Evidence Based Treatments

The research regarding empirically supported treatments for the psychosocial and cognitive sequelae of pediatric TBI is relatively limited (for a review, see Donders 2007). However, in the past two decades, investigators have begun to study medical, rehabilitative, psychological/behavioral, and cognitive treatments for this population.

The literature on the use of psychotropic medications in the treatment of neurobehavioral sequelae of pediatric TBI is quite limited compared with the literature for adult TBI. Jin and Schachar (2004) conducted a systematic review of the literature on the use of methylphenidate in the treatment of ADHD symptoms after pediatric and adult TBI and found only modest evidence of efficacy. In contrast, Mahalich et al. (1998) found that the short-term use of methylphenidate after pediatric TBI led to improvements in multiple neuropsychological measures of attention and concentration.

Patrick et al. (2003) found that the use of dopamine agonists accelerated the coma recovery of a group of children following TBI. Amantadine, a specific dopamine agonist, has been hypothesized to positively influence the cognitive and behavioral outcomes following TBI directly via its dopamin-ergic properties and to possibly act as a neuropro-tective mechanism through its action on glutamate receptors (Green et al. 2004). Green et al. (2004) investigated the use of amantadine in pediatric TBI and found some subjective improvements but little objective evidence of effectiveness. Beers et al. (2005) examined the effectiveness of amantadine on parent report and neuropsychological test performance of executive functions after TBI and found improvements on parent ratings compared with a placebo group but no differences on performance-based measures. The examination of medication treatments following pediatric TBI is an area in clear need of further investigation.

Comprehensive reviews of the inpatient and outpatient rehabilitation of children with TBI have been published elsewhere (Anderson and Catroppa 2006; Beaulieu 2002; Ylvisaker et al. 2005a). The goals of rehabilitation ultimately involve the promotion of recovery of adaptive, cognitive, motor, and behavioral skills. Unfortunately, relatively few published studies have investigated the rehabilitation of pediatric TBI (Anderson and Catroppa 2006; Beaulieu 2002). A distinction has been made between restorative and compensatory rehabilitative strategies (Anderson and Catroppa 2006). Restorative strategies involve direct training in deficient cognitive skills, whereas compensatory strategies teach the child to compensate for his or her deficits by using alternate strategies to complete a task. Studies have suggested that restorative ap proaches can be effective for training attention and memory skills and that compensatory strategies are more useful in less severe injuries (Anderson and Catroppa 2006). The inclusion of family members in the rehabilitation of children with TBI has been supported by many studies, as has the integration of home and school services following discharge from inpatient rehabilitation (Ylvisaker et al. 2005a).

Outcome studies of the effectiveness of psychological and behavioral treatments on the emotional and behavioral problems that follow pediatric TBI are rare despite the high incidence of these problems in this population. Empirical support exists for treatments of behavioral and social problems following pediatric TBI (Warschausky et al. 1999; Ylvisaker et al. 2005b). More specifically, operant conditioning has been found to be effective in decreasing aggressive behaviors following TBI in children and adolescents, and school-based social interventions have received empirical support as well (Warschausky et al. 1999). In contrast, few outcome studies have focused on treatments for internalizing problems (e.g., depression and anxiety) after TBI.

Treatment programs addressing the remediation of specific neurocognitive deficits following TBI have been developed. Unfortunately, few published outcome studies have examined the efficacy of cognitive remediation programs in pediatric TBI. Laatsch et al. (2007) conducted a systematic evidence-based review of cognitive and behavioral treatment studies of pediatric TBI and determined that cognitive remediation for attention skills was supported by the literature, as was the involvement of family members as active members of the treatment team. Catroppa and Anderson (2006) conducted a review of intervention studies of executive deficits following childhood TBI and concluded that few methodologically sound outcome studies had been conducted in this area, although they found some support for specific interventions. For a comprehensive review of cognitive remediation in pediatric populations, see Butler (2007).

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