Long-term Benefits of an Early Online Problem-Solving Intervention for Executive Dysfunction After Traumatic Brain Injury in Children

Abstract

IMPORTANCE Executive dysfunction after traumatic brain injury (TBI) in children is common and leads to significant short- and long-term problems in functioning across multiple settings. We hypothesized that improvements in short-term executive function would be maintained to 24 months after injury and that improvements would increase over time in a counselor-assisted problem-solving (CAPS) intervention. OBJECTIVE To evaluate the efficacy of a CAPS intervention administered within 7 months of complicated mild to severe TBI compared with an Internet resource condition in improving long-term executive dysfunction. DESIGN, SETTING, AND PARTICIPANTS Multisite, assessor-blinded, randomized clinical trial at 3 tertiary pediatric hospitals and 2 tertiary general medical centers. Participants included 132 adolescents aged 12 to 17 years who sustained a moderate to severe TBI 1 to 7 months before study enrollment. INTERVENTION Web-based CAPS intervention. MAIN OUTCOMES AND MEASURES The primary outcome was the parent-reported Global Executive Composite (GEC) of the Behavior Rating Inventory of Executive Function. Secondary outcomes included the Behavioral Regulation Index (BRI) and Metacognition Index (MI) of the GEC. RESULTS In older (>14 to 17 years) adolescents, the CAPS intervention was associated with lower GEC ratings at 12 (β = −0.46; P = .03) and 18 (β = −0.52; P = .02) months after enrollment. Trends were also observed for older adolescents toward lower GEC ratings at 6 months (β = −0.40; P = .05), lower BRI ratings at 12 (β = −0.40; P = .06) and 18 (β = −0.47; P = .04) months, and lower MI ratings at 6 (β = −0.41; P = .05), 12 (β = −0.46; P = .03), and 18 (β = −0.50; P = .03) months. In younger (12–14 years) adolescents, no group differences were found on the GEC, BRI, or MI ratings. CONCLUSIONS AND RELEVANCE Delivery of the CAPS intervention early after TBI in older adolescents improves long-term executive function. This trial is, to our knowledge, one of the few large, randomized clinical treatment trials performed in pediatric TBI to demonstrate the efficacy of an intervention for management of executive dysfunction and long-term benefits of an intervention delivered soon after injury. Use of the CAPS intervention clinically should be considered; however, further research should explore ways to optimize delivery. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00409448

Personality Change Due to Traumatic Brain Injury in Children and Adolescents: Neurocognitive Correlates

“…Clinical trials of mood stabilizers are very difficult to accomplish, especially for children with PC, but should be done. Cognitive rehabilitation targeting processing speed, attention, problem solving, and memory may enhance cognitive control (a form of executive function) over emotional expression and should be tested 39 . It is conceivable that more specific emotional probes such as utilized in social cognition and affect recognition studies will further clarify important mechanisms in children with PC and possibly other disorders of affective dysregulation 34,36,40-42 .…”

Online Problem-Solving Therapy After Traumatic Brain Injury: A Randomized Controlled Trial

“…5,7 Tele-health treatments may benefit adolescents after TBI. [5][6][7][12][13][14][15]20 However, meta-analyses comparing online to traditional face-to-face approaches for various psychiatric and medical conditions have yielded mixed conclusions. 14,21,22 Although some reviews indicated comparable efficacy of traditional and tele-health interventions, 22 others noted smaller effects for online treatments.…”

“…The structured interview and parent-reported measures were completed at baseline and again immediately after treatment (6 months postbaseline) and at 12 and 18 months postbaseline. 20 Participants were randomly assigned to the following groups: (1) Counselor-Assisted Problem Solving (CAPS), a 6-month Web-based, therapist-moderated intervention providing training in problem-solving, communication, and self-regulation, or (2) IRC, a control intervention providing self-guided, Web-based TBI information and resources. Randomization was stratified according to race and gender.…”

“…The CAFAS was chosen as a primary outcome because it better predicts subsequent service utilization than either behavior checklists or psychiatric diagnoses 31 and has been widely used to assess changes in clinical outcomes for youth receiving mental health services. 20 The CAFAS generates ratings of functioning in 8 domains: school, home, community, behavior toward others, moods/ emotions, self-harmful behaviors, substance abuse, and thinking. 32 Functioning in each domain is rated on an ordinal scale ranging from 0 (no impairment) to 30 (severe impairment) in increments of 10.…”

Costs of development and maintenance of an internet program for teens with type 1 diabetes

“…[14] Researchers are also exploring ICBT for youth, but research on efficacy is limited. [15, 16] Other internet programs have been shown to improve outcomes in the management of conditions such as headache, back pain, tinnitus, urinary stress incontinence, smoking cessation, and medication adherence in adults[17–20], and encopresis[21], traumatic brain injury[22], diabetes management[23, 24], eating disorders[25], and prevention of high risk behaviors[26, 27] in youth.…”