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Pediatric TBI Among Underrepresented Ethnic Groups

Categories: Professionals

By Nancy Doria, B.S., Nathalia Jimenez, M.D., MPH, and Monique R. Pappadis, M.Ed., Ph.D.

Traumatic brain injury (TBI) is a leading cause of death and disability among children and young adults in the United States. Each year, an average of 62,000 children sustain brain injuries requiring hospitalization as a result of motor vehicle crashes, falls, sports injuries, physical abuse, and other causes. The long-term physical, emotional, social, and cognitive effects after an injury can also affect children in the school system and the quality of life of children and their families. American Indian/Alaskan Native, Latinx, and Black/African American children are affected disproportionally by TBI. Learning about the ethnic disparities in pediatric TBI patients will pave the way to identify contributing factors and possible interventions to decrease existing disparities.

Pediatric TBI in American Indian/ Alaskan Native (AI/AN) Children

Few studies have examined the lived experiences, TBI treatment, long-term outcomes, and health disparities of AI/AN children with TBI, despite having the highest rates of TBI-related hospitalizations and deaths compared to other racial/ethnic groups.1.2 AI/AN children are disproportionately affected by TBI through violent, intentional mechanisms (e.g., assault, self-infected). Most studies either combine AI/AN individuals with other marginalized groups, exclude them due to small sample sizes, or do not have a large enough sample to make appropriate recommendations. Some evidence suggests that children with TBI of AI/AN race are not associated with cognitive or motor functioning during inpatient rehabilitation,3 but more studies are needed to explore post-acute care and health outcomes following pediatric TBI. More culturally relevant programs, such as ThinkFirst Navajo, are needed to promote prevention, health, and wellness among AI/AN children. Some examples of recommendations for health care professionals include improving care practices by receiving training on providing culturally and linguistically appropriate services, raising awareness to policy leaders and advocacy groups on dismantling health disparities, and advocating for policy changes and improved access to care.4

Latinx children with TBI

Latinx children, compared to non-Hispanic White (NHW) children, are more likely to have more severe injuries and to experience significant long-term post-injury disparities, measured by lower quality of life, participation in social activities, communication skills, and self-care abilities.5 Importantly, disparities are not present at discharge from acute care.6 These develop post-hospitalization where known risk factors for poor TBI outcomes play a large role in accessing care in the community.7 Underinsurance, low socioeconomic status, and limited parental education are highly prevalent among Latinx in the U.S., especially among recent immigrants. While parents play a critical role in their child’s recovery, Latinx parents face substantial barriers that can result in delayed initiation of treatments and suboptimal outcomes.8 Nevertheless culturally and linguistically concordant navigation and education programs informed by Latinx parents and rooted in strengths of the Latinx community,9 are promising interventions to improve access to post-acute care and outcomes in this vulnerable and rapidly growing population.

Pediatric TBI in Black Children

Similar to adults, Black children and adolescents are disproportionately affected by TBI. Similar to AI/AN children, TBI is often caused by intentional violence, whether blunt trauma, penetrating, or firearm injury. Once admitted to hospitals, Black children will exhibit significant comorbidities, such as preexisting respiratory illnesses and behavioral or cognitive disorders, which may affect their course of treatment and post-hospitalization outcomes. Racial disparities exist in the evaluation, treatment, and post-injury outcomes of Black children compared to NHW or Latinx children, such as being more extensively evaluated for abuse compared to NHW children who are often under-evaluated.10 Black children also report poorer functional outcomes at acute hospital discharge, often driving the need for rehabilitation following injury. Still, following rehabilitation discharge, non-Hispanic Blacks reported lower functional outcomes.6 Despite depression being common in up to 25% of children with TBI, Black children are less likely to have access to outpatient mental health services compared to other children.8 Future work is needed to explore the experiences of Black children with TBI, their interaction with the school and healthcare system, and post-injury outcomes, to ensure success in the classroom, reduce health disparities, and improve their quality of life following TBI.

In summary, children with TBI from marginalized groups experience significant disparities in care and outcomes following injury. Healthcare providers and school personnel should be aware of the needs of these populations and their families. In addition, when working with persons from diverse backgrounds it is helpful to practice cultural humility to reduce implicit biases that may influence diagnosis, assessment, referral for services, and treatment following pediatric TBI. More efforts are needed to explore the unique experiences of LatinX, American Indian/Alaskan Native, and Black children with TBI and their families to improve outcomes following injury.

References

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  • Peterson AB, Sarmiento K, Xu L, Haileyesus T. Traumatic brain injury-related hospitalizations and deaths among American Indians and Alaska natives – United States, 2008-2014. Journal of Safety Research. 2019;71:315-318.
  • Fuentes MM, Jimenez N, Apkon SD, Rivara FP. Functional outcomes during inpatient rehabilitation for American Indian and Alaska Native children with traumatic brain injury. J Pediatr Rehabil Med. 2016 May 31;9(2):133-41. doi: 10.3233/PRM-160376. PMID: 27285806; PMCID: PMC5099074.
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  • Jimenez N, Fuentes M, Virtue A, Alonso-Gonzalez L, Lopez E, Zhou C, Crawley D, Apkon S, Johnston B, Rivara F. Feasibility and Acceptability of a Telephone-Based Intervention for Hispanic Children to Promote Treatment Adherence After Traumatic Brain Injury: A Pilot Study. The Journal of Head Trauma Rehabilitation. 2021 Feb 22.
  • Wood JN, Hall M, Schilling S, Keren R, Mitra N, Rubin DM. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics. 2010 Sep 1;126(3):408-14.