Inflicted traumatic brain injury (TBI) is one of the leading causes of childhood injury and death. Studies have consistently demonstrated worse outcomes for children with inflicted TBIs compared to accidental TBIs. Out of home placement, a known developmental risk factor, is a frequent occurrence in inflicted TBI, which may also contribute to worse outcomes for children. Little is known about what injury, child, and family factors predict out-of-home versus in-home placements. We hypothesize that injury severity, child, and family risk factors will be predictive of out-of-home placement after hospital discharge from an inflicted TBI.

Participants included 175 children with inflicted head injuries ages who received care at a large children’s hospital from 2012 to 2021. 88% of children were alive at discharge and were included in the study. The total sample included 154 children. Ages ranged from 0.2 to 76 months (M = 11.81, SD = 14.50) and 64.9 % were male. Race/Ethnicity distribution was as follows: 66.9% White, 29.9% Latinx or Hispanic, 4.6% Black, 3.3% American Indian or Alaskan, and 22.5% identified another race or ethnicity or identified as multiracial. Measures included injury severity (e.g., days spent in the PICU, post-resuscitation GCS), child (e.g., race/ethnicity, gender), and family factors (e.g., prior history of domestic violence, type of insurance). Individual logistic regressions were run to assess the effect of each injury severity, child, and family factor on placement after hospital discharge.

Results indicated that having a caregiver with a history of mental health difficulties and/or a history of substance abuse increased the likelihood of an out-of-home placement for the child after an inflicted TBI. Results also demonstrated that the more caregiver psychosocial concerns reported, the higher the risk of an out-of-home placement for the child after discharge from the hospital. Finally, results indicated that having public insurance significantly increased the risk of an out-of-home placement for the child after discharge from the hospital. Post-hoc analyses were conducted to assess the effect of insurance type on out-of-home placement, while controlling for psychosocial concerns. Results indicated that, even when taking total psychosocial concerns into account, having public insurance significantly increased the risk of an out-of-home placement. Logistic regressions were carried out to assess the effect of injury severity, child, and every other family factor (e.g., prior criminal history) on placement after hospital discharge and the overall models were not significant.

One explanation for these findings is that families with public insurance have less of a social safety net and, thus, are unable to meet the needs of a child with an inflicted TBI. However, we cannot rule out the effect of bias in child welfare practices. Similarly, caregivers with histories of mental health difficulties and substance abuse are likely to have a harder time meeting their child’s needs and providing a stable household, increasing the likelihood of an out-of-home placement. Despite expectations, child and injury severity factors did not play a role in placement decisions after an inflicted TBI, indicating that placement decisions rely more heavily on caregivers’ abilities to meet the child’s needs rather than the child’s medical complexity or the severity of the inflicted TBI.