Traumatic Brain Injury Positive Strategies for Families: A Pilot Randomized Controlled Trial of an Online Parent-Training Program.

OBJECTIVE: To determine program satisfaction and preliminary efficacy of Traumatic Brain Injury Positive Strategies (TIPS), a web-based training for parenting strategies after child brain injury. DESIGN: A randomized controlled trial with parallel assignment to TIPS intervention or usual-care control (TAU). The three testing time-points were pretest, posttest within 30 days of assignment, and 3-month follow-up. Reported in accordance with CONSORT extensions to randomized feasibility and pilot trials SETTING: Online. PARTICIPANTS: Eighty-three volunteers recruited nationally who were 18 years of age or older, U.S. residents, English speaking and reading, had access to high-speed internet, and were living with and caring for a child who was hospitalized overnight with a brain injury (ages 3-18 years, able to follow simple commands; N=83). INTERVENTIONS: Eight interactive behavioral training modules on parent strategies. The usual-care control was an informational website. MAIN OUTCOME MEASURES: The proximal outcomes were User Satisfaction, Usefulness, Usability, Feature Preference, Strategy Utilization and Effectiveness, and Learning and Self-Efficacy for TIPS program participants. The primary outcomes were: Strategy Knowledge, Application, and Strategy-Application Confidence; Family Impact Module of Pediatric Quality of Life Inventory (PedsQL); and Caregiver Self-Efficacy Scale. The secondary outcomes were TIPS vs TCore PedsQL and Health Behavior Inventory (HBI) RESULTS: Pre- and posttest assessments were completed by 76 of 83 caregivers; 74 completed their 3-month follow-up. Linear growth models indicated that relative to TAU, TIPS yielded greater increases in Strategy Knowledge over the 3-month study (d=.61). Other comparisons did not reach significance. Outcomes were not moderated by child age, SES, or disability severity measured by Cognitive Function Module of PedsQL. All TIPS participants were satisfied with the program. CONCLUSIONS: Of the 10 outcomes tested, only TBI knowledge significantly improved relative to TAU.

Concussion education for youth athletes using Pre-Game Safety Huddles: a cluster-randomised controlled trial.

OBJECTIVES: Determine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes. METHODS: A cluster-randomised trial compared Safety Huddles to usual care. Safety Huddles bring together athletes and coaches from both teams before the start of each game for coaches to briefly affirm the importance of speaking up if a concussion is suspected. Participants were athletes from 22 competitive community-based American football and girls and boys soccer teams (ages 9-14), and randomisation into intervention or control occurred at the level of the bracket (group of teams that compete against each other during the regular season). The primary outcome was expected likelihood of reporting concussion symptoms to the coach, measured via validated athlete survey at the beginning and end of the season. RESULTS: Of 343 eligible participants, 339 (99%) completed baseline surveys and 303 (88%) completed surveys at season end. The mean (SD) age was 11.4 (1.1) years, 26% were female soccer athletes, 27% were male soccer athletes and 47% were football athletes. In adjusted analyses accounting for baseline values and clustering by sport and team via random effects, expected likelihood of concussion reporting at the end of the season was significantly higher in the intervention group compared to controls (mean difference=0.49, 95% CI 0.11 to 0.88; Cohen's d=0.35). CONCLUSIONS AND RELEVANCE: Pre-Game Safety Huddles increased the expected likelihood of athletes reporting concussion symptoms. While further study is warranted, sport organisations should consider this approach a promising low-resource option for improving concussion safety in their setting. TRIAL REGISTRATION NUMBER: NCT04099329.

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

OBJECTIVE: Children who experience traumatic brain injury (TBI) of any severity may need accommodations when they return to school-the setting that manages academic achievement and learning. However, variations exist in current return to school (RTS) programs that address a child's transition to school following TBI. This article describes some of these return to school (RTS) programs and how they vary by setting. DESIGN: This article provides insights from a modified evaluability assessment that examined RTS programs and their readiness for rigorous evaluation. A secondary analysis was conducted to better describe the types and location of programs examined. RESULTS: Differences exist in program structure, access, and how care for children is monitored over time. RTS programs that serve children following TBI are located in healthcare settings, schools, and state agencies and vary in models of care due to their location and organizational structure. CONCLUSIONS: Children who experience TBI benefit from a healthcare assessment and follow-up upon RTS that includes parental involvement. Models of care for this process vary based on program location and organizational structure. Further research and program evaluation are needed to better understand effectiveness and how to optimally monitor and care for children returning to school after a concussion or TBI.

Staff Traumatic Brain Injury Skill Builder: Evaluation of an Online Training Program for Paraprofessional Staff Serving Adults With Moderate-Severe TBI.

OBJECTIVE: To evaluate the online, self-guided, interactive Staff TBI Skill Builder training program for paraprofessional staff. DESIGN: A within-subjects, nonexperimental evaluation involving 79 paraprofessionals and professionals working across a range of settings. Participants completed a pretest (T1), a posttest immediately upon program completion (T2), and follow-up (T3) 60 days after program completion. MEASURES: (1) Knowledge of basic traumatic brain injury facts; (2) knowledge application; (3) self-efficacy in responding to text-based application scenarios; (4) self-report of skill utilization and effectiveness; and (5) program satisfaction (ease-of-use and usefulness). RESULTS: Participants demonstrated high levels of knowledge, knowledge application, and self-efficacy at pretest. Despite the high pretest levels, participants showed significant improvements in knowledge application (d = 0.50) after using the program. Nonsignificant gains in knowledge (d = 0.13) and self-efficacy (d = 0.02) were found. The use of selected skills significantly increased from posttest to follow-up. Participants reported high program satisfaction; 99% of the participants indicated that they would recommend the program to others. CONCLUSION: These results demonstrate the feasibility of providing interactive, online training for paraprofessionals serving adults with moderate-severe traumatic brain injury.

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

BACKGROUND: Many children who experience a traumatic brain injury (TBI) return to school without receiving needed support services. OBJECTIVE: To identify services received and predictors of formal special education services (ie, Individualized Education Plan [IEP]) for students with TBI 1 year after returning to school. SETTING AND PARTICIPANTS: A total of 74 students with TBI recruited from children's hospitals in Colorado, Ohio, and Oregon. DESIGN: Secondary analysis of previously reported randomized control trials with surveys completed by caregivers when students returned to school (T1) and 1 year later (T2). This study reports data collected at T2. RESULTS: While 45% of students with TBI reported an IEP 1 year after returning to school, nearly 50% of students received informal or no services. Male students, those who sustained a severe TBI, and students whose parents reported domain-specific concerns were more likely to receive special education services at 1 year. In a multivariate model, sex remained the only significant predictor of IEP services at T2. CONCLUSIONS: Females and students with less severe or less visible deficits were less likely to receive special education services. While transition services may help students obtain special education for the first year after TBI, identifying students with TBI who have subtle or later-developing deficits remains a challenge.

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

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

A survey of the training experiences and needs of paraprofessionals serving adults with brain injury.

Objective: To conduct a survey of the training experiences and needs of paraprofessionals (frontline staff) serving adults with moderate-severe TBI from the perspectives of four stakeholder groups: paraprofessionals, professionals, adults living with brain injury, and family members.Participants: Participants were (a) 28 paraprofessionals, (b) 45 professionals, (c) 41 adults living with brain injury, and (d) 22 family members, for a total of 136 participants.Design: We conducted an online, nationwide survey containing closed and open-ended questions. Four different versions of the survey were developed, one for each of the stakeholder groups, to capture their unique perspectives on the topic of paraprofessional training.Results: Descriptive statistics, non-parametric statistics, and qualitative, comment-based information across the four groups revealed that (a) paraprofessionals require comprehensive training to address the complex needs of persons with brain injury; (b) a range of training options and modalities is preferred; and (c) there are several challenges associated with providing paraprofessional training.Conclusions: This survey highlights the need for a comprehensive range of paraprofessional training options that address both knowledge and skill acquisition. These data have informed the development of an online, interactive training program for paraprofessionals serving this population.

Preliminary Efficacy of Online Traumatic Brain Injury Professional Development for Educators: An Exploratory Randomized Clinical Trial.

OBJECTIVE: To examine the efficacy of an online traumatic brain injury (TBI) professional development intervention, In the Classroom After Concussion: Best Practices for Student Success. DESIGN: A randomized controlled trial with a sample of 100 general educators, who were randomly assigned to the In the Classroom Web site (treatment group) or the LEARNet Web site (control group). Participants completed the pretest, accessed the In the Classroom or LEARNet site and the posttest and completed follow-up assessments 60 days after posttest. MEASURES: (1) Knowledge of effective strategies for working with students with TBI; (2) knowledge application; (3) self-efficacy in handling situations presented in text and video scenarios, and (4) a standardized self-efficacy measure. RESULTS: On the posttest assessment, In the Classroom educators showed significantly greater gains in knowledge (P < .0001, d = 1.36 [large effect]), TBI knowledge application (P = .0261, d = 0.46), and general self-efficacy (P = .0106, d = 0.39) than the LEARNet controls. In the Classroom educators maintained significant gains in knowledge (P = .001, d = 0.82) and general self-efficacy (P = .018, d = 0.38) but not in TBI knowledge application (P = .921, d = 0.02). CONCLUSION: Given the prevalence of TBI, it is important to develop evidence-based, cost-effective approaches to knowledge transfer and exchange in TBI professional development. In the Classroom is one such approach.

Results from a randomized trial evaluating a hospital-school transition support model for students hospitalized with traumatic brain injury.

OBJECTIVE: To evaluate the utility of the STEP model, a systematic hospital-school transition protocol for children hospitalized for TBI. SETTING: Five children's hospitals in Colorado, Ohio, and Oregon. PARTICIPANTS: Hundred families of children with mild, complicated mild, moderate, or severe TBI. DESIGN: Randomized controlled trial (RCT); participants were randomized while hospitalized to the STEP (a standardized hospital-school transition protocol for children treated for TBI) or usual care condition. MAIN MEASURES: Questionnaire about child's special education eligibility status, support services, and academic accommodations; Achenbach Child Behaviour Checklist (CBCL); Behaviour Rating Inventory of Executive Function (BRIEF); Child and Adolescent Scale of Participation (CASP); Child and Adolescent Scales of Environment (CASE) Results: There were no significant effects, indicating that STEP participants did not differ from usual care participants on any study outcome at one month post-discharge or at one-year follow-up. CONCLUSION: The lack of significant findings in this study does not imply that effective hospital-to-school transition programming is unnecessary. Rather, the findings raise important questions regarding timing and dosage/intensity of intervention, appropriate measurement of outcomes, and fidelity of programme delivery. The study highlights difficulties involved in the conduct of community-based RCTs in the paediatric TBI population.

Building Statewide Infrastructure for the Academic Support of Students With Mild Traumatic Brain Injury.

OBJECTIVES: To focus attention on building statewide capacity to support students with mild traumatic brain injury (mTBI)/concussion. METHOD: Consensus-building process with a multidisciplinary group of clinicians, researchers, policy makers, and state Department of Education personnel. RESULTS: The white paper presents the group's consensus on the essential components of a statewide educational infrastructure to support the management of students with mTBI. The nature and recovery process of mTBI are briefly described specifically with respect to its effects on school learning and performance. State and local policy considerations are then emphasized to promote implementation of a consistent process. Five key components to building a statewide infrastructure for students with mTBI are described including (1) definition and training of the interdisciplinary school team, (2) professional development of the school and medical communities, (3) identification, assessment, and progress monitoring protocols, (4) a flexible set of intervention strategies to accommodate students' recovery needs, and (5) systematized protocols for active communication among medical, school, and family team members. The need for a research to guide effective program implementation is stressed. CONCLUSION: This guiding framework strives to assist the development of support structures for recovering students with mTBI to optimize academic outcomes. Until more evidence is available on academic accommodations and other school-based supports, educational systems should follow current best practice guidelines.

Building statewide infrastructure for effective educational services for students with TBI: promising practices and recommendations.

OBJECTIVE: To identify promising practices in educational service delivery. METHODS: Consensus-building process with a multidisciplinary group of researchers, policy makers, and state Department of Education personnel. RESULTS: This white paper presents the group's consensus on the essential components of a statewide educational infrastructure to support students with traumatic brain injury across the spectrum of injury severity: (a) identification, screening, and assessment practices; (b) systematic communication between medical and educational systems; (c) tracking of child's progress over time; and (d) professional development for school personnel. The white paper also presents key outcomes for measuring success and provides recommendations both for policy change and for furthering research in childhood brain injury.

Web-based training in family advocacy.

OBJECTIVE: To examine the efficacy of an interactive multimedia intervention that teaches advocacy skills to people caring for a family member with traumatic brain injury. PARTICIPANTS: A total of 201 individuals (control, n = 97; treatment, n = 104) providing support to a family member with traumatic brain injury. DESIGN: Randomized controlled study. MAIN MEASURES: Caregiver knowledge, skill application, behavioral intention, and overall life satisfaction. INTERVENTION: The Brain Injury Partners program, a Web site focused on advocacy, communication skills, and resources for families affected by brain injury. RESULTS: Univariate analyses revealed that compared with the control group, the Brain Injury Partners group reported statistically significant higher adjusted means for application, knowledge, and attitudes scales immediately postintervention and at follow-up. Satisfaction with life, assessed at follow-up but not posttest, was not significant. DISCUSSION: This study demonstrated the effectiveness of a Web-based intervention to teach effective skills to caregivers advocating for a family member with traumatic brain injury.

School experiences following traumatic brain injury: A longitudinal qualitative study.

BACKGROUND: This longitudinal qualitative study tracked students with traumatic brain injury (TBI) from hospital discharge through their return to school and then for an average of four years of school. OBJECTIVE: To better understand the experiences of students and parents in the education system following TBI. METHODS: Participants were parents and educators of 21 students with TBI. Interviews were conducted using open-ended questions and students were observed in the classroom. RESULTS: From these data, three themes were identified: lack of student tracking year to year, lack of educator training, and conflicting views between educators and parents about students' needs. These factors ultimately led to parent frustration and eventually conflict and deteriorating relationships between parents and educators. CONCLUSION: The results suggest that improving educator training could positively affect the factors identified and possibly mitigate parent frustration.

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

BACKGROUND: For students with traumatic brain injury (TBI), the COVID-19 pandemic exacerbated challenges they were already experiencing at school. METHODS: This qualitative study employed focus groups and interviews with students, parents, school, and medical personnel to explore the school experiences of students with TBI. Thematic qualitative analyses were used. RESULTS: Key themes from the analysis include (a) incidence of brain injuries decreased; (b) screen time for students with TBI exacerbated symptoms; (c) COVID protocols at school made it difficult for educators to identify and provide accommodations for students with TBI; (d) COVID protocols at school could inadvertently exacerbate mental health difficulties after a TBI; and (e) COVID-related logistics increased the time between an injury and return to school or return to play. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The results from this study suggest that professional development for teachers supporting students with TBI is needed, especially for online learning environments. Additionally, because mental/behavioral health concerns may arise for students with TBI in online learning environments, school health care providers can work with families to assess a student's mental health, making referrals to appropriate supports. CONCLUSIONS: There is a significant need for professional development and school-wide infrastructure supportive of students with TBI.

Developing a conceptual model of coach concussion communication by adapting the theory of planned behavior and the social ecological model.

Objective: Acknowledging that coach communication about concussion increases the likelihood of athletes reporting concussive symptoms, the goal of this study was to examine factors affecting such communication, in order to develop a conceptual model that would inform the design of future educational interventions.Participants: Division I contact sport coaches.Methods: We conducted structured qualitative interviews with coaches and analyzed interviews using Thematic Analysis, viewed through the lens of the Theory of Planned Behavior nested within the Social Ecological Model.Results: Coaches had good knowledge of concussion and understood the dangers of playing with symptoms. However, they also discussed the lack of objective criteria for concussion diagnosis, and pressure to win in order to remain employed, both of which created barriers to concussion communication. Ultimately, most coaches reported not engaging in significant concussion communication as they did not feel this was their role, instead deferring to medical staff.Conclusions: Educational interventions might benefit from a focus on the importance of coach concussion safety-supportive coach communication, with a goal of increasing the likelihood of athlete concussion reporting.

Effect of RISE Bundle implementation on school adoption of a student-centered return-to-learn program in Washington state.

BACKGROUND: Appropriate concussion care in school is vital for full recovery, but school return-to-learn (RTL) programs are lacking and vary in quality. Establishing student-centered RTL programs may reduce disparities in RTL care. OBJECTIVE: To examine the effect of RISE Bundle (Return to Learn Implementation Bundle for Schools) implementation on high school adoption of a student-centered RTL program. METHODS: A convenience sample of fourteen (4 rural and 10 urban) small and large Washington (WA) State public high schools were enrolled in a stepped-wedge study with baseline, end of study, and monthly measures over the 2021-2022 academic year. Schools identified an RTL champion who led RISE Bundle implementation in 6-week steps. Concussion knowledge and impact of RTL program on concussion care were examined. RESULTS: Ten schools (71.4%) successfully completed RISE Bundle implementation and established a functional RTL program. Self-reported concussion knowledge from RTL Champions increased post intervention. Establishing RTL programs facilitated provision of tailored accommodations, and perceived variation and inequities in RTL care were reduced. CONCLUSION: RISE Bundle implementation proved feasible, supported the establishment of a functional RTL program, and perceived to reduce disparities in concussion care in rural and urban WA State public high schools of varying sizes.

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

BACKGROUND: In Oregon in 2019, only 261 students were eligible for special education under the traumatic brain injury (TBI) category. Many students with TBIs are not treated by a medical provider, so the requirement for a medical statement could prevent eligible youth from receiving special education services. OBJECTIVE: This study investigated barriers to using a medical statement to establish special education eligibility for TBI, support for using a guided credible history interview (GCHI), and training needs around GCHI. RESULTS: Among participants, 84% reported difficulty obtaining a medical statement for TBI eligibility determination, and 87% favored the GCHI as an alternative, though they reported a need for training in TBI and GCHI. CONCLUSION: The results support the use of GCHI to establish special education eligibility for TBI and informed Oregon's addition of GCHI to TBI special education eligibility determination.

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

BACKGROUND: For children, the post-concussion return to school process is a critical step towards achieving positive health outcomes. The process requires integration between healthcare professionals, parents, and school personnel. OBJECTIVE: This research team conducted focus groups with stakeholders including parents, education personnel, school nurses, external healthcare providers (nurses) and athletic trainers to identify communication patterns between healthcare providers outside of the school setting and school personnel. METHODS: Data from focus groups were analyzed using a Thematic Analysis approach. Researchers used an inductive (bottom-up) coding process to describe semantic themes and utilized a critical realist epistemology. RESULTS: We identified four key themes within focus group data: (1) lack of effective communication between hospital and outpatient healthcare providers to school personnel; (2) parents who were strong advocates had improved communication with healthcare professionals and garnered more accommodations for their children; (3) non-school professionals and families were often confused about who the point of contact was at a given school; and (4) differing experiences for athletes vs. non-athletes. CONCLUSION: This study suggests gaps in communication between healthcare and school professionals when children return to school following a concussion. Improving communication between healthcare providers and school staff will require a multi-faceted approach.

Systematic instruction for individuals with acquired brain injury: results of a randomised controlled trial.

The goal of this study was to evaluate experimentally systematic instruction compared with trial-and-error learning (conventional instruction) applied to assistive technology for cognition (ATC), in a double-blind, pre-test-post-test, randomised controlled trial. Twenty-nine persons with moderate-severe cognitive impairments due to acquired brain injury (15 in systematic instruction group; 14 in conventional instruction) completed the study. Both groups received 12, 45-minute individual training sessions targeting selected skills on the Palm Tungsten E2 personal digital assistant (PDA). A criterion-based assessment of PDA skills was used to evaluate accuracy, fluency/efficiency, maintenance, and generalisation of skills. There were no significant differences between groups at immediate post-test with regard to accuracy and fluency. However, significant differences emerged at 30-day follow-up in favour of systematic instruction. Furthermore, systematic instruction participants performed significantly better at immediate post-test generalising trained PDA skills when interacting with people other than the instructor. These results demonstrate that systematic instruction applied to ATC results in better skill maintenance and generalisation than trial-and-error learning for individuals with moderate-severe cognitive impairments due to acquired brain injury. Implications, study limitations, and directions for future research are discussed.

Seeking Out Social Learning: Online Self-Education in Parents of Children With Intellectual and Developmental Disabilities.

Supportive, informed parenting is critical to improve outcomes of children who experience intellectual and developmental disabilities (IDD). Parents want to learn about their child's condition, needs, and strategies to improve family life. The internet is a valuable resource, but how parents evaluate and apply information is unknown. We conducted focus groups to understand how parents use internet resources to learn about their children with IDD. Parents described using the internet to access information from trusted sources, find examples to apply their knowledge, and seek social support. Social learning theory, which posits that cognitive, behavioral, and social processes influence each other to support real-world learning, could provide a theoretical framework for unifying these findings and for designing efficacious online interventions.