconcussion Symptoms After Injury

: media-1vid110.1542/5828371885001PEDS-VA_2018-0939Video Abstract OBJECTIVES: We examined whether preinjury, demographic, and family factors influenced vulnerability to postconcussion symptoms (PCSs) persisting the year after mild traumatic brain injury (mTBI).

METHODS

Children with mTBI (n = 119), complicated mild traumatic brain injury (cmTBI) (n = 110), or orthopedic injury (OI) (n = 118), recruited from emergency departments, were enrolled in a prospective, longitudinal cohort study. Caregivers completed retrospective surveys to characterize preinjury demographic, child, and family characteristics. PCSs were assessed using a validated rating scale. With multivariable general linear models adjusted for preinjury symptoms, we examined predictors of PCSs 3, 6, and 12 months after injury in children ages 4 to 8, 9 to 12, and 13 to 15 years at injury. With logistic regression, we examined predictors of chronic PCSs 1 year after traumatic brain injury.

RESULTS

Postinjury somatic, emotional, cognitive, and fatigue PCSs were similar in the mTBI and cmTBI groups and significantly elevated compared with the OI group. PCS trajectories varied with age and sex. Adolescents had elevated PCSs that improved; young children had lower initial symptoms and less change. Despite similar preinjury PCSs, girls had elevated symptoms across all time points compared with boys. PCS vulnerability factors included female sex, adolescence, preinjury mood problems, lower income, and family discord. Social capital was a protective factor. PCSs persisted in 25% to 31% of the traumatic brain injury group and 18% of the OI group at 1 year postinjury. The odds of chronic PCSs were almost twice as high in girls as in boys and were >4 times higher in young children with cmTBI than in those with mTBI.

CONCLUSIONS

A significant minority of children with mTBI and OI have PCSs that persisted 1 year after injury.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients

BACKGROUND

Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge.

METHODS

We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients.

RESULTS

Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge.

CONCLUSIONS

Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

Assessment of pre-injury health-related quality of life: a systematic review

Background

Insight into the change from pre- to post-injury health-related quality of life (HRQL) of trauma patients is important to derive estimates of the impact of injury on HRQL. Prospectively collected pre-injury HRQL data are, however, often not available due to the difficulty to collect these data before the injury. We performed a systematic review on the current methods used to assess pre-injury health status and to estimate the change from pre- to post-injury HRQL due to an injury.

Methods

A systematic literature search was conducted in EMBASE, MEDLINE, and other databases. We identified studies that reported on the pre-injury HRQL of trauma patients. Articles were collated by type of injury and HRQL instrument used. Reported pre-injury HRQL scores were compared with general age- and gender-adjusted norms for the EQ-5D, SF-36, and SF-12.

Results

We retrieved results from 31 eligible studies, described in 41 publications. All but two studies used retrospective assessment and asked patients to recall their pre-injury HRQL, showing widely varying timings of assessments (soon after injury up to years after injury). These studies commonly applied the SF-36 (n = 13), EQ-5D (n = 9), or SF-12 (n = 3) using questionnaires (n = 14) or face-to-face interviews (n = 11). Two studies reported prospective pre-injury assessment, based on prospective longitudinal cohort studies from a sample of initially non-injured patients, and applied questionnaires using the SF-36 or SF-12. The recalled pre-injury HRQL scores of injury patients consistently exceeded age- and sex-adjusted population norms, except in a limited number of studies on injury types of higher severity (e.g., traumatic brain injury and hip fractures). All studies reported reduced post-injury HRQL compared to pre-injury HRQL. Both prospective studies reported that patients had recovered to their pre-injury levels of physical and mental health, while in all but one retrospective study patients did not regain the reported pre-injury levels of HRQL, even years after injury.

Conclusions

So far, primarily retrospective research has been conducted to assess pre-injury HRQL. This research shows consistently higher pre-injury HRQL scores than population norms and a recovery that lags behind that of prospective assessments, implying a systematic overestimation of the change in HRQL from pre- to post-injury due to an injury. More prospective research is necessary to examine the effect of recall bias and response shift. Researchers should be aware of the bias that may arise when pre-injury HRQL is assessed retrospectively or when population norms are applied, and should use prospectively derived HRQL scores wherever possible to estimate the impact of injury on HRQL.

Electronic supplementary material

The online version of this article (doi:10.1186/s12963-017-0127-3) contains supplementary material, which is available to authorized users.

Language control in bilingual adults with and without history of mild traumatic brain injury

Adults with a history of traumatic brain injury often show deficits in executive functioning (EF), including the ability to inhibit, switch, and attend to tasks. These abilities are critical for language processing in bilinguals. This study examined the effect of mild traumatic brain injury (mTBI) on EF and language processing in bilinguals using behavioral and eye-tracking measures. Twenty-two bilinguals with a history of mTBI and twenty healthy control bilinguals were administered executive function and language processing tasks. Bilinguals with a history of mTBI showed deficits in specific EFs and had higher rates of language processing errors than healthy control bilinguals. Additionally, individuals with a history of mTBI have different patterns of eye movements during reading than healthy control bilinguals. These data suggest that language processing deficits are related to underlying EF abilities. The findings provide important information regarding specific EF and language control deficits in bilinguals with a history mTBI.

Utilization of Mental Health Services After Mild Pediatric Traumatic Brain Injury

BACKGROUND

Mild traumatic brain injury injuries (mTBIs), including concussions, represent >2 million US pediatric emergency department visits annually. Post-mTBI mental health symptoms are prominent and often attributed to the mTBI. This study examined whether individuals seeking post-mTBI mental health care had previous mental health diagnoses or a new onset of such disorders, and determined if mental health care utilization differed by race/ethnicity.

METHODS

Retrospective cohort study, using the Medicaid Marketscan claims national dataset (2007-2012). Utilization of mental health services 1 year before and 1 year after mTBI was compared between children with and without mental health diagnoses before injury. Primary outcome was receipt of post-mTBI outpatient mental health care.

RESULTS

A total of 31 272 children 20 years or younger were included, 8577 (27%) with mental health diagnoses before their mTBI and 22 695 without one. After injury, children without previous mental health disorders increased mental health services utilization; however, most (86%) postinjury mental health care was received by children with previous mental health disorders. Having a mental health diagnosis pre-mTBI was the most important risk factor for receiving post-mTBI mental health care (odds ratio 7.93, 95% confidence interval 7.40-8.50). Hispanic children were less likely to receive post-mTBI mental health care.

CONCLUSIONS

mTBI was associated with increased utilization of mental health services but most of these services were received by children with previous mental health disorders. Our documentation of racial/ethnic disparities in mental health care utilization reemphasize the importance of providing individualized, culturally, and linguistically competent care to improve outcomes after mTBI for all children.

Availability of Outpatient Rehabilitation Services for Children After Traumatic Brain Injury: Differences by Language and Insurance Status

OBJECTIVE

The objective of this study was to explore associations between English proficiency, insurance status, outpatient rehabilitation service availability, and travel time for children with traumatic brain injury.

DESIGN

The authors used an ecologic cross-sectional design. Data were analyzed from a cohort of 82 children with moderate to severe traumatic brain injury and rehabilitation providers in Washington State. Main measures included availability and travel time to services.

RESULTS

Less than 20% of providers accepted children with Medicaid and provided language interpretation. Mental health services were most limited. Adjusted for median household income, multilingual service availability was lowest in counties with greater language diversity; for every 10% increase in persons older than 5 yrs speaking a language other than English at home, there was a 34% decrease in availability of multilingual services (prevalence ratio, 0.66; 95% confidence interval, 0.48-0.90). Adjusted for education and Medicaid status, children from Spanish-speaking families had significantly longer travel times to services (mean, 16 additional minutes to mental health; 9 to other therapies).

CONCLUSIONS

Children in households with limited English proficiency and Medicaid faced significant barriers in availability and proximity of outpatient rehabilitation services. Innovative service strategies are needed to equitably improve availability of rehabilitation for children with traumatic brain injury. Similar studies in other regions will inform one's understanding of the scope of these disparities.

Outpatient Rehabilitation for Medicaid-Insured Children Hospitalized With Traumatic Brain Injury

OBJECTIVES

To describe the prevalence of postdischarge outpatient rehabilitation among Medicaid-insured children hospitalized with a traumatic brain injury (TBI) and to identify factors associated with receipt of services.

METHODS

Retrospective cohort of children <21 years, hospitalized for a TBI between 2007 and 2012, from a national Medicaid claims database. Outcome measures were receipt of outpatient rehabilitation (physical, occupational, or speech therapies or physician visits to a rehabilitation provider) 1 and 3 years after discharge. Multivariable regression analyses determined the association of demographic variables, injury severity, and receipt of inpatient services with receipt of outpatient rehabilitation at 1 and 3 years. The mean number of services was compared between racial/ethnic groups.

RESULTS

Among 9361 children, only 29% received any type of outpatient rehabilitation therapy during the first year after injury, although 62% sustained a moderate to severe TBI. The proportion of children receiving outpatient therapies declined to 12% in the second and third years. The most important predictor of receipt of outpatient rehabilitation was receipt of inpatient therapies or consultation with a rehabilitation physician during acute care. Compared with children of other racial/ethnic groups, Hispanic children had lower rates of receipt of outpatient speech therapy.

CONCLUSIONS

Hospitalized children who received inpatient assessment of rehabilitation needs were more likely to continue outpatient rehabilitation care. Hispanic children with TBI were less likely than non-Hispanics to receive speech therapy. Interventions to increase inpatient rehabilitation during acute care might increase outpatient rehabilitation and improve outcomes for all children.

Functional outcomes during inpatient rehabilitation for American Indian and Alaska Native children with traumatic brain injury

PURPOSE

American Indian/Alaska Native (AI/AN) people have the highest traumatic brain injury (TBI)-related mortality in the United States, but little is known about AI/AN children who survive traumatic brain injury (TBI). This study compares function and factors associated with discharge function between AI/AN and White children with TBI during inpatient rehabilitation.

METHODS

Retrospective national cohort study of 114 AI/AN and 7,267 White children aged 6 months-18 years who received inpatient TBI rehabilitation between 2002-2012 at facilities utilizing the Uniform Data System for Medical Rehabilitation\scriptsize®. The outcome measure was developmental functional quotients (DFQ is the FIM\scriptsize® or WeeFIM\scriptsize® score divided by age norms x 100) at discharge.

RESULTS

AI/AN race was not associated with motor (regression coefficient (β) 0.18, 95% confidence interval (CI) -2.39, 2.76) or cognitive (β -1.54, 95% CI -3.75, 0.67) function. Among a subgroup with loss of consciousness > 24 hours (AI/AN n= 13, White n= 643), AI/AN race was associated with lower motor DFQ (β -12.83, 95% CI -25.39, -0.34).

CONCLUSIONS

Overall, AI/AN race was not associated with inpatient rehabilitation function for children with TBI, but providers should not assume AI/ANs with more severe injuries have equitable outcomes.

Occipital Nerve Blocks for Pediatric Posttraumatic Headache: A Case Series

Posttraumatic headache is one of the most common and disabling symptoms after traumatic brain injury. However, evidence for treating posttraumatic headache is sparse, especially in the pediatric literature. This retrospective chart review evaluated the use of occipital nerve blocks in adolescents treated for posttraumatic headache following mild traumatic brain injury, presenting to the Complex Concussion and Traumatic Brain Injury clinic. Fifteen patients (mean age 15.47; range: 13-17) received occipital nerve block for posttraumatic headache. Follow-up was obtained in 14 patients at 5.57 (standard deviation = 3.52) months postinjury. The headache burden was high, with all except one having headaches 15 or more days per month (median 30, range 10-30). Sixty-four percent reported long-term response to the occipital nerve blocks, with associated improved quality of life and decreased postconcussion symptom scores (P < .05). One patient reported transient allopecia. Occipital nerve blocks are well tolerated and can be helpful in posttraumatic headache.

Role of contextual factors in the rehabilitation of adolescent survivors of traumatic brain injury: emerging concepts identified through modified narrative review

BACKGROUND

Recently research in traumatic brain injury (TBI) intervention has identified the benefits of contextualized, embedded, functionally based approaches to maximize treatment outcomes. An essential component of contextualized intervention is the direct and purposeful consideration of the broader context, in which the person with TBI functions. However, systematic consideration of contextual factors remains limited both in research and clinical practice.

AIMS

The purposes of this modified narrative review were (1) to provide a succinct review of the available literature regarding the contextual factors that are specific to adolescent survivors of TBI, one of highest incidence groups for brain injury; (2) to connect these contextual factors to the direct long-term management of TBI and to identify their potential impact on outcome; and (3) to highlight areas that are open to research and clinical advances that could enhance positive outcomes for adolescent survivors of TBI. The framework of the World Health Organization's (WHO) International Classification of Functioning, Disability and Health-Children and Youth Version (ICF-CY; 2007) was used as a foundation for this review.

METHODS & PROCEDURES

A systematic literature search was conducted using databases and hand searches. A total of 102 articles were originally identified. Twenty-five original research articles, eight review papers and four expert opinion papers met inclusion and exclusion criteria and were included in the final review.

MAIN CONTRIBUTION

The body of research specifically focused on contextual factors is an emerging area. Early findings indicate that a focus on the direct modification of contextual factors is promising for the facilitation of positive outcomes long into the chronic phase of management for adolescences who have survived a TBI. The contextual factors included in this review were the overall ability of the school to support a student post-TBI, family psychosocial risk (sibling/sibling relationships/stress/burden/support), coping style (TBI survivor and their caregivers), and socioeconomic status of the family. Given the promise of these findings, research and clinical application efforts should be focused on identifying well-prescribed rehabilitation paradigms that capitalize on the modification of contextual factors throughout the recovery process.

CONCLUSIONS & IMPLICATIONS

The results of this modified narrative review provide an initial summary of the available evidence for addressing contextual factors in the rehabilitation process for adolescents with TBI. This is an area that is wide open for both systematic research and clinical application and holds potential to improve long-term outcome for survivors of adolescent TBI.

Functional independence after inpatient rehabilitation for traumatic brain injury among minority children and adolescents

OBJECTIVE

To compare motor and cognitive functional independence scores between Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW) children with traumatic brain injury (TBI) after discharge from inpatient rehabilitation.

DESIGN

Retrospective cohort study using the Uniform Data System for Medical Rehabilitation national dataset from the years 2002 to 2012.

SETTING

Inpatient rehabilitation units.

PARTICIPANTS

Children (N=10,141) aged 6 months to 18 years who received inpatient rehabilitation for TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Motor and cognitive functional independence after discharge from inpatient rehabilitation, adjusting for age, sex, admission function, length of stay, insurance, and region.

RESULTS

Inpatient rehabilitation therapy improved functional independence for all children. Younger age, lower admission functional independence scores, and Medicaid insurance were associated with lower functional independence at discharge. Hispanic and NHB children had lower discharge cognitive scores compared with NHW children; however, differences were small and were partially explained by insurance status and region. Children who received rehabilitation therapy at pediatric facilities had greater cognitive improvement.

CONCLUSIONS

While racial/ethnic disparities are small, minority children are more likely to be younger, to have Medicaid, and to be cared for at nonpediatric facilities, factors that increase their risk for lower functional outcomes.

Health-related quality of life after TBI: a systematic review of study design, instruments, measurement properties, and outcome

Measurement of health-related quality of life (HRQL) is essential to quantify the subjective burden of traumatic brain injury (TBI) in survivors. We performed a systematic review of HRQL studies in TBI to evaluate study design, instruments used, methodological quality, and outcome. Fifty-eight studies were included, showing large variation in HRQL instruments and assessment time points used. The Short Form-36 (SF-36) was most frequently used. A high prevalence of health problems during and after the first year of TBI was a common finding of the studies included. In the long term, patients with a TBI still showed large deficits from full recovery compared to population norms. Positive results for internal consistency and interpretability of the SF-36 were reported in validity studies. The Quality of Life after Brain Injury instrument (QOLIBRI), European Brain Injury Questionnaire (EBIQ), Child Health Questionnaire (CHQ), and the World Health Organization Quality of Life short version (WHOQOL-BREF) showed positive results, but evidence was limited. Meta-analysis of SF-36 showed that TBI outcome is heterogeneous, encompassing a broad spectrum of HRQL, with most problems reported in the physical, emotional, and social functioning domain. The use of SF-36 in combination with a TBI-specific instrument, i.e., QOLIBRI, seems promising. Consensus on preferred methodologies of HRQL measurement in TBI would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of the burden of TBI.

The rich get richer: brain injury elicits hyperconnectivity in core subnetworks

There remains much unknown about how large-scale neural networks accommodate neurological disruption, such as moderate and severe traumatic brain injury (TBI). A primary goal in this study was to examine the alterations in network topology occurring during the first year of recovery following TBI. To do so we examined 21 individuals with moderate and severe TBI at 3 and 6 months after resolution of posttraumatic amnesia and 15 age- and education-matched healthy adults using functional MRI and graph theoretical analyses. There were two central hypotheses in this study: 1) physical disruption results in increased functional connectivity, or hyperconnectivity, and 2) hyperconnectivity occurs in regions typically observed to be the most highly connected cortical hubs, or the "rich club". The current findings generally support the hyperconnectivity hypothesis showing that during the first year of recovery after TBI, neural networks show increased connectivity, and this change is disproportionately represented in brain regions belonging to the brain's core subnetworks. The selective increases in connectivity observed here are consistent with the preferential attachment model underlying scale-free network development. This study is the largest of its kind and provides the unique opportunity to examine how neural systems adapt to significant neurological disruption during the first year after injury.

Traumatic brain injury: considering collaborative strategies for early detection and interventional research

Mild traumatic brain injury (mTBI) is a graded sequence of injuries, which is clinically defined based on subjective symptoms observed by clinicians and/or those reported by patients. Much of the focus on research and prevention of mTBI has been on professional or collegiate-level athletes, despite children and young teenagers being at greatest risk for mTBI. Further, continued involvement in sports across the lifespan, increases the likelihood that youth athletes may sustain repetitive brain trauma, which may result in permanent neurological and psychological deficits. Thus, there is a clear need for a population health initiative and research efforts that focus on the juvenile athlete population; in order to fill in the gap in knowledge about the long-term physiological effects of injury and social outcomes, as well as devise strategies that can help in early detection, prevention and treatment; and in the setting of evidence-based Return-To-Play guidelines.