Description of School Outcomes Among Children With Traumatic Brain Injuries, Centers for Disease Control and Prevention’s National Concussion Surveillance System Pilot

Abstract

Background:

Traumatic brain injury (TBI) is a common injury in children. Though research on youth TBI has largely focused on high school students, this study describes selected school outcomes after TBI in the past 12 months among children aged 5–17 years.

Methods:

Data from parent-proxy respondents from the pilot administration of the National Concussion Surveillance System (a random-digit-dial telephone survey with over 10,000 adult respondents) were examined. Descriptive statistics of demographic and injury characteristics of children who sustained a TBI were calculated. The association between TBI signs/symptoms and selected school outcomes were determined by multinomial logistic regressions.

Results:

Among the 3557 children sampled via parent-proxy-reporting, 9.9% sustained a TBI in the past year. Changes in sleep or being more tired than usual, trouble concentrating, sensitivity to light or noise, and difficulty learning or remembering new things were associated with a greater risk of worse school outcomes following a TBI.

Implications for School Health Policy, Practice, and Equity:

To promote a positive return to learn (RTL) experience among children following TBI, school districts may prioritize accommodations (e.g., breaks in learning, extra time for assignments) and implement existing ascending levels of academic support where warranted.

Conclusion:

These findings may inform stakeholders seeking to enhance RTL and provide needed support or services for school-aged children who sustain a TBI.

Traumatic brain injury (TBI), including concussion, is a common injury experienced by school-aged children [1]. A large, national self-report survey found that approximately 10% of children aged 5–17 sustained a TBI in the past year [2]. While all children are at risk for sustaining a TBI, boys [3] and children who play sports [4] display higher prevalence and incidence rates than other groups. Most children experience a complete recovery from a mild TBI or concussion within several weeks [5–7], and it is recommended that children return to school within days after their injury. However, some common symptoms, such as headache, fatigue, and sensitivity to light and noise, can interfere with a child’s ability to attend school and complete coursework.

Previous research has found that a student’s attendance and grades may suffer as a result of their injury. Russell and colleagues, using data collected as part of a large, longitudinal study of high school students conducted in Canada, reported that sustaining a concussion resulted in a small drop in GPA [8]. Students with a sports-related concussion have also been shown to miss more days of schools compared to students with a sports-related extremity fracture [9]. A recent systematic review examined the effect of concussion or mild TBI on a variety of school outcomes and found that these injuries are strongly associated with missed school [10].

Most of the previous research that examined school outcomes after concussion have focused on adolescents and high school students. For example, Youth Risk Behavior Surveillance System (YRBSS) core survey includes a concussion question, but the question only assesses sports- and recreation-related concussion among high school students and a limited number of middle school students; information on concussions sustained through other mechanisms is not gathered [11]. Similar issues occur with other national data from other sources such as the High School Reporting Information Online (HS-RIO) system (https://datalyscenter.org/programs/rio/) or ask about the lifetime history of TBI (e.g., monitoring the future (https://monitoringthefuture.org/)) among adolescent and high school students. Less is known about how children in elementary or middle/junior high school fare after their brain injury. However, one such study, the Adolescent Brain Cognitive Development (ABCD) study, helps address this gap by longitudinally examining child brain development and health (including lifetime TBI) of children between the ages of 9- and 10 years old across the United States over 10 years.

The aim of this paper is to describe selected school outcomes, including school absences, changes in grades, usage of school support services, and level of school functioning, after proxy-reported TBI (due to any cause) in the past 12 months among children aged 5–17 years.

1 |. Methods

1.1 |. Participants

Data from the U.S. Centers for Disease Control and Prevention’s (CDC) pilot administration of a National Concussion Surveillance System (NCSS) were examined. A detailed NCSS survey methodology has been previously described [12, 13], with the goal of developing a TBI-tiered case definition to use in self-report surveys. The NCSS pilot was a random-digit-dial (RDD) telephone survey that used a computer-assisted telephone interviewing to collect data, following a protocol designed to minimize bias (e.g., calling people both during the day and evening) while maximizing completeness (e.g., protocols designed to reach every eligible respondent). Over 10,000 adults participated in the survey, and data were collected from September 2018 to September 2019. Sampled adults were surveyed directly, and adult respondents with children aged 5–17 years in the household were asked about head injuries sustained by these children and hereafter are referred to as “parent-proxy respondents.”

1.2 |. Instrumentation

Parent-proxy respondents were asked two questions to determine whether their child had sustained a head injury in the past 12 months: “In the last year, that is since [date 1 year ago from interview date] was your child examined in a doctor’s office, clinic, hospital or elsewhere because of a head injury?” and “In the last year, that is since [date 1 year ago from interview date], did your child experience any other injuries to their head that they did not see a doctor about?” Following a “yes” response about whether the child sustained a head injury in the preceding 12 months, parent-proxy respondents were asked 12 yes/no questions regarding signs and symptoms that may have occurred as a result of the child’s head injury. If the parent-proxy respondent endorsed at least one sign or symptom for the child’s head injury, that child was considered to be a TBI case. There were multiple questions that assessed school outcomes, some of which were “Did your child miss any school due to the head injury?”, “Did your child receive extra help, support, or services at school due to the head injury?”, and “Have your child’s grades declined since the head injury?”. Please refer to Supporting Information 1 for a comprehensive list of the questions and responses used in this study.

1.3 |. Data Analysis

Descriptive statistics (frequencies and percentages) of parent-proxy-reported demographics and injury characteristics of school-aged children were calculated. Additionally, parent-proxy-reported injury circumstances and outcomes for each child’s most recent TBI were examined. Statistical significance was assessed via the Rao–Scott chi-square tests. To estimate independent associations between TBI signs/symptoms and selected school outcomes, separate multinomial logistic regression models were computed for each outcome of interest. Associations are presented as adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs). All models were adjusted by all other TBI signs/symptoms as well as demographics (i.e., sex, age, and race/ethnicity). All estimates met the CDC’s National Center for Health Statistics data presentation standards for percentages and means [14]. Analyses were performed using SAS (version 9.4; SAS Institute Inc.) and SUDAAN (version 11.0.4; Research Triangle Institute), taking the complex survey design into account. Although it was determined that IRB approval was not required because the project was deemed not research, the survey protocol was approved by ICF’s IRB (#FWA00000845). Weighted estimates from this pilot were not intended to produce nationally representative estimates of TBI.

2 |. Results

Data on 3557 children aged 5–17 years were included in the study via parent-proxy-reporting (Table 1). The data consisted of 51.0% males and 49.0% females, with about a third of the sample representing each age group (5–9 years old: 38.1%; 10–13 years old: 30.8%; 14–17 years old: 31.1%). The two highest race/ethnicity groups were non-Hispanic White (49.1%) and Hispanic (23.3%) children. An estimated 9.9% of children sustained a TBI during the preceding 12 months. Among males, 11.2% sustained a TBI, which was higher than the percentage of females who sustained a TBI (8.5%), p = 0.01. There were no overall statistical differences between age group or for race/ethnicity.

TABLE 1 |.

Parent-proxy-reported demographic and injury characteristics of school-aged children, National Concussion Surveillance System (NCSS) Pilot, 2018–2019.

Characteristic	Total sample		TBIa
			Yesb		No		Test statistic	p-value
	N	Weighted %	N	Weighted %	N	Weighted %
Sex							7.0	0.01
Male	1824	51.0	208	11.2	1616	88.8
Female	1733	49.0	156	8.5	1577	91.5
Age (years)							2.2	0.33
5–9	1241	38.1	134	10.9	1107	89.1
10–13	1122	30.8	117	9.2	1005	90.8
14–17	1194	31.1	113	9.3	1081	90.7
Race/Ethnicity							5.8	0.22
White, non-Hispanic	2234	49.1	233	10.5	2001	89.5
Black, non-Hispanic	315	12.8	23	7.4	292	92.6
Asian, non-Hispanic	88	4.6	—c	—c	79	91.3
Hispanic	471	23.3	43	8.7	428	91.3
Other, non-Hispanic	449	10.2	56	13.3	393	86.7
TBIa							—	—
Yesb	364	9.9	—	—	—	—
No	3193	90.1	—	—	—	—

^aFor most recent injury.

^bThis comprises parent-proxy-reported head injuries with at least one sign or symptom.

^cSuppressed estimate that did not meet the National Center for Health Statistics data presentation standards for percentages and means.

Approximately three-quarters (74.5%) of the most recent TBIs occurred during the school year or when school was in session. Among those children whose most recent TBI occurred during the school year or when school was in session, 29.4% missed school due to their injury (Table 2); 1 day of school was the only length of absence reported (data not shown). Among children’s most recent TBI, 9.9% received extra help, support, or services at school and 8.0% were reported to have declining grades since the injury. For approximately 10.0% of children’s most recent TBIs, their parent reported moderate to extreme effects on school functioning.

TABLE 2 |.

Parent-proxy-reported injury circumstances and outcomes of school-aged children for their most recent TBI^a, National Concussion Surveillance System Pilot, 2018–2019.

	TBIa (N = 339b)
Characteristic	N	Weighted percentage
Child injured during school
Yes	252	74.5
No	87	25.5
Child missing school due to the head injuryc
Yes	78	29.4
No	172	70.6
Child receiving extra help, support, or services at school
Yes	36	9.9
No	298	90.1
Child receiving letter or number grades
Yes	181	51.5
No	151	48.5
Decline in child’s grades since the head injuryd
Yes	17	8.0
No	160	90.6
Too soon to tell/not evaluated yet	—e	—e
Impairment in school functioning
Not at all/slightly	297	90.0
Moderately/quite a bit/extremely	40	10.0

^aThis comprises parent-proxy-reported head injuries with at least one sign or symptom.

^bSample size is lower due to data either being missing or a respondent indicating do not know or refused for the school-related questions.

^cOnly asked among parent-proxies that answered “yes” if the child was injured during school.

^dOnly asked among parent-proxies that answered “yes” if the child received letter or number grades.

^eSuppressed estimate that did not meet the National Center for Health Statistics data presentation standards for percentages and means.

Among children’s most recent TBI (Table 3), sports- and recreation-related activities accounted for the majority of unintentional injuries (69.1%), followed by falls (18.4%). TBI caused by intentional (assault and self-harm) and other/unknown mechanisms of injury was too small and unstable to report and was thus not shown in the table. A little over half (56.1%) of children were medically evaluated for their most recent TBI, of which 34.4% were evaluated by a nurse, followed by a doctor (24.8%) and an athletic trainer (24.5%). The mean and median number of symptoms reported were 3.3 and 1.7, respectively (data not shown). Headache was the most common symptom reported (86.0%), followed by change in mood or temperament (38.4%) and sensitivity to light or noise (32.5%). Loss of consciousness (LOC) was reported by 8.3% of parent-proxy respondents for their child’s most recent TBI. About one in five (18.6%) of children had symptoms lasting more than 8 days or were yet to resolve at the time of the interview, and a little less than half (47.3%) had symptoms that resolved in 1 day. Among those injuries where symptoms had resolved by the time of the interview, the mean time to symptom resolution was 6 days. For approximately 10.0% of children’s most recent TBIs, their parent reported moderate to extreme effects on social functioning.

TABLE 3 |.

Parent-proxy-reported indicators of school outcomes for their school-aged child’s most recent TBI, National Concussion Surveillance System (NCSS) Pilot, 2018–2019.

Characteristic	TBIa (N = 364)
	N	Weighted %
Mechanism of injury (unintentional)
Sports- and recreation-related activities	248	69.1
Motor vehicle crash	—c	—c
Struck by or against an object	25	8.0
Fall	59	18.4
Medically evaluated
Yes	193	56.1
No	147	43.9
Medical professional who did the evaluationb
Nurse	58	34.4
Doctor	49	24.8
EMT or paramedic	18	9.6
Athletic trainer	51	24.5
Other medical professional	—c	—c
Location of care (where the first evaluation was sought)b
In a doctor’s office, urgent care, or clinic	39	19.2
At a hospital or emergency department	34	19.5
At the time and place of head injury	119	61.3
TBI signs and symptoms
Headache	318	86.0
Change in mood or temperament	131	38.4
Sensitivity to light or noise	115	32.5
Changes in sleep or more tired than usual	106	30.0
Dizziness, clumsiness, or balance problems	103	27.4
Dazed, confused, or trouble thinking straight	99	25.2
Trouble concentrating	83	22.7
Nausea or vomiting	77	20.1
Difficulty remembering what happened just before/after injury	51	15.1
Difficulty learning or remembering new things	56	14.3
Blurred or double vision	53	13.5
Loss of consciousness	32	8.3
Symptoms not resolved or that occurred for 8+ days
Yes	65	18.6
No	261	81.4
One day of signs or symptoms
Yes	154	47.3
No	172	52.7
Social impairment
Not at all/slightly	299	90.0
Moderately/quite a bit/extremely	38	10.0

^aThis comprises parent-proxy-reported head injuries with at least one sign or symptom.

^bSample is only among those that were evaluated for TBI, N = 193.

^cSuppressed estimate that did not meet the National Center for Health Statistics data presentation standards for percentages and means.

Figure 1 displays the results of the multinomial logistic regressions, putting all TBI signs/symptoms and demographic variables into each model. After adjusting for all other signs and symptoms and demographics, children who had changes in sleep or were more tired than usual, who had trouble concentrating, who had nausea or vomiting, or who had LOC were more likely to miss school due to their injury (PR = 2.27, 95% CI = 1.32–3.90; PR = 1.99, 95% CI= 1.16–3.44; PR = 1.49, 95% CI = 1.04–2.13; PR = 2.01, 95% CI = 1.11–3.65, respectively). After adjustment, children who had sensitivity to light or noise or who had difficulty learning or remembering new things were more likely to receive extra help, support, or services during school due to their TBI (PR = 3.61, 95% CI= 1.66–7.85; PR = 3.42, 95% CI = 1.46–8.01, respectively). The symptom of headache was independently associated with a lower prevalence of receiving extra help, support, or services during school (PR = 0.39, 95% CI = 0.19–0.77). Children who had sensitivity to light or noise or who had trouble concentrating were more likely to have moderate to extreme effects on school functioning (PR= 2.46, 95% CI = 1.23–4.92, PR = 3.50, 95% CI = 1.37–8.94, respectively). The symptom of blurred or double vision was independently associated with a lower prevalence of having moderate to extreme effects on school functioning (PR = 0.47, 95% CI = 0.25–0.90).

FIGURE 1 |.

Adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) for associations between parent-proxy-reported TBI signs and symptoms and indicators of school outcomes for their child’s most recent TBI*, National Concussion Surveillance System (NCSS) Pilot, 2018–2019.

*This comprises parent-proxy-reported head injuries with at least one sign or symptom.

3 |. Discussion

This study examined demographic characteristics, injury circumstances, and school outcomes of the most recent TBI reported in the preceding 12 months among children aged 5–17 years. Study findings indicate that about 9.9% of children, and more boys than girls (11.2% compared with 8.5%), were reported by their parent-proxy to have sustained a TBI in the preceding 12 months. Further, sports- and recreation-related activities were the most common mechanism of injury for the child’s most recent TBI.

Research [15, 16] suggests for most children who sustain a concussion or mild TBI that there is a positive recovery trajectory, with them feeling better within 2–4 weeks of their injury [2, 17, 18]. For a small proportion of children, concussion symptoms may persist months and sometimes years later [16], affecting them in school and as they develop into adulthood [10, 19, 20]. For example, a recent study [19] found that individuals with childhood TBI had lower rates of obtaining a high school degree or higher compared to those without TBI. While certain signs and symptoms of TBI are reported more often, the signs and symptoms that were independently associated with a greater prevalence of worse school outcomes in the NCSS pilot data included changes in sleep or being more tired than usual, trouble concentrating, sensitivity to light or noise, and difficulty learning or remembering new things. Educators and school administrators can support students who are experiencing such symptoms following a TBI by providing flexible and temporary academic support (e.g., limiting or restricting noisy environments/bright lights in the classroom/exposure to screens, allow frequent breaks, adjustment of academic task type and amount, providing extra time to complete assignments) [21] within the first month post-injury where warranted.

NCSS pilot data revealed that among children who sustained their most recent TBI during the school year, nearly a third missed at least some school. This finding corroborates previous research, which found that students with a concussion often missed school when assessed 3 days to 3 months after their brain injury [10, 22–25]. Additionally, previous research suggests that the type of injury sustained can affect the length of school absence among students. Two prospective cohort studies [9, 22] demonstrated that concussed high school and/or college students took nearly twice as long to return to school than students who sustained a musculoskeletal extremity injury (e.g., 5.4 days compared with 2.8 days). Returning to school following concussion is a multifactorial decision focused on the child’s severity of concussion and postconcussion symptoms, recommended cognitive rest, and/or school-based accommodations/academic supports provided following their injury. Concussion can negatively impact a child’s cognitive skills, affecting them in school, which is important to consider as our study estimated that 10% of children had moderate to extreme impairment on school functioning following their most recent TBI.

Current research [21, 26–28] on successful return to school following a concussion describes ascending levels of academic support (immediate and informal academic adjustments to formalized academic support outlined in an Individualized Education Plan or 504 Plan) provided by schools. In Pennsylvania, McAvoy et al. [28] described the effect of premature requests for formalized academic support, rather than utilizing immediate informal educational supports, for students following a concussion that can delay the provision of such support and due length of time to complete legal or policy-based processes, and this potentially lead to contentious relationships between parents and schools. Although this study did not assess the type of academic support provided following TBI, NCSS pilot data suggested that approximately 10% of children received extra help, support, or services at school following their most recent TBI. To promote a positive return to learn (RTL) experience among children following a concussion, school districts may prioritize the most feasible accommodations (e.g., breaks in learning, extra time to submit assignments) and implement existing ascending levels of academic support where warranted to help ensure that students have the appropriate supports in place according to their needs in order to return to their pre-injury abilities.

Additionally, this study showed that although only about half of children were evaluated for their most recent TBI, a large proportion of those (61.3%) were evaluated at the time and place of head injury. These findings suggest that the NCSS pilot likely captured TBIs where medical care was not sought, as well as those where medical care is sought outside of the emergency department (ED) (e.g., sideline of game or practice, urgent care, concussion clinic). This hypothesis is substantiated by previous research that found that only approximately 12% of pediatric concussions were initially treated in the ED when assessed in a large, urban, pediatric health care system [29]. Taken together, our study findings add to epidemiological research on TBIs among children that were historically limited to pediatric patients presenting in EDs or concussion clinics, and that estimates of TBI incidence based solely on ED visits underestimate the true burden of injury.

3.1 |. Implications for School Health Policy, Practice, and Equity

Most children who sustain a concussion or TBI will fully recover within 2–4 weeks of their injury [2, 17, 18]. However, some children may have symptoms that persist for longer [16] and can affect them in school. To promote a positive and robust RTL experience among children following TBI, school districts may prioritize the most feasible accommodations (e.g., breaks in learning, extra time to submit assignments) and implement existing ascending levels of academic support where warranted.

This study demonstrates that 9.9% of children sustained a TBI in the past 12 months via parent-proxy-reporting, providing evidence that TBI is not an uncommon condition among school-aged children. In order for children to get the appropriate support needed post-injury, training for school professionals is important to aid in the improved identification and facilitation of services and interventions for students with a TBI who may be struggling in school [30–32]. To fill this information gap and support schools with management of students with TBI, CDC offers a free online training for school professionals (https://www.cdc.gov/heads-up/training/school-professionals.html). Schools and school districts may consider offering this training to staff to help ensure that at least one person at each school is trained on TBI and to increase the awareness of evidence-based practices.

3.2 |. Limitations

There are several limitations to this study. First, there is potential for recall bias, telescoping, and social desirability given data collection was based on proxy-reporting. Second, there is potential of underreporting of TBIs by parent-proxies as in some cases parents may be unaware of their child’s injury or symptoms. For example, prior studies [33, 34] have shown that youth self-report estimates of TBI result in a 2- to 3-fold increase in TBI prevalence compared to parent-proxy-reporting. This suggests that the estimates of past year TBIs reported may be underestimated. Third, the TBI case definition in this study was originally developed using adult survey respondents and its applicability to children remains unknown. Nevertheless, the TBI case definition employed in this dataset aligns with those published elsewhere [35, 36].

4 |. Conclusions

The results of this study demonstrate that 9.9% of children in this study sustained a TBI in the past 12 months. Changes in sleep or being more tired than usual, trouble concentrating, sensitivity to light or noise, and difficulty learning or remembering new things were independently associated with a greater prevalence of worse school outcomes (e.g., missing school; receiving extra help, support, or services during school; or moderate to extreme impact on school functioning). These findings may inform stakeholders seeking to enhance a smooth RTL process and provide insight into beneficial support or services for school-aged children who sustain a TBI.

Supplementary Material

Additional supporting information can be found online in the Supporting Information section.