Effect of Social Determinants of Health on Pediatric Traumatic Brain Injury Phenotypes: Retrospective Cohort Analysis

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Abstract
Background: Traumatic brain injury (TBI) in children disrupts cognitive, physical, and emotional functioning, posing a significant public health challenge in the United States. Recovery after pediatric TBI is nonlinear, influenced not only by fluctuations in progress but also by social determinants of health (SDoH), including sociodemographic features and health care access. Objective: This study investigates how SDoH influence TBI phenotypes and associated recovery trajectories. Our retrospective cohort analysis evaluates health disparities among pediatric patients and examines how these disparities influence health outcomes following TBI. Methods: We extracted 926 pediatric patients from the Children’s Health After Injury (CHAI) dataset to ensure consistency across 5 key variables: Abbreviated Injury Scale (AIS) scores, vital signs and assessments, comorbidities, complications, and Glasgow Coma Scale (GCS) scores. Dimensionality reduction and density-based hierarchical clustering identified distinct phenotypes and their SDoH characteristics. Further exploratory analysis revealed distinct recovery trajectories across the phenotypes. To confirm the effect of SDoH on the phenotypes, generalized linear modeling and the random forest modeling were used. Results: Four distinct pediatric TBI phenotypes were identified, each with a unique injury-severity profile, recovery trajectory, and pattern of SDoH association: (1) adolescents with high injury severity and stable GCS scores (n=278) showed a significant association between phenotype membership and age. This group experienced a gradual increase in psychological and behavioral impairment over the recovery period, with total impairment scores increasing by 25% from baseline to the 12-month follow-up. (2) Younger children with moderate injuries and stable GCS scores (n=141) showed no significant SDoH associations. Total impairment scores remained stable across the follow-up period, though neurological and physical conditions showed long-term worsening, warranting ongoing monitoring. (3) Critically injured children with severe neurological impairment (n=98) showed the strongest SDoH associations, with race/ethnicity and its interaction with age significantly linked to phenotype membership; Asian children had 1.8 (95% CI 1.02‐3.34) times the odds of belonging to this critically injured phenotype compared with White children. Despite carrying the lowest overall impairment of any cluster at baseline, this group showed escalating psychological burden and fluctuating neurological conditions through the 12-month follow-up. (4) Moderately injured children with stable GCS scores followed by a sharp progression (n=409) showed no significant SDoH associations, yet carried the highest overall impairment burden of any cluster across all time points. Total scores increased 31% from baseline to the 12-month follow-up, driven by a marked escalation in psychological/neurological issues. Conclusions: Age and race/ethnicity were the most influential predictors of cluster membership, with SDoH risk concentrated in the 2 most severely injured groups. Identified SDoH-driven phenotypic disparities can guide targeted interventions for pediatric patients at high risk for TBI sequelae. Future studies should extend follow-up beyond 12 months and validate these phenotypes in diverse cohorts to strengthen generalizability and inform equitable care.

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