Despite what is known about the prevalence of agitation post TBI in the adult and pediatric populations, there is little in the literature addressing this issue with children. Significant increases in problematic behaviours such as aggression, disinhibition, impulsiveness, defiance, and non-compliance are very common post injury (Gerring et al. 2009; Sohlberg 2001). Additionally, following a TBI, children are at a greater risk for internalizing behaviours, such as anxiety, depression, and personality changes (Li & Liu 2013). Often, these behaviours occur during the critical stages of rehabilitation, interrupting rehabilitation and education goals (Gurdin et al. 2005).
Non-Pharmacological Interventions to Treat Behavioural Disorders
Behavioural therapies are directed at reducing or eliminating such problematic behaviours through the application of well-established behavioural and social learning principles. These treatments involve identifying relevant stimulus cues, systematically charting behaviours, and implementing reinforcement contingencies to establish appropriate behaviours. Once adequate behavioural control is established in specific situations, external cues and contingencies can eventually be reduced or withdrawn with maintenance of the desired behaviours.
Different behavioural profiles are typically seen at different stages after injury. For example, early behavioural consequences often include restlessness and agitation associated with confusion and disorientation. As recovery continues, problems with impulse control, cooperation with treatment activities and appropriate social interactions may emerge. Challenging behaviors have been related to both neurological (e.g. injury severity) and interpersonal (e.g., coping skills) factors, and several models have been put forward to describe the various influences on behavioral difficulties following ABI (Prigatano 1992; Sbordone 1990). Continued problematic behavior in children and adolescents after brain trauma is a major barrier to medical care, rehabilitation, and eventual independent living (Gerring et al. 2009).
In their review of psychological interventions in children with ABI, Warschausky et al., (1999) indicated that most of the literature on behavioural therapies in children with ABI has focused on externalizing features (e.g., aggression, disruptive behaviours) but that few studies had involved rigorous evaluation of specific interventions. These authors concluded that behavioural therapies in this population appear promising but are in need of further empirical support. It appears that operant conditioning paradigms for decreasing aggressive behaviours has been successful, although there are inconsistent reports of maintenance of gains. Currently, three categories of behavioural therapies have been evaluated in the literature for pediatric TBI. The three categories that are outlined below are online counsellor assisted problem solving therapy, cognitive behavioural therapy, and case studies with specific behavioural interventions.
Three studies examined the effects of online problem solving for adolescents within one year following a moderate TBI, in hopes of remediating refractory behavioural problems (Wade et al. 2014; Wade, Taylor, et al. 2015; Wade et al. 2011). Online problem solving improved parental ratings of externalizing, but not internalizing behaviours in children (Wade et al. 2014). Conflict between parents and adolescents was significantly reduced following training, which may lead to additional behavioural improvements over time (Wade et al. 2011). Adolescents with low socioeconomic status and greater injury severity were more susceptible to initial behavioural problems following injury; however, this subset of adolescents received the greatest benefit from online problem solving therapy (Wade et al. 2011). Similarly, children that had more externalizing behaviours prior to the intervention indicated significant reduction in externalizing behaviours post-intervention (Wade, Taylor, et al. 2015). Problem solving training is important for teaching general coping skills that will lead to situational adaptations and improvement in behavioural competence, which can reduce or prevent the negative associations with stress that are prominent following a TBI (Wade et al. 2014).
Cognitive behavioral therapy used in children that had sustained a severe TBI improved adaptive behaviour and reduced dysfunctional behaviours such an anxiety, depression, and internalizing behaviours, compared to controls (Pastore et al. 2011). As seen with online therapy (Wade et al. 2011), children with greater behavioural impairments at baseline improved the greatest in parental ratings of behaviour on the child behaviour checklist (Pastore et al. 2011). Cognitive behavioural therapy would be beneficial for children to obtain adequate social reintegration following a severe TBI (Pastore et al. 2011).
An earlier method of evaluating a particular behavioural therapy was to compare pre- and post-intervention results for a small number of subjects (Pruneti et al. 1989; Slifer et al. 1993; Slifer et al. 1995; Slifer et al. 1997). One study in this area used a similar but somewhat more robust design by implementing multiple baselines (Selznick & Savage 2000). While all of the studies reviewed reported at least short-term gains in behaviour management following the interventions, the majority of these studies were uncontrolled multiple or single case reports. Moreover, in many of the multiple-case studies, subjects were not matched on many seemingly important variables, such as age, IQ, extent of cognitive deficits, or concurrent medication use.
An important variable that differs widely across studies is the time since injury. This is important because, as previously mentioned, different behavioural problems may appear at different stages of recovery. For example, Slifer and colleagues (1993; 1995; 1997) have focused on the very early stages of recovery, during the post-traumatic amnesia phase, whereas other researchers have studied children or adolescents years after a brain injury (Glang et al. 1997; Selznick & Savage 2000).
There is a need for research in this area to focus on family factors that influence behaviour problems. It has been shown that behavioural problems in children with ABI are related to aspects of family functioning (Rivara et al. 1992; Taylor et al. 2002). Moreover, the family context is an important aspect of rehabilitation that clearly distinguishes children from adults with ABI. Finally, the majority of the research in this area has been carried out with adolescents and school age children. There is little to inform practice with very young children (under 5 years of age), although this age group shows a relatively high peak in incidence for ABI.
There is Level 1b evidence that online problem solving therapy improves externalizing behaviours in adolescents, when compared to an internet resource control group.
There is Level 2 evidence that cognitive behavioural therapy is effective to reduce parent-adolescent conflict compared to children who did not receive therapy.
There is Level 4 evidence that behavioural therapies for children with ABI are effective at reducing or eliminating problematic behaviours.
Behavioural therapies for children are effective at mitigate behavioural problems in children following an ABI. Little is currently known with respect to family factors that influence treatment, behavioural therapies for preschool children, and therapy for behaviours beyond the scope of externalizing problems.
Online problem solving therapy improves externalizing behaviours in adolescents following a moderate TBI.
Cognitive behavioural therapy improves behavioural and psychological problems in children following a severe TBI.
PHARMACOLOGICAL INTERVENTIONS TO TREAT BEHAVIOURAL DISORDERS
Pharmacological interventions are often introduced to treat aggressive or agitated behaviours post TBI in children and adults (Suskauer & Trovato 2013). To date, no medication has proven to be effective in modifying outcomes in a child with a brain injury. Investigators have studied the role of the psychostimulant methylphenidate and other dopamine enhancing medication, such as amantadine, and the efficacy of these medications on aggression and agitation.
As mentioned earlier in promoting emergence from the unconscious state, amantadine is a non-competitive N-methyl-D-aspartate receptor antagonist. Currently it is used as a prophylaxis for influenza-A, for the treatment of neurological diseases such as Parkinson’s disease and for the treatment of neuroleptic side-effects such as dystonia, akinthesia and neuroleptic malignant syndrome (Schneider et al. 1999). It is also thought to work pre- and post-synaptically by increasing the amount of dopamine (Napolitano et al. 2005).
Amantadine administration was determined to be safe to administer to children (Green et al. 2004). Although there were unfavourable side effects, such as aggression and nausea, these side effects remitted upon modification of dosage, cessation of amantadine treatment (Green et al. 2004) or following 2 days of administration (Beers et al. 2005).
In terms of efficacy, amantadine administration reduced the frequency of negative behaviours associated with frontal lobe injuries after 12 weeks of treatment (Beers et al. 2005). Subjective review of charts from observed behaviours in children (alertness, verbalizations, agitation) also improved; however a lack of comparator questions if such improvements would be due to natural recovery or amantadine itself (Green et al. 2004). Although behaviours improved following amantadine treatment, cognitive function did not improve (Beers et al. 2005). Results must be taken with caution due to lack of blinding between conditions and lack of comparators. Future placebo controlled trials are warranted to determine the efficacy of amantadine to reduce negative behaviours in children following a TBI (Beers et al. 2005).
There is Level 2 evidence that the use of amantadine can decrease the amount of aberrant behaviours compared to usual care among children with a TBI.
There is Level 3 evidence that amantadine is safe to administer in children following a TBI and facilitates rate of recovery post-traumatic brain injury.
Amantadine has been shown to decrease undesirable behaviours post TBI in children.
Amantadine has also been shown to be safe to administer and to improve the rate of recovery in children post TBI.