The Translational Research Center for TBI and Stress Disorders (TRACTS) National Network TBI Center at the VA Boston Healthcare System. TRACTS has been competitively funded by the Veterans Administration Rehabilitation Research & Development service that is committed to conducting the highest quality research aimed at understanding the unique problems faced by our nation's post-9/11 Veterans.
Mild Traumatic Brain Injury (mTBI) is a relatively common injury of OEF/OIF/OND, yet its identification and diagnosis is controversial and fraught with challenges. Diagnosis of military-related mTBI in Veterans is complex and unique from the diagnosis of civilian acquired brain injuries in a number of ways. This is due to the novel mechanism of injury (exposure to blast(s) such as an improvised explosive device or IED), the frequent co-occurrence of head injury and psychological trauma during the chaos of combat that make the determination of altered mental status difficult, and the difficulty obtaining in-theater documentation of symptoms at the time of injury for determining the presence or absence of mTBI. The detection of TBI, and mTBI in particular, in returning Veterans is thus primarily reliant on self-report of a historical event, which often occurs in the context of a military trauma.
One of the overarching goals of TRACTS is to promote multidisciplinary research that will lead to innovations in the diagnosis and treatment of the complex issues presented by the growing population of Veterans who suffer the consequences of mTBI occurring in the context of stress-related disorders. Toward this end, a gold standard for the assessment of mTBI specific to Veterans was needed in the field. For these reasons, we developed the Boston Assessment of Traumatic Brain Injury- Lifetime (BAT-L) (Fortier et al., 2014). The BAT-L is the first validated post-combat semi-structured clinical interview to characterize head injuries and diagnose TBIs throughout the lifespan. Guidelines for establishing a timeline for alteration of mental status, posttraumatic amnesia, and loss of consciousness, the forensic approach to the interview, and diagnostic categories were all refined over time as the distinctive experiences of post-9/11 Veterans were realized. The BAT-L, unlike existing TBI interviews, includes detailed assessment of blast exposure and blast-related TBI, evaluates TBIs acquired throughout a veteran's lifetime, and includes specific probes targeting the unique experiences of this cohort of Veterans in an effort to help guide the examiner assess the physiological disruption of consciousness in the context of co-occurring traumatic events. TBI is assessed during 3 time epochs: (1) prior to military service (Pre-Military), (2) during active military training and duties (Military: blast-related & other mechanism(s) during combat, training, or other activities during active duty), and (3) after returning stateside (Post-Deployment). The three most severe injuries in each epoch are evaluated.
Fortier, C.B., Amick, M.A., Grande, L.J., McGlynn, S., Kenna, A., Morra, L., Clark, A., Milberg, W.P., and McGlinchey, R.E. (2014). The Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) Semi-structured Interview: Evidence of Research Utility and Validity. The Journal of Head Trauma Rehabilitation. 29(1), 89-98. PMC3997066.
We have also compared the BAT-L diagnosis of military TBI to the four-item VA TBI Screen as well as the clinical Polytrauma Service using the Comprehensive TBI Evaluation (CTBIE). As a result of these findings, we have provided suggestions for how to improve the VA clinical screen and the CTBIE. We believe future work is needed to establish a more reliable and valid method for identifying military mTBI that can be utilized by VA both for the care of our Veterans and for appropriate distribution of benefits and are working to achieve this goal.
Fortier, C.B., Amick, M.A., Kenna, A., Milberg, W.P., and McGlinchey, R.E. (2015). Correspondence of the Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) clinical interview and the VA TBI Screen. The Journal of Head Trauma Rehabilitation. 30(1): E1-7.
Radigan, L., McGlinchey R., Milberg W.P., Fortier C.B. (2017). Correspondence of the Boston Assessment of Traumatic Brain Injury-Lifetime (BAT-L) and the VA Comprehensive TBI Evaluation (CTBIE). The Journal of Head Trauma Rehabilitation. Nov 29 (ePub ahead of print). DOI: 10.1097/HTR.0000000000000361.
The BAT-L is designed to be used by doctoral level neuropsychologists or other comparably trained professionals (e.g., neuropsychology graduate students, fellows or clinical psychologists with supervision of a licensed neuropsychologist) and was validated as a consensus diagnostic instrument (Fortier et al., 2014). It was created for use in a research setting where detailed information regarding TBI incidence and severity is necessary. The instrument guides the examiner in gathering necessary information from Veterans and service members about the three worst TBIs for each category of injury (military blast, military other, pre-military, and post-military). Information is reviewed by a TBI diagnostic consensus team consisting of at least three doctoral-level psychologists, including at least one neuropsychologist. The consensus approach is integral to the instrument. If used without a consensus team, review of selected cases is suggested to assure a consistent diagnostic approach. It may be used both independently as well as part of a larger clinical interview.
The BAT-L is available for free public download and is being used by clinicians and researchers both locally and nationally. Variations of the interview for civilians and for the screening of TBI have also been developed. More recently, per consultation with Rehab R&D, the interview has been augmented to capture sub-acute exposure to blast and blunt injuries. The instrument has over 100 citations to date.
We provide consultation on the use of the BAT-L for Principal Investigators requiring a standardized, validated assessment of TBI, as well as training in administration of the interview. Trainings are performed on an as needed basis currently as new grants are funded and PI’s requests training for staff are received. Efforts to further standardize training including development of training materials and learning courses within VA and a complete manual are ongoing.
Boston Assessment of Traumatic Brain Injury-Lifetime/Intimate Partner Violence
In a recent publication from The Journal of Head Trauma Rehabilitation we report the validation of the Boston Assessment of TBI–Lifetime (BAT-L) interview specifically for female survivors of intimate partner violence (IPV) and report prevalence of head injury in 51 female survivors of IPV. Correspondence between the BAT-L/IPV and the OSU-TBI-ID score was excellent. On the BAT-L/IPV, over one third (35.3%) of IPV survivors reported TBI secondary to an IPV-related assault; 76.5% reported IPV subconcussive head injury; 31.4% reported attempted strangulation; 37.3% reported non-IPV TBI. The BAT-L is the first validated instrument to diagnose traumatic brain injuries (TBIs) throughout the lifespan for female IPV survivors. Prevalence of TBI was frequent; subconcussive head injury was pervasive. Greater awareness for head injury risk and increased diagnostic specificity of TBI in IPV survivors is needed.
Fortier, CB, Beck, BM, Werner, KB, Iverson, KM, Kim, S, Currao, A, Fonda, JR, Galovski, TE. (2021). The Boston Assessment of Traumatic Brain Injury–Lifetime (BAT-L/IPV) semistructured interview for assessment of TBI and subconcussive injury among female survivors of intimate partner violence: Evidence of research utility and validity. The Journal of Head Trauma Rehabilitation. DOI: 10.1097/HTR.0000000000000700.
Boston Assessment of Traumaic Brain Injury-Lifetime Brief
Our team is currently validating a brief self report version of the BAT-L that can be completed electronically or on paper. This abbreviated version aims to increase the accessibility of the BAT-L and reduce the time burden required to complete the assessment.
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