The BATL is an extensively validated and widely used semi-structured clinical interview designed to diagnose traumatic brain injury (TBI) across the lifespan in post-9/11 military veterans with particular attention to blast-related injury. The BATL uses a forensic approach designed to differentiate clinical symptoms of TBI (e.g., altered mental status, posttraumatic amnesia, loss of consciousness) from other common physiological and psychological reactions to head injury and trauma. The BATL has been updated to: (1) incorporate the most up-to-date TBI diagnostic criteria (American Congress of Rehabilitation Medicine [ACRM] 2023; Veterans Affairs [VA]/Department of Defense [DoD] Clinical Practice Guidelines); (2) assess for subconcussive repetitive head injury risk from blast and blunt force trauma; and (3) offer a flexible battery approach to allow clinicians and researchers to select modules specifically tailored to high-risk TBI contexts (e.g., military, civilian, intimate partner violence, and sports). These changes will expand the breadth of context in which the BATL can be utilized and reduce time burden for administering the BATL interview based on research and clinical goals. Prevalence of injury using the BATL-2 will be presented for a large cohort of U.S. Veterans from the Translational Research Center for TBI and Stress Disorders (TRACTS), a 15-year, 2-site VA Rehabilitation Research and Development National Center for TBI Research. The sample consists of 878 combat exposed post-9/11 Veterans, 90% male, 71% Non-Hispanic White, with mean age of 35 (SD = 9.2) and mean education level of 14 years (SD = 2.2). On average, they served in 1.68 tours (SD = 1.1) for 16 months (SD = 11.2) and completed the BATL interview 70 months (SD = 52.0) after returning from their last deployment. TBI was highly prevalent, as 74% (n = 645) sustained a TBI in their lifetime and 54% (n = 474) sustained a TBI during military service. Additionally, 32% (n = 284) of Veterans sustained a blast force military TBI, while 33% (n = 290) sustained a blunt force military TBI. Data on subconcussive blast and blunt exposure were collected in a subset of 228 of these veterans, revealing that 60% (n = 137) reported exposure to subconcussive blast events and 43% (n = 99) reported exposure to subconcussive blunt force trauma. Results of an initial psychometric evaluation of BATL-2 scores in 2 samples of military veterans will be presented. Overall, results indicate that the BATL-2 is a psychometrically sound measure of both ACRM 2023 and VA/DoD TBI diagnosis and symptom severity. Importantly, the BATL-2 strongly corresponds with the BATL-1, suggesting the BATL-2 provides continuity in evidence-based assessment of TBI with the transition to ACRM 2023 criteria.

BACKGROUND: Post-9/11 U.S. Veterans are clinically complex with multiple co-occurring health conditions contributing to morbidity/mortality and decreased quality of life. Traumatic Brain Injury (TBI) diagnosis can worsen these outcomes. STEP-Home is a cognitive-behavioral transdiagnostic intervention for TBI and common comorbidities.

OBJECTIVES: Determine if STEP-Home improves anger and impulse control, frontal system function, civilian readjustment, neurobehavioral symptoms, and work/life functioning in post-9/11 Veterans. TBI may influence Veterans’ ability to learn core skills and, thus, impact response to treatment. Treatment outcomes for Veterans with and without TBI will be explored.

METHODS: A total of 56 (39M/17F; mean age = 40) post-9/11 Veterans with high rates of psychiatric comorbidity, with and without TBI received 12 weeks of the STEP-Home transdiagnostic group intervention. STEP-Home sessions teach cognitive behavioral skills relevant across diagnostic category, including Problem Solving (PS) and Emotional Regulation (ER). These skills are integrated and applied across Veteran-specific content areas to assist in community reintegration and functioning. Assessments at baseline, posttreatment (12 weeks), and follow-up (24 weeks) included: State-Trait Anger Expression Inventory 2 (STAXI-2); Military to Civilian Questionnaire (M2CQ); Post-Deployment Readjustment Inventory (PDRI); Frontal Systems Behavioral Scale (FrSBe); Neurobehavioral Symptom Inventory (NSI); World Health Disability Scale (WHODAS); PTSD Checklist (PCL-5); Depression Anxiety and Stress Scale (DASS-21).

RESULTS: STEP-Home significantly improved anger expression (STAXI-2 p = .0320), inhibitory control (FrSBe p =.0001), and reintegration status (MC2Q p=.0001; PDRI p =.0097) posttreatment. Similar improvements were seen in neurobehavioral symptoms, work/life functioning, PTSD, depression, and stress (p’s < .01). Treatment gains were maintained at follow-up (p < .001). Treatment response did not differ by TBI status.

CONCLUSIONS: STEP-Home teaches Veterans cognitive-behavioral skills to improve anger, impulse control, executive functioning, reintegration, and work/life functioning. STEP-Home is equally as effective for participants with and without TBI. There was no effect of TBI status on treatment maintenance over time. This is critical given TBI prevalence among post-9/11 Veterans and the need for additional palatable treatment options.

BACKGROUND: Insomnia disorder and obstructive sleep apnea (OSA) are common co-morbidities among Veterans with mild traumatic brain injury (mTBI). Clinical practice guidelines include recommendations for evidence-based interventions that effectively treat insomnia (e.g., cognitive behavioral therapy for insomnia) and OSA (e.g., positive airway pressure), but clinical benefit depends on Veterans’ consistent adherence to treatment. While adherence to interventions for insomnia disorder and OSA are challenging for many patients, Veterans with mTBI may experience unique barriers worthy of consideration. However, such barriers to adherence are poorly understood in this population. The purpose of this study was to understand factors influencing adherence to recommended treatment for insomnia and OSA among Veterans with mTBI.

METHOD: Semi-structured interviews (n=49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach.

RESULTS: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., mTBI sequalae), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support).

CONCLUSIONS: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population, ensuring they sustain treatment engagement and reap the desired clinical benefits.

BACKGROUND: Traumatic brain injury (TBI) and problems related to substance use (SU) commonly co-occur in the military and veteran population. Individuals with co-occurring TBI and SU (TBI + SU) are at greater risk for multiple negative outcomes, including death by suicide. Intensive interdisciplinary treatment for TBI can support improvement in symptoms and quality of life, but individuals using substances are often denied access to TBI treatment until they maintain lengthy periods of abstinence.

METHOD: Our interdisciplinary treatment program for military TBI has undertaken efforts to: 1) characterize substance use among those seeking treatment, 2) develop and implement an approach to assessment, integrated treatment, and follow-up support for TBI + SU, and 3) evaluate access and treatment outcomes. We categorized all individuals who inquired about or applied for care within a 26-month period according to level of care accessed or reason for no access. Among 160 participants consented, 101 started intensive outpatient treatment (IOP) for TBI and completed measures related to substance use in addition to assessments for clinical care. This group was divided based on scores on SU-related measures into TBI (n = 59) and TBI + SU (n = 42) groups. Mixed ANOVAs were conducted to determine effects of treatment and group membership on TBI symptoms and consequences related to SU, captured by scores on the Neurobehavioral Symptom Inventory (NSI) and the Short Inventory of Problems - Revised (SIP-R).

RESULTS: An integrated care model of TBI treatment for clients with co-occurring SU was developed by modifying programing and adding resources to help those with TBI + SU safely and effectively participate in interdisciplinary TBI care. There was a significant main effect of treatment (F(1, 100) = 64.37, p < 0.001) on NSI scores, with decreased symptoms at discharge across both groups. Between-group differences were not significant, indicating that groups had similar NSI score reductions with treatment. There was a significant main effect of treatment F(1, 100) = 18.45, p < 0.001 and group membership F(1, 100) = 21.41, p < 0.001 and a group x time interaction F(1, 100) = 9.34, p = 0.003 on SIP-R scores, showing higher SIP-R scores among the TBI + SU group prior to treatment and greater reductions in SIP-R scores for the TBI + SU group with treatment. Among research participants who engaged in IOP treatment during this timeframe (n = 101), four were early discharges, and one of these instances was related to substance use.

CONCLUSIONS: This programming has enabled entry and retention in treatment for many clients with TBI + SU. Initial results related to treatment outcomes are promising, with follow-up data collection ongoing. Lessons from these efforts may inform programming in other interdisciplinary programs treating individuals with TBI + SU.

OBJECTIVES: To examine aggression, executive functioning, and recidivism risk in a sample of incarcerated males with traumatic brain injury (TBI).

METHODS: Cross-sectional study including 89 males with TBI. Data was collected as a baseline assessment for a clinical trial. Participants were recruited within 12 months of anticipated release date.

MEASURES: The Aggression Questionnaire (AQ) total score was used to assess aggression in addition to the verbal and physical aggression subscales. The Behavioral Rating Inventory of Executive Function-Adult Version (BRIEF-A) was used to measure self-regulation. The Level of Service Inventory–Revised (LSI-R) is a structured interview for correctional populations used to predict recidivism risk, adjustment, and institutional misconduct using criminal history, education, employment, finances, relationships, alcohol and drug problems, emotional/personal factors, and attitudes.

RESULTS: The majority of the sample (59%) reported high-very high aggression (T-scores = 60) on the total AQ (mean T-score = 59.93, 95% CI [57.95, 61.91]). 54% of the sample reported high-very high verbal aggression (mean T-score = 56.55, 95% CI [54.58, 58.53]) and 51% reported high-very high physical aggression (mean T-score = 58.89, 95% CI [56.40, 61.39]). Scores on the BRIEF-A were also clinically significant with a mean Global Executive Composite (GEC) T-score of 68.80 (95% CI: [65.95, 71.66]) indicating significant difficulty with executive functioning. The Behavioral Regulation Index (BRI) was also elevated (mean T-score = 69.70, 95% CI [67.07, 72.33]) suggesting increased deficits related to inhibiting impulsive responses and controlling emotions and behavior. The Metacognition Index (MI) was also above average (mean T-score = 66.03, 95% CI [62.90, 69.16]) suggesting impairments related to self-management of tasks and self-monitoring. The sample also showed an increased recidivism risk with a mean LSI-R score of 29.77 (moderate risk), 95% CI [28.26, 31.27] and the majority of the sample (86%) scoring in the moderate or higher risk categories. LSI-R risk scores were significantly correlated with AQ total aggression (r =.404; p<.001) and physical aggression (r=.393; p<.001), but not verbal aggression (r = .081; p=.498). LSI-R scores were also significantly correlated with executive function impairment: GEC (r =.489; p<.0001), BRI (r =.494; p<.0001), and MI (r =.446; p<.0001).

CONCLUSIONS: Aggression and executive dysfunction are common consequences of TBI that are believed to contribute to high incarceration and recidivism rates. The results from this sample suggest that incarcerated individuals with TBI are more likely to display elevated levels of aggression as well as suffer from executive dysfunction. Furthermore, the significant linear relationships between aggression (especially physical) and executive functioning with recidivism risk highlight the need for interventions designed to address and mitigate these deficits in individuals with TBI within the corrections environment as a strategy to potentially reduce recidivism and reincarceration.