Characterizing Health Literacy and Its Correlates Among Individuals With Traumatic Brain Injury (TBI): A TBI Model Systems Study.

OBJECTIVE: To characterize health literacy among individuals with traumatic brain injury (TBI) at least a year postinjury and to explore its relationship to sociodemographic variables, injury severity, and cognition. SETTING: Community following discharge from inpatient rehabilitation. PARTICIPANTS: In total, 205 individuals with complicated mild to severe TBI who completed follow-up as part of a national longitudinal study of TBI and completed a web-based health literacy measure. DESIGN: Multicenter, cross-sectional, observational study. MAIN MEASURES: Health Literacy Assessment Using Talking Touchscreen Technology. RESULTS: Thirty-one percent of the sample demonstrated marginal/inadequate health literacy; 69% demonstrated adequate health literacy. A higher proportion of non-Hispanic White adults had adequate health literacy than non-Hispanic Black and Hispanic adults. Individuals with greater than a high school education were more likely to have adequate health literacy than those with a high school education or less. Better executive functioning performance was related to adequate health literacy. Better episodic memory performance was related to adequate health literacy, but only for those with complicated mild to moderate injury. CONCLUSIONS: A substantial proportion of individuals with TBI have marginal/inadequate health literacy, which may impact their understanding, appreciation, and use of health-related information and recommendations. While low health literacy may be preexisting, directly related to TBI, or a combination of both, it should be screened and considered by professionals when communicating with persons with TBI. Healthcare providers should tailor their communication approaches and presentation of health information, particularly for those with low health literacy.

The Relationship of Health Literacy to Health Outcomes Among Individuals With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine the associations between health literacy and health outcomes among individuals with traumatic brain injury (TBI) at least a year post-injury. SETTING: Community following discharge from inpatient rehabilitation. PARTICIPANTS: A total of 205 individuals with complicated mild to severe TBI who completed a TBI Model Systems National Database follow-up interview and a web-based health literacy measure. DESIGN: A multicenter, cross-sectional, observational study. MAIN MEASURES: The Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT), number of comorbid conditions (Medical and Mental Health Comorbidities Interview [MMHCI]), perceived physical and mental health (PROMIS Global Physical and Mental Health subscales), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). RESULTS: After controlling for sociodemographic, injury, cognition, and time post-injury, adequate health literacy was associated with higher odds of greater perceived physical health compared with participants with marginal/inadequate health literacy (odds ratio = 4.10; CI = 1.52-11.70]. Participants with inadequate/marginal health literacy had 3.50 times greater odds of depression (PHQ-9 ≥ 10) compared with those with adequate health literacy. Participants 45 years and older reported a greater number of MMHCI physical health conditions, but fewer MMHCI mental health conditions and GAD-7 anxiety symptoms compared with those who were younger. Non-Hispanic White participants and those with mild/moderate TBI were more likely to report a greater number of MMHCI mental health conditions compared with non-Hispanic Black participants or those with severe TBI. Greater time post-injury was associated with greater number of chronic physical and mental health conditions, and less odds of good-to-excellent perceived global mental health. CONCLUSIONS: Inadequate health literacy is associated with worse perceived physical health and greater depressive symptoms among adults with TBI. Greater efforts are needed to explore the mechanisms by which health literacy influences chronic disease management and mental health after TBI to improve postinjury health status and outcomes, particularly among those with limited health literacy skills.

Caregiver resilience following traumatic brain injury: Findings at six months postinjury.

PURPOSE/OBJECTIVE: Examine contributors to resilience among caregivers of individuals who have sustained a moderate-to-severe traumatic brain injury (TBI), with the goal of identifying important targets for an intervention to improve caregiver resilience as well as outcomes for people with TBI. RESEARCH METHOD/DESIGN: Participants were adult caregivers (n = 176) and individuals with TBI who required inpatient rehabilitation at six TBI Model System sites. Measures included the Connor-Davidson Resilience Scale-10, Family Needs Questionnaire, Zarit Burden Interview, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7. Data were collected between September 2018 and June 2021. RESULTS: Caregivers endorsed levels of personal resilience that were comparable to norms for community samples and slightly higher than groups under stress or with medical illness. Reports of the burden associated with the caregiving role were relatively low, as was reported psychological distress. In a multivariable model, higher proportions of met emotional support needs were associated with increased resilience. CONCLUSIONS/IMPLICATIONS: Resilience may be strengthened by emotional support networks, including friends or family who may not already be directly involved in the provision of care. Supporting engagement with community agencies, peer mentors, or other informal resources within the family system that provide emotional support may bolster resilience outcomes for caregivers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Understanding and identifying the needs of parent caregivers of children with hydrocephalus: a qualitative study.

OBJECTIVE: Hydrocephalus is inherently unpredictable. Most parents whose child is diagnosed with hydrocephalus do not anticipate the diagnosis, nor can anyone predict if or when a child's shunt will fail and require emergency surgery. Previous research has shown that children with hydrocephalus and their caregivers experience significant posttraumatic stress symptoms secondary to the diagnosis. This study aims to understand caregiver experiences and needs, identify gaps in resources/support, and determine opportunities to improve care. METHODS: Semistructured interviews were conducted with parent caregivers of children with hydrocephalus to learn about their experiences with the hydrocephalus diagnosis, hospitalizations, surgeries, coping and support, challenges of caring for a child with hydrocephalus, and logistics for a proposed support program. De-identified interviews were audio-recorded, transcribed, and analyzed for themes. RESULTS: Thematic saturation was reached after 17 interviews. Five major themes emerged: 1) coping with the diagnosis, 2) received support, 3) hydrocephalus management, 4) implications for intervention, and 5) psychosocial stressors for caregivers. A top priority was balanced, trustworthy information delivered with compassion and updated throughout the child's life. Caregivers described a variety of coping strategies, but a majority reported a need for support in processing complex emotions and dealing with the uncertainty of their child's hydrocephalus. Most agreed that having a caregiver support network, medical professionals available for referrals and questions, and referrals to support services and therapies would facilitate feeling supported and providing the best care for their children. CONCLUSIONS: Parent caregivers are critical to the health and well-being of children with hydrocephalus, and it is essential to understand their experiences to improve care. Providing well-defined information, psychosocial support, and resources will help to equip parent caregivers to be advocates for their children and to improve both the caregiver and the child's quality of life.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI. SETTING: Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. PARTICIPANTS: Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition). DESIGN: This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review. MAIN MEASURES: Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported). RESULTS: Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors. CONCLUSIONS: Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

Barriers to driving and psychosocial outcomes after traumatic brain injury.

OBJECTIVE: Examine considerations and perceived barriers to return to driving, and their association with psychosocial outcomes among adults with traumatic brain injury (TBI) who were not driving. METHODS: 174 adults with moderate-to-severe TBI enrolled in the TBI Model System participated in this cross-sectional study. All participants were drivers prior to their TBI. Outcome measures included the Barriers to Driving Questionnaire, Disability Rating Scale, Patient Health Questionnaire-9, General Anxiety Disorder-7, and Satisfaction With Life Scale. Descriptive analyses examined considerations and barriers to driving, including differences associated with demographic characteristics. Moderation analyses investigated the extent to which disability moderated the relationship between barriers and psychosocial outcomes. RESULTS: Social barriers were the most strongly endorsed domain, whereas physical barriers were endorsed least. The profile of endorsements differed for men and women, and for Black and White participants, on both theoretical considerations in returning to drive and experiences of barriers in doing so. Disability level moderated the relationship between barriers to driving and depression and life satisfaction, but not anxiety. CONCLUSION: The experience of barriers to driving is differentially associated with psychosocial outcomes among nondriving adults with TBI. Adults with low disability appear to be at risk for distress, even compared to other nondrivers.

Crash Risk Following Return to Driving After Moderate-to-Severe TBI: A TBI Model Systems Study.

OBJECTIVE: To examine motor vehicle crash frequency and risk factors following moderate-to-severe traumatic brain injury (TBI). SETTING: Eight TBI Model Systems sites. Participants: Adults ( N = 438) with TBI who required inpatient acute rehabilitation. DESIGN: Cross-sectional, observational design. MAIN MEASURES: Driving survey completed at phone follow-up 1 to 30 years after injury. RESULTS: TBI participants reported 1.5 to 2.5 times the frequency of crashes noted in the general population depending on the time frame queried, even when accounting for unreported crashes. Most reported having no crashes; for those who experienced a crash, half of them reported a single incident. Based on logistic regression, age at survey, years since injury, and perception of driving skills were significantly associated with crashes. CONCLUSION: Compared with national statistics, crash risk is higher following TBI based on self-report. Older age and less time since resuming driving were associated with lower crash risk. When driving was resumed was not associated with crash risk. These results do not justify restricting people from driving after TBI, given that the most who resumed driving did not report experiencing any crashes. However, there is a need to identify and address factors that increase crash risk after TBI.

Anxiety Trajectories the First 10 Years After a Traumatic Brain Injury (TBI): A TBI Model Systems Study.

OBJECTIVE: Determine anxiety trajectories and predictors up to 10 years posttraumatic brain injury (TBI). DESIGN: Prospective longitudinal, observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: 2836 participants with moderate to severe TBI enrolled in the TBI Model Systems National Database who had ≥2 anxiety data collection points (N=2836). MAIN OUTCOME MEASURE: Generalized Anxiety Disorder-7 (GAD-7) at 1, 2, 5, and 10-year follow-ups. RESULTS: Linear mixed models showed higher GAD-7 scores were associated with Black race (P<.001), public insurance (P<.001), pre-injury mental health treatment (P<.001), 2 additional TBIs with loss of consciousness (P=.003), violent injury (P=.047), and more years post-TBI (P=.023). An interaction between follow-up year and age was also related to GAD-7 scores (P=.006). A latent class mixed model identified 3 anxiety trajectories: low-stable (n=2195), high-increasing (n=289), and high-decreasing (n=352). The high-increasing and high-decreasing groups had mild or higher GAD-7 scores up to 10 years. Compared to the low-stable group, the high-decreasing group was more likely to be Black (OR=2.25), have public insurance (OR=2.13), have had pre-injury mental health treatment (OR=1.77), and have had 2 prior TBIs (OR=3.16). CONCLUSIONS: A substantial minority of participants had anxiety symptoms that either increased (10%) or decreased (13%) over 10 years but never decreased below mild anxiety. Risk factors of anxiety included indicators of socioeconomic disadvantage (public insurance) and racial inequities (Black race) as well as having had pre-injury mental health treatment and 2 prior TBIs. Awareness of these risk factors may lead to identifying and proactively referring susceptible individuals to mental health services.

Family Needs After Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To describe the self-reported needs of family caregivers of service members and veterans (SMVs) who sustained a traumatic brain injury (TBI) and to identify predictors of the unmet family caregiver needs. SETTING: Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: Family caregivers of SMVs enrolled in the VA PRC TBI Model Systems (TBIMS) national database who were within their first 5 years post-TBI ( n = 427). DESIGN: Observational study. MAIN OUTCOME MEASURE: The Family Needs Questionnaire-Revised (FNQ-R) was completed by each SMV's designated caregiver. ANALYSES: Descriptive analyses were conducted on the FNQ-R responses at the item, domain, and total score levels. Unadjusted univariable and adjusted multivariable regression models were fitted to identify predictors of total unmet needs and unmet family need domains. RESULTS: FNQ-R item-level and domain-level descriptive results indicated that health information was the most frequently met need domain. In contrast, emotional and instrumental support domains were the least often met. On average, family caregivers reported that 59.2% of the 37 FNQ-R needs were met at the time of the follow-up assessment. Regression models indicated that both the number of SMV-perceived environmental barriers and whether the SMV received mental health treatment within the past year predicted the number of unmet FNQ-R needs. SMV-reported environmental barriers predicted increased unmet needs in all 6 family caregiver domains, and SMV mental health treatment in the past year predicted more unmet family caregiver emotional support, community support, and professional support needs. CONCLUSIONS: The current findings can be used to inform policy and programming for VA and Department of Defense to proactively address the specific needs of families and caregivers experienced in the first 5 years post-TBI.

Changes in alcohol use and mood during the COVID-19 pandemic among individuals with traumatic brain injury: A difference-in-difference study.

OBJECTIVE: To evaluate the impact of COVID-19 pandemic exposure on changes in alcohol use and mood from years 1 to 2 after traumatic brain injury (TBI). METHODS: We used a difference-in-difference (DiD) study design to analyze data from 1,059 individuals with moderate-to-severe TBI enrolled in the TBI Model Systems (TBIMS) National Database. We defined COVID-19 pandemic exposure as participants who received their year 1 post-injury interviews prior to January 1, 2020, and their year 2 interview between April 1, 2020 and January 15, 2021. Pandemic-unexposed participants had both year 1 and 2 follow-up interviews before January 1, 2020. We measured current alcohol use as any past month alcohol use, average number of drinks per drinking occasion, and past month binge drinking. We measured depression symptoms using Patient Health Questionnaire-9, and anxiety symptoms using the Generalized Anxiety Disorder-7. RESULTS: We found persons with TBI exposed to the pandemic had greater increases in the average number of drinks per occasion from year 1 to 2 post-injury compared to pandemic-unexposed individuals (ß = 0.36, 95% CI: 0.16, 0.57, p = 0.001), with males, adults <65 years old, and Black and Hispanic subgroups showing the greatest increases in consumption. Though average consumption was elevated, changes in rates of any alcohol use or binge drinking by pandemic exposure were not observed. Overall, there were no significant changes in depressive and anxiety symptoms over time between pandemic exposed and unexposed groups; however, pandemic-exposed Hispanics with TBI reported significant increases in anxiety symptoms from year-1 to year-2 post-injury compared to pandemic-unexposed Hispanics (ß = 2.35, 95% CI: 0.25, 4.47, p = 0.028). CONCLUSION: Among persons living with TBI, those exposed to the pandemic had significant increases in average alcohol consumption. Pandemic-exposed Hispanics with TBI had large elevations in anxiety symptoms, perhaps reflecting health inequities exacerbated by the pandemic, and suggesting a need for targeted monitoring of psychosocial distress.

Aging with Traumatic Brain Injury: Deleterious Effects of Injury Chronicity Are Most Pronounced in Later Life.

Understanding the effects of age on longitudinal traumatic brain injury (TBI) outcomes requires attention to both chronic and evolving TBI effects and age-related changes in health and function. The present study examines the independent and interactive effects of aging and chronicity on functional outcomes after TBI. We leveraged a well-defined cohort of individuals who sustained a moderate/severe TBI and received acute inpatient rehabilitation at specialized centers with high follow up rate as part of their involvement in the TBI Model Systems longitudinal study. We selected individuals at one of two levels of TBI chronicity (either 2 or 10 years post-injury) and used an exact matching procedure to obtain balanced chronicity groups based on age and other characteristics (N = 1993). We found that both older age and greater injury chronicity were related to greater disability, reduced functional independence, and less community participation. There was a significant age by chronicity interaction, indicating that the adverse effects of greater time post-injury were most pronounced among survivors who were age 75 or older. The inflection point at roughly 75 years of age was corroborated by post hoc analyses, dividing the sample by age at 75 years and examining the interaction between age group and chronicity. These findings point to a need for provision of rehabilitation services in the chronic injury period, particularly for those who are over 75 years old. Future work should investigate the underlying mechanisms of this interaction towards the goal of developing interventions and models of care to promote healthy aging with TBI.

Driving patterns, confidence, and perception of abilities following moderate to severe traumatic brain injury: a TBI model system study.

OBJECTIVE: Describe driving patterns following moderate-to-severe traumatic brain injury (TBI). Participants: Adults (N = 438) with TBI that required inpatient acute rehabilitation who had resumed driving. DESIGN: Cross-sectional, observational design. SETTING: Eight TBI Model System sites. MAIN MEASURES: A driving survey was completed at phone follow-up. RESULTS: Most respondents reported driving daily, although 41% reported driving less than before their injury. Driving patterns were primarily associated with employment, family income, sex, residence, and time since injury, but not injury severity. Confidence in driving was high for most participants and was associated with a perception that the TBI had not diminished driving ability. Lower confidence and perceived loss of ability were associated with altered driving patterns. CONCLUSION: Most people with moderate-to-severe TBI resume driving but perhaps not at pre-injury or normal levels compared to healthy drivers. Some driving situations are restricted. The relationship between low confidence/perceived loss of ability and driving patterns/restrictions suggests people with TBI are exhibiting some degree of caution consistent with those perceptions. Careful assessment of driving skills and monitoring during early stages of RTD is warranted, particularly for younger, male, and/or single drivers who express higher levels of confidence.

Predictors of Driving Status in Service Members and Veterans at 1 Year Posttraumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To identify predictors of driving status in service members and veterans 1 year following a traumatic brain injury (TBI). SETTING: The 5 Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: A total of 471 service members and veterans (128 with mild/complicated mild TBI and 343 with moderate/severe TBI) who received TBI-focused inpatient rehabilitation at one of the VA PRCs and who participated in a 1-year postinjury follow-up assessment. DESIGN: Secondary analysis from the Department of Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems (VA PRC TBIMS) national database. MAIN MEASURES: Primary outcome was a single item that assessed driving status at 1 year postinjury. Predictor variables included demographics; sensory impairment, substance use, and employment status at time of injury; PTSD symptoms reported at study enrollment; and functional impairment rated at rehabilitation discharge. RESULTS: In unadjusted bivariate analyses, among those with a mild/complicated mild TBI, older age and greater functional impairment were associated with lower likelihood of driving. Among those with a moderate/severe TBI, discharge to a nonprivate residence, greater functional impairment, and higher PTSD symptoms were linked to lower likelihood of driving. Adjusted multivariate analyses indicated that functional impairment was uniquely associated with driving status in both TBI severity groups. After controlling for other predictors, self-reported PTSD symptoms, particularly dysphoria symptoms, were associated with lower likelihood of driving in both severity groups. CONCLUSION: Given the significance of clinician-rated functional impairment and self-reported PTSD symptoms to the prediction of driving status 1 year post-TBI among service members and veterans, rehabilitation efforts to improve functioning and reduce negative affect may have a positive impact on driving and community integration.

Return to Driving After Moderate-to-Severe Traumatic Brain Injury: A Traumatic Brain Injury Model System Study.

OBJECTIVE: Describe who is able to return to driving (RTD) after moderate-to-severe traumatic brain injury (TBI), when this occurs, who maintains that activity, and the association with outcome. DESIGN: Cross-sectional descriptive study. SETTING: Eight follow-up sites of the TBI Model Systems (TBIMS) program. PARTICIPANTS: 618 participants enrolled in the TBIMS and 88 caregivers (N=706). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A survey was completed from 1-30 years postinjury focusing on RTD. Descriptors included demographic information, injury severity, and current employment status. Outcome was assessed at the time of the interview, including depression, quality of life, functional status, and community participation. RESULTS: Of 706 respondents, 78% (N = 552) RTD, but 14% (N = 77) of these did not maintain that activity. Of those who RTD, 43% (N = 192) did so within 6 months of the injury and 92% did so within 24 months postinjury. The percentage of people driving after TBI did not differ significantly based on age at time of injury or follow-up. There were significant differences between drivers and nondrivers with respect to severity of injury, seizures, race, education, employment, rural vs urban setting, marital status, and family income. We performed a multivariate logistic regression to examine the association between driving status and demographic variables, adjusting for other variables in the model. The strongest associations were with current employment, family income, race, seizures, and severity of injury. Driving was associated with greater community participation, better functional outcomes, fewer symptoms of depression, and greater life satisfaction. CONCLUSIONS: Over a span of 30 years, three-quarters of people experiencing moderate-to-severe TBI return to driving a personal vehicle, although not everyone maintains this activity. Employment, race, family income, and seizures are strongly associated with RTD.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

OBJECTIVE: To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI). SETTING: Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years). DESIGN: Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations. RESULTS: Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites. CONCLUSIONS: The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

Hydrocephalus-related quality of life as assessed by children and their caregivers.

OBJECTIVE: Hydrocephalus is a chronic medical condition that has a significant impact on children and their caregivers. The objective of this study was to measure the quality of life (QOL) of children with hydrocephalus, as assessed by both caregivers and patients. METHODS: Pediatric patients with hydrocephalus and their caregivers were enrolled during routine neurosurgery clinic visits. The Hydrocephalus Outcomes Questionnaire (HOQ), a report of hydrocephalus-related QOL, was administered to both children with hydrocephalus (self-report) and their caregivers (proxy report about the child). Patients with hydrocephalus also completed measures of anxiety, depression, fatigue, traumatic stress, and headache. Caregivers completed a proxy report of child traumatic stress and a measure of caregiver burden. Demographic information was collected from administration of the Psychosocial Assessment Tool (version 2.0) and from the medical record. Child and caregiver HOQ scores were analyzed and correlated with clinical, demographic, and psychological variables. RESULTS: The mean overall HOQ score (parent assessment of child QOL) was 0.68. HOQ Physical Health, Social-Emotional Health, and Cognitive Health subscore averages were 0.69, 0.73, and 0.54, respectively. The mean overall child self-assessment (cHOQ) score was 0.77, with cHOQ Physical Health, Social-Emotional Health, and Cognitive Health subscore means of 0.84, 0.79, and 0.66, respectively. Thirty-nine dyads were analyzed, in which both a child with hydrocephalus and his or her caregiver completed the cHOQ and HOQ. There was a positive correlation between parent and child scores (p < 0.004 for all subscores). Child scores were consistently higher than parent scores. Variables that showed association with caregiver-assessed QOL in at least one domain included child age, etiology of hydrocephalus, and history of endoscopic third ventriculostomy. There was a significant negative relationship (rho -0.48 to -0.60) between child-reported cHOQ score and child-reported measures of posttraumatic stress, anxiety, depression, and fatigue. There was a similar significant relationship between caregiver report of child's QOL (HOQ) and caregiver assessment of the child's posttraumatic stress symptoms as well as their assessment of burden of care (rho = -0.59 and rho = -0.51, respectively). No relationship between parent-reported HOQ and child-reported psychosocial factors was significant. No clinical or demographic variables were associated with child self-assessed cHOQ. CONCLUSIONS: Pediatric patients with hydrocephalus consistently rate their own QOL higher than their caregivers do. Psychological factors such as anxiety and posttraumatic stress may be associated with lower QOL. These findings warrant further exploration.

The Association Between Community Participation and Social Internet Use Among Adults With Traumatic Brain Injury.

OBJECTIVE: To examine the association between social Internet use and real-world societal participation in survivors of moderate-severe traumatic brain injury. DESIGN: Prospective cross-sectional observational study. SETTING: Ten Traumatic Brain Injury Model Systems Centers. PARTICIPANTS: A total of 331 participants in the Traumatic Brain Injury Model Systems, interviewed at any follow-up year between April 2014 and March 2015. MAIN MEASURES: Survey on Internet use, including social media and other online socialization; Participation Assessment with Recombined Tools-Objective with separate analyses of Productivity, Social Relations, Out and About subscales; covariates included demographics, injury variables, and functional and emotional status at follow-up. RESULTS: Participants were classified as social Internet users (N = 232) or nonusers (N = 99). Users had significantly higher Participation Assessment with Recombined Tools-Objective Social Relations scores than nonusers. A similar finding pertained to Out and About scores, with the between-group difference significantly greater for those with greater depressive symptoms severity. Users and nonusers did not differ significantly on Productivity subscale. CONCLUSIONS: The positive association between social Internet use and real-world social participation suggests that people with traumatic brain injury do not use social media as an alternative to real-world socialization. Rather, it is likely that similar barriers and facilitators affect both online and real-world social participation following traumatic brain injury. Emotional function should be considered as a moderating factor in further studies.

Predictors of 1-Year Global Outcomes After Traumatic Brain Injury Among Older Adults: A NIDILRR Traumatic Brain Injury Model Systems Study.

Objective: To assess predictors of global function and driving status among older adults (50 years and older) who survived 1 year following inpatient rehabilitation for moderate-to-severe traumatic brain injury (TBI). Methods: Functional status at 1-year post-TBI was determined for 1,845 individuals. The relationship age category to function was studied using associations and predictive modeling. Results: The final model accounted for 34% variance in Glasgow Outcome Scale-Extended (GOS-E) among 60- to 69-year-olds and 70- to 79-year-olds, and 25% variance in 50- to 59-year-olds and 80+-year-olds. FIM Motor at rehabilitation discharge made the greatest contribution to GOS-E variance across all age groups. Inpatient rehabilitation discharge to nursing home or adult home and rehospitalization were associated with a one-level decrease in GOS-E. Alcohol use predicted lower GOS-E among the 70- to 79-year-olds. Gender, ethnicity, and rehospitalizations were negatively associated driving. Discussion: Rehabilitation approaches to older adults with TBI may help maximize function and, thereby, improve later outcomes and decrease rehospitlaizations. Such strategies may include longer and more intensive acute rehabilitation with greater patient engagement and enhanced transitions of care.

Sleep following traumatic brain injury (TBI): experiences and influencing factors.

Objective: This study aimed to 1) describe and explore the experiences of sleep following a moderate or severe traumatic brain injury (TBI) in community-dwelling adults, 2) elicit factors that positively or negatively impact the sleep experience, and 3) understand sleep-related education provided to survivors.Design: Qualitative description.Methods: Face-to-face interviews with 16 individuals using a semi-structured interview guide. Transcripts were systematically coded and common themes were identified. The final sample consisted of primarily Caucasian men with average age of 32.4 years (SD = 9.9), and average of 2.6 years (SD = .89) years post injury.Results: Community-dwelling survivors of TBI experienced poor sleep quality and quantity post-injury and described a variety of approaches to manage their sleep. Survivors described coping with sleep changes and using sleep as a coping mechanism for TBI. Additionally, survivors' responses indicated perceived lack of resources and preference for receiving education from knowledgeable, familiar clinicians during face-to-face encounters.Conclusions: This study provides a description of reported sleep experiences following TBI and adds new knowledge regarding sleep management strategies and preferences for resources. The findings suggest a need for education regarding sleep for rehabilitation professionals and long-term sleep support after discharge from rehabilitation.

Resilience Among Caregivers of Injured Service Members: Finding the Strengths in Caregiving.

OBJECTIVE: To examine the relationships between caregiver resilience and a comprehensive set of sociodemographic and health-related quality of life (HRQOL) predictors among both caregivers and injured service members. DESIGN: Cross-sectional analysis of an observational cohort. SETTING: Community dwelling. PARTICIPANTS: Caregivers (n=87) who provide instrumental or emotional support to injured service members (n=73)(N=160). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Connor-Davidson Resilience Scale 25-item version. RESULTS: Higher caregiver resilience scores were related to lower depressive symptom severity, greater health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, stress management, and problem-solving orientation. A multivariable regression model showed that spiritual growth and aspects of problem-solving orientation were significantly related to resilience. CONCLUSIONS: Results highlight the relationships between resilience and spirituality, problem-solving orientation, and aspects of HRQOL among caregivers of injured service members. These findings have important implications for caregiver behavioral health programs designed to promote resilience and draw upon caregiver strengths when taking on a caregiver role. Approaches that include a more integrative medicine or strengths-based emphasis may be particularly beneficial when working with families of injured military.