Objectives:

The goal was to conduct a systematic review of the literature about child and adolescent traumatic brain injury (TBI) oriented around key research questions and to create a tool that would be used in future evidence-based investigations about recovery from TBI in this population. A matrix was prepared to organize research according to the developmental dimensions and age categories addressed by studies. With the assistance of technical experts, key questions were formulated about (1) the effectiveness of early, intensive rehabilitation; (2) referral of children with TBI to special education; (3) the effectiveness of special education for children with TBI; (4) the effect of developmental phase on prediction and outcome; and (5) the effect of support for families. Patient populations, interventions, and outcome measures were defined, and literature was compiled and categorized from seven databases -- medical, educational, and psychological. The strongest studies that contained data about the key questions were reviewed, and an evidence table template was created for use in future comprehensive studies. In the evidence report, methods are proposed for conducting research and evaluating data about children and adolescents with TBI that can incorporate and account for individual differences and the influence of growth and change on the recovery process.

Search Strategy:

A search was conducted of MEDLINE (1976-1998), CINAHL (1982-1998), HealthSTAR 1995-1998), PsychINFO (1982-1998), ERIC (1996-1998), Current Contents (1998), and the Cochrane Library, supplemented by reference lists of review articles, book chapter bibliographies, and the advice of peers.

Results:

The initial search strategy yielded 1,464 abstracts of potentially relevant studies. All studies about child or adolescent TBI -- from acute management through long-term rehabilitation -- were categorized by study design, deficit, intervention, outcome, and predictors, and they were included in the bibliography. Three-hundred fifty-six articles identified from electronic databases and manual searches relevant to one of the five research questions were retrieved and read. Studies containing data were evaluated by a member of the research team. One study was found for question 1; 15 studies were found for question 2; 8 studies were found for question 3; 61 studies were found for question 4; and 3 studies were found for question 5 (88 total). The remaining 268 articles described programs or interventions without providing patient or student data.

No randomized controlled trials and very few comparative studies were found that addressed the key research questions. One study suggests that the early introduction of physiatry during the acute care phase of treatment aids in detecting musculoskeletal trauma that may otherwise be missed. No literature was found that accurately documents rates of referral for children with TBI to special services. Although the available single-subject studies suggest beneficial effects of special school programs, methodologic flaws in the one comparative study render its findings inconclusive. A large body of literature documents the utility of patients' developmental information in predicting deficits and outcomes. Correlational studies associate family support with better family functioning.

In general, studies have not been conducted with designs capable of providing evidence on the effectiveness of interventions for children and adolescents with TBI. 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 the important hypotheses for controlled studies.