Psychological interventions for challenging behaviours following moderate-to-severe traumatic brain injury: A systematic review, meta-analysis and GRADE evaluation

This systematic review (SR) of psychological interventions treating challenging behaviours (CBs) contributed to development of Australian Clinical Practice Guideline for Psychosocial Difficulties after moderate-to-severe Traumatic Brain Injury (msTBI). It is the first SR of CBs to provide certainty of evidence ratings using Grading of Recommendations, Assessment, Development and Evaluation framework (GRADE). Three databases were searched from inception to August 2024. Eligible studies comprised adults with msTBI who received psychological interventions targeting CB; compared to a control condition and with outcomes documented by self-report or observed behaviour. Twenty-seven studies were identified (7 Randomized Controlled Trials, 1 Non-Randomized Study of Intervention, and 19 Single Case Experimental Design trials reporting 39 cases). Interventions were grouped into three categories; two behavioural support approaches (contingent reinforcement [BSA-CR] or positive behaviour support [BSA-PBS]) or psychotherapeutic approaches [PA]. Effects of interventions ranged from moderate to trivial. Certainty of evidence (GRADE ratings) was low for PA for verbal/physical aggression; and BSA-PBS for apathy; and very low for BSA for verbal/physical aggression, sexualized behaviour, inappropriate social behaviour and poor treatment adherence; and for PA for inappropriate social behaviour, apathy and poor treatment adherence. Future trials with stronger methodological rigour will increase certainty of evidence in managing CBs after msTBI.