2S:  Supplement. Rehabilitation for Traumatic Brain Injury in Children and Adolescents: Evidence Report/Technology Assessment Number 2, Supplement

Suggested citation

Carney N, du Coudray H, Davis-O'Reilly C, et al. Rehabilitation for traumatic brain injury in children and adolescents. Evidence report no. 2, supplement (Contract 290-97-0018 to Oregon Health Sciences University). Rockville, MD: Agency for Health Care Policy and Research. September 1999.

Introduction

The estimated incidence of traumatic brain injury (TBI) doubles between the ages of 5 and 14 years and peaks for both males and females during adolescence and early adulthood to approximately 250 per 100,000. Children and adolescents are more likely than adults to survive following TBI. Because the lives of most survivors of moderate to severe TBI involve chronic, life-long disabilities with varying degrees of dependence, the cost in individual suffering, family burden, and financial burden to society is greater for those who have more years to live.

Limitations in bathing, dressing, and walking are observed in between 50 percent and 90 percent of children with TBI with multiple functional deficits, depending upon and directly proportional to the number of functional deficits. For children with four or more functional deficits, 75 percent have impairments in self-feeding, cognition, and behavior; there also may be impairments in speech (67 percent), vision (29 percent), and hearing (16 percent).

In the 18^th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, the number of children receiving services because of TBI for the 1994 to 1995 school year was 7,188 students aged 6 to 21 years. The gap between this number and reports of incidence of TBI among children and adolescents suggests that many children with TBI may be misidentified or unidentified. The concern is that the problems of these children may go unrecognized, or they may be treated with methods that were developed for other pathologies but are inappropriate to the special needs of children with TBI.

Although many children with TBI may transition to inpatient rehabilitation and some to long-term care facilities, the goal, when possible, is return to school. Laws requiring schools to provide for the special education needs of students define schools as the best place for ongoing rehabilitation of most children with TBI. Ideally, a child identified with TBI would be evaluated for special needs and provided with an individualized education program (IEP) designed to meet those needs. However, the content and quality of the program would depend on the resources available in the school and varies across States and regions.

Characteristics such as social inappropriateness, lack of awareness, and decreased control of attention, memory, and strategic thinking may result in difficulties when integrating a child with TBI into mainstream educational settings. Some States provide training for public school teachers that is focused on the special needs of children with TBI. Some programs serve both children who live at home and those who require residential treatment in a specialized educational/neurorehabilitative setting. Choice of model (mainstream vs. separate) may be dictated by the severity of deficits and functional capabilities of the child; it also may be influenced by the availability of resources within the community, family choice, or the local or regional philosophy of inclusive vs. segregated education of students with disabilities.

Background

In 1997 the Evidence-based Practice Center (EPC) at Oregon Health Sciences University (OHSU) contracted with the Agency for Health Care Policy and Research (AHCPR) to produce an evidence report on rehabilitation from TBI in adults. At the conclusion of the project, AHCPR requested that the OHSU EPC conduct a survey of the literature regarding child and adolescent TBI rehabilitation. Specific objectives for the project were to:

• 1

  Identify studies of all phases of rehabilitation for child/adolescent TBI from a variety of bibliographic databases and compile a data set of studies ranging from acute care through in- and outpatient rehabilitation, educational reintegration, and long-term functional status.

• 2

  Document the process of applying search strategies to the literature, including where the strategies failed and succeeded, producing a road map to this body of literature for use in future investigations.

• 3

  Categorize the retrieved studies and produce a bibliography.

• 4

  Working with a panel of technical experts, including a parent of a child with TBI, define key questions regarding child and adolescent TBI rehabilitation and use them to search the database to locate studies with evidence for effectiveness of interventions.

• 5

  Summarize the studies relevant to each key question.

• 6

  Construct a template for evidence tables to address the key questions by specifying important variables to define the columns in the tables.

• 7

  Propose a research agenda for rehabilitation of child and adolescent TBI.

The main goal was to create a template for a comprehensive, systematic review of existing literature. A secondary goal was to describe research projects capable of closing information gaps revealed by a survey of the literature.

Conceptual Model for Rehabilitation of TBI in Children and Adolescents

Children are naturally changing and developing both before and after they are injured, including while they are receiving rehabilitative interventions. Therefore, in order to examine the effects of rehabilitation, information is required on normal child development. Longitudinal studies that compare development of injured and uninjured children also are needed. To be useful the studies must assess capabilities of children at different ages and determine individual variation in developmental outcomes of children with different injuries and in different social environments.

The best organizing principle for reviewing the literature on child and adolescent TBI comes from the modern study of human development and, in particular, the metatheoretical approach known as Life-Span Developmental Psychology. Simply stated, any research question about child and adolescent TBI must be oriented to the relevant developmental category and age group. Also, subsets of information within a research question must address developmental phases. For example, when describing the sample of a particular study, age at injury, age at evaluation, and time since injury, as well as the developmental implications of those age-related landmarks, all should be identified.

Key Questions

Two panels of experts, one local and one national, worked with the research team to identify the following key questions in the rehabilitation and survivor phases of recovery from TBI for children and adolescents. For each question, they provided a rationale for asking the question, as well as definitions, target populations, and outcome measures. The questions are:

• 1

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

• 2

  Among children diagnosed with TBI, how many are provided with special education that is designed to accommodate the needs of TBI?

• 3

  Do children with TBI who receive special education designed to accommodate the needs of TBI have better outcomes than those who are provided with special education that is not so designed and those who do not receive special education?

• 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 exhibit the needs, behaviors, and problems resulting from brain injury?

• 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?

Methods

Literature was searched using MEDLINE (1976-1998), CINAHL (1982-1998), HealthSTAR (1995-1998), PsychINFO (1982-1998), ERIC (1996-1998), the Cochrane Library, and Current Contents (1998), and 1,464 potential references were identified. Abstracts of these references were reviewed independently by two members of the research team, who applied predefined, broad eligibility criteria. The process resulted in 376 studies about TBI in children or adolescents. These studies were coded and categorized according to study design, deficit, intervention, outcomes, and predictors and placed in a bibliography in both written and electronic form for use in future investigations. The studies were read a second time, and 236 were identified that were relevant to one or more of the five key questions. An additional 120 articles were added from reference lists, book chapter bibliographies, and the advice of peers. A total of 356 full-text articles were retrieved and read, and those studies containing data relevant to one of the key questions were identified. One study was found for question 1, 15 for question 2, 8 for question 3, 61 for question 4, and 3 for question 5 (88 total). The remaining 268 articles described programs or interventions without providing patient or student data.

Findings

Conclusions and Future Research

In general, studies have not been conducted with designs capable of providing evidence for effectiveness of interventions for children and adolescents with TBI. Because the focus of this project was effectiveness, many studies were excluded because they did not provide experimental evidence that could be used to guide practice. The published literature for this topic is primarily exploratory. It provides descriptions of programs that are widely accepted, including logical approaches to treatment that have not been validated either through experimental design or in carefully controlled observational studies. The clinical experience represented in the published literature that has guided the design of intervention programs should generate important hypotheses for controlled studies.

Investigations of what might work to rehabilitate children with TBI may benefit from the literature in other related fields. Future research could be guided by themes that have emerged across many disability groups. Although TBI has its unique features, it shares many characteristics with other disabilities. The task is to identify the shared characteristics, and include what has been learned in other fields when designing interventions. One example is social skills training. Certain models for social skills training and cognitive rehabilitation have been shown to be ineffective with people who have other, similar disabilities, yet these models are being used in TBI rehabilitation. At the very least, the failure of these interventions in other fields should call into question their effectiveness with TBI. Similarly, it is important to pay attention to and systematically test successful approaches in other fields.

Three gaps in the literature about child and adolescent TBI define priorities for future research.

• 1

  There is insufficient evidence about the natural history of TBI in this population. Longitudinal, observational studies with large samples are needed to provide this information. Such studies could help researchers and clinicians understand and define the subsets of severity categories, assessments, and interventions. Without distinct subsets, researchers will continue to pool diverse groups into the same study samples and produce results of questionable value.

• 2

  Interventions must be tested with experimental study designs.

• 3

  Because of the strong influence of development on all aspects of life for this population, both longitudinal and experimental studies must incorporate concepts of human development presented in this paper, as well as sophisticated methods of analysis capable of accounting for individual variation.

Finally, the field of Life-Span Developmental Psychology provides a technology for designing studies and analyzing data that accounts for individual variation, which is important for the evaluation of recovery from TBI for both adults and children. The approaches suggested here will result in complex research designs and data sets in which children with and without TBI are followed for extended periods of time with multiple times of assessment. In addition, the children -- and possibly their families, teachers, and/or friends -- would be asked to complete multiple assessments at each time of measurement. The focus becomes predicting individual growth curves from antecedent variables such as age at injury, initial status, environmental factors (e.g., family functioning), and intervention techniques. Hence, the focus is on the prediction of growth curves and trajectories in performance among children following TBI compared with control children and/or children with TBI participating in alternative interventions. To maximize these data, several statistical techniques are available, including growth curve modeling, cluster analysis, and time-series analysis.

Conceptual Model for Rehabilitation of TBI in Children and Adolescents

Matrix of Developmental Stages and Categories of Development

Table 1. Developmental stages and categories of development (more...)

Table 1. Developmental stages and categories of development

Development Category
Chronological developmental stage	Somatic: neurological/hormonal	Somatic: sensorimotor	Intel./cognitive executive functions	Language	Emotional/ behavioral	Social
Infancy: 0 to 6 months
Infancy: 7 to 12 months
Infancy: 13 to 18 months
Infancy: 19 to 24 months
Childhood: 2 years
Childhood: 3 to 4 years
Childhood: 5 to 6 years
Childhood: 6 to 8 years
Pre-puberty: 9 to 11 years
Early Adolescence: 11 to 14 years
Late Adolescence: 15 to 20 years

Plainly, the more we can say about plasticity and critical periods in the first column of the matrix, the more we will know about the possibilities of recovery after early injury. Work by Levin, Eisenberg, Wigg, et al., (1982) found that younger children had worse deficits in memory and intelligence, and Woods (1980) found effects of lateralization as early as 1 year of age. Similar results have been found many times since (e.g., Riva and Cazzaniga, 1986; Kaufmann, Fletcher, Levin, et al., 1993; Anderson and Moore, 1995; Dennis, Barnes, Donnelly, et al., 1996). It may be that too much weight has been given to simple anatomical plasticity of childhood and not enough to the idea of critical periods and how other aspects of development interact with the somatic categories (Krashen, 1973).

Burden of Illness of TBI in Children and Adolescents

The estimated incidence of TBI doubles between the ages of 5 and 14 years, and peaks for both males and females during adolescence and early adulthood to approximately 250 per 100,000 (Centers for Disease Control and Prevention, 1998). Motor vehicle accidents are the cause of one-third to one-half of TBI in adolescents. In younger children, pedestrian traffic accidents are the leading cause of TBI, followed by falls.

The greatest proportion of people who survive TBI are children and adolescents. Because the lives of most survivors of moderate to severe TBI involve chronic, life-long disabilities with varying degrees of dependence (Chesnut, Carney, Maynard, et al., 1999), the cost in individual suffering, family burden, and financial burden to society may be greater for those who have more years to live.

For children with TBI who have multiple functional deficits, limitations in bathing, dressing, and walking are observed in between 50 percent and 90 percent, depending upon and directly proportional to the number of functional deficits (DiScala, Osberg, and Savage, 1997). For children with four or more functional deficits, impairments in self-feeding, cognition, and behavior can be observed in 75 percent, as well as impairments in speech in 67 percent, vision in 29 percent, and hearing in 16 percent (DiScala, Osberg, and Savage, 1997).

The opinion has been expressed by a number of clinicians and researchers that one of the most important problems in child and adolescent TBI is underdiagnosis (Bergman, 1998; DePompei, 1998; Glang, 1999; Gordon, 1999; Sohlberg, 1999; Ylvisaker, 1998). They believe that many children with TBI are either not identified as having a problem or receive the wrong diagnosis. The concern is that the problems of these children remain unrecognized or are treated with methods developed for other pathologies that are inappropriate to the special needs of TBI. In the 18^th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act (U.S. Department of Education, 1996) the number of children receiving services because of their disabilities was tabulated by diagnosis. For the 1994-1995 school year, only 7,188 students ages 6 to 21 years were identified within the school system as having a traumatic brain injury. The gap between this number and reports of incidence of TBI among children and adolescents suggests that many children with TBI may be misidentified or unidentified. Consequently, we do not have a complete picture of the burden of illness, either on an individual level or a population basis.

For children who have been accurately identified, comparative studies of TBI need to include mediators of outcome that account for variations in outcome. Individuals with TBI are part of a diverse group. For example, with respect to severity, the range of outcome is from death or persistent unresponsiveness at one extreme to full recovery within a relatively short period of time at the other extreme. Between these two extremes are different profiles of ability and need -- at every level of severity -- depending on preexisting factors, the exact location and nature of the brain injury, and other factors. In addition to type and location of injury and the child's developmental stage, factors such as injury severity, time from injury to evaluation, age at injury, and pre-injury characteristics appear to be important predictors of recovery.

Practice Settings

Assessment and Outcome Evaluation

Ylvisaker and Gioia (1998) defined the complexities of assessing children and adolescents with TBI as follows:

• 1

  Most children with severe TBI improve neurologically in ways that are difficult to predict for several weeks or months or possibly even years after the injury. Therefore, an assessment completed in the early weeks or months following injury may quickly lose its validity as an accurate description of the child's profile of strengths and weaknesses.

• 2

  Executive function deficits (associated with prefrontal lobe injury) are notoriously resistant to identification and classification with standardized office tests alone.

• 3

  Recovered knowledge and skills acquired before the injury can combine with new disability, including severe difficulty acquiring new knowledge and skills, to create misleading profiles of ability.

• 4

  Pronounced inconsistency in a child's performance, related to neurologic, emotional, and contextual factors, adds to the difficulty of straightforward interpretation of test results. (Ylvisaker and Gioia, 1998, p. 161)

This account of the difficulties associated with assessing children with TBI echoes our earlier evidence report on rehabilitation for traumatic brain injury in adults (Chesnut, Carney, Maynard, et al., 1999) and introduces special problems with assessment that are unique to children. In the adult report, we tabulated all tests of cognitive function used to evaluate adult samples from studies included in the report. Ninety-one different assessment tools were used in 160 separate testing sessions reported in 24 studies, indicating extreme lack of standardization. Additionally, we found little evidence of an association between high scores on tests and better functional capacity. We concluded that the value of these tests as accurate indicators of functional capacity and predictors of performance in life situations is questionable.

In addition to the question of the predictive validity of assessment methods, the tools also may lack reliability, especially with children who have sustained prefrontal injury. Inconsistency in test scores is commonly observed in both children and adults with executive function deficits (Ylvisaker and Gioia, 1998). Also, a person may perform poorly when new information or skills are required or when effective behavior regulation is necessary but perform adequately when knowledge and skill acquired before the injury are needed. First it must be determined which tests are reliable indicators for which subgroups of children with TBI. The question of their predictive validity can then be addressed.

Summary

Topic Assessment and Refinement

Two panels of experts, one local and one national (see Appendix A), worked with the research team to identify key questions in the rehabilitation and survivor phases of recovery from TBI for children and adolescents. The panels were composed of three pediatric physiatrists, the mother of a child with brain injury, two neuropsychologists, an educational psychologist, a clinical psychologist, and two speech pathologists -- one from a children's hospital and one who works in the public school system. The local panel met to develop a common understanding of the main concepts bearing on questions of effectiveness in rehabilitation specific to children and adolescents and to identify key questions for investigation. Prior to the first meeting, the panel was sent a document describing the prevalence, incidence, and burden of illness of TBI, as well as the key questions that directed the adult evidence report investigation. The format of the meeting was structured to promote a full and free interaction among the members. This first meeting was aimed at identifying the main issues of rehabilitation for children with TBI, including their integration into the educational system.

Five questions concerning the rehabilitation of children and the effect of the disability on families were proposed by the local panel. Questions were refined through further discussion and submitted to the national panel for review.

The national panel traced the child's path through the medical, rehabilitative, and educational systems to highlight differences in the context of adult and pediatric rehabilitation. Unlike adults, most children's rehabilitation occurs in schools rather than in medical settings. Also, provisions for children with handicaps are mandated by law, whereas choice of adult rehabilitation setting is driven primarily by insurance funding. An understanding of these issues contributed to the final articulation of the key research questions. The final questions are:

• 1

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

• 2

  For children diagnosed with TBI, what is the proportion provided special education that is designed to accommodate the needs of 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 (b) those who do not receive special education?

• 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?

• 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?

Literature Search and Retrieval

Figure 1. Process of search and selection of articles (more...)

   Figure 1. Process of search and selection of articles for review

Figure 1

Two members of the research team read the abstracts of these references and eliminated articles based on the following exclusion criteria: (1) not TBI (e.g., cerebral palsy); (2) adult sample; (3) instrument development; or (4) alcohol/drug abuse. Following this process, we were left with 376 studies about TBI in children or adolescents. Note that we included all study designs and did not limit inclusion by our five key questions. Our intention was to begin assembling a bibliography for use in future research. We categorized each study by (1) design, (2) deficit resulting from the injury, (3) therapeutic intervention, (4) outcome of intervention, and (5) predictors of outcome; within those categories, each study was coded (refer to Appendix D).

There were additional exclusion criteria for the second research question. This question sought information about referral to special education for students with TBI. For this question, the following studies were excluded:

• Studies that predated the 1975 All Handicapped Children Act and those that were conducted outside the United States. It was thought that these studies would artificially inflate the observed variability in student placement patterns after TBI.

• Studies that relied on selected samples.

• Prospective studies with a design that may have influenced school placement, thus introducing bias to the outcome.

Of the 376 studies, 236 addressed one of the five key questions. An additional 120 articles were added from reference lists, book chapter bibliographies, and the advice of peers. A total of 356 full-text articles were retrieved and read. Studies containing data relevant to one of the questions were evaluated by a member of the research team. For question 1, we found 1 study containing relevant data; for question 2, 15; for question 3, 8; for question 4, 61; and for question 5, 3, for a total of 88 studies. The remaining 268 articles described programs or interventions without providing patient or student data.

Review of Key Studies

The investigation for each key question was managed by a member of the research team. That person read all articles containing data relevant to the question and specified and read additional articles to be included from reference lists. Investigators met individually with the principal investigator to confer about included studies, and the entire team met weekly to discuss progress and maintain a common theme across the five questions.

A template for constructing evidence tables is presented in Appendix E. Categories from the evidence tables in the adult report were used as a guide for data abstraction. The template also incorporates variables specifically relevant to child and adolescent TBI that should be abstracted in a comprehensive systematic review. More details of the construction of evidence tables are given in sections on each key question. Summaries of key studies are presented in Chapter 3 of this report.

Literature Search

An initial strategy modeled after the one used for the adult evidence report was applied to one MEDLINE database (1995-1998). The strategy failed to capture 43 articles we had previously identified as relevant. We located those articles in MEDLINE, noted their MeSH terms, added those terms to the strategy, applied it to the same file, and confirmed that the new strategy would capture the articles missed by the first strategy. We applied the new strategy to MEDLINE and HealthSTAR. We then wrote more general strategies for databases from ERIC, PsychINFO, CINAHL, Current Contents, and the Cochrane Library (see Appendix C) and acquired the articles captured by the searches.

As we began retrieving and reading articles, we referred to reference lists of those articles for additional studies, and discovered an unacceptable number of relevant studies still not captured by the strategies. Examples of problems encountered are:

• 1

  Several publications in the Journal of Head Trauma Rehabilitation (JHTR) were not captured. We found that CINAHL contains some, but not all, of these articles.

• 2

  A large body of literature is indexed as "chronic brain damage" that mainly contains studies on outcomes from perinatal anoxia, a condition we excluded from this review. However, a number of studies about "traumatic brain injury" are indexed in "chronic brain damage" and not in "traumatic brain injury." To acquire these studies with a search strategy would require accessing the full body of "chronic brain damage" literature and manually eliminating all but the ones about TBI that were miscategorized.

• 3

  The revised search strategy failed to capture all relevant articles about language development.

Table 2. Studies acquired from electronic and manual (more...)

Table 2. Studies acquired from electronic and manual searches

Question	Electronic search	Manual search	Total found	Percent manual
Initial total	236	120	356	34
Used for Quest. 1	1	0	1	0
Used for Quest. 2	10	5	15	33
Used for Quest. 3	5	3	8	38
Used for Quest. 4	11	50	61	82
Used for Quest. 5	2	1	3	33
# used in review	29	59	88	67
% used in review	12%	49%	25%

Key Questions

• 1

  Does the application of early, intensive medical rehabilitation in the acute care hospital improve outcomes for children with traumatic brain injury?

We found no randomized controlled trials and no comparative studies that investigated the efficacy of early, intensive rehabilitation for children or adolescents. Inferences about this intervention for children have been drawn from studies with adult samples.

Of three observational studies we located that used child and adolescent samples and contained data about this question, one (Berger, Worgotter, Oppolzer, et al., 1997) specifically reported outcomes associated with early, intensive rehabilitation. In this prospective, uncontrolled study, 38 severely injured children and adolescents admitted to one inpatient rehabilitation center were evaluated during their stay in the acute care hospital and at 6 months postdischarge from inpatient rehabilitation. Patients received intense, multidisciplinary neurorehabilitation in the hospital and in the rehabilitation center. Two measures of function were employed: the Glasgow Outcome Scale (GOS) score and a vigilance score designed by the researchers for this study. On admission to the rehabilitation center, 74 percent of the children were minimally responsive as measured by the vigilance score. By the 12^th week of treatment, only 21 percent were minimally responsive. Deducting 6 patients in whom rehabilitation was incomplete at time of discharge, rehabilitation discharge GOS was 3 vegetative, 13 severe, 7 moderate, and 8 good; 1 patient died. Of the patients located at 6-month followup, GOS was 1 vegetative, 13 severe, 9 moderate, and 7 good.

Of the remaining two studies, one retrospectively compared outcomes of children who suffered anoxic brain injury with those who suffered TBI (Vander Schaaf, Kriel, Krach, et al., 1997). Ninety-eight patients from one inpatient pediatric rehabilitation facility were introduced to rehabilitation at varying times after injury, some sooner than others. They were evaluated for functional mobility at discharge from the center and at 1 or 2 years postdischarge. It was found at followup that the children with more functional mobility had been admitted to rehabilitation sooner after injury than those with less functional mobility, suggesting that earlier rehabilitation may be a factor in improving functional mobility. However, children who had less severe injuries may have been discharged to rehabilitation earlier than more seriously injured children, confounding the effects of severity with those of the timing of treatment. To address this, authors removed children in a vegetative state or those who could only smile (and thus those with longer time from injury to rehabilitation due to severity) from the data set and performed a discriminant analysis. It showed a significant relationship between duration of unconsciousness and functional mobility but no significant relationship between length of time from injury to rehabilitation and functional mobility, either at discharge or followup. Therefore, the analysis did not support the suggestion that early rehabilitation improves outcomes.

The third study (Sobus, Alexander, and Harcke, 1993) demonstrated that some children with TBI suffer from undetected musculoskeletal trauma and heterotopic ossification, indirectly arguing for early physiatry intervention. Eighty-two children and adolescents (60 with TBI and 22 with spinal cord injury [SCI]) treated at one rehabilitation unit over 18 months were given bone scans within 4 months of the injury. If the bone scan showed previously unrecognized trauma, its clinical significance was determined by reviewing nursing, physical therapy (PT), and occupational therapy (OT) charts to track whether the child had been favoring the traumatized extremity or whether complaints of pain during therapy led to behavior problems. Fifty-four patients were found to have trauma sites undetected prior to the bone scan; 28 did not. Of the 54 patients with previously undetected trauma sites, 43 had TBI and 11 had SCI; (3 SCI and 16 TBI had skeletal trauma; 4 SCI and 19 TBI had soft tissue trauma; 4 SCI and 8 TBI had heterotopic ossification). Fifteen patients had impeded rehabilitation as a function of their undetected traumas; all 15 had TBI. The authors suggested that the difficulties in communication unique to TBI warrant special methods for detecting physical traumas with that population. A primary weakness of this study is that, of the original 82 patients given bone scans, no evaluation was performed of the 28 patients for whom the scans did not show previously undetected trauma sites. Their charts would need to be reviewed as with the 54 patients discussed above, and the results of the two groups would have to be compared in order to verify the value of the bone scan.

We sought information about the effect of early, intensive rehabilitation on four outcomes (see Appendix B) specified by our technical panel as relevant to child and adolescent TBI. We found no evidence to support or disprove the effectiveness of this intervention. The question has not been addressed with studies employing research designs capable of demonstrating efficacy. The one study that evaluated relevant functional outcomes did not include a comparison group. While the point of the article about undetected musculoskeletal trauma was to recommend early bone scans (and not necessarily early physiatry), it raises pertinent questions about the unique communication problems associated with TBI and the possible positive results of early attention to physical therapy issues.

• 2

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

This question has two parts: (1) How many children with TBI receive special education services, and (2) Are the programs and services they receive delivered by people who understand and can manage TBI in children?

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 is provided in a number of different ways. An individual education program (IEP) is one method for delivering special education. It is a contract between parents and the school for the student who has been found eligible for special services, tutoring, or accommodations. An IEP is a tool for parents and teachers that identifies skills, strategies, and behaviors the student needs to function in school. It encompasses traditional educational goals and should include planning to create opportunities for social integration, leisure activities, preparation for work, and independent living skills.

Children with TBI who can resume academic activities may receive an IEP or some other form of special education. They 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. Some schools have professionals who are trained in the care and recovery process of children with TBI and can contribute that knowledge to the planning and implementation of special education programs for those children.

Prior to passage of the Education for All Handicapped Children Act of 1975 (Public Law 94-142), a report to Congress indicated that more than 50 percent of handicapped children in the United States were not receiving special educational services or were excluded from public education altogether. Since that time, a limited number of studies have attempted to quantify the proportion of children with head injury receiving special education (U.S. Department of Education, 1996).

Please refer to Chapter 2 (Methods) for literature exclusion criteria specific to this question. A total of 24 studies were evaluated for this question; 9 were excluded because they contained no data. Of the remaining 15 studies that contained data, three predated 1975 (Heiskanen and Kaste, 1974; Kleinpeter, 1976; Klonoff and Paris, 1974), four were conducted outside of the United States (Kinsella, Prior, Sawyer, et al., 1995; Kinsella, Prior, Sawyer, et al., 1997; Klonoff, Low, and Clark, 1977; Rutter, Chadwick, Shaffer, et al., 1980), and four were retrospective studies that included only students with TBI who were referred to a behavioral or psychiatric clinic (Burke, Wesolowski, Buyer, et al., 1990; Donders, 1992; Donders, 1994; Max, Sharma, and Qurashi, 1997). Four studies provide limited information regarding referral to special education programs among students diagnosed with brain injury. We found no studies that documented numbers of special education programs that are delivered by personnel who are trained in caring for and educating students with TBI; therefore, we were only able to address the first part of this question.

The most salient study that evaluated referral to special education for children with TBI (DiScala, Osberg, and Savage, 1997) gathered data from the National Pediatric Trauma Registry, encompassing 76 pediatric trauma centers or children's hospitals in the United States, over a period of 8 years. Descriptive data on 24,021 children were analyzed. Recommendations for special education at discharge from the acute care hospital were evaluated for the subset of children age 5 or older who were not discharged to a medical environment (n = 3,303). Although 18.7 percent were diagnosed with cognitive limitations, special education was recommended for only 1.8 percent (60 children); 3.6 percent received a referral for a home tutor. The authors speculate that lack of guidelines in trauma centers linking them to the educational system may account for low referral rates to special education. Discharges during the summer, a season of frequent pediatric injuries, also may contribute to the low referral rate. Finally, this study tracked referral at time of discharge from acute care; referrals to special education may have been provided during followup examinations.

Based on hospital admissions, two retrospective studies estimated that between 12 percent (Greenspan and MacKenzie, 1994) and 38 percent (Chapman, Culhane, Levin, et al., 1992) of students with known brain injury received special education (excluding premorbid special education enrollment). However, no evaluation of the students with TBI who did not receive special education was provided. Thus, it is not possible to determine if these students needed special services or what proportion of them was functioning well without services. Therefore, we do not know whether these reported referral rates indicate adequate referral, under-referral, or over-referral. Also, using hospital admission records as the denominator in making this estimate probably results in an overestimate of the actual number of children with TBI who receive special services because it does not include children with TBI who were never admitted to a hospital. Finally, excluding children with premorbid special education enrollment may further distort the findings, since children with existing problems appear to be predisposed to sustaining a brain injury.

One cross-sectional State-wide study (Virginia Department of Education, 1991) illustrated that school records underestimate the number of enrolled students who have a brain injury. All public school division special education directors and the superintendent of the Virginia School for the Deaf and Blind at Hampton were surveyed to gather information about students with TBI in the State. Fifty-eight percent of school districts responded representing 60 percent of students in public education in Virginia. Of 133 students identified with a brain injury, 36 percent of students' personal identification files mentioned brain injury. Twenty percent had TBI noted in the School Entrance Physical and Immunization Certificate. Of those students eligible for special education, a brain injury was mentioned in 82 percent of student's "confidential section" of the student file and on 33 percent of students' IEPs. The report did not specify the method used by the special education directors to respond to the survey for identifying the 133 students with TBI.

Few data from peer reviewed, published studies are available to determine patterns of referral to special education for children diagnosed with TBI. The data that are available may underestimate the proportion of children referred. Moreover, no available study used an independent measure of the need for special education to determine whether referral rates were appropriate. Instead, the available data measured the ratio of:
the number of special education referrals
to
the total number of TBI diagnoses.

The important question is, if the child with TBI needs special services, did that child receive them? The answer to that question depends on being able to measure independently the need or potential benefit from special education and then determining what proportion of children who could benefit are actually referred. We did not locate these data in the published literature.

• 3

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

Refer to the previous question for a definition of "special education that is designed to accommodate the needs of TBI." No randomized controlled trials were found that examined the effect of special education designed to accommodate the needs of children with TBI. The greatest proportion of studies about education for children with brain injury consists of program descriptions written by clinicians and educators with field experience in integrating children with disabilities into educational settings (e.g., Blosser and DePompei, 1989; Ylvisaker and Feeney, 1995). One study with a comparison group, one small case series, one survey, and five case studies provide data about this question.

In the comparative study (Light, Neumann, Lewis, et al., 1987), a treatment group of children with TBI who met eight inclusion criteria (n = 15) was composed of consecutive admissions to a children's inpatient rehabilitation center over approximately 21 months. Children in the comparison group (n = 6) met the inclusion criteria but could not participate in the treatment because of distance from the hospital, time of referral, conflict with cointerventions, or lack of parental consent. Three classes of measures were used: neuropsychological and intelligence, educational, and adaptive and behavioral. Children were evaluated before and after the intervention. The program, the Neuro-Cognitive Education Project (NEP), provides one-on-one tutoring for each child, with instruction at home and/or in the school setting, and includes a component to assist families in understanding the child's new disabilities. The curriculum and protocol were individually designed for each child to meet that child's needs based on his or her strengths and weaknesses. Duration of the intervention varied from 3 to 7 months and from 19 to 68 hours of tutoring.

For the neuropsychological and intelligence measures, the comparison group performed significantly better than the treatment group at pre-test. Both groups had improved scores at post-test, but no significant difference between groups was evident. For the educational measures that were available for analysis, no significant differences were apparent between groups at pre- or post-test. At pre-test, children in the comparison group performed significantly better than those in the intervention group on six of eight adaptive and behavioral measures; for four of those six measures, at post-test the comparison group performed significantly better than the treatment group. In general, children in both groups improved from pre- to post-test. The baseline differences between groups prior to intervention, as well as differences in level and duration of the intervention, render the results of this study inconclusive.

The case series (Brett and Laatsch, 1998) presents a model for introducing cognitive rehabilitation into the school setting. Teachers providing the intervention had received special training and were supervised by psychologists who specialized in cognitive rehabilitation. Ten students received the intervention twice a week for 20 weeks. Students showed significant improvement from pre- to post-treatment on one of nine laboratory-based neuropsychological tests.

In the survey study, parents of children with brain injury were asked what factors contributed to successful return to school for their children (Parkin, Maas, and Rodger, 1996). Fifty-three of 80 surveys sent were returned. Of 26 variables that might be associated with outcome within five domains, parents thought four were associated with successful return to school. Two of these were attributes of the school program -- presence of a reintegration aide and school attitude toward integration. The other two predictors were home medical aide and pre-trauma medical and behavioral condition. This result suggests that parents perceive attributes of the school program important to children's successful return to school.

Five case studies using patients as their own controls provided data about this question. In these studies, researchers measured target behaviors or abilities before introducing the intervention (baseline phase) and took the same measures during the intervention (treatment phase). An increase in target abilities during treatment suggests an effect of treatment for the individual being examined. In some cases, the intervention was removed and an additional measure was taken (return-to-baseline) to observe if a decrease in the target ability would occur in the absence of the intervention.

In one study (Glang, Todis, Cooley, et al., 1997), a program was introduced into the school environment to enhance social networks for three students with brain injury, producing an increase in number of social contacts and parent satisfaction during the treatment phase. A second study (Suzman, Morris, Morris, et al., 1997) provided cognitive and behavioral training to enhance problem-solving skills for five children with brain injury in a program delivered in a special educational setting. All students had a decrease in errors on computerized tasks during the treatment phase. In a third study (Franzen, Roberts, Schmits, et al., 1996), two children given a cognitive intervention performed significantly better on verbal memory tests during the treatment phase than during baseline and approached performance level of one uninjured comparison subject. In a fourth study (Feeney and Ylvisaker, 1995), student involvement in planning daily routines, photograph cues, and verbal rehearsal were incorporated into the established programs of three adolescents in a TBI school reentry project who were presenting severe behavioral problems. During treatment, frequency of challenging behaviors and aberrant behaviors decreased for all three students, and the amount of completed work increased. The reverse was observed during the return-to-baseline phase. In the fifth study (Glang, Singer, Cooley, et al., 1992), individualized direct instruction produced increased academic performance for three students in targeted instructional areas of reading, language, math, and keyboarding.

One comparative study, one case series, one survey, and five case studies provide limited data about the effect of special educational programs for children with TBI, with varied results. For the study that attempted to compare outcomes for two groups of children with TBI -- one that received an intervention -- the pre-treatment performance between the groups was too different to be able to draw conclusions from the results. In the case series, a treatment effect was observed on only one of nine measures. In the five case studies, all patients showed improvement on measures taken during intervention as opposed to pre-treatment measures. However, the observed effect cannot be generalized to a larger population of children. The lack of reliable data on the effectiveness of special education makes it difficult to develop or verify criteria for entry into such programs.

• 4

  For children who have sustained traumatic 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?

Unfortunately, any given study of developmental outcomes in pediatric TBI is usually limited to one or a few of the listed aspects of outcome. For example, we found a large number of longitudinal studies for some topics (for example, intellectual/cognitive, or language) but not for others. Sixty-one articles reporting data related to developmental issues in pediatric TBI were found; 51 were prospective, 4 were population-based, and 13 were multicenter, and 12 studies evaluated patients for 3 or more years.

Table 3. Description and rating of articles for question (more...)

Table 3. Description and rating of articles for question 4

		Design			Sample		Age			Injury
Author	Date	Category	Study length	Prospecretros	Populat.	Select	Range	Span	Comp	Sev	Loc	Age	Since	f-u yrs	Anal	Sum
(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)	(13)	(14)	(15)	(16)	(17)
Thal	1991	4	5	2	2	2	1-3y	4	3	3	2	4	1	3	2	30.0
Hudspeth	1990	1	0	1	1	1	1-21y	4	3						5	15.0
Thatcher	1991	1	0	1	1	1	2m-26y	4	3						5	15.0
Stiles	1993	3	5	2	1	1	4-6y	4	3	0	2	4	1	6	5	28.0
Stiles	1996	3	5	2	1	1	4-4.5y	4	3	0	2	4	1	4	5	28.0
Thompson	1994	2	5	2	2	2	6.5-16y	4	2	1	0	4	1	5	5	28.0
Feldman	1992	4	2	2	2	2	1-4y	4	3	3	2	4	1	3	5	30.0
Ew-Cob	1989	2 3 4	1	2	1	2	4m-5y	2	2	2	0	1	1	0.5	3	17.0
Prior	1994	3 6	1	2	1	2	6-16y	0	2	2	0	0	2	0.5	1	13.0
Bagnato	1986	2 3 4 5 6	1	2	1	2	8m-5y	2	2	1	0	3	1	0.5	3	18.0
Anderson	1997	3 4 6	2	2	1	2	2-7y	3	3	2	0	3	2	1	4	24.0
Bijur	1996	3 5	4	1	3	4	10y	4	4	1	0	2	1	2.5	3	27.0
Klonoff	1977	1 3 5	5	2	1	2	2.7-16y	2	3	2	0	2	2	5	3	24.0
Ew-Cob	1994	3 4	4	2	1	2	1.5-14y	2	2	2	2	2	2	3	1	22.0
Rudel	1974	2	0	2	1	1	7.5-17y	1	3	1	0	0	0	0	1	10.0
Brink	1970	2	0	1	1	2	2-18y	0	1	2	0	0	1	7	1	9.0
Stiles	1991	3	5	2	1	1	3-4y	4	3	0	2	4	1	4	4	27.0
Stiles	1988	3	5	2	1	1	4-5y	4	3	0	2	4	1	5	4	27.0
Stiles	1985	3	3	2	1	1	2y	4	3	0	2	4	1	2	4	25.0
Kaufmann	1993	3	1	2	2	2	7-16y	4	2	2	0	4		2	4	23.0
Yeates	1995	3	1	2	1	2	5-16y	4	3	2	0	1	1	0	4	21.0
Anderson	1995	3	3	2	1	2	4-14y	3	2	2	0	3	1	2	3	22.0
Levin	1988	3	2	2	2	2	6-15y	4	2	2	0	4	2	1	3	25.0
Levin	1982	3	1	2	1	1	2-19y	3	1	2	0	2	1	2	2	16.0
Levin	1979	3	0	2	1	1	6-18y	2	2	3	2	2.5	1	0	2	18.5
Dennis	1996	3	0	2	0	0	6-15y	4	3	2	2	4	1	0	4	22.0
Dennis	1985	3	0	1	0	0	?	0	2	0	1	0	0	0	4	8.0
Winogron	1984	1 3	0	0	1	0	5-18y	1	1	2	0	1	1	0	3	10.0
Riva	1986	3	0	2	1	1	8-12y	3	2	0	1	3		0	3	16.0
Woods	1980	3	0	1	1	1	?	0	1	0	2	0	0	0	2	8.0
Selz	1979	3	0	2	0	0	?	0	4	0	0	0	0	0	4	10.0
Gaidolfi	1980	3	5	2	1	0	18-27y	4	2	1	0	1	1	7	1	18.0
Bijur	1996	3	2	2	3	4	10y	4	3	1	1	2	1	10	3	26.0
Ew-Cob	1998	4	0	2	0	1	4-11y	2	3	2	2	2	1	0	3	18.0
Ew-Cob	1987	4	0	2	1	1	5-15y	2.5	2	2	1	2.5	1	0	3	18.0
Jordan	1992	4	0	2	1	2	16-23y	4	3	2	1	1	1	0	2	19.0
Jordan	1991	4	0	2	1	2	5-13y	1	3	2	1	1	1	0	2	16.0
Trauner	1996	4	0	2	0	0	5-20y	1	1	3	2	1	1	0	2	13.0
Harris	1996	4	0	2	2	1	8-14y	2	3	3	2	2	1	0	2	20.0
Eisele	1998	4	0	2	1	1	4-17y	1	3	3	2	1	1	0	3	18.0
Chapman	1992	4	0	2	2	1	9-18y	2	3	3	2	2	1	0	3	21.0
Hallett	1997	4	0	2	2	1	6-22y	1.5	3	2	1	1.5	1	0	2	17.0
Aram	1987	4	0	2	1	1	5-16y	1	3	3	2	1.5	1	0	2	17.5
Reilly	1998	4	0	2	0	0	3-9y	3	3	3	2	3	1	0	3	20.0
Dennis	1990	4	0	2	1	0	6-22y	1	3	0	1	1	1	0	4	14.0
Woods	1979	4	0	2	1	0	10-25y	2	3	0	2	0	1	0	2	13.0
Chapman	1998	4	1	2	1	2	6-9y	3	2	2	1	3	1	1	3	21.0
Jordan	1994	4	1	2	2	1	17-50y	3	3	2	1	1	1	20	3	20.0
Campbell	1990	4	2	2	2	1	5-16y	1	1	2	2	1	1	1	3	18.0
Chadwick	1981	1 4	0	2	3	2	7-17y	1	2	1	2	1	1	0	3	18.0
Jordan	1996	4	0	2	3	2	10-18y	2	3	3	2	2	1	0	3	23.0
Filley	1987	1 5	0	1	1	2	<18y	2	2	3	2	0	1	0	2	16.0
Nass	1987	5	0	2	1	1	1-3y	2	1	3	2	3	1	0	4	20.0
Dennis	1998	1 4 5	0	2	1	1	6-15y	3	3	0	2	1.5	1	3	4	18.5
Segalowitz	1991	5	0	1	1	4	13-20y	3	1	0	0	3	1	7	1	15.0
Pettersen	1991	5 6	0	2	1	1	5-17y	1	3	2	1	1	1	1	2	15.0
Coster	1994	6	2	2	2	1	1m-5+y	2	3	2	1	2	2	0.5	3	22.0
Kleinpeter	1976	6	2	2	1	1	10-25y	3	1	2	1	3	1	10	1	18.0
Marchman	1991	4	2	2	1	1	9m-22m	3	3	3	2	3	1	1	2	23.0
Asarnow	1995	3 5 6	2	2	2	2	8-16y	3	4	2	1	3	1	1	4	26.0
Klonoff	1993	1 3 5 6	2	2	2	2	25-40y	3	2	3	1	3	1	23	3	24.0

NOTE: Key to rating categories can be found in Appendix F.

We developed this system for rating articles to provide a method for selecting which articles were most likely to include reliable information about the long-term developmental outcome of TBI. It is not validated, and therefore its use is based on the unproven assumption that high ratings are correlated with other measures of quality. Validating such a system could be a useful part of a comprehensive systematic review designed to evaluate the large and diverse developmental literature.

To demonstrate how the system might be used, we selected seven articles that had the highest methodological scores for detailed review. These seven studies address four key issues in development and TBI. One evaluates the effect of focal brain damage on language development; two track the correspondence of brain growth with cognitive development; two demonstrate the presence of subtle, undetected deficits; and two use the growth trajectory method of analysis to evaluate development of a variety of cognitive and motor skills.

Conclusions

Our goal was to conduct a systematic review of the literature about child and adolescent TBI oriented around key research questions and to create a tool that could be used in future evidence-based investigations about recovery from TBI in this population. We prepared a matrix to be used to organize research according to the developmental dimensions and age categories addressed by studies. With the assistance of technical experts, we specified key questions about child and adolescent TBI rehabilitation and defined patient populations, interventions, and outcome measures. We compiled and categorized literature from seven databases -- medical, educational, and psychological. We reviewed the strongest of the studies we found containing data about key questions and created an evidence table template for use in future comprehensive studies.

Quality of the Existing Literature

In general, studies have not been conducted with designs capable of providing evidence for effectiveness of interventions for children and adolescents with TBI. Because the focus of this project was effectiveness, many studies were excluded because they did not provide experimental evidence that could be used to guide practice. The published literature for this topic is primarily exploratory. It provides descriptions of programs that are widely accepted, logical approaches to treatment that have not been validated either through experimental design or in carefully controlled observational studies. The clinical experience represented in the published literature that has guided the design of intervention programs should generate the important hypotheses for controlled studies.

We did not find that assessment is any more standardized in the child and adolescent literature than in studies about adults. Some instruments are designed specifically for children, and others are a child's version of an adult instrument. The vast array of instruments used and their lack of standardization, superimposed upon the complexity of assessing children discussed earlier (Ylvisaker and Gioia, 1998), combine to illustrate the difficulties in assessment of technology for children. We suggest that questions about differences in evaluation between children and adults are premature. The important questions that apply to both adult and pediatric populations are, how and to what extent should assessment be standardized? What cognitive tests are the best predictors of function in life settings?

Literature Retrieval

The literature on child and adolescent TBI -- found in databases spanning medicine, education, and psychology -- is not organized to facilitate an exhaustive systematic review. However, with respect to four of our five key questions (questions 1, 2, 3, and 5), we believe this review encompasses the relevant studies that contain data from the sources we used. Sources of information regarding special education placement patterns (question 2) other than scientific literature, such as State registries that may account for regional differences and give a more accurate tally of prevalence, need to be accessed and evaluated. Without knowing the extent of TBI in children and adolescents, we cannot estimate the proportion of children who are receiving special education. Without knowing the number of children with TBI who truly need special education, we cannot know if the current referral rate is adequate.

As discussed in Chapter 3 (Results), only 11 of the 61 studies reviewed for question 4 were acquired through applying the search strategy to bibliographic databases. Fifty studies were found from manual methods described in this report. We suspended the search for articles before exhausting all manual methods for acquiring them; therefore, the studies surveyed for question 4 may not constitute the entire body of relevant literature, and a complete, systematic review addressing subquestions within that topic is recommended.

Recommendations for Including the Developmental Perspective in a Systematic Review

Table 4. Relevance of selected studies to topics and (more...)

Table 4. Relevance of selected studies to topics and stages of development

Developmental Category
Chronological developmental stage	Somatic: neuro/hormonal	Somatic: sensorimotor	Intellectual/cognitive	Language	Emotional/behavioral	Social
Infancy: 0 to 24 months	Hudspeth,'90Thatcher,'91			Thal,'91Feldman,'92Marchman,'91
Preschool childhood:2 to 5 years	Hudspeth,'90Thatcher,'91		Anderson,'97Anderson,'95Stiles,'96Stiles,'93Stiles,'91Stiles,'88	Anderson,'97Thal,'91Feldman,'92Reilly,'98		Anderson,'97
School-age childhood: 6 to 11 years	Hudspeth,'90Thatcher,'91	Thompson,'94	Anderson,'97Anderson,'95Stiles,'93Kaufmann,'93 Asarnow,'95 Levin,'88Dennis,'96Riva,'86	Anderson,'97Reilly,'98Chapman,'98	Asarnow,'95	Anderson,'97Kleinpeter,'76 Asarnow,'95
Puberty and adolescence: 12 to 19 years	Hudspeth,'90Thatcher,'91Klonoff,'93	Thompson,'94	Kaufmann,'93Anderson,'95 Asarnow,'95 Klonoff,'93Levin,'88Dennis,'96Riva,'86		Segalowitz,'91 Asarnow,'95 Klonoff,'93	Kleinpeter,'76 Asarnow,'95 Klonoff,'93

Figure 2. Rating of pediatric TBI literature on developmental (more...)

   Figure 2. Rating of pediatric TBI literature on developmental issues

Figure 2

Life-Span Developmental Psychology and the Study of Child and Adolescent TBI

Conclusion

Large longitudinal studies and controlled experimental research that incorporate important concepts from developmental science are needed to investigate specific questions about the effectiveness of treatments for TBI in children and adolescents. Methods for designing studies and evaluating data provided by life-span developmental psychology may be well suited for the study of recovery from TBI in this population.

Local Panel

• Anita Asmussen, MA

• Speech Pathologist

• Emanuel Hospital

• Janice Cockrell, MD

• Pediatric Physiatrist

• Medical Director, Pediatric and Adolescent Rehabilitation

• Emanuel Children's Hospital

• Don Lange, PhD

• Neuropsychologist

• Margaret Sutko, PhD

• Neuropsychologist

• Emanuel Children's Hospital

• Robert Butler, PhD

• Psychologist

• OHSU/Doernbecher

• Colleen Hanson, EdD

• Legacy Health System

• Portland Public School System

• Shuana Perkins

• Parent

• Kathy Ware, MS

• Speech-Language Pathologist

• Portland Public School District

National Panel

• Robert DePompei, PhD, CCCSLP/A

• Professor, School of Speech-Language

• Pathology and Audiology

• University of Akron, Ohio

• Marilyn Lash-Cluett, MSW

• Director, L & A Publishing/Training

• Wolfeboro, NH

• Assistant Clinical Professor, Department of Physical Medicine and Rehabilitation

• Tufts University School of Medicine

• Boston, MA

• Linda Michaud, MD

• Director, Pediatric Physical Medicine and Rehabilitation

• Children's Hospital Medical Center

• Cincinnati, OH

• Eldon Schulz, MD

• Chief, Pediatric Physical Medicine and Rehabilitation and Developmental Pediatrics

• University of Arkansas for Medical Sciences

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.

Bibliographic Entries with Coding¹

Adelson,Kochanek, 1998.
des/rev

Alexander, 1993.
des/oped

Alexander, Schor, Smith Jr, 1986.
des/case observ; def/phys

Anderson, Moore, 1995.
des/control long pro; observ fu; def/lang cog;
predict/sev age fam socio cause

Anderson, Morse, Klug, et al, 1997.
des/pro observ; def/cog; predict/sev

Andrews, Rose, Johnson, 1998.
des/control observ; def/beh psyc soc

Aram,1986.
des/control pro observ; def/lang; predict/site

Aram, 1988.
des/rev

Aram, Ekelman, Whitaker, 1987.
des/control pro observ; def/lang; predict/age dev sex
socio site

Arnarson, Halldorsson, 1995.
des/pop observ retro; def/mort

Asarnow, Satz, Light, et al, 1991.
des/retro observ fu; def/beh reint

Ashwal, Eyman, Call, 1994.
des/retro observ fu; def/lang mot mort

Asikainen, Kaste, Sarna, 1996.
des/long observ pop; def/soc; reint work; predict/sev
age pedu

Asikainen, Kaste, Sarna, 1998.
des/long observ pop; def/reint; predict/sev age

Bagnato, Feldman, 1989.
des/review

Bagnato, Mayes, 1986.
des/comp cor pro int conv; def/phys mot lang psyc
soc; interv/iprehab; out/phys mot lang psyc soc adl

Bagnato, Neisworth, 1986.
des/case int; def/cog beh; interv/iprehab; out/phys
beh cog

Bagnato, Neisworth, 1989.
des/case fu; def/cog edu famf; predict/pfam treat
pedu

Bailey, Burchinal, McWilliam, 1993.
des/method

Baltes, 1987.
des/method

Baltes, Reese, Nesselroade, 1977.
des/method

Baracchini-Muratorio, Cantini, Pruneti, 1985.
des/pro observ long; def/phys; cog psy; predict/age

Barry, Clark, 1992.
des/pro int; def/reint; interv/iprehab; out/oreint;
predict/sev pre pfam

Bassett, Slater, 1990.
des/comp pro observ; def/mot lang cog

Basso, Scarpa, 1990.
des/comp pro observ fu; def/lang edu

Bawden, Knights, Winogron, 1985.
des/comp observ pro; def/phys mot cog; predict/sev

Beattie, 1997.
des/rev

Beca, Cox, Taylor, et al, 1995.
des/retro observ; def/phys; predict/sev

Beers, 1992.
des/rev; def/cog ed; predict/dev

Benz, McIntosh, Kallieris, et al, 1993.
des/observ; def/phys; interv/prev

Berger E, Worgotter, Oppolzer, et al, 1997.
des/observ int fu pro; def/reint; interv/iprehab;
out/oreint

Berger K, 1998.
des/method

Bergman, Eklund, Magnusson, 1991.
des/method

Berney, Favier, Froidevaux AC, 1994.
des/retro cons; def/phys mort

Berney, Favier, Rilliet, 1995.
des/retro observ; out/mort

Berney, Froidevaux, Favier, 1994.
des/retro cons observ; def/phys

Biagas, Gaeta, 1998.
des/rev

Bigler, Clark, Farmer, 1997.
des/rev; text book

Bijur, Haslum, Golding, 1990.
des/comp long pro observ pop; def/phys beh psyc soc
cog fam; predict/sev age cog sex socio soc

Bijur, Haslum, Golding, 1996.
des/control retro observ; def/phys cog edu;
predict/sev

Bishop, 1981.
des/rev

Blau, 1936.
des/case retro observ cons; def/phys psyc

Blendonohy, Philip, 1991.
des/case; def/phys

Blosser, DePompei, 1989.
des/prog

Blosser, DePompei, 1992.
des/oped; def/lang cog famf

Blosser, Pearson, 1997.
des/rev; def/edu

Bohn D, 1993.
des/rev

Bowen, Clark, Bigler, 1997.
des/observ retro; def/cog mot; predict/sev cause

Boyer, Edwards P, 1991.
des/pro int cons long; def/mot; lang beh edu cog;
interv/oprehab; out/ophys olang ocog adl oedu;
predict/sev cogd

Brett, Laatsch, 1998.
des/pro int long; def/cog; interv/edu; out/ocog

Brink, Garrett, Hale, et al, 1970.
des/comp retro observ fu; def/mot; lang beh psyc edu
cog reint; predict/sev age

Brodsky, 1988.
des/case

Brookes, MacMillan, Cully, et al, 1990.
des/comp pro retro observ; def/phys; predict/sev age
sex cause

Brooks, Campsie, Symington, et al, 1986.
des/observ pro long; def/phys psy beh famf;
predict/sev

Brown, Chadwick, Shaffer, et al, 1981.
des/control pro observ long fu; def/psyc beh;
predict/pre

Bruce, Schut, Sutton, 1982.
des/rev

Bryk, Raudenbush, 1987.
des/method

Bryk, Raudenbush, 1992.
des/method

Burchinal, Appelbaum, 1991.
des/method

Burke, 1984.
des/case; def/famf

Burke, Wesolowski, Buyer, et al, 1990.
des/retro int fu; def/reint work; interv/oprehab

Burke, Wesolowski, Guth, 1988.
des/retro observ fu; def/cog psy; predict/sev cogd

Burkett, 1989.
des/rev

Butinar, Gostisa, 1996.
des/pro observ; def/mort

Campbell D, Stanley, 1966.
des/method

Campbell TF, Dollaghan, 1990.
des/comp pro long int; def/lang; interv/oprehab;
out/lang; predict/sev

Capruso, Levin, 1992.
des/rev; def/cog

Carney, Gerring, 1990.
des/rev

Cattelani, Lombardi, Brianti, et al, 1998.
des/retro observ long; def/cog soc beh psyc;
predict/sev

Chadwick, Rutter, Brown, et al, 1981.
des/control pro observ long fu; def/cog; predict/sev
age cog sex

Chadwick, Rutter, Shaffer, et al, 1981.
des/control pro observ long fu; def/cog; predict/cogd

Chadwick, Rutter, Thompson, et al, 1981.
des/pro observ pop; def/lang edu cog; predict/sev age
site

Chapman, Culhane, Levin, et al, 1992.
des/pro observ fu; def/lang cog; predict/cogd

Chapman, Levin, Wanek, et al, 1998.
des/pro observ fu; def/lang; predict/age site

Chesnut, Carney, Maynard, et al, 1999.
des/rev

Cioni, Prechtl, Ferrari, et al, 1997.
des/method

Clark, 1996.
des/case rev; def/edu soc

Cockrell, Gregory, 1992.
des/retro observ; def/phys

Connell, Skinner, 1990.
des/method

Connor, Steingard, 1996.
des/rev

Conoley, Sheridan, 1996.
des/rev; def/psy soc famf

Costeff, Abraham, Brenner, et al, 1988.
des/retro comp observ fu; def/phys cog mot;
predict/cog

Costeff, Groswasser, Landman, et al, 1985.
des/pro observ fu; def/mot lang psyc

Coster, Haley, Baryza, 1994.
des/comp long pro observ pop; def/beh soc reint fam;
predict/sev

Crowley, Miles, 1991.
des/case int pro; def/cog; interv/cog; out/ocog

D'Amato, Rothlisberg, 1996.
des/rev

Dalby, Obrzut, 1991.
des/rev

Dall' Oglio, Bates, Volterra, et al, 1994.
des/long case pro observ fu; def/lang; predict/age

Dam Hieu, Sizun, Person, et al, 1996.
des/retro observ case; interv/surg; out/ophys

Davidson, 1990.
def/work

Day, Ulatowska, 1979.
des/case pro observ; def/mot lang cog

Deaton, Poole, Long, 1987.
des/rev; def/work

Dennis, 1985.
des/cor retro observ pop; def/cog; predict/med

Dennis, 1992.
des/rev; def/lang

Dennis, Barnes, 1990.
des/comp cor observ conv; def/lang

Dennis, Barnes, Donnelly, et al, 1996.
des/comp cor pro pop; def/lang cog; predict/sev age
site

Dennis, Barnes, Wilkinson, 1998.
des/comp cor pro observ pop; def/lang; predict/age
site

Dennis, Lovett, Wiegel-Crump, 1981.
des/case

Dennis, Whitaker, 1976.
des/case

DePompei, Blosser, 1997.
des/oped; def/edu

DePompei, Williams, 1994.
des/rev; def/famf

DiScala, Grant, Brooke, et al, 1992.
des/comp retro observ fu; def/phys

DiScala, Osberg, Savage, 1997.
des/retro pop surv; def/phys reint

Doelling, Bryde, Parette, 1997.
des/method

Donders, J Abnorm Child Psychol, 1992.
des/comp surv; def/beh psy soc; predict/pre

Donders, J Clin Psychol 48(2), 1992.
des/cor observ; def/cog

Donders, J Clin Psychol 48(3), 1992.
des/observ cor; def/cog

Donders, 1993.
des/comp observ; def/cog

Donders, 1994.
des/retro observ cons fu; def/phys cog; predict/sev
pre age cogd

Donders, Ballard E, 1996.
des/cor retro surv fu; def/psys psy soc beh;
predict/sev psy soc pre

Donders, Strom, 1997.
des/control retro observ; def/ed cog; predict/pre cogd

dos Santos, Plese, Ciquini Jr, 1994.
des/cor observ; def/phys

Duhaime, Eppley, Margulies, et al, 1995.
des/case retro observ; def/phys

Edwards, 1987.
des/retro observ fu; def/phys reint

Eiben, Anderson, Lockman, et al, 1984.
des/retro surv; def/lang soc cog; predict/sev age

Eisele, Aram, 1994.
des/control pro observ conv; def/lang; predict/site

Eisele, Lust, Aram, 1998.
des/control pro observ conv; def/lang; predict/site

Emanuelson, Von Wendt, 1998.
des/cor retro observ pop fu; def/phys

Emanuelson, Von Wendt, 1998.
des/cor retro observ pop fu; def/phys

Emanuelson, Von Wendt, Beckung, et al, 1998.
des/case observ fu; def/cog mot soc reint

Emanuelson, Von Wendt, Bjure, et al, 1997.
des/comp pro observ; def/phys

Emanuelson, Von Wendt, Lundalv, et al, 1996.
des/retro observ long fu; def/lang beh cog soc

Engberg, Teasdale, 1998.
des/retro observ pop fu; def/phys

Eriksson, Perfilieva, Bjork-Eriksson, et al, 1998.
des/anatomy

Ersahin, Mutluer, Mirzai, et al, 1996.
des/retro observ pop; def/phys

Ewing-Cobbs, 1986.
des/rev

Ewing-Cobbs, Brookshire, Scott, et al, 1998.
des/comp observ fu; def/cog lang

Ewing-Cobbs, Fletcher, Levin, 1989.
des/comp pro observ fu; def/cog mot
lang; predict/sev age

Ewing-Cobbs, Fletcher, Levin, et al, 1997.
des/pro observ long; def/lang cog mot

Ewing-Cobbs, Kramer, Prasad, et al, 1998.
des/comp pro long observ; def/phys cog mot

Ewing-Cobbs, Levin, Eisenberg, et al, 1987.
des/comp pro observ conv; def/lang; predict/sev age

Ewing-Cobbs, Levin, Fletcher, et al, 1990.
des/pro observ fu; def/cog

Ewing-Cobbs, Thompson, Miner, et al, 1994.
des/long pro observ cons; def/mot lang beh edu cog
reint; predict/age dev

Farley, 1990.
des/rev; def/phys

Farmer JE, Clippard, Luehr-Wiemann, et al, 1996.
des/rev

Farmer JE, Peterson, 1995.
des/rev

Farmer M, Singer, Mellits, et al, 1987.
des/comp pro surv cons; def/phys mot lang beh psyc soc;
predict/age site

Fay, Jaffe, Polissar, et al, 1993.
des/control cor pro cons observ fu; def/phys soc psy
edu reint; predict/sev

Fay, Jaffe, Polissar, et al, 1994.
des/control pro observ pop fu; def/phys soc psy edu
reint; predict/sev

Feldman HM, Holland, Brown, 1992.
des/case pro observ fu; def/lang; predict/site

Feldman HM, Holland, Kemp, et al, 1992.
des/control long pro observ conv; def/lang;
predict/age site

Feldman HM, Janosky, Scher, et al, 1994.
des/comp cor pro observ fu; def/lang

Feldman KW, Brewer, Shaw, 1995.
des/retro observ; def/phys

Fields, Coble, Pollack, et al, 1993.
des/case pro observ surv fu; def/phys

Filley, Cranberg, Alexander, et al, 1987.
des/comp pro observ cons; def/beh soc edu reint
work;predict/sev site

Fisher, 1997.
des/rev

Fletcher, 1990.
des/comp long pro observ cons fu; def/phys beh soc;
predict/sev age sex socio cause site

Fletcher, Levin, 1988.
des/method

Fletcher, Levin, Lachar, et al, 1996.
des/comp observ; def/cog psy psyc; predict/sev

Fletcher-Janzen, Kade, 1997.
des/method

Fowler, Kriel, Krach, 1992.
des/retro observ cons; def/phys

Frances, Jensen, 1985.
def/phys psy

Francis, Fletcher, Stuebing, et al, 1991.
des/method

Franzen, Roberts, Schmits, et al, 1996.
des/aba case; def/cog

Freeman, Burrell, Sedger, 1990.
des/int case observ fu; def/reint; interv/oprehab;
out/oreint ofam cost

Frewen, Sumabat, Del Maestro, 1985.
des/comp observ fu; def/phys

Fuld, Fisher, 1977.
des/case pro observ conv fu; def/sev mot lang soc edu
cog

Gaidolfi, Vignolo, 1980.
des/observ long fu; def/psy cog soc; predict/sev age

Gambardella, Zaccone, Cardia, et al, 1993.
des/pro int; def/phys; interv/surg; out/ophys

Genuardi, King, 1995.
des/retro pop observ; def/phys

Gerberich, Finke, Madden, et al, 1987.
des/observ surv; def/phys; sports hockey

Gill, Cohen, Korn, et al, 1996.
des/observ fu; def/beh cog lang mot work

Glang, Todis Cooley, et al, 1997.
des/case pro int fu; def/edu soc reint; interv/educ

Glass, Bulas, Wagner, et al, 1998.
des/comp pro; def/phys cog mot

Godbout, 1997.
des/aba case int; def/phys mot; interv/iprehab

Gold, 1985.
des/case; def/cog edu

Goldberg, Sachs, 1992.
des/rev

Goldstein B, DeKing, DeLong, et al, 1993.
des/pro observ; def/phys mort

Goldstein F, 1985.
des/rev

Goshen, Zwas, Shahar, et al, 1996.
des/int pro; def/phys; interv/acute

Gotschall, Papero, Snyder, et al, 1995.
des/cor pro observ cons long; def/phys beh soc cog
mot

Greenspan, 1996.
des/rev

Greenspan, MacKenzie, 1994.
des/comp pro surv sons fu; def/phys beh edu;
predict/sev pre socs pfam

Greenwald, Ghajar, 1995.
des/rev int; def/phys; interv/acute

Groswasser, Costeff, Tamir, 1985.
des/retro surv; def/phys cog

Guerriere, McKeever, 1997.
des/case; def/famf

Gulbrandsen, 1984.
des/control observ fu; def/cog; predict/age

Gutentag, Naglieri, Yeates, 1998.
des/control observ; def/cog

Haley, Cioffi, Lewin, et al, 1990.
des/rev; def/mot

Hall DM, Johnson, Middleton, 1990.
des/rev

Hall JR, Reyes, Meller, et al, 1996.
des/comp retro observ cons; def/phys; interv/acute;
out/ophys omort; predict/sev treat

Hallett, 1997.
des/comp observ; def/cog lang; predict/age dev

Hanigan, Wright, Wright, 1986.
des/retro observ; def/phys

Harris, 1996.
des/comp pro observ conv; def/cog; predict/sev

Hart BL, Dudley, Zumwalt, 1996.
des/case retro observ; def/phys

Hart K, Faust, 1988.
des/surv; des/phys; predict/age dev

Hayward, 1987.
des/prog

Hegel, 1988.
des/case int; def/beh; interv/behm

Heindl, Laub, 1996.
des/comp retro observ fu; def/phys; predict/sev

Helfaer, Wilson, 1993.
des/rev

Helgadottir, 1996.
des/case; def/lang reint psy soc

Hemphill, Feldman, Camp, et al, 1994.
des/comp pro observ; def/lang

Hendrickson, Becker, 1996.
des/rev int; def/phys; interv/prev

Henry, 1983.
des/prog rev; def/cog

Hicks, Gaughan, 1995.
des/retro observ; def/mort

Hinnant, 1994.
des/case; def/phys

Hirsch, DuBois, 1991.
des/method

Hofer, 1993.
des/retro observ; def/phys mort

Horton Jr, 1996.
des/rev int; interv/edu

Hu, Wesson, Kenney, et al, 1993.
des/long pro observ cons; def/phys beh psyc reint
fam; predict/fam psyc age sev

Hudspeth, Pribram, 1990.
des/control retro observ pop; def/phys; predict/age
dev

Humphreys, Hendrick, Hoffman, 1990.
des/case; def/lang mort

Hurvitz, Mandac, Davidoff, et al, 1992.
des/retro observ; def/phys

Jaffe, Fay, Polissar, et al, 1992.
des/cscon long pro cons; def/phys beh edu cog;
predict/sev age cogd sex

Jaffe, Fay, Polissar, et al, 1993.
des/cscon cor long pro observ pop; def/phys cog mot
edu; predict/sev

Jaffe, Hays, 1986.
des/rev

Jaffe, Massagli, Martin, et al, 1993.
des/cor long pro observ; out/cost; predict/sev cause
site

Jaffe, McDonald, 1992.
des/long pop

Jaffe, Okamoto, Lemire, 1986.
des/rev

Jaffe, Polissar, Fay, et al, 1995.
des/cscon long pro observ; def/phys cog mot;
predict/sev pre

James, Madauss, Tibbs, et al, 1979.
des/int; def/phys; interv/pharm; out/ophys ocog oreint
omort

Johnson BP, 1995.
des/case; def/famf

Johnson DA, 1992.
des/rev; def/sev cog

Johnson DL, Krishnamurthy, 1996.
des/retro pop; def/phys mort; interv/acute surg;
out/omort; predict/sev treat

Johnston, Gerring, 1992.
des/rev

Johnstone, Zuberi, Scobie, 1996.
des/retro observ pop; def/phys; predict/sev age sex
cause

Jordan, Cannon, Murdoch, 1992.
des/control pro observ fu; def/lang

Jordan, Cremona-Meteyard, King, 1996.
des/control pro observ conv; def/lang cog

Jordan, Murdoch, 1990.
des/cont pro observ conv; def/mot lang; predict/sev

Jordan, Murdoch, 1994.
des/control pro observ conv; def/lang

Jordan, Murdoch, Buttsworth, 1991.
des/control pro observ conv; def/lang; predict/sev

Jordan, Ozanne, Murdoch, 1990.
des/control observ; def/lang

Kaiser, Pfenninger, 1984.
des/ pro int long fu; def/phys psy cog ed; int/acute surg
pharm; out/ophys omort opsy ocog oreint

Kaufmann, Fletcher, Levin, et al, 1993.
des/comp pro observ cons; def/cog; predict/sev age

Kehle, Clark, Jenson, 1996.
des/rev prog; def/beh

Kennedy, Freeman, 1986.
des/rev

Kersenbrock, Kirchner, Sammons, 1983.
des/case

Kinsella, Prior, Sawyer, et al, 1995.
des/long observ; def/cog edu; predict/sev cog

Kinsella, Prior, Sawyer, et al, 1997.
des/long observ; def/sev cog; predict/sev cog

Kissoon, Dreyer, Walia, 1990.
des/rev; def/phys

Kleinpeter, 1976.
def/soc reint

Klonoff, Paris, 1974.
des/comp long pro observ cons; def/phys mot lang
beh psyc soc psy edu cog reint fam; predict/sev pre
age dev sex cogd

Klonoff, Low, Clark, 1977.
des/control pro observ cons fu; def/phys mot cog;
predict/age

Knights, Ivan, Ventureyra, et al, 1991.
des/comp long pro observ cons; def/phys mot lang
cog psyc soc edu; predict/sev

Koelfen, Freund, Dinter, et al, 1997.
des/comp observ fu; def/phys cog; predict/sev

Kolb, 1989.
des/rev

Krach, Kriel, Morris, et al, 1997.
des/observ retro cons fu; def/phys cog mot mort;
predict/sev

Krashen, 1973.
des/rev

Kraus, Fife, Conroy, 1987.
des/retro observ pop; def/phys mort

Kraus, Fife, Cox, et al, 1986.
des/retro observ surv; def/phys age

Kraus, Rock, Hemyari, 1990.
des/rev; interv/prev

Krell, 1997.
des/case

Kriel, Krach, Panser, 1989.
des/comp retro; def/phys mot cog; predict/age treat

Kumar, West, Quirke, et al, 1991.
des/comp bl retro observ cons; def/phys lang cog
mort; interv/acute; out/phys cog; predict/sev age treat

Kuyper, van Tol-de Jager, Post, et al, 1996.
des/cor retro surv fu; def/phys cog

Lange-Cosack, Riebel, Grumme, et al, 1981.
des/comp pro observ fu; def/phys psy cog soc ed
reint; predict/sev

Lawson, Rice, 1989.
des/case; def/cog lang

Leathem, Body, 1997.
des/control pro observ; def/beh cog

Lehr, Psychological management, 1990.
des/rev; def/cog edu psyc beh soc famf; text book

Lehr, A developmental perspective, 1990.
des/method

Leichtman, 1992.
des/case; def/psyc

Levin, 1992.
des/rev; def/psy soc famf; interv/pharm

Levin, 1993.
des/rev; def/psyc cog; predict/age site

Levin, Culhane, Fletcher, et al, 1994.
des/control observ fu; def/phys cog; predict/age site

Levin, Culhane, Mendelsohn, et al, 1993.
des/control cor observ fu; def/phys cog; predict/sev site

Levin, Eisenberg, 1979.
des/observ; def/psy cog; predict/sev

Levin, Eisenberg, Wigg, et al, 1982.
des/control pro observ conv fu; def/cog; predict/sev age

Levin, High, Ewing-Cobbs, et al, 1988.
des/control pro observ fu; def/cog; predict/sev age

Levy ML, Masri, Levy, et al, 1993.
des/comp observ; def/phys; predict/age sex site socio

Levy Y, Amir, Shaley, 1992.
des/long case; def/lang

Lewis, Shanok, Pincus, et al, 1982.
des/observ; def/psyc beh

Lieh-Lai, Theodorou, Sarnaik, et al, 1992.
des/comp retro observ; def/phys mort; predict/sev

Lloyd, Martin, Taylor, et al, 1985.
des/cor int pro; def/phys; interv/acute pharm;
out/phys

Lord-Maes, Obrzut, 1996.
des/rev

Loroni, Ciucci, Piccinini, et al, 1996.
des/retro observ pro int phys; def/phys; predict/sev
age

Luerssen, 1997.
des/rev; def/phys

Luerssen, Klauber, Marshall, 1988.
des/long pro observ pop fu; def/mort; predict/age

Luiselli, Gardner, Arons, et al, 1998.
des/prog; def/phys psyc soc ed cog

Lumenta, Kramer, Sprick, et al, 1985.
des/pro int fu; def/phys; interv/acute surg; predict/age
site

Macnab, 1991.
des/retro observ; def/phys; interv/prev; predict/treat

Manchester, Hodgkinson, Pfaff, et al, 1997.
des/case int; def/soc beh; interv/behm

Mansfield, 1997.
des/rev; def/phys

Marchman, Miller, Bates, 1991.
des/comp long pro observ; def/lang; predict/site

Massagli, Jaffe, Gay, et al, 1996.
des/cscon cor pro fu; def/phys cog beh; predict/sev

Massagli, Michaud, Rivara, 1996.
des/retro observ cons fu; def/phys reint cog edu
work; predict/sev

Mateer, Kerns, Eso, 1996.
des/rev int; def/cog reint

Matthews, 1997.
des/oped

Max, Bowers, Baldus, et al, 1998.
des/comp cor observ blind; def/phys psyc; predict/sev

Max, Castillo, Bokura, et al, 1998.
des/observ long pro observ cons; def/psyc;
predict/sev psy socio

Max, Castillo, Robin, et al, 1998.
des/cor long pro observ; def/psyc famf; predict/pre
pfam

Max, Lindgren, Knutson, et al, 1997.
des/cor retro observ cons; def/psyc; predict/sev pre
cogd pfam socio

Max, Lindgren, Knutson, et al, . . . disruptive behavior, 1998.
des/cor retro observ cons; def/beh psyc famf;
predict/sev pre pfam

Max, Lindgren, Knutson, et al, . . . injury severity, 1998.
des/cor retro observ cons; def/lang beh psyc ed;
predict/sev

Max, Lindgren, Robin, et al, 1997.
des/pro observ fu; def/psyc beh famf; predict/sev pre
pfam

Max, Robin, Lindgren, et al, 1998.
des/cor pro observ; def/phys psyc beh cog;
predict/pre pfam socio cogd

Max, Sharma, Qurashi, 1997.
des/cscon retro observ cons; def/psyc

Mayer, Walker, 1982.
des/pro observ; def/phys mort; predict/sev

Mazza, Pasqualin, Feriotti, et al, 1982.
des/pro observ; def/phys; predict/sev site

McArdle, Epstein, 1987.
des/method

McClelland, Rekate, Kaufman, et al, 1980.
des/retro; def/phys

McCrea, Kelly, Kluge, et al, 1997.
des/retro int; def/phys; interv/acute; out/phys

McDonald, Jaffe, 1992.
def/phys beh famf

McDonald, Jaffe, Fay, et al, 1994.
des/cscon cons pro observ fu; def/phys cog edu;
predict/sev pre age sex

McLean, Kaitz, Keenan, et al, 1995.
des/rev; def/phys

Melamed, Wozniak, 1998.

Merten, Osborne, 1983.
des/rev; def/phys

Michaud, 1994.

Michaud, 1995.
out/cost

Michaud, Duhaime, 1995.
des/rev; def/phys

Michaud, Rivara, Grady, et al, 1992.
des/long retro observ cons; def/phys mot mort;
predict/sev treat

Michaud, Rivara, Jaffe, et al, 1993.
des/cscon retro surv; def/beh cog edu; predict/age

Milton, Scaglione, Flanagan, et al, 1991.
des/rev case; def/cog edu

Minde, 1984.
des/rev

Miner, Cabrera, Ford, et al, 1986.
des/case; def/phys

Mitchell, Cusick, 1998.
des/prog int; def/reint cog

Mittenberg, Wittner, Miller, 1997.
des/rev; def/phys

Molnar, Easton, Badell, et al, 1987.
des/rev

Montgomery, 1984.
des/case

Moviat, Janssen, Jaeken, et al, 1995.
des/retro case observ; def/cog beh

Muller, Rothermel, Behen, et al, 1998.
des/comp observ; def/phys cog lang; predict/site

Mwaria, 1990.
des/case; def/psyc famf

Nass, Koch, 1987.
des/comp pro observ conv; def/psy; predict/site

Newcombe, 1982.
des/rev

Newman, Lovett, Dennis, 1986.
des/case; def/lang

Noah, Hahn, Rubenstein, et al, 1992.
des/rev; def/phys

O' Sullivan, 1996.
des/case

Oberg, Turkstra, 1998.
des/case int fu; def/lang; interv/oprehab edu;
out/ocog

Ong, Selladurai, Dhillon, et al, 1996.
des/cor retro observ; def/phys mort; predict/sev

Osberg, Brooke, Baryza, et al, 1997.
des/cor pro observ surv fu; def/phys famf; predict/sev
pfam socio pay

Osberg, DiScala, Gans, 1990.
des/retro observ pop; def/phys mot soc reint;
predict/sev treat

Ottewell, 1992.
des/case

Otto, 1960.
des/case retro observ; def/phys cog psyc

Paret, Barzilay, 1995.
des/cor pro observ; def/phys mort; predict/med

Paret, Dekel, Yellin, et al, 1996.
des/cor retro observ; def/phys; predict/sev med

Parker, 1994.
des/rev; def/phys cog mot lang psyc; predict/sev age
socs psych

Parkin, Maas, Rodger, 1996.
des/cor retro surv fu; def/phys cog beh psyc;
predict/pre pfam socs med

Parmelee, 1989.
des/rev; def/psyc

Parmelee, Kowatch, Sellman, et al, 1989.
des/case

Parmelee, O' Shanick, 1987.
des/case; def/psyc

Patterson, 1998.
des/oped

Perrott, 1991.
des/cscon pro observ conv; def/phys mot beh psyc
soc cog reint fam; predict/sev

Pettersen, 1991.
des/control pro observ conv; def/psy cog

Pfenninger, Kaiser, Lutschg, et al, 1983.
des/pro int; def/phys; interv/acute surg; out/phy

Polissar, Fay, Jaffe, et al, 1994.
des/cscon cor retro cor fu; def/phys reint; predict/sev

Pollack, Patel, Ruttimann, 1997.
des/cor pro observ cons; def/phys mort

Prior, Kinsella, Sawyer, et al, 1994.
des/comp pro observ cons fu; def/beh soc cog; predict/sev

Quine, Pierce, Lyle, 1988.
des/pro int fu; def/famf; int/fam; out/ofam

Ramundo, McKnight, Kempf, et al, 1995.
des/pro int; def/phys; interv/acute; out/ophys;
predict/med

Reilly, Bates, Marchman, 1998.
des/cscon int; def/lang; interv/ed; out/olang;
predict/age site

Ried, Strong, Wright, et al, 1995.
des/oped; def/soc; predict/socs

Riva, Cazzaniga, 1986.
des/control pro observ conv; def/cog; predict/age site

Rivara F, Mueller, 1986.
des/rev

Rivara JB, 1994.
des/cons pro fu; def/famf phys; predict/sev pre pfam

Rivara JB, Fay, Jaffe, et al, 1992.
des/comp observ survcons pro fu; def/famf phys;
predict/sev pre pfam

Rivara JB, Jaffe, Fay, et al, 1993.
des/cor cons pro fu; def/famf phys reint; predict/sev
age pre pfam

Rivara JB, Jaffe, Polissar, et al, 1994.
des/cor cons pro fu; def/famf phys edu beh;
predict/sev pre pfam

Rivara JB, Jaffe, Polissar, et al, 1996.
des/long pro cons fu; def/phys famf reint beh soc;
predict/pre pfam sev

Roddy, Cohn, Moller, et al, 1998.
des/retro observ; def/phys; predict/med

Rogers, Kreutzer, 1984.
def/famf

Rose, Johnson, Attree, 1997.
des/oped

Ross, Ernst, Kreis, et al, 1998.
des/observ; def/phys

Rossi, Sullivan, 1996.
des/pro observ fu; def/mot

Rudel, Teuber, 1971.
des/control pro observ conv; def/mot lang cog

Rudel, Teuber, Twitchell, 1974.
des/control pro observ conv; def/phys mot cog;
predict/age

Ruijs, Keyser, Gabreels, 1990.
des/pro observ long; def/phys mot cog beh psy soc

Ruijs, Keyser, Gabriel, 1994.
des/rev

Russo, Bressolle, Duboin, 1997.
des/case int; def/phys; interv/pharm; out/ophys

Rutter, 1981.
des/rev; def/cog psyc; predict/sev med pre socs

Rutter, 1982.
des/rev; def/cog beh psy

Rutter, Chadwick, Shaffer, et al, 1980.
des/cscon pro long; def/phys lang beh psyc soc psy
ed cog; predict/sev

Sakzewski, Ziviani, 1996.
des/rev; def/phys; predict/sev med treat

Sakzewski, Ziviani, Swanson, 1996.
des/comp pro int; def/phys; predict/age sex cause
treat; out/cost phys

Sandermann, Haase, Bartholdy, et al, 1986.
des/case pro int fu; def/phys; int/acute surg; out/phys

Savage, 1991.
des/rev

Savage, 1997.
des/oped; predict/treat

Schmitt, Bauersfeld, Fanconi, et al, 1997.
des/pro observ; def/phys

Schmitz, Skinner, 1993.
des/method

Segalowitz, Brown, 1991.
des/surv pop; def/mot beh edu; predict/age

Segalowitz and Lawson, 1995.
des/cor retro surv; def/phys cog beh psyc

Sellars, Vegter, and Flaig, 1997.
des/case rev

Selz, 1979.
des/com pro observ conv; def/mot cog

Shaffer, Bijur, Chadwick, et al, 1980.
des/pro observ pop fu; def/lang; predict/site

Sharma and Sharma, 1994.
des/retro pop observ; def/phys mort reint

Shurtleff, Massagli, Hays, et al, 1995.
des/case; def/cog

Sigelman and Shaffer, 1995.
des/method

Silver, Boake, and Cavazos, 1994.
des/case int fu; def/cog beh reint; interv/behm;
out/beh adl

Skinner, Zimmer-Gembeck, and Connell, 1998.
des/method

Skippen, Seear, Poskitt, et al, 1997.
des/pro int; def/phys; interv/phys; out/ophys

Slater and Bassett, 1988.
des/control retro observ fu; def/cog lang

Slifer, Cataldo, Babbitt, et al, 1993.
des/case int; def/beh; interv/behm; out/obeh

Slifer, Cataldo, Kurtz, 1995.
des/case int; def/beh; interv/behm; out/beh

Slifer, Tucker, Gerson, et al, 1996.
des/case int; def/beh; interv/behm; out/obeh

Slifer, Tucker, Gerson, et al, 1997.
des/case pro int fu; def/beh; interv/behm; out/obeh

Sobus, Alexander, Harcke, 1993.
des/pro observ cons; def/phys

Sokol, Ferguson, Pitcher, et al, 1996.
des/comp observ fu; def/beh famf; predict/age pfam
socio psych

Sollee, Kindlon, 1987.
des/comp pro; def/cog beh; predict/site

Song, Kim, Kim, et al, 1997.
des/rev; def/phys mort

Splaingard, Gaebler, Havens, et al, 1989.
des/comp retro observ fu; def/phys mort reint;
predict/med

St. James-Roberts, 1979.
des/rev

Sternlicht, 1989.
des/method

Stiles, Nass, 1991.
des/cscon observ; def/cog; predict/site

Stiles, Stern, Trauner, et al, 1996.
des/control observ; def/phys cog; predict/site

Stiles-Davis, Sugarman, Nass, 1985.
des/comp pro observ conv; def/cog; predict/site

Stiles-Davis, Janowsky, Engel, et al, 1988.
des/control pro observ conv; def/mot cog; predict/site

Sutton, Wang, Duhaime, et al, 1995.
des/pro observ; def/phys; interv/acute; out/ophys

Suzman, Morris, Morris, et al, 1997.
des/case pro int fu; def/phys cog; interv/edu; out/ocog
oedu

Szatmari, 1985.
des/rev

Taylor, Alden, 1997.
des/rev; def/phys beh cog; predict/pre site socs

Telzrow, 1987.
des/rev; def/ed

Tepas, DiScala, Ramenofsky, et al, 1990.
des/retro observ pop; def/mort; predict/cause

Thakker, Splaingard, Zhu, et al, 1997.
des/retro observ pop fu; def/phys reint mort;
predict/sev age

Thal, Marchman, Stiles, et al, 1991.
des/long pro observ pop fu; def/lang; predict/age dev
site

Thatcher, 1991.
des/control retro observ pop; def/phys; predict/age
site

Thompson, Francis, Stuebing, et al, 1994.
des/long pro observ conv; def/mot cog; predict/sev
age dev

Tomberg, Rink, Pikkoja, et al, 1996.
des/retro observ cons; def/phys reint; predict/med

Tompkins, Holland, Ratcliff, et al, 1990.
des/cor long observ; def/beh cog lang phys;
predict/sev pre age pfam

Trauner, Ballantyne, Friedland, et al, 1996.
des/control pro observ conv; def/lang; predict/site

Tucker, Colson, 1992.
des/rev

Turkstra, Holland, 1998.
des/cscon observ; def/lang cog

Turkstra, McDonald, Kaufmann, 1996.
des/comp case observ; def/lang cog

Vander, Sherman, Luciano, 1970.
des/method

Vander Schaaf, Kriel, Krach, et al, 1997.
des/comp cor observ cons fu; def/phys mot;
predict/sev cause

Vartiainen, Karjalainen, Karja, 1985.
des/case observ fu; def/phys

Vigil-Sewell, Sargent, 1996.
des/oped

Virginia, 1991.
des/retro surv pop; def/phys mot lang psyc edu

Waaland, Kreutzer, 1988.
des/rev

Waaland, 1991.
des/rev; famf

Waaland, Burns, Cockrell, 1993.
des/surv; def/famf reint

Wade, Drotar, Taylor, et al, 1995.
des/rev; def/famf; predict/pre pfam

Wade, Taylor, Drotar, et al, 1996.
des/control cor pro observ fu; def/phys psy famf;
predict/socs psych

Wade, Taylor, Drotar, et al, 1998.
des/control long observ; def/phys famf psyc;
predict/sev

Ward, 1995.
des/oped

Warschausky, Cohen, Parker, et al, 1997.
des/cscon observ; def/cog soc; predict/sev sex

Warzak, Allan, Ford, et al, 1995.
des/comp surv cor; def/reint

Webb, Rose, Johnson, et al, 1996.
des/comp observ sur; def/reint; predict/age

Willett, Ayoub, Robinson, 1991.
des/method

Willett, Sayer, 1994.
des/method

Williams D, Mateer, 1992.
des/case observ fu; def/cog beh soc; predict/site age

Williams SE, Ris, Ayyangar, et al, 1998.
des/control pro dbl int; def/beh cog; int/acute pharm;
out/obeh ocog

Wilson, Powell, Brock, et al, 1996.
des/case int rev; def/phys; interv/acute; out/phys;
predict/age sex

Winogron, Kinghts, Bawden, 1984.
des/comp pro observ conv; def/mot cog; predict/sev

Wit, Maassen, Gabreels, et al, 1994.
des/cscon control comp observ; def/lang;
predict/cause

Wolcott, Lash, Pearson, 1995.
des/prog rev; def/edu

Woods, 1980.
des/comp pro observ cons; def/cog; predict/site

Woods, Carey, 1979.
des/control pro observ conv; def/lang; predict/age

Worley, Hoffman, Paine, et al, 1995.
des/case cor pro int fu; def/phys; interv/phys;
out/ophys; predict/treat

Worthington, 1989.
des/rev; def/psy famf soc reint

Yeates, Blumenstein, Patterson, et al, 1995.
des/control pro observ consec; def/cog; predict/sev
age

Yeates, Taylor, Drotar, et al, 1997.
des/comp pro observ fu; def/cog beh famf soc;
predict/sev pre pfam socs

Ylvisaker, 1986.
des/rev

Ylvisaker, 1993.
des/rev

Ylvisaker, Feeney, 1995.
des/rev

Ylvisaker, Szekeres, Hartwick, et al, 1994.
des/rev

Ylvisaker, Weinstein, 1989.
des/rev; def/phys psy cog beh soc famf

Yorkston, Jaffe, Polissar, et al, 1997.
des/cscon cor pop observ; def/cog lang; predict/sev
cog

Zencius, Wesolowski, Burke, 1989.
des/case pro int fu; def/beh psy; int/behm; out/reint

Zimmer-Gembeck, 1998.
des/method

Zuckerman, Conway Jr, 1997.
des/rev