- Email: [email protected]
Traumatic Brain Injury in Adolescents: Incidence and Correlates
LETTERS TO THE EDITOR
different disorders to the clinical formulation and diagnosis.”1 The Cultural Formulation section of the DSM-5 emphasizes that all forms of distress are shaped by a person’s cultural context, including language, religion and spirituality, family structure, customs, and moral and legal systems.2 However, each person embraces religion and culture in idiosyncratic and individualized ways, and thus will vary in the way these contexts shape their experience of mental illness and their relationship with clinicians. Indeed, in the case example in our article, the patient’s family believed that his symptoms were caused by a jinni, but once stabilized, the boy himself supplied the hypothesis that he had a substance-induced psychosis. Neither the boy nor his family had religious delusions; the family’s attribution of his symptoms to jinn influence was a cogent and rational explanation for his symptoms within their cultural and religious belief system. Understanding these beliefs allowed the psychiatrist to engage with the family, incorporating their goals and perspectives into the child’s care. Thoughtful cultural psychiatry is the antithesis of stereotyping and prejudice; instead, it promotes respectful collaboration with each patient and family. Finally, although we respect Dr. Ghaziuddin’s concern about offending American Muslim patients by asking specific questions about beliefs in jinn, we agree with Kleinman et al. that understanding the patient’s and family’s explanatory model of illness is a crucial element of providing good care.3 Inviting the family to discuss this through open-ended questions, like many suggested in our article, can convey the psychiatrist’s interest in learning their perspective. However, as Lim et al. note, individuals who believe their symptoms are caused by jinn are often reluctant to disclose this to others.4 Psychiatrists working with adolescents routinely ask specific and probing questions that may be offensive in other settings; often, a humble, tactful, and well-timed question invites relief and engagement by the patient or family rather than offense. This has been our experience in inquiring specifically about jinn: particularly if framed with an explanation of why the question is being asked and how it is relevant to clinical care, our familiarity with the concept of jinn influence and openness to conversation has often led to greater rapport and partnership with families in the care of their adolescents. Sandra J. Rackley, MD, MAEdHD Charles P. Lewis, MD Christopher R. Takala, DO Asfia Qaadir, DO Kirsten E. Cowan, MD Drs. Lewis and Rackley are with the Division of Child and Adolescent Psychiatry, Mayo Clinic, Rochester, MN. Dr. Takala is with the Division of Child and Adolescent Psychiatry, Medical College of Wisconsin, Milwaukee. Dr. Qaadir is with PrairieCare, Maplewood, MN. Dr. Cowan is with the Child and Adolescent Psychiatry Fellowship, Mayo Clinic. Disclosure: Please see the disclosure statement in the original article published in June 2017.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
Correspondence to Sandra J. Rackley, MD, MAEdHD: rackley.sandra@mayo. edu 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.07.788
REFERENCES
1. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;52:1101-1115. 2. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, VA: American Psychiatric Publishing, Inc.; 2013. 3. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-258. 4. Lim A, Hoek HW, Blom JD. The attribution of psychotic symptoms to jinn in Islamic patients. Transcult Psychiatry. 2015;52:18-32.
Traumatic Brain Injury in Adolescents: Incidence and Correlates To the Editor:
I
n a large sample of Canadian adolescents, we investigated the incidence and risks associated with traumatic brain injury (TBI). We defined TBI broadly to include milder injuries, and focused on both single and multiple injuries. Furthermore, we evaluated risk associated with TBI emerging from sport activities, physical assault, and illicit drug use. The University of British Columbia and Simon Fraser University provided research ethics board approval for the study. Data were taken from a survey carried out by the McCreary Centre Society, The 2013 British Columbia Adolescent Health Survey (BCAHS), and summarized in a report on multiple aspects of health entitled: “From Hastings Street to Haida Gwaii: Provincial Results of the 2013 BC Adolescent Health Survey.”1 In total, 42,453 students (grades 712) from a randomly drawn stratified sample of 1,645 classrooms in 443 schools completed the anonymous questionnaire. There was a 70% response rate, yielding valid survey data from 29,832 students. Respondents (age range, 1219 years; mean [SD] age, 14.9 [1.76] years) reported all head injuries sustained in the last year, for events that involved loss of consciousness (LOC), and/or being dazed, confused, or experiencing a gap in memory.1,2 Multinomial logistic regression was used in the Complex Samples Module of SPSS to evaluate correlates of TBI. The incidence of reporting a single TBI in the past year was estimated at 12.2% (95% CI, 11.7–12.6%) and 4.2% (95% CI, 4.0–4.5%) for reporting 2 or more TBIs. Of respondents reporting at least 1 TBI, 25.1% (95% CI, 23.8–26.4%) reported losing consciousness for 1 or more of their TBIs. The odds ratios for reporting 2 or more TBIs for each of sports with a coach, without a coach, and extreme sports were 1.99 (95% CI, 1.70–2.32), 1.21 (95% CI, 1.05–1.41), and 2.17 (95% CI, 1.84–2.55), respectively (Table 1). Of those students who reported a physical assault experience
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895
Multinomial Logistic Regression for Traumatic Brain Injury (TBI; N ¼ 29,289 Respondents)a Odds Ratios (95% CI)
www.jaacap.org
b
JOURNAL OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
Sex Female Male Age 12 13 14 15 16 17 18þ Sports with coach <1/wk 1þ/wk Sports without coach <1/wk 1þ/wk Extreme sports <1/wk 1þ/wk Assault experience Neither victim nor perpetrator Victim, perpetrator, or both Alcohol consumption Never Lifetime Cannabis use Never Lifetime Other drug used Never Lifetime
Adjusted Odds Ratios (95% CI)
1 vs. 0
2þ vs. 0
1 vs. 0b
2þ vs. 0b
Wald Statisticc
1 [Reference] 1.48 (1.37 e 1.59)***
1 [Reference] 1.72 (1.52 e 1.94)***
1 [Reference] 1.23 (1.13 e 1.33)***
1 [Reference] 1.31 (1.14 e 1.51)***
F1302¼ 17.02***
1 [Reference] 1.25 (1.07 e 1.46 (1.24 e 1.65 (1.40 e 1.51 (1.28 e 1.39 (1.18 e 1.23 (0.99 e
1 [Reference] 1.56 (1.11 e 2.02 (1.46 e 2.33 (1.69 e 2.56 (1.64 e 2.05 (1.49 e 1.87 (1.25 e
1 [Reference] 1.24 (1.04 e 1.20 (1.01 e 1.25 (1.05 e 1.07 (0.89 e 0.96 (0.80 e 0.85 (0.67 e
1 [Reference] 1.43 (0.99 e 1.50 (1.06 e 1.44 (1.01 e 1.28 (0.89 e 1.13 (0.79 e 0.98 (0.62 e
1.47)** 1.72)*** 1.95)*** 1.78)*** 1.64)*** 1.53)
b
2.19)** 2.78)*** 3.21)*** 3.10)*** 2.84)*** 2.79)***
1.47)* 1.43)* 1.50)* 1.29) 1.16) 1.07)
F1292¼ 3.35*** 2.05) 2.12)* 2.04)* 1.83) 1.63) 1.54) F1302¼ 116.98***
1 [Reference] 1.93 (1.78 e 2.10)***
1 [Reference] 1.86 (1.62 e 2.13)***
1 [Reference] 1.90 (1.73 e 2.08)***
1 [Reference] 1.99 (1.70 e 2.32)***
1 [Reference] 1.67 (1.54 e 1.80)***
1 [Reference] 1.85 (1.63 e 2.10)***
1 [Reference] 1.21 (1.11 e 1.32)***
1 [Reference] 1.21 (1.05 e 1.41)*
F1302¼ 11.59***
1 [Reference] 2.59 (2.35 e 2.85)***
1 [Reference] 3.47 (3.02 e 3.99)***
1 [Reference] 1.83 (1.63 e 2.04)***
1 [Reference] 2.17 (1.84 e 2.55)***
F1298¼ 84.25***
1 [Reference] 2.43 (2.17 e 2.72)***
1 [Reference] 5.00 (4.34 e 5.76)***
1 [Reference] 2.07 (1.82 e 2.36)***
1 [Reference] 3.39 (2.86 e 4.02)***
F1302¼ 130.26***
1 [Reference] 2.08 (1.91 e 2.26)***
1 [Reference] 3.56 (3.09 e 4.12)***
1 [Reference] 1.82 (1.63 e 2.03)***
1 [Reference] 2.59 (2.12 e 3.18)***
F1302¼ 92.74***
1 [Reference] 1.91 (1.77 e 2.07)***
1 [Reference] 2.93 (2.59 e 3.31)***
1 [Reference] 1.21 (1.09 e 1.34)***
1 [Reference] 1.17 (0.99 e 1.39)
1 [Reference] 1.78 (1.64 e 1.94)***
1 [Reference] 3.30 (2.92 e 3.73)***
1 [Reference] 1.34 (1.21 e 1.49)***
1 [Reference] 2.16 (1.87 e 2.49)***
F1302¼ 7.29***
F1302¼ 63.09***
Note: Data come from the 2013 BC Adolescent Health Survey. a Listwise deletion resulted in the following numbers and percentages of students: no TBI in the past 12 months (n ¼ 23,343; 83.1%), 1 (n ¼ 3,673; 12.5%), and 2 or more (n ¼ 1,273; 4.4%). b Number of TBIs in the past 12 months. c Degrees of freedom are calculated by the following: (number of sampled classrooms) e (number of strata). d Other drug use included any of the following: prescription pills without doctor consent, cocaine, hallucinogens, ecstasy/MDMA, psilocybin, inhalants, amphetamines, crystal meth, heroin, ketamine, steroids. *p < .05; ** p < .01; *** p < .001.
LETTERS TO THE EDITOR
896
TABLE 1
LETTERS TO THE EDITOR
(victim, perpetrator, or both), the odds ratio for reporting 2 or more TBIs in the past 12 months was 3.39 (95% CI, 2.86– 4.02). Engaging in assault, alcohol use, and other drug use was associated with higher odds for multiple TBIs, relative to the somewhat lower odds that they conferred for a single injury (Table 1). A previous investigation of all-cause annual head injuries reported that 5.6% of adolescents sustained at least 1 TBI with at least 5 minutes of unconsciousness or overnight hospitalization.3 Our estimate of 16.4% coincides with our more inclusive definition. This higher estimate is of concern, given the emergent evidence that single and repetitive mild TBIs may well increase the risk for more debilitating neurodegenerative diseases.4 Finally, respondents engaged in either assault or in noncannabis substance use are at an even higher risk for multiple versus single TBI. Importantly, adolescents using substances may be particularly vulnerable, given that such use may exacerbate the negative consequences of TBI.5 Emily M. Livingston, BSc Allen E. Thornton, PhD David N. Cox, PhD
Ms. Livingston and Drs. Thornton and Cox are with Simon Fraser University, Burnaby, BC, Canada. Funding for the 2013 BC Adolescent Health Survey was provided by BC Ministry of Children and Family Development, BC Ministry of Health, and Office of the Representative for Children and Youth. This study was presented as an abstract at the 45th Annual Meeting of the International Neuropsychological Society, New Orleans, LA, February 14, 2017.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
The authors thank Elizabeth Saewyc, PhD, University of British Columbia, and Annie Smith, ALM, with the McCreary Centre Society, for their support and contribution to this study. Neither received compensation for their contribution. The authors also thank the McCreary Centre Society for the use of their survey data and facilities to the conduct analyses. Disclosure: Dr. Thornton has received funding from the Canadian Institute of Health Research and the William and Ada Isabelle Steel Fund. Dr. Cox has served as an unpaid research advisor to the McCreary Center Society. Ms. Livingston reports no biomedical financial interests or potential conflicts of interest. Correspondence to Allen E. Thornton, PhD: [email protected] 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.07.787
REFERENCES 1. Smith A, Stewart D, Poon C, Peled M, Saewyc EM; McCreary Centre Society. From Hastings Street to Haida Gwaii: Provincial results of the 2013 BC adolescent health survey. Vancouver, BC, Canada: McCreary Centre Society; 2014. 2. Corrigan JD, Bogner J. Initial reliability and validity of the Ohio State University TBI Identification Method. J Head Trauma Rehabil. 2007;22: 318-329. 3. Ilie G, Boak A, Adlaf EM, Asbridge M, Cusimano MD. Prevalence and correlates of traumatic brain injuries among adolescents. JAMA. 2013;309: 2550-2552. 4. Gardner RC, Yaffe K. Epidemiology of mild traumatic brain injury and neurodegenerative disease. Mol Cell Neurosci. 2015;66:75-80. 5. Graham DP, Cardon AL. An update on substance use and treatment following traumatic brain injury. Ann NY Acad of Sci. 2008;1141: 148-162.
All statements expressed in this column are those of the authors and do not reflect the opinions of the Journal of the American Academy of Child and Adolescent Psychiatry. See the Instructions for Authors for information about the preparation and submission of Letters to the Editor.
www.jaacap.org
897
different disorders to the clinical formulation and diagnosis.”1 The Cultural Formulation section of the DSM-5 emphasizes that all forms of distress are shaped by a person’s cultural context, including language, religion and spirituality, family structure, customs, and moral and legal systems.2 However, each person embraces religion and culture in idiosyncratic and individualized ways, and thus will vary in the way these contexts shape their experience of mental illness and their relationship with clinicians. Indeed, in the case example in our article, the patient’s family believed that his symptoms were caused by a jinni, but once stabilized, the boy himself supplied the hypothesis that he had a substance-induced psychosis. Neither the boy nor his family had religious delusions; the family’s attribution of his symptoms to jinn influence was a cogent and rational explanation for his symptoms within their cultural and religious belief system. Understanding these beliefs allowed the psychiatrist to engage with the family, incorporating their goals and perspectives into the child’s care. Thoughtful cultural psychiatry is the antithesis of stereotyping and prejudice; instead, it promotes respectful collaboration with each patient and family. Finally, although we respect Dr. Ghaziuddin’s concern about offending American Muslim patients by asking specific questions about beliefs in jinn, we agree with Kleinman et al. that understanding the patient’s and family’s explanatory model of illness is a crucial element of providing good care.3 Inviting the family to discuss this through open-ended questions, like many suggested in our article, can convey the psychiatrist’s interest in learning their perspective. However, as Lim et al. note, individuals who believe their symptoms are caused by jinn are often reluctant to disclose this to others.4 Psychiatrists working with adolescents routinely ask specific and probing questions that may be offensive in other settings; often, a humble, tactful, and well-timed question invites relief and engagement by the patient or family rather than offense. This has been our experience in inquiring specifically about jinn: particularly if framed with an explanation of why the question is being asked and how it is relevant to clinical care, our familiarity with the concept of jinn influence and openness to conversation has often led to greater rapport and partnership with families in the care of their adolescents. Sandra J. Rackley, MD, MAEdHD Charles P. Lewis, MD Christopher R. Takala, DO Asfia Qaadir, DO Kirsten E. Cowan, MD Drs. Lewis and Rackley are with the Division of Child and Adolescent Psychiatry, Mayo Clinic, Rochester, MN. Dr. Takala is with the Division of Child and Adolescent Psychiatry, Medical College of Wisconsin, Milwaukee. Dr. Qaadir is with PrairieCare, Maplewood, MN. Dr. Cowan is with the Child and Adolescent Psychiatry Fellowship, Mayo Clinic. Disclosure: Please see the disclosure statement in the original article published in June 2017.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
Correspondence to Sandra J. Rackley, MD, MAEdHD: rackley.sandra@mayo. edu 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.07.788
REFERENCES
1. Pumariega AJ, Rothe E, Mian A, et al. Practice parameter for cultural competence in child and adolescent psychiatric practice. J Am Acad Child Adolesc Psychiatry. 2013;52:1101-1115. 2. American Psychiatric Association. The Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Arlington, VA: American Psychiatric Publishing, Inc.; 2013. 3. Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-258. 4. Lim A, Hoek HW, Blom JD. The attribution of psychotic symptoms to jinn in Islamic patients. Transcult Psychiatry. 2015;52:18-32.
Traumatic Brain Injury in Adolescents: Incidence and Correlates To the Editor:
I
n a large sample of Canadian adolescents, we investigated the incidence and risks associated with traumatic brain injury (TBI). We defined TBI broadly to include milder injuries, and focused on both single and multiple injuries. Furthermore, we evaluated risk associated with TBI emerging from sport activities, physical assault, and illicit drug use. The University of British Columbia and Simon Fraser University provided research ethics board approval for the study. Data were taken from a survey carried out by the McCreary Centre Society, The 2013 British Columbia Adolescent Health Survey (BCAHS), and summarized in a report on multiple aspects of health entitled: “From Hastings Street to Haida Gwaii: Provincial Results of the 2013 BC Adolescent Health Survey.”1 In total, 42,453 students (grades 712) from a randomly drawn stratified sample of 1,645 classrooms in 443 schools completed the anonymous questionnaire. There was a 70% response rate, yielding valid survey data from 29,832 students. Respondents (age range, 1219 years; mean [SD] age, 14.9 [1.76] years) reported all head injuries sustained in the last year, for events that involved loss of consciousness (LOC), and/or being dazed, confused, or experiencing a gap in memory.1,2 Multinomial logistic regression was used in the Complex Samples Module of SPSS to evaluate correlates of TBI. The incidence of reporting a single TBI in the past year was estimated at 12.2% (95% CI, 11.7–12.6%) and 4.2% (95% CI, 4.0–4.5%) for reporting 2 or more TBIs. Of respondents reporting at least 1 TBI, 25.1% (95% CI, 23.8–26.4%) reported losing consciousness for 1 or more of their TBIs. The odds ratios for reporting 2 or more TBIs for each of sports with a coach, without a coach, and extreme sports were 1.99 (95% CI, 1.70–2.32), 1.21 (95% CI, 1.05–1.41), and 2.17 (95% CI, 1.84–2.55), respectively (Table 1). Of those students who reported a physical assault experience
www.jaacap.org
895
Multinomial Logistic Regression for Traumatic Brain Injury (TBI; N ¼ 29,289 Respondents)a Odds Ratios (95% CI)
www.jaacap.org
b
JOURNAL OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
Sex Female Male Age 12 13 14 15 16 17 18þ Sports with coach <1/wk 1þ/wk Sports without coach <1/wk 1þ/wk Extreme sports <1/wk 1þ/wk Assault experience Neither victim nor perpetrator Victim, perpetrator, or both Alcohol consumption Never Lifetime Cannabis use Never Lifetime Other drug used Never Lifetime
Adjusted Odds Ratios (95% CI)
1 vs. 0
2þ vs. 0
1 vs. 0b
2þ vs. 0b
Wald Statisticc
1 [Reference] 1.48 (1.37 e 1.59)***
1 [Reference] 1.72 (1.52 e 1.94)***
1 [Reference] 1.23 (1.13 e 1.33)***
1 [Reference] 1.31 (1.14 e 1.51)***
F1302¼ 17.02***
1 [Reference] 1.25 (1.07 e 1.46 (1.24 e 1.65 (1.40 e 1.51 (1.28 e 1.39 (1.18 e 1.23 (0.99 e
1 [Reference] 1.56 (1.11 e 2.02 (1.46 e 2.33 (1.69 e 2.56 (1.64 e 2.05 (1.49 e 1.87 (1.25 e
1 [Reference] 1.24 (1.04 e 1.20 (1.01 e 1.25 (1.05 e 1.07 (0.89 e 0.96 (0.80 e 0.85 (0.67 e
1 [Reference] 1.43 (0.99 e 1.50 (1.06 e 1.44 (1.01 e 1.28 (0.89 e 1.13 (0.79 e 0.98 (0.62 e
1.47)** 1.72)*** 1.95)*** 1.78)*** 1.64)*** 1.53)
b
2.19)** 2.78)*** 3.21)*** 3.10)*** 2.84)*** 2.79)***
1.47)* 1.43)* 1.50)* 1.29) 1.16) 1.07)
F1292¼ 3.35*** 2.05) 2.12)* 2.04)* 1.83) 1.63) 1.54) F1302¼ 116.98***
1 [Reference] 1.93 (1.78 e 2.10)***
1 [Reference] 1.86 (1.62 e 2.13)***
1 [Reference] 1.90 (1.73 e 2.08)***
1 [Reference] 1.99 (1.70 e 2.32)***
1 [Reference] 1.67 (1.54 e 1.80)***
1 [Reference] 1.85 (1.63 e 2.10)***
1 [Reference] 1.21 (1.11 e 1.32)***
1 [Reference] 1.21 (1.05 e 1.41)*
F1302¼ 11.59***
1 [Reference] 2.59 (2.35 e 2.85)***
1 [Reference] 3.47 (3.02 e 3.99)***
1 [Reference] 1.83 (1.63 e 2.04)***
1 [Reference] 2.17 (1.84 e 2.55)***
F1298¼ 84.25***
1 [Reference] 2.43 (2.17 e 2.72)***
1 [Reference] 5.00 (4.34 e 5.76)***
1 [Reference] 2.07 (1.82 e 2.36)***
1 [Reference] 3.39 (2.86 e 4.02)***
F1302¼ 130.26***
1 [Reference] 2.08 (1.91 e 2.26)***
1 [Reference] 3.56 (3.09 e 4.12)***
1 [Reference] 1.82 (1.63 e 2.03)***
1 [Reference] 2.59 (2.12 e 3.18)***
F1302¼ 92.74***
1 [Reference] 1.91 (1.77 e 2.07)***
1 [Reference] 2.93 (2.59 e 3.31)***
1 [Reference] 1.21 (1.09 e 1.34)***
1 [Reference] 1.17 (0.99 e 1.39)
1 [Reference] 1.78 (1.64 e 1.94)***
1 [Reference] 3.30 (2.92 e 3.73)***
1 [Reference] 1.34 (1.21 e 1.49)***
1 [Reference] 2.16 (1.87 e 2.49)***
F1302¼ 7.29***
F1302¼ 63.09***
Note: Data come from the 2013 BC Adolescent Health Survey. a Listwise deletion resulted in the following numbers and percentages of students: no TBI in the past 12 months (n ¼ 23,343; 83.1%), 1 (n ¼ 3,673; 12.5%), and 2 or more (n ¼ 1,273; 4.4%). b Number of TBIs in the past 12 months. c Degrees of freedom are calculated by the following: (number of sampled classrooms) e (number of strata). d Other drug use included any of the following: prescription pills without doctor consent, cocaine, hallucinogens, ecstasy/MDMA, psilocybin, inhalants, amphetamines, crystal meth, heroin, ketamine, steroids. *p < .05; ** p < .01; *** p < .001.
LETTERS TO THE EDITOR
896
TABLE 1
LETTERS TO THE EDITOR
(victim, perpetrator, or both), the odds ratio for reporting 2 or more TBIs in the past 12 months was 3.39 (95% CI, 2.86– 4.02). Engaging in assault, alcohol use, and other drug use was associated with higher odds for multiple TBIs, relative to the somewhat lower odds that they conferred for a single injury (Table 1). A previous investigation of all-cause annual head injuries reported that 5.6% of adolescents sustained at least 1 TBI with at least 5 minutes of unconsciousness or overnight hospitalization.3 Our estimate of 16.4% coincides with our more inclusive definition. This higher estimate is of concern, given the emergent evidence that single and repetitive mild TBIs may well increase the risk for more debilitating neurodegenerative diseases.4 Finally, respondents engaged in either assault or in noncannabis substance use are at an even higher risk for multiple versus single TBI. Importantly, adolescents using substances may be particularly vulnerable, given that such use may exacerbate the negative consequences of TBI.5 Emily M. Livingston, BSc Allen E. Thornton, PhD David N. Cox, PhD
Ms. Livingston and Drs. Thornton and Cox are with Simon Fraser University, Burnaby, BC, Canada. Funding for the 2013 BC Adolescent Health Survey was provided by BC Ministry of Children and Family Development, BC Ministry of Health, and Office of the Representative for Children and Youth. This study was presented as an abstract at the 45th Annual Meeting of the International Neuropsychological Society, New Orleans, LA, February 14, 2017.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 10 OCTOBER 2017
The authors thank Elizabeth Saewyc, PhD, University of British Columbia, and Annie Smith, ALM, with the McCreary Centre Society, for their support and contribution to this study. Neither received compensation for their contribution. The authors also thank the McCreary Centre Society for the use of their survey data and facilities to the conduct analyses. Disclosure: Dr. Thornton has received funding from the Canadian Institute of Health Research and the William and Ada Isabelle Steel Fund. Dr. Cox has served as an unpaid research advisor to the McCreary Center Society. Ms. Livingston reports no biomedical financial interests or potential conflicts of interest. Correspondence to Allen E. Thornton, PhD: [email protected] 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2017.07.787
REFERENCES 1. Smith A, Stewart D, Poon C, Peled M, Saewyc EM; McCreary Centre Society. From Hastings Street to Haida Gwaii: Provincial results of the 2013 BC adolescent health survey. Vancouver, BC, Canada: McCreary Centre Society; 2014. 2. Corrigan JD, Bogner J. Initial reliability and validity of the Ohio State University TBI Identification Method. J Head Trauma Rehabil. 2007;22: 318-329. 3. Ilie G, Boak A, Adlaf EM, Asbridge M, Cusimano MD. Prevalence and correlates of traumatic brain injuries among adolescents. JAMA. 2013;309: 2550-2552. 4. Gardner RC, Yaffe K. Epidemiology of mild traumatic brain injury and neurodegenerative disease. Mol Cell Neurosci. 2015;66:75-80. 5. Graham DP, Cardon AL. An update on substance use and treatment following traumatic brain injury. Ann NY Acad of Sci. 2008;1141: 148-162.
All statements expressed in this column are those of the authors and do not reflect the opinions of the Journal of the American Academy of Child and Adolescent Psychiatry. See the Instructions for Authors for information about the preparation and submission of Letters to the Editor.
www.jaacap.org
897