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Program Written Summary
Audio-Digest Psychology
Volume 02, Issue 03
February 7, 2013

Traumatic brain injury’s effect on families,Study data, Reciprocal influences, Current interventions, Implications for future research – Shari Wade, PhD,
From The 21st Butters-kaplan West Coast Neuropsychology Conference: Advances In The Neuropsychological Assessment And Treatment Of School-aged Children With Cognitive Deficits, Sponsored By The University Of California, San Diego, School Of Medicine
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The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program.

Psychology Program Info  Accreditation InfoCultural & Linguistic Competency Resources

Children with Traumatic Brain Injuries

From the 21st Butters-Kaplan West Coast Neuropsychology Conference: Advances in the Neuropsychological Assessment and Treatment of School-Aged Children with Cognitive Deficits, sponsored by the University of California, San Diego, School of Medicine

Shari Wade, PhD, Professor of Pediatrics and Director of Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Educational Objectives

The goal of this program is to improve psychologic and behavioral outcomes of children with traumatic brain injuries (TBI) and their caregivers. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize how caring for a child with a TBI affects families and parenting styles.

2. Promote family and environment traits that may improve recovery outcomes.

3. Identify parenting behaviors that may exacerbate behavioral issues.

4. Empower families to solve their own issues through the use of family problem-solving strategies.

5. Improve functioning in high school students with TBI through the use of web-based interventions.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Wade and the planning committee reported nothing to disclose.

Effects of traumatic brain injury (TBI) on families: profoundly disruptive; significant injury-related burden and distress; anxiety and depression in parents; increased conflict and dysfunction

Findings from speaker’s studies of TBI in school-aged children: high levels of distress seen in caregivers of children with severe TBI; earlier study showed comparable levels of distress with moderate TBI, but not in group with orthopedic injuries (OI); families report significant psychologic distress after injury; families coping with severe TBI have much higher loads of acute injury-related burden, and families dealing with moderate and severe TBI never return to baseline (burden and distress remain elevated 6 yr after injury)

Changes in level of family dysfunction: families showed few changes when comparing preinjury reports to reports taken immediately after TBI; however, at 6 mo after injury, families dealing with severe TBI reported significantly greater dysfunction (compared with other groups); this dysfunction returned to normal during later follow-ups, but often reemerged during adolescence (possibly due to stress over managing life transitions)

Gender-related differences in coping: mothers more likely to cope with TBI and OI through acceptance; fathers more likely to engage in denial (associated with increased distress); active coping strategies  used by fathers soon after injury, but gradually abandoned; in contrast, mothers increased their use of active coping strategies over time; fathers in TBI and OI groups reported greater degrees of psychologic distress and symptoms (bordering on clinical levels of distress)

Disagreements about parenting in severe TBI group: when compared to preinjury assessments, mothers (but not fathers) began reporting significant increases in frequency of disagreements at 6 mo; frequency never completely returned to baseline levels

Focusing on families: physicians should strive to include both parents in feedback sessions in order to resynchronize their experiences; families play critical role in child’s recovery from TBI; studies show that trajectories of recovery superior in patients from better functioning families, even if TBI severe; however, overall, children with more severe injuries create greater burdens for families (particularly when accompanied by severe behavioral problems); study data show how neurologic insults intensify ties between children and parents

Important aspects of family: socioeconomic status (SES) acts as predictive distal factor; speaker’s studies attempted to assess characteristics of parent-child relationship and quality of parental discipline

Influences on typical child development: warm responsive parenting contributes to improved self-regulation in children and reduces behavior problems; harsh critical parenting contributes to higher levels of externalizing behaviors, conduct disorders, and delinquency; harsh or lax discipline appears to increase incidence of behavior problems

Methodology of speaker’s study: relied on recorded videos of children and parents playing together; coding systems used to measure warmth, contingent responsiveness, and negativity (on 5-point scales); included measurements of how often parents directed children or attempted to “scaffold” behavior; methodology showed high degree of reliability (when assessed by interclass correlations)

Traits of positive parenting: highly responsive (parent reflects what child says and praises child for specific behaviors); fosters sense of connection

Results of speaker’s study: across first 12 mo after injury, few differences in parenting behavior noted; however, parents of children with TBI showed decreased warmth at initial and 6-mo follow-ups (while engaging in free play and collaborative solving of puzzles); at 12 mo, all groups showed similar ratings; no difference seen in parental negativity at any point in time; decreased warmth may stem from increased focus on controlling child’s behavior

Parenting behaviors and emerging behavioral issues in children: after controlling for baseline preinjury behaviors, warmth and negativity assessed as predictive variables via regression analysis; at low levels of warmth and responsiveness, children with severe TBI had significantly more behavioral issues (as measured by attention-deficit/hyperactivity disorder [ADHD] checklists); all groups significantly worse than OI comparison group

Negativity and ADHD symptoms: children with severe TBI showed significantly more symptoms when parents displayed any negativity during 5 min of recorded play; while negativity does not cause dysregulation, children may develop more externalizing behaviors if their parents respond to their dysregulation with negativity

Conclusions: warm responsive parenting and harsh negative parenting have stronger effects on children with TBI (relative to comparison group), due to high prevalence of emerging behavioral problems

Baumrind’s typology of parenting: authoritative  friendly and democratic; consistent; applies reasonable consequences; permissive  laissez-faire style; authoritarian  highly strict and harsh; applies draconian consequences

Permissive parenting in children with TBI: in children who have suffered prolonged hospitalizations and severe trauma, parents often feel obligated to avoid imposing consequences; speaker’s studies found decreased use of authoritative parenting of children who had severe TBI; this decrease may be due to difficulties communicating with recently injured and severely dysregulated children; authoritative parenting returned to baseline by 6 mo

Parental discipline and behavioral recovery: children with moderate TBI developed far more severe behavioral problems when exposed to high degrees of authoritarian parenting; however, no effects seen with severe TBI

Conclusions on parenting and behavioral recovery after TBI: quality of parenting and family environment play important role in early recovery of young children (particularly those with severe TBI); while these effects may be less pronounced with regard to cognitive recovery, behavioral recovery often has far more significant effects on day-to-day functioning; many children with TBI perform well during neuropsychologic tests, but have severe issues at school and with peers due to behavioral problems; interventions emphasizing sensitive parenting and consistent discipline may be effective at treating these problems (particularly in younger children)


Background: historically, most efforts focused on family support and education; nearly all centers have inpatient and outpatient groups, but many outpatient programs have poor attendance; modern interventions apply family problem-solving approaches and may emphasize positive parenting skills for added benefits

Supportive vs problem-solving interventions: only limited evidence backs support; support interventions study (1994)  small study comparing problem-solving stress management to support; patients receiving support alone had poorer outcomes; speaker’s study of web-based problem solving vs internet resources (2006)  group receiving internet resources had poorer outcomes; conclusions  education and support often provide insufficient assistance and may be iatrogenic; families with fewer resources and poorer premorbid functioning may particularly struggle without more intensive interventions and skill-building services

Study data on family problem solving: effective in reducing behavioral problems and parental psychologic distress (with effect size of 0.3-1.5); variations in effect size between studies reflect heterogenous nature of TBI; slightly different interventions may work differently for some families; greatest benefits seen with older children and adolescents, among families of low SES, and with more severe TBI

Background on problem-solving therapy: used for many conditions (in adult and pediatric patients); structured approach to teaching coping and problem solving; intended to increase adaptive situational coping and behavioral competence; problem-solving skills have been proven to benefit depression, distress, and coping; rationale  helping families cope can facilitate child’s adaptation; efficacy  excellent heuristic for children with TBI; older children internalize skills without family interactions, and directly apply them

Speaker’s latest intervention study: largest behavioral study of TBI; included 132 children (12-17 yr of age at time of injury, having moderate to severe TBI, enrolled 1-7 mo after injury); patients randomized to receive counselor-assisted problem solving (CAPS) or internet resources (control group); all families received complimentary computers and high-speed internet access and links to helpful TBI resources, but one group received CAPS module plus videoconferences with therapist; internet-based approached helped ensure access at all levels of SES

CAPS intervention: relatively brief (8 core sessions over 6 mo); initial session conducted face-to-face at home, and revolved around identifying issues and goals; second session focused on positivity and cognitive reframing; families began problem solving during third session; remaining sessions involved identifying goals, applying problem-solving heuristic to goals, and implementing problem solving between sessions; targeting issues specific to TBI  session topics included organization, compensatory strategies for impaired executive function; both groups in study received education on how to work with schools; final sessions  revolved around self-regulation and “hot” sides of executive function; both parents learn to provide support and scaffolding for behavioral regulation; children assess their self-regulation (particularly in affectively laden social situations); focused on verbal and nonverbal communication, staying in control, and handling crisis; concluded with self-assessment of skills (to identify unmet needs); content added based on feedback  self-care; guilt; grief; marital and sibling issues; pain; sleep; memory

Features of CAPS website: video clips of teenagers discussing effects of TBI and coping strategies, and of teen actors modeling important skills; exercises to reinforce and practice skills; audio reading of all text

Web-based entry of goals: completed by therapist while talking to family during first session; parents and children identify their own goals and assess each goal’s importance; after session, therapists ask whether goals achieved

Positivity (second session): teaches parents and adolescents how to better monitor behavior to facilitate finding better solutions; website attempts to normalize issues by offering many examples of individuals with TBI talking about their recoveries

Findings at 6 mo follow-up in speaker’s latest study: included 56 participants in CAPS group and 61 in control group, divided into middle school and high school subgroups; although interaction and regression did not quite reach significance (P-value 0.06), important differences between high school subgroups noted; middle school subgroups failed to improve on any measure; in high school students, both CAPS and control groups showed significantly improved internalizing symptoms; however, all forms of externalizing symptoms (eg, ADHD, oppositional-defiant disorder, aggression) showed significantly greater improvements in CAPS group

Speaker’s conclusions: benefits not mediated by changes in families, but result from direct changes in and learning of strategies by children

Reanalysis: participants with low vocabulary scores (ie, lacking cognitive reserve) received much greater benefit when placed in CAPS group (by 66%-75% of 1 standard deviation); children from low income families also derived greater benefit

Benefits of family problem solving: flexibility allows application to wide array of issues; empowers families to solve their own problems; drawback  strategy found to be ineffective in young children

Updates to CAPS: after initial study, additional content added to place increased focus on self-regulation and self-management in adolescents; 2 sessions added to cover language pragmatics and social skills

Speaker’s study of positive parenting skills with younger children with TBI: loosely based on modalities taken from parent interaction therapy; parents received live coaching over internet while therapists observed them playing with their children; this coaching teaches parents to follow their child’s lead and provide consistent direction and followthrough; all families received complimentary computers, high-speed internet access, and wireless earpieces (to facilitate coaching); parents coded and assessed at 3 mo and 6 mo (mid- and poststudy)

Structure: 10 online sessions provided didactic information on parenting skills (with video demonstrations of helpful and unhelpful behaviors); initial session conducted face-to-face, while all other sessions relied on synchronous videoconferencing; early sessions focused on positive parenting, before progressing to stress management for parents, behavior control, and cognitive and behavioral issues unique to TBI

Outcomes: primarily measured as changes in parental behavior with children (changes in child’s behavior measured secondarily); treatment group showed significantly greater improvements in most targeted parenting skills (eg, reflecting, behavioral descriptions), and greater reduction in disruptive use of questions and commands; however, despite changes in parental behaviors, no statistically significant changes in child behavior found; this contradiction may be due to study design (ie, allowed inclusion of children who did not have behavioral problems at baseline)

Conclusions: interventions should be tailored to address diverse developmental needs of children at different levels, as well as heterogeneity in severity of injury and family characteristics; ultimate goals may include correlating efficacy for particular child and family with findings on imaging or genetic variation

Editor’s Note

Dr. Wade cited the following websites as internet sources for families dealing with traumatic brain injury: ­

<a href="">

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<a href=""> (Betty Clooney Center)

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Suggested Reading

Antonini TN et al: An online positive parenting skills programme for paediatric traumatic brain injury: feasibility and parental satisfaction. J Telemed Telecare 18:333, 2012; Bendikas EA et al: Mothers report more child-rearing disagreements following early brain injury than do fathers. Rehabil Psychol 56:374, 2011; Fulton JB et al: Cognitive predictors of academic achievement in young children 1 year after traumatic brain injury. Neuropsychology 26:314, 2012; Karver CL et al: Age at injury and long-term behavior problems after traumatic brain injury in young children. Rehabil Psychol 57:256, 2012; Kurowski BG et al: Caregiver ratings of long-term executive dysfunction and attention problems after early childhood traumatic brain injury: family functioning is important. PM R 3:836, 2011; Peterson RL et al: Adolescents’ Internalizing Problems Following Traumatic Brain Injury Are Related to Parents’ Psychiatric Symptoms. J Head Trauma Rehabil 2012 Aug 29. [Epub ahead of print]; Potter JL et al: Parenting style is related to executive dysfunction after brain injury in children. Rehabil Psychol 56:31, 2011; Rhine T et al: Clinical predictors of outcome following inflicted traumatic brain injury in children. J Trauma Acute Care Surg 73:S248, 2012; Wade SL et al: A randomized trial of teen online problem solving for improving executive function deficits following pediatric traumatic brain injury. J Head Traua Rehabil 25:409, 2010; Wade SL et al: A randomized trial of teen online problem solving: Efficacy in improving caregiver outcomes after brain injury. Health Psychol 31:767; Wade SL et al: Caregiver functioning following early childhood TBI: do moms and dads respond differently? Neurorehabilitation 27:63, 2010; Wade SL et al: The relationship of parental warm responsiveness and negativity to emerging behavior problems following traumatic brain injury in young children. Dev Psychol 47:119, 2011; Wade SL: Effect on behavior problems of teen online problem-solving for adolescent traumatic brain injury. Pediatrics 128:e947, 2011; Yeates KO et al: The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children. Neuropsychology 24:345, 2010.

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