COMMUNITY SUPPORT
When the child with TBI is discharged from the hospital, it is almost certain that the child, at a minimum, will have a need for increased supervision. Ideally, the child will be transitioned back to school full time, but the family will need to care for that child when school is not in session. Community services become paramount in caring for these family units.
IN-HOME SERVICES
There are many reasons why additional support may be needed within the family home to care for the child with TBI. If the child is dependent for all aspects of care, personal care assistants (PCAs) or skilled nursing care may be necessary for a time. Even if the child is not dependent for mobility, marked behavioral changes in the child with TBI may warrant some of these services. Furthermore, if ongoing therapy services are needed to meet active rehabilitation goals, these therapies can sometimes be provided in the home setting. Social workers and case managers may be helpful, especially when poor family functioning is present. This is especially critical to attempt to offset the development of behavioral problems in these children status post-TBI (232).
OUT-OF-HOME SERVICES
The majority of children with TBI are discharged to home in the care of their families. Some children transition to medical foster placement, group homes, or skilled nursing facilities as an alternative living situation. In these circumstances, the children still need to have school services identified and accessed locally, as well as potential outpatient therapy services for their ongoing rehabilitation goals and needs.
PLANNING FOR LONG-TERM NEEDS
Ultimately, the child with a TBI becomes an adult with a remote TBI, and often ongoing services as well as resources are still needed. The time may come for the child who is dependent for all cares to require transition out of the home and into a long-term care facility or medical foster care placement. Resources are often limited in this regard, so early planning with the help of a social work team and perhaps legal consultation is appropriate. Vocational rehabilitation services should also be identified for these patients if appropriate. Often, the school system can be helpful in accessing these resources. The school may collaborate with local vocational services, independent living centers, community-based advocacy agencies, and other support systems to establish and coordinate a transition plan from the school to the community (231).
RETURNING TO SPORTS AND RECREATIONAL ACTIVITIES
Since sports and other recreational activities are typically an integral part of the childhood lifestyle, return to the community for children often involves planning for return to these activities.
For the child who has sustained a TBI, counseling the family on the safety of returning them to playing sports is challenging. This is partly due to a lack of evidence or guidelines in the rehabilitation literature. In recent years, better guidelines have become available for the management of return to play within sports after a child sustains a concussion during sporting activities (see this chapter's section on concussion), but these recommendations do not necessarily translate to appropriate recommendations in the child who sustains a TBI unrelated to sports activities. For instance, the grading of nonsports TBIs as mild, moderate, and severe is a different rating scale than grading the sports-related concussion as mild, moderate, or severe.
For the child who was injured with a moderate to severe brain injury, the guidelines remain unclear. It is known that in certain sports, such as high school football, approximately 20% of players incur a concussion each year, though other "collision" sports can result in concussions as well, including boxing and ice hockey (234). Furthermore, sports such as basketball and soccer may result in an inadvertent concussion if players come into contact with each other, though with less force than one would expect in the collision sports. Other high-risk sports, including downhill skiing, snowboarding, and gymnastics, can be as dangerous as contact or collision sports from potential resulting blows to the body (235). For these reasons, it is challenging as a rehabilitation clinician to allow a patient who sustained a TBI to return to these activities. It is known that cognitive impairments will follow multiple mild concussions. Mildly concussed athletes demonstrate a decline in memory compared with their baseline performance (236), and athletes with a history of multiple concussions score significantly lower on memory testing (237). In the individual with a recent TBI, risking subsequent brain injury or concussion and worsening their clinical outcome is not recommended. Furthermore, the patient may sustain other traumatic injuries in attempting to return to sports as a result of poor performance due to impaired speed, response time, and information processing (238).
