Disability and Rehabilitation, 2011; 33(8): 675683

RESEARCH PAPER

Efficacy of cognitive behavioural therapy for children and adolescents

with traumatic brain injury

VALENTINA PASTORE, KATIA COLOMBO, MARIAROSARIA LISCIO,

SUSANNA GALBIATI, ANNA ADDUCI, FEDERICA VILLA & SANDRA STRAZZER
IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
Accepted July 2010

Abstract
Purpose. Behavioural and psychological disorders after traumatic brain injury (TBI) are very common. The purposes of this
study were to estimate the frequency of these problems in our sample, to evaluate the effectiveness of cognitive behavioural
therapy (CBT) and to assess the predictive value of important clinical variables for the treatment outcome.
Method. Forty patients aged 418 years were included in this study. Twenty-eight patients received CBT at our Institute
(clinical group), while 12 patients did not receive any treatment at all (control group). The CBCL/4-18 and the VABS were
administered to parents at the beginning of the study and after 12 months.
Results. A high frequency of psychological and behavioural problems was found in both groups of patients. After CBT, the
clinical group showed a significant advantage on several CBCL scales and a greater increase in adaptive behaviour on the
VABS Socialisation domain. The Glasgow Coma Scale score, days of unconsciousness and age at injury were not predictors
of the severity of psychological problems at the follow-up for the patients of the clinical group.
Conclusions. Our results suggest that CBT is an effective intervention for young patients with psychological problems after
TBI.

Keywords: Traumatic brain injury, cognitive behavioural therapy, psychological intervention

Introduction
Traumatic brain injury (TBI) is the most common
cause of acquired disability in childhood and
adolescence [1] and represents a major public health
problem. Outcome research has shown that social
and behavioural disorders after TBI are very
common for children and affect their family members and teachers as well, who need to cope with
these difficulties in daily life [2].
Difficulties vary according to several factors:
recovery stages, gender [3,4], age [57], age at
injury [8], family functioning [9], socioeconomic
status (SES) [10]. Frequent problems include
attention deficits, hyperkinesia and hyperactivity,
irritability, aggressiveness and opposition behaviour
[713]. Anxiety and depression, which are frequent
in adult patients [14], are less common in children

and adolescents in the post-acute phase, but their

incidence increases in the outcome phase, when the
patients have a greater awareness of residual limitations. The risk of developing social deficits is also
very high [15].
Studies suggest that behavioural and emotional
problems in these paediatric patients negatively
influence the quality of their adult life to an extent
greater than intellectual or physical problems [16,17].
The impact that these difficulties have on patients
underlines how important it is to administer effective
treatments.
Despite several rigorous reviews of empirically
supported psychological therapies with paediatric
patients [18,19], few studies focus on children and
adolescents with acquired brain dysfunctions.
Over the last few years, cognitive behavioural
therapy (CBT) has been extensively used in the

Correspondence: Valentina Pastore, PhD, IRCCS Eugenio Medea, Via Don Luigi Monza 20, 23842, Bosisio Parini, Lecco, Italy. Tel: 39-031-877111.
Fax: 39-031-877499. E-mail: valentina.pastore@bp.lnf.it
ISSN 0963-8288 print/ISSN 1464-5165 online 2011 Informa UK, Ltd.
DOI: 10.3109/09638288.2010.506239

676

V. Pastore et al.

treatment of emotional and behavioural difficulties in

young patients with TBI.
Its efficacy is supported by many studies in the
literature on a variety of clinical adult and paediatric
populations [2023]. CBT focuses on, yet it is not
restricted to, behavioural modifications by manipulating their consequences. The cognitive and
behavioural model suggests that physical and mental
symptoms are partially a consequence of maladaptive
thoughts, feelings or behaviours. Therapy thus
focuses on the thoughts, feelings and behaviours
causing distress and aims at modifying them. This
approach, along with the social skills training,
appears to be particularly useful to individuals with
acquired brain lesions.
In a previous study [24], we demonstrated the
efficacy of CBT with young tumour survivors. The
goals of the present study were as follows:
.

To estimate the frequency of psychological and

behavioural problems in a sample of children
and adolescents with TBI attending our
Scientific Institute;
To evaluate the effectiveness of CBT in
improving problem behaviours and increasing
behavioural adjustment;
To assess the predictive value of three important clinical variables (GCS score, days of
unconsciousness and age at injury) for the
treatment outcome in patients who received
CBT.

Measures
The following clinical data were collected from each
of the patients: sex, age at injury, age at assessment,
scores on the Glasgow Coma Scale (GCS) [29] and
on the Glasgow Outcome Scale (GOS) [30], days of
unconsciousness, neurosurgery, full scale IQ. The
GOS score was recorded at the time of the study.
All the patients received two age-appropriate
clinical functional assessments: the first at the
beginning of the hospitalisation and the second after
12 months, during their subsequent admission for
the follow-up. The examiners testing the children
were unaware of their treatment status.
The cognitive assessment was performed by means
of the Wechsler Intelligence Scales WPPSI-R,
WISC-R and WAIS-R.
The GOS [30] was used to assess the outcome after
a severe brain injury. It is based on five global
categories (Death, Persistent Vegetative State, Severe
Disability, Moderate Disability, Good Recovery).
The psychological evaluation protocol included
the following scales:
1.

Method
The sample
Patients were recruited from a cohort of children and
adolescents with TBI attending the Eugenio Medea
Scientific Institute. Our Unit provides rehabilitation
to young patients with acquired brain lesions [25
27]. In most cases, post-acute patients with mild or
moderate-to-severe TBI are referred to our Institute
by several hospitals, located in different Italian
regions, in order to receive rehabilitation for their
cognitive, motor and behavioural difficulties.
Inclusion criteria were as follows: (a) age between
4 and 18 years; (b) no previous psychological
disorders; (c) no previous brain lesions (acquired
or congenital); (d) no pre-existing acute or chronic
serious illness; (e) baseline full scale IQ 4 75; (f) no
drug therapy before our clinical assessment; (g) time
since the insult: at least 3 months.
We included only the patients with scores above
the clinical cut-off on the following Child Behaviour
Checklist 4/18 [28] scales: Internalising and/or
Externalising and/or Total Problems.

2.

The Child Behaviour Checklist (CBCL) [28] is

one of the most widely used measures in the
assessment of behavioural and emotional disorders in children/adolescents. Parents are
asked to rate the childs current behaviour.
The checklist generates T scores for three
summary scales (Total, Internalising, Externalising problems) and eight subscales (Withdrawn,
Somatic
Complaints,
Anxiety/
Depression, Social Problems, Thought Problems, Attention Problems, Delinquent Behaviour, Aggressive Behaviour). Scores 4 60 are
considered pathological on the Internalising,
Externalising and Total Problem Scales and
scores 4 70 are considered pathological on all
other scales. Parents did not fill in the items of
the Somatic Complaints scale which described
symptoms related to the disease.
The Vineland Adaptive Behaviour Scales
Expanded Form (VABS) [31,32] are designed
to assess the adaptive behaviour of subjects.
Data about four domains (Communication,
Daily Living Skills, Social Skills, Motor Skills)
are collected through a semi-structured interview with caregivers.

Procedures
All the patients were enrolled in the study: as this
treatment had proved effective with other patients and
psychological and behavioural disorders have a great
impact on the patients outcome, we offered CBT

Psychotherapy for children with brain injury

(and its benefits) to all of them. Therefore, ours is not a
randomised controlled trial because we consider
unethical to withhold a potentially beneficial treatment. According to several recent reviews, estimates
of treatment effect sizes obtained from well-designed
observational studies are comparable with those
obtained from randomised controlled trials [33].
Moreover, half the patients attending our Department
came from outside the Lombardy region. None of the
patients families refused to take part to the study:
some patients met the inclusion criteria but did not
receive treatment because they lived far away from our
Institute. The Italian regions from which our patients
came were a considerable distance away from the
Institute, but they were no more disadvantaged than
ours. The local research Ethics Committee approved
the project, and all the parents gave their informed
consent in line with the Declaration of Helsinki.

The intervention
Our intervention was based on the CBT. The aim
of this approach is to extinguish dysfunctional

677

behaviours and increase more functional behaviours.

Several techniques were used (Table I). In the
case of older children and adolescents, the behavioural techniques were supported by cognitive
mediation.
The behavioural intervention focuses on problem
behaviours or exaggerated behaviours and modifies
them by environmental manipulations according to
the so-called A-B-C model, where B (Behaviour) is
the target behaviour to be changed, A (Antecedent)
is the situation that leads to the Behaviour and C
(Consequence) is the effect produced by B. C
reinforces the target Behaviour and thus sustains it,
even if it is dysfunctional or problematic.
CBT is also based on the cognitive model which
presupposes that emotions and behaviours are
influenced by an individuals perception of events.
It is not the situation that causes individuals to feel
what they feel, but it is the way they interpret some
experiences. Disorders are thus caused by dysfunctional thinking which impacts on the patients
behaviour. The CBT helps individuals to identify
their dysfunctional thoughts, evaluate how real they
are and replace them with more appropriate thoughts

Table I. Behavioural techniques used in CBT.

Techniques used to:
Support spontaneous adaptive
behaviours

Elicit new adaptive behaviours

Reduce maladaptive behaviours

Positive reinforcement (reward for the appropriate behavioural response)

Negative reinforcement (ceasing of aversive stimulation)
Contingent reinforcement (reinforcement provided only in response)
Non-contingent reinforcement (random reinforcement regardless of manifested behaviour so
that the individual receiving it attributes the environment a reinforcement function and value)
Continuous reinforcement (the patients behaviour is reinforced each time it is manifested. This
type of reinforcement supports a new or weak behaviour and is adopted initially when the
individual is taught a new response)
Intermittent reinforcement (expected behaviours are not reinforced each time they are
manifested but only at some instances. This type of reinforcement is aimed at preserving and
augmenting appropriate behaviours once they have been acquired through continuous
reinforcement)
Contingency contract (reinforcement contingencies are agreed on beforehand)
Chaining (an invariable sequence of behaviours at the end of which reinforcement is provided)
Shaping (this technique is aimed at increasing the frequency and the number of behaviours
typical of the individuals repertoire. This term indicates differential reinforcement of
sequential approximations, progressively nearing the meta-behaviour)
Prompting and Fading (these techniques are aimed at facilitating an expected response by using
external stimuli which are more likely to elicit the desired response. These prompts are
provided at the exact time when the required action should take place and are later removed by
gradually removing the stimulus)
Modelling (the individual is exposed to a model to promote acquisition of behaviors, their
facilitation and disinhibition)
Positive reinforcement
Negative reinforcement
Cost of reply (reinforcement contingencies are agreed on beforehand so that the individual is
aware of the aversive consequences of his or her actions)
Isolation time-out and time-out without isolation (procedure immediately following the
inappropriate behaviour. In isolation time-out, the individual is taken away from the
reinforcing environment. In contrast, in time-out without isolation the individual remains in
the reinforcement environment but is not allowed to participate in reinforcing activities for a
certain period of time.
Extinction (a response is not followed by reinforcement)

678

V. Pastore et al.

(cognitive restructuring). The cognitive intervention

is particularly important with older children and
children who are more aware of their residual
limitations, since they often show poor self-esteem
and have dysfunctional thoughts of being different
and inadequate, that can interfere with their re-entry
into the community.
The interventions were structured as follows: first,
a careful observation in different settings helps to
identify the patients behavioural and emotional
problems. Once the maladaptive behaviours, their
antecedents and their consequences have been
identified, the appropriate techniques are chosen.
Finally, an individualised intervention plan is developed for each patient.
It is important to involve in the process the
different subjects who interact with the patients
during their daily life (parents, teachers, therapists).
The treatment lasted from 4 to 8 months, with two/
three weekly individual sessions lasting 4560 min. A
weekly session for parents was also planned.
The psychoeducational intervention directed at
parents had various aims: to inform parents of their
childs clinical picture, to teach them useful techniques to improve their childs dysfunctional behaviours, increase their coping strategies in complex
situations, clarify some aspects of the cognitive
intervention, and teach them how to apply the
techniques used in our Institute outside the hospital
setting.
Two therapists of our Institute worked with the
patients of the clinical group; the therapist working
with the children and adolescents during individual
sessions also worked with their parents during weekly
sessions.

Data analysis
Data are presented as means, standard deviations
(SDs) and percentage. Qualitative variables were
investigated by w2 statistics, while t testing was
applied to quantitative variables.
Differences (D) between the CBCL and VABS
scores at first evaluation and the follow-up were
calculated for each patient. A comparison between
the Ds (Dclinical and Dcontrol) in the two groups was
performed by t test.
The predictive value of three clinical variables
(GCS score, age at injury and days of unconsciousness) for the treatment outcome was determined by
multiple regression.
Statistical analysis was performed using SPSS 13.0
(SPSS Inc, Chicago, IL). Significance was assumed
at a p value of 5 0.05. In regression analyses, the p
value for multiple comparisons was set at a lower
level (50.01).

Results
Patients
A total of 263 patients with TBI received a multidisciplinary clinical and functional assessment during the 20012007 period. Seventy-eight patients
met the inclusion criteria. The majority of the
patients excluded from the study did not meet the
inclusion criterion for age or cognitive level. Among
these 78 subjects, 43 children obtained pathological
scores in the CBCL 4/18 scales.
Twenty-eight patients received psychological treatment in our Institute (clinical group) and 12 patients
did not receive the psychological treatment (control
group), but they agreed to come back after a year for
a follow-up assessment.
Three patients were treated elsewhere. They were
not included in the experimental group because we
could not monitor their psychological intervention
(Table II). As stated above, all the patients families
who did not take part in the study did so because
they lived too far away from our Institute.
Fourteen patients received CBT combined with a
pharmacological intervention, 14 patients received
only CBT, 5 patients received only drug therapy and
7 patients received no treatment at all. At the first
assessment, our neurologists, according to their
clinical experience, identified the patients for whom
drugs could be usefully combined with psychological
intervention. Patients were administered either
mood stabilisers or antipsychotic drugs. Drug
therapy was mainly administered to patients with
marked psychological and behavioural problems
during the early recovery stages at the Institute,
when psychological therapy had yet to be started (for
example, due to the patients clinical conditions).
Most of the patients in our sample were in the
outcome phase (time between insult and treatment at
the first assessment: 2.52 years for the clinical group,
2.45 years for the control group).
The demographic and clinical characteristics of
the clinical and the control groups are shown in
Table III.
A comparison of the demographic and clinical
variables between the two groups was made. Despite
the fact that age at insult and at first evaluation of the
patients in the control group was lower, no significant differences were found between patients who
received CBT and the control group. No significant
differences in the CBCL and VABS scores were
found in the baseline evaluation either, suggesting
that initially the two groups were characterised by
psychological and behavioural problems of the same
severity.
We also compared the CBCL and VABS mean
scores of the group of patients who received drug

Psychotherapy for children with brain injury

679

Table II. Flow chart of the patients recruitment.

Table III. Demographic and clinical characteristics of the clinical and control groups.
Clinical group (n 28)

Age at injury (years)

Age at first assessment (years)
Days of unconsciousness
GCS score
GOS score
Full scale IQ

Sex:
Male
Female
Neurosurgery
Yes
No
Rehabilitation treatments
Physiotherapy
Speech therapy
Neuropsychological treatment
Drug therapy
Yes
No

Control group (n 12)

Mean

SD

Mean

SD

8.39
10.91
25.30
5.54
2.65
78.80

4.28
3.82
17.09
2.04
0.832
10.88

6.57
8.94
18.58
6.91
2.83
82.83

3.16
3.32
13.59
3.24
0.408
13.09

n.s.
n.s.
n.s.
n.s.
n.s.
n.s.

21
7

75.0
25.0

10
2

83.33
16.67

n.s.

17
11

60.7
39.3

7
5

58.33
41.67

n.s.

16
15
17

57.1
53.5
60.7

8
6
7

66.6
50.0
58.3

n.s.
n.s.
n.s.

14
14

50.0
50.0

5
7

41.7
58.3

n.s.

therapy and the group who did not receive any drugs
at the first evaluation, in order to verify whether
subjects with more severe behavioural problems were
more likely to receive drugs. We did not find any
significant differences between the two groups, with
the exception of the CBCL Somatic Complaint scale
scores: children who did not receive drugs at the first
evaluation obtained higher scores (t 2.498; degrees
of freedom [df]: 34.48; p 0.017).

Frequency of psychological and behavioural problems

The CBCL scores of subjects from both groups
were considered. The scales in which most of the
patients scored higher than the clinical cut-off
included: Internalising Problems (92.5% of the
sample), Total Problems (80%), Externalising Problems (67.5%), Social Problems (40%), Withdrawn
(37.5%), Attention Problems (35%), Anxiety/

680

V. Pastore et al.

Depression (27.5%) and Somatic Complaints

(22.5%).
Our patients showed a moderate impairment of
adaptive behaviour on the VABS; the most severely
impaired domains were Daily Living Skills and
Socialisation.
These data suggest that initially the two groups
had important psychological and behavioural problems.

Comparison of the clinical and the control group

Table IV shows the mean CBCL scores obtained by
the clinical and the control groups at two assessments. This table also reports the mean differences
(D) between the CBCL scores at first evaluation and
at the follow-up for the two groups of patients. A
comparison between the mean Ds in the two groups
was performed by t test.
Significant differences between the two groups were
found for the following CBCL scales: Withdrawn,
Somatic Complaints, Anxiety/Depression, Social
Problems, Internalising and Total Problems.
In all cases, the patients who received CBT
showed a greater improvement in problem behaviours vs. the control group.

Table V shows the mean VABS scores obtained by

the two groups at the first assessment and at the
follow-up as well as the mean differences (D).
Significant differences were found in the Socialisation domain: patients who received CBT scored
higher than patients of the control group, revealing
an improvement in their social skills.
In order to verify that these findings were
not influenced by the drug therapy, we repeated the
analysis only for the patients who did not receive any
drug (clinical group: N 14, control group: N 7).
The statistical analysis confirmed the same significant differences found for the whole group. In
addition, we found a significantly greater improvement in the scores for the clinical group on the
following CBCL scales, too: Aggressive Behaviour
(t 3.693, df: 19; p 0.002) and Externalising
(t 3.244, df: 19; p 0.004).
We also considered the group of patients who
received CBT and compared the CBCL and VABS
scores of patients who received drugs (N 14) and
patients who did not receive any drugs (N 14). A
greater improvement in scores was observed in the
group of patients who had not received any drugs vs.
patients who had received drugs. This was seen in all
CBCL scales, except for the Thought Problems
scales.

Table IV. CBCL scores (means and standard deviations) for the two groups at baseline and follow-up and Ds mean between pre-treatment
and post-treatment scores.
Clinical group
CBCL

Baseline
Mean (SD)

Withdrawn
Somatic complaints
Anxiety/Depression
Social problems
Thought problems
Attention problems
Delinquent behaviour
Aggressive behaviour
Internalising
Externalising
Total Problems

67.39
65.39
67.82
67.82
60.14
70.54
60.00
65.46
67.04
65.32
65.14

(7.83)
(9.26)
(8.75)
(5.03)
(9.38)
(7.09)
(6.67)
(6.98)
(6.16)
(7.29)
(8.26)

Control group

Follow-up
Mean (SD)
56.71
56.11
57.11
59.04
55.54
62.04
57.11
55.14
56.86
53.44
56.61

(7.70)
(6.83)
(7.09)
(9.58)
(7.14)
(9.34)
(6.62)
(7.31)
(10.05)
(12.21)
(10.77)

Mean D

Baseline
Mean (SD)

710.68
79.28
710.71
78.78
74.60
78.50
72.89
710.32
710.18
711.78
78.53

63.67
62.00
64.92
65.42
59.75
70.08
57.25
65.83
65.08
63.67
66.83

(7.63)
(6.25)
(8.08)
(4.83)
(7.46)
(8.32)
(8.21)
(8.07)
(7.10)
(7.59)
(6.47)

Follow-up
Mean (SD)
59.08
61.17
62.67
61.25
58.33
65.75
57.00
60.92
62.58
59.42
65.08

(7.15)
(8.34)
(7.11)
(6.98)
(7.39)
(10.36)
(7.68)
(8.11)
(7.81)
(8.53)
(8.51)

Mean D
74.58
70.83
72.25
74.17
71.42
74.33
70.25
74.92
72.50
74.25
71.75

t (df)
2.063
2.207
2.915
2.538
1.826
1.530
1.021
1.760
2.226
1.895
2.372

(38)
(38)
(38)
(37.840)
(37.880)
(22.852)
(38)
(38)
(38)
(37)
(38)

p
0.046
0.033
0.006
0.015
0.076
0.140
0.314
0.086
0.032
0.066
0.023

Table V. VABS scores (means and standard deviations) for the two groups at baseline and follow-up and Ds mean between pre-treatment
and post-treatment scores.
Clinical group

Control group

VABS

Baseline
Mean (SD)

Follow-up
Mean (SD)

Mean D

Baseline
Mean (SD)

Follow-up
Mean (SD)

Mean D

t (df)

Communication
Daily living skills
Socialisation

0.83 (0.19)
0.69 (0.20)
0.61 (0.09)

0.88 (0.15)
0.78 (0.17)
0.82 (0.13)

0.07
0.12
0.21

0.82 (0.17)
0.69 (0.25)
0.76 (0.14)

0.96 (0.04)
0.89 (0.12)
0.85 (0.11)

0.13
0.19
0.07

0.866 (34)
0.788 (34)
72.635 (34)

0.392
0.436
0.013

Psychotherapy for children with brain injury

The same group showed a significantly greater
improvement in adaptive behaviour in the VABS
Socialisation domain.

Prediction of treatment outcome

The predictive value of three clinical variables (GCS
score, days of unconsciousness and age at injury) for
the treatment outcome in patients who received CBT
was determined by multiple regression (Table VI).
The dependent variable was the CBCL Total
Problems scale score at the follow-up.
These variables did not prove predictive of the
severity of the psychological problems at follow-up
for the patients of the clinical group.

Discussion
Over the last few years, an ever-increasing amount of
research has substantiated the efficacy of CBT in the
treatment of psychological disturbances in paediatric
patients. In this perspective, our results are on the
whole very encouraging.
Our patients showed important problems related
to TBI (in particular, withdrawal, anxiety, depression
and poor social skills). Different studies suggest that
problems in young patients with TBI are most
frequently related to Externalisation [713]. This
can be explained by the fact that most patients were
in the outcome stage: they were more aware of their
residual limitations and were at a higher risk of
developing internalising problems.
Patients who received CBT showed a greater
decrease in behavioural and psychological problems
at the follow-up than patients who did not receive it.
The behavioural change was more evident for the
domains which appeared to be more impaired at the
first evaluation: the patients of the clinical group
improved significantly on the CBCL Withdrawn,
Somatic Complaint, Anxiety/Depression, Social
Problems, Internalising and Total Problems
scales and in the VABS domain of Socialisation.
Recent studies in the literature [3436] point to
the effectiveness of CBT in reducing anxiety and
Table VI. Prediction of the CBCL Total Problems scale score at
follow-up for patients who received CBT.

Predictor
Constant
GCS scores
Days of unconsciousness
Age at injury
R2 (adjusted)

Unstandardised
coefficients

Standardised
coefficients

52.44
0.486
0.049
70.003
0.125

0.113
0.075
70.015

681

somatic symptoms in children. The CBT is aimed at

increasing the childrens awareness after TBI and
improving their ability to identify anxiety-provoking
situations, express and share their emotional states as
well as develop more effective coping strategies.
Moreover, several young patients suffering TBI
perceive themselves as different and inadequate with
respect to their peers: this aspect is often related to
depressive symptoms and withdrawal. CBT focuses
on this feeling of inferiority and on self-esteem; it
helps patients to improve their social skills, which are
limited because of the neurological impairments, the
impossibility of living a normal school experience
and the isolation from their peers.
Somatic complaints were also common in our
sample: after a long hospitalisation, children often
give more attention to their somatic symptoms and
tend to exaggerate them, even if they are irrelevant.
In other cases, they use them in a dysfunctional way,
to capture other peoples attention. CBT is aimed at
focusing the patients selective attention on other
somatic sensations and increases their ability to cope
with symptoms, while the psychoeducational intervention directed at parents contributes to reducing
their dysfunctional behaviours. In point of fact,
parents often tend to reinforce these behaviours
unconsciously. For example, they give their child too
much attention; they anticipate his/her requests and
make him/her even more dependent. Changing the
parents behaviours (i.e. the environmental responses
to the childs behaviour) often leads to an improvement in somatic complaints.
These findings were confirmed when we analysed
only the group of patients who did not receive any
drug therapy, even though this group consisted of
fewer individuals. In addition, the clinical group
showed a significantly greater improvement in the
CBCL Aggressive Behaviour and Externalising scale
scores. These data provide further confirmation to
our results; however, it would be important to carry
out a further investigation on a wider sample in order
to compare patients receiving CBT, drugs, CBT
combined with drugs or placebo.
Finally, among the patients who received CBT,
those who did not receive any drug therapy showed a
greater decrease in problem behaviours.
These data could be influenced by a bias in the
selection of our sample, even though the two parentbased questionnaires showed that the patients who
received drugs at the first evaluation did not have
more severe problems than those who received no
drugs, with the exception of the CBCL Somatic
Complaint scale scores. On this scale, the children
who did not receive drugs scored higher: it is possible
that the patients who received drug therapy felt more
reassured and therefore were less inclined to
exaggerate their somatic symptoms. Furthermore,

682

V. Pastore et al.

the significantly higher effect of therapy in patients

not receiving drugs could be due to the same reason
and problems why the drugs were prescribed to
them. For example, it cannot be excluded that
patients who receive drugs had a more limited
potential for improvement during the psychotherapeutical intervention.
We also set out to investigate the effect of age at
trauma, days of unconsciousness and GCS score on
the treatment outcome of children who received
CBT. Linear multiple regression showed that these
variables did not affect the treatment outcome.
Therefore, CBT can be usefully proposed to a wide
range of patients, even if their clinical picture appears
to be more severe in the acute phase.
A limitation of this study concerns our sample,
which is relatively small and heterogeneous. Future
investigations are needed to confirm the efficacy of
CBT with young patients with TBI. Furthermore, it
would be desirable to compare CBT with an alternative
psychological treatment as well as include two other
conditions in the comparison: CBT with drug therapy
or placebo. Finally, future studies should focus on SES
and parents implication in therapy.
On the whole, our findings suggest that CBT can
be extensively used in the treatment of emotional and
behavioural problems of young patients with TBI in
order to limit the risk of inadequate social integration
and of more severe psychological or psychiatric
disturbances.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
1. Michaud LJ, Duhaime AC, Batshaw ML. Traumatic brain
injury in children. Pediatr Clin North Am 1993;40:553565.
Review.
2. Ylvisaker M, Feeney T. Pediatric brain injury: social,
behavioral, and communication disability. Phys Med Rehabil
Clin N Am 2007;18:133144, vii. Review.
3. Farace E, Alves WM. Do women fare worse: a metaanalysis of
gender differences in traumatic brain injury outcome. J
Neurosurg 2000;93:539545.
4. Pillai S, Praharaj SS, Mohanty A, Kolluri VR. Prognostic
factors in children with severe diffuse brain injuries: a study of
74 patients. Pediatr Neurosurg 2001;34:98103.
5. Poggi G, Liscio M, Adduci A, Galbiati S, Sommovigo M,
Degrate A, Strazzer S, Castelli E. Neuropsychiatric sequelae
in TBI: a comparison across different age groups. Brain Inj
2003;17:835846.
6. Morton MV, Wehman P. Psychosocial and emotional
sequelae of individuals with traumatic brain injury: a literature
review and recommendations. Brain Inj 1995;9:8192. Review.
7. Brown G, Chadwick O, Shaffer D, Rutter M, Traub M. A
prospective study of children with head injuries. III. Psychiatric sequelae. Psychol Med 1981;11:6378.

8. Wells R, Minnes P, Phillips M. Predicting social and

functional outcomes for individuals sustaining paediatric
traumatic brain injury. Dev Neurorehabil 2009;12:1223.
9. Max JE, Robin DA, Lindgren SD, Smith WL Jr, Sato Y,
Mattheis PJ, Stierwalt JA, Castillo CS. Traumatic brain injury
in children and adolescents: psychiatric disorders at one year. J
Neuropsychiatry Clin Neurosci 1998;10:290297.
10. Max JE, Smith WL Jr, Sato Y, Mattheis PJ, Castillo CS,
Lindgren SD, Robin DA, Stierwalt JA. Traumatic brain injury
in children and adolescents: psychiatric disorders in the first
three months. J Am Acad Child Adolesc Psychiatry 1997;36:
94102.
11. Gualtieri CT, Johnson LG. Traumatic brain injury: special
issues in psychiatric assessment. NeuroRehabilitation 1999;
13:103115.
12. Max JE, Robin DA, Lindgren SD, Smith WL Jr, Sato Y,
Mattheis PJ, Stierwalt JA, Castillo CS. Traumatic brain injury
in children and adolescents: psychiatric disorders at two years.
J Am Acad Child Adolesc Psychiatry 1997;36:12781285.
13. Fletcher JM, Ewing-Cobbs L, Miner ME, Levin HS,
Eisenberg HM. Behavioral changes after closed head injury
in children. J Consult Clin Psychol 1990;58:9398.
14. Bryant RA, ODonnell ML, Creamer M, McFarlane AC,
Clark CR, Silove D. The psychiatric sequelae of traumatic
injury. Am J Psychiatry 2010;167:312320.
15. Max JE, Roberts MA, Koele SL, Lindgren SD, Robin DA,
Arndt S, Smith WL Jr, Sato Y. Cognitive outcome in children
and adolescents following severe traumatic brain injury:
influence of psychosocial, psychiatric, and injury-related
variables. J Int Neuropsychol Soc 1999;5:5868.
16. Cattelani R, Lombardi F, Brianti R, Mazzucchi A.
Traumatic brain injury in childhood: intellectual, behavioural and social outcome into adulthood. Brain Inj
1998;12:283296.
17. Nybo T, Koskiniemi M. Cognitive indicators of vocational
outcome after severe traumatic brain injury (TBI) in childhood. Brain Inj 1999;13:759766.
18. Kazdin AE, Weisz JR. Identifying and developing empirically
supported child and adolescent treatments. J Consult Clin
Psychol 1998;66:1936. Review.
19. Kendall PC. Empirically supported psychological therapies. J
Consult Clin Psychol 1998;66:36. Review.
20. Butler AC, Chapman JE, Forman EM, Beck AT. The
empirical status of cognitive-behavioral therapy: a review of
meta-analyses. Clin Psychol Rev 2006;26:1731. Review.
21. Compton SN, March JS, Brent D, Albano AM 5th, Weersing
R, Curry J. Cognitive-behavioral psychotherapy for anxiety
and depressive disorders in children and adolescents: an
evidence-based medicine review. J Am Acad Child Adolesc
Psychiatry 2004;43:930959. Review.
22. Burns BJ, Hoagwood K, Mrazek PJ. Effective treatment for
mental disorders in children and adolescents. Clin Child Fam
Psychol Rev 1999;2:199254.
23. Soo C, Tate R. Psychological treatment for anxiety in people
with traumatic brain injury. Cochrane Database Syst Rev
2007;Issue 3:Art. No.: CD005239. DOI: 10.1002/14651858.
CD005239.pub2.
24. Poggi G, Liscio M, Pastore V, Adduci A, Galbiati S,
Spreafico F, Gandola L, Massimino M. Psychological
intervention in young brain tumor survivors: the efficacy
of the cognitive behavioural approach. Disabil Rehabil
2009;31:10661073.
25. Liscio M, Adduci A, Galbiati S, Poggi G, Sacchi D,
Strazzer S, Castelli E, Flannery J. Cognitive-behavioural
stimulation protocol for severely brain-damaged patients in
the post-acute stage in developmental age. Disabil Rehabil
2008;30:275285.

Psychotherapy for children with brain injury

26. Tavano A, Galbiati S, Recla M, Formica F, Giordano F,
Genitori L, Strazzer S. Language and cognition in a
bilingual child after traumatic brain injury in infancy:
long-term plasticity and vulnerability. Brain Inj 2009;
23:167171.
27. Galbiati S, Recla M, Pastore V, Liscio M, Bardoni A, Castelli
E, Strazzer S, Attention remediation following traumatic brain
injury in childhood and adolescence. Neuropsychology
2009;23:4049.
28. Achenbach TM, Edelbrock C. The child behaviour checklist
and revised child behaviour profile. Burlington, VT: Queen
City Printers; 1983.
29. Teasdale G, Jennett B. Assessment of coma and impaired
consciousness. A practical scale. Lancet 1974;2:8184.
30. Jennet B, Bond M. Assessment of outcome after severe brain
damage. Lancet 1975;1:480484.
31. Sparrow S, Balla DA, Cicchetti DV. Vineland Adaptive
Behaviour Scale. Circe Pines, MN: American Guidance
Service; 1984.

683

32. Balboni G, Pedrabissi L, Molteni M, Villa S. Discriminant

validity of the Vineland Scales: score profiles of individuals
with mental retardation and a specific disorder. Am J Ment
Retard 2001;106:162172.
33. Concato J, Shah N, Horwitz RI. Randomized, controlled
trials, observational studies, and the hierarchy of research
designs. N Engl J Med 2000;342:18871892.
34. Masia Warner C, Reigada LC, Fisher PH, Saborsky AL,
Benkov KJ. CBT for anxiety and associated somatic complaints in pediatric medical settings: an open pilot study. J
Clin Psychol Med Settings 2009;16:169177.
35. Monga S, Young A, Owens M. Evaluating a cognitive behavioral
therapy group program for anxious five to seven year old
children: a pilot study. Depress Anxiety 2009;26:243250.
36. Suveg C, Hudson JL, Brewer G, Flannery-Schroeder E,
Gosch E, Kendall PC. Cognitive-behavioral therapy for
anxiety-disordered youth: secondary outcomes from a randomized clinical trial evaluating child and family modalities. J
Anxiety Disord 2009;23:341349.

Copyright of Disability & Rehabilitation is the property of Taylor & Francis Ltd and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.