Screening for Prior Traumatic Brain Injuries

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Screening for Prior TraumaticBrain Injuries

• John D. Corrigan, PhD
• Ohio Regional TBI Model System
• Department of Physical Medicine Rehabilitation
• Ohio State University

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Topics Addressed

• Why screen for a history of TBI?
• Methodological Issues in Screening
• Methods of Screening
• Conclusions

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Why screen for/identify TBI?

• Determine prevalence

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Rates of TBI in Prison Studies
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Why screen for/identify TBI?

• Determine prevalence
• Conduct cohort studies

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Clients in Treatment for Substance Abuse and
Severe Mental Illness (N50)
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Why screen for/identify TBI?

• Determine prevalence
• Conduct cohort studies
• Inform intervention

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TBI and Substance Use Disorders among Minnesota
State Prisoners (N998)
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Symptoms past 12 months of Clients Admitted for
Substance Abuse Treatment in Kentucky (N7,932)
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Issues in Screening/Identification

• Biomarkersonly prospects to date lifetime
  exposure will be very difficult
• Capture from medical treatment
• Only as good as the diagnosis recorded (Powell et
  al, 2008)
• Medical treatment may not be sought
• Self-report
• Not aware of injury
• Do not recall injuries (telescoping, poor
  memory)
• Cannot self-diagnose
• Issues biasing disclosure (secondary gain, stigma)

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Challenges Determining the Validity
ofSelf-reported Lifetime History

• No gold standard
• In lieu of sensitivity specificity, how can
  validity be determined?
• Self-administered screens compared to results of
  clinical interview
• Findings compared from different cohorts
• Summary indices derived for which reliability and
  predictive validity are determined

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Methods of Screening

• TBI-TAC identified 20 different tools being used
• VA mild TBI screening process
• DVBIC Brief TBI Screen (BTBIS Schwab et al.)
• TBI Questionnaire (TBIQ Diamond et al.)
• Brain Injury Screening Questionnaire (BISQ
  Gordon et al.)
• OSU TBI Identification Method (OSU TBI-ID
  Corrigan Bogner)

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Brain Injury Screening Questionnaire (BISQ)

• Part 1 Report on lifetime blows to head in
  various situations (e.g., MVAs, falls, assaults)
  and losses of consciousness or alterations in
  mental state
• Part 2 Frequency of 100 functional problems
  commonly observed after TBI (physical, cognitive,
  emotional/behavioral)
• Part 3 Issues other than BI that may account for
  symptoms reported (e.g., developmental
  difficulties, psychiatric history, medications)

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BISQ (continued)

• Paper and online versions (5-20 minutes)
• Originally validated by Gordon et al., 2000 25
  items found to be sensitive and specific to TBI.
  
• Has been used in pediatric, substance abuse and
  homeless populations (Cantor et al., 2004, 2006
  Fenske et al., unpublished manuscript)
• New CDC-funded validation study under way to
  examine BISQ items that are sensitive and
  specific to TBI, compared to other populations
  with cognitive problems (i.e., chronic pain,
  long-term depression)

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OSU TBI Identification Method

• Structured interview designed to elicit lifetime
  history of TBI
• Uses multiple probes to stimulate memory
• Avoids misunderstanding about what a TBI is by
  first eliciting injuries, then determining if
  altered consciousness occurred as a result
• Provides richer information about history than
  simple yes/no (e.g., number, severity, effects,
  timing, etc.)

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OSU TBI Identification Method (contd)

• Summary indices of lifetime exposure to TBI have
  demonstrated both inter-rater and test/re-test
  reliability.
• Criterion-related validity demonstrated in two
  studiessummary indices, when combined with other
  indicators of cerebral compromise, are
  significant predictors of cognitive performance,
  symptomology and behaviors associated with
  frontal lobe dysfunction.

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Issues Identified from Structured Interviews

• General public has limited understanding of
  altered consciousness
• Spurring recall multiple ways is essential
• Multiple mild injuries require special attention
• Alcohol blackouts and anoxic events need to be
  distinguished from loss of consciousness
• Knowledge of childhood injuries is incomplete
  not sure about extent of altered consciousness,
  completely unaware of injuries before age 5

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Conclusions

• Screening/identification of lifetime TBI is being
  done in both clinical and research settingsbut
  is not being done well.
• Structured interview by an informed interviewer
  is the current gold standard.
• One- or two-item screeners of questionable
  validity.
• Self-administered methods in general have to be
  looked at with skepticism.
• Research needed to improve our methods.