Educational and employment outcomes associated with childhood traumatic brain injury in Scotland: a population-based record-linkage cohort study

Visnick, M. J., Pell, J. P. , Mackay, D. F. , Clark, D., King, A. and Fleming, M. (2023) Educational and employment outcomes associated with childhood traumatic brain injury in Scotland: a population-based record-linkage cohort study. PLoS Medicine, 20(3), e1004204. (doi: 10.1371/journal.pmed.1004204) (PMID:36976782) (PMCID:PMC10047529)

Abstract

Background: Traumatic brain injury (TBI) is a leading cause of death and disability among young children and adolescents and the effects can be lifelong and wide-reaching. Although there have been numerous studies to evaluate the impact of childhood head injury on educational outcomes, few large-scale studies have been conducted, and previous research has been limited by issues of attrition, methodological inconsistencies, and selection bias. We aim to compare the educational and employment outcomes of Scottish schoolchildren previously hospitalised for TBI with their peers. Methods and findings: A retrospective, record-linkage population cohort study was conducted using linkage of health and education administrative records. The cohort comprised all 766,244 singleton children born in Scotland and aged between 4 and 18 years who attended Scottish schools at some point between 2009 and 2013. Outcomes included special educational need (SEN), examination attainment, school absence and exclusion, and unemployment. The mean length of follow up from first head injury varied by outcome measure; 9.44 years for assessment of SEN and 9.53, 12.70, and 13.74 years for absenteeism and exclusion, attainment, and unemployment, respectively. Logistic regression models and generalised estimating equation (GEE) models were run unadjusted and then adjusted for sociodemographic and maternity confounders. Of the 766,244 children in the cohort, 4,788 (0.6%) had a history of hospitalisation for TBI. The mean age at first head injury admission was 3.73 years (median = 1.77 years). Following adjustment for potential confounders, previous TBI was associated with SEN (OR 1.28, CI 1.18 to 1.39, p < 0.001), absenteeism (IRR 1.09, CI 1.06 to 1.12, p < 0.001), exclusion (IRR 1.33, CI 1.15 to 1.55, p < 0.001), and low attainment (OR 1.30, CI 1.11 to 1.51, p < 0.001). The average age on leaving school was 17.14 (median = 17.37) years among children with a TBI and 17.19 (median = 17.43) among peers. Among children previously admitted for a TBI, 336 (12.2%) left school before age 16 years compared with 21,941 (10.2%) of those not admitted for TBI. There was no significant association with unemployment 6 months after leaving school (OR 1.03, CI 0.92 to 1.16, p = 0.61). Excluding hospitalisations coded as concussion strengthened the associations. We were not able to investigate age at injury for all outcomes. For TBI occurring before school age, it was impossible to be certain that SEN had not predated the TBI. Therefore, potential reverse causation was a limitation for this outcome. Conclusions: Childhood TBI, sufficiently severe to warrant hospitalisation, was associated with a range of adverse educational outcomes. These findings reinforce the importance of preventing TBI where possible. Where not possible, children with a history of TBI should be supported to minimise the adverse impacts on their education.

• Item Type: Articles
• Additional Information: The study was sponsored by Health Data Research UK (to MF) (grant reference number MR/S003800/1). Health Data Research UK is a joint investment led by the Medical Research Council, together with the National Institute for Health Research (England), the Chief Scientist Office (Scotland), Health and Care Research Wales, Health and Social Care Research and Development Division (Public Health Agency, Northern Ireland), the Engineering and Physical Sciences Research Council, the Economic and Social Research Council, the British Heart Foundation and Wellcome.
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Pell, Professor Jill and Fleming, Dr Michael and Mackay, Professor Daniel

Creator Roles

Pell, J. P.: Methodology, Supervision, Writing – original draft, Writing – review and editing
Mackay, D. F.: Methodology, Writing – review and editing
Fleming, M.: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review and editing

• Authors: Visnick, M. J., Pell, J. P., Mackay, D. F., Clark, D., King, A., and Fleming, M.
• College/School: College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Public Health
• Journal Name: PLoS Medicine
• Publisher: Public Library of Science
• ISSN: 1549-1277
• ISSN (Online): 1549-1676
• Published Online: 28 March 2023
• Copyright Holders: Copyright © 2023 Visnick et al.
• First Published: First published in PLoS Medicine 20(3): e1004204
• Publisher Policy: Reproduced under a Creative Commons License

Project Code	Award No	Project Name	Principal Investigator	Funder's Name	Funder Ref	Lead Dept
303197		Linking education and health data together to study relationships between various health factors and children's educational and health outcomes	Jill Pell	Medical Research Council (MRC)	MR/S003800/1	HW - Public Health