Am Fam Physician. 2000 Jun 1;61(11):3465-3466.
The Agency for Healthcare Research and Quality (AHRQ; formerly the Agency for Health Care Policy and Research) has released an evidence-based report on the rehabilitation of children and adolescents with traumatic brain injury. The report is the product of the AHRQ evidence-based practice program. This program compiles and analyzes scientific information on which to base clinical guidelines, performance measures and other tools for improving the quality of health care. AHRQ contracts with institutions to review all relevant scientific literature on a particular clinical topic and produce evidence reports and technology assessments, conduct research on the effectiveness of various methods of clinical care and participate in technical assistance activities.
The AHRQ evidence report on rehabilitation after traumatic brain injury in children and adolescents was developed at the Oregon Health Sciences University, Portland, which is one of the AHRQ's evidence-based practice centers.
The five-page summary of the evidence report is available on the AHRQ Web site (http://www.ahrq.gov/clinic/). Print copies are available from the AHRQ Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907; phone: 800-358-9295 in the United States; 410-381-3150 from outside the United States. The following summarizes the AHRQ evidence-based report on rehabilitation after traumatic brain injury in children and adolescents.
Key Questions to Answer
The evidence report, titled “Rehabilitation for Traumatic Brain Injury in Children and Adolescents” (AHRQ Publication No. 99-E025), identifies five key questions for assessing the effectiveness of rehabilitation interventions in children and adolescents with traumatic brain injury. The five questions are as follows:
Does early, intensive medical rehabilitation in the hospital improve outcomes in children with traumatic brain injury?
How many children with traumatic brain injury receive special education designed to accommodate their needs as a result of the brain injury?
Do children who receive special education designed to accommodate their needs have better outcomes than children who do not receive such individualized special education or who receive no special education at all?
Does identification of the child's developmental stage at the time of the brain injury and at the time of assessment help predict the child's outcome? Does the extent to which the injury has arrested the child's normal development increase the ability to predict when the child will exhibit the needs, behaviors and problems resulting from the brain injury?
Does support of the families of children with brain injury enhance the family's ability to cope and reduce the burden of illness?
The report notes that any research question about childhood brain injury must be oriented to the relevant developmental category and age group of the child, including the child's age at the time of injury, the child's age at evaluation and the interval between the injury and the assessment.
In an attempt to answer the five key questions, a total of 356 articles were reviewed. Of these articles, one study was found for the first question, 15 for the second question, eight for the third question, 61 for the fourth question and three for the fifth question. The remaining 268 articles described interventions but did not provide data on the patients/students.
Question 1: How Effective Is Early Rehabilitation?
According to the report, no randomized controlled trials and no comparative studies have investigated the efficacy of early, intensive rehabilitation following traumatic brain injury in children and adolescents. Inferences about early intervention in children have been drawn from studies of adults.
Three studies were reviewed for indirect information. One study suggested that early, thorough evaluation, including bone scans, may identify undetected musculoskeletal trauma and heterotopic ossification. The authors of the study indicated that special methods for detecting physical trauma are important in patients with traumatic brain injury.
Question 2: How Many Children Receive Special Education?
The AHRQ report notes that three retrospective studies and one cross-sectional statewide study revealed that between 9 and 38 percent of students with identified brain injury are referred to special education. Whether the reported referral rates represent adequate referral, under-referral or overreferral could not be determined. Students with traumatic brain injury who did not receive special education were not included in the studies. Thus, data are not available on the number of children who are functioning well without special education services.
Question 3: Does Special Education Improve Outcome?
Data about the effects of special education programs are limited, according to the AHRQ report. One nonrandomized comparative study, one small case series, one survey and five case studies provide varied results. The report notes that the methodology of the comparative study is flawed because the control group performed significantly better than the treatment group at pretesting, suggesting that the control group was not as impaired as the treatment group. In the five case studies, all of the patients showed improvement over baseline measures.
Question 4: Can Deficits Predict Subsequent Needs and Problems?
A review of the literature uncovered 61 studies that provided data on the predictability of deficits based on developmental issues. The seven studies with the highest methodologic scores were selected for analysis.
In a study of language acquisition, predictable patterns of delays and deficits in language acquisition were demonstrated in children up to three years of age. Two cross-sectional studies established the base rate measures of brain growth at each stage of development that are necessary to detect the developmental effects of injury. Two comparative studies revealed subtle, hidden deficits in children who appeared to perform normally. Two studies demonstrated changes in growth that were strongly related to brain injury variables.
Question 5: Does Family Support Reduce the Burden of Illness?
No randomized controlled trials have been performed to compare the effects of support to families with the effects of no support. According to the AHRQ report, a randomized trial on the effects of two forms of support for the family suggest that intervention for parents of children with brain injury may be more effective in reducing the burden of illness if it focuses on the needs of the parents as opposed to the needs of the child. In a prospective observational study, a direct correlation was found between the presence of social support and measures of family functioning three years after the injury occurred. In addition, a number of studies have demonstrated a relationship between higher levels of family functioning and better outcomes for the injured child.
The AHRQ evidence-based report on rehabilitation following traumatic brain injury ends with the statement that no studies have been conducted to provide evidence of the effectiveness of rehabilitation interventions in children and adolescents. The published literature contains information on descriptions of intervention programs that are widely accepted but their effectiveness has not been validated. The report suggests that future research could be guided by themes that have emerged across many disability groups. While traumatic brain injury is unique, it also shares features of other disabilities.
Analysis of the literature revealed three gaps in the literature, which, according to the report, serve to identify priorities for future research. One gap is the insufficient evidence about the natural history of traumatic brain injury in children and adolescents. Another is the absence of experimental studies to assess effectiveness of different interventions. The third gap relates to the failure to incorporate concepts of child and adolescent development in longitudinal and experimental studies of traumatic brain injury.
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