Strategic Teams in Applied Injury Research (STAIR) Preventing TBI in Vulnerable Populations: Family and Peer Influences George Kazolis, BSc (Hons), University of Toronto Lorne Tepperman, PhD, University of Toronto Brain Injury Association of Canada 10 th annual conference September 26 th , 2013 1
Research Objective Objective : to improve our understanding of traumatic brain injury (TBI) by exploring the social and developmental histories of unintentional fall-based TBI participants. Funding : CIHR (grant # TIR-103946), and the Ontario Neurotrauma Foundation. Principal Investigator : Dr. Michael Cusimano, St. Michael’s Hospital. 2
Risk factors associated with TBI Falls and TBI: Unintentional falls are the leading cause of non-fatal TBI. Individuals that fall are 2 – 3 times more likely to sustain a recurrent fall. Substance abuse and TBI: Approximately two thirds of individuals with TBI have a history of substance abuse pre-injury. Young adult males have the highest incidence of TBI and the highest incidence of substance abuse.
1. Study Design The data for analysis was collected through structured open-ended interviews with (unintentional fall-based) TBI participants. All interviews were tape-recorded and transcribed. The transcribed materials were analyzed using qualitative methods to search for patterns and major themes. 4
1. Study Design Structured open-ended interview: Details about a) most recent, b) first, and c) most severe TBI. The participant elaborated on key events and episodes prior to the injury, including childhood. 5
2. Subjects and setting Inclusion Criteria Age equal to or greater than 18 years; Patients with Glasgow Coma Scale score of 13 or less (i.e. moderate to severe TBI); TBI sustained due to an unintentional fall within the preceding 1-3 years. Exclusion Criteria Are unable to undergo MRI scanning; Medically unstable or still hospitalized in- patients. 6
2. Subjects and setting 27 participant transcripts were included for data coding. Samples were stratified by age and gender. Participants were recruited from St. Michael’s Hospital (SMH); a major regional trauma centre in Toronto. 7
3. Data Analysis Transcript analysis was based on the Grounded Theory method. The Coding Process: ▪ The coding process involved the generation of codes , which led to categories , and finally themes that helped formulate a theory. ▪ Three coding steps were used: open coding , axial coding , and selective coding . 8
The Coding Process Level I OPEN coding Level II AXIAL coding Level III SELECTIVE coding 9
Level I – Open coding # of Code # of Sources References Prior history of risky behaviour 23 119 Prior alcohol or substance abuse 17 52 Participant's friends or co-workers abuse recreational drugs or alcohol 16 27 Participant believes they are suffering from memory deficits since the 14 18 accident Participant has displayed more emotional or irritable behaviour since 12 25 the accident Participant accepts responsibility for causing their accident 12 23 Family history of alcoholism 12 22 Participant's friends or co-workers involved in risky activities 11 21 Participant had suffered a head injury in the past 11 13 Participant believes they are suffering from deficits in attention or 11 12 concentration since the accident Participant believes there is nothing they could have done to prevent 11 12 the accident Participant believes their recent head injury could have been avoided 11 14 10 Table 1. Level I Codes - codes ranked in (descending) order of linkages
Level II – Axial coding Category # of # of Sources References Dispositional factors 27 225 Family influences 21 90 Peer influences 21 58 Physical vulnerabilities 19 53 Situational factors 16 30 Psychological vulnerabilities 9 26 Community influences 6 19 Table 2. Level II Categories (Axial coding)
RISK theme coding flowchart (partial) Selective Open codes Axial codes code Prior head injury Pre-existing medical Physical conditions Vulnerabilities Under the influence of alcohol at time of injury Safety helmet not Situational required at work RISK Influences Work-related unintentional fall Stress prior to injury Psychological Vulnerabilities History of mental illness 12
OPPORTUNITY theme coding flowchart (partial) Selective Open codes Axial codes code Prior history of risky behaviour Dispositional Prior alcohol or Factors substance abuse Family history of alcoholism Family OPPORTUNITY Influences Childhood history of verbal conflict Friends or co-workers abuse drugs or alcohol Peer Influences Friends or co-workers involved in risky activities 13
Level III – Selective coding Opportunity theme Theme Categor y Code Example from t ranscripts Opportunity Family Family history of I: Okay and besides your dad, has drinking Influence s alcoholism ever been a problem for anybody else? Yep. My uncles – P: they were all alcoholics. My grandfather. And my mother’s brothers. Yeah I was surrounded. Growing up it was rampant . Participant’s family a bad boy so there’s that … M y brother was most of his friends I don’t hang out with involved in risky because I’ll go to jail if I hang out with activities them. Participant’s friends I normally drink with friends I don’t like Peer P: Influences or co - workers abuse to drink by myself drugs or alcohol I: did drinking ever cause any of your friends’ problems? P: health wise yeah, quite a few of them di ed I: because of alcohol? P: yeah Participant’s friends Oh for hockey I was in a team but we used or co - workers to do all kinds of crazy stuff. Dirt bike, you know you wipe out. I’m sure there’s been a involved in risky activities few times I smacked my head. Yeah. Table 3. Level III Oppor ortuni unity ty Theme with sample Level II Cate tego gori ries and Level I Codes
Level III – Selective coding Opportunity theme Family history of I: “Okay and besides your dad, has alcoholism drinking ever been a problem for anybody else?” P: “Yep. My uncles – they were all alcoholics. My grandfather. And my mother’s brothers. Yeah I was surrounded. Growing up it was rampant.” Family members P: “My brother was a bad boy so involved in risky there’s that… most of his friends I activities don’t hang out with because I’ll go to jail if I hang out with them.”
Level III – Selective coding Opportunity theme Participant’s P: “In the last 20 years, there’s friends or co- not many people I’ve met that workers abuse don’t, you know? I know there drugs or alcohol are, here and there, but no, most people I know do drugs .” Participant’s P: “Oh for hockey I was in a team friends or co- but we used to do all kinds of workers involved in crazy stuff. Dirt bike, you know risky activities you wipe out. I’m sure there’s been a few times I smacked my head. Yeah .”
Level III – Selective coding Risk and Opportunity themes RISK theme - ‘Stumblers’ • Participants that are more vulnerable to fall-based TBI due to internal vulnerabilities and external situations. OPPORTUNITY theme - ‘Tumblers’ • Participants that played an active role in their fall-based TBI through their involvement in risky and/or delinquent behaviours. 17
Two pathways to fall-based injury: ‘Stumblers’ vs. ‘Tumblers’ ‘Stumblers’ ‘Tumblers’ Stumblers played a passive In contrast, Tumblers played role in their TBI injury event. an active role in their TBI injury event i) Physical vulnerabilities i) Dispositional influences ii) Situational influences ii) Family influences iii) Psychological vulnerabilities iii) Peer influences 18
Family and Peer influences Social Learning Theory (SLT): behaviours are learned by observing the social environment. A child learns behaviours through modeling processes early in development. SLT suggests that youth learn to be violent by observing the behaviour of intimate primary groups, such as family and peers. 19
The life course perspective and later TBI The life course perspective focuses on the social organization of lives by positing the concept of trajectories . A ‘ cumulation of disadvantages’ . Earlier family conflict and delinquent peer relationships can lead to other negative events and transitions in an individual’s life . These consequences, in turn, can lead to actively making riskier choices – contributing to these individuals’ TBI event later in life. 20
Conclusions ▪ For a subset of our participants – the active fallers termed Tumblers – early personal history played an important role in the precipitation of later injury. Their life course trajectories were altered by early psychosocial influences leading to increased involvement in substance abuse and risky activities -- which ultimately contributed to their TBI event. 21
Prevention Effective prevention lies in reducing psychosocial risk factors in many domains: 1) Reduce Media Violence Adolescents have reported committing homicides to impress peers or be on TV (Kashani, Darby, Allan, Hartke, & Reid,1997). 2) Limit Youth Access to Drugs and Alcohol Stricter national laws, harsher penalties on local businesses (e.g., liquor stores that sell alcohol to minors). 3) Involve Schools Teachers and school counsellors can assist mental health professionals in early identification. 22
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