Neurobehavioral Symptom Profiles for the Behavioral Assessment Screening Tool in Chronic Traumatic Brain Injury.

OBJECTIVE: To identify neurobehavioral symptom profiles among persons with chronic traumatic brain injury (TBI) using the Behavioral Assessment Screening Tool (BAST) and to consider participant characteristics that differ between profile groups. SETTING: Community. PARTICIPANTS: Participants (n = 615) were English-speaking adults (≥18) and had a self-reported history of at least one TBI of any severity. DESIGN: Secondary analysis of cross-sectional data. MAIN MEASURES: The BAST measures neurobehavioral symptoms in the domains of Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, and Substance Misuse. RESULTS: Using latent profile analysis (LPA), we identified 3 different neurobehavioral profiles. Overall symptom frequency and differences in the pattern of symptom frequency across domains differentiated the profile groups. Average domain scores differed significantly across the profiles (P < .001) for all domains except Fatigue (P = .076). Those in profile 3 (High-Risk group) reported the most frequent symptoms across all domains (similar Negative Affect frequency as profile 1). Substance Misuse was especially high in this group. Compared to profile 2 (High Negative Affect group), participants in profile 1 (Moderate-Risk group) endorsed significantly more frequent (and more variable) symptoms across all BAST domains, particularly Impulsivity and Substance Misuse. Participants in profile 2 endorsed the least frequent symptoms across all domains. Demographic comparison showed that groups differed based on gender, age, and injury severity (mild vs moderate-severe), with profile 3 composed of the most men and the most persons in early adulthood, and profile 2 composed of the most women and those with mild TBI. CONCLUSIONS: We differentiated 3 neurobehavioral symptom profiles among persons with chronic TBI and determined differences in sociodemographic factors between the groups. Future research should focus on validating these profiles in another sample of individuals with chronic TBI. Characterizing persons according to multidimensional symptom profiles could allow for more tailored approaches to predict and prevent long-term negative outcomes.

Convergent, discriminant, and known groups validity of the Behavioral Assessment Screening Tool (BAST) in chronic traumatic brain injury.

The Behavioral Assessment Screening Tool (BAST) measures self-reported neurobehavioral symptoms commonly experienced by adults with traumatic brain injury (TBI). To assess the convergent, discriminant, and known-groups validity of the BAST among community-dwelling adults with chronic traumatic brain injury (TBI), we conducted correlation analyses and tests of group differences with previously validated symptom measures in two samples (n = 111, n = 134). Measures used for comparison were: Patient Health Questionnaire (depression), Generalized Anxiety Disorder-7 (anxiety), Positive and Negative Affect Schedule, Frontal Systems Behavior Scale (Executive Dysfunction, Apathy, Disinhibition), Modified Fatigue Impact Scale, PROMIS Fatigue, Aggression Questionnaire (anger, hostility, physical and verbal aggression), and Alcohol Use Disorders Test (alcohol misuse). BAST subscales had stronger correlations with measures of similar (|r|=.602-.828, p < .001) and related (|r|>.30, p < .001) constructs and weaker correlations (|r|<.300) with measures of dissimilar/unrelated constructs, supporting hypotheses of convergent and discriminant validity, respectively. Statistically significant group differences (p's < .001) in BAST subscales were found, with large effect sizes (Cohen's d = 1.2-1.9), for known-groups with moderate-severe depression, moderate-severe anxiety, clinically significant fatigue, problematic disinhibited and frontal-executive behaviors, and alcohol use. Conclusions: Results support the convergent and discriminant validity of the BAST subscales. The BAST was specifically developed as a self-reported measure for remote symptom reporting, supporting its incorporation into mobile health platforms to improve chronic symptom monitoring in community-dwelling adults with TBI. With further validation research, the BAST could be used for early identification of persons with TBI who could benefit from intervention.

Emotional, Behavioral, and Cognitive Symptom Associations With Community Participation in Chronic Traumatic Brain Injury.

OBJECTIVES: To determine the association between self-reported emotional and cognitive symptoms and participation outcomes in chronic traumatic brain injury (TBI) and to explore the relative contribution of self-reported versus performance-based cognition to participation outcomes. SETTING: Community. PARTICIPANTS: Community-dwelling adults ( n = 135) with a lifetime history of mild to severe TBI. DESIGN: Secondary analysis of a cross-sectional study on neurobehavioral symptoms in chronic TBI. MAIN MEASURES: Behavioral Assessment Screening Tool (BAST) (Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, Substance Abuse subscales) measured self-reported neurobehavioral symptoms; Participation Assessment with Recombined Tools (Productivity, Social Relations, and Out and About) measured self-reported participation outcomes; and Brief Test of Adult Cognition by Telephone (BTACT) measured performance-based cognition (Episodic Memory and Executive Function summary scores) in a subsample ( n = 40). RESULTS: The BAST Executive Dysfunction was significantly associated with less frequent participation and had the strongest effect on participation in all participation domains. No other BAST subscales were associated with participation, after adjusting for all subscale scores and age, with the exception of BAST Impulsivity, which was associated with more frequent Social Relationships. Exploratory analysis in the sample including the BTACT revealed that, after accounting for subjective Executive Dysfunction using the BAST, performance-based Executive Function was associated with Productivity and Working Memory was associated with Social Relations, but neither was associated with being Out and About; the BAST Executive Dysfunction remained significant in all models even after including BTACT scores. CONCLUSIONS: Self-reported Executive Dysfunction contributed to participation outcomes after mild to severe TBI in community-dwelling adults, whereas self-reported emotional and fatigue symptoms did not. Performance-based cognition measures may capture different variability in participation after injury.

Predictors of Missed Follow-up Visits in the National Traumatic Brain Injury Model Systems Cohort Study.

OBJECTIVE: To identify key variables that could predict risk of loss to follow-up (LTFU) in a nationally funded longitudinal database of persons with traumatic brain injury. DESIGN: Secondary analysis of a prospective longitudinal cohort study. SETTING: Traumatic Brain Injury Model System (TBIMS) Centers in the US. PARTICIPANTS: A total of 17,956 TBIMS participants (N=17,956) with interview status data available were included if eligible for 1-, 2-, 5-, 10-, 15-, or 20-year follow-ups between October 31, 1989, and September 30, 2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Follow-up data collection completion status at years 1, 2, 5, 10, 15, and 20. RESULTS: Information relevant to participants' history, injury characteristics, rehabilitation stay, and patterns of follow-up across 20 years were considered using a series of logistic regression models. Overall, LTFU rates were low (consistently <20%). The most robust predictors of LTFU across models were missed earlier follow-ups and demographic factors including Hispanic ethnicity, lower education, and lack of private health insurance. CONCLUSIONS: Efforts to retain participants in such social disadvantaged or minority groups are encouraged given their disproportionate rate of LTFU. Repeated attempts to reach participants after a previously missed assessment are beneficial because many participants that missed 1 or more follow-ups were later recovered.

Understanding loss to follow-up in a longitudinal study of people with traumatic brain injury.

OBJECTIVE: To examine factors related to attrition in a traumatic brain injury (TBI) study sample assessed up to 15 years after injury. PARTICIPANTS: One thousand twenty-eight participants with TBI who completed the year 1 follow-up assessment at a TBI Model Systems Center between 1992 and 2018. METHOD: Secondary analysis of data from a prospective longitudinal cohort study considering follow-up data collection completion status at years 1, 2, 5, 10, and 15. RESULTS: In univariable analyses, multiple factors were associated with loss to follow-up (LOFU) including being a member of a socially disadvantaged group, substance use history, residence, payor, cause of injury, and results of earlier follow-up attempts. In a multiple logistic regression analysis examining the prediction of follow-up condition at 10 or 15 years post-injury, only payor and race/ethnicity were significant predictors. Hispanic ethnicity was associated with higher odds of LOFU, and these participants often spoke Spanish and were born outside of the United States. CONCLUSIONS: The findings suggest a need to understand sociodemographic variables and their influence on participant attrition in longitudinal TBI research. With a better understanding of these predictors, procedures can be developed to address retention of participants who are identified as being at increased risk for study drop out.

Patterns of Cognitive Test Scores and Symptom Complaints in Persons with TBI Who Failed Performance Validity Testing.

OBJECTIVE: To determine clinically meaningful subgroups of persons with traumatic brain injury (TBI) who have failed performance validity testing. METHOD: Study participants were selected from a cohort of 674 participants with definitive medical evidence of TBI. Participants were those who failed performance validity testing (the Word Memory Test, using the standard cutoffs). Participants were administered cognitive tests and self-report questionnaires. Test and questionnaire results were summarized as 12 dimension scores. Cluster analysis using the k-means method was performed. RESULTS: Cluster analysis for the 143 retained participants indicated three subgroups. These subgroups differed on patterns of scores. Subgroup 1 was impaired for memory and had no excessive complaints. Subgroup 2 had impaired memory and processing speed as well as concern regarding cognition function. Subgroup 3 showed impairment on all cognitive tests and excess complaints in multiple areas. CONCLUSIONS: These results provide a preliminary basis for improved understanding of poor performance validity.

The Discrepancy Between Cognitive Complaints and Neuropsychological Test Findings in Persons With Traumatic Brain Injury.

OBJECTIVE: To better identify variables related to discrepancies between subjective cognitive complaints and objective neuropsychological findings in persons with traumatic brain injury (TBI). SETTING: Three rehabilitation centers in the United States. PARTICIPANTS: In total, 504 community-dwelling adult survivors of TBI following discharge from inpatient rehabilitation. DESIGN: Prospective cohort observation study. MAIN MEASURES: Wechsler Adult Intelligence Scale, Fourth Edition, Digit Span; Rey Auditory Verbal Learning Test; Trail Making Test, Part B; Word Memory Test; Patient Health Questionnaire-9; Neurobehavioral Symptom Inventory; TBI-Quality of Life item bank. RESULTS: Statistical analyses revealed multiple factors associated with subjective-objective discrepancies in attention, memory, and executive functions. Depression was consistently associated with underestimation of cognitive abilities. However, subjective-objective discrepancies varied by cognitive domains in regard to other factors related to underestimation and overestimation of abilities. CONCLUSIONS: Reconciling and interpreting subjective-objective discrepancies regarding cognitive functions following TBI are important tasks for case conceptualization and treatment planning. Depression is an important patient characteristic to consider when discrepancy patterns indicate underestimation of cognitive abilities. This study highlights the importance of assessing mood, a modifiable patient characteristic, with self-report symptom inventories. Future studies are needed to connect these findings with TBI outcomes.

The relationship between resilience, emotional distress, and community participation outcomes following traumatic brain injury.

Purpose/Objective: To determine how resilience is associated with social participation outcomes in persons with traumatic brain injury (TBI), in the context of emotional distress, demographics, and injury-related factors.Setting: Individuals with a history of TBI recruited the following stay at three rehabilitation facilities in the USA.Participants: 201 community-dwelling persons with medically documented TBI ranging in severity from mild to severe.Design: Prospective cohort observational study. Data were collected at two time points, approximately 6 months apart.Main Measures: TBI-QOL; PART-OResults: Resilience at baseline was moderately to strongly correlated with baseline psychological distress variables (rs= -.66) and social participation variables (rs =.33 to.57). In regression analyses, resilience was directly associated with social participation outcomes and formed a significant interaction with emotional distress in some models. Resilience failed to show a relationship with social participation at 6-month follow-up, when controlling for baseline social participation.Conclusions: Though related to emotional distress, self-reported resilience makes a unique contribution to predicting outcomes over time following brain injury, and may impact the relationship between stress and negative participation outcomes. As such, it is possible interventions that promote resilience may mitigate distress and promote community integration.

Comparison of the Neurobehavioral Symptom Inventory and the Rivermead Postconcussion Symptoms Questionnaire.

Objective: This study sought to determine the similarity of constructs measured by the Neurobehavioral Symptom Inventory (NSI) and Rivermead Postconcussive Symptoms Questionnaire (RPQ) and the potential for interchangeability of scores from the two scales. Setting: Three acute inpatient rehabilitation hospitals in the USA. Participants: 497 community dwelling persons with traumatic brain injury (TBI) who completed the NSI and the RPQ during the same assessment. Inclusion criteria were (a) medical documentation of TBI, (b) age 18 to 64 years, (c) capacity to give informed consent, (d) resides in the community, (e) ability to complete all study measures in English, (f) absence of interfering medical or psychiatric condition. Design: Prospective cohort observational study Main Measures: NSI; RPQ Results: Scores from the NSI and RPQ showed a strong association (Spearman's r = 0.89). Exploratory factor analysis showed that items from the two measures loaded on similar factors. A crosswalk between the two measures was created by equating scores from the scales based on percentile ranks. Conclusion: Results indicate substantial conceptual and empirical overlap between the NSI and RPQ. The percentile crosswalk developed from this dataset may allow combined analysis of post-concussive symptoms from datasets that include either the NSI or the RPQ.

Rasch Analysis of Postconcussive Symptoms: Development of Crosswalks and the Brain Injury Symptom Scale.

OBJECTIVE: The first aim of this study was to develop a Rasch-based crosswalk between 2 postconcussive symptom measures, the Neurobehavioral Symptom Inventory (NSI) and the Rivermead Postconcussive Symptom Questionnaire (RPQ). The second goal was to utilize Rasch analysis to formulate a new proposed scale containing the best theoretical and psychometric items. DESIGN: Prospective cohort observational study. SETTING: Three acute inpatient rehabilitation hospitals in the United States. PARTICIPANTS: Community-dwelling persons (N=497) who were previously hospitalized and were diagnosed with mild to severe traumatic brain injury. Participants were (1) 18-64 years old; (2) could give informed consent; (3) able to complete study measures in English; (4) did not have an interfering medical or psychiatric condition. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: NSI, RPQ. RESULTS: Rasch analysis revealed 4 subdimensions across the 2 scales: cognitive, affective, physical, and visual. Crosswalk tables were generated for the first 3. Visual items were too few to generate a crosswalk. Iterative Rasch analysis produced a new scale with items rated from none to severe including the best items in each of these dimensions. CONCLUSIONS: The NSI and RPQ have considerable overlap and measure the same overarching constructs. Crosswalk tables may be helpful for clinicians and researchers to convert scores from 1 measure to the other. A more psychometrically sound scale, the Brain Injury Symptom Scale, composed of items from the NSI and RPQ, is proposed and will need further validation.

Gender differences in employment and economic quality of life following traumatic brain injury.

OBJECTIVE: Due to limited systematic research on gender differences in health and quality of life outcomes following traumatic brain injury (TBI), the present study sought to contribute to the growing literature on gender differences in postinjury employment while also adding an examination of postinjury economic quality of life, an emerging area in disability research. METHOD: Independent variables included demographic and injury characteristics. Outcome variables included postinjury employment and economic quality of life, measured by the Participation Assessment With Recombined Tools-Objective and the Economic QOL, respectively. Hypotheses that women would experience poorer outcomes in postinjury employment and economic quality of life were tested with logistic and linear regression models. RESULTS: Postinjury employment was associated with gender, higher educational attainment, and preinjury employment. Those with greater injury severity and those identifying as Black or African American were less likely to be employed postinjury. For men and women who were unemployed prior to injury, the odds of postinjury employment for men were 184% higher than for women. Men reported significantly greater economic quality of life. Contrary to hypotheses, postinjury employment was inversely related to economic quality of life in the final model. CONCLUSION: The results suggest that if unemployed prior to injury, women with TBI are less likely to be employed postinjury and also experience decreased economic quality of life postinjury, regardless of employment status. Although further research is needed to determine which strategies will improve economic quality of life for women with TBI, clinicians may utilize these preliminary findings to guide treatment and advocacy efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Cognitive Log performance among individuals without brain injury in an inpatient rehabilitation setting.

PURPOSE/OBJECTIVE: Despite the widespread use of the Cognitive Log, information regarding normative performance is only available in individuals with known brain injury and in healthy college students. The purpose of the current research is to provide information about Cognitive Log performance in a regional group of rehabilitation patients without history of brain injury. Secondarily, non-neurological factors that may predict performance are considered. Research Method/Design: Participants included in this study were 121 consecutive patients admitted to an inpatient rehabilitation hospital spinal cord and orthopedic floor. Based on history, only patients without insult to the brain were included. RESULTS: This study provides normative information for Cognitive Log performance in a nonbrain injured population, showing that these patients score in between those with acquired brain injury and healthy controls. Variables including age, estimated intelligence, and self-reported pain, fatigue, and affective distress accounted for 47.5% of the variance in Cognitive Log scores, although age and estimated intelligence, which accounted for 43.3% of the variance, were the only individually significant contributors to performance. CONCLUSIONS/IMPLICATIONS: This study provides an estimate of normative Cognitive Log performance in a nonbrain injured population. This information is especially useful in that it signifies that both neurological and non-neurological factors contribute to Cognitive Log performance, and this information may shape how clinicians conceptualize scores in patients with and without brain injury. Age and longstanding intellectual abilities should be taken into consideration when interpreting Cognitive Log performances, developing rehabilitation strategies, and determining need for additional testing. (PsycINFO Database Record

Maintaining perceptual constancy while remaining vigilant: left hemisphere change blindness and right hemisphere vigilance.

A considerable literature suggests that the right hemisphere is dominant in vigilance for novel and survival-related stimuli, such as predators, across a wide range of species. In contrast to vigilance for change, change blindness is a failure to detect obvious changes in a visual scene when they are obscured by a disruption in scene presentation. We studied lateralised change detection using a series of scenes with salient changes in either the left or right visual fields. In Study 1 left visual field changes were detected more rapidly than right visual field changes, confirming a right hemisphere advantage for change detection. Increasing stimulus difficulty resulted in greater right visual field detections and left hemisphere detection was more likely when change occurred in the right visual field on a prior trial. In Study 2 an intervening distractor task disrupted the influence of prior trials. Again, faster detection speeds were observed for the left visual field changes with a shift to a right visual field advantage with increasing time-to-detection. This suggests that a right hemisphere role for vigilance, or catching attention, and a left hemisphere role for target evaluation, or maintaining attention, is present at the earliest stage of change detection.

Construct and criterion validity of the Behaviour Rating Inventory of Executive Function (BRIEF) in children referred for neuropsychological assessment after paediatric traumatic brain injury.

The construct and criterion validities of the parent version of the Behaviour Rating Inventory of Executive Function (BRIEF) were evaluated in a sample of 100 6- to 16-year-old children with traumatic brain injury (TBI). Maximum-likelihood factor analysis identified two latent constructs that largely replicated the factor structure reported for the standardization sample, with the notable exception that the Inhibit scale covaried primarily with the metacognition factor and not with behavioural regulation factor. Only the former factor demonstrated evidence for sensitivity to the severity of TBI. Results on both factors were affected by a premorbid history of attention-deficit/hyperactivity disorder or other out-patient psychiatric treatment. It is concluded that the BRIEF has construct and criterion validity in the evaluation of children with TBI but that findings on this instrument can only be interpreted within the context of review of the child's premorbid history.