Long-Term Behavioral Outcomes after a Randomized, Clinical Trial of Counselor-Assisted Problem Solving for Adolescents with Complicated Mild-to-Severe Traumatic Brain Injury

Abstract

Family problem-solving therapy (FPST) has been shown to reduce behavior problems after pediatric traumatic brain injury (TBI). It is unclear whether treatment gains are maintained. We sought to evaluate the maintenance of improvements in behavior problems after a Web-based counselor-assisted FPST (CAPS) intervention compared to an Internet resource comparison (IRC) intervention provided to adolescents within the initial year post-TBI. We hypothesized that family socioeconomic status, child educational status, and baseline levels of symptoms would moderate the efficacy of the treatment over time. Participants included 132 adolescents ages 12-17 years who sustained a complicated mild-to-severe TBI 1-6 months before study enrollment. Primary outcomes were the Child Behavior Checklist Internalizing and Externalizing Totals. Mixed-models analyses, using random intercepts and slopes, were conducted to examine group differences over time. There was a significant group×time×grade interaction (F(1,304)=4.42; p=0.03) for internalizing problems, with high school-age participants in CAPS reporting significantly lower symptoms at 18 months postbaseline than those in the IRC. Post-hoc analyses to elucidate the nature of effects on internalizing problems revealed significant group×time×grade interactions for the anxious/depressed (p=0.03) and somatic complaints subscales (p=0.04). Results also indicated significant improvement over time for CAPS participants who reported elevated externalizing behavior problems at baseline (F(1, 310)=7.17; p=0.008). Findings suggest that CAPS may lead to long-term improvements in behavior problems among older adolescents and those with pretreatment symptoms.

Trial registration: ClinicalTrials.gov NCT00409448.

Keywords: adolescent; behavior; brain injury; child; online; therapy.

Figures

FIG. 1.

CONSORT flow diagram.

FIG. 2.

Significant group×time×grade interaction (p=0.03). CAPS high school–age participants scored significantly lower than IRC high school–age participants at 18 months postbaseline (p<0.05). CAPS, counselor-assisted problem solving; IRC, Internet resource comparison; HS, high school.

FIG. 4.

Significant group×time grade interaction (p=0.04). High school–age CAPS participants had significantly lower internalizing symptoms at 18 months postbaseline than IRC high school–age participants, after controlling for age and gender. CAPS, counselor-assisted problem solving; IRC, Internet resource comparison; HS, high school.

FIG. 5.

Significant group×time×baseline externalizing symptoms (T>60; p=0.008). CAPS participants with elevated baseline externalizing symptoms had significantly lower levels of externalizing symptoms than IRC participants with elevated baseline externalizing symptoms at both 12 and 18 months postbaseline. CAPS, counselor-assisted problem solving; IRC, Internet resource comparison; HS, high school.

FIG. 3.

Significant group×time×grade interaction (p=0.03). Symptom scores did not differ between the CAPS and IRC groups in high school or middle school at any time point. CAPS, counselor-assisted problem solving; IRC, Internet resource comparison; HS, high school.