J Head Trauma Rehabil. 2014 Nov-Dec;29(6):479-89.

Screening for traumatic brain injury: findings and public health implications.


Dams-OʼConnor K1, Cantor JB, Brown M, Dijkers MP, Spielman LA, Gordon WA.

1Icahn School of Medicine at Mount Sinai, Department of Rehabilitation Medicine , New York, NY 10029, USA.



Objective: To provide an overview of a series of projects that used a structured self-report screening tool in diverse settings and samples to screen for lifetime history of traumatic brain injury (TBI).

Setting: Diverse community settings.

Participants: Homeless persons (n=111), individuals with HIV seeking vocational rehabilitation (n=173), youth in the juvenile justice system (n=271), public schoolchildren (n=174), substance users (n=845), intercollegiate athletes (n=90), and community-based samples (n=396).

Design: Cross-sectional.

Main Measure: Brain Injury Screening Questionnaire (BISQ).

Results: Screening using the BISQ finds that 27-54% of those in high-risk populations report a history of TBI with chronic symptoms. Associations between TBI and social, academic, or other problems are evident in several studies. In non-high-risk community samples, 9-12% of individuals report TBI with chronic symptoms.

Conclusion: Systematic TBI screening can be implemented efficiently and inexpensively in a variety of settings. Lifetime TBI history data gathered using a structured self-report instrument can augment existing estimates of the prevalence of TBI, both as an acute event and as a chronic condition. Identification of individuals with TBI can facilitate primary prevention efforts, such as reducing risk for re-injury in high-risk groups, and provide access to appropriate interventions that can reduce the personal and societal costs of TBI (tertiary prevention).

PMID: 25370440



Traumatic brain injury (TBI) occurs when an external force to the head disrupts normal brain functioning.1 The critical elements of this definition are: (1) a blow to the head and (2) altered mental status (loss of consciousness or a feeling of being dazed and confused). A TBI or “TBI event” can result from blunt force to the head, penetrating injury, whiplash, or blast exposure. The consequences of TBI can range from mild transient symptoms (e.g., headache, confusion) to significant lifelong impairments in cognitive functioning, behavior, mood, and physical functioning. Not all TBI events have lasting consequences, but those that do can be referred to as “chronic TBI”.

Obtaining an accurate estimate of the incidence and prevalence of TBI in the United States is a major challenge. When we rely on health system encounters and TBI-related deaths to estimate the number of individuals who sustain a TBI each year, people who do not seek medical care (whether in an emergency department or physicians’ office) and those whose TBI is not indicated in the medical record are not counted.


Systematic Screening for TBI Events and Chronic TBI: a Public Health Responsibility

For individuals with lasting symptoms (chronic TBI), it is important to recognize the etiology of these symptoms so the person can receive appropriate treatment and symptom management. High rates of TBI are seen in settings like homeless shelters, prison systems, and vocational rehabilitation facilities (see below), suggesting that untreated TBI-related symptoms may have played a role in these poor outcomes. However, screening for and recording TBI events that do NOT result in lasting symptoms can also be important. Evidence suggests that a history of single and multiple TBI events may be associated with cognitive problems later in life. 2-5 It is well known that a history of TBI increases the risk for re-injury, so recording prior TBI events can allow athletes to make informed decisions about risk tolerance. Despite the importance of documenting TBI history across multiple contexts, screening for lifetime history of TBI is rarely included in routine health care visits, athlete pre-season physicals, or research projects investigating cognitive outcomes across the lifespan.


Methods for TBI Screening

Structured self-report screening tools is increasingly recognized as the best way to estimate TBI incidence and chronic TBI prevalence.10-12 The Brain Injury Screening Questionnaire (BISQ) was developed to document lifetime history of TBI by asking respondents whether they have ever experienced a blow to the head in 19 specific situations that serve as recall cues. For every event endorsed, the informant is asked if s/he experienced either a loss of consciousness or a period of being dazed and confused and, if so, for how long. The BISQ also queries the presence of current physical, emotional, and behavioral symptoms that can be used to characterize transient or chronic symptoms after brain injury.14-17

The BISQ has been used by researchers at the Brain Injury Research Center of Mount Sinai (BIRC-MS) and colleagues across the world. Table 1 below illustrates some of the samples and settings in which the BISQ has been used. In addition to highlighting the prevalence of unidentified TBI in some settings, these projects illustrate the feasibility of systematic TBI screening.


Table 1.

 Description of Sample   


Report of blow to the head (%) Report of a TBI event (%) Report of a Chronic TBI(%)   


Urban public school children 174 N/A 44% 10% None of the children had been recognized by the school district as having had a TBI. 80% of children with Chronic TBI showed impaired performance on 2 or more cognitive tests 18
Adult volunteers self-identified as “healthy controls” in a TBI study 396 N/A 12% N/A Individuals who reported 1 or more previously undiagnosed TBI events performed similarly to individuals with known TBI on objective cognitive tests 19
Adults seeking substance abuse treatment at state facilities 845 76%: 1+ blow69%: 2+ blows

27%: 4+ blows

16% 10+

N/A 54% Treatment seeking individuals with a history of Chronic TBI were more likely than those without TBI history to have prior substance abuse treatment episodes and DSM-IV disorders. 20
Adolescents incarcerated through state juvenile justice system 271 N/A 76% 29% Unpublished data; study is ongoing
Adults with HIV seeking Vocational rehabilitation services 173 74%: 1+ blow60% 2+ blows (27% sustained a TBI with LOC>20 min) N/A Adults with HIV who screened positive for TBI reported twice as many cognitive, physical, and mood symptoms as those with no TBI history 6
Adult males at an urban homeless shelter in Canada 111 N/A 77% 45% 87% of those who screened positive for TBI reported that the injury occurred before the onset of homelessness 7
College athletes at an urban university 90 45% (range: 1-14 blows) N/A N/A 12 out of 73 (16%) athletes who denied concussion history on a single-item screen reported TBI with LOC lasting several minutes-1 hour on the BISQ 21


The data presented in Table 1 demonstrate that TBI events and Chronic TBI are often un-identified, and rates of undiagnosed and untreated TBI are unacceptably high in many settings. Other studies that have used structured TBI screening tools in homeless shelters, vocational rehabilitation services, mental health clinics, and among victims of domestic violence report similar findings.13,22-23 Individuals with chronic TBI have unique treatment needs and comorbid clinical diagnoses that may necessitate tailored interventions that address the cognitive and behavioral deficits that commonly result from TBI.8

Systematic TBI screening is essential for accurate injury surveillance, prevention of secondary and tertiary consequences of TBI, and facilitating access to appropriate interventions for individuals with lasting symptoms. A growing body of research supports a range of effective interventions, even for individuals who are many years post-injury.8,9 Brief but comprehensive screening tools are also needed in research, particularly cognitive aging research, given the potential impact of TBI history on cognitive and functional outcomes as we age. Exclusion of TBI history from these studies precludes a full understanding of the factors that cognitive aging.

Given the public health implications of unidentified TBI, the best available tools should be used for comprehensive screening. It is recommended that a structured TBI screening tools that comprehensively query lifetime history of injury events (of any severity) using plain and understandable language, and that also query about current symptomatology that may be used to distinguish TBI-related consequences from nonspecific symptoms and make appropriate clinical referrals.



Under-estimation of the rates of TBI and TBI-related disability has important personal and public health consequences. For individuals, screening for TBI events and chronic TBI can open the door for treatment and/or accommodations; and accurate documentation of TBI history in the medical or academic record can inform health-related decision making, at the time of screening or years down the road. Systematic TBI screening allows for more accurate estimates of the prevalence of TBI events and chronic TBI. This information is needed in studies of aging and cognitive decline, to support the development of educational efforts for clinicians and other medical and social service professionals, to support the expansion of accessible primary and secondary prevention opportunities for people with TBI, and ultimately to decrease the personal and social costs of TBI.



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DK FIG3Contact:

Kristen Dams-O’Connor, Ph.D.

Associate Professor

Co-Director, Brain Injury Research Center

Research Director, Mount Sinai Injury Control Research Center

Mount Sinai School of Medicine

Department of Rehabilitation Medicine

(212) 241-7587 p

(212) 241-0137 f


Acknowledgements: The compilation of this work was supported in part by Grant No. 1R49CE001171 from the Centers for Disease Control and Prevention, to Icahn School of Medicine at Mount Sinai, New York City. We would like to acknowledge Mary Hibbard, Ph.D.’s contributions to the development of the BISQ.

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