Screening for Traumatic Brain Injury: Findings and Public Health Implications

Screening for Traumatic Brain Injury: Findings and Public Health

Implications

Kristen Dams-O’Connor, PhD, Joshua B. Cantor, PhD, Margaret Brown, PhD, Marcel P.

Dijkers, PhD, Lisa A. Spielman, PhD, and Wayne A. Gordon, PhD

Departments of Rehabilitation Medicine (Drs Dams-O’Connor, Cantor, Dijkers, Spielman, and

Gordon) and Preventive Medicine (Dr Brown), Icahn School of Medicine at Mount Sinai, New

York, New York

Abstract

Objective—To provide an overview of a series of projects that used a structured self-report

screening tool in diverse settings and samples to screen for lifetime history of traumatic brain

injury (TBI).

Setting—Diverse community settings.

Participants—Homeless persons (

= 111), individuals with HIV seeking vocational

rehabilitation (

= 173), youth in the juvenile justice system (

= 271), public schoolchildren (

174), substance users (

= 845), intercollegiate athletes (

= 90), and other community-based

samples (

= 396).

Design—Cross-sectional.

Main Measure—Brain Injury Screening Questionnaire.

Results—Screening using the Brain Injury Screening Questionnaire finds that 27% to 54% of

those in high-risk populations report a history of TBI with chronic symptoms. Associations

between TBI and social, academic, or other problems are evident in several studies. In non–high-

risk community samples, 9% to 12% of individuals report TBI with chronic symptoms.

Conclusion—Systematic TBI screening can be implemented efficiently and inexpensively in a

variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can

augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic

condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as

reducing risk for reinjury in high-risk groups, and provide access to appropriate interventions that

can reduce the personal and societal costs of TBI (tertiary prevention).

Keywords

prevention

;

public health

;

screening

;

traumatic brain injury

Corresponding Author:

Kristen Dams-O’Connor, PhD, Department of Rehabilitation Medicine, Icahn School of Medicine at Mount

Sinai, 5 East 98th St, Box 1163, New York, NY 10029 (kristen.dams-o’[email protected]).

The authors acknowledge the contributions of Mary Hibbard, PhD, to the development of the Brain Injury Screening Questionnaire.

The authors declare no other conflicts of interest.

HHS Public Access

Author manuscript

J Head Trauma Rehabil

. Author manuscript; available in PMC 2016 August 15.

Published in final edited form as:

J Head Trauma Rehabil

. 2014 ; 29(6): 479–489. doi:10.1097/HTR.0000000000000099.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

TRAUMATIC BRAIN INJURY (TBI) has been defined by the Centers for Disease Control

and Prevention (CDC) as “a bump, blow or jolt to the head that disrupts the normal function

of the brain” that can result from external force to the head, including whiplash, blast

exposure, or penetrating injury.

There are 2 critical elements of this definition: (1) a blow to

the head, resulting in (2) altered mental status, that is, loss of consciousness or a feeling of

being dazed and confused. Throughout this article, we use the term TBI or “TBI event”

when these criteria are met. The consequences of TBI can range from mild symptoms (eg,

headache, confusion) that quickly resolve to significant lifelong impairments in cognitive

functioning,

2,3

behavior and mood,

4–6

and physical functioning (eg, fatigue, balance

problems).

Because not all TBI events have lasting consequences,

we refer herein to TBI

with lasting symptoms as “chronic TBI.”

Obtaining an accurate estimate of the incidence and prevalence of TBI in the United States is

a major challenge. The CDC uses population-based data on TBI-related healthcare

encounters and deaths to estimate the number of individuals who sustain a TBI each year.

This method excludes individuals who do not seek medical care, whether in an emergency

department (ED) or physicians’ office, those whose TBI is not indicated in the medical

record, and those who are treated at a federal, military, or Veterans Affairs hospital. The

CDC estimates in 2009 were based on ED visits, hospitalizations, and physician visits, and

indicated that at least 3.5 million people sustained a TBI that year,

and that 5.3 million

people in the US are living with cognitive, physical, and/or emotional sequelae of chronic

TBI.

However, the 2009 incidence estimate was recently revised downward to 2.4 million when

the CDC removed physician visits from the estimation formula because of the potential for

duplication in the count.

Both of these methods, although reasonable and data-driven,

grossly underestimate the true incidence of TBI in the United States. One Internet-based

survey found that among respondents who indicated that they had incurred a TBI (as defined

by the CDC case definition), 42% never sought medical attention.

Other studies suggest

that the true count of individuals who sustain a TBI each year may be 3 to 5 times higher

than CDC’s estimate, although many of these are limited by selection bias.

13,14

Community-

based epidemiological studies in the United States and other developed countries further

augment these estimates and demonstrate that including TBI for which medical attention is

not sought and/or gathering TBI incidence data from multiple sources (healthcare providers,

hospitals, ambulance services, national healthcare databases, prisons, death registry, schools,

and other community services) yields considerably higher estimates of the incidence and

prevalence of TBI

15–17

than do studies that rely solely on ED or hospital admission data.

SYSTEMATIC SCREENING FOR TBI EVENTS AND CHRONIC TBI: A PUBLIC

HEALTH RESPONSIBILITY

Identification of TBI is particularly important when the injury results in continuing

symptoms (chronic TBI) that can lead to reduced productivity, poor community integration,

and other social problems. History of TBI is rarely queried in primary care or other health

service and educational settings, and its symptoms (if reported) may be inappropriately

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attributed to other causes such as aging,

depression, or, in schools, to learning or emotional

disabilities.

Failure to recognize the etiology of these symptoms precludes appropriate

treatment or symptom management.

Even in the absence of lasting symptoms, prospective identification and recording of the TBI

events themselves can be important. Recent literature

21–27

on delayed or late effects of

single and multiple TBI events makes a compelling case for systematic screening for and

documentation of TBI, even if an individual is asymptomatic at the time of screening. For

example, a child could have few acute symptoms after TBI but may begin to experience

difficulties when academic and social demands become more complex. If the TBI event had

been documented when it occurred or was identified later through screening, appropriate

accommodations could be made. In both athletes and community samples, a history of TBI

increases the risk for reinjury.

22,23

When risk for reinjury is modifiable (eg, removal from

contact sports or other high-risk environments), awareness of prior TBI provides important

information to allow individuals and parents, coaches, clinicians, and other parties to make

informed decisions about risk tolerance. Moreover, prior TBI may negatively affect recovery

from a subsequent TBI.

22,28,29

Individuals who are reinjured may suffer more severe

consequences because of the cumulative effects of multiple injuries.

23–26

Information about

lifetime TBI history can assist in accounting for current symptoms and altered trajectories of

recovery in athletic contexts and primary care settings. Moreover, although the evidence

remains mixed, a history of TBI may increase the risk for accelerated cognitive decline,

dementia, depression, and other health problems later in life.

21,22,27,30–33

A known history

of recent or remote TBI events may signal a need for more intensive medical management,

particularly in later adulthood. Together, these findings suggest that identification of TBI as

an injury event (whether or not it results in chronic symptoms) may have important personal

and public health implications.

The disproportionate rates of TBI seen in settings such as homeless shelters, prison systems,

and vocational rehabilitation facilities (relative to the rates in the general population)

34–37

further underscore the need for systematic TBI screening. It is logical to assume that

untreated TBI-related sequelae (such as impaired cognitive and social functioning, mood or

behavior changes, and job loss

) may increase one’s risk for chronic unemployment,

homelessness, committing acts of violence, or incarceration, and the prevalence of TBI in

these settings is alarming.

32,34,39–43

Conclusions as to causality are limited in cross-

sectional studies, but studies conducted in Canada and the United Kingdom indicated that

70% to 90% of homeless people with a history of TBI report that their first TBI preceded the

onset of homelessness.

39,44

At the individual level, systematic screening for TBI events and chronic TBI using validated

tools can provide a useful starting point for a comprehensive evaluation to establish a TBI

diagnosis, if necessary and appropriate, and for linking a person to rehabilitation

interventions,

45,46

school or work accommodations,

and educational programming. At the

population level, systematic TBI screening can provide data to correct current

underestimates of the incidence and prevalence of TBI. Better estimates can support the

expansion of educational efforts both for the general population and for professionals in

health care, social service, education, and criminal justice settings to increase their

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understanding of TBI and to support delivery of services that take TBI into account. Better

estimates may also support the creation of accessible treatment opportunities for people with

chronic TBI-related challenges and be used to advocate for needed research funding.

METHODS FOR TBI SCREENING

Self-report elicited through structured screening tools is increasingly recognized as the best,

or perhaps only, way to estimate TBI incidence and chronic TBI prevalence.

48–52

Because

many (but not all) cases of unidentified TBI are mild injuries,

there may be no medical

record of the original injury. Even when medical evaluation and treatment is sought,

standard neuroimaging results, such as a computed tomographic scan or

electroencephalogram, are often normal after mild TBI.

Advanced neuroimaging, such as

magnetic resonance imaging, can result in normal findings even in cases of known TBI,

and costly imaging techniques are simply unrealistic to be used as screening tools. The

Veterans Health Administration and Department of Defense recognize that many TBIs

sustained by service members during deployment were neither witnessed nor documented

shortly after the event and implemented TBI screening systems in 2008-2009 to identify

individuals in need of medical services. Several structured TBI screening tools have been

developed for military and civilian use in response to the clear need to accurately document

lifetime history of TBI events and enduring TBI-related symptoms.

48–50,54,55

Structured TBI screening tools are preferred over single-item methods (“Have you ever had

a TBI?”), which may have lower reliability and validity, and tend to underestimate TBI

history. The way in which TBI history is queried has a nontrivial impact on prevalence

estimates. For example, some studies suggest that single-item questions about TBI history

miss more than 35% of the individuals found to have sustained a TBI via a subsequent

structured interview.

56,57

Carefully worded single-item queries can of course provide

valuable data in large-scale health outcomes studies designed to evaluate the association of

TBI with other health issues or behaviors but do not suffice for estimating TBI prevalence.

THE BRAIN INJURY SCREENING QUESTIONNAIRE

The Brain Injury Screening Questionnaire (BISQ) was developed with the goal of creating a

TBI screening tool that could be used to document lifetime history of self-reported TBI and

the presence of current symptoms, if any, as well as to rule out alternative explanations for

reported symptoms (eg, other neurological or developmental conditions). The BISQ is

divided into 3 parts: TBI History, Symptoms, and Other Health Conditions (see Table 1 for

sample items from each part, or request a copy of the BISQ at www.tbicentral.org). Part I is

loosely based on the HELPS card,

which queries lifetime TBI by asking, “Did you ever hit

your head?” and “Were you ever seen in an ED, by a doctor, or hospitalized?” to broadly

elicit recall of prior injuries. The BISQ provides more structured and detailed cueing by

asking respondents whether they have ever experienced a blow to the head in 19 specific

situations in which a blow may have occurred (see the Table). The provision of structured

recall cues is intended to serve as a memory jog and has been shown to enhance recall of

situations in which a TBI event may have occurred.

56–60

For every event endorsed, the

informant is asked whether he or she experienced either a loss of consciousness or a period

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of being dazed and confused and, if so, for how long. Next, respondents are asked whether

they have ever been hospitalized or treated in an ED for any of 13 specific medical events

(eg, electrical injury, near drowning) to document alternative explanations for clinically

significant symptoms. People who report no TBI events on part I are considered a negative

screen and are not asked to complete parts II or III.

Part II is an inventory of 100 cognitive, physical, emotional, and behavioral symptoms that

can be used to characterize transient or chronic symptoms after brain injury (see the Table

for sample items). The list of symptoms is based on symptom checklists disseminated by

researchers at The Institute for Rehabilitation and Research,

as well as at the Medical

College of Virginia.

These lists were modified to cover a comprehensive range of

symptoms based on an extensive literature review and clinical expertise. Respondents are

asked to rate on a 4-point Likert scale the extent to which each symptom has been a problem

for them in the past month. Research indicates that while a healthy adult control group

reported an average of 3 symptoms, and those with a disability (spinal cord injury, people

who are HIV positive, or have undergone a liver transplant) endorsed an average of 10,

individuals with mild TBI reported an average of 15.

This research identified 25 symptoms

that are commonly reported by individuals with TBI and uncommonly by those without

TBI.

Of the symptoms that reliably distinguished the TBI and control (non-TBI disability

or healthy control) samples after controlling for age, sex, ethnicity, education, income, and

self-reported depression, those that were endorsed by at least 33% of the TBI participants

and

endorsed by less than 10% of the healthy control group

and

less than 25% of the non-

TBI disability group were included in this cluster of symptoms.

Because these 25

symptoms are relatively unique to TBI, researchers who have used the BISQ have

considered endorsement of these symptoms in defining a “positive screen” for TBI, as

described later.

Part III of the BISQ is designed to help clarify the relationship of reported symptoms to

prior brain injury. It asks for age at the first and most recent blow to the head resulting in

alteration in mental status, as well as the presence of other health conditions that may

contribute to or explain the symptoms a person reports, including use of certain medications,

developmental delays, or neurological conditions.

The BISQ is a widely used and clinically relevant tool that can be used to document a TBI

event and/or to detect possible chronic TBI. When parts I, II, and III are used as a part of a

clinical evaluation, inferences about the extent to which a person’s current symptoms are

attributable to TBI history can be made.

The BISQ can be used as a self-report measure or

can be completed by a proxy and is available in English, Spanish, Chinese, and Greek. The

full BISQ takes 10 to 15 minutes to complete, and less time is needed by someone who

reports no blows to the head. The BISQ shares many of the limitations found in other

structured TBI screening tools that rely on self-report information,

48–50,54,55

such as biased

recall of injury events and under-/overreporting of symptoms. The absence of an appropriate

reference standard against which self-report can be compared precludes traditional

approaches to validating a screening tool. Thorough reviews of TBI screening methods in

the military have concluded that screening will result in both false-positive and false-

negative results but acknowledge that false positives are in fact an intended consequence of

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thorough screening and may be eliminated by a more extensive clinical evaluation.

64,65

The

possible iatrogenic effects of screening (eg, worry, unnecessary resources lavished on false

positives)

should not be dismissed. In keeping with the distinction between TBI events and

chronic TBI outlined previously, the BISQ can be used to address both potential goals of

systematic TBI screening: documenting TBI events that are currently asymptomatic as well

as those that result in lasting symptoms.

Here, we describe the full portfolio of projects conducted to date by researchers at the Brain

Injury Research Center of Mount Sinai and colleagues that have used the BISQ in TBI

screening efforts across North America. By describing the use of the same screening

instrument across samples and settings, we hope to illustrate the feasibility of systematic

TBI screening and also the prevalence of unidentified TBI as elicited using a structured self-

report tool.

ESTIMATING PREVALENCE OF TBI IN COMMUNITY SAMPLES

Study 1: New York City public schools

Cantor et al

67,68

conducted a study in which schoolchildren and their parents were invited by

mail or in person to complete the BISQ after providing informed consent. Approximately

29% of the 600 children who were invited to participate in the study provided complete data

on the BISQ. Participants were 174 adolescents (aged 12-17 years) from 3 New York City

schools; all participants were given comprehensive neuropsychological testing to determine

whether positive TBI screens were associated with objectively measured cognitive

problems.

In 74% of the cases, the BISQ was completed by a parent and a child together,

in 21%, the child completed the BISQ independently, and in the remaining cases, the parent

completed the BISQ independently. While none of the students had been previously

identified by the school system as having had a TBI, 44% of the children reported a TBI

event. A “positive screen” for chronic symptomatic TBI in this study was made when a

parent or a child reported a TBI event and also reported at least 5 of the 25 symptoms that

have been associated with TBI.

Approximately 10% of the total sample screened positive

for chronic TBI, and 79% of these students had scores on the Conners Parent Rating Scale-

Revised indicative of a “significant problem” (compared with 31% of negative screens), and

80% of these students demonstrated impaired performance in more than 2 domains of

cognitive functioning on objective neuropsychological testing.

Study 2: Community-based sample of adult research volunteers

Individuals who volunteer for participation in a TBI study as “non-TBI controls” are

theoretically people who do not believe that they have ever sustained a TBI. Volunteers from

the New York metropolitan area were recruited using flyers, mailings, and Internet

advertisements; those who self-identified as either healthy controls or individuals with

depression or chronic pain (but no history of TBI) were invited to complete the BISQ.

Prior to scheduling a study visit, candidates for the non-TBI control group were reminded of

the eligibility criterion of never having sustained a TBI. Yet, of the total sample of “non-TBI

controls” (

= 396), 12% reported having sustained 1 or more TBI events when they

completed the BISQ. To explore whether these individuals with previously unidentified TBI

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reported symptoms that were similar to those of people with (self-)identified, or known TBI,

we compared their symptom report with that of a subsample (demographically matched 2:1)

of individuals from the known TBI group (

= 141 included in these analyses). The 2 groups

reported similar levels of cognitive and behavioral symptoms (

values ranged from 0.11 to

0.85).

Those with previously unidentified TBI reported slightly more (rather than less)

mood and physical symptoms, but the difference was not significant. Individuals in both

groups performed similarly on the Automated Neuropsychological Assessment Metrics

(ANAM 4)

computerized assessments of processing speed, attention, encoding, spatial

processing, and accuracy (

values ranged from 0.20 to 0.95), but individuals with

unidentified TBI demonstrated poorer working memory (

= 0.049). These findings indicate

that, while individuals in the community with previously unidentified TBI have similar

symptom profiles as individuals with known TBI and in some areas may demonstrate poorer

functioning, they do not causally associate their symptoms with a prior brain injury.

IDENTIFYING INDIVIDUALS WITH UNIDENTIFIED TBI IN HIGH-RISK

POPULATIONS

Study 3: New York State Office of Alcohol and Substance Abuse Services Facilities

Substance abuse is a risk factor for TBI and is also a common sequela of TBI, even among

individuals who did not evidence preinjury substance abuse.

71,72

In collaboration with the

New York State Office of Alcohol and Substance Abuse Services, the BISQ was

administered during intake evaluations to 845 individuals seeking substance abuse treatment

at 27 participating New York State Office of Alcohol and Substance Abuse Services

facilities (including inpatient detoxification short-term treatment programs, methadone

maintenance programs, transitional living facilities, and outpatient treatment programs).

Overall, 76% reported having sustained at least 1 blow to the head, 69% reported 2 or more,

27% reported 4 or more, and 16% reported more than 10. (Not all of these injuries resulted

in loss of consciousness or even a period of being dazed or confused; blows to the head not

resulting in altered mental status are not considered “TBI events.”) In all, 54% of the sample

screened positive for chronic TBI on the BISQ, meaning that they had sustained a blow to

the head that resulted in a period of altered mental status

and

that they reported at least 5 of

25 symptoms that have been associated with TBI.

The average age of the first TBI was

14.5 years, and those who screened positive for TBI were more likely to have had substance

abuse treatment episodes (eg, inpatient detoxification, outpatient treatment) prior to the

index intake session; they also had more Diagnostic and Statistical Manual of Mental

Disorders (Fourth Edition)

DSM-IV

diagnoses.

Study 4: El Paso Juvenile Justice Department

Considerable evidence indicates that TBI is highly prevalent in individuals convicted of

criminal offenses.

9,30,32,41,73–79

Estimates from recent meta-analyses suggest that 50% to

60% of adult offenders have sustained a TBI.

32,41

Traumatic brain injury is associated with

an increased risk of violence, recidivism, and psychiatric disorders in adults and youths

involved with the criminal justice system.

76,78,80–83

Because of the lack of systematic

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screening for TBI in juvenile justice departments, TBI is usually not identified and goes

untreated in this population.

84,85

The CDC-funded Mount Sinai Injury Control Research Center (a component of the Brain

Injury Research Center of Mount Sinai) has begun to evaluate an adapted, empirically

validated cognitive rehabilitation intervention that was originally developed for adults with

TBI in a recidivist juvenile offender population served by the El Paso Juvenile Justice

Department. As of this writing, 271 adolescents have been screened with the BISQ. Of

these, 76% reported at least 1 TBI (blow to the head resulting in loss of or alteration of

consciousness). Based on their self-report of cognitive, physical, and emotional symptoms,

approximately 29% of the sample reported clinically significant enduring TBI-related

symptoms.

Study 5: Community-based vocational services organization for individuals with HIV

Jaffe and colleagues

used the BISQ to investigate the frequency of TBI in individuals with

HIV recruited from a community-based vocational services agency in New York City. The

majority (74%) of the 173 participants (mean age [SD] = 38.0 [10.9]) reported having

experienced at least 1 blow to the head in their lifetime, and 60% reported more than 1 blow.

Twenty-seven percent of those who reported a history of 1 or more blows to the head

sustained what would be considered moderate to severe TBI (loss of consciousness

minutes

When the symptom profiles of those with and without a TBI history were

compared, individuals with HIV who screened positive for TBI reported more than twice as

many symptoms.

Study 6: Urban homeless shelter in Canada

A growing body of literature documents rates of TBI among homeless individuals that far

exceed rates in the general population.

34,39

Although findings differ across studies, the

largest (

= 904) found that 53% of the sample reported a history of TBI.

Topolovec-

Vranic and colleagues

used the BISQ to screen for TBI in a sample of men who received

services at an urban adult homeless shelter in Toronto, Canada. Of the 111 screened, 77%

reported having sustained a blow to the head, resulting in alteration of consciousness, and

45% screened positive for TBI with enduring symptoms. Importantly, 87% of the individuals

who screened positive for TBI (defined in this study as having sustained a blow to the head,

resulting in altered mental status and endorsing at least 8 chronic symptoms) reported that

the TBI occurred before the onset of homelessness.

Individuals with a positive TBI screen

were more likely than those with no history of TBI to report past arrests and mental

illness.

Study 7: Intercollegiate athletes at an urban university

The number of visits to US EDs for sports and recreation-related TBIs by children and

adolescents is approximately 173 000 per year.

These data suggest that many college-level

athletes may have sustained 1 or more concussions prior to the start of their college career.

Most research on sports concussions fails to assess or account for the potentially

confounding role of a lifetime TBI history in evaluating outcomes of sports concussions.

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In an ongoing study, the Mount Sinai Injury Control Research Center used the BISQ to

screen college athletes at an urban Division II university for lifetime TBI history prior to the

start of the 2010-2011 athletic season. Of 90 athletes, 45% reported having sustained 1 or

more blows to the head (range: 1-14).

Few of these injuries were reported on the single-

item concussion history included in the Immediate Postconcussion Assessment and

Cognitive Testing (ImPACT),

which queries whether the respondent had been “diagnosed

with a concussion” and was administered before the BISQ. Of the athletes who reported

blows to the head on the BISQ but no concussions on the ImPACT, about half reported

experiencing 5 or more of the 25 symptoms specific to TBI.

A small but meaningful

proportion of these athletes reported injuries on the BISQ that were clinically significant (eg,

12 athletes reported a blow to the head, with loss of consciousness lasting several minutes to

an hour), despite having reported on the ImPACT that they had never been diagnosed with a

concussion. This finding highlights the risk of underreporting when case definitions of TBI

events include only injuries for which medical attention is sought. Given that having

sustained a prior TBI is associated with a slower recovery from a subsequent concussion

(and is, therefore, an important consideration in most return-to-play guidelines

89,90

incomplete information about lifetime history of TBI can result in premature return to play

and poorer recovery from injury-related deficits.

DISCUSSION

The findings presented here come from a series of TBI screening studies that used the BISQ

in diverse populations and collectively demonstrate that systematic screening for TBI, using

a structured self-report measure reveals a higher prevalence of TBI events and of chronic

TBI than would be expected on the basis of existing estimates.

These findings are consistent with studies that have used other structured TBI screening

tools in homeless shelters, vocational rehabilitation services, mental health clinics, and

among victims of domestic violence.

54,92,93

Individuals with chronic TBI have unique

treatment needs and comorbid clinical diagnoses that may create barriers to self-sufficiency.

Once a TBI is identified, individuals with lasting symptoms who have received no treatment

or who have been unable to benefit from other interventions (eg, substance abuse treatment,

vocational rehabilitation) can access more appropriate interventions that target the TBI-

related symptoms and/or modify treatments to take into account the cognitive and other

deficits that commonly result from TBI.

2,45,94–95

A growing body of research supports a

range of effective interventions, even for individuals who are many years postinjury.

45,46

Some may argue that TBI screening is unnecessary or even harmful in military contexts due

to the possibility of expectancy bias or “catastrophic reactions” to a positive screen, resulting

in iatrogenic illness and costs associated with further diagnostic workup that may prove

unnecessary.

Research in the broader health screening literature (eg, dementia, cancer)

suggests that people generally want to know the results of health screens.

85,96–101

Results of

a screen should be provided along with psychoeducation about positive expectations for

recovery from mild TBI

102

and a clear statement that a screening tool is not capable of

attributing causality or making a diagnosis. Clinically significant symptoms should be

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further evaluated and all contributing factors considered—including TBI, Post Traumatic

Stress Disorder, and depression.

103

The research discussed here suggests that failing to identify TBI may have serious

consequences. An accurate estimate of the true incidence and prevalence of TBI will provide

an important catalyst for the dissemination of interventions found to be effective,

45,46,104

well as further research and development of new interventions. Limitations of the studies

presented here warrant consideration. They were conducted in convenience samples, and

their findings cannot be generalized to other groups or the general population. These studies

are cross-sectional, and it cannot be determined whether symptoms, neurocognitive

impairment, or other negative outcomes (eg, incarceration, homelessness) were causally

related to TBI. The BISQ instrument itself also has limitations. The version used in all the

studies reported here did not specifically ask about combat-related or blast injuries in part I

and, therefore, may not be appropriate for documenting TBI history in military service

members. Part II includes 100 symptoms, which may be onerous for some responders;

further research is needed to inform the development of an abbreviated version. Finally, the

list of medical conditions (in parts I and III) that could impact symptom report is not

exhaustive, and a revised version of the BISQ will solicit more comprehensive reporting of

potential contributors to current symptoms. As is the case with all structured TBI screening

tools,

48–50,54,55

the BISQ is not capable of diagnosing TBI or causally associating symptoms

with an injury. The BISQ is a tool for characterizing lifetime TBI history and current

symptoms. Clinically significant symptoms require further evaluation that considers

contributing factors other than TBI so that treatment (if indicated) is appropriate to symptom

etiology.

Systematic TBI screening is essential for accurate injury surveillance, prevention of

secondary and tertiary consequences of TBI, and facilitating access to appropriate

interventions for individuals with lasting symptoms. Systematic screening tools are also

needed to measure the impact of injury prevention efforts. Given the public health

implications of unidentified TBI, the best available tools should be used for comprehensive

screening. In the absence of a “gold standard” tool for TBI ascertainment, traditional

validation approaches such as sensitivity and specificity analyses are not available for self-

report screening tools. A thorough screening tool will elicit more false positives than false

negatives to ensure that as few individuals as possible with TBI are missed; a high

specificity is sacrificed to obtain high sensitivity. Further evaluation can minimize false

positives. The challenge is to identify or develop structured TBI screening tools that

comprehensively query lifetime history of injury events (of any severity) using plain and

understandable language and that also query about current symptomatology that may be

used to distinguish TBI-related consequences from nonspecific symptoms and make

appropriate clinical referrals. Research to identify constellations of symptoms that may be

useful in distinguishing chronic TBI from other psychological and medical health conditions

is currently underway at the Brain Injury Research Center of Mount Sinai.

The definition of TBI delineated by the CDC,

together with the CDC’s comprehensive list

of symptoms and signs that can help in diagnosing and managing a TBI,

105

provides a

framework for what might be considered the minimal requirements for a structured TBI

Dams-O’Connor et al.

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screening tool. As demonstrated here, the BISQ not only meets these minimal requirements

but is also relatively brief, easy to administer in a wide range of settings and populations, has

good construct validity and criterion validity,

40,43,68,69

and appears to be more sensitive to

comprehensive TBI history than many existing measures.

56,57,59,87

The BISQ is not without

limitations, and other tools may be more appropriate in some settings. A report on a subset

of results of large-scale expansion of the initial BISQ validation study

is currently under

review.

CONCLUSIONS

Underestimation of the rates of TBI and TBI-related disability has important personal and

public health consequences. For individuals, screening for TBI events and chronic TBI can

open the door for treatment and/or accommodations; and accurate documentation of TBI

history in the medical or academic record can inform health-related decision making at the

time of screening or years down the road. Systematic TBI screening allows for more

accurate estimates of the prevalence of TBI events and chronic TBI. Such data are needed to

support the development of educational efforts for clinicians and other medical and social

service professionals, support the expansion of accessible primary and secondary prevention

opportunities for people with TBI, and ultimately decrease the personal and social costs of

TBI.

Acknowledgments

The preparation of this article was supported in part by grant No. 1R49CE001171 from the Centers for Disease

Control and Prevention to Icahn School of Medicine at Mount Sinai, New York City. The Brain Injury Screening

Questionnaire discussed in this article as a tool for screening for traumatic brain injury is sometimes sold to

agencies/organizations that want to screen people for brain injury. The proceeds of such sales benefit the Brain

Injury Research Center of Mount Sinai, with which all authors are associated.

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Dams-O’Connor et al. Page 17

TABLE 1

Sample items from parts I, II, and III of the Brain Injury Screening Questionnaire

Part I

For each event listed, record the number of times you

experienced a blow to the head in that type of

situation.

For each blow to the head recorded in Column

A…

Column A Column B

Did you ever lose consciousness? Were you ever dazed and

confused?

Did you ever experience a blow to

the head…

How many

times?

How

many

times?

Longest

period?

How

many

times?

Longest

period?

In a car crash?

While on the playground?

Being assaulted or mugged?

Part II

Please check the boxes below to indicate how often, in

the past month, you have been bothered by each of the

difficulties listed.

Always Often Some-

times

Never N/A

Having double vision or blurred vision

Difficulty concentrating, having a poor span of

attention

Doing things without thinking them through, being

impulsive

Part III

Yes No Don't

Know

Were you labelled as having a learning disability or an attention deficit

disorder?

Were you ever medicated for a psychiatric condition?

Were you ever hospitalized or seen in the emergency room for a brain

infection?

Abbreviation: N/A, not applicable.

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