Patient Presentation
D.W. is an 11-year-old, right-handed Caucasian male of low socioeconomic status and a rural upbringing. He was first seen by our clinic for neuropsychological evaluation. That assessment resulted in a referral for psychotherapy. We describe here his psychosocial history before injury, the results of his neuropsychological examination, and his course of treatment for behavior problems.
Preinjury History, Family Environment, and Testing
D.W. was born full term weighing 7 pounds 2 ounces and achieved developmental milestones at or before the developmentally expected timepoints. D.W.'s immediate family lives together and consists of his biological mother, stepfather, and younger sister (aged 4 years). D.W.'s biological father has not been in contact with the family since D.W. was 12 months old. D.W. also has several aunts, uncles, and cousins living within close driving distance, and his family is close with their church community. Both of his parents completed High School, his stepfather is a farmer, and his mother stays at home with both children and is the primary disciplinarian. At the request of his parents, D.W. was evaluated at age 5 years by a school psychologist and subsequently diagnosed with ADHD—Combined Type, which was treated with atomoxetine for the 6 years preceding his accident. D.W.'s historical diagnosis of ADHD was confirmed in the context of his post-TBI neuropsychological evaluation. Following his school evaluation, formal school accommodations were implemented to address D.W.'s ADHD-related learning needs, including extra time on tests and perimission to take examinations in a separate room. Prior to his TBI, he obtained As and Bs in school, had always been on the honor roll, and had several close friends. His mother completed the Behavior Assessment System for Children—Second Edition (BASC-2; Reynolds & Kamphaus, 2004) and the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) as part of his neuropsychological evaluation in order to (retrospectively) assess his behavior before the injury. On these measures, D.W. was rated as having normal levels of behavior on all scales ( Table I ). His history is not significant for any major illnesses or injuries.
Description of Injury, Postinjury Presentation, and Testing
At the age of 10 years, 3 months D.W. was the victim of an accidental gunshot wound to the head from a handgun that he and another child found in the home. Neuroimaging showed that the bullet entered the right frontal brain region and exited in the right parietal region, causing parenchymal laceration and hemorrhage along the bullet tract, as well as skull fractures along the right frontal and parietal bones. D.W. was intubated in the ambulance and upon admission to the emergency department was reported to have a Glasgow Coma Scale (Jennett & Bond, 1975) of 8 (in the context of intubation), which according to common severity classifications (e.g., Fletcher et al., 1990) indicated a severe TBI. Imaging further revealed subarachnoid and thin subdural hemorrhages and multiple bullet fragments in the right frontal region. He underwent a right decompressive craniectomy, right frontal lobectomy, and evacuations of intraparenchymal and epidural hematomas. After 5 weeks of inpatient acute hospital care, he was transferred to a rehabilitation hospital where he remained for 2 weeks before being discharged home into his family's care and outpatient rehabilitation services.
D.W. was first seen through our clinic 8 months postinjury for neuropsychological testing (with author S.H.) to evaluate his cognitive and behavioral functioning and to offer recommendations for faster school reintegration and continued functional recovery. At that time, his family noted that he had difficulties with attention, memory, and impulsivity in excess of what he experienced before the injury. He had left-sided hemiparesis and walked with an ankle/calf brace, but was otherwise able to ambulate without assistance. No difficulties were observed in his speech or language, and his mother did not report any observed deficits in these domains. Formal post-TBI neuropsychological testing revealed significant impairment in perceptual reasoning, processing speed, working memory, visual immediate memory, broad math and written language skills, visuospatial skills, fine motor dexterity, executive functioning, and attention (abbreviated results are presented in Table I ). Behaviorally, D.W.'s family reported that since his injury he had become verbally and physically aggressive, emotionally volatile, impulsive, oppositional, defiant, and inattentive ( Table I ). D.W.'s teacher, who completed the same measures, reported behavior problems consistent with parent ratings. It should be noted that D.W. did not resume taking atomoxetine for his ADHD symptoms after the injury at the recommendation of his neurosurgeons, and there is some uncertainty regarding how much of his behavior change is attributable to the TBI/lobectomy and how much is due to the cessation of atomoxetine. However, this potential confound is representative of the pediatric TBI population, in that children with ADHD are more likely to sustain a TBI (Bloom et al., 2001) than children without ADHD.
Course of Psychotherapy
D.W.'s mother reported a constellation of symptoms that included both internalizing and externalizing components, such as frequent mood changes, crying, anger, aggressive behavior, opposition, and defiance. Therapy initially focused on helping D.W. develop strategies to relax, problem-solve, and identify and verbalize his emotions (five sessions). As therapy continued, more was learned about the time course of D.W.'s symptoms. Often, his emotional difficulties followed the repercussions he experienced for his impulsive, attention seeking, oppositional, or defiant behaviors. For example, feelings of anger, sadness, or anxiety often followed negative feedback from parents, teachers, and peers. In an effort to curtail this sequence, we established a token economy to reward good behaviors and punish bad behaviors with poker chips that could accumulate to a tangible reward. This was monitored over seven additional sessions in which he continued to practice relaxation and problem-solving strategies. However, the token economy was only mildly successful, and we speculated that its ineffectiveness was partially due to the failure of an abstract reinforcement (poker chips) to overcome his executive functioning deficits (e.g., stopping and switching). Furthermore, the system of reward and punishment was complicated by patterns of negative interaction within the family system, which became more apparent as therapy progressed.
The behaviors that were created and/or exacerbated by D.W.'s TBI caused significant strain on his family system. His mother reported significant caregiver burden, anxiety (including panic attacks), and feelings of guilt following the accident. Although we would have liked to see her for individual psychotherapy, this was not financially viable for the family. As therapy progressed it also became evident that D.W. and his mother could benefit from learning skills to facilitate communication and improve their relationship. Unlike the token economy, which provided abstract and delayed feedback, D.W. required a system that involved immediate, direct, and concrete feedback on his behavior. To meet this goal and also to foster a more positive home environment with positive, effective communication, we applied PCIT, which has been successful in meeting both of these goals (Eisenstadt et al., 1993). Although we are not aware of any studies specifically applying this treatment approach to older children with pediatric TBI, we hypothesized that PCIT would be a viable approach.