DEVELOPMENTAL DISABILITIES
RESEARCH REVIEWS 15: 159 – 166 (2009)
A REVIEW OF FAMILY INTERVENTION GUIDELINES
FOR PEDIATRIC ACQUIRED BRAIN INJURIES
Wesley R. Cole,1* Stephanie K. Paulos,1,2 Carolyn A.S. Cole,1,2 and Carol Tankard1
1
Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, Maryland
2
Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
Pediatric acquired brain injury (BI) not only affects the child with
the injury, but also greatly impacts their family. Studies suggest there are
higher rates of caregiver and sibling psychological distress after a child in
the family has sustained a BI. Also, family functioning after BI impacts
the child’s recovery. In reviewing the literature, we identified seven theo-
retical clinical guidelines for working with families of children and adoles-
cents with BI. These clinical guidelines are as follows: (1) select develop-
mentally appropriate interventions, (2) match the intervention to the
family, (3) provide advocacy, (4) provide injury education, (5) focus on
family realignment, (6) appropriately adjust the child’s environment, and
(7) provide skills training to the family and child. The existing research on
family interventions for BI is reviewed within the context of these theo-
retical guidelines, and the empirical support for each guideline is subse-
quently evaluated using specific criteria for empirically supported
treatments. Unfortunately, very few randomized controlled studies exist,
and continued research is needed to classify all clinical guidelines as
‘‘efficacious.’’ In addition, continued research will aid in informing
professionals of specific approaches to utilize when working with a
family of a child with BI. Currently, clinicians and researchers can turn
to the existing clinical guidelines to help address the numerous
barriers posed by implementing and studying family interventions for
pediatric BI. ' 2009 Wiley-Liss, Inc.
Dev Disabil Res Rev 2009;15:159–166.
Key Words: brain injury; pediatric brain injury; family interventions; fam-
ily stress; injury education
P
ediatric acquired brain injuries (BI) often result in a
wide range of persistent cognitive, behavioral, social,
and functional difficulties for the child [Fletcher et al.,
1990; Fay et al., 1994; Max et al., 1998a; Taylor, 2004].
Symptom expression is highly variable and problems may per-
sist for years, adversely impacting not only the youth (i.e.,
child or adolescent) with a BI, but also the youth’s caregivers
and siblings [Rivara et al., 1996; Wade et al., 2002]. Accord-
ing to Ylvisaker [1998], pediatric BI should be considered an
injury to the individual and the family, as families are left
extremely vulnerable to stress and distress after a child has sus-
tained a BI.
Increased family dysfunction following pediatric BI has
been clearly documented in the literature [Gan et al., 2006;
Wade et al., 2006a,b; Wade, 2006; Stancin et al., 2008].
Numerous issues have been reported in studies of caregivers,
including family strain, depression, emotional difficulties, bur-
den, anxiety, social isolation, loss of income, and problems
' 2009 Wiley -Liss, Inc.
adjusting to new roles [Lezak, 1986; Rivara et al., 1992; Ergh
et al., 2002; Gan and Schuller, 2002; Wade et al., 1998,
2006a,b]. Further, parents of children with BI also have more
difficulty than parents of children without BI expressing their
emotional and personal needs, placing them at even higher
risk for persistent and worsening difficulties [Wade, 2006]. In
fact, prospective investigations have documented continued
family dysfunction among families of children with severe
traumatic brain injury (TBI) for 3 or more years postinjury,
despite available rehabilitation resources [Wade, 2006; Wade
et al., 2006b]. Max et al. suggest negative family functioning
predicts the development of new psychological disorders in
children with BI [Max et al., 1997, 1998a,c,d, 2000, 2006].
On the other hand, a supportive family environment following
BI can buffer the family from additional stress and burden, as
well as improve the child’s adaptation to the injury [Wade,
2006]. Additionally, care of the child and family following
pediatric BI can serve an important role in the functional
recovery of the child as well as the psychological health of
caregivers and family members [Ylvisaker, 1998; Cavallo et al.,
2005].
Investigators have established that interventions for pedi-
atric BI should target the family because changes in one fam-
ily member will affect the entire family system [Maitz and
Sachs, 1995; Gan and Schuller, 2002; Laroi, 2003; Cavallo
et al., 2005; Gan et al., 2006]. However, very few evidence-
supported interventions have been developed to target the
entire family [Zitnay et al., 2008]. In addition, few of the
existing family interventions for pediatric BI have been eval-
uated via randomized controlled studies (RCT). To date, most
research involves case studies, small ‘‘n’’ studies, or exploratory
investigations. Boschen et al. [2007] review of literature on
family interventions after pediatric BI and other chronic con-
ditions indicates the extant data does not yet identify a gold
standard intervention for families of youth with BI. However,
*Correspondence to: Wesley R. Cole, Department of Neuropsychology, Kennedy
Krieger Institute, 700 N. Broadway, Baltimore, MD 21207.
E-mail: colew@kennedykrieger.org
Received 24 February 2009; Accepted 22 March 2009
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/ddrr.58
 Table 1. Description of Chambless’ Criteria for Evidence-Supported Treatments
(EST) [Chambless and Hollon, 1998]
Classification Required Empirical Evidence

Efficacious
Probably efficacious
Promising, but not yet validated
Probably ineffective
Two well controlled between group design experiments or a large series (N > 9) well controlled single case design
experiment. Studies are conducted by at least two independent research groups using a treatment group, a treatment
manual, and defined sample characteristics.
Superior effectiveness compared to a control group shown in at least two studies conducted by the same group of
researchers. Small series (N > 3) of a well controlled single case design experiment.
One well controlled experiment showing treatment is not harmful. Two or more well controlled experiments with
small numbers. We also use this classification for guidelines that have a strong theoretical basis but no well controlled
experiments.
Treatment results reveal null or harmful outcomes.

numerous investigators have independ-
ently identified guidelines that should
be considered when providing family
interventions for pediatric BI [Conoley
and Sheridan, 1996; Waaland, 1998;
Ylvisaker, 1998; Wade, 2006]. Unfortu-
nately, these guidelines are primarily
based on limited quantitative evidence,
isolated case studies, anecdotal clinical
experience, or family interventions for
conditions other than BI.
In an attempt to advance the de-
velopment of family interventions for
pediatric BI, we propose a comprehen-
sive set of theoretical clinical guidelines
for working with families of youth with
BI. It is our hope that these clinical
guidelines help guide future research
and continue to be refined through sys-
tematic research. We conducted a thor-
ough review of previously proposed
guidelines as well as current literature of
interventions for pediatric BI and sev-
eral related adult studies of family inter-
ventions for BI. Similarities and themes
from this body of literature were identi-
fied and a cohesive and comprehensive
set of theoretical clinical guidelines for
working with families of youth with BI
was created. In total, seven theoretical
clinical guidelines for professionals to
consider when working with families of
youth with BI were derived. The clini-
cal guidelines are as follows:
1. Developmental Considerations:
Recognition of how the injured
youth’s developmental stage
would present unique chal-
lenges and alter the needs and
foci of intervention.
2. Match the Intervention to the
Family: Individually tailor and
match the intervention to
meet the family’s needs and
level of functioning.
3. Provide Advocacy: Provide advo-
cacy for the family via per-
formance of case management
160 Dev Disabil Res Rev
including linking the family to
community resources and
organizations.
4. Injury Education: Provide com-
prehensive education regarding
the youth’s injury.
5. Family Realignment: Encourage
and support reorganization of
the family system to realign in
healthy and positive ways.
6. Adjusting the Child’s Environ-
ment: According to the identi-
fied goals for treatment, facili-
tate adjustments in the home,
school, and community envi-
ronments that reduce the op-
portunity for behavior prob-
lems and conflict to emerge
and to support the youth’s
ongoing recovery from injury.
7. Skills Training: Use skills train-
ing to foster coping skills,
problem solving, and positive
communication as well as to
decrease sense of burden.
In addition to introducing these theo-
retical clinical guidelines, we seek to
review the current pediatric BI litera-
ture within the context of these pro-
posed guidelines. In this review, we
evaluate the current empirical support
for each guideline by using Chambless’
criteria for evidence supported treat-
ments [Chambless and Hollon, 1998].
In 1999, these criteria became the gold
standard in evaluating psychological
interventions by the American Psycho-
logical Association’s Clinical Psychology
Division (Division 12) [Chambless and
Ollendick, 2001]. In addition, these cri-
teria have also become internationally
incorporated into the promotion of
intervention awareness. The Chambless
criteria identify levels of empirical evi-
dence required for treatments to be
considered as efficacious, probably effi-
cacious, promising but not yet validated,
and probably ineffective. The level of
supporting empirical evidence required
 FAMILY INTERVENTION GUIDELINES
to determine the appropriate classifica-
tion level is summarized in Table 1.
DEVELOPMENTAL
CONSIDERATIONS
When designing interventions for
families of youth with BI, it is impor-
tant to consider the youth’s develop-
mental stage and how this may differen-
tially impact future outcomes and their
response to intervention [Waaland,
1998; Wade, 2006]. Previously, it was
believed that children injured at young
ages may have better outcomes due to
the brain’s plasticity and ability to ‘‘reor-
ganize’’ after insult. However, current
literature suggests that children who
sustain a BI are at greater risk for nega-
tive outcomes, such as cognitive, behav-
ioral, social, and vocational outcomes,
than adults who sustain a BI [Anderson
et al., 2006; Donders and Warschausky,
2007; Hessen et al., 2007]. Further,
injury during early childhood and ele-
mentary years is often associated with
worse outcomes than injury in adoles-
cence [Donders and Warschausky,
2007]. BI at a young age may disrupt
the acquisition of prerequisite skills that
later development depends on, or the
child may experience increased difficul-
ties as they age and environmental de-
mands increase in complexity [Donders
and Warschausky, 2007].
The unique challenges of various
developmental levels will impact the
identified goal for treatment. For exam-
ple, if developmentally appropriate,
treatment expectations may use cogni-
tive strategies rather than behavioral
strategies for skills training or for
increasing functional independence
[Waaland, 1998]. Also, interventions
may need to shift their focus from rein-
tegration of the child into the family to
reintegration of the child into school.
Further, the demands of the school sys-
tem may vary dramatically from grade
to grade [Waaland, 1998; Ylvisaker,
FOR PEDIATRIC ACQUIRED BI  COLE ET AL.
 Table 2. Summary of the Clinical Guidelines for Family Interventions for Pediatric BI and the
Chambless Classification Each Guideline Meets Based on Existing Literature
Clinical Guideline Description Classification Supporting Literature

Developmental
considerations
Match the intervention
to the family
Provide advocacy
Injury education
Family realignment
Adjusting the child’s
environment
Skills training
Recognition of how the developmental
stage of the child with the injury would
present unique challenges and alter the
needs and foci of intervention.
Provide family interventions for brain injury
that are individually tailored to the
family’s needs and level of functioning
Perform case management including linking
the family to community resources and
organizations.
Family interventions for brain injury should
begin with comprehensive education
regarding their child’s injury
Encourage and support reorganization of the
family system.
Facilitate adjustments in the home, school,
and community environments that reduce
the opportunity for behavior problems
and conflict to emerge and to support
ongoing recovery from injury.
Foster coping skills, problem-solving and
positive to communication. Lend
emotional support to help reduce sense of
burden and stress.
Promising, but not yet
validated
Promising, but not yet
validated
Probably efficacious
Efficacious
Promising, but not
yet validated
Probably efficacious
Probably efficacious
[Waaland, 1998; Ylvisaker, 1998; Wade,
2004; Wade et al., 2006, 2006a,b, 2008]
[Max et al., 1997, 1998b; Waaland, 1998;
Ylvisaker, 1998; Kreutzer et al., 2002;
2006; Wade, 2006; Boschen et al., 2007]
[Conoley and Sheridan, 1996; Albert et al.,
2002; Leith et al., 2004; Boschen et al.,
2007; Glang et al., 2007]
[Conoley and Sheridan, 1996; Kosciulek,
1997; Waaland, 1998; Ylvisaker, 1998;
Kreutzer et al., 2002; Leith et al., 2004;
Wade, 2006; Boschen et al., 2007]
[Conoley and Sheridan, 1996; Waaland,
1998; Ylvisaker and Feeney 1998; Laroi,
2003; Swift et al., 2003; Wade et al.,
2003; Leith et al., 2004; Stancin et al.,
2004; Wade et al., 2004, 2006a,b; Gan
et al., 2006; Wade, 2006; Sambuco et al.,
2008]
[Feeney et al., 2001; Ducharme et al., 2002;
Ducharme, 2003; Gardner et al., 2003;
Leith et al., 2004; Braga et al., 2005;
Ylvisaker, 2005]
[Conoley and Sheridan, 1996; Kinsella
et al., 1999; Stancin et al., 2002;
Verhaeghe et al., 2004; Waaland, 1998;
Wade et al., 2001, 2004, 2005, 2006a,b,
2008]

1998]. In general, it is important to
consider the impact of the injury on
ongoing development, especially as the
child approaches age-expected develop-
mental milestones. These milestones
should be anticipated to help the child
acquire the new skill. Also, interven-
tions should be adjusted as the child
achieves various milestones or new
interventions added to address issues
that arise if the child fails to fully ac-
quire a new developmental skill [Waa-
land, 1998].
Wade et al. have implemented
family problem-solving interventions,
discussed in greater detail later, with
both school-aged children and adoles-
cents. The content of these interven-
tions was designed to be age-appropri-
ate for the target age groups. Results
suggest that in both age groups, the
intervention was well received by fami-
lies and youth, and positive outcomes
were seen in desired behavioral, cogni-
tive, and family-systems domains [Wade
et al., 2004, 2006a,b, 2008]. Wade et al.
successful adaptation of an intervention
approach for various age groups pro-
vides support for making interventions
developmentally appropriate. Unfortu-
nately, systematic research regarding
Dev Disabil Res Rev  FAMILY INTERVENTION GUIDELINES
developmentally appropriate family
interventions for pediatric BI does not
exist. However, given what we know
about the impact BI can have on a
child’s development and the differing
needs of children and families at various
stages of development, this guideline is
within Chambless’ ‘‘Promising, but
not yet validated’’ classification (see
Table 2).
MATCH THE INTERVENTION
TO THE FAMILY
The uniqueness of postinjury chal-
lenges each youth with BI and their fami-
lies face presents a sizeable challenge to
conducting family interventions and
research. Various individual differences
will affect intervention needs, such as the
heterogeneity of injuries, varying levels
of subsequent disability, differences in the
time and amount of recovery, and the de-
velopmental level of the child at the time
of injury. Also, every family is expected
to respond differently to their child’s
injury, suggesting treatment cannot be
conceptualized and administered using a
‘‘one size fits all’’ approach. For example,
research suggests families with lower lev-
els of interpersonal functioning prior to
their child’s injury likely require a more
FOR PEDIATRIC ACQUIRED BI
comprehensive approach which addresses
both preinjury dysfunction as well as
recently emerged concerns. On the other
hand, families who show high levels of
preinjury functioning may only require
interventions exclusively addressing
injury-related concerns [Max et al.,
1997, 1998b, 2006].
In an attempt to deliver family
interventions that are clinically appro-
priate, researchers and clinicians should
individually tailor treatment to the fam-
ily’s needs [Waaland, 1998; Wade, 2006;
Boschen et al., 2007]. Implementation
of a carefully planned and individually
designed treatment program for families
can address each youth and family’s
unique presentations and characteristics.
Professionals providing family interven-
tions must consider the family’s prein-
jury functioning, the presence of sib-
lings and the impact the injury has had
on siblings, the family’s perceptions of
the demands they face and their resour-
ces for meeting these demands, the
existing structure and hierarchy of the
family, the family’s readiness for change,
and their access to services.
The need to design individualized
family interventions makes it difficult to
standardize and systematically study such
 COLE ET AL. 161
interventions [Boschen et al., 2007].
However, standardized and carefully
structured family interventions that plan
for addressing commonly encountered
problems after BI can be highly valuable
[Kreutzer et al., 2002]. Therefore, com-
prehensive treatments that are general
enough to encompass common chal-
lenges that typically arise postinjury
while being specific enough to meet
the family’s individual needs should be
the goal of family intervention develop-
ment. The common challenges families
face after pediatric BI include:
1. BI impacts everyone in the
child’s family, and thus the nature
of intervention should focus on
the entire family system.
2. Because of the nature of injuries,
there are particular vulnerabilities
in cognitive, social, behavioral,
and academic domains.
3. Particular populations of youth
are at increased risk for BI, es-
pecially TBI, and families with
poorer preinjury functioning
are at greater risk for poorer
outcomes after injury.
4. Family members often go
through stages of grieving as
they mourn the loss of the
child they knew and cope with
the changes in their expecta-
tions for the child.
5. Injury education is critical as
well-informed families have
better outcomes.
6. The majority of long-term
rehabilitation responsibility falls
on the family. [adapted from
Kreutzer et al., 2002; Ylvi-
saker, 1998].
Wade [2006] proposed creating module-
based family interventions that target
such commonly encountered difficulties.
This design approach allows for stream-
lined design and delivery while maintain-
ing flexibility to tailor the intervention to
the family’s readiness for change as well as
their goals for treatment. Other research-
ers have also proposed methods for
implementing module-based family
interventions. Waaland [1998] presented
a treatment approach for families of
youth with BI using Zarski and Depom-
pei’s [1991] ‘‘matrix model’’ of family
counseling. In this model, family needs
are conceptualized as falling into one of
four levels, whereby each level reflects
the degree of distress experienced by the
family as well as their ability to engage in
higher level skill acquisition.
Adapting the intervention to fit
the family’s unique needs helps address
162 Dev Disabil Res Rev
complications posed by the heterogene-
ity of pediatric BI. This approach may
also help families feel more invested in
the treatment process, increasing the
likelihood of treatment compliance and
follow-through. However, currently this
clinical guideline is at a primarily theo-
retical basis of development, with
researchers suggesting tailoring inter-
ventions be considered in future studies.
As such, because empirical support is
presently lacking, this guideline meets
Chambless’ criteria of ‘‘Promising, but
not yet validated’’ (see Table 2).
PROVIDE ADVOCACY
Some researchers have stressed the
importance of professionals advocating
for families of youth with brain injuries
[Conoley and Sheridan, 1996; Leith
et al., 2004]. In particular, professionals
are encouraged to provide case manage-
ment and connect families with com-
munity resources and appropriate
organizations. Conoley and Sheridan
[1996] found that families’ sense of bur-
den and stress were reduced when pro-
fessionals performed case management,
as it promotes familial adjustment to a
child’s injury.
Other researchers have also investi-
gated the importance of advocacy for fam-
ilies of youth with BI. Although Boschen
et al.’s [2007] conclusions were limited by
the methodology and marginal results of
existing studies, they suggest that advocacy
may facilitate increased family access to
services, delivery of additional education
to caregivers, and addressing of otherwise
ignored concerns. Studies of adults with
BI suggest that providing a social work liai-
son to caregivers of individuals with BI af-
ter hospital discharge has benefits in reduc-
ing caregivers’ sense of burden, increasing
caregivers’ life satisfaction, and helping
caregivers feel increased mastery over reha-
bilitation outcomes [Albert et al., 2002].
Glang et al. [2007] investigated an
educational advocacy intervention pro-
gram where parents of children with BI
were taught educational advocacy skills
via an innovative CD-ROM based pro-
gram. This intervention was created
from the text-based Family Advocacy
Skills Training program as well as clini-
cal experience, and consisted of four
key sections: (1) preparing for a meet-
ing, (2) active listening with professio-
nals, (3) advocating and specifying a
request, and (4) negotiating and work-
ing toward a solution when parents and
professionals disagree. When the group
receiving the training program was
compared to a control group postinter-
vention, large effect sizes were seen in
 FAMILY INTERVENTION GUIDELINES
the areas of effectively applying educa-
tional advocacy skills, increased knowl-
edge of educational advocacy, and
improvement in parents’ attitudes
regarding their ability to advocate for
their child in the educational setting.
Although this was a RCT, the sample
size was relatively small and homoge-
nous, which limits the generalization of
these results. However, their approach
provides both advocacy and concrete
skills training, consistent with current
clinical guidelines, and uses an innova-
tive treatment delivery model that may
help reduce the access to services bar-
rier many families face. Providing advo-
cacy appears to be ‘‘Probably Effica-
cious’’ (see Table 2) though additional
investigations of this intervention are
warranted.
INJURY EDUCATION
Most professionals recommend
that family interventions for pediatric
BI should begin with providing com-
prehensive education to the family
regarding the youth’s injury [Conoley
and Sheridan, 1996; Waaland, 1998;
Ylvisaker, 1998; Leith et al., 2004;
Wade, 2006]. In a recent review of the
literature of family interventions follow-
ing pediatric BI and other chronic ill-
nesses, Boschen et al. [2007] found that
the leading interventions were educa-
tional and informational in nature. The
numerous educational interventions
reviewed showed increased caregiver
knowledge of the youth’s condition as
well as decreased misplaced anxiety in
caregivers. In addition, educationally
based interventions were also found to
be associated with reductions in care-
giver stress, burden, and fear for the
future. Overall, this is an area of pediat-
ric BI that has received a significant
amount of focus, and meets Chambless’
criteria of ‘‘Efficacious’’ (see Table 2).
Conoley and Sheridan [1996]
encouraged clinical professionals to pro-
vide families with information that
furthered their understanding of the
extent and nature of the youth’s injury,
potential impact of the injury on sib-
lings, development of realistic expecta-
tions and goals for the child, and the
creation and utilization of effective
problem-solving in the family. In a
study featuring 87 primary caregivers
(i.e., mothers and spouses) of adults
with BI, Kosciulek [1997] found that a
family’s schema of the individual’s BI
(i.e., their beliefs, values, goals, and
expectations surrounding the injury)
predicts adaptation to the demands
placed on the family by the individual’s
FOR PEDIATRIC ACQUIRED BI  COLE ET AL.
disabilities subsequent to the BI. Family
adaptation to the injury improved when
perceptions of manageability and mean-
ingfulness were increased. Therefore, if
a family’s schemas regarding the youth’s
injury are positively impacted by infor-
mation about the injury that impacts
their, their adaptation can be improved
[Kosciulek, 1997]. Wade’s [2006] review
of the BI literature reported that pro-
viding families of youth with BI brief
and basic information via educational
pamphlets on the topic of BI resulted in
reduced feelings of familial stress and
distress.
Kreutzer et al. [2002] developed a
Brain Injury Family Intervention (BIFI)
to deliver to families of adults with BI.
BIFI features a structured, 16-topic inter-
vention educating families on a variety of
topics related to BI. The 16 topics
addressed four common areas of need
associated with BI. These areas involved
education designed to help family mem-
bers (1) recognize and cope with change,
(2) understand and promote long-term
recovery, (3) effectively manage stress and
other problems, and (4) work effectively
with rehabilitation professionals. This
program was developed from a review of
the literature and clinical experience and
to date has not been empirically vali-
dated. Although it currently lacks empir-
ical validation and was developed for
families of adults with BI, this appears to
be a comprehensive program with theo-
retical underpinnings and adapting this
program for families of youth with BI
would be a valuable next step.
Although providing injury educa-
tion appears ‘‘Efficacious’’ it is not
without caveats. Family intervention
research suggests that educational inter-
ventions alone are not sufficient in pro-
ducing substantial changes and that fam-
ily support and skills training should be
added to maximize impact. Further-
more, educational support must be pro-
vided over a minimum of 3–6 months
to have an effect and that importantly,
the intervention must match the family’s
stage of readiness for change [Miller and
Rollnick, 1991].
FAMILY REALIGNMENT
Most researchers agree that family
interventions for youth with brain inju-
ries have been found to be most effec-
tive when they incorporate a positive
realignment and reorganization of the
family system [Conoley and Sheridan,
1996; Ylvisaker and Feeney, 1998;
Laroi, 2003; Leith et al., 2004]. Various
investigators have described the realign-
ment of the family system in different
Dev Disabil Res Rev  FAMILY INTERVENTION GUIDELINES
terms. For example, Conoley and Sher-
idan [1996] stated family intervention
should aid parents in resolving differen-
ces in their reactions to the child with
the injury. On the other hand, Leith
et al. [2004] highlighted the importance
of parental empowerment to encourage
realignment within the family structure,
with the parents taking a leadership role
together to support a functional hierar-
chy in the family structure. Ylvisaker
et al. have extensively discussed family
realignment in terms of incorporating
positive behavioral supports into the
family’s everyday routines. Within the
context of BI, the notion of positive
behavioral supports involves using ante-
cedent-management procedures to min-
imize situations that commonly lead to
problem behaviors, implementing con-
sequences to minimize problem behav-
iors, increasing the amount of positive
Family intervention
research suggests that
educational interventions
alone are not sufficient in
producing substantial
changes and that family
support and skills
training should be added
to maximize impact.
communication between caregivers and
the individual with the injury, and cre-
ating positive routines that instill mean-
ing into the individual’s day-to-day life
[Ylvisaker and Feeney, 1998; Feeney
and Ylvisaker, 2003; Ylvisaker et al.,
2003].
To help families facilitate the pro-
cess of positive realignment, Waaland
[1998] recommends that family inter-
ventions for pediatric BI highlight
positive change and family competency.
Interventions should feature compo-
nents that encourage the family to work
as a team and that guide parents to set
appropriate expectations and boundaries
for the child with the injury. Also,
interventions focused on realigning
families should help families establish
more positive patterns of communica-
tion between caregivers and youth.
Wade et al.’s [2004, 2006a,b] problem-
solving intervention has been shown to
improve parent–child communication.
However, it is unclear to what extent
intervention related improvement in
FOR PEDIATRIC ACQUIRED BI
communication had a positive effect on
parental burden as well as on the youth’s
recovery. These studies provide support
for further investigation of family-sys-
tems focused interventions after pediat-
ric BI, but because of a lack of RCT,
currently only meet Chambless’ criteria
of ‘‘Promising, but not yet validated’’
(see Table 2).
Another important component of
family realignment addresses the issue of
sibling coping. Sibling distress and con-
flict after an individual has sustained a
BI has been well documented [Gan
et al., 2006]. Siblings should be pro-
vided with adjustment and problem-
solving skills to help reduce the poten-
tial burden they may experience regard-
ing their sibling’s injury [Conoley and
Sheridan, 1996]. When siblings of chil-
dren with moderate and severe BI were
compared to siblings of children with
orthopedic injuries, researchers found
that siblings of children with BI with
subsequent behavioral difficulties were
at risk for more negative sibling rela-
tionships and display of behavior prob-
lems [Swift et al., 2003]. Sambuco et al.
[2008] reviewed the literature on sibling
outcomes following TBI sustained by a
brother or sister. Their review extends
the findings by Swift et al. [2003], in
that they concluded siblings of children
with TBI were at risk for residual psy-
chological distress, especially if the child
with the injury displayed behavioral dif-
ficulties. Siblings of children with BI
may also experience numerous qualita-
tive life changes, placing them at
increased risk for psychological distress.
Findings from Swift et al. [2003] and
Sambuco et al. review [2008] indicate
the importance of incorporating siblings
into family interventions for pediatric
BI. However, specific sibling interven-
tions have not been systematically stud-
ied, and thus this clinical guideline falls
within the ‘‘Promising, but not yet vali-
dated’’ classification (see Table 2).
ADJUSTING THE CHILD’S
ENVIRONMENT
Providing intervention within the
context of real-world settings and mak-
ing necessary adjustments to the injured
child’s environment to support ongoing
recovery has received widespread sup-
port within BI literature [Ylvisaker,
1998; Braga et al., 2005]. Adjustments
and supports in the child’s environment
that help the child and family achieve
their chosen goals are of fundamental
importance [Ylvisaker et al., 2005].
Leith et al. [2004] stated that environ-
mental adjustment should include pro-
 COLE ET AL. 163
moting a feeling of social belongingness
for the child to the greatest extent pos-
sible. Specific adjustments recom-
mended by these authors include
increasing structure and predictability
into the youth’s routine, being proactive
in behavioral approaches (i.e., using an-
tecedent control whenever possible),
involving people and activities that are
meaningful to and desired by the youth,
and using positive behavioral supports
and strategies, such as errorless learning
[Ducharme et al., 2002; Ducharme,
2003; Leith et al., 2004; Ylvisaker et al.,
2005].
Braga et al. [2005] conducted a
RCT of an indirect, family-supported
intervention for children with chronic
impairments due to an earlier sustained
BI. The family-supported intervention
involved regular hospital visits by at least
one member of the child’s family, multi-
disciplinary assessment of the child, hav-
ing parents attend group meetings and
parent training sessions, involving the
parents in assessments of the child, and
home visits by a rehabilitation professio-
nal to help the family incorporate the
rehabilitation program into their every-
day routines. Patients receiving the fam-
ily-supported intervention were com-
pared to patients receiving a clinician
delivered intervention which followed
‘‘conventional rehabilitation procedures,’’
where relevant clinicians treated the
child in a clinic setting. They hypo-
thesized family members could be
adequately trained to deliver interven-
tions within real-world settings and that
when compared to clinician delivered
interventions, the family-supported
intervention would result in more posi-
tive cognitive, physical, and functional
outcomes for the youth with the injury.
Data were collected over a 1-year pe-
riod at the SARAH network of hospi-
tals in Brazil during the child’s chronic
phase of recovery (i.e., at least 6 months
postinjury). Physical/ functional out-
comes were measured with the SARAH
Scale of Motor Development, second
edition and cognitive outcomes were
measured with the WISC-III. Results
revealed that families could be trained
adequately to deliver the indirect fam-
ily-supported intervention, irrespective
of education level. Also, when compari-
sons were made between direct clinician
delivered intervention and indirect fam-
ily-supported rehabilitation of children
with BI, children participating in the
indirect family-supported intervention
displayed statistically and clinically sig-
nificant improvements in physical/func-
tional and cognitive outcomes. These
164 Dev Disabil Res Rev
findings support the delivery of inter-
ventions in real-world environments
compared to laboratory and clinic set-
tings, making a strong case for context-
relevant and family-oriented interven-
tions.
At present, most environment
adjustment-related research has been
conducted using adult samples. For
example, errorless learning strategies
have been effectively employed with
adults with cognitive and behavioral
impairments secondary to BI [Du-
charme et al., 2002; Ducharme, 2003].
Feeney et al. [2001] found that behav-
ioral supports can be used effectively in
the community to assist individuals with
significant behavior challenges after BI.
Skills training programs
often involve teaching
coping skills to the
parents, siblings, and the
child with the injury,
helping the family build
emotional support, or
developing problem-
solving skills in both the
caregivers and the
individual with the
injury.
Another adjustment that is central
to promoting ongoing recovery involves
introducing structured everyday routines
into the day-to-day life of the individ-
ual with BI. Ylvisaker et al. discuss
realigning the family to incorporate
positive behavioral supports into the
family’s routines. This also involves a
significant amount of adjustment to the
injured individual’s environment in
order to increase positive interactions
with others, minimize opportunities for
failure and allow for success in basic
daily routines, enhance access to pre-
ferred activities, and increase the
amount of choice and control the indi-
vidual has over their activities. Case
studies of adolescents with substantial
behavior problems (i.e., physical aggres-
sion, significant disruptions in the class-
room, and property destruction) follow-
ing BI revealed that the introduction of
positive behavioral supports reduced tar-
geted behaviors to near zero, increased
adolescent’s domains of activity, and
 FAMILY INTERVENTION GUIDELINES
improved the adolescents’ self-manage-
ment abilities [Feeney and Ylvisaker,
2003; Gardner et al., 2003]. Unfortu-
nately, with the exception of Braga
et al.’s [2005] study, most evidence
regarding adjusting the child’s environ-
ment is based on adult studies, disabil-
ities other than BI, theory, or case stud-
ies. Therefore, this clinical guideline
falls within the ‘‘Probably Efficacious’’
classification (see Table 2).
SKILLS TRAINING
During rehabilitation, caregivers
often receive skills training to improve
their ability to care for their child after
BI. Skills training programs often
involve teaching coping skills to the
parents, siblings, and the child with the
injury, helping the family build emo-
tional support, or developing problem-
solving skills in both the caregivers and
the individual with the injury. Recently,
emotional support and skills training are
areas that have been targeted in research
on interventions for pediatric BI. Uti-
lizing skills training in rehabilitation
allows therapists to identify concrete
goals as well as to provide specific inter-
ventions, such as increasing the use of
effective problem-solving strategies.
This approach lends itself to conducting
well controlled, randomized studies.
Caregivers and other family mem-
bers may feel overwhelmed in the pe-
riod immediately following injury, espe-
cially when the child is released from
the acute rehabilitation setting and is
reintegrated into the home. Waaland
[1998] proposed that stress reduction in
family members may be facilitated
through fostering coping skills, develop-
ment of problem-solving abilities, and
by learning positive communication
skills. Caregiver coping resources have
been found to impact behavioral seque-
lae shown by children with BI. For
example, Kinsella et al. [1999] assessed
51 children with BI up to 2 years post-
injury and found that parent’s access to
coping resources made a substantial
impact on their child’s behavioral pre-
sentation.
Stress resulting from the youth’s
injury is not limited to the critical pe-
riod of adjustment immediately follow-
ing injury. Verhaeghe et al. [2004]
reviewed BI literature and discovered
that families of individuals with BI
experienced significant levels of stress
and sometimes required psychological
intervention as long as 10–15 years after
the injury occurred. With regard to
caregiver outcomes, Wade et al. [2001]
identified coping strategies impacting
FOR PEDIATRIC ACQUIRED BI  COLE ET AL.
caregiver adjustment following pediatric
BI as compared to orthopedic injuries.
Findings suggested healthier coping
strategies, such as acceptance of the
changes resulting from the child’s injury,
were associated with a lower sense of
parental burden. Studies examining the
importance of reducing parent stress
and promoting healthy adjustment high-
light the need to provide families of
youth with BI with coping skills to alle-
viate commonly experienced stresses
and burdens.
In addition to addressing caregiver
needs postinjury, the youth with BI
may also directly benefit from skills
training. Family coping has been found
to have a direct effect on the child’s
recovery from BI [Verhaeghe et al.,
2004]. In addition, research has found
that adolescents with severe BI displayed
lower health-related quality of life than
did adolescents with orthopedic injuries
[Stancin et al., 2002]. Communication
skills, daily living skills, and general
adaptive functioning were also lower
amongst individuals with severe BI,
likely contributing to their reported
health related quality of life. Skills train-
ing in these areas may be an important
step to improving the youth’s quality of
life after injury.
Family-oriented problem-solving
interventions have historically been suc-
cessful at reducing problem behaviors in
children who have not sustained a BI.
This finding has important implications
for pediatric BI because behavioral
sequelae resulting from BI typically rep-
resents the most common change expe-
rienced by youth following BI [Wade
et al., 2008]. In addition to addressing
behavioral sequelae of BI, problem-
solving approaches also focus on
improving executive functioning,
decreasing social isolation, and capitaliz-
ing on positive social and emotional
changes after BI [Wade et al., 2008].
Wade et al. have developed the
family problem solving (FPS) approach,
which to date has undergone several
revisions. Currently, the FPS features a
short-term intervention (8–12 sessions
over approximately 6 months) that
focuses on concrete skills training to
increase self-monitoring, self-regulation,
and social problem-solving skills. Fami-
lies are enrolled for participation during
acute rehabilitation stays. Comparisons
of prepost ratings as well as comparisons
of the group in the FPS to usual care
control groups have suggested that this
approach is not only feasible for deliv-
ery in the real world, but it is also posi-
tively received by families [Wade et al.,
Dev Disabil Res Rev  FAMILY INTERVENTION GUIDELINES
2008]. In addition, family and adoles-
cent problem-solving training has
resulted in desirable outcomes for care-
givers of youth with BI [Wade et al.,
2008]. More specifically, improvements
have been documented in parent-child
relationships [Wade et al., 2004, 2006],
parents’ sense of injury-related burden,
parental psychiatric symptoms, parent-
ing stress [Wade et al., 2005], and pa-
rental adaptation to the child’s injury
[Wade et al., 2006a,b]. Wade et al.
should be commended for developing
an innovative web-based family problem
solving intervention to help families in
rural areas access services. Innovative
approaches such as this will facilitate
intervention dissemination and system-
atic investigations.
Although Wade et al. have made
notable progress in this area of research,
it will be important to conduct RCT
studies with larger sample sizes and
clinically indicated youth and families.
Because of a lack of RCT with clini-
cally indicated samples, this clinical
guideline currently meets Chambless’
classification of ‘‘Probably Efficacious’’
(see Table 2).
CONCLUSIONS AND FUTURE
DIRECTIONS
When reviewing the state of the
literature regarding family interventions
for pediatric BI, it becomes clear why
there is a strong need for increasing
family intervention research. There are
very few randomized and well con-
trolled studies and even fewer multisite
studies. The clinical guidelines that cur-
rently exist are primarily theoretically
derived, though emerging empirical
evidence appears promising for these
guidelines. Of the seven clinical guide-
lines we identified after reviewing the
literature, only one has ‘‘efficacious’’
support, three are ‘‘probably efficacious,’’
while three are ‘‘promising, but not yet
validated.’’ Continued research is needed
to refine the clinical guidelines and
move all toward the ‘‘efficacious’’ classi-
fication, as well as to provide specific
approaches to utilize when working
with a family of a child with BI. As
future family interventions for pediatric
BI are developed and studied, clinicians
should strive to incorporate the clinical
guidelines into their interventions while
gathering empirical evidence for the
appropriateness of these guidelines.
Clinicians and researchers can also
turn to the existing clinical guidelines
to help address the numerous barriers to
developing, implementing, and studying
family interventions for pediatric BI.
FOR PEDIATRIC ACQUIRED BI
For example, choosing developmentally
appropriate interventions and individu-
ally tailoring interventions to each fam-
ily can help address the barriers posed
by the heterogeneous nature of pediat-
ric BI and varying impact injuries have
on youth and their families. Therapists
and researchers must also work around
the common issues plaguing consistent
participation by families in intervention,
such as feeling overwhelmed with
numerous medical appointments, the ge-
ographic location of these resources, or
transportation difficulties. Providing ad-
vocacy, injury education, and skills train-
ing can help increase a family’s invest-
ment in therapy thus decreasing the rates
of attrition. In addition, there are typi-
cally multiple treatment components
required to provide adequate treatment,
making it difficult for researchers to
determine unique contributions of inter-
vention methods as well as to objectively
measure treatment impact. Developing
specific approaches to interventions, such
as problem-solving or positive communi-
cation training, or creating ‘‘module-
based’’ interventions, as recommended by
Wade [2006], can aide in systematically
studying the unique contributions of
separate intervention techniques. These
guidelines can also aid in selecting and
measuring outcomes that are consistent
across studies to aid in future cross-study
comparisons. n
REFERENCES
Albert SM, Im A, Brenner L, et al. 2002. Effect
of a social work liaison program on family
caregivers to people with brain injury.
J Head Trauma Rehabil 17:175–189.
Anderson VA, Catroppa C, Dudgeon P, et al.
2006. Understanding predictors of functional
recovery and outcome 30 months following
early childhood head injury. Neuropsychol-
ogy 20:42–57.
Boschen K, Gargaro J, Gan C, et al. 2007. Family
interventions after acquired brain injury and
other chronic conditions: a critical appraisal
of the quality of the evidence. NeuroReha-
bilitation 22:19–41.
Braga LW, Da Pax J unior AC, Ylvisaker M. 2005.
Direct clinician-delivered versus indirect
family-supported rehabilitation of children
with traumatic brain injury: a randomized
controlled trial. Brain Inj 19:819–831.
Cavallo MM, Kay T, Ezrachi O, 2005. Problems
and changes after traumatic brain injury: dif-
fering perceptions within and between fami-
lies. Brain Inj 6:327–335.
Chambless DL, Hollon SD. 1998. Defining
empirically supported therapies. J Consult
Clin Psychol 66:7–18.
Chambless DL, Ollendick TH. 2001. Empirically
supported psychological interventions: con-
troversies and evidence. Annu Rev Psychol
52:685–716.
Conoley JC, Sheridan SM. 1996. Pediatric trau-
matic brain injury: challenges and interven-
 COLE ET AL. 165
 tions for families. J Learn Disabil 29:662–
669.
Donders J, Warschausky S. 2007. Neurobehavioral
outcomes after early versus late childhood
traumatic brain injury. J Head Trauma
Rehabil 22:296–302.
Ducharme JM. 2003. ‘‘Errorless’’ rehabilitation:
stategies of proactive intervention for indi-
viduals with brain injury and their children.
J Head Trauma Rehabil 18:88–101.
Ducharme JM, Spencer T, Davidson A, et al.
2002. Errorless compliance training: building
a copperative relationship between parents
with brain injury and their oppositional chil-
dren. Am J Orthopsychiatry 72:585–595.
Ergh TC, Rapport LJ, Coleman RD, et al. 2002.
Predictors of caregiver and family function-
ing following traumatic brain injury: social
support moderates caregiver distress. J Head
Trauma Rehabil 17:155–174.
Fay GC, Jaffe KM, Polissar NL, et al. 1994. Out-
come of pediatric traumatic brain injury at
three years: a cohort study. Arch Phys Med
Rehab 75:733–741.
Feeney TJ, Ylvisaker M. 2003. Context-sensitive
behavioral supports for young children with
TBI: short-term effects and long-term out-
come. J Head Trauma Rehabil 18:33–51.
Feeney TJ, Ylvisaker M, Rosen BH, et al. 2001.
Community supports for individuals with
challenging behavior after brain injury: an
analysis of the New York State Behavioral
Resource project. J Head Trauma Rehabil
16:61–75.
Fletcher J, Ewing-Cobbs L, Miner M, et al. 1990.
Behavioral changes after closed head injury in
children. J Consult Clin Psychol 58:93–98.
Gan C, Cambell KA, Gemeinhardt M, et al.
2006. Predictors of family system function-
ing after brain injury. Brain Inj 20:587–600.
Gan C, Schuller R. 2002. Family system outcome
following acquired brain injury: clinical and
research perspectives. Brain Inj 16:311–322.
Gardner RM, Bird FL, Maguire H, et al. 2003.
Intensive positive behavior supports for
adolescents with acquired brain injury: long-
term outcomes in community settings.
J Head Trauma Rehabil 18:52–74.
Glang A, McLaughlin K, Schroeder S. 2007.
Using interactive multimedia to teach parent
advocacy skills: an exploratory study. J Head
Trauma Rehabil 22:198–205.
Hessen E, Nestvold K, Anderson V. 2007. Neuro-
psychological function 23 years after mild
traumatic brain injury: a comparison of out-
come after paediatric and adult head injuries.
Brain Inj 21:963–979.
Kinsella G, Ong B, Murtagh D, et al. 1999. The
role of the family for behavioral outcome in
children and adolescents following traumatic
brain injury. J Consult Clin Psychol 67:
116–123.
Kosciulek JF. 1997. Relationship of family schema
to family adaptation to brain injury. Brain
Inj 11:821–830.
Kreutzer JS, Kolakowsky-Hayner SA, Demm SR,
et al. 2002. A structured approach to family
intervention after brain injury. J Head
Trauma Rehabil 17:349–367.
Laroi F. 2003. The family systems approach to
treating families of persons with brain injury:
a potential collaboration between family
therapist and brain injury professional. Brain
Inj 17:175–187.
Leith KH, Phillips L, Sample PL. 2004. Exploring
the service needs and experiences of persons
with TBI and their families: the South Car-
olina experience. Brain Inj 18:1191–1208.
Lezak MD. 1998. Brain damage is a family affair.
J Clin Exp Neuropsychol 10:111–123.
Maitz EA, Sachs PR. 1995. Treating families of
individuals with traumatic brain injury from
a family systems perspective. J Head Trauma
Rehabil 10:1–11.
Max JE, Koele SL, Castillo CC, et al. 2000. Per-
sonality change disorder in children and
adolescents following traumatic brain injury.
J Int Neuropsychol Soc 6:279–289.
Max JE, Koele SL, Smith WL, et al. 1998a. Psy-
chiatric disorder in children and adolescents
after severe traumatic brain injury: a
controlled study. J Am Acad Child Adolesc
Psychiatry 37:832–840.
Max JE, Levin HS, Schachar RJ, et al. 2006. Pre-
dictors of personality change due to trau-
matic brain injury in children and adoles-
cents six to twenty-four months after injury.
J Neuropsychiatry Clin Neurosci 18:21–32.
Max JE, Lindgren SD, Knutson C, et al. 1998b.
Child and adolescent traumatic brain injury:
correlates of disruptive behavior disorders.
Brain Inj 12:41–52.
Max JE, Lindgren SD, Knutson C, et al. 1998c. Child
and adolescent traumatic brain injury: correlates
of injury severity. Brain Inj 12:31–40.
Max JE, Robin DA, Lindgren SD, et al. 1997.
Traumatic brain injury in children and ado-
lescents: psychiatric disorders at two years. J
Am Acad Child Adolesc Psychiatry 36:1278–
1285.
Max JE, Robin DA, Lindgren SD, et al. 1998d.
Traumatic brain injury in children and ado-
lescents: psychiatric disorders at one year. J
Neuropsychiatry Clin Neurosci 10:290–297.
Miller WR, Rollnick S. 1991. Motivational inter-
viewing: preparing people to change addic-
tive behavior. New York: Guilford Press.
Rivara JB, Fay GC, Jaffe KM, et al. 1992. Predic-
tors of family functioning one year following
traumatic brain injury in children. Arch Phys
Med Rehabil 73:899–910.
Rivara JB, Jaffe KM, Polissar NL, et al. 1996. Pre-
dictors of family functioning and change 3
years after traumatic brain injury in children.
Arch Phys Med Rehabil 77:754–764.
Sambuco M, Brookes N, Lah S. 2008. Paediatric
traumatic brain injury: a review of siblings’
outcome. Brain Inj 22:7–17.
Stancin T, Drotar D, Taylor HG, et al. 2002.
Health-related quality of life of children and
adolescents after traumatic brain injury.
Pediatrics 109:1–8.
Stancin T, Wade SL, Walz NC, et al. 2008. Trau-
matic brain injuries in early childhood: ini-
tial impact on the family. J Dev Behav
Pediatr 29:253–261.
Swift EE, Taylor HG, Kaugars AS, et al. 2003.
Sibling relationships and behavior after pedi-
atric traumatic brain injury. J Dev Behav
Pediatr 24:24–31.
Taylor HG. 2004. Research on outcomes of pedi-
atric traumatic brain injury: current advances
and future directions. Dev Neuropsychol
25:199–225.
Verhaeghe S, Defloor T, Grypdonck M. 2004.
Stress and coping among families of patients
with traumatic brain injury: a review of the
literature. J Clin Nurs 14:1004–1012.
Waaland PK. 1998. Families of children with trau-
matic brain injury. In: Ylvisaker M, editor.
Traumatic brain injury rehabilitation: chil-
dren and adolescents, 2nd ed. Boston: But-
terworth-Heinemann. p 345–368.
Wade SL. 2006. Interventions to support families
of children with traumatic brain injuries. In:
Farmer JE, Donders J, Warschausky S,
editors. Treating neurodevelopmental disabil-
ities: clinical research and practice. New
York: The Guilford Press. p 170–185.
Wade SL, Borawski EA, Taylor HG, et al. 2001.
The relationship of caregiver coping to fam-
ily outcomes during the initial year follow-
ing pediatric traumatic injury. J Consult Clin
Psychol 69:406–415.
Wade SL, Carey J, Wolfe CR. 2006a. An online
family intervention to reduce parental dis-
tress following pediatric brain injury. J Con-
sult Clin Psychol 74:445–454.
Wade SL, Taylor HG, Drotar D, et al. 1998. Fam-
ily burden and adaptation during the initial
year after traumatic brain injury in children.
Pediatrics 102:110–116.
Wade SL, Taylor HG, Drotar D, et al. 2002. A pro-
spective study of long-term caregiver and
family adaptation following brain injury in
children. J Head Trauma Rehabil 17:96–111.
Wade SL, Taylor HG, Yeates KO, et al. 2006b.
Long-term parental and family adaptation
following pediatric brain injury. J Pediatr
Psychol 31:1072–1083.
Wade SL, Walz NC, Carey JC, et al. 2008. Brief
report: description of feasibility and satisfac-
tion findings from an innovative online fam-
ily problem-solving intervention for adoles-
cents following traumatic brain injury.
J Pediatr Psychol 23:369–377.
Wade SL, Wolfe C, Maines Brown T, et al. 2005.
Putting the pieces together: preliminary
efficacy of a web-based family intervention
for children with traumatic brain injury.
J Pediatr Psychol 30:437–442.
Wade SL, Wolfe CR, Pestian JP. 2004. A web-
based family problem-solving intervention
for families of children with traumatic brain
injury. Behav Res Methods Instrum Comput
36:261–269.
Ylvisaker M. 1998. Traumatic brain injury in chil-
dren and adolescents: introduction. In: Ylvi-
saker M, editor. Traumatic brain injury reha-
bilitation: children and adolescents, 2nd ed.
Boston: Butterworth-Heinemann.
Ylvisaker M, Adleson D, Braga LW, et al. 2005.
Rehabilitation and ongoing support after pe-
diatric TBI: twenty years of progress. J Head
Trauma Rehabil 20:95–109.
Ylvisaker M, Feeney T. 1998. Collaborative brain
injury intervention: positive everyday rou-
tines. San Diego: Singular Publishing Group.
Ylivsaker M, Jacobs HE, Feeney T. 2003. Positive
supports for people who experience behav-
ioral and cognitive disability after brain
injury: a review. J Head Trauma Rehabil
18:7–32.
Zarski JJ, Depompei R. 1991. Family therapy as
applied to head injury. In Williams JM, Kay
T, editors. Head injury: a family matter. Bal-
timore: Paul H. Brookes. p 283–297.
Zitnay GA, Zitnay KM, Povlishock JT, et al.
2008. Traumatic brain injury research prior-
ities: the Conemaugh International Brain
Injury Symposium. J Neurotrauma 25:1–
18.

166 Dev Disabil Res Rev  FAMILY INTERVENTION GUIDELINES FOR PEDIATRIC ACQUIRED BI  COLE ET AL.