Acquired brain injury (ABI) in children

Acquired brain injury (ABI) refers to any damage to the brain that occurs after birth. Acquired brain injury is often divided into two categories; traumatic(resulting from an external force to the brain, for example from road traffic accidents or falls), and non-traumatic (such as a stroke or brain tumour).

The prevalence rates of ABI occurring in childhood are very high. Reports from the United Kingdom suggest that approximately 3000 children acquire significant new neurological or cognitive disability as a result of ABI every year.1 However, these figures probably underestimate the true incidence of ABI because of diagnostic errors, as well as a large proportion of people who do not seek medical attention, resulting in an under-reporting of mild injury.

The incidence of ABI is most common in the age group 15–35 years, and is more common in males, which is thought to be related to increased risk taking behaviour, such as accidents involving sport or alcohol.2 Road traffic accidents are the most common cause of ABI in older children and adolescents, whilst falls, being dropped or non-accidental injuries are more common in younger children and infants.3

The consequences of ABI

The range in severity of ABI is broad, ranging from concussion to persistent vegetative states, or fatality. The majority of children with ABI suffer concussion (85%), which is not considered to cause permanent impairments in children.4 However, ABI is also a significant cause of permanent disability amongst children and adolescents.5,6

ABI is often referred to as a “hidden disability”, as survivors may have no physical evidence of their injury, and many of the impairments are not visible to others. Indeed, as a child recovers from the initial stages of ABI, longer term effects may become apparent. The negative consequences of ABI can severely and permanently change a child’s life, as well as having a profound impact on the child’s family as a whole.

ABI can cause a range of long-term disabilities such as communication and cognitive deficits,7 sleep disturbance,8 physical impairments such as post traumatic epilepsy,9 depression 10 and high rates of behaviour problems.11 ABI is usually categorised as either mild, moderate, or severe, depending on the level of consciousness and functioning post-injury. More severe ABI is related to greater impairments of neurobehavioural function.12,13

It is usually the cognitive, behavioural and personality deficits that produce the greatest disruption to quality of life, rather than the physical deficits. Indeed, the long-term effects, when children move into adolescence and adulthood, can lead to unemployment, difficulties maintaining personal relationships, marital breakdown, loss of pre-injury roles, and loss of independence in adulthood. Indeed, the true extent of these impairments may only become apparent when the child or adolescent returns to education. Many behavioural and cognitive problems tend to emerge when the child fails to meet developmental milestones.14

 Impact on the family:

It is well recognised that ABI affects not just the injured individual, but the family as a whole.19,20 Immediately after their child’s injury, families experience common emotional reactions, including panic and fear, shock and denial, anger, guilt, isolation, and hope.21 Although many families eventually adapt favourably to the increased demands of the injury, it is also common for parents of children with ABI to experience high levels of parental burden, psychological distress, and deterioration in family relationships 22 which can persist for as long as 3 years post-injury.23 Emerging behaviour problems and concerns about the child’s ability to function independently 13,24 may drain family resources and coping abilities. Furthermore, the high levels of stress observed amongst parents of children with ABI may also contribute to marital breakdown.25

The developmental transitions from childhood to adolescence or young adulthood and the associated challenges can contribute to greater parental stress and family conflict. 26 Families also tend to experience deteriorating family functioning when they have low social resources or support. This suggests that social support may serve as a protective factor from the additional adversity arising from severe ABI.27

Prognosis of ABI

A number of recent studies have found pre- and post-injury factors which may have a significant effect on both cognitive and behavioural outcomes after ABI, and hence, recovery. With regard to pre-injury factors, research has indicated that children who are younger at time of injury, have a pre-injury history of developmental or behavioural problems,29 lower pre-injury adaptive abilities,30 and that those who are from psychosocial disadvantaged families, (those who are at a disadvantage socially, because of their psychological difficulties) 31 are at higher risk for poor outcome. Furthermore, other research has found more positive developments after ABI in children from more advantaged backgrounds.32,33 Post-injury factors which may influence recovery from ABI include the area of the brain which is damaged, the severity of the damage,28 the quality and frequency of rehabilitation services, parental reactions to the injury, and parental stress.15

Many of the factors outlined above have also been associated with increased risk of having an accident which may lead to brain injury. Preinjury concentration difficulties and impulsivity have been identified as risk factors for ABI in children. Other research has found that low levels of maternal education and lower socio-economic status are associated with increased risk of accident.34,35

Prognosis and the recovery process of both children and adults vary considerably. It is, therefore, unlikely that one single factor can account for this wide variability in recovery patterns.36 It is most likely that a multitude of factors may act, both independently and interactively, to determine long-term prognosis.37,38

Implications for rehabilitation

Factors which appear to be critical for post-injury progress (e.g. social support, social advantage, and family adaptation) could be incorporated into rehabilitation interventions, which could improve the potential for positive change more than is currently recognised. Furthermore, a better understanding of factors that moderate outcomes of ABI would be useful in identifying high-risk children and families who may benefit most from intervention.

Rehabilitation

ABI rehabilitation often consists of two phases — inpatient and community management. Inpatient management is required for the acute phases of ABI within hospital settings, and sometimes placements within residential rehabilitation housing. Community rehabilitation involves discharge from an inpatient rehabilitation service, and the implementation of outpatient interventions, the goals of which are adjustment to the changes resulting from the injury, and the maximisation of independent daily living skills.39,40 For the child, the enhancement of everyday skills such as social competence and returning to school is frequently a major goal of outpatient rehabilitation.

Types of intervention for children with ABI:

• Neuropsychological interventions
Rehabilitation for ABI often utilises a neurobehavioural approach, in that itattempts to modify the person’s behaviour by teaching skills and strategies, whilst also taking into account the difficulties and limitations present as the result of the brain injury. Brain injury rehabilitation involves re-learning and practicing skills and abilities which can be restored to pre-injury level, and learning new skills and alternative strategies, where functions cannot be restored. The focus is on applying these skills in everyday settings and situations. Practicing alternative strategies enables the child to compensate for cognitive deficits and thus, lessen the functional impact of these impairments. A number of strategies can be used to enhance memory,41 whilst behavioural techniques based on operant conditioning 42 can be effective methods for reducing, managing, and/or preventing the inappropriate or challenging behaviours which can result from ABI.43,44

• Environmental modification
Making changes to the child’s environment, both within the home and school setting, can minimise the impact of impairments, aid children’s learning and minimise challenging behaviour. These include the implementation of a well-structured daily routine, minimising noise or other forms of distraction when the child needs to pay attention to a particular task, regular breaks from school work, providing reminders for upcoming tasks, reducing the demands of the task, or the provision of specially designed adaptive equipment. For children with severe deficits following ABI, education that focuses on teaching functional skills through day-to-day activities, rather than strictly academic content, may be required.

• Psycho-educational interventions
Studies have found that children with brain dysfunction have a limited understanding of how their brain injury was caused and the consequent impairments.45 Efforts have been made to investigate whether providing children and families with information about ABI would lead to positive outcomes. One study found that an educational programme designed to improve knowledge of ABI and awareness of deficit, failed to show any benefit for children and adolescents with ABI, although parents did report better understanding of their child’s difficulties.46 However, other research has demonstrated that providing an information booklet tailored for both children with ABI and their parents, resulted in a significant reduction in anxiety and in reporting of ABI symptoms 3 months after injury.47

• Family-based interventions
Some of the research reviewed so far has highlighted the important and influential role of family factors on the child’s recovery process and family adjustment to the injury. Parents, therefore, are in a strong position to facilitate their child’s recovery within a variety of everyday settings. Research indicates that family-based interventions can lead to reductions in parental anxiety and depression, increased understanding of their child’s injury and awareness of strategies to improve attention and behaviour, as well as improved parent– child relationships.48,49

 • Medication
Drugs are sometimes useful in the management of the symptoms resulting from ABI. Medication is often used for mood disorders, such as depression and anxiety, the neurological changes resulting from the injury such as epilepsy, and also for attention deficits.50

Remaining unmet needs and recommendations

Despite the abundance of research into the deficits resulting from ABI and the identified risk factors which have important implications for effective interventions, public and professional knowledge about paediatric ABI remains low within local communities, and hence, the needs of children with ABI are still largely unmet.

• Lack of knowledge and understanding of the consequences and support services available for children with ABI
Knowledge about the consequences and support needs of children with ABI is limited within communities, and among general practitioners and teachers. Additionally, as the children get older, the long-term consequences of TBI are often largely ignored or misinterpreted, having a negative impact on their education and quality of life. These issues were highlighted at the Task Force for Children and Adolescents during the International Brain Injury Association’s 2003 Conference in Stockholm, Sweden.

The recovery and adjustment processes of children with ABI and their families can be improved by ensuring that professionals involved in the child’s care and education are knowledgeable about ABI and the available support services, and can provide this information to families in a clear and understandable way.

• Lack of post-acute rehabilitation services specifically for children
Although acute medical care and corresponding rates of survival of ABI have improved dramatically,51 the treatment of the cognitive and behavioural changes following ABI is still in its infancy. Unfortunately, these are potentially the most enduring and, at times, incapacitating effects of brain injury with respect to long-term functional outcome. Hence, the availability and quality of care for post-acute rehabilitation and long-term interventions remains undeveloped in comparison. The availability of comprehensive post-acute rehabilitation services is particularly scarce for children and adolescents with ABI.

Although rehabilitation programmes have proven effective for children and adolescents with ABI,52 studies have found evidence to suggest that the profound and persistent negative impact on both the child and the family following paediatric ABI is typically not addressed by existing services. Internationally, professionals report limited availability of such resources for children, with disturbingly small numbers of injured children having access to rehabilitation resources.53 In a recent study of TBI in children and adolescents in western Sweden,54 it was shown that only 19% had received any form of rehabilitation. Di Scala and Savage (1997)55 have commented on this problem after following up 24,021 children and adolescents hospitalised for TBI. They reported that 27% of their sample had evidence of functional impairment on discharge. However, 75% of these children were discharged home with no active rehabilitation programme, and only 1.8% were referred for educational assistance.

The lack of child-specific rehabilitation within the community and in outpatient services may be the result of the incorrect assumption that children will recover more easily than adults from brain injury. In the face of the increasing evidence suggesting that children are in fact particularly vulnerable to persisting impairments after ABI, the lack of rehabilitation is particularly concerning.

While much is now known about outcome following ABI in the schoolaged population, only a small number of studies have examined the consequences and recovery in infants and young children with ABI. More research is required in this area. Similarly, child interventions have borrowed substantially from adult models of ABI rehabilitation. However, despite their strong research-base, such interventions are rarely the subject of rigorous testing. Indeed, Wade et al. (2005)56 point out that only two investigations have evaluated interventions for families following paediatric TBI.48,49

Furthermore, rehabilitation services rarely take into account the important developmental factors that need to be considered when working with children. An understanding of normal child development needs to be incorporated into contemporary intervention models for maximum efficacy. Child-specific rehabilitation approaches need to be appropriate for the developmental stage of the individual child. For example, many active rehabilitation strategies used in adult rehabilitation may be of limited use in early childhood because certain skills (e.g. executive functions) have yet to mature.

Some children may be more ‘at risk’ of poor prognosis after an ABI. The mounting evidence indicating that children from socially disadvantaged families are less likely to progress and adapt to their impairments and are more likely to have limited access to resources to aid recovery, suggests that these families may be most in need of ongoing specialist rehabilitation support.38 Research also suggests that families lacking social supports may benefit from interventions that provide support and facilitate coping, which may protect families from the additional adversity arising from severe ABI.56

• Rehabilitation services are often time-limited
When children and families do have access to rehabilitation services, these services are often time-limited. However, the ongoing impairments associated with ABI (particularly moderate and severe ABI) will often require lifelong ongoing professional involvement and rehabilitation. Information and support for children with ABI needs to be an ongoing process that engages every service provider involved in the child’s care.

The reviewed literature also demonstrates that children with ABI tend to particularly struggle with their impairments when approaching a developmental transition such as adolescence, or when failing to meet developmental milestones. These findings suggest that families may benefit from professional guidance in managing challenging life transitions with their injured child in order to aid adjustment.27

• Children often return to school without a psychological assessment or clinical input, and have teachers who are unaware of their injuries
For children with ABI, a return to mainstream school is often associated with good recovery. However, children with significant impairments in attention and memory after ABI are likely to struggle.57 Despite this, many children return to school after brain injury without adequate assessment or support.16,17

Indeed, Hawley (2004)18 found  that a significant majority of children with ABI had not received a psychological assessment or any clinical input from a psychologist following the ABI. This left 34 children exhibiting significant maladaptive behaviours. Not all teachers knew about the children’s ABI, particularly if it had occurred over a year ago. Consequently, teachers rarely associated behavioural problems and poor school performance with the ABI, leading to some child being formally disciplined by teachers.

These findings highlight the need for children with ABI to be screened to identify significant behavioural problems before they return to school. Steps need to be taken to ensure that all educators are knowledgeable about ABI and are prepared to help accommodate these students in any classroom environment. For children with significant difficulties, it is likely that specialised support will be needed when the child returns to school, and may be required throughout the child’s education.58 In the USA, Ylvisaker, Feeney and Mullins (1995)59 have proposed a school-based system for monitoring the academic and behavioural performance of children with ABI as part of a school re-entry programme, designed as a safety net to avoid the potential downward spiral of academic failure and negative behaviours in response to such failure. Indeed, such a programme may be beneficial in the UK.

• Lack of local specialised support and geographical limitations
Because local mental health providers may lack essential knowledge and expertise regarding ABI, child rehabilitation services are usually centralised in urban locations, serving large geographic areas. This means that families offered rehabilitation services have to make continuous long-distance journeys for a period of months or years to obtain services. This can be very time-consuming, involve arranging transportation, child care for other children and co-ordinating school and work schedules , which can add to parents’ stress. Although charities such as the Child Brain Injury Trust (CBIT)60 offer training courses and child and family support within local communities, this support is limited to Scotland, Northern Ireland, the north east of England, Oxfordshire and Buckinghamshire. More mental health resources within local communities are needed to assist families after the child returns home.58

 • Lack of accessible information about ABI
Following acute treatment of ABI, families report needing support as well as additional information about the child’s injury.3 However, many families report a lack of accessible information and this causes considerable stress. A review commissioned by the charity, Cerebra,61 found that nearly all of the parents of children with infection-related conditions and ABI reported severely inadequate information about their child’s condition and strategies to help them manage their child’s disability. Information booklets (such as the ones used in the Ponsford et al. 2001 study) seem to be a potentially important and simple measure, which could be provided to families and children by general practitioners and other professionals involved in the child’s recovery, and could be made available online.

Although a number of websites currently provide information and referrals regarding brain injury, most information is geared toward adult ABI. Wade, Wolfe, Brown and Pestian (2005)62 also discovered that there are no existing websites which provide one-to-one, synchronous assistance in coping with the challenges of TBI. Consequently, they tested the efficacy of a web-based family problem-solving intervention to improve family understanding, coping abilities, and adaptation to ABI. Eight parents and six children with moderate to severe ABI completed self-guided web exercises on problem-solving, communication, and antecedent behaviour management strategies. Positive outcomes included significant reductions in parents’ burden, depression, and stress, as well as reduced antisocial behaviours in the injured child. These findings suggest that a computer-based intervention may successfully be used to improve both parent and child outcomes following ABI in children.

Although in the early stages of research, computer-based interventions for children with ABI appear to be feasible and promising approaches for providing information and for facilitating the recovery progress of children along with adjustment, and coping in parents. Furthermore, these methods would also eliminate barriers to treatment highlighted above such as time, distance, and the unavailability of knowledgeable providers. Indeed, the findings also indicate that individuals with varied education and socioeconomic status can benefit from an online intervention.62 More research in this area with larger samples, control groups and measurements of the potential moderators is required.

Conclusion

ABI can have a profound negative impact on both the child and the child’s family. Yet knowledge about the consequences and support needs of children with ABI is limited within local communities, and among general practitioners and teachers. Both research and service provision for families of children with ABI remain underdeveloped in comparison to acute medical treatment and adult interventions.

Research has demonstrated that rehabilitation interventions can lead to positive outcomes for children with ABI and their families. Children, particularly those with significant impairments, require long-term multidisciplinary professional support and rehabilitation (possibly lifelong) within local communities, with particular emphasis on developmental transitions (e.g., school entry, adolescence). These interventions need to focus on enabling children to apply skills to everyday situations, which means supporting the family to facilitate the child’s recovery within the familiar home environment and enabling schools to accommodate the child’s needs. These services need to be tailored to meet the specific needs of the child and family, altering as their needs change over time. Interventions should be delivered using a variety of formats (e.g. computer based) in order to maximise access. Additional or specialised support may also be required for families from disadvantaged backgrounds with limited resources and social support, and for children with more severe impairments.

A number of pre- and post-injury factors have been found to moderate recovery and adjustment, and consequently, have important implications for developing and implementing much needed specialised child rehabilitation services. However, it is important to point out that, to date, no treatment after severe head injury is totally restorative. Therefore, interventions targeting the prevention of ABI are critical. Indeed, some of the moderators of change also represent risk factors for accidents leading to ABI, and should, therefore, be considered within preventative strategies.

References

1 Sharples, P.M. (1998). Head injury in children. In: Little and Ward Platt, eds. Injury in the young. Cambridge: Cambridge University Press, 151-75

 2 Khan, F., Baguley, I. J. and Cameron, I. D. (2003). Rehabilitation after traumatic brain injury. Rehabilitation Medicine, Vol 178, 290-295

 3 Hawley, C. A., Ward, A. B., Long, J., Owen, D. W., and Magney, A. R. (2002) Prevalence of Traumatic Brain Injury Amongst Children Admitted to Hospital in one Health District : A Population-based Study Injury prevalence revised march 02.doc

4 Asarnow R. F., Satz P., Light R., et al. (1995). The UCLA study of mild head injury in children and adolescents, in Broman SH, Michel ME (eds): Traumatic Head Injury in Children. New York, Oxford University Press, pp 117–46

 5 Kraus, J. F., Rock, A. and Hemyari, P. (1990). Brain injuries among infants, children, adolescents, and young adults. American Journal of Diseases in Children, 144: 684-691

 6 Snow, J. H. and Hooper, S. R. (1994). Pediatric Traumatic Brain Injury. California: Sage Publications

 7 Chapman S. (1997). Cognitive-communication abilities in children with closed head injury. American Journal of Speech- Language Pathology, 6:50–58

 8 Milroy G., Dorris L., and McMillan T. M. (2007). Brief Report: Sleep Disturbances following Mild Traumatic Brain Injury in Childhood. Journal of Pediatric Psychology

 9 Anderson V., Catroppa C., Morse S., et al. (2005). Identifying factors contributing to child and family outcome at 30 months following traumatic brain injury in children. JNNP, 76:401–8

 10 Joseph A. B. and Wroblewski B. (1995). Depression, antidepressants and traumatic brain injury. J Head Trauma Rehabil, 10: 90-95

 11 Bruce S., Selznick-Gurdin L., and Savage R. (1994). Strategies for managing challenging behaviors of students with brain injuries. Wake Forest, NC: Lash and Associates Publishing and Training, Inc

 12 Winogron H. W., Knights R. M. and Bawden H. N. (1984). Neuropsychological deficits following head injury in children. J Clin Neuropsychol, 6: 269–86

 13 Fletcher J. M., Ewing-Cobbs L., Miner M. E., Levin H. S., and Eisenberg H. M. (1990). Behavioral changes after closed head injury in children. J Consult Clin Psychol, 58: 93–8

 14 Barnes M., Dennis M., and Wilkinson M. (1999). Reading after closed head injury in childhood: Effects on accuracy, fluency and comprehension. Dev Neuropsychol 15:1–24

 15 Kinsella, G., Ong, B., Murtagh, D., Prior, M., Sawyer, M. (1999). The role of the family for behavioural outcome in children and adolescents following traumatic brain injury. Journal of Consulting and Clinical Psychology, 67(1): 116-123

 16 Jones, A. and Johnson, D. (1994). A study of the educational provision for head injured children. British Journal of Special Education, 21, 113-117

 17 Scott-Jupp, R., Marlow, N., Seddon, N. and Rosenbloom, L. (1992). Rehabilitation and outcome after severe head injury. Archives of Disease in Childhood, 67: 222-226

 18 Hawley, C. A. (2004). Behaviour and school performance after brain injury. University of Warwick

 19 Thomsen, I.V. (1974). The patient with severe head injury and his family. Scandinavian Journal of Rehabilitation Medicine, 6, 180-183

 20 Brooks, N., Campsie, L., Symington, C., Beattie, A. and McKinlay, W. (1987). The effects of severe head injury on patient and relative within seven years of injury. Journal of Head Trauma Rehabilitation, 2: 1-13

 21 Wagner M. and Stenger K. (2000). Acute brain injury: a guide for family and friends. Iowa: University of Iowa Health Care, University Hospital School

 22 Rivara, J. B., Jaffe, K. M., Polissar, N. L., Fay, G. C., Liao, S., and Martin, K. M. (1996). Predictors of family functioning and change 3 years after traumatic brain injury in children. Archives of Physical Medicine, 77, 754–764

 23 Wade, S. L., Taylor, H. G., Drotar, D., Stancin, T., Yeates, K. O., and Minich, N. M. (2002). A prospective study of long-term caregiver and family adaptation following brain injury in children. Journal of Head Trauma Rehabilitation, 17, 96–111 13

 24 Schwartz, L., Taylor, H. G., Drotar, D., Yeates, K. O., Wade, S. L., and Stancin, T. (2003). Long term postinjury-onset behavior problems following pediatric traumatic brain injury: Incidence, predictors, and correlates. Journal of Pediatric Psychology, 28(4), 251–263

 25 Hawley, C. A., Ward, A. B., Magnay, A. and Long, J. (2003). Parental stress and burden following traumatic brain injury amongst children and adolescents. Brain Injury, 17 (1): 1-23

 26 Silverberg S. B. (1996) Parents well-being at their children’s transition to adolescence. In Ryff C. D. and Seltzer M. M. (Eds.). The Parental Experience at Midlife (University of Chicago Press,Chicago) pp. 215–254

 27 Wade, S. L., Taylor, H. G., Yeates, K. O., Drotar, D., Stancin, T., Minich, N. M. and Schluchter, M. (2006). Long-term Parental and Family Adaptation Following Pediatric Brain Injury. Journal of Pediatric Psychology, 31(10):1072-1083

 28 Anderson V., Catroppa C., Morse S., et al: (2005). Functional plasticity or vulnerability following early brain injury? Pediatrics, 116:1374–82

 29 Ponsford J., Willmott C., Rothwell A., et al. (1997). Cognitive and behavioural outcome following mild traumatic brain injury in children. JINS, 3:225

 30 Anderson, V. A, Morse, S. A., Catroppa, C., Haritou, F. and Rosenfeld, J. V. (2004). Thirty month outcome from early childhood head injury: a prospective analysis of neurobehavioural recovery. Brain, 127 (12):2608-2620

 31 Brown G., Chadwick O., Shaffer D., Rutter M. and Traub M. (1981). A prospective study of children with head injuries: II. Psychiatric sequelae Psychol Med, 11: 49–62

 32 Max, E., Koele, S., Smith, W., Sato, Y., Lindgren, S., Robin, D., and Arndt, S. (1998). Psychiatric Disorders in Children and Adolescents After Severe Traumatic Brain Injury: A Controlled Study. Journal of the American Academy of Child & Adolescent Psychiatry: Volume 37 - Issue 8 - pp832-840

 33 Taylor, H. G., Yeates K. O., Wade S. L., Drotar D., Stancin T. and Minich N. (2002). A prospective study of short- and long-term outcomes after traumatic brain injury in children: behavior and achievement. Neuropsychology, 16: 15–27

 34 Bijur P., Goulding J., Haslum M. and Kurzon M. (1988). Behavioral predictors of injury in school-aged children. Am J Dis Child, 142: 1307–1214

 35 Larson, C. P. and Pless, I. B. (1988). Risk factors for injury in a 3-year-old birth cohort. American Journal of Diseases of Children, 142, 1052– 1057

 36 Fletcher, J.M., Ewing-Cobbs, L., Francis, D.J. and Levin, H.S. (1995). Variability in outcomes after traumatic brain injury in children: A developmental perspective. In S.H. Broman & M.E. Michel

(Eds.) Traumatic head injury in children; traumatic head injury in children.(pp.3–21). London:Oxford University Press

 37 Breslau, N. (1990). Does brain dysfunction increase children’s vulnerability to environmental stress. Arch Gen Psychiat, 47: 15–20

38 Taylor H. G. and Alden J. (1997). Age related differences in outcomes following childhood brain insults: An introduction and overview. J Int Neuropsychol Soc, 3:555–67

 39 Wilson, B. A. (1997). Cognitive rehabilitation: How it is and how it might be. JINS, 3:487–96

 40 Ylivasaker, M. (1998). (ed): Head Injury Rehabilitation: Children and Adolescents. Boston, Butterworth-Heinemann

 41 Chesnut R. M., Carney N., Maynard H., et al. (1999). Rehabilitation for traumatic brain injury. Rockville, Md: Agency for Health Care Policy and Research. Evidence Report/ Technology Assessment, 2, 1-176

 42 Skinner, B. F. (1987) Skinner on Behaviourism. In R. L. Gregory (Ed.) The Oxford Companion to the Mind. Oxford: Oxford University Press

 43 Mottram L., and Berger-Gross P. (2004). An intervention to reduce disruptive behaviours in children with brain injury. Pediatr Rehabil, 7:133–43

 44 Gardner R., Bird F., Maguire H., et al: (2003). Intensive behavior supports for adolescents with acquired brain injury: Long-term outcomes in community settings. J Head Trama Rehabil, 18:52–74

 45 Jacobs, M. P. (1993). Limited understanding of deficit in children with brain dysfunction.Neurological Rehabilitation, 3, 341-365

 46 Beardmore S., Tate R. and Liddle B. (1999). Does information and feedback improve children’sknowledge and awareness of deficits after traumatic brain injury? Neuropsychol Rehabil, 9:45–62 15

 47 Ponsford, Willmott, Rothwell, Cameron, Ayton, Nelms, Curran, and Ng (2001). Impact of EarlyIntervention on Outcome After Mild Traumatic Brain Injury in Children. Pediatrics, 108:1297–1303

 48 Singer, G. H. S., Glang, A., Nixon, C., Cooley, E., Kerns, K. A., Williams, D., et al. (1994). A comparison of two psychosocial interventions for parents of children with acquired brain injury: An exploratory study. Journal of Head Trauma Rehabilitation, 9, 38–49

 49 Wade, S. L., Michaud, L. M., and Brown, T. M. (2004). Putting the Pieces Together: Family Intervention to Improve Child Outcomes following Traumatic Brain Injury (TBI). Manuscript submitted for publication

 50 Mahalick, D. (2004). Psychopharmacological treatment of acquired attentional disorders in children with brain injury. Pediatr Neurosurg, 85:1732

 51 Head injury: Triage, assessment, investigation and early management of head injury in infants,children and adults. Clinical Guidelines 4. London: National Institute for Clinical Excellence, NHS,2003

 52 Pace G. M., Sclund M. W., Hazard-Haupt T., Christensen J. R., Laschno M., McIver J., et al.(1999). Characteristics and outcomes of a home and community-based neuro-rehabilitationprogramme. Brain Injury 13 (7):535–546

 53 Cronin, A. F. (2000). Traumatic brain injury in children: Issuers in community function. American Journal of Occupational Therapy, 55, 377-384

54 Emanuelson I. and von Wendt L. (1997). Epidemiology of traumatic brain injury in children and adolescents in southwestern Sweden. Acta Paediatr 86:730– 735

 55 Di Scala C., and Osberg Savage R. C. (1997). Children hospitalised for traumatic brain injury: Transition to post-acute care. J Head Trauma Rehabil, 12:1–10

 56 Wade, S. L., Drotar, D., Taylor, H. G., and Stancin, T. (1995). Assessing the effects of traumatic brain injury (TBI) on family functioning: Conceptual and methodological issues. Journal of Pediatric Psychology, 20, 737-752

 57 Bevington, J. and Wishart, J.G. (1999). The influence of classroom peers on cognitive performance in children with behavioural problems. British Journal of Educational Psychology, 69: 19-32

 58 Savage R. C., De Pompei R., Tyler J., and Lash M. (2005). Paediatric traumatic brain injury: a review of pertinent issues Paediatric Rehabilitation, 8(2):92-103

59 Ylvisaker, M., Feeney, T., and Mullins, K. (1995). School re-entry following mild traumatic brain injury: A proposed hospital-to-school protocol. Journal of Head Trauma Rehabilitation, 10(6): 42-49

 60 Child Brain Injury Trust UK (2009) (online) available from www.cbituk.org accessed 06/11/2009

 61 Hylton, C., Margetson, J. and Wright, A. (2009). In the Dark: Barriers to information for parents and carers of disabled children. Cerebra, Carmarthen

 62 Wade, S. L., Wolfe, C., Brown, T. M. and Pestian, J. P. (2005). Putting the Pieces Together: Preliminary Efficacy of a Web-Based Family Intervention for Children with Traumatic Brain Injury. Journal of Pediatric Psychology, 30 (5) :437-442 17