Objective Adolescence is recognised as a risk period for offending and head injury (HI), with higher rates of HI found in the young offender (YO) population compared to the general population. Drug and alcohol use has also been associated with increased risk of offending. This study aims to explore the relationships between HI, Post-concussion symptoms (PCS), reactive and proactive aggression, and offending behaviour in YOs, whilst considering the effects of drug and alcohol use on these relationships. Participants A sample of ninety eight males was recruited from a Young Offender Institute: the age range was 16-18 years of age with an average age of 17. Design A between subjects cross sectional design was employed. Participants were recruited using an opportunistic sampling strategy. Main Measures Self-rated/report measures of: HI, Post-Concussion Symptoms (Adapted Rivermead Post-Concussion Symptom Questionnaire), Aggression (Reactive-Proactive Scale), criminal histories, and drug and alcohol history. Results HI was reported by 73.5% of the overall sample, with 61.1% reporting a “knock out”. Frequency and severity of HI was associated with significantly higher PCS scores. Examination of covariate- drug and alcohol use did not affect these relationships. PCS were a significant predictor of reactive aggression, total number of convictions and number of previous violent convictions. However, dosage of HI (severity and frequency) was not a significant predictor of reactive aggression or criminal profiles. Conclusions There appears to be a dose-response effect of severity and frequency of HI on PCS, with PCS predicting reactive aggression. Such symptoms may compromise functions and lead to increased aggression. This highlights the need for better screening and interventions for HI and on-going symptoms in YOs.

Background: Heading is an important part of soccer, yet recent research has indicated that cumulative effects of repetitive heading may cause sub-concussive injury (Koerte et al., 2015). Objective: The current study aimed to prospectively investigate the effects of repetitive, intentional heading in soccer practice on brain structure and cognitive function using a within-subjects design. Methods: Participants included 11 soccer players (M=20.09, SD=2.88) that were examined immediately pre and post heading practice. Magnetic resonance imaging data were acquired on a 3T GE Scanner with diffusion tensor imaging (DTI). Behavioural measures were also completed pre and post soccer heading and included the Sideline Concussion Assessment Tool 3 (SCAT-3) and several short-computerized executive function tasks. An accelerometer was used to measure the force of the impact during soccer heading. Heart-rate data was collected on Polar Monitors. DTI analyses were completed using FSL’s Tract Based Spatial Statistics to examine changes in both fractional anisotropy (FA) and mean diffusivity (MD) due to heading the soccer ball. The current study investigated microstructural changes and behavioural performance in young soccer players. Heart rate variability data were not available for analyses due to technical difficulties. Results: Heading impacts were not greater than 10g. At this level of impact, there were no significant pre-post heading differences in either FA or MD. There were no significant differences between pre and post heading in the three behavioural tasks. Additionally, there were no significant differences in SCAT-3 scores between groups. Some practice effects were demonstrated in one behavioural task and a section of the SCAT-3. Conclusion: The current work shows initial evidence that repetitive heading in soccer in a practice setting does not cause changes in brain structure or cognitive function. Future research should investigate heading in games and sex differences with a greater sample size. / Graduate

Brain injury has become the signature wound of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF), based on estimates that 10% of all returning warriors may have sustained a brain injury secondary to blast exposures. Traumatic brain injury (TBI) affects the lives of survivors as well as their loved ones, and the consequences associated with TBI inform well-being for all involved. This research uses grounded theory to understand contributing factors of female spousal well-being, specifically the female partners of servicemen who have sustained mild to moderate traumatic brain injury (mMTBI) during combat in OIF/OEF. Through the use of sequential interviews and transcript analysis, the Combat Related Traumatic Brain Injury (CoRTs) Model of Spousal Well-Being emerged illustrating the dynamic relationships among supports, role engagement, the process of redefining self, perceptions of personal empowerment and subjective wellbeing. Four key conclusions were identified from these findings: a) mMTBI affects the life of the surviving service member as well as the life of his partner, b) the myriad consequences of combat-related mMTBI on the female spouse prompted these women to engage in a journey of redefining self, c) communities of influence became the centerpiece from which participants could move forward with their lives or remain in their current state, and d) successful engagement in roles of choice provided study participants experiences from which to establish their new self, fostered perceptions of empowerment, and informed well-being. The CoRTs Model of Well-Being and conclusions provide a framework for future programming designed to target the needs of veterans and family members whose lives have been disrupted by brain injury sustained in combat. / Ph. D.

A complete understanding of the functional and structural impairments driving persistent post-concussive symptom (PCS) expression in approximately one-third of those who suffer from mild traumatic brain injury (mTBI) is essential for the development of effective treatment strategies and improving quality of life. While traditional outcome measures, such as neuropsychological testing and structural magnetic resonance imaging, are sensitive to the severe functional impairments and widespread tissue damage frequently seen after moderate-to-severe injuries, more advanced measures that are sensitive to the subtle changes in cognitive function and tissue microstructure that may underlie persistent PCS are necessary for the assessment of recovery from mTBI. Toward this end, the current study investigates the utility of eye-tracking analysis and high-definition fiber tractography (HDFT) as advanced measures of functional and microstructural outcome in 11 adults with chronic mTBI and varying levels of PCS (ages 20-60; mean time post-injury = 9.53 ± 6.74 years) in comparison to 10 healthy adults (ages 20-54). Performance on neuropsychological and eye-tracking tasks of processing speed, attention, and working memory, and HDFT-derived quantitative measures of the microstructural integrity of the forceps major, inferior fronto-occipital fasciculus, middle longitudinal fasciculus, and superior longitudinal fasciculus were compared between groups, and the results were used to define discriminatory functions for mTBI classification. The relationships between neuropsychological and eye-tracking measures of cognitive function and HDFT-derived measures of tract integrity were explored, as was the utility of these functional and structural measures for predicting persistent PCS in chronic mTBI. The results suggest that eye-tracking analysis may be more specific to cognitive impairments resulting from mTBI than neuropsychological testing, and HDFT is highly sensitive and specific to the subtle microstructural changes that persist chronically in this population. Furthermore, white matter integrity assessed using HDFT is more strongly associated with impairments in processing speed, attention, and memory indicated through eye-tracking analysis relative to performance on neuropsychological tests. Finally, although the predictive utility of eye-tracking and HDFT for the experience of persistent PCS was not demonstrated in the present sample, the possibility that these data are confounded by symptom exaggeration, comorbid mental health impairment, or lack of self-awareness for functional deficits cannot be ruled out, and future research using large, homogenous sample of mTBI is necessary to validate the present findings.

Le traumatisme craniocérébral léger (TCCL) s'accompagne d'une constellation de symptômes de nature variée, appelés symptômes post-commotionnels (SPC). La majorité des patients se rétablissent complètement et rapidement, à savoir dans le mois qui suit l'accident. Cependant, 10 à 20 % d'entre eux présentent un rétablissement prolongé avec des SPC persistants (SPCP), lesquels entravent la qualité de vie, l'intégration à la communauté et le retour aux activités. Pour la minorité de patients présentant des SPCP, il est donc nécessaire d'intervenir au-delà de la psychoéducation préventive aiguë recommandée par les guides de pratique. Or, il existe très peu d'interventions visant spécifiquement à outiller ces patients afin de diminuer les SPC et ainsi, accélérer le rétablissement. En effet, à l’heure actuelle, les interventions psychologiques et psychoéducatives développées spécifiquement pour la phase post-aiguë, qui prend place entre les phases aiguë (0-1 mois après le TCCL) et chronique (> 6 mois post-accident), sont particulièrement rares. Les quelques études existantes plaident en faveur d'une approche brève de quelques séances de psychoéducation et/ou de soutien. Cependant, il s'agit de données préliminaires et de nombreuses inconnues subsistent encore quant au format idéal (ex. : en personne vs par téléphone, individuel vs en groupe, nombre de séances, contenu précis). En outre, la pauvre qualité méthodologique des études complique significativement les interprétations possibles à ce sujet (ex. : absence de groupe contrôle, groupes non randomisés). L'objectif principal de cette thèse était donc de développer une nouvelle intervention de psychoéducation et de soutien destinée aux personnes en phase post-aiguë du rétablissement post-TCCL, et d’explorer sa faisabilité ainsi que son efficacité. L'objectif du premier article de la thèse (Chapitre 2) était de remédier à la pauvreté de la littérature en ce qui a trait, d'une part, à la description des protocoles d'intervention de psychoéducation et, d'autre part, relativement à leurs assises théoriques. Il avait donc pour objectif de présenter la démarche théorique et méthodologique associée au développement de l'intervention SAAM, un programme de quatre séances d'intervention individuelles d’une heure, données en personne, et visant chacune un type de SPC fréquent en phase post-aiguë : Sommeil/fatigue, Attention, Anxiété/humeur, Mémoire/organisation. Le programme offre de l'information au patient, le rassure sur son rétablissement et l'accompagne vers un retour graduel aux activités, en l'outillant à cet effet. Cette approche est ancrée dans un modèle théorique intégratif de persistance des symptômes (Hou et al., 2012), dont les composantes sont expliquées dans l'article. Celui-ci permet non seulement de mieux saisir les fondements théoriques associés à la création du nouvel outil d'intervention, mais en dévoile également son contenu. Il met donc en lumière une démarche qui s'inscrit parfaitement dans un effort de clarification et de transparence, essentiel au progrès de la recherche interventionnelle. Plus largement, ce travail permettra de faciliter la réplication scientifique et de soutenir le transfert de connaissances vers les milieux cliniques. Le deuxième article de la thèse (Chapitre 3) avait pour objectif d'estimer la faisabilité et d’explorer l'effet de l'intervention SAAM auprès de patients symptomatiques en phase post-aiguë de leur rétablissement. Une étude pilote d’essai contrôlé randomisé à deux groupes parallèles (expérimental, n = 13 et liste d'attente, n = 12) a permis de démontrer la faisabilité et la tolérance à l’intervention SAAM. Les données préliminaires suggèrent un effet de l’intervention sur la diminution des SPC en général. En ce qui a trait plus directement aux SPC visés par l'intervention SAAM, une amélioration des plaintes reliées aux symptômes dépressifs, à la fatigue et à la perception de la qualité du sommeil a été mise en évidence à la suite de l'intervention. Cependant, l’étude n'a pas montré d’effet bénéfique du programme SAAM en termes de plaintes somatiques ni de performance cognitive (attention, mémoire). De plus, aucun effet n'a été observé sur le plan de l'intégration à la communauté. Des analyses supplémentaires (Chapitre 4) suggèrent que l'intervention SAAM pourrait restaurer le besoin de compétence, un besoin psychologique fondamental intimement relié au bien-être des individus. Enfin, des analyses supplémentaires portant sur un questionnaire de satisfaction face à l'intervention confirment un haut taux de satisfaction des participants face à l'intervention, ce qui est de bon augure pour l'implémentation en milieux cliniques. Par son aspect novateur, son format standardisé bref et facilement accessible, ainsi que ses effets objectivés sur plusieurs SPCP particulièrement invalidants à la suite du TCCL, le programme d'intervention SAAM est prometteur. La portée clinique de cette thèse est donc particulièrement importante et est discutée, avec ses limites et les avenues de recherche futures, dans le dernier chapitre. Ces résultats soulignent l'importance de poursuivre la recherche dans le champ des interventions post-TCCL, afin d’outiller les cliniciens et d’offrir les meilleurs soins possibles aux patients ayant subi un TCCL. / Mild traumatic brain injury (mTBI) is accompanied by a constellation of manifestations known as post-concussive symptoms (PCS). The majority of patients recover completely and promptly, i.e. within one month of injury. However, 10-20 % experience prolonged recovery with persistent PCS (PPCS), which impact quality of life, community integration and resumption of activities. For the minority of patients who present PPCS, it is necessary to provide them with resources beyond the acute preventive psychoeducation recommended by practice guidelines. However, there are very few interventions available to reduce PCS and thus enhance recovery. To date, psychological and psychoeducational interventions developed specifically for the post-acute phase, which takes place between the acute (0-1 month after mTBI) and the chronic phase (> 6 months post-injury), are particularly rare. The scarce existing evidence suggests that the optimal intervention should be brief, including a few sessions of psychoeducation and/or counseling. Nevertheless, these are preliminary data and many open questions remain regarding the optimal format (e.g., in person vs. on the phone, individual vs. group, number of sessions, specific content). Moreover, the poor methodological quality of previous intervention studies significantly complicate interpretations (e.g., absence of control groups, non-randomized groups). The main objective of this thesis was therefore to develop and explore the feasibility and treatment effect of a novel psychoeducational and counseling intervention program for the post-acute phase after mTBI. The objective of the first article of the thesis (Chapter 2) was to overcome the paucity of work describing psychoeducational intervention protocols and their theoretical underpinnings. The article therefore aimed to present the theoretical and methodological approach associated with the development of the SAAM intervention. SAAM is a program including four 1-hour individual intervention sessions given in person, each targeting a type of common PCS in the post-acute phase: Sleep/fatigue, Attention, Anxiety/mood, Memory/organization. It informs the patient, provides reassurance about recovery, and supports the gradual resumption of activities by giving the patient the tools to do so. This approach is anchored in an integrative theoretical model of symptom persistence (Hou et al., 2012), the components of which are explained in the article. The latter provides a better understanding of the theoretical rationale behind the development of the SAAM intervention, and includes a detailed description of the protocol. The article is meant to align with efforts to clarify the theoretical underpinnings of the intervention program and enhance transparency in scientific reporting, an essential step in the advancement of interventional research. More broadly, this work will facilitate scientific replication and knowledge transfer in clinical settings. The second article (Chapter 3) aimed to estimate feasibility and explore the treatment effect of the SAAM intervention in symptomatic patients during the post-acute phase. A pilot randomized controlled trial with two parallel groups (experimental, n = 13 and wait list, n = 12) demonstrated the feasibility and tolerability of the intervention. Preliminary data suggest an effect of the intervention in reducing overall PCS. More specifically, regarding the PCS targeted by the SAAM intervention, an improvement in complaints related to depressive symptoms, fatigue, and sleep quality perception was observed post-intervention. However, the intervention failed to show a positive effect in addressing anxiety or somatic complaints, nor was it significantly impactful in improving cognitive performance (attention, memory). No effect was observed in terms of community integration either. Nonetheless, additional analyses (Chapter 4) suggest that SAAM intervention might restore the need for competence, a basic psychological need closely related to the individual's well-being. Finally, additional analyses pertaining to an intervention satisfaction questionnaire confirm that participants report a high level of satisfaction with the intervention, which bodes well for clinical implementation. The SAAM intervention holds promise because of its innovative aspect, its brief and easily accessible standardized format, and its demonstrated effects on several disabling PCS. The clinical significance of this thesis is notable and is discussed, along with study limitations and future avenues of research, in the final chapter. This work emphasizes the importance of pursuing research efforts in the field of post-mTBI interventions, in order to provide clinicians with the tools they need to offer the best possible care to patients who have sustained mTBI.