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Carney N, Coudray Hd, Davis-O'Reilly C, et al. Rehabilitation for Traumatic Brain Injury in Children and Adolescents (Supplement). Rockville (MD): Agency for Health Care Policy and Research (US); 1999 Sep. (Evidence Reports/Technology Assessments, No. 2S.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Cover of Rehabilitation for Traumatic Brain Injury in Children and Adolescents (Supplement)

Rehabilitation for Traumatic Brain Injury in Children and Adolescents (Supplement).

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Appendix B: Key Questions

1. Does the application of early, intensive medical rehabilitation in the acute care hospital improve outcomes for children with TBI?

Rationale: The timing and intensity of the application of rehabilitation for children and adolescents with brain injury in the acute care hospital may vary as a function of geographic location, treatment facility, payer protocol, or other factors. Evidence that early, intense rehabilitation improves outcomes could provide a basis for provision of the intervention as a standard practice.

Definitions: Early applies to treatment extending from admission into the emergency department to discharge from the acute care hospital ward.

Intensity - Levels of the intervention vary in intensity based on (a) whether the rehabilitation intervention was directed and managed, either by a pediatrician or pediatric physiatrist, (b) number, kinds, and frequency of methods applied, and (c) coordination of a team-based, transdisciplinary set of methods which produces a "milieu effect."

Medical rehabilitation is an intervention that utilizes methods including, but not limited to, physical therapy, occupational therapy, and speech therapy. Medical rehabilitation services may be provided in the acute medical setting, and in the in- and out-patient setting.

Patient Population: Children whose onset of traumatic brain injury occurred between the ages of 2 and 18 years, whose injury severity warranted admission to a hospital emergency department and subsequent transfer to acute care.

Outcome Measures: Presence or absence of complications (i.e., skin problems, pneumonia) Health status at discharge from hospital (age-appropriate motor skills, ADLs, play skills, social interaction, behavior, communication, and measures of cognitive function) Long-term measures of impairment and disability (reintegration into school, family, and social groups; academic achievement, transitions through developmental stages) Measures of functional independence

2. For children diagnosed with traumatic brain injury, what is the proportion provided special education that is designed to accommodate the needs of TBI?

Rationale: A gap is evident between child and adolescent TBI prevalence data and the numbers of children diagnosed with TBI who are receiving special education services. The concern is that children with TBI are being returned to their schools without adequate provision for their needs.

Definitions: We define "special education designed to accommodate the needs of TBI" as a school or program that has the benefit of being informed by professionals who are trained in and/or understand the needs specific to children with TBI. Special education may be provided in a number of different ways, including through an Individual Education Program (IEP). Children may be reintegrated into their pre-injury classroom, be placed in a separate class with other children with disabilities, receive private tutoring, or attend classes provided by the long-term care facility in which they live.

Patient Population: Children whose onset of traumatic brain injury occurred between the ages of 2 and 18 years.

Outcome Measures:

1.

Placement patterns for children diagnosed with TBI.

2.

Characteristics of special education, such as (a) was the assessment appropriate to TBI, (b) was the assessment used to help create the program, and (c) are the people who implement the program trained in caring for and educating children with TBI?

3. Do children with traumatic brain injury who are provided special education that is designed to accommodate the needs of TBI have better outcomes than (a) those provided special education that is not so designed, and (3) those who do not receive special education?

Rationale: Some schools have professionals who are trained in the care and recovery process of children with TBI, and can contribute that knowledge to preparing and implementing the special education programs. This question seeks evidence that outcomes are better for children with TBI who are cared for in a school system with such resources than those who are not.

Definition: See Question 2.

Patient Population: Children whose onset of traumatic brain injury occurred between the ages of 2 and 18 years, with a functional status that allows for some level of pursuit of academic development.

Outcome Measures:

  • Academic achievement
  • ADLs
  • Peer integration and social functioning
  • Play skills
  • Behavior
  • Communication and speech
  • Motor skills
  • Cognitive capabilities
  • Functional capabilities
  • Long-term disposition (i.e., do they remain in the school system or drop out; have they been referred to the mental health system; are they in the juvenile correction system?)

4. For children who have sustained brain injury, does the early identification of (a) the child's developmental stage at the time of injury, (b) the child's developmental stage at the time of assessment, and (c) the extent to which the injury has arrested the child's normal developmental process increase the ability to predict when the child will present the needs, behaviors, and problems resulting from brain injury?

Rationale: Specific cognitive capabilities, and performances consistent with those capabilities, are expected to emerge for children at predictable intervals. A child with brain injury may function without presenting deficits during an earlier phase of development, masking the fact that the developmental process has been arrested. Deficits resulting from brain injury may surface when the child reaches a chronological age at which educators and family members expect performances beyond the cognitive capabilities of the child. If accurate, early identification of the child's developmental stage, both at the time of injury and time of evaluation, enhances the ability to predict when problems are likely to surface, educators and family members could use that information to design interventions that account for damaged cognitive capabilities and their behavioral manifestations.

Definitions: Developmental Stages. A number of schemas for understanding childhood development exist. Two that will be used in this review are Jean Piaget's theory of cognitive development (1952), and the model for neurodevelopment in children articulated by Ronald Savage, Ed.D.

Patient Population: Children whose onset of traumatic brain injury occurred between birth and 18 years.

Outcome Measure: Predictability of the onset of deficits at specific ages or educational landmarks, measured by strength of the association between results of diagnostic/prognostic tests and actual manifestations of needs and deficits.

5. Does the provision of support to families of children with brain injury enhance the family's ability to cope and reduce the burden of illness?

Rationale: The effect of having a child with brain injury on the composition of the family, and the effect of the family on the recovery process for the child, has been conceptualized as a recursive loop. The event of brain injury may damage or destroy an otherwise functional family. The event of brain injury within a dysfunctional family may have catastrophic results for the child and other family members. Support services that target the family as well as the child and that aid in the coordination of, and transition between, treatment environments are believed to enhance the family's ability to cope with the demands resulting from having a child with brain injury.

Definitions: Support to families may be provided in the form of information, case management, counseling, support groups, respite centers, state or federal agency support, or support from school staff.

Patient Population: The target population for this question includes children whose onset of traumatic brain injury occurred between the ages of 2 and 18 years, as well as the members of their family.

Outcome Measures: Measures of coping, adjustment, satisfaction; measures of stress, and family and caregiver burden.

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