http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2014; 28(10): 1301–1310 ! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.916416

ORIGIANL ARTICLE

Prevalence of traumatic brain injury and access to services in an undergraduate population: A pilot study Miriam Krause1 & Stephanie Richards2 1

Department of Communication Sciences and Disorders, Bowling Green State University, Bowling Green, OH, USA and 2Department of Communication Disorders, Central Michigan University, Mount Pleasant, MI, USA Abstract

Keywords

Objectives: The aim of this pilot study was to identify the prevalence of traumatic brain injury (TBI) among undergraduate college students, compare common TBI symptoms reported by students with and without a history of TBI and explore how often students with and without TBI access campus services. Methods: A campus-wide email recruited participants to an online survey containing questions about their history of TBI, experience of TBI symptoms and use of services. Results: Of 201 undergraduates, 55.7% reported no history of TBI or hospitalization, 27.9% reported a history of hospitalization but not TBI and 16.4% reported a history of TBI. Significant differences were seen among groups in their experience of some physical and psychosocial symptoms such as dizziness and difficulty with relationships. Healthy and TBI groups reported significantly more symptoms than the hospitalized group, but did not differ from each other. Most participants reported using no services and there were no significant differences in the average number of symptoms experienced by those seeking vs not seeking services. Conclusions: A substantial proportion of undergraduates reported a history of TBI and the experience of symptoms that could negatively impact academic performance. Further study is needed to examine factors influencing their use of available services.

College, concussion, survey

Introduction There has been increasing public awareness of traumatic brain injury (TBI) in recent years, particularly with regard to sportsrelated concussions and brain injuries among military personnel [1, 2]. Among civilians, the Centers for Disease Control estimates that 3.2 million people in the US are living with long-term disability due to TBI [3] and adolescents aged 15–19 have the second-highest rate of TBI-related emergency department visits (after children under 4) [4]. Despite this increasing public attention and high risk, little is known about the number of students attending college after TBI and the characteristics of symptoms and services utilized by these students. Using an online survey, the goal of the current pilot study was to determine a preliminary estimate of the prevalence of TBI history and access to services among the campus population of a mid-sized midwestern university. Many adults with TBI recover sufficiently to attend college and may be eligible to receive reasonable accommodations to maximize their academic success. Using a paper-and-pencil questionnaire, Powell and Holmes [5] found that 9.97% of undergraduates surveyed reported either a ‘medically diagnosed brain injury or disorder’ (including seizures, strokes and Correspondence: Miriam Krause, PhD, CCC-SLP, Bowling Green State University, Bowling Green, OH, USA. Tel: 419-372-7182. E-mail: [email protected]

History Received 3 July 2013 Revised 26 February 2014 Accepted 15 April 2014 Published online 22 May 2014

other non-traumatic brain injuries) or any loss of consciousness greater than 20 minutes. The current study focused on traumatic injuries and included reports of altered consciousness and loss of consciousness of any duration in an attempt to capture the full spectrum of TBI; for the purposes of the current study, Menon et al.’s [6] useful definition of TBI as ‘an alteration in brain function, or other evidence of brain pathology, caused by an external force’ (p. 1637) was used. Once people with TBI begin attending college, they may face many challenges in attempting to complete their programme. Even mild TBI can lead to long-term effects, including problems with dizziness, memory and attention [7–9]. In a study using the College Survey for Students with Brain Injury (CSS-BI), Kennedy et al. [10] found that college students with TBI reported more cognitive effects (e.g. memory and organization problems) and academic challenges (e.g. feeling overwhelmed when studying) than healthy controls. Although few additional studies have focused specifically on college students, other studies have used symptom checklists to examine the symptoms experienced by adults with TBI or post-concussive syndrome (PCS) and have also found that individuals with a history of TBI (with or without LOC) experience a higher number of PCS symptoms than those without TBI [8, 11–16]. More specifically, Fox et al. [11] found that adults in a healthcare system who had been knocked unconscious reported significantly more PCS

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symptoms (i.e. headache, memory problems, dizziness, tinnitus, noise sensitivity, concentration problems, fatigue, impatience and irritability) than those who had not been knocked unconscious. They also found that being knocked out was a significant predictor of eight of the 10 symptoms and that being ‘bumped on the head’ without LOC contributed unique variance to nine of the 10 symptoms. Additionally, Gordon et al. [8] used the TIRR symptom checklist [17] to compare the self-reported symptoms among adults with TBI and three control groups (i.e. adults without disability [ND], with spinal cord injury [SC], with HIV [HIV] and with liver transplantation [LT]) and found that participants with mild TBI reported significantly more cognitive, physical and behavioural/affective symptoms than the other groups, including those with moderate/severe TBI. An additional finding of the Fox et al. [11] study was that a large proportion of participants in the evaluation group (those entering the healthcare system who were not being seen for any specific psychiatric or medical needs) did endorse PCS symptoms, including 44% reporting headaches and 33% reporting irritability. Furthermore, in the Gordon et al. [8] study, 23 of the 25 symptoms that were identified as being sensitive and specific to mild TBI were in the cognitive domain and five of these symptoms (i.e. current difficulty with reading, writing or doing math; learning new information; being easily distracted; losing your train of thought; and forgetting things you have done) were sensitive and specific to TBI in both mild and moderate/severe groups. Taken together, these findings suggest that factors other than TBI or the severity of TBI (such as psychological, medical, even litigation status) play a role in the experience of PCS symptoms. Therefore, examining the PCS symptoms experienced in healthy and brain-injured college students, a population commonly experiencing other conditions that may contribute to endorsement of PCS symptoms (e.g. high stress levels, possible depression), could provide further insight into symptoms that are specific/sensitive to TBI vs those that relate more heavily to other factors. Another issue seen in college students with TBI is the fact that many of them do not seek out services to help them be academically successful. In fact, Kennedy et al. [10] found that less than half of the college students with TBI in their study had ever accessed services via campus Disability Services. The remaining students may have been unaware of the accommodations available and/or may have been reluctant to self-identify as having a disability. This failure to access services is clearly problematic, as it has been found that adolescents and young adults who sustain TBIs are less likely than their typical peers to attend postsecondary school [18] and are likely to drop out and/or have difficulty while working on their post-secondary education [19, 20]. Dawson et al. [19] found that 73.8% of 46 participants with TBI returned to work and/or school within 4 years of injury, but that 47.2% of these individuals had experienced difficulties upon their return. Johnstone et al. [20] examined six adolescents who had sustained TBIs during their transition to college and found that four participants either decided not to go to college or dropped out of college, one went from being an A/B student in high school to failing many college courses and one was able to start at

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a small college and successfully transfer to a larger 4-year university. Another important finding of Kennedy et al.’s [10] survey study was that reports of cognitive, physical and psychosocial effects of TBI were significantly correlated with reported academic difficulties in college. That is, more reported TBI symptoms correlated with more reported academic challenges. The list of TBI symptoms used in the current survey was adapted from the CSS-BI partly for this reason. The purpose of the Kennedy et al. [10] study was to examine the experiences of students who return to college after a TBI and it, therefore, specifically targeted participants with TBI. The respondents in that study self-identified as having a brain injury and were recruited through avenues such as the Brain Injury Association. It is possible that the group was, therefore, self-selecting for greater severity or longevity of symptoms than would be found among the general population of adults with a history of TBI. By sampling from an entire campus population without specifically recruiting participants with or without TBI, the current study provides a more accurate picture of the prevalence of TBI in the college campus community, as well as the prevalence of long-term effects of TBI. This information may be useful for Disability Services, Veterans’ Services and the Nontraditional and Transfer Student Services Office, as well as for future research related to the long-term effects of TBI among college students. This pilot study addresses the following research questions:  What is the prevalence of TBI history among college students on a mid-sized midwestern college campus?  Do reports of common TBI sequelae differ between students with and without a history of TBI?  Are students who are potentially eligible for services accessing them?

Methods The current study was designed as a preliminary exploration of the campus population at a midwestern US university of roughly 20 000 students. An online survey methodology was chosen for the sake of expediency and access. In a comparison of Web-based and paper-and-pencil questionnaires, Gosling et al. [21] found that data collected using Web-based questionnaires are of similar quality to data collected using more traditional approaches. Questions of TBI history are somewhat more problematic, as people may be prone to under-reporting without individualized questions about medical history [22]. In an effort to elicit accurate reports, the key question about history of TBI in this survey was phrased, ‘Have you ever experienced a brain or head injury? This could include concussion, TBI or other brain injury’. (For military respondents, the word ‘blast’ was added to the list.) The survey also asked about participants’ demographics, history of hospitalization, military service and experience of symptoms. Those who replied ‘yes’ to the TBI question were given the opportunity to provide details of up to three different TBIs. Questions about symptoms such as fatigue, headaches and cognitive difficulties were presented slightly differently depending on the group (e.g. military/civilian,

TBI and use of services among undergraduates

DOI: 10.3109/02699052.2014.916416

TBI/non-TBI), but all participants responded to the same symptom list, comprising 13 items adapted from the 16 used in the CSS-BI [8]. Participants Participants were recruited through an announcement in a campus-wide daily electronic newsletter distributed to all students, faculty and staff. The advertisement contained a link to the survey and offered the opportunity to be entered in a drawing for a $50 gift card as compensation for participating in the study, which was described as a ‘Student Health Survey’ to avoid selection bias regarding brain injury. The informed consent process was conducted on the first page of the survey and all procedures were approved by the university’s Human Subjects Research Board. A total of 312 survey responses were collected during spring 2012, of which six respondents declined to give consent on the front page or gave consent but then did not respond to any further questions. Five of the remaining 306 respondents were veterans or active duty military service members. Because there were so few, these responses were excluded from analysis rather than being used as a comparison group. Of the 301 civilian responses, 223 were from undergraduates and 78 were graduate students, faculty or staff. In the present study, only data from undergraduate students were analysed. Eighteen of the undergraduate civilian responses were excluded for reasons explained below, resulting in data from 201 surveys included in the current analysis. Undergraduate respondents were divided into three groups: individuals with a history of TBI (TBI group), those without TBI but with a history of hospitalization (hospitalized group) and those with neither TBI nor hospitalization histories (healthy group). The TBI group comprised any respondent who replied ‘yes’ to the question ‘Have you ever experienced a brain or head injury? This could include concussion, TBI or other brain injury’. One participant was excluded from the TBI group because she described her injury as being the result of a dog attack that required stitches, but did not mention a brain injury component. The hospitalized group comprised individuals who reported no history of TBI but endorsed having been admitted to the hospital at some time. The purpose of including this group was to control for the possibility that some symptoms associated with TBI could also be related to the emotional or psychological impact accompanying any serious medical event [23, 24]. Nine participants were excluded from this group, five because they stopped filling out the survey after the question about hospitalization and four because they endorsed receiving services for symptoms without endorsing experiencing the symptoms themselves (e.g. they checked a response stating they had received therapy for memory problems, but did not check the response stating they had experienced memory problems). This reflects a drawback in the survey structure, which allowed participants to check ‘received therapy for the symptom’ for symptoms they did not first endorse experiencing. The healthy group comprised survey respondents who endorsed neither TBI nor hospitalization history. One person

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who identified as a healthy control was excluded from this group because of a possible TBI that was disclosed in an open-ended question and seven others were excluded because they repeatedly endorsed therapies without symptoms. With these seven from the healthy group and the four from the hospitalized group, a total of 11 participants were excluded from the analysis because they reported receiving treatment for symptoms they did not endorse experiencing. The two relevant types of question (experiencing symptoms and receiving therapy) were presented on the same page of the survey, with side-by-side check boxes. Because none of these excluded participants were from the TBI group, it is anticipated that their endorsement of therapy without symptoms was a misunderstanding of the survey instructions rather than a lack of self-awareness of their symptoms (i.e. anosagnosia) and, therefore, their data are simply excluded from analysis. Characteristics of these 11 participants were examined in some detail to ensure that their exclusion would not bias the overall results of the study. The four people excluded from the hospitalized group for this reason reported that they were hospitalized for tonsillectomies, appendicitis and the removal of wisdom teeth, again making it unlikely that they had reduced awareness of deficits but were accurately reporting therapies. All four endorsed receiving nearly all of the treatment options presented in the survey, which suggested that they may have simply checked boxes on the survey without reading the instructions for the options. Demographics for the excluded participants were extremely similar to the included groups and the rates of symptoms that were endorsed later in the survey were also quite similar, both within the hospitalized and healthy groups and across both groups. For these reasons, the exclusion of these participants from analysis was judged unlikely to bias the overall findings of the study. After all exclusions, the TBI group included 33 participants, the hospitalized group included 56 and the healthy group included 112. Table I shows the demographics for each group, with the overall undergraduate population for comparison. Survey As described above, the survey was constructed using branching logic (Figure 1). The first branch separated civilian from military respondents with the question, ‘Are you either currently serving or a veteran of the military?’ The second branch separated those with and without a history of TBI; military respondents were presented with a version of this question that included blast, as mentioned previously. The third branch separated respondents without TBI into groups with and without a history of hospitalization using the question, ‘Even though you have never had a brain injury, have you ever been hospitalized for something else?’ After being separated into groups through the branching questions, all participants answered questions about their experience of symptoms. The list of symptoms presented to all participants is shown in Table II. The TBI group was asked, ‘Did you experience any of the following symptoms after your brain injury? If yes, did you receive treatment or therapy for the symptoms? Please check the relevant boxes’.

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Table I. Demographics of the three participant groups and the university campus overall. Group

n Age mean (SD) Sex, F:M (%F) Freshman Sophomore Junior Senior White

Healthy

Hospitalized

TBI

Campus overall

112 19.8 (2.1) 91:21 (81%) 35 (31%) 34 (30%) 24 (21%) 19 (17%) 101 (90%)

56 21.9 (7.4) 45:11 (80%) 21 (38%) 12 (21%) 9 (16%) 14 (25%) 54 (96%)

33 20.8 (2.8) 25:8 (76%) 7 (21%) 8 (24%) 9 (27%) 9 (27%) 27 (82%)

14 803 8108:6695 5219 3069 2799 3716 11 495

(55%) (35%) (21%) (19%) (25%) (78%)

Table III. Services checklist presented to all participants. Services Campus Disability Services Office State vocational rehabilitation The Learning Commons Campus Veterans’ services Campus counselling services VA TBI services State or National Brain Injury Association Academic tutoring Support group None of the above

Figure 1. Survey branching logic.

Table II. Symptoms checklist presented to all participants. Symptoms Dizziness Headaches Hearing loss Memory problems Balance or co-ordination problems Reduced mobility Irritability/anger Depression Difficulty with planning/organization Pain Post-traumatic stress disorder Difficulty with schoolwork Difficulty with relationships

was asked, ‘Have you ever experienced any of the following symptoms to a degree that affected your quality-of-life? If yes, did you receive treatment or therapy for the symptoms? Please check the relevant boxes’. The purpose of specifying effect on quality-of-life for the healthy control group was to avoid responses reflecting isolated or transient effects such as dizziness during a flu or pain from a minor injury. After the symptom checklist, all participants were asked about their use of services that could be relevant to those experiencing long-term effects of TBI (Table III). The question for participants with a history of TBI asked, ‘Which of the following services or resources have you used since your brain injury? Check all that apply’. Participants in the hospitalized and healthy control groups were asked, ‘Have you ever used any of the following services or resources? Check all that apply’. Analysis A descriptive analysis was conducted to examine demographics among the three groups. Between-group comparisons were conducted with chi-square analysis. This was done using the crosstabs utility of SPSS, which applied a Bonferroni correction to adjust for multiple comparisons. In addition, ANOVAs were used to detect group differences in the average number of symptoms reported and the use of services.

Results Prevalence of TBI

The hospitalized group was asked, ‘After being in the hospital, did you experience any of the following symptoms? If yes, did you receive treatment or therapy for the symptoms? Please check the relevant boxes’. Finally, the healthy group

The first research question asked about the prevalence of TBI among undergraduates on the university’s campus. The results indicated that 55.7% (n ¼ 112) of participants reported no history of hospitalizations or TBI, 27.9% (n ¼ 56) reported

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Figure 2. Symptoms endorsed by each participant group. a,b,cEach letter denotes a subset of participant categories whose column proportions do not differ significantly.

a history of hospitalizations but no history of TBI and 16.4% (n ¼ 33) reported a history of TBI. The demographics of each group are shown in Table I. Of the participants endorsing a history of TBI, 18 (55%) reported loss of consciousness (LOC) ranging from ‘momentarily’ to 1 hour. However, among the 15 people reporting no LOC, five (33%) reported altered consciousness (e.g. dizziness, disorientation, post-traumatic amnesia) in the open-ended description of their injury and another four (27%) simply reported that they had experienced a concussion. Experience of symptoms Participants in each group were asked about their experience of symptoms (listed in Table II) that are commonly associated with TBI. Figure 2 illustrates that some group differences occurred in the expected direction, in that the TBI group reported more symptoms than the other groups. Most notably, headaches, dizziness, memory and balance/co-ordination problems were far more commonly reported by participants in the TBI group than those in the healthy or hospitalized groups. Other results were counter to expectations, such as the greater number of students in the healthy group reporting depression, irritability/anger and relationship difficulty compared to the TBI group. A chi-square analysis was conducted to more closely analyse the differences in symptoms experienced among groups and supported the initial impressions described based on Figure 2. The results of the chi-square analysis revealed significant group differences with regard to the experience of dizziness, 2(2, n ¼ 201) ¼ 44.72, p50.001 and headaches, 2(2, n ¼ 201) ¼ 32.39, p50.001. More specifically, the TBI group reported a higher prevalence of dizziness and

headaches than the healthy or hospitalized groups and the healthy group reported a higher prevalence of dizziness and headaches than the hospitalized group. There were also group differences in other physical symptoms, including problems with balance/co-ordination and reduced mobility, (2(2, n ¼ 201) ¼ 52.42, p50.001 and 2(2, n ¼ 201) ¼ 15.71, p50.001, respectively). Participants with TBI reported significantly more problems with balance and co-ordination than either the healthy or hospitalized groups, who were not significantly different from each other. The hospitalized group reported significantly more problems with mobility than either the TBI or healthy groups, while the TBI and healthy groups did not significantly differ from one another in mobility impairments. Significant differences were seen in the prevalence of memory problems reported among groups, 2(2, n ¼ 201) ¼ 7.94, p ¼ 0.019. More specifically, the TBI group reported significantly more memory problems than the hospitalized group, but the healthy group did not differ from either the TBI or hospitalized groups. Reports of irritability and anger were also significantly different among groups, 2(2, n ¼ 201) ¼ 15.19, p ¼ 0.001. A significantly higher number of healthy participants reported experiencing symptoms of irritability and anger than hospitalized participants, while the TBI group’s reporting of irritability and anger symptoms did not differ significantly from either the healthy or hospitalized groups. Additionally, depression significantly differed among groups, 2(2, n ¼ 201) ¼ 10.75, p ¼ 0.005, with the healthy group reporting higher proportions of depression than the hospitalized and TBI groups. The hospitalized and TBI groups did not differ significantly in their reports of depression. Finally, reports of relationship difficulties were significantly different among groups, 2(2, n ¼ 201) ¼ 14.56,

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p ¼ 0.001. Significantly more participants in the healthy group reported relationship difficulties than in the hospitalized group, while the TBI group was not significantly different from either of these groups. No statistically significant differences were seen among groups for the symptoms of hearing loss, planning and organization problems, pain, PTSD and schoolwork difficulty. In addition to the symptom-by-symptom chi-square analysis described above, the overall experience of symptoms was examined by conducting a one-way analysis of variance (ANOVA) to determine whether or not group differences existed based upon the average number of symptoms experienced per group. Results of this analysis revealed significant group differences in the number of symptoms experienced, F(2,198) ¼ 8.69, p50.001. Post-hoc analyses using the Bonferroni correction indicated that the mean number of symptoms reported by the healthy group (2.60, SD ¼ 2.68) was significantly higher than the mean number of symptoms reported by the hospitalized group (1.43, SD ¼ 1.76). The TBI group (3.52, SD ¼ 2.17) also experienced significantly more symptoms than the hospitalized group. However, the healthy and TBI groups did not significantly differ with regard to number of symptoms they experienced. Use of services by quantity of symptoms Each participant group was asked to provide information about the types of services they had used either after their brain injury (TBI group) or at some point in their lives (healthy and hospitalized groups). Figure 3 shows that few participants in any of the groups reported seeking services and that the highest proportion of participants in all groups reported seeking no services. To further examine the use of services reported by each group, a chi-square analysis was performed. The results showed that significant differences in services sought were seen among groups in the areas of campus Disability Services, 2(2, n ¼ 201) ¼ 12.77, p ¼ 0.002, and no services,

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2(2, n ¼ 201) ¼ 6.27, p ¼ 0.043. A significantly higher proportion of the hospitalized group reported seeking services through campus Disability Services than the healthy group, but the TBI group did not significantly differ from either the hospitalized or healthy groups. In addition, a significantly higher proportion of the TBI group reported seeking no services compared to the hospitalized group, while the healthy group did not significantly differ from either the hospitalized or TBI groups. Because a limited number of participants reported using any one service, the use of services was also analysed by categorizing participants into two groups—service(s) accessed vs no services accessed, and the number of symptoms reported by each of these groups was calculated (see Figure 4). To determine whether or not participants within each group who reported seeking services experienced more symptoms than participants within each group who did not seek services, a two-way ANOVA was conducted. The results showed a significant main effect for participant group, F(2,195) ¼ 7.20, p ¼ 0.001, 2 ¼ 0.07, such that (as described above) the TBI and healthy groups reported significantly more symptoms on average than the hospitalized control group, but did not significantly differ from each other. There was no significant difference in average symptoms across groups between those who used services and those who did not, F(1,195) ¼ 0.09, p ¼ 0.762, 250.01, and the interaction between group and services/no services sub-group was not significant, F(2,195) ¼ 1.63, p ¼ 0.198, 2 ¼ 0.12. Because the healthy and TBI groups showed opposite directions of results in their report of symptoms and services (Figure 4), a post-hoc ANOVA was conducted to compare those two groups alone. In this analysis, the group by subgroup interaction (symptoms reported for those who had services vs no services in the healthy vs TBI groups) trended toward significance, F(1,140) ¼ 3.056, p ¼ 0.08, 2 ¼ 0.02.

Discussion The three main research questions in this study were (1) What is the prevalence of TBI history on campus? (2) Do reports of TBI symptoms and academic challenges differ between

Figure 3. Services used by each participant group. a,b,cEach letter denotes a sub-set of participant categories whose column proportions do not differ significantly (labelled for ‘disability services’ category only).

Figure 4. Average number of symptoms reported by participants within each group receiving or not receiving services.

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students with and without a history of TBI? and (3) Are students with TBI who are potentially eligible for services accessing them? Prevalence The finding that 16% of undergraduates surveyed reported having a history of TBI was higher than the 10% described by Powell and Holmes [5], but it is perhaps not surprising given the deliberate inclusion of individuals with no LOC in this study and their exclusion from the earlier one. A chi-square analysis showed no significant differences in any of the reported symptoms for those with vs without LOC among the TBI participants. This finding among the self-reported TBI group emphasizes the importance of not using LOC as the only defining criterion for TBI. In addition to providing a straightforward estimate of the prevalence of TBI among undergraduates on campus, this study provides the opportunity to compare this prevalence with the actual number of students who are receiving accommodations due to TBI. The university’s Disability Services office had 566 students (combined undergraduate and graduate—separate numbers were not available) during spring 2012, the semester in which this survey was conducted. Seven undergraduates were registered whose primary disability was TBI. In fall 2012, there were a total of 620 undergraduates registered, eight of whom were registered on the basis of a TBI (personal communication, Le Ann Kessler, 5 November 2012). The current study did not directly compare TBI with other sources of disability; nevertheless, although 30% of survey respondents with TBI reported memory problems and 19% reported difficulty with academics (among other symptoms that could justify accommodations), only one participant in the TBI group (3%) reported using campus Disability Services. This contrasts with the survey findings of Kennedy et al. [10], who reported that 14 of their 35 respondents (40%) used campus Disability Services at least occasionally. This may reflect the focus of Kennedy et al.’s study on individuals who self-identified as having attended college after a TBI, as opposed to the current study’s broader recruitment of college students in general. It could also relate to students’ perception or awareness of Disability Services on the respective campuses where the studies were conducted. Overall, although the degree to which symptoms are currently affecting academic performance was not addressed in this study, these numbers suggest that, for every student with TBI who is experiencing symptoms with cognitive/academic consequences and is enrolled in Disability Services, there may be five to 10 who are not. In other words, this important resource may be drastically under-used by students with a history of TBI who could benefit from accommodations. Group differences The complex pattern of group differences found in the current study is comparable to previous research examining postconcussion symptoms in young adults with and without TBI [13–15]. Given the range of studies comparing symptom reports between those with and without TBI, it is interesting to examine the specific areas of similarity and difference that

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were found in the current project. Some of the group differences found in the symptom reports were in the predicted direction, such that the symptoms were least common among healthy controls and most common among participants with TBI. Common physical symptoms of TBI such as dizziness, headaches and balance/co-ordination problems were significantly more common among the TBI group. Hospitalized controls reported more mobility problems than either of the others, which supports the validity of the hospitalized category as a control group who may have had some of the same medical experiences as individuals with TBI without the same symptom profile. Other symptom reports did not exhibit expected group differences and there may be several possible reasons for this. The first may relate to statistical power. For example, memory problems were qualitatively more prevalent among the TBI group (30%) than the healthy (13%) or hospitalized (9%) group, but, in the chi-square analysis, the proportion of healthy controls reporting this symptom was not different from either of the other two groups. The second likely factor leading to unexpected results in the analysis of group differences has to do with the nature of post-concussion symptoms, the undergraduate population being studied and the method of data collection. As Iverson and Lange [25] pointed out, post-concussion-like symptoms are frequently endorsed by people without TBI. In that study, researchers found that 36–76% of participants with no history of brain injury endorsed post-concussive symptoms such as nausea, irritability and headaches at a mild level; 3–16% endorsed the symptoms at a moderate–severe level. They also found that post-concussion-like symptoms were moderately correlated with a measure of depression. That study did not have a TBI group for comparison, so they were not able to state whether the rate of endorsement for these symptoms was greater than, less than or equal between people with and without a history of injury. In their study comparing symptom checklists for TBI vs ND, SC, HIV and LT control groups, Gordon et al. [8] found that the symptom clusters associated with TBI were independent of depression. Wang et al. [16] also found that college students without a history of TBI frequently endorsed PCS symptoms. They gave 124 university students in China a post-concussion symptom questionnaire and a battery of neuropsychological tests and found high reports of symptoms such as fatigue (77%), poor concentration (59%) and frustration (46%). The total mean symptom scores of the ‘high symptom’ healthy participants were not significantly different from a group of participants with a history of TBI; however, although the TBI group did significantly more poorly on the neuropsychological assessments in Wang et al.’s study, they were also currently engaged in outpatient rehabilitation, making them quite different from the TBI group in the current study [26]. Comorbidities and assumptions about what symptoms are associated with TBI may also play a role in symptom self-reports such as those in the current study. Gunstad and Suhr [14] examined what symptoms people expected to be associated with various injuries and disorders. They asked a group of 82 undergraduates to describe their current symptoms and to speculate about what they would expect to experience if they had suffered a head injury, depression,

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PTSD or orthopaedic injury. All groups except the orthopaedic injury group predicted similar rates of various cognitive symptoms. Indeed, in 2004 [15], the same authors found that factors such as depression, pain and subjective expectations contributed to reports of PCS symptoms along with actual history of head injury among a sample of 190 undergraduates. Smith-Seemiller et al. [27] also noted that post-concussion-like symptoms were reported by people with chronic pain at rates no different from those of people with mild TBI; further study would be needed to determine whether any participants in the current project would identify as having chronic pain. The frequency of TBI symptoms endorsed by those with a history of brain injury in the current study was similar in some instances to those reported by Kennedy et al. [10] in their initial report on the CSS-BI and different in others. For example, Kennedy et al. found that, of the 35 people with TBI who were surveyed in their initial sample, 69% endorsed experiencing headaches, 49% reported dizziness and 83% reported memory problems. In the current study, participants in the TBI group reported these symptoms at 79%, 73% and 30%, respectively (Figure 2). Although the two studies both surveyed people in college who had experienced TBI, the earlier study specifically recruited individuals who identified themselves as having gone to college after TBI. The current study, in contrast, recruited broadly from a college population and, thus, many of the participants may not have identified as ‘college students with TBI’ in the same way as those in the earlier study. Therefore, it is not surprising that the TBI group may include more individuals with fewer symptoms such as memory impairments. In the current study, the symptoms that were unexpectedly endorsed significantly more by the healthy control group (depression, irritability/anger and difficulties with relationships) are consistent with some of the post-concussion symptoms discussed by Iverson and Lange [25] and others; moreover, they are all part of the typical psychosocial development stage experienced by young adults in college. Seventy-nine per cent of the participants in Iverson and Lange’s study were also between 15–24 years old. This confounding factor of psychosocial development may have been exacerbated by the phrasing of survey questions among the different groups. For the TBI group, the question about symptoms asked, ‘Did you experience any of the following symptoms after your brain injury?’ The hospitalized group was asked, ‘After being in the hospital, did you experience any of the following symptoms?’ Since the healthy controls could not be asked about symptoms since a particular traumatic event like the other two groups, they were asked ‘Have you ever experienced any of the following symptoms to a degree that affected your quality-of-life?’ This phrasing was chosen in an attempt to emphasize the severity of symptoms (e.g. the ‘pain’ symptom was not intended to refer to minor headaches, papercuts or other day-to-day experiences of pain). However, it may be that the symptoms endorsed by the healthy control group may not have been equivalent to those reported by the other two groups and it, therefore, may not be possible to assert with confidence that the healthy control group experienced these symptoms to a significantly greater extent than the others. These complications certainly warrant

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further research into psychosocial symptoms experienced among young adults with TBI and how they compare with their typically-developing peers. The likelihood that healthy controls may have endorsed symptoms disproportionately to the other two groups is supported by the analysis comparing the average number of symptoms reported for each group. The hospitalized control group reported a mean 1.4 symptoms (SD ¼ 1.8), significantly fewer than both the healthy control group (2.6, SD ¼ 2.7) and the TBI group (3.5, SD ¼ 2.2). On the other hand, the significant group differences that were found (e.g. the prevalence of dizziness and headaches in the TBI group over the other groups) may be all the more robust given the possible over-reporting of symptoms by the healthy control group. Use of services and quantity of symptoms Relatively few participants reported using any of the services asked about in the survey, which led to few group differences in the chi-square comparison of those reports. The only two categories that resulted in significant group differences were campus Disability Services and no services. A higher proportion of hospitalized participants reported using Disability Services than the healthy and TBI participants. Additionally, a higher proportion of the TBI group (69.7%) reported using no services than the hospitalized group (42.9%), but the healthy group (56.3%) did not differ significantly from either the TBI or hospitalized group for those that used no services. In both of these instances, the differences were in the opposite direction than what would be expected: the TBI group did not report using significantly more services than either the hospitalized or healthy groups. One interpretation of these unexpected group differences is that the TBI group included participants with a wide range of injury severities, while the hospitalized group was by definition more severely injured and, therefore, more likely to need services. On the other hand, given the number of TBI participants reporting symptoms (such as the 30% with memory problems) that could affect academic success, it is also possible that people with TBI are either not aware of the services available to them or are aware but choose not to take advantage of them. Academic tutoring and the Learning Commons (a walk-in academic assistance centre on campus) were other categories whose use was not significantly different across groups, but whose group differences were not in the expected direction. For academic tutoring, 9% of students with TBI reported using this service compared to 14% of healthy controls and 21% of hospitalized controls. For the Learning Commons, 29% of the healthy and hospitalized groups and 19% of the TBI group reported using this service. The trends found here, while not statistically significant, suggest an area for further research: if there is a genuine effect in which students with TBI are accessing academic services less often than their healthy peers, this would be an area of concern—and potential intervention. Analysis comparing the number of symptoms reported for participants who used any services vs those who reported using none also supports the idea that students with TBI may not be accessing services that could be useful to them.

DOI: 10.3109/02699052.2014.916416

On the other hand, there was a lack of significant difference between the number of symptoms reported by those who have received services and those who have not. This could mean that this survey was not asking the right questions about symptoms that lead people to access services; or that the range of number of symptoms (0–6 for the hospitalized group, 0–10 in the TBI group and 0–13 in the healthy control group) was too small to be sensitive in this case. The analysis performed made the assumption that more symptoms was equivalent to greater severity, but this is certainly not always the case: a single severe symptom could lead someone to seek services much more than several very mild symptoms, for example. Limitations and future directions One of the limitations of the current study was that the broad, self-selecting recruitment methods resulted in a sample whose demographics did not match that of the campus population. Specifically, while the distribution among undergraduate classes was roughly equivalent to that of the campus overall, sex and race distributions were not representative. Some prior studies have found differences between men and women on their experience of PCS symptoms [12] and others have not [14, 16]. Future studies could use more targeted recruitment strategies to collect data from a more demographically representative sample. Another limitation to the study was the wide range of injury history among both the hospitalized control and TBI groups. Respondents with TBI were specifically asked about their age of injury, but, because the hospitalization explanation was open-ended in the survey, some participants reported their age of hospitalization and others did not. Future studies could rectify this by gathering more detailed hospitalization information and could then include comparative analyses of the effects of age of injury on reported symptoms across groups. As mentioned previously, the survey allowed responses in which participants stated that they had received therapy for symptoms which they did not endorse experiencing. A total of 11 participants were excluded from analysis because of this problem. Future surveys should include clearer instructions for completing this section of the survey and/or should return an error message if a respondent reports therapy for a symptom that he or she did not endorse experiencing. Another challenge arose when comparing reports of symptoms among the three groups because it was unclear whether over-reporting occurred in the control group relative to the other groups and, if so, why. There are several ways that future studies using this methodology could attempt to address the question of comparative severity. For example, providing anecdotal anchors or specific examples of affected tasks for each symptom could help with calibration of responses across groups. Alternatively (or in addition), openended descriptions could be requested for each symptom endorsed, allowing for a mixed-methods analysis comparing both quantitative and qualitative symptom reports. Further research is also needed regarding the psychosocial effects of TBI on late-adolescent college students compared to their uninjured peers. Depression is known to play a role in

TBI and use of services among undergraduates

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reporting of PCS symptoms [13]. In addition, people with TBI are at increased risk of depression and those with major depression have an increased likelihood of executive function and social functioning deficits for those with TBI [28]. Further study of this inter-relationship is needed. While the analysis of symptoms reported and services used suggests that students with TBI may be under-utilizing available services, further research is needed to elaborate these findings. For example, more specific questions would help establish to what extent there is a relationship between the memory difficulties endorsed here and academic challenges that could benefit from particular campus services. Future research could also explore factors other than specific symptoms that lead people with TBI to use or not use the services available to them. In addition, the current study asked only whether participants had ever accessed various services; follow-up studies could delve further into the timing of services, awareness of available university resources and interest in accessing resources or accommodations in the future. It is important to determine what students know (or think they know) about Disability Services and the types of accommodation that are available.

Conclusion Results of this study demonstrate that there are a considerable number of undergraduate students with a history of TBI and that many injuries even without LOC were reported to include altered consciousness and post-traumatic amnesia. Even with a risk of under-reporting, the population of undergraduate students with a history of TBI is substantial (16%) and, although many of those with TBI endorsed experiencing symptoms that could affect academics, few reported accessing supportive services. This suggests that greater outreach efforts are warranted to encourage students to take advantage of available services. Many post-TBI symptoms were also endorsed by healthy control participants and further study is needed to explore the complex psychosocial development that occurs during college and how it may interact with TBI.

Acknowledgements The authors are grateful to Dr Alex Goberman for his assistance with data analysis.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Alvarez L. War veterans’ concussions are often overlooked. New York (NY): New York Times; 2008. [Internet]. Available online at: http://www.nytimes.com/2008/08/26/us/26tbi.html, accessed 13 May 2014. 2. Schwartz A. The next step for researchers is not finding brain trauma. New York (NY): New York Times; 2011. [Internet]. Available online at: http://www.nytimes.com/2011/05/08/sports/ football/08duerson.html, accessed 13 May 2014. 3. Zaloshnja E, Miller T, Langlois JA, Selassie AW. Prevalence of long-term disability from traumatic brain injury in the civilian

1310

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

M. Krause & S. Richards

population of the United States, 2005. The Journal of Head Trauma Rehabilitation 2008;23:394–400. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic Brain Injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2004. Available online at: http://stacks.cdc.gov/view/cdc/ 13379, accessed 21 May 2014. Powell BD, Holmes CB. Prevalence of head injury among four-year college students: A replication and combined results. Perceptual and Motor Skills 1995;81:227–230. Menon DK, Menon DK, Schwab K, Wright DW, Maas AI. Position statement: Definition of traumatic brain injury. Archives of Physical Medicine and Rehabilitation 2010;91:1637–1640. Carroll L, Cassidy JD, Peloso P, Borg J, Holst von H, Holm L, Paniak C, Pe´pin M. Prognosis for mild traumatic brain injury: Results of the who collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine 2004;36:84–105. Gordon WA, Haddad L, Brown M, Hibbard MR, Sliwinski M. The sensitivity and specificity of self-reported symptoms in individuals with traumatic brain injury. Brain Injury 2000;14:21–33. O’Connor C, Colantonio A, Polatajko H. Long term symptoms and limitations of activity of people with traumatic brain injury: A ten-year follow-up. Psychological Reports 2005;97:169–179. Kennedy M, Krause M, Turkstra L. An electronic survey about college experiences after traumatic brain injury. NeuroRehabilitation 2008;23:511–520. Fox DD, Lees-Haley PR, Earnest K, Dolezal-Wood S. Base rates of postconcussive symptoms in health maintenance organization patients and controls. Neuropsychology 1995;9:606. Maria MPS, Pinkston JB, Miller SR, Gouvier WD. Stability of postconcussion symptomatology differs between high and low responders and by gender but not by mild head injury status. Archives of Clinical Neuropsychology 2001;16:133–140. Trahan DE, Ross CE, Trahan SL. Relationships among postconcussional-type symptoms, depression, and anxiety in neurologically normal young adults and victims of mild brain injury. Archives of Clinical Neuropsychology 2001;16:435–445. Gunstad J, Suhr JA. Perception of illness: Nonspecificity of postconcussion syndrome symptom expectation. Journal of the International Neuropsychological Society: JINS 2002;8:37–47. Gunstad J. Cognitive factors in Postconcussion Syndrome symptom report. Archives of Clinical Neuropsychology 2004;19:391–405.

Brain Inj, 2014; 28(10): 1301–1310

16. Wang Y, Chan R, Deng Y. Examination of postconcussion-like symptoms in healthy university students: Relationships to subjective and objective neuropsychological function performance. Archives of Clinical Neuropsychology 2006;21:339–347. 17. Lehmkuhl D. The TIRR Symptom Checklist. Houston (TX): The Institute of Rehabilitation Research; 1988. 18. Wagner M, Newman L, Cameto R, Garza N, Levine P. After high school: A first look at the postschool experiences of youth with disabilities. Menlo Park, CA: A report from the National Longitudinal Transition Study-2 (NLTS2); 2005. Available online at: http://files.eric.ed.gov/fulltext/ED494935.pdf, accessed 21 May 2014. 19. Dawson DR, Schwartz ML, Winocur G, Stuss DT. Return to productivity following traumatic brain injury: Cognitive, psychological, physical, spiritual, and environmental correlates. Disability & Rehabilitation 2007;29:301–313. 20. Johnstone B, Pinkowski M, Farmer J, Hagglund KJ. Neurobehavioral deficits, adolescent traumatic brain injury, and transition to college. Journal of Clinical Psychology in Medical Settings 1994;1:375–386. 21. Gosling SD, Vazire S, Srivastava S, John OP. Should we trust webbased studies? A comparative analysis of six preconceptions about internet questionnaires. American Psychologist 2004;59:93. 22. Corrigan JD, Bogner J. Initial reliability and validity of the Ohio State University TBI identification method. The Journal of Head Trauma Rehabilitation 2007;22:318–329. 23. Orgel SA, Mcdonald RD. An evaluation of the Trail Making Test. Journal of Consulting Psychology 1967;31:77. 24. Woods AJ, Mark VW, Pitts AC, Mennemeier M. Pervasive cognitive impairment in acute rehabilitation inpatients without brain injury. Physical Medicine & Rehabilitation 2011;3:426–432. 25. Iverson GL, Lange RT. Examination of ‘‘postconcussion-like’’ symptoms in a healthy sample. Applied Neuropsychology 2003;10: 137–144. 26. Chan RC. attention deficits in patients with persisting postconcussive complaints: A general deficit or specific component deficit? Journal of Clinical and Experimental Neuropsychology 2002;24: 1081–1093. 27. Smith-Seemiller L, Fow NR, Kant R, Franzen MD. Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury. Brain Injury 2003;17:199–206. 28. Jorge RE, Robinson RG, Moser D, Tateno A, Crespo-Facorro B, Arndt S. Major depression following traumatic brain injury. Archives of General Psychiatry 2004;61:42–50.

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