The Pediatric Injury Check-Up for Brain Health Monitor Group, Galveston Conference May 1, 2019 Care for traumatic brain injury (TBI) is often fragmented or ceases after discharge from acute medical services. For the purposes of monitoring children’s recovery from TBI, a simple but effective screening tool is needed. We propose the Pediatric Injury Check-Up for Brain Health (PIC-UP) as a new measure that may serve that purpose. Modeled on existing measures of post-concussive symptoms and quality of life, the PIC-UP is designed to be completed by parents, youth, and school personnel, thereby providing the opportunity to elicit multiple perspectives and coordinate care across settings. The PIC-UP needs to be validated through research prior to widespread dissemination and implementation. The proposed parent version is presented below: PIC-UP At this time, is your child experiencing any of the following difficulties? 1.
Physical problems (e.g., poor balance, dizziness, headache sleep disturbance) Y/N
2.
Learning or school problems (e.g., problems remembering, mental slowing, organizational difficulties, difficulties following directions, poor school attendance, poor grades) Y/N
3.
Emotional problems (e.g., sadness, worry, anxiety, anger, irritability) Y/N
4.
Attention or behavioral issues (e.g., difficulty sitting still, inattention, aggressive behavior, behavioral outbursts, disruptive behavior, school suspension) Y/N
5.
Social problems (e.g., social withdrawal, difficulties making or keeping friendships, rejection or victimization by other children) Y/N
If you answered NO to all of these questions, you are done with the survey. If you answered YES to any of the questions, please answer the next two questions: 1.
Is your child receiving help for any difficulties you report above? Y/N
2.
If yes, do you feel the help is meeting your child’s needs? Y/N
*If you answered NO to question 6 or 7, you should discuss your child’s difficulties with your child’s healthcare provider and school. Several other versions of PIC-UP for youth and school personnel will be developed; and a plan for validation and future dissemination will be completed at the 2020 Galveston meeting.
22 BRAIN INJURY professional
A tool to monitor children with a previously identified TBI needs to be appropriate for administration in multiple settings (i.e., home, school, healthcare), and easy to administer, score and interpret. The goal of such a tool would be to identify problems and unmet or unrecognized needs, not to determine definitively if these concerns and needs are TBI-related. We propose a new screening tool that may serve this purpose, which we have called the Pediatric Injury Check-Up for Brain Health (PIC-UP). (see side bar). The PIC-UP provides a brief but comprehensive overview of common problems that can occur after TBI, and asks simply if a child is experiencing them and whether they are receiving adequate help for those problems. The reliability, validity, and utility of any screening tool, such as the PIC-UP, must be evaluated across multiple settings, including the home, school, and community. Broad implementation of such of a tool will likely be associated with various challenges. Defining ways to optimize implementation will be critical. Development of local, state, and national policies focused on implementation of monitoring systems will be critically important in facilitating use of monitoring tools across multiple settings. Rules for continuing versus stopping monitoring also will need to be developed and validated. For instance, if a child has fully recovered and returned to his or her preinjury functioning level relatively soon after a mild TBI, then monitoring could potentially be stopped. However, long-term, ongoing monitoring might be necessary after a severe TBI in early childhood. Also, as unrecognized or unmet needs are identified through monitoring, links to appropriate management will be needed. Furthermore, problems unrelated or only indirectly related to the brain injury may be identified. Therefore, when ongoing problems are identified, children with brain injury and their families should be assessed by a provider with expertise in brain injury to advise them on the most appropriate management approach. In some situations, discerning whether current problems are directly related to the injury will be difficult, and more detailed assessments will be required to develop an individualized treatment plan (Masel and DeWitt, 2010).
What are the next steps? The support of organizations such as state and federal branches of the American Academy of Pediatrics is needed to promote awareness of brain injury sequelae and the need to monitor their possible emergence over time. Professional education efforts have been successful in the area of concussion when they have been designed specifically to change behavior, rather than just knowledge. The Centers for Disease Control and Prevention “Heads Up” program is a model for educating diverse providers and disseminating current return to play approaches for sport-related concussion (Daugherty, DePadilla, and Sarmiento, 2019; Sarmiento et al., 2014). Similarly, the American Academy of Pediatrics promulgates practice guidelines for identification and management of sport-related concussion (Halstead, Walter, and Moffatt, 2018). These guidelines emphasize collaboration across medical, educational, and family systems. Similar programmatic initiatives need to be extended to cover the spectrum of TBI severity and etiologies. The development and funding of effective monitoring approaches will require the collaboration of lead state agencies on brain injury such as state health departments and brain injury associations/ alliances with other agencies. Engagement of insurance companies in developing these models is also necessary to support identification and treatment for both short- and long-term sequelae, not limited to the medical sequelae of TBI. Engagement of state and federal legislative systems will be essential to develop and implement policy.
