We know the value of preventing adverse childhood experiences, but promoting positive childhood experiences is also important. © 2024, Author. All rights reserved.

BACKGROUND: Traumatic brain injury is a major cause of death and disability worldwide, with almost half of new cases occurring in children, adolescents, and young adults. However, data on injury characteristics stratified by social determinants of health are scarce. This study explores severity, intent, and mechanism of traumatic brain injury sustained during childhood, adolescence, and young adulthood by social determinants of health. METHODS: This study utilizes a population-based birth cohort of births in publicly funded hospitals in Ontario, Canada, between April 1, 1992 and March 31, 2020 (n = 3,648,760). Individuals experiencing a traumatic brain injury requiring medical attention to the emergency department or acute care between April 1, 2002 and November 20, 2020 (n = 94,514) were identified using International Classification of Diseases Version 10 diagnosis codes. Social determinants of health variables included age, sex, rurality of residence, neighbourhood income quintile, and the following Ontario Marginalization Index variables: households and dwellings, material resources, and racialized and newcomer populations. The primary outcome was percentage of injuries falling under each mechanism, intent, and severity of injury category, stratified by social determinants of health variables. RESULTS: Approximately 50% of injuries were mild and 96.2% of injuries were unintentional. Injury severity and intent of injury significantly varied by social determinants of health; for example, the proportion of traumatic brain injury-related healthcare visits for moderate/severe and intentional injuries was highest in areas with the lowest income quintile (13.3% and 6.1%, respectively), lowest households and dwellings stability (12.2% and 5.7%, respectively), lowest material resources (12.8% and 6.0% respectively), and highest racialized and newcomer populations (13.5% and 4.5% respectively). The percentage of traumatic brain injury-related healthcare visits for a sports-related injury significantly varied by social determinants of health; for example, the proportion of traumatic brain injury-related healthcare visits for sports-related injuries was highest among males (45.5%), those living rural areas (44.0%), and those living in areas with the highest income (47.2%), highest households and dwellings stability (44.0%), highest material resources (45.8%), and lowest racialized and newcomer populations (43.4%). CONCLUSIONS: Characteristics of traumatic brain injury-related healthcare visits vary based on social determinants of health. Targeted prevention of traumatic brain injury beyond the sports settings, including fall prevention among young children, are encouraged, and guidelines to identify and address traumatic brain injury outside of the sports setting must be developed to support early intervention of traumatic brain injury across social determinants of health.

BACKGROUND: Healthcare providers play a critical role in the return to school (RTS) process after a child sustains a mild traumatic brain injury (mTBI). The purpose of this study was to examine healthcare providers' perspectives on effective communication with school personnel and gaps within those practices, using a qualitative approach. METHODS: Twelve community-based healthcare providers in suburban Oregon and Ohio completed semi-structured interviews between February 2021 and July 2021 via Zoom. Data were analyzed using thematic analysis. RESULTS: Primary themes centered on how breakdowns in communication between healthcare and education systems occur easily without formalized systems, and how formalized systems of care are beneficial. CONCLUSIONS: Children with mTBI benefit when there is (1) a consistent communication system between school-based staff, caregivers, and healthcare providers and (2) a clear point person in the school system. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Schools should create intentional and formalized communication pathways with healthcare providers as an effective approach to meeting the needs of students and their families.

ARTICLE SUMMARY: Prescribed early physical activity and behavioral management did not improve outcomes in youth following acute concussion compared to the standard of care. OBJECTIVE: To determine the efficacy of early physical activity and behavioral management for acute concussion in pediatric patients. STUDY DESIGN: A multicenter, prospective, 2x2 factorial randomized controlled trial was conducted among patients aged 11-24 years who presented within 72 hours of injury. Participants were randomized into four groups based on early physical activity (or usual care) and behavioral management (or none). The early activity group was encouraged to meet step targets despite symptoms. The primary outcomes were post-concussion symptom severity and quality of life at 14 days post-enrollment. RESULTS: A total of 239 participants were randomized, and 210 completed all study procedures. The early activity group demonstrated higher daily step counts compared with the usual care group. However, no significant differences were observed in post-concussion symptom severity or quality of life at 14 days between groups. The early activity group experienced higher daily post-concussion symptom severity during the first 7 days and took longer to recover compared with the usual care group. Behavioral management showed no effect on outcomes. CONCLUSIONS: Early prescribed physical activity and behavioral management did not improve post-concussion outcomes in the first two weeks following injury. Early prescribed activity despite symptoms was associated with delayed symptom resolution. Clinical trial registration ClinicalTrials.gov NCT03869970.

This cohort study examines incident and subsequent health care visits associated with traumatic brain injury and stratified by social determinants of health. | eng

OBJECTIVE: Traumatic brain injury (TBI) can result in new onset of comorbidities and limited studies suggest health care utilization following TBI may be high. Setting, Participants, Mean Measures, and Design: This study used 2018 and 2019 MarketScan Commercial Claims and Encounters data to examine differences in longitudinal health outcomes (health care utilization and new diagnoses) by various demographic factors (age, sex, U.S. region, intent/mechanism of injury, urbanicity, and insurance status) among individuals with and without a TBI in the year following an index health care encounter. RESULTS: Results show that within 1 year of the initial encounter, a higher percentage of patients with TBI versus without TBI had at least one outpatient visit (96.7% vs 86.1%), emergency department (ED) visit (28.5% vs 13.1%), or hospital admission (6.4% vs 2.6%). Both children (33.8% vs 23.4%) and adults (43.8% vs 31.4%) who sustained a TBI had a higher percentage of new diagnoses within 1 year compared to the non-TBI group. Additionally, individuals with a TBI had greater health care utilization across all types of health care settings (outpatient and inpatient), visits (ED visits and hospital admissions), and across all demographic factors (P < .001). CONCLUSION: These results may inform future research around the development of systems of care to improve longer-term outcomes in individuals with TBI.

IMPORTANCE: Many recent advances in pediatric concussion care are implemented by specialists; however, children with concussion receive care across varied locations. Thus, it is critical to identify which children have access to the most up-to-date treatment strategies. OBJECTIVE: To evaluate differences in the sociodemographic and community characteristics of pediatric patients who sought care for concussion across various points of entry into a regional health care network. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study included children seen for concussions across a regional US health care network from January 1, 2017, to August 4, 2023. Pediatric patients aged 0 to 18 years who received an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification code for concussion were included. The study took place at emergency department (ED) and outpatient (primary care [PC] and specialty care [SC]) settings. EXPOSURES: Age at visit, biological sex, parent-identified race and ethnicity, payer type, median income and percentage of adults with a bachelor's degree for home zip code, and overall and subdomain Child Opportunity Index (COI) score based on patient address. MAIN OUTCOMES AND MEASURES: The association of exposures with point of entry of ED, PC, and SC were examined in both bivariate analysis and a multinomial logistic regression. RESULTS: Overall, 15 631 patients were included in the study (median [IQR] age, 13 [11-15] years; 7879 [50.4%] male; 1055 [6.7%] Hispanic, 2865 [18.3%] non-Hispanic Black, and 9887 [63.7%] non-Hispanic White individuals). Race and ethnicity were significantly different across settings (1485 patients [50.0%] seen in the ED were non-Hispanic Black vs 1012 [12.0%] in PC and 368 [8.7%] in SC; P < .001) as was insurance status (1562 patients [52.6%] seen in the ED possessed public insurance vs 1624 [19.3%] in PC and 683 [16.1%] in SC; P < .001). Overall and individual COI subdomain scores were also significantly different between settings (overall COI median [IQR]: ED, 30 [9-71]; PC, 87 [68-95]; SC, 87 [69-95]; P < .001). Race, insurance status, and overall COI had the strongest associations with point of entry in the multivariable model (eg, non-Hispanic Black patients seen in the ED compared with non-Hispanic White patients: odds ratio, 2.03; 95% CI, 1.69-2.45). CONCLUSIONS AND RELEVANCE: In this cross-sectional study, children with concussion seen in the ED setting were more likely to be non-Hispanic Black, have public insurance, and have a lower Child Opportunity Index compared with children cared for in the PC or SC setting. This highlights the importance of providing education and training for ED clinicians as well as establishing up-to-date community-level resources to optimize care delivery for pediatric patients with concussion at high risk of care inequities.

BACKGROUND: Limited information about school outcomes among children (especially early childhood) with lifetime history of head injury, including traumatic brain injury (TBI), may inhibit efforts to support their academics and physical and mental health. METHODS: Baseline data (2016-2018) from the Adolescent Brain Cognitive Development (ABCD) study were analyzed to describe associations between parent-proxy reported lifetime history of head injury or TBI before age 9 and school outcomes and behavioral challenges among 9- and 10-year-old children. RESULTS: Having a lifetime history of head injury before age 9 was associated with increased odds of parent-perceived poor school performance (adjusted odds ratio [AOR] = 1.44, 95% confidence interval [CI] = 1.14-1.81), a drop in grades (AOR = 1.28, 95%CI = 1.06-1.54), recent receipt of detentions or suspensions (AOR = 1.29, 95%CI = 1.02-1.65), and receipt of special educational services (AOR = 1.23, 95%CI = 1.08-1.41). Of those with a lifetime history of head injury, males displayed poorer school outcomes and greater behavioral challenges than females. Similar associations were observed between lifetime history of TBI before age 9 and worse school outcomes, with males continuing to demonstrate stronger associations. CONCLUSIONS: These findings underscore the importance of screening for history of head injury and TBI and providing training for school professionals to help ensure students with a history of head or traumatic brain injury have appropriate supports in place.

Objective: To (1) estimate the lifetime prevalence of suspected and diagnosed traumatic brain injury (TBI) based on parent report overall and select sociodemographic characteristics; and (2) describe differences in prevalence of health conditions and health-related risk factors by whether a child had a lifetime history of diagnosed TBI. Study design: We analyzed data from the 2020 National Survey of Children's Health, a cross-sectional address-based survey of US households. A categorical variable was created on the basis of parent responses to 3 questions inquiring about their suspicion of their child having a brain injury, if they sought medical care, and if the health care provider provided a diagnosis. Parents also were asked to report on their child's additional health conditions, functional indicators, school and social factors, and health care access and service use. Results: The prevalence of lifetime diagnosed TBI was 4.2% (95% CI 3.8-4.5). Children with a parent-reported lifetime history of diagnosed TBI were more likely to have a variety of health conditions, special health care needs, disabilities, activity limitations, missed days of school, and unmet care coordination needs, compared with those without a history. However, they were more likely to have a usual source of sick care and to receive more health-related services. Conclusions: For school-aged children, a history of TBI is associated with parent-reported health needs and conditions, as well as missed days from school. It is particularly important for parents to seek care when they suspect their child has experienced a TBI to receive a diagnosis and monitor the impacts of the TBI. © 2024

BACKGROUND: Children aged 0-4 years have the highest rate of emergency department (ED) visits for traumatic brain injury (TBI); falls are the leading cause. Infants younger than 2 years are more likely to sustain a fractured skull after a fall. OBJECTIVE: This study examined caregiver actions and products associated with ED visits for fall-related fractured skulls in infants aged 0-4 months. METHODS: Data were analyzed from the 2001-2017 National Electronic Injury Surveillance System-All Injury Program. Case narratives of infants aged 0-4 months who visited an ED for a fall-related skull fracture were examined to code caregiver actions preceding the fall. Product codes determined fall location and product type involved (e.g., flooring, bed, or stairs). All national estimates were weighted. RESULTS: There were more than 27,000 ED visits (weighted estimate) of infants aged 0-4 months for a nonfatal fall-related fractured skull between 2001 and 2017. Most were younger than 2 months (46.7%) and male (54.4%). Falls occurred primarily in the home (69.9%) and required hospitalization (76.4%). Primary caregiver actions coded involved placing (58.6%), dropping (22.7%), and carrying an infant (16.6%). Floor surfaces were the most common product (mentioned in 24.0% of the cases). CONCLUSIONS: Fall-related fractured skulls are a health and developmental concern for infants, highlighting the importance of a comprehensive assessment at the time of the injury to better understand adult actions. Findings indicated the need to develop prevention messages that include safe carrying and placement of infants.

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.

Sexual violence (SV) is a critical public health problem that is associated with numerous negative health consequences, including immediate- and long-term physical and mental health conditions and health-risk behaviors. Some of these health-risk behaviors (e.g., substance use, unsafe driving practices, poor mental health, lower impulse control, and abnormal brain circuitry) might increase the risk for sustaining a traumatic brain injury (TBI). A TBI causes neurological or neuropsychological changes and may also lead to various symptoms that affect a person's cognition, mobility, behavior, and mental health. Determining if those who have experienced SV are at increased risk of sustaining a TBI in their lifetime is critical given the high prevalence and health impacts of SV, the potential vulnerability to TBI after SV, and the known detrimental effects of TBI. This exploratory study examined data from the 2017 Connecticut behavioral risk factor surveillance system and found that lifetime SV victimization (controlling for age and sex) was associated with increased odds of reporting a recent TBI in the past 12 months (adjusted odds ratio [AOR] = 2.1; 95% confidence interval [CI] [1.03, 4.21]). Further research is needed to better understand how SV history is related to the risk of sustaining a TBI. Healthcare professionals can support patients who experience SV by providing resources to help reduce associated physical and mental health conditions and health-risk behaviors.

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.

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.

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.

THE CENTERS for disease control and prevention (CDC) Report to Congress on the Management of Traumatic Brain Injury (TBI) described the management of TBI in children as an important public health issue.1 A brain injury of any severity can occur at 1 or multiple times during childhood. As a result of TBI during childhood, changes in health, cognition, family environment, and behavior can affect learning, self-regulation, and social participation, which are critical skills to optimize functioning in adulthood.2 TBI affects children differently than it affects adults because it can impact brain development during key periods that may alter developmental trajectories over time.2 Although most children recover well physically, they can experience changes in behavior and cognition that may not be recognized immediately.2 During childhood, a history of TBI is often associated with several health conditions, including epilepsy, headache/migraine, autonomic disturbances, intellectual disability, vision problems, speech and language problems, and behavior and mental health problems.3

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.

OBJECTIVE: Adverse childhood experiences (ACEs) are associated with increased risk of sustaining a traumatic brain injury (TBI). Alcohol use may play an important role in this relationship. This study examines whether binge drinking mediates the relationship between four ACEs and TBIs sustained in adulthood. METHODS: Using the National Longitudinal Survey of Youth, 1979 cohort, we conducted longitudinal mediation analyses (n=6317). Interviews occurred annually from 1979 to 1994 and biennially until 2016. We evaluated the direct and indirect effects of individual ACEs (ie, experiencing physical violence, low parental warmth, familial alcoholism and familial mental illness; reported retrospectively) and a cumulative ACEs score on mean level of binge drinking (calculated across waves) and having a TBI in adulthood. To establish temporality, we included binge drinking that was measured at age 18 or older and before any reported TBI. RESULTS: Cumulative ACEs, familial alcoholism and physical abuse exposure were significantly associated with having a TBI through binge drinking, although this only explained a small part of the association between ACEs and TBI. Other ACEs were not significantly associated with binge drinking or TBI. CONCLUSION: The results indicate that while ACEs and adult TBI risk were significantly associated, lifetime binge drinking explains only a small part of the association. Future research could examine alternative social, biological and behavioural mechanisms along the pathway between ACEs and TBI. Determining this mechanism will allow public health practitioners to design and implement effective TBI prevention programmes for those at higher risk of injury due to ACE exposure.

BACKGROUND: Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents. OBJECTIVE: To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response. METHODS: This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days. CONCLUSION: Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.

Traumatic brain injuries (TBIs) are a leading cause of morbidity and mortality in the US.1 In recent years, these injuries have received greater attention as a public health concern due to increased awareness of sport- and military-related TBIs.2 However, older adults have been reported to have higher rates of TBI than any other age group.1 In 2017, adults aged 65 years or older accounted for 38.4% of all TBI-related deaths and 43.9% of all TBI-related hospitalizations in the US.1 In addition, older adults who experience a TBI are more likely to have higher morbidity and mortality, slower recovery, and worse outcomes than younger adults.2

BACKGROUND: To inform prevention strategies, this study provides incidence, factors, and actions taken when a suspected concussion occurred in K-12 schools in Utah. METHODS: Data were collected using Utah's Student Injury Reporting System (SIRS) from the academic years 2011-2012 to 2018-2019. SIRS is a unique online system that tracks injuries that occur in the school setting among K-12 students in Utah. Descriptive statistics were computed to characterize students with a suspected concussion. Chi-square (χ(2) ) analysis looking at characteristics by school level was also conducted. RESULTS: Over 63,000 K-12 students in Utah sustained an injury at school during the study period. Suspected concussions comprised 10% of all injuries. The prevalence of concussions was highest among males (60.6%) and elementary school students (42.6%) and most often occurred outdoors (57.6%) or on a playground/playfield (33.9%), and in sports- and recreation-related activities (75.1%) (specifically contact sports, 24.0%). Most students with a suspected concussion were absent 1 day or less from school (71.4%) but about 68% were seen by a medical professional. Further, there were differences by school level. Females and students playing contact sports had a higher percentage of suspected concussions as school level increased, whereas males and concussions sustained during school hours had a lower percentage of suspected concussions as school level increased. CONCLUSIONS: SIRS enables schools in Utah to identify groups at risk for concussion, as well as activities most commonly associated with these injuries, within the school environment. Using this information, schools may implement targeted prevention strategies to protect students.

BACKGROUND: Understanding parents' concussion-related knowledge and attitudes will contribute to the development of strategies that aim to improve concussion prevention and sport safety for elementary school children. This study investigated the association between parent- and child-related factors and concussion symptom knowledge and care-seeking attitudes among parents of elementary school children (aged 5-10 years). METHODS: Four hundred parents of elementary school children completed an online questionnaire capturing parental and child characteristics; concussion symptom knowledge (25 items, range = 0-50; higher = better knowledge); and concussion care-seeking attitudes (five 7-point scale items, range = 5-35; higher = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher score levels. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) excluding 1.00 were deemed statistically significant. RESULTS: Select parent and child characteristics were associated with higher score levels for both outcomes. For example, odds of better knowledge level in parents were higher with increased age (10-year increase aOR = 1.59; 95% CI = 1.10-2.28), among females (aOR = 3.90; 95% CI = 2.27-6.70), and among white/non-Hispanics (aOR = 1.79; 95%CI = 1.07-2.99). Odds of more positive concussion care-seeking attitude levels were higher among parents with a college degree (aOR = 1.98; 95%CI = 1.09-3.60). Child sports participation was not associated with higher score levels for either outcome. CONCLUSIONS: Certain elementary school parent characteristics were associated with parents' concussion symptom knowledge and care-seeking attitudes. While the findings suggest providing parents with culturally and demographically relevant concussion education might be helpful, they also emphasize the importance of ensuring education/prevention regardless of their children's sports participation. Practical Applications: Pediatric healthcare providers and elementary schools offer an optimal community-centered location to reach parents with this information within various communities.

BACKGROUND: Little is known about the effectiveness of school district concussion policies on reducing the concussion prevalence among students. METHODS: Data from the 2016 School Health Policies and Practices Study and 2017 Youth Risk Behavior Survey for 10 school districts were linked. The outcome variable was having a sports- or physical activity-related concussion during the 12 months before of the survey. Exposure variables were 2 district policies, including district-funded professional development and prioritizing return to the classroom before returning to athletics. Logistic regression models estimated the odds of a concussion among students in districts with one, both, or neither policy (referent). RESULTS: In districts with district-funded professional development, the odds of students self-reporting ≥2 sports- or physical activity-related concussions were 1.4 times higher than in districts with neither policy. In districts with a policy prioritizing a return to the classroom before returning to athletics, the odds of students self-reporting ≥2 concussions were significantly lower (OR = 0.6) than in districts with neither policy. CONCLUSION: School district concussion policies may have positive effects by identifying and reducing multiple concussions among students.

OBJECTIVE: While prior studies have found parental socioeconomic status (SES) affects the outcomes of pediatric traumatic brain injury (TBI), the longitudinal trajectory of this effect is not well understood. METHODS: This prospective cohort study included children 8-18 years of age admitted to six sites with a complicated mild (n = 123) or moderate-severe TBI (n = 47). We used caregiver education and household poverty level as predictors, and multiple quality of life and health behavior domains as outcomes. Differences at 6, 12, and 24 months from baseline ratings of pre-injury functioning were compared by SES. We examined the association between measures of SES and domains of functioning over the 24 months post-injury in children with a complicated mild or moderate- severe TBI, and determined how this association varied over time. RESULTS: Parental education was associated with recovery among children with complicated mild TBI; outcomes at 6, 12, and 24 months were substantially poorer than at baseline for children with the least educated parents. After moderate-severe TBI, children in households with lower incomes had poorer outcomes compared to baseline across time. IMPLICATIONS: Parental education and household income were associated with recovery trajectories for children with TBI of varying severity.

Although many patients diagnosed with traumatic brain injury (TBI), particularly mild TBI, recover from their symptoms within a few weeks, a small but meaningful subset experience symptoms that persist for months or years after injury and significantly impact quality of life for the individual and their family. The factors associated with an increased likelihood of negative TBI outcomes include not only characteristics of the injury and injury mechanism, but also the individual's age, pre-injury status, comorbid conditions, environment, and propensity for resilience. In this article, as part of the Brain Trauma Blueprint: TBI State of the Science framework, we examine the epidemiology of long-term outcomes of TBI, including incidence, prevalence, and risk factors. We identify the need for increased longitudinal, global, standardized, and validated assessments on incidence, recovery, and treatments, as well as standardized assessments of the influence of genetics, race, ethnicity, gender, and environment on TBI outcomes. By identifying how epidemiological factors contribute to TBI outcomes in different groups of people and potentially impact differential disease progression, we can guide investigators and clinicians towards more precise patient diagnosis along with tailored management and improve clinical trial designs, data evaluation and patient selection criteria.

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.

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.

BACKGROUND AND OBJECTIVES: Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection. METHODS: Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health (NSCH), the National Health Interview Survey (NHIS), and the Monitoring the Future (MTF) Survey were examined. Children were grouped by ages 3-17 years and adolescents ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH, NHIS) and adolescents (MTF Survey). The primary outcome measure is an estimate of LCHI in children. RESULTS: Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language. CONCLUSIONS: Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

OBJECTIVE: Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion symptom knowledge and care-seeking attitudes among parents of MS children (aged ∼10-15 years). METHODS: A panel of 1224 randomly selected US residents, aged ≥18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 points (range = 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range = 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) (excluding 1.00) were deemed statistically significant. RESULTS: Median scores were 39 (interquartile range (IQR) = 32-44) for symptom knowledge and 32 (IQR = 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71) and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics versus other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99), and higher parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47). CONCLUSION: Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

OBJECTIVE: To provide state-level traumatic brain injury (TBI)-related emergency department (ED) visit, hospitalization, and death estimates by age group for 2014. SETTING AND PARTICIPANTS: Centers for Disease Control and Prevention's Core Violence and Injury Prevention Program and State Injury Indicators-participating states. DESIGN: Cross-sectional. MAIN MEASURES: Number and population-based incidence rates of TBI-related ED visits, hospitalizations, and deaths by age group-children and young adults (0-24 years), adults (25-64 years), and older adults (≥65 years)-in 36 states. RESULTS: South Dakota had the lowest rates of TBI-related ED visits for all age groups-children and young adults: 566.2 (95% CI: 539.2-593.3) per 100 000; adults: 269.2 (95% CI: 253.0-285.4) per 100 000; and older adults: 324.3 (95% CI: 293.4-355.2) per 100 000. Rhode Island had the lowest rate of TBI-related hospitalizations for children and young adults-25.9 (95% CI: 20.7-32.0) per 100 000. The lowest rate of TBI-related hospitalizations among adults and older adults was in Virginia-39.6 (95% CI: 37.7-41.4) per 100 000-and Ohio-129.3 (95% CI: 124.0-134.6) per 100 000-respectively. Maryland had the lowest rate of TBI-related deaths for children and young adults-3.1 (95% CI: 2.3-3.9) per 100 000. Rhode Island had the lowest rate of TBI-related deaths for adults-7.2 (95% CI: 5.2-9.8) per 100 000-and New Jersey had the lowest rate of TBI-related deaths for older adults-29.4 (95% CI: 26.5-32.4) per 100 000. CONCLUSION: This analysis demonstrated that there are variations in TBI-related ED visits, hospitalizations, and deaths by age. State public health professionals may use these findings to develop state-based strategies to address TBI.