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. 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. 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. 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. Schools should create intentional and formalized communication pathways with healthcare providers as an effective approach to meeting the needs of students and their families.

Objective: To evaluate an online intervention to support family members of individuals who sustained a traumatic brain injury (TBI). Research Design: Randomized control trial. Parallel assignment to TBI Family Support (TBIFS) intervention or enhanced usual care control (TAU). Three testing timepoints: pretest baseline (T1), posttest within 2 weeks of assignment (T2), and follow-up 1 month after posttest (T3). Setting: Online. Participants: Sixty-eight caregivers recruited nationally: 18 years of age or older, English speaking, providing primary caregiving to an adult family member with TBI and mild to moderate disability. Intervention: Eight interactive modules providing information about cognitive, behavioral, and social consequences of TBI, training in problem-solving framework, and application exercises (N = 35). TAU was an informational website (N = 33). Measures: Proximal outcomes-program use, usability, and user satisfaction for TBIFS participants. Primary outcomes-TBI content knowledge, strategy application objective response and open-ended response, and strategy-application confidence. Secondary outcomes-appraisals of burden, satisfaction, uncertainty in mastery, guilt, and negative environment. Results: Proximal outcomes-about 80% of TBIFS participants completed the posttest assessment, and 91% reported moderate to high usability and user satisfaction. Primary outcomes-greater posttest gains in TBI content knowledge for TBIFS than TAU (t = 3.53, p = .0005, adjusted p = .0090, d = 0.91). Gains maintained through follow-up (t = 2.89, p = .0038, adjusted p = .0342, d = 0.90). No other effects for the primary or secondary outcomes. Conclusion: TBIFS improved TBI content knowledge relative to TAU. Modifications might be needed to improve application and distal outcomes for caregivers.

PURPOSE:First responders (law enforcement officers, firefighters, and emergency medical personnel) are at high risk for traumatic brain injury (TBI) and other catastrophic injury (CI) requiring long-term caregiver support. The aim of this pilot survey was to investigate, via caregiver perception, the lived experiences and needs of: (1) US first responders who experienced TBI/CI, (2) the caregivers themselves, and (3) children living in the home. MATERIALS AND METHODS:Caregiver participants (n = 27) completed an online survey including closed and open-ended questions. RESULTS:Results show first responders are living with adverse injury outcomes. Caregivers reported first responder suicidal ideation, suicide completion among their children, and a need for suicide risk support services. Four themes of most concern emerged. First responders are experiencing: (1) multiple challenges post injury (e.g., medical, benefits, vocational); (2) lack of support (e.g., state, departmental, peer, honor); (3) multiple adverse family impacts (e.g., relationship issues, family health); and (4) unmet/ongoing needs (e.g., education, alternative treatments, social support). CONCLUSIONS:The results provide critical data on US first responders with TBI/CI, their caregivers, and children. Study results can assist in the development of evidence-based supports and interventions to meet the needs of this understudied and underserved population.

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.

AbstractPhysical contact such as tackling is a part of youth sport, but associated with concussion risk. Coach communication with athletes about how to approach contact could be a strategy to reduce concussion risk. We interviewed n = 50 adult stakeholders (coaches, referees and administrators) in youth football and soccer to identify barriers and facilitators to coach communication about contact. We framed interviews using the Theory of Planned Behavior, discussing: knowledge/experience, attitudes/beliefs, norms/values and perceived behavioral control. Stakeholders could easily describe ‘good’ contact (knowledge/experience) like keeping your head up (football) and tackling shoulder-to-shoulder (soccer), and ‘bad’ contact like spearing (football) and retaliating against an opponent (soccer). They also talked about the importance of sportsmanship and playing by the rules. Most coaches believed ‘bad’ contact was associated with greater injury (attitudes/beliefs). Coaches felt responsible for managing contact (norms/values), but also described not receiving any information indicating that this was part of their role. Coaches worried about creating a fear of injury, and felt it was important for discussions to be framed positively (perceived behavioral control). In summary, youth football and soccer coaches believe ‘bad’ contact is associated with greater injury risk and feel it is their role to provide youth guidance about contact, but describe a lack of institutional guidance regarding this role. They also are concerned about barriers, including creating fear, and describe ways to address this barrier with language. Developing programs to support coach communication about contact with youth athletes presents a potential strategy for concussion prevention.

Early childhood special education (ECSE) professionals were forced to drastically change their methods of providing services as a result of the COVID-19 pandemic. In this qualitative study, we conducted interviews to understand how the COVID-19 pandemic has impacted ECSE professionals both personally and professionally. ECSE professionals described challenges as well as unexpected positive outcomes associated with continuing to work in the midst of the COVID-19 pandemic. Professionals also explained the importance of increasing parent interaction through coaching interventions while engaging in remote service delivery. The findings conclude with professionals’ discussions of how the field may be impacted by the pandemic in the future. Results were discussed in the context of service provision and implications for supporting professionals who work with young children with disabilities.

The purpose of this pilot study was to evaluate the online, self-guided, interactive Traumatic Brain Injury Family Support Program (TBIFS) with caregivers of law enforcement officers, fire fighters, and veterans (SOPs, service oriented professionals) with traumatic brain injury (TBI). Participants (n = 38) were caregivers of SOPs with TBI in the United States. The participants completed an online pretest (T1) and a posttest immediately upon completion of the online TBIFS program (T2). The study used a within-subjects, nonexperimental evaluation. The main measures were: (1) knowledge of basic TBI facts; (2) self-efficacy, measured by the General Self-Efficacy Scale, and (3) hope, measured by the Herth Hope Index. Participants demonstrated significant improvements in knowledge (n = 38, p = .001, d = 1.20) and self-efficacy (n = 37, p = .006, d = 0.48) and a non-significant gain in hope (n = 38, p =.054, d = 0.32). Improvements in participant knowledge about TBI and confidence (i.e., self-efficacy) about dealing with issues related to caregiving were associated with their use of the TBIFS program. Future research should include a controlled experimental investigation with caregivers from more diverse backgrounds.

Unintentional injuries are a leading cause of child death. The present study evaluated the effectiveness of a behavioral injury prevention program for children aged 3-18 years and their caregivers. To accommodate families during the Coronavirus-19 pandemic, training was modified to be delivered virtually. Forty-one children aged 3-18 years and 14 parents/caregivers of children aged 3-5 years attended one of several 4-hour online injury prevention training sessions directed toward residents of Washington state. Training was targeted to three different developmental stages (ages 3-5, 6-12 and 13-18 years). Study outcomes included knowledge about injury prevention strategies, perceived vulnerability for injury, self-efficacy to engage in safety behaviors and behavioral intentions to be safe. Following training, participants showed improved self-efficacy to stay safe, excellent knowledge about the learned material and increased behavioral intention to engage safely. There was minimal change in perceived vulnerability to injury among children; caregivers of young children felt their children were somewhat less vulnerable to injury following the training. Almost all participants said they would recommend the program to others. Results suggest that a virtual behavioral training program delivered remotely is feasible and may be effective to create behavior change and reduce child injury risk. Given its scalability and reach, such programs are recommended for further study, refinement and, if demonstrated effective in larger-scale controlled trials, dissemination to address the leading cause of child mortality in the United States, unintentional injury.

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.

Contact with other players, objects or the ground is an unavoidable part of youth sports, but also associated with injury risk such as concussion. Certain types of contact (e.g., tackling with head lowered) are particularly dangerous, and rules have been instituted to limit these types of contact in youth sports. Communication with youth athletes about good and bad physical contact could potentially be an important strategy towards decreasing injury risk in youth sport, but little is known about factors affecting such communication. We chose to fill this gap by interviewing adult stakeholders in youth sport. We conducted a qualitative interview study with n=49 adult stakeholders in youth football and soccer (coaches, referees and administrators) in two geographic regions to better understand barriers and facilitators to adult communication about physical contact with youth athletes. We viewed communication about physical contact through the lens of the Theory of Planned Behavior, conducting interviews that covered knowledge/ experience, attitudes/ beliefs, norms/ values and perceived behavioral control. All stakeholders were able to describe types of contact they felt were "good," like keeping head up (football) and going shoulder-to-shoulder (soccer), and "bad," like targeting/ spearing (football) and high kicking/ tripping (soccer). They also described the importance of sportsmanship and playing by the rules. Stakeholders believed certain types of contact, such as tackling with head lowered or aggressive retaliation, were associated with greater risk of injury, even if such contact was not always preventable due to misjudgment or player error. Management of physical contact was felt to be critical to sport and thought of as a shared responsibility between all key stakeholders, but a particular responsibility for coaches as they could emphasize appropriate physical contact both during practice and after game play. Referees were responsible for calling out bad physical contact during a game, and parents were key for reinforcing this messaging, even though respondents felt these roles were not always followed. Coaches felt comfortable talking about physical contact with their players, but noted they did not always feel like such discussions were supported by their community. They also emphasized the importance of phrasing these discussions positively ("lead with head up" rather than "do not put your head down") to improve likelihood of shifting behavior. Coaches and other adult stakeholders in youth sport have a clear vision of types of physical contact that are "good" and "bad," and understand that certain types of physical contact are associated with greater injury risk. They also believe that adult stakeholders, particularly coaches, referees and parents, can play a key role in providing guidance to youth regarding good and bad physical contact. Coach communication about physical contact with youth athletes presents a potential target for education programs, with a goal of reducing risk of injuries such as concussion.

High-stress events (e.g., natural disasters, political unrest, disease) significantly impact the lives of children and families. The Coronavirus Disease 2019 (COVID-19) is one event that has brought numerous hardships to families and children with developmental disabilities (DD), likely exacerbating already heightened levels of stress. For this study, we interviewed mothers living in the U.S. (N = 14) of 2- to 8-year-old children with DD about how COVID-19 has affected their family life. The interviews examined how the pandemic impacted (a) their child’s educational, therapeutic, and medical services, (b) their stress and resiliency, and (c) their parenting role as an advocate, educator, and interventionist. The results of our thematic analysis of the qualitative data highlight four domains with themes that describe families’ experiences as indicated by the mothers interviewed. Voices of families are essential in the delivery of effective and ethical early intervention for young children with disabilities. Based on the data from these interviews with mothers, suggestions for family-focused intervention to support families during high-stress events are discussed. As the long-term effects of the pandemic remain unknown, suggestions for future research to continue to examine the impact of high-stress experiences on young children with DD and their families are also presented.

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.

For students with traumatic brain injury (TBI), the COVID-19 pandemic exacerbated challenges they were already experiencing at school. 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. 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. 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. There is a significant need for professional development and school-wide infrastructure supportive of students with TBI.

BACKGROUND:The transition from hospital to school is regarded by researchers as a key factor in the educational success of students with traumatic brain injury (TBI).OBJECTIVES:The objective of this study is to look closely at what transition services consist of, how they are delivered, and how they are received by educators.METHODS:Parents and educators of 21 students with TBI participated in a qualitative study of the delivery of transition services and implementation of hospital recommendations.RESULTS:This paper presents two themes that emerged from interview and observational data collected over a 7-year period: 1) provision of hospital-school transition services is inconsistent and 2) teachers lack sufficient awareness of and training in TBI to implement hospital transition recommendations. Regardless of the type and quality of transition support, most educators in the students' schools remained unaware of the students' needs and how to meet them.CONCLUSION:Recommendations include more consistent and specific communication between hospital and school for all students with TBI, long-term tracking of the injury in student files, and increased training of educators in how to meet the needs of students with TBI.

ObjectivesDetermine whether Pre-Game Safety Huddles, a novel and low-resource approach to concussion education, increase the expected likelihood of concussion reporting for youth athletes.MethodsA 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.ResultsOf 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 relevancePre-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 numberNCT04099329.

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.

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: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.