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. Author manuscript; available in PMC: 2017 Nov 1.
Published in final edited form as: Rehabil Psychol. 2016 Nov;61(4):347–357. doi: 10.1037/rep0000098

A Randomized Problem-Solving Trial for Adolescent Brain Injury: Changes in Social Competence

Sarah J Tlustos 1, Michael W Kirkwood 1, H Gerry Taylor 2, Terry Stancin 3, Tanya M Brown 4, Shari L Wade 5
PMCID: PMC5113734  NIHMSID: NIHMS809398  PMID: 27831729

Abstract

Purpose/Objective

Traumatic brain injury (TBI) in adolescence has well documented effects on social competence. Few studies have examined the effects of behavioral interventions on social competence or identified factors associated with changes in social competence after injury.

Research Method/Design

Adolescents with moderate to severe TBI ages 12–17 years were randomized within 6 months of injury to either a problem solving and communication (CAPS) group that received online counseling (n=65) or an internet resources comparison (IRC) group (n=67) for a comparative effectiveness trial. Parent-report measures of social competence (Child Behavior Checklist, CBCL; Home and Community Social Behavior Scales, HCSBS; Behavioral and Emotional Rating Scale, BERS-2) were administered at baseline (pre-intervention) and approximately 6 months later. Analyses examined these measures in relation to treatment group, TBI severity, and age. Regression analyses were also conducted to examine baseline measures of cognition as predictors of social competence after TBI.

Results

CAPS had a more positive effect than the comparison condition on the HCSBS and BERS-2 for younger teens with moderate TBI and older teens with severe TBI. More parent-rated executive dysfunction at baseline was related to both lower concurrent levels of social competence and less positive gains in competence over time, whereas higher baseline IQ predicted greater gains in competence.

Conclusions/Implications

CAPS may be effective for improving social competence for teens after TBI, with benefits dependent on the teen’s age and injury severity. Parent-rated executive dysfunction, moreover, has utility in predicting both lower concurrent levels of social competence and subsequent post-injury gains in competence.

Keywords: social adjustment, traumatic brain injury, closed head injury, adolescence

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of acquired disability in childhood and often results in persistent deficits of cognition and behavior (Casey, Jones, & Hare, 2008; CDC, 2010; Langlois, Rutland-Brown, & Thomas, 2006). Impairments in executive function, social competence, and emotion regulation are common consequences of moderate to severe TBI in both children and adolescents (Casey, Jones, & Hare, 2008; Chapman et al., 2010; Ganesalingam, Sanson, Anderson, & Yeates, 2006; Rosema, Crowe, & Anderson, 2012; Steinberg, 2008; Warriner & Velikonja, 2006; Yeates et al., 2004; Yeates et al., 2007; Yeates et al., 2013). Children and teens with TBI are often more impulsive, have less emotional awareness, poorer emotional recognition, reduced emotion regulation, and more externalizing behavior problems, particularly following severe TBI (Chapman et al., 2010; Ganesalingam, Sanson, Anderson, & Yeates, 2006; Tlustos et al., 2011; Warriner & Velikonja, 2006; Yeates et al., 2007). They also tend to have worse social cognition, including poor social problem-solving (Janusz et al., 2002; Turkstra, McDonald, & DePompei, 2001; Walz et al., 2009), which places them at risk for peer rejection and victimization (Yeates et al., 2013). Social competence is one critical dimension of outcome after TBI that is important for the development and maintenance of personal relationships and has implications for functional and adaptive outcomes, including academic and long-term occupational success (Chen, Rubin, & Li, 1997; DeRosier & Lloyd, 2010; Merrell & Caldarella, 2002; Muscara, Catroppa, Eren, & Anderson, 2009; Rockhill, Stoep, McCauley, & Katon, 2009). In adults, the psychosocial consequences of TBI may be more predictive of engagement in activities of daily living than cognitive and physical impairments (Struchen et al., 2008). Research in children suggests that children with low social competence are at risk for a variety of negative outcomes, including educational underachievement, antisocial behavior and drug abuse, mood problems, and even suicide (DeRosier & Lloyd, 2010). These difficulties often persist and contribute to family distress. Studies have documented limited recovery of social function after TBI, with worsening outcomes over time (Yeates, et al., 2004; Ganesalingam et al., 2006; Bornhofen & McDonald, 2008).

Socio-emotional and cognitive-control networks, including frontal and temporal regions, are especially vulnerable to insult following TBI (Wilde et al., 2005). Disruption by diffuse brain injury during development may interfere with the integration and connectivity of these regions and have widespread impact on brain development and growth. Implications for psychosocial functioning include the development of new-onset psychiatric disorders and adverse effects on daily functioning at home, at school, and in the community (Max et al 1998; Stancin et al 2002). Incidence rates for TBI are particularly high during adolescence (Faul et al., 2010), a period in which TBI has the potential to disrupt the ongoing processes of brain growth and behavioral development (Adolphs, 2001; Blakemore & Choudhury, 2006; Frith & Frith, 2001; Luna & Sweeney, 2004; Phillips, Drevets, Rauch, & Lane, 2003). Normative developmental changes during adolescence also heighten the potential risks and social consequences of TBI (Yeates et al., 2007). Adolescence is also a time of increased emotional reactivity when social relationships begin to shift toward peers and away from family members (Casey, Jones, & Hare, 2008; Nelson, Leibenluft, McClure, & Pine, 2005). Adolescents assume increasing independence, autonomy, and academic demands and responsibilities in the context of incompletely developed cognitive-regulatory and executive function abilities. The combination of adolescent emotional reactivity and ongoing brain development with dynamic social relationships and increased demands for autonomy may contribute to the higher incidence of social problems during adolescence, including affective disorder onset and engagement in risky behaviors (Hessler & Katz, 2010).

Despite evidence for social deficits following adolescent TBI and of treatments for post-injury behavior, academic, and cognitive problems, few randomized controlled trials (RCTs) have been conducted and none to our knowledge have specifically targeted deficits in social competence (Anderson & Catroppa, 2006; Ylvisaker et al., 2007). Because teens with TBI are at risk for increasing difficulties in social functioning over time (Yeates, et al., 2004; Ganesalingam et al., 2006; Bornhofen & McDonald, 2008), interventions may be important for staving off declines in functioning as well as for remediating social deficits in the acute phases after injury. Problem-solving interventions may be particularly useful for children and their caregivers after TBI, given the high rates of new behavioral problems and other stressors that impact adjustment after injury which may render their old coping strategies ineffective. Problem-solving interventions may be helpful for identifying areas in need of intervention, learning new skills or approaches to manage problems, and learning to implement new strategies (Wade, Michaud, & Brown, 2006). Social problem-solving theories suggest that constructive problem-solving approaches better enable individuals to regulate emotions and maintain instrumental approaches to problems (e.g., D’Zurilla et. al., 2004). Such interventions have been found to be helpful in improving overall distress and decreasing dysfunctional problem-solving styles in caregivers of adults with TBI (Rivera, Elliott, Berry, & Grant, 2008). Investigators (Wade, Carey, & Wolfe, 2006) used an RCT to assess the efficacy of a family-based, counselor-assisted online problem solving intervention compared to internet resources in improving behavior outcomes of moderate to severe TBI in children 5–17 years of age. Their findings documented a positive effect of the problem-solving intervention on both child externalizing behavior and social competence, though only among the older children in the sample. In a larger and more recent RCT, this group of investigators assessed the efficacy of an updated problem solving and communication (CAPS) intervention compared to an internet resources-only comparison (IRC) group, a self-guided psychoeducational intervention, in improving behavior outcomes of moderate to severe TBI in a sample of adolescents 12–18 years of age. Previous reports of this study confirm positive effects of the CAPS intervention on externalizing symptoms and behavior ratings of executive function (Kurowski et al., 2013; Wade et al., 2013), with improvements again limited to older, high-school age participants.

CAPS reduced symptoms of externalizing behavior and improved behavioral ratings of executive functions in older adolescents, and these outcomes are likely to be inversely associated with social competence (Anderson et al., 2006; Beauchamp & Anderson, 2010; Ganesalingam et al., 2011; Parker, Rubin, Erath, Wojslawowicz, & Buskirk, 2006; Struchen et al., 2008). Therefore, the primary aim of this study was to investigate the effects of CAPS vs. IRC intervention on parent ratings of teen social competence collected as part of this RTC. We hypothesized that CAPS would be more effective than exposure to internet resources alone in improving social competence, at least in older teens. Because social competence is more adversely affected following severe TBI (Anderson et al., 2013; Yeates et al., 2004), teens with severe TBI have greater potential to benefit from intervention. We thus further anticipated that the positive effects of CAPS relative to the IRC condition would be more pronounced in teens with severe compared with moderate TBI.

A secondary study aim was to examine factors in addition to TBI severity that place teens at higher risk for decreased social competence after TBI. Because moderate to severe TBI has negative effects on cognitive ability and on behavior ratings of executive dysfunction (Anderson et al., 2004; Donders & Janke, 2008; Mangeot, Armstrong, Colvin, Yeates, & Taylor, 2002; Sesma, Slomine, Ding, & McCarthy, 2008), these consequences may serve as markers or proxies for variations in injury severity not reflected in the GCS score or in lesions that are identifiable on clinical neuroimaging. Our hypothesis with regard to this study aim was that, controlling for treatment group, lower cognitive abilities and greater behavioral ratings of executive dysfunction at our baseline post-injury assessment would predict lower levels of social competence at baseline, but may lend to greater improvements in social competence across follow-up. Identification of post-acute risks for decreased social competence would help identify the teens most in need of interventions to improve social outcomes.

METHODS

Participants

Adolescents ages 11–18 years with a history of hospitalization for moderate to severe TBI in the previous 6 months, were recruited to participate in this study. The study was conducted at five major trauma-centers in three states1, with participants enrolled 1–6 months after injury. Consistent with past research (Kirkwood et al., 2000; Schwartz et al., 2003), moderate TBI was defined as a Glasgow Coma Scale (GCS, Teasdale & Jennett, 1974) score of 9–12 and/or evidence of a TBI-related lesion on neuroimaging and severe TBI as a GCS score <9. Additional inclusion criteria included English as a primary language, no history of significant psychiatric or behavioral problems in the parent(s) or adolescent, and no significant history of developmental delay (Kurowski et al., 2013; Peterson et al., 2012; Wade et al., 2013). The project was approved by the local Institutional Review Board at each participating institution, with informed parental consent and adolescent assent provided prior to participation.

Of the 308 families initially identified as potentially eligible to participate in the study, 132 participants were enrolled (65% males, 20% African American), 81 with moderate and 51 with severe TBI (MGCS=10.1, SD=4.6). Participants did not differ significantly from non-participants in demographic characteristics. The mean age of injury was 14.5 years (SD = 17) and mean time since injury was 3.48 months (SD = 1.8). Table 1 presents injury and background characteristics for the two severity and two treatment groups. The CAPS and IRC groups did not differ in injury and demographic characteristics. Additional comparisons of the two TBI severity groups failed to reveal differences on demographic factors; although the severe TBI group had fewer individuals of non-White race, this difference did not meet statistical significance (p=.07). The two groups differed by definition on GCS (p<.01). The interval between injury and the baseline assessment was also significantly longer for the severe TBI group (p<.05). Of the 132 teens participating in the baseline assessment, 124 completed the 6-month follow-up (6% attrition rate). The group that completed the follow-up did not differ from the larger sample based on injury severity classification, treatment group, age, race, gender, SES, or parent education.

TABLE 1.

Sample characteristics: demographic and injury variables

Moderate TBI (n=81) Severe TBI (n=51) CAPS (n=65) IRC (n=67) Total (N=132)
Gender (% Male) 54 (67%) 32 (63%) 68% 63% 65%
Race (% Caucasian) 75% 88% 80% 81% 80%
SES z-score†, M (sd) −0.1(1.1) 0.1(0.9) 0.0(1.1) 0.0(0.9) 0.0(1.0)
Parent Education, % > HS 57% 52% 60% 51% 55
Age at Injury: yrs M (sd) 14.4(1.7) 14.7(1.7) 14.4(1.7) 14.7(1.8) 14.5(1.7)
Time since Injury at Baseline: months, M (sd) 3.36 (1.8) 3.96(1.7)* 3.6(1.9) 3.6(1.6) 3.48(1.8)
GCS, M (sd) 13.4(1.9) 4.9(1.9)** 10.1(4.8) 10.0(4.3) 10.6(4.6)
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Note: GCS=Glasgow Coma Scale; CAPS=Communication and Problem-Solving group; IRC=Internet Resources Comparison group.

†

SES z-score represents the mean of combined z-scores for census tract income and primary caregiver education

*

p<0.05;

**

p<0.01

Procedure and Measures

Information on injury severity was obtained from the medical record. Parent and adolescent measures were administered during home visits, with SES defined as the mean of the sample z scores for maternal education and census tract income. Teens with TBI were randomly assigned to one of two treatment conditions (CAPS and IRC groups in a comparative effectiveness trial. Assignment was made immediately following the baseline assessment and individuals conducting the assessments remained naïve to group membership (see Appendix A: CONSORT Flow Chart). As described in greater detail in our previous reports (Kurowski et al., 2013; Wade et al., 2013), teens and their families randomized to the CAPS condition received a computer with internet access and were provided with a 6-month web-based, family-centered intervention that coupled self-guided web modules and videoconferencing with a licensed psychologist. The intervention focused on problem solving, communication, and self-regulation. Modules included weekly or biweekly core sessions covering topics such as staying positive, problem-solving, self-management, communication, and handling crises, followed by up to 4 supplemental sessions addressing individual family needs and a final session for all families scheduled in month 6. Each session included family review of online content followed by therapist review and application of suggested strategies. Participants in the CAPS group had an initial face-to-face session with the psychologist to explain the CAPS intervention and to learn more about the adolescent’s injury and how the family had been affected and to identify goals that each family member wanted to address during the program. Each subsequent CAPS session consisted of a self-guided online portion providing didactic content regarding problem-solving skills, video clips modeling this skill, and exercises and assignments that provide the family with opportunities to practice the new skill. New material was then released upon completion of each online session with the therapist. The average reading grade-level of the materials was 6.6. Online videoconference sessions with the therapist were scheduled biweekly for the first three months of the intervention, for a total of six videoconference sessions using Skype or a similar audio-visual link. The individualized portion occurred during months four and five of the intervention; all families were scheduled for a final, wrap-up session with the therapist in the sixth month.

Teens and families assigned to the IRC condition were provided with a computer and internet connection with links to web sites on TBI but were not able to access specific session content and they did not have contact with a therapist. Resources included links to local, state, and national brain-injury associations and to sites specific to pediatric brain injury. These websites provided didactic information regarding TBI as well as modules about working with schools and family advocacy, handling stress, and problem-solving around common issues. The average reading grade-level of a selection of frequently utilized websites was 8.8. Families were encouraged to spend at least an hour each week accessing information regarding pediatric brain injury on the web throughout the 6-month intervention period and to track the sites they visited. At follow-up, parents provided information about the TBI-related websites visited and the time spent at each site.

Four clinical psychologists, licensed an average of 3.25 years (range 0–7), delivered the CAPS treatment. Prior to beginning the recruitment, a two-day face-to-face training session was conducted by four licensed clinical psychologists with prior experience with TBI treatment and telehealth. A detailed treatment manual outlined session objectives and provided specific step-by-step instructions for meeting these objectives. All psychologists participated in weekly supervision calls to maintain treatment fidelity and adherence to session objectives was verified by end of session checklists completed by the psychologists and participating parents. Bi-weekly conference calls with investigators and coordinators at each site were conducted throughout the study to ensure fidelity of procedures across sites. Additionally, coordinators held weekly conference calls to discuss recruitment, retention, and data collection issues across sites and to maintain reliability on certain measures. Coordinators at each site were trained to provide support around website access issues to participants in both groups with additional support from Biomedical Informatics at the primary site.

The primary goal of the parent study was to reduce problem behaviors after adolescent TBI. Previous publications have explored the impact of this intervention on behavioral problems (Wade et al., 2014; 2015), executive function behaviors (Kurowski et al,, 2013; 2014), and family and caregiver outcomes (Narad et al., 2015; Petranovich et al., 2015). Exploration of prosocial outcomes, the focus of the current study, was a key secondary goal. As such, the comparative effectiveness of the two treatments was examined by administering three measures of social competence to the primary informant (most often mothers) during both a pre-treatment baseline assessment and a 6-month post-treatment follow-up: (1) The Social Competence Scale of the Home and Community Social Behavior Scales (HCSBS; Merrell & Caldarella, 2002) parent rating form, for children ages 5 to 18 years, was used to assess the teen’s level of prosocial adaptive behaviors. The Social Competence Scale measures social competence across two domains: peer relations and self-management/compliance. The HCSBS have been well validated in relation to other measures of social behavior and has good reliability (Merrell & Caldarella, 2002). (2) The Social Competence subscale of the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) parent rating form served as a second measure of social competence. This scale measures parent report of the teen’s level and quality of participation in social activities. The CBCL is a widely used instrument for clinical and research purposes for children ages 6 to 18, and is standardized with established reliability and validity. (3) The Behavioral and Emotional Rating Scale, Second Edition (BERS-2; Epstein, Ryser, & Pearson, 2002) was developed to measure the personal strengths and competencies of children ages 5 through 18 years. The BERS-2 measures several aspects of a child’s social behavior, including interpersonal strength, involvement with family, intrapersonal strength, school functioning, affective strength, and career strength, and has adequate internal consistency validity, content, construct, and criterion-related validity. T-scores for these three measures provided age-standardized measures of social competence (M=50, SD=10), with higher scores reflecting higher social competencies.

During the baseline assessment, research assistants also administered tests of cognitive ability and parent and teen self-report ratings of executive function. A short-form estimate of general intelligence (IQ) was obtained by administering the Vocabulary and Matrix Reasoning subtests of the Wechsler Abbreviated Scale of Intelligence (WASI; Wechsler, 1999). A Processing Speed Index (PSI) was also obtained by administering the Coding and Symbol Search subtests from either the Wechsler Intelligence Scale for Children, Fourth Edition (WISC-IV; Wechsler, 2003), for teens aged 16 years or younger, or the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV; Wechsler, 2008), for teens 17 years or older. Executive function behaviors in the home environment were assessed using the Global Executive Composite (GEC) from Behavior Rating Inventory of Executive Function parent- and self-rating forms (BRIEF-P and BRIEF-SR, Gioia et al., 2000; Guy et al., 2004). All measures are age-standardized. IQ and PSI have a normative mean of 100 and SD of 15 with higher scores reflecting higher ability. GEC T-scores have a mean of 50 and SD of 10 with higher scores reflecting greater deficits in executive function behaviors. Preliminary analysis of these baseline measures failed to reveal significant differences between the CAPS and IRC groups. The moderate TBI group had higher mean PSI than the severe TBI group (p<.01), with respective means (SDs) of 96.0 (14.1) vs. 82.8 (15.8). The moderate and severe TBI groups did not differ significantly on estimated IQ, BRIEF-P GEC, or the BRIEF-SR GEC (see Table 2).

TABLE 2.

Cognitive Functioning by Severity and Group

Moderate TBI (n=81) Severe TBI (n=51) CAPS (n=65) IRC (n=65) Total (N=132)
Cognitive Functioning:
Cognitive Ability: WASI, M(sd) 98.9(13.9) 97.6(11.7) 97.3(13.7) 99.4(12.5) 98.4(13.1)
Processing Speed: PSI, M(sd) 96.0(14.1) 82.8(15.8)** 91.3(17.8) 90.43(14.4) 90.8(16.1)
BRIEF GEC, Parent Report, M(sd)
 Baseline 59.4(10.6) 61.4(9.7) 59.1(10.0) 61.2(10.5) 60.2(10.3)
 6-month 59.1(11.5) 58.8(12.3) 57.2(11.3) 60.6(12.0) 59.0(11.8)
BRIEF GEC, Self Report, M(sd)
 Baseline 52.6(13.0) 52.4(12.1) 50.9(12.5) 54.0(12.6) 52.5(12.6)
 6-month 51.7(12.5) 50.5(11.9) 50.3(11.9) 52.1(12.6) 51.2(12.2)
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Note: CAPS=Communication and Problem-Solving group; IRC=Internet Resources Comparison group; WASI=Wechsler Abbreviated Scale of Intelligence; PSI=Processing Speed Index†; BRIEF = Behavior Rating Inventory of Executive Function; GEC = Global Executive Composite; HCSBS=Home and Community Social Behavior Scales; CBCL=Child Behavior Checklist; BERS-2=Behavioral and Emotional Rating Scale.

†

PSI from either the Wechsler Intelligence Scale for Children, Fourth Edition or the Wechsler Adult Intelligence Scale, Fourth Edition, based on age at testing.

*

p<0.05;

**

p<0.01

Analyses

Repeated measures analysis of covariance (ANCOVA) was conducted to examine intervention effects on each of the three social competence variables. Assessment time point (baseline and 6-month follow-up) was the repeated factor. Between-subjects factors included treatment group (CAPS vs. IRC), TBI severity (moderate vs. severe), and age (younger=grades 6–8 vs. older=grades 9–12). SES, race, and gender were also included in analysis as covariates.

Secondary hierarchical regression analyses were performed to explore associations of baseline cognitive skills and behavioral ratings of executive function with social competence at baseline and with change in social competence from baseline to 6 months. In examining predictors of baseline social competence, injury and demographic factors (TBI severity, age, SES, race, and gender) were entered in the first step of analysis followed by IQ, PSI, BRIEF-P, and BRIEF-SR, with forward stepwise selection of these predictors. Predictors of residualized change in social competence from baseline to 6 months were identified in a similar fashion. Social competence at 6 months was the dependent measure in these analyses with baseline social competence included as an additional covariate. Treatment group (CAPS vs. IRC) was also included to control for the differential treatments of the two groups from baseline to 6-month follow-up. Multicollinearity was assessed by calculating inter-correlations and by examining variance inflation factor (VIF). Separate regressions were run for each of the three social competence indices.

RESULTS

Effects of Intervention and TBI Severity

Results from repeated measures ANCOVAs failed to reveal significant main effects for any of the between subjects factors (treatment group, TBI severity, or age) on any of the three social competence measures (all ps >.1). Higher SES was associated with significantly higher scores on all three measures of social competence (all ps <.05; HCSBS partial η2=.11; CBCL partial η2=.17, BERS-2 partial η2=.06). For the HCSBS, there was a significant visit × Treatment Group × TBI Severity Group × Age group interaction (p<.01; partial η2=.08), with follow-up tests indicating greater increases in social competence for CAPS compared to IRC for younger teens with moderate injuries and older teens with severe injuries. A similar interaction was found for the BERS-2 (p<.05; partial η2=.04); see Figure 1. A significant visit × TBI severity interaction was found for the CBCL (p <.05; partial η2=.05), with the severe TBI group demonstrating reduced social competence over the 6 month follow-up. Severity groups did not differ significantly on CBCL at baseline but approached significance at follow-up (p=.07). Analysis failed to reveal significant changes across visits in measures of social competence for the moderate TBI group.

FIGURE 1. Mean Ratings of Social Competence on the HCSBS by TBI Severity, Intervention Group, and Age Group.

FIGURE 1

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Note: HCSBS=Home and Community Social Behavior Scales; BERS-2=Behavioral and Emotional Rating Scale.

* Difference between pre- and post-intervention scores, p<0.05

** Difference between CAPS and IRC interventions, p<0.05

Baseline Cognitive and Executive Function as Predictors of Social Competence

Table 3 presents findings from linear regression analysis examining associations of social competence at baseline with the baseline measures of cognitive ability and executive function behaviors. Controlling for TBI severity and demographic factors, only the BRIEF-P GEC was significantly related to social competence. Specifically, higher ratings of problems on the BRIEF-P GEC were associated with lower scores on all three social competence measures at baseline (all ps<.01). Estimated IQ, PSI, and BRIEF-SR GEC did not significantly contribute to the prediction of social competence at baseline.

TABLE 3.

Summary of hierarchical linear regression analyses examining predictors of baseline social competence

Predictors Dependent Variable
HCSBS (n=120) CBCL (n=119) BERS-2 (n=113)
STEP 1 β
 Age° .08 .00 .03
 Race .05 −.23* .06
 Gender −.04 −.12 .10
 TBI Severity .01 −.02 .04
 SES† .39** .36** .21*
Total R2 for Step 1 .18** .12** .07
STEP 2 β
 BRIEF GEC, Parent −.54** −.36** −.45**
Δ R2 for Step 2^ .26** .11** .18**
TOTAL Model R2 .44 .24 .25
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Note: ° Age: categorical variable, younger=grades 6–8 vs. older=grades 9–12

^

Excluded variables include: Estimated IQ (WASI), PSI, and BRIEF GEC, Self-Report

WASI=Wechsler Abbreviated Scale of Intelligence; PSI=Processing Speed Index; BRIEF=Behavioral Rating Inventory of Executive Function; GEC=Global Executive Composite

†

SES z-score represents the mean of combined z-scores for census tract income and primary caregiver education

*

Significant at p<0.05;

**

Significant at p<0.01

Findings from regressions examining cognitive predictors of residualized change in social competence at the 6-month assessment (controlling for baseline competence and treatment group) are reported in Table 4. Results revealed significant associations of higher baseline ratings of problems on the BRIEF-P GEC with less positive changes in social competence as measured by the HCSBS across follow-up (p<.01) and of higher estimated IQ with more positive changes over time on CBCL Social Competence (p<.05). Analysis failed to reveal any significant predictors of changes across follow-up in social competence on the BERS-2.

TABLE 4.

Summary of hierarchical linear regression analyses, exploring predictors of social competence at 6-month follow-up

Predictors Dependent Variable
HCSBS (n=108) CBCL (n=103) BERS-2 (n=103)
STEP 1 β
 Age° .07 −.03 .01
 Race .04 −.11 .11
 Gender −.07 −.10 .09
 TBI Severity .04 −.14 .14
 SES .30** .41** .26*
 Group (CAPS v IRC) .14 .09 .04
Total R2 for Step 1 .13* .18** .13*
STEP 2 β
 Baseline Social Competence .56** .54** .70**
Δ R2 for Step 2 .24** .26** .43**
STEP 3 β
 Baseline BRIEF GEC, Parent −.27**
 Estimated IQ (WASI) .21*
Δ R2 for Step 3^ .05** .03* --
TOTAL Model R2 .42 .47 .56
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Note: ° Age: categorical variable, younger=grades 6–8 vs. older=grades 9–12;

^

Excluded variables include: PSI and BRIEF GEC, Self-Report

WASI=Wechsler Abbreviated Scale of Intelligence; PSI=Processing Speed Index; BRIEF=Behavioral Rating Inventory of Executive Function; GEC=Global Executive Composite; CAPS=Communication and Problem-Solving group; IRC=Internet Resources Comparison group

Baseline functioning refers to corresponding social competence measure at baseline measurement.

†

SES z-score represents the mean of combined z-scores for census tract income and primary caregiver education

*

Significant at p<0.05;

**

Significant at p<0.01

DISCUSSION

Prior research has shown evidence that a telehealth intervention (CAPS) designed to improve behavioral outcomes after TBI is effective for improving adolescent behavior, adolescent and parental psychiatric symptoms, and parent-child relationships (e.g., Wade et al., 2004; 2006; 2008; 2011). Similarly, analyses of the primary outcomes for the larger project indicate that CAPS was effective in reducing externalizing behavior problems and behavioral ratings of executive dysfunction in older adolescents (Kurowski et al., 2013; Wade et al., 2013). The primary aim of the current study was to examine whether CAPS might also improve teens’ social competence.

Results provide partial support for our primary hypothesis that CAPS would be most effective for older teens with more severe injuries. Specifically, the CAPS intervention improved social competence on the HCSBS and BERS-2, with the effects differing based on the teen’s injury severity and age; statistically significant visit × Treatment Group × TBI Severity × Age group interactions were identified for both measures, with small to medium effect sizes (HCSBS partial η2=.08; BERS-2 partial η2=.04). For younger teens (grades 6–8), those with moderate injuries showed the most gains in social competence with participation in CAPS for older teens (grades 9–12), those with severe injuries were more likely to show improved social competence with CAPS. The finding that CAPS was beneficial for improving social competence in older teens with severe injuries is consistent with our hypothesis and prior research (Kurowski et al., 2013; Wade et al., 2010; Wade et al., 2013). The intervention sessions target self-monitoring, self-regulation, and social problem solving. Thus, youth who successfully learn and implement the skills in everyday settings should display improved social competence. Younger adolescents with more severe injuries may lack the developmental foundation and cognitive resources to integrate the skills into their behavioral repertoires. For older teens with greater cognitive development prior to the injury, a higher degree of cognitive “reserve” may allow them to take more advantage of the intervention in spite of severe TBI. However, alternative explanations are also feasible. Older teens, for example, may have been more engaged in the intervention or may have had more opportunities or a greater willingness to apply the strategies in the daily social interactions. It is also important to note that findings suggestive of cognitive reserve as a potential explanation were found only for the HCSBS and BERS-2 and not for the CBCL Social Competence subscale. Analysis of the latter measure revealed only a general trend for declines in social competence across follow-up for both groups of teens with severe TBI (partial η2=.05). These findings may be, at least in part, related to differing social constructs being assessed with these varying measures, described further below.

The secondary aim of the study was to examine factors in addition to TBI severity that place teens at higher risk for decreased social competence after TBI. Specifically, we sought to examine associations of cognitive ability and behavior ratings of executive dysfunction with social competence shortly after injury and change in social competence over the 6-month period during which families were engaged in an intervention. The results of the current study provide partial support for our hypothesis that evidence for greater problems in executive function behaviors at the baseline would be associated with lower levels of social competence or less improvement in social competence across follow-up. Specifically, higher parent ratings of problems in executive function behaviors were associated with statistically significant lower social competence on all three measures at baseline, even when controlling for demographic and injury-related factors related to outcomes after TBI (Fay et al., 2009). Findings also revealed factors associated with statistically significant changes in social competence across follow-up. Specifically, higher parent-rated executive dysfunction at baseline predicted less positive changes in social competence across the 6-month follow-up on the HCSBS, whereas higher estimated IQ at baseline predicted more positive changes in social functioning as measured by the CBCL.

Because multiple measures were used in the present study to capture different aspects of social competence, different patterns of findings across the three measures of social competence might be expected. The CBCL Social Competence scale measures level of social engagement, and estimates competence based on parents’ ratings of how the teen’s performance in each of the social activities compares with that of his/her peers. By contrast, the HCSBS Social Competence scale is designed to measure prosocial adaptive and interpersonal behaviors and traits that are typical of well-adjusted children on two domains, namely peer interactions and socially-appropriate behaviors. The BERS-2 was developed to capture an even wider range of a child’s social “strengths,” including factors related to interpersonal and intrapersonal functioning, affect, family, and school. Thus, the finding of greater improvements for certain teens with TBI who participated in CAPS compared to the IRC condition as measured by the HCSBS and BERS-2, but not CBCL, may suggest greater improvements in prosocial adaptive behaviors and interpersonal skills than in social engagement. Social participation, such as measured by the CBCL Social Competence subscale, was not addressed in the CAPS intervention but may constitute a key aspect of social competence post TBI (Bedell et al., 2004; 2008; 2005; 2011). Promotion of social participation may require alternative intervention strategies that address environmental or more global cognitive barriers to successful participation in addition to skill deficits.

The finding that executive abilities are strong predictors of all three measures at baseline is consistent with findings from prior research (Clark, Prior, & Kinsella, 2002; Ganesalingam et al., 2011; Kurowski et al., 2013; Kurowski et al., 2011) which has demonstrated the important association between executive functioning and psychosocial functioning. Associations of higher IQ and lower levels of behavioral ratings of functioning t baseline with greater gains over time in social competence also suggest that higher functioning relatively early after TBI portend greater recovery of social competence. One explanation for these associations is that the teens with higher baseline skills sustained less damage to neural networks contributing to the developing social competence. Alternatively, the teens with higher baseline skills have higher cognitive reserve, allowing them to maintain more normative development gains despite brain insult.

The current study has several limitations. The sample is composed of adolescents with moderate to severe TBI, thus the results cannot be generalized to younger children or to those with less severe injuries. Further, as a randomized controlled trial of an intervention for TBI, the study did not include a non-TBI control group. Additionally, as many of the primary measures of interest in the current study are based on parent-report the results are inherently affected by shared method variance and impacted by rater biases, as has been demonstrated in research on behavioral outcomes of TBI (Redpath & Linden, 2004). The similarity of some of the behavioral items comprising ratings of executive function behaviors and social competence also suggest that there may be some measurement overlap in between the predictor and dependent variables examined in this study. Similarly it is acknowledge that the means for all groups at baseline and 6-month follow-up were in the average range across measures of social competence, indicating that a statistically significant change in social competence may not reflect clinically-significant change at the individual level. From a conceptual perspective, it is also important to consider the limitations of reliance on parent ratings of social competence. Although these ratings may be useful as part of a broader strategy for assessing social competence, they fail to provide a comprehensive evaluation of this complex and multi-dimensional construct. A variety of other methods may provide a more ecologically valid assessment of social competence (Turkstra, McDonald, & DePompei, 2001). For example, some tools ask children to solve social dilemmas or interpret various social interactions. Others rely on observational methods, such as classroom observations or peer-ratings. Recent research has shown the utility of these other methods in assessing social competence after childhood TBI (e.g., Anderson et al., 2013; Yeates et al., 2013).

In sum, the findings indicate that CAPS is effective for improving social competence after TBI, at least for some subsets of teens. Additionally, post-acute weaknesses in executive function behaviors are related to both concurrent social competence and subsequent gains in these skills. Prior research has also shown CAPS to be effective for improving executive function behaviors, suggesting that improvements in these areas are interrelated. Results varied across measures tapping different aspects of social competence, underscoring the need to better understand how interventions impact both cognitive and social functioning. The results highlight the importance of incorporating assessments of social competence into neuropsychological evaluations of adolescents with TBI.

IMPACT.

  • This article provides preliminary support for the effectiveness of a problem-solving and communication intervention for improving social competence, and in particular the development of prosocial behaviors, in adolescents with TBI. The results also help in identifying teens most likely to benefit from the intervention.

  • Higher cognitive and executive functioning shortly after injury is related to greater gains in social competence across the subsequent 6 months.

  • The findings highlight the importance of incorporating assessments of social competence into neuropsychological evaluations of adolescents with TBI.

Acknowledgments

This work was supported in part by 1) NIH grant R01-MH073764 from the National Institute of Mental Health, 2) a grant from the Colorado Traumatic Brain Injury Trust Fund Research Program, Colorado Department of Human Services, Division of Vocational Rehabilitation, Traumatic Brain Injury Program, and by grant H133B090010, to Dr. Shari L. Wade, from the National Institute of Disability and Rehabilitation Research, Department of Education. The authors acknowledge the contributions of Mary Ann Toth, Kendra McMullen, Robert Blaha, Elizabeth Hagesfeld, Michelle Jacobs, Daniel Maier, and Nina Fox in data collection and entry, Amy Cassedy in data management, and John Stullenberger in Website support. The authors also acknowledge the contributions of the therapists JoAnne Carey, PsyD, Britt Nielsen, PsyD, and Brad Jackson, PhD.

APPENDIX A

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Footnotes

1

names of states removed to facilitate masked review

References

  1. Achenbach TM, Rescorla LA. Manual for the ASEBA school-age form and profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families; 2001. [Google Scholar]
  2. Adolphs R. The neurobiology of social cognition. Current Opinion in Neurobiology. 2001;11:231–239. doi: 10.1016/s0959-4388(00)00202-6. [DOI] [PubMed] [Google Scholar]
  3. Anderson VA, Beauchamp MH, Yeates KO, Crossley L, Hearps SJC, Catroppa C. Social competence at 6 Months following childhood traumatic brain injury, Journal of the International Neuropsychology Society. 2013;19:539–550. doi: 10.1017/S1355617712001543. [DOI] [PubMed] [Google Scholar]
  4. Anderson VA, Catroppa C. Advances in postacute rehabilitation after childhood acquired brain injury: A focus on cognitive, behavioral, and social domains. American Journal of Physical Medicine & Rehabilitation. 2006;85:767–778. doi: 10.1097/01.phm.0000233176.08480.22. [DOI] [PubMed] [Google Scholar]
  5. Anderson VA, Catroppa C, Dudgeon P, Morse SA, Haritou F, Rosenfeld JV. Understanding predictors of functional recovery and outcome 30 months following early childhood head injury. Neuropsychology. 2006;20(1):42–57. doi: 10.1037/0894-4105.20.1.42. [DOI] [PubMed] [Google Scholar]
  6. Anderson VA, Morse SA, Catroppa C, Haritou F, Rosenfeld JV. Thirty month outcome from early childhood head injury: a prospective analysis of neurobehavioral recovery. Brain. 2004;127:2608–2620. doi: 10.1093/brain/awh320. [DOI] [PubMed] [Google Scholar]
  7. Beauchamp MH, Anderson VA. SOCIAL: An integrative framework for the development of social skills, Psychological Bulletin. 2010;136:39–64. doi: 10.1037/a0017768. [DOI] [PubMed] [Google Scholar]
  8. Bedell G, Coster W. Measuring participation of school-aged children with traumatic brain injuries: Considerations and approaches. Journal of Head Trauma Rehabilitation. 2008;23:220–229. doi: 10.1097/01.HTR.0000327254.61751.e7. [DOI] [PubMed] [Google Scholar]
  9. Bedell G, Cohn E, Dumas H. Exploring parents’ use of strategies to promote social participation in school-age children with acquired brain injuries. American Journal of Occupational Therapy. 2005;59:273–284. doi: 10.5014/ajot.59.3.273. [DOI] [PubMed] [Google Scholar]
  10. Bedell G, Dumas H. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: A follow-up study. Brain Injury. 2004;18:65–82. doi: 10.1080/0269905031000110517. [DOI] [PubMed] [Google Scholar]
  11. Bedell G, Khetani M, Cousins M, Coster W, Law M. Parent perspectives to inform development of measures of children’s participation and environment. Archives of Physical Medicine and Rehabilitation. 2011;92:765–773. doi: 10.1016/j.apmr.2010.12.029. [DOI] [PubMed] [Google Scholar]
  12. Blakemore S-J, Choudhury S. Development of the adolescent brain: implications for executive function and social cognition. Journal of Child Psychology and Psychiatry. 2006;47(3/4):296–312. doi: 10.1111/j.1469-7610.2006.01611.x. [DOI] [PubMed] [Google Scholar]
  13. Bornhofen C, McDonald S. Emotion perception deficits following traumatic brain injury: A review of the evidence and rationale for intervention. Journal of the International Neuropsychological Society. 2008;14:511–525. doi: 10.1017/S1355617708080703. [DOI] [PubMed] [Google Scholar]
  14. Byles J, Byrne C, Boyle MH, Offord DR. Ontario Child Health Study: Reliability and validity of the General Functioning subscale of the McMaster Family Assessment Device. Family Process. 1988;27:97–104. doi: 10.1111/j.1545-5300.1988.00097.x. [DOI] [PubMed] [Google Scholar]
  15. Casey, Jones, Hare The adolescent brain. Annals of the New York Academy of Sciences. 2008;1124:111–126. doi: 10.1196/annals.1440.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance – United States, 2009. 2010 (Surveillance Summaries MMWR 2010; 59, No. SS-#5). Retrieved from http://www.cdc.gov/HealthyYouth/yrbs/index.htm.
  17. Chapman LA, Wade SL, Walz NC, Taylor HG, Stancin T, Yeates KO. Clinically significant behavior problems during the initial 18 months following early childhood traumatic brain injury. Rehabilitation Psychology. 2010;55:48–57. doi: 10.1037/a0018418. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Chen X, Rubin KH, Li D. Relation between academic achievement and social adjustment: evidence from Chinese children. Developmental Psychology. 1997;33:518–525. doi: 10.1037//0012-1649.33.3.518. [DOI] [PubMed] [Google Scholar]
  19. Clark C, Prior M, Kinsella G. The relationship between executive function abilities, adaptive behavior, and academic achievement in children with externalizing behavior problems. Journal of Child Psychology and Psychiatry. 2002;43:785–796. doi: 10.1111/1469-7610.00084. [DOI] [PubMed] [Google Scholar]
  20. DeRosier ME, Lloyd SW. The impact of children’s social adjustment on academic outcomes. Reading and Writing Quarterly. 2010;27:25–47. doi: 10.1080/10573569.2011.532710. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Donders J, Janke K. Criterion validity of the Wechsler Intelligence Scale for Children—Fourth Edition after pediatric traumatic brain injury. Journal of the International Neuropsychological Society. 2008;14:651–655. doi: 10.1017/S1355617708080752. [DOI] [PubMed] [Google Scholar]
  22. D’Zurilla Thomas J, Nezu Arthur M, Maydeu-Olivares Albert. In: Social problem solving: Theory, research, and training. Chang Edward C, D’Zurilla Thomas J, Sanna Lawrence J., editors. Washington, DC, US: American Psychological Association; 2004. pp. 11–27.pp. xvipp. 276 http://dx.doi.org/10.1037/10805-001. [Google Scholar]
  23. Epstein MH, Ryser G, Pearson N. Standardization of the Behavioral and Emotional Rating Scale: factor structure, reliability, and criterion validity. The Journal of Behavioral Health Services and Research. 2002;29:208–216. doi: 10.1007/BF02287707. [DOI] [PubMed] [Google Scholar]
  24. Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevent ion and Control; 2010. [Google Scholar]
  25. Fay TB, Yeates KO, Wade SL, Drotar D, Stancin T, Taylor HG. Predicting longitudinal patterns of functional deficits in children with traumatic brain injury. Neuropsychology. 2009;23:271–282. doi: 10.1037/a0014936. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Frith U, Frith C. The biological basis of social interaction. Current Directions in Psychological Science. 2001;10:151–155. [Google Scholar]
  27. Ganesalingam K, Yeates KO, Taylor HG, Walz NC, Stancin T, Wade S. Executive functions and social competence in young children 6 months following traumatic brain injury. Neuropsychology. 2011;25:466–476. doi: 10.1037/a0022768. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Gioia GA, Isquith PK, Guy SC. Behavior Rating of Executive Function (BRIEF) Child Neuropsychology. 2000;6:235–238. [Google Scholar]
  29. Guy SC, Isquith PK, Gioia GA. BRIEF-SR: Behavior Rating Inventory of Executive Function--Self-Report Version. Lutz, FL: Psychological Assessment Resources; 2004. [Google Scholar]
  30. Hessler DM, Katz LF. Brief report: associations between emotional competence and adolescent risky behavior. Journal of Adolescence. 2010;33:241–246. doi: 10.1016/j.adolescence.2009.04.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Janusz JA, Kirkwood MW, Yeates KO, Taylor HG. Social problem-solving skills in children with traumatic brain injury: long-term outcomes and predictions of social competence. Child Neuropsychology. 2002;8(3):179–194. doi: 10.1076/chin.8.3.179.13499. [DOI] [PubMed] [Google Scholar]
  32. Kirkwood M, Janusz J, Yeates KO, Taylor GH, Wade SL, Stancin T, et al. Prevalence and correlates of depressive symptoms following traumatic brain injuries in children. Child Neuropsychology. 2000;6:195–208. doi: 10.1076/chin.6.3.195.3157. [DOI] [PubMed] [Google Scholar]
  33. Kurowski BG, Wade SL, Kirkwood MW, Brown TM, Stancin T, Cassedy A, Taylor HG. Association of parent ratings of executive function with global- and setting-specific behavioral impairment after adolescent traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2013;95:543–550. doi: 10.1016/j.apmr.2012.10.029. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Kurowski BG, Wade SL, Kirkwood MW, Brown TM, Stancin T, Taylor HG. Online problem-solving therapy for executive dysfunction after child traumatic brain injury. Pediatrics. 2013;132:1–9. doi: 10.1542/peds.2012-4040. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Kurowski BG, Wade SL, Kirkwood MW, Brown TM, Stancin T, Taylor HG. Long-term benefits of an early online problem-solving intervention for executive dysfunction after traumatic brain injury in children: a randomized clinical trial. JAMA Pediatr. 2014 Jun;168(6):523–31. doi: 10.1001/jamapediatrics.2013.5070. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Kurowski BG, Taylor HG, Yeates KO, Walz NC, Stancin T, Wade SL. Caregiver ratings of long-term executive dysfunction and attention problems after early childhood traumatic brain injury: family functioning is important. Physical Medicine and Rehabilitation. 2011;3:836–845. doi: 10.1016/j.pmrj.2011.05.016. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006. Retrieved from CDC website: www.cdc.gov/ncipc/pub-res/tbi.../tbi%20in%20the%20us_jan_2006.pdf. [Google Scholar]
  38. Luna B, Sweeney JA. The emergence of collaborative brain function: FMRI studies of the development of response inhibition. Annals of the New York Academy of Sciences. 2004;1021:296–309. doi: 10.1196/annals.1308.035. [DOI] [PubMed] [Google Scholar]
  39. Mangeot S, Armstrong K, Colvin AN, Yeates KO, Taylor HG. Long-term executive function deficits in children with traumatic brain injuries: Assessment using the Behavior Rating Inventory of Executive Function (BRIEF) Child Neuropsychology. 2002;8:271–284. doi: 10.1076/chin.8.4.271.13503. [DOI] [PubMed] [Google Scholar]
  40. Max JE, Koele SL, Lindgren SD, Robin DA, Smith WL, Sato Y, Arndt S. Psychiatric disorders in children and adolescents after severe traumatic brain injury: a controlled study. Journal of the American Academy of Child and Adolescent Psychiatry. 1998;37:832–840. doi: 10.1097/00004583-199808000-00013. [DOI] [PubMed] [Google Scholar]
  41. Merrell KW, Caldarella P. Home and community social behavior scales (HCSBS): User’s guide. Eugene, OR: Assessment-Intervention Resources; 2002. [Google Scholar]
  42. Muscara F, Catroppa C, Eren S, Anderson V. The impact of injury severity on long-term social outcome following paediatric traumatic brain injury. Neuropsychological Rehabilitation. 2009;19:541–561. doi: 10.1080/09602010802365223. [DOI] [PubMed] [Google Scholar]
  43. Narad ME, Minich N, Taylor HG, Kirkwood MW, Brown TM, Stancin T, Wade SL. Effects of a web-based intervention on family functioning following pediatric traumatic brain injury. Journal of Developmental Behavioral Pediatrics. 2015;36(9):700–7. doi: 10.1097/DBP.0000000000000208. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Nelson EE, Leibenluft E, McClure EB, Pine DS. The social re-orientation of adolescence: a neuroscience perspective on the process and its relation to psychopathology. Psychological Medicine. 2005;35:163–174. doi: 10.1017/S0033291704003915. [DOI] [PubMed] [Google Scholar]
  45. Parker J, Rubin KH, Erath S, Wojslawowics JC, Buskirk AA. Peer relationships and developmental psychopathology. In: Cicchetti D, Cohen D, editors. Developmental psychopathology: Risk, disorder, and adaptation. 2. Vol. 2. New York: Wiley; 2006. pp. 419–493. [Google Scholar]
  46. Peterson RL, Kirkwood MW, Taylor GH, Stancin T, Brown T, Wade SL. Adolescents’ internalizing problems following traumatic brain injury are related to parents’ psychiatric symptoms. Journal of Head Trauma Rehabilitation. 2012 doi: 10.1097/HTR.0b013e318263f5ba. [Epub ahead of print] [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Petranovich CL, Wade SL, Taylor HG, Cassedy A, Stancin T, Kirkwood MW, Maines Brown T. Long-term caregiver mental health outcomes following a predominately online intervention for adolescents with complicated mild to severe traumatic brain injury. Journal of Pediatric Psychology. 2015 doi: 10.1093/jpepsy/jsv001. pii: jsv001. [Epub ahead of print] [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Phillips ML, Drevets WC, Rauch SL, Lane R. Neurobiology of emotion perception I: the neural basis of normal emotion perception. Biological Psychiatry. 2003;54:504–514. doi: 10.1016/s0006-3223(03)00168-9. [DOI] [PubMed] [Google Scholar]
  49. Rivera PA, Elliott TR, Berry JW, Grant JS. Problem-solving training for family caregivers of persons with traumatic brain injuries: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2008;89:931–941. doi: 10.1016/j.apmr.2007.12.032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Rockhill CM, Stoep AV, McCauley E, Katon WJ. Social competence and social support and mediators between comorbid depressive and conduct problems and functional outcomes in middle school children. Journal of Adolescence. 2009;32:535–553. doi: 10.1016/j.adolescence.2008.06.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Redpath SJ, Linden MA. Attitudes towards behavioural versus organic acquisition of brain injury. Brain Injury. 2004;18:861–869. doi: 10.1080/02699050410001671838. [DOI] [PubMed] [Google Scholar]
  52. Rosema S, Crowe L, Anderson V. Social function in children and adolescents after traumatic brain injury: A systematic review 1989–2011. Journal of Neurotrauma. 2012;29:1277–1291. doi: 10.1089/neu.2011.2144. [DOI] [PubMed] [Google Scholar]
  53. Schwartz L, Taylor GH, Drotar D, Yeates KO, Wade SL, Stancin T. Long-term behavior problems following pediatric traumatic brain injury: prevalence, predictors, and correlates. Journal of Pediatric Psychology. 2003;28:251–263. doi: 10.1093/jpepsy/jsg013. [DOI] [PubMed] [Google Scholar]
  54. Sesma HW, Slomine BS, Ding R, McCarthy ML. Executive functioning in the first year after pediatric traumatic brain injury. Pediatrics. 2008;121:e1686–e1695. doi: 10.1542/peds.2007-2461. [DOI] [PubMed] [Google Scholar]
  55. Steinberg L. A social neuroscience perspective on adolescent risk-taking. Developmental Review. 2008;28(1):78–106. doi: 10.1016/j.dr.2007.08.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Struchen MA, Clark AN, Sander AM, Mills MR, Evans G, Kurtz D. Relation of executive functioning and social communication measures to functional outcomes following traumatic brain injury. NeuroRehabilitation. 2008;23:185–198. [PubMed] [Google Scholar]
  57. Stancin T, Drotar D, Taylor HG, Yeates KO, Wade SL, Minich NM. Health-related quality of life of children and adolescents after traumatic brain injury. Pediatrics. 2002;109(2) doi: 10.1542/peds.109.2.e34. URL: http://www.pediatrics.org/cgi/content/full/109/2/e34. [DOI] [PubMed] [Google Scholar]
  58. Teasdale, Jennett Assessment of coma and impaired consciousness. The Lancet. 1974;2:81–83. doi: 10.1016/s0140-6736(74)91639-0. [DOI] [PubMed] [Google Scholar]
  59. Tlustos SJ, Chiu C-YP, Walz NC, Taylor GH, Yeates KO, Wade SL. Emotion Labeling and Socio-Emotional Outcomes 18 Months after Early Childhood Traumatic Brain Injury. Journal of the International Neuropsychological Society. 2011;17:1132–1142. doi: 10.1017/S1355617711001202. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Turkstra LS, McDonald S, DePompei R. Social information processing in adolescents: data from normally developing adolescents and preliminary data from their peers with traumatic brain injury. Journal of Head Trauma Rehabilitation. 2001;16:469–483. doi: 10.1097/00001199-200110000-00006. [DOI] [PubMed] [Google Scholar]
  61. Wade SL, Carey J, Wolfe C. The efficacy of an online cognitive-behavioral family intervention in improving child behavior and social competence following pediatric brain injury. Rehabilitation Psychology. 2006;51:179–189. [Google Scholar]
  62. Wade SL, Michaurd L, Brown TM. Putting the pieces together: preliminary efficacy of a family problem-solving intervention for children with traumatic brain injury. Journal of Head Trauma Rehabilitation. 2006;21:57–67. doi: 10.1097/00001199-200601000-00006. [DOI] [PubMed] [Google Scholar]
  63. Wade SL, Stancin T, Kirkwood M, Brown TM, McMullen KM, Taylor HG. Counselor-Assisted Problem Solving (CAPS) improved behavioral outcomes in older adolescents with complicated mild to severe TBI. Journal of Head Trauma Rehabilitation. 2014;29(3):198–207. doi: 10.1097/HTR.0b013e31828f9fe8. Epub 2013 May. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Wade SL, Taylor HG, Cassedy A, Zhang N, Kirkwood MW, Brown TM, Stancin T. Long-term behavioral outcomes following a randomized clinical Ttial of Counselor-Assisted Problem-Solving for adolescents with complicated mild to severe traumatic brain injury. Journal of Neurotrauma. 2015;32(13):967–75. doi: 10.1089/neu.2014.3684. Epub 2015 Mar 4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  65. Wade SL, Walz NC, Carey JA, Williams KM. Preliminary efficacy of a web-based family problem-solving treatment program for adolescents with traumatic brain injury. Journal of Head Trauma Rehabilitation. 2008;23:369–377. doi: 10.1097/01.HTR.0000341432.67251.48. [DOI] [PubMed] [Google Scholar]
  66. Wade SL, Walz NC, Carey JA, Williams KM. A randomized trial of teen online problem solving for improving executive function deficits following pediatric traumatic brain injury. Journal of Head Trauma Rehabilitation. 2010;25:409. doi: 10.1097/HTR.0b013e3181fb900d. [DOI] [PubMed] [Google Scholar]
  67. Wade SL, Walz NC, Carey JA, Williams KM, Cass J, Mark E, Yeates KO. Effect on behavior problems of teen online problem-solving for adolescent traumatic brain injury. Pediatrics. 2011;128:947–953. doi: 10.1542/peds.2010-3721. [DOI] [PMC free article] [PubMed] [Google Scholar]
  68. Walz NC, Yeates KO, Wade SL, Mark E. Social information processing skills in adolescents with traumatic brain injury: relationship with social competence and behavior problems. Journal of Pediatric Rehabilitation Medicine. 2009;2:285–295. doi: 10.3233/PRM-2009-0094. [DOI] [PubMed] [Google Scholar]
  69. Warriner EM, Velikonja D. Psychiatric disturbances after traumatic brain injury: neurobehavioral and personality changes. Current Psychiatry Reports. 2006;8:73–80. doi: 10.1007/s11920-006-0083-2. [DOI] [PubMed] [Google Scholar]
  70. Wechsler D. Wechsler Abbreviated Scale of Intelligence. Austin, TX: Psychological Corporation; 1999. [Google Scholar]
  71. Wechsler D. Wechsler Adult Intelligence Scale. 4. San Antonio: Pearson Education, Inc; 2008. [Google Scholar]
  72. Wechsler D. Wechsler Intelligence Scale for Children. 4. San Antonio: Pearson Assessment; 2003. [Google Scholar]
  73. Wilde EA, Hunter JV, Newsome MR, Scheibel RS, Bigler ED, Johnson JL, … Levin HS. Frontal and temporal morphometric findings on MRI in children after moderate to severe traumatic brain injury. Journal of Neurotrauma. 2005;22:333–344. doi: 10.1089/neu.2005.22.333. [DOI] [PubMed] [Google Scholar]
  74. Yeates KO, Swift E, Taylor G, Wade SL, Drotar D, Stancin T, Minich N. Short- and long-term social outcomes following pediatric traumatic brain injury. Journal of the International Neuropsychological Society. 2004;10:412–426. doi: 10.1017/S1355617704103093. [DOI] [PubMed] [Google Scholar]
  75. Yeates KO, Bigler ED, Dennis M, Gerhardt CA, Rubin KH, Stancin T, Taylor HG, Vannatta K. Social Outcomes in Childhood Brain Disorder: A Heuristic Integration of Social Neuroscience and Developmental Psychology. 2007;133:535–556. doi: 10.1037/0033-2909.133.3.535. [DOI] [PMC free article] [PubMed] [Google Scholar]
  76. Yeates KO, Bigler ED, Abildskov T, Dennis M, Gerhardt CA, Vannatta K, Rubin KH, Stancin T, Taylor HG. Social competence in pediatric traumatic brain injury: From brain to behavior. Clinical Psychological Science. 2014;2:97–107. [Google Scholar]
  77. Ylvisaker M, Turkstra L, et al. Behavioral interventions for children and adults with behavior disorders after TBI: a systematic review of the evidence. Brain Injury. 2007;21:769–805. doi: 10.1080/02699050701482470. [DOI] [PubMed] [Google Scholar]

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