Psychopharmacology
The paucity of psychopharmacological treatment research in children with a TBI has led to a general approach to address syndromes and target symptoms that is similar to the approach used in children without brain damage.
PC—affective instability and aggressive subtypes. The following guidelines are anecdotal because there are no studies of treatment of children with PC. It is important clinically to differentiate the subtypes of PC because treatment modalities are different for each. The affective instability and aggressive subtypes often co-occur and respond to treatment in a similar manner. Mood stabilizers, such as valproic acid and carbamazepine(Drug information on carbamazepine), can be effective when they accompany a behavior modification program that targets aggression. The addition of an SSRI to a mood stabilizer may also be helpful. This may be surprising for clinicians who work with children, because of the well-known adverse effects of restlessness and irritability with SSRIs. (Adults with affective instability in the form of pathological laughter and pathological crying respond well to SSRIs.)
PC—disinhibited, paranoid, apathetic subtypes. The disinhibited subtype is difficult to treat with psychotropics or behavioral therapy. Aides at school may be required to closely supervise the child. Support and education for parents are important to optimize overall family function. The paranoid subtype is uncommon in children. Use of a neuroleptic medication, such as risperidone(Drug information on risperidone), may be beneficial during the acute hospitalization or in the rehabilitation unit if the symptoms are interfering with treatment regimens. The clinical presentation will guide decision making. Potential treatment benefits versus risks with regard to modification of neuronal recovery have been elucidated in animal models. The apathetic subtype is also uncommon and may respond to stimulants or SSRIs.
Neuroimaging lesion correlates of specific novel psychiatric disorders
ADHD. In a review of the literature on use of stimulants in children with a TBI who have attention and concentration deficits, several studies showed positive results, while one study reported negative results.5 Anecdotal evidence suggests that children with SADHD respond to stimulants. There is an unfortunate popular belief that children with brain damage do not respond to this treatment. However, even with stimulant treatment of SADHD, a child with a severe TBI may still have comorbid disorders that may require management. In addition, cognitive and adaptive function impairments necessitate other interventions. There are no studies of bupropion or TCAs for SADHD. Bupropion is generally avoided because of a risk of seizures; however, there are no research data to guide its use in children with a TBI. Caution should be observed when prescribing TCAs, especially because of their adverse effects on cardiac conduction.
Depression. There are no studies of treatment of depressive disorders in children with a TBI. Clinical experience suggests that SSRIs are effective. Amitriptyline(Drug information on amitriptyline) may be effective for depression and comorbid posttraumatic migraines if the child cannot tolerate an SSRI.
Psychosocial therapies
A series of studies by Wade and associates6 has found that family problem-solving interventions have resulted in a decrease in children’s internalizing symptoms, depression, anxiety, and withdrawal symptoms. The online provision of family or teen problem-solving interventions improved teen executive functioning and decreased injury-related burden; parental psychiatric symptoms, including depression; parental stress; teen antisocial behavior; and parent-teen conflict.
There are encouraging preliminary findings regarding Web-based family treatment protocols that have been modified for young children with TBI. The focus on the family in treatment studies is appropriate, given that preinjury family function significantly predicts child outcome and postinjury family function. Families should be offered educational, clinical, school re-entry program consultation, and advocacy services. Enhancing the family’s ability to manage the child appropriately and limit complications from a delay in diagnosis and treatment of psychiatric, cognitive, academic, and medical problems in the intermediate and long-term phases after a TBI may lead to improved outcomes for the child.
General principles of psychosocial treatment should be applied to emotional or behavioral sequelae of post-TBI disorders, such as phobias, PTSD, and ODD, until there are studies to guide the clinician. Situations in which families react to the child with overindulgence because of guilt or with a laissez-faire approach to danger of reinjury by reexposing the child prematurely to hazards may need to be addressed.
