The family environment as a moderator of psychosocial outcomes following traumatic brain injury in young children.

Objective: This study sought to determine whether the family environment moderates psychosocial outcomes after traumatic brain injury (TBI) in young children. Method: Participants were recruited prospectively from consecutive hospital admissions of 3- to 6-year-old children, and included 19 with severe TBI, 56 with complicated mild/moderate TBI, and 99 with orthopedic injuries (OI). They completed 4 assessments across the first 18 months postinjury. The initial assessment included measures of parenting style, family functioning, and the quality of the home. Children's behavioral adjustment, adaptive functioning, and social competence were assessed at each occasion. Mixed model analyses examined the relationship of the family environment to psychosocial outcomes across time. Results: The OI and TBI groups differed significantly in social competence, but the family environment did not moderate the group difference, which was of medium magnitude. In contrast, group differences in behavioral adjustment became more pronounced across time at high levels of authoritarian and permissive parenting; among children with severe TBI, however, even those with low levels of permissive parenting showed increases in behavioral problems. For adaptive functioning, better home environments provided some protection following TBI, but not over time for the severe TBI group. These 3-way interactions of group, family environment, and time postinjury were all of medium magnitude. Conclusion: The findings indicate that the family environment moderates the psychosocial outcomes of TBI in young children, but the moderating influence may wane with time among children with severe TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Parent-child interactions during the initial weeks following brain injury in young children.

Objective: To understand how traumatic brain injury (TBI) affects parent-child interactions acutely following injury. Participants: Young children hospitalized for TBI (n = 80) and orthopedic injuries (OI; n = 113). Method: Raters coded videotaped interactions during free play and structured tasks for parental warmth/responsiveness and negativity and child warmth, behavior regulation, and cooperation. Raters also counted parental directives, critical/restricting statements, and scaffolds. Results: Parents of children with TBI exhibited less warm responsiveness and made more directive statements during a structured task than parents in the OI group. Children with TBI displayed less behavior regulation than children with OI. Parental warm responsiveness was more strongly related to child cooperativeness in the OI group than in the TBI group. Child behavior also mediated group differences in parental responsiveness and directiveness. TBI accounted for as much variance in parental behaviors as or more than did sociodemographic factors. Conclusion: TBI-related changes in child behavior may negatively influence parent-child interactions and disrupt the reciprocity between parent and child. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurocognitive outcomes and recovery after pediatric TBI: Meta-analytic review of the literature.

Traumatic Brain Injury (TBI) continues to be one of the leading causes of death and disability in the pediatric population. Although the literature on neurocognitive outcomes is relatively rich, studies vary significantly in the methods used to group subjects on several moderating variables, including age at injury, injury severity, and time since injury, making it difficult to combine and summarize the data for comparison. Further complicating this effort is the wide range of measures used to document functional outcomes in key neurocognitive domains. In this meta-analytic review, 28 publications (1988 to 2007) that met inclusion criteria were summarized based on three distinct injury severity and time post injury groups for 14 key neurocognitive domains. Effect sizes were calculated to reflect the extent to which the above groups differed in case-control and case-case studies, as well as address recovery based on longitudinal studies. To the best of our knowledge, this is the first published quantitative summary of the literature on neurocognitive outcomes after pediatric TBI. Limitations of the current state of the literature as well as recommendations for future studies are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An online family intervention to reduce parental distress following pediatric brain injury.

This study examined whether an online problem-solving intervention could improve parental adjustment following pediatric traumatic brain injury (TBI). Families of children with moderate-to-severe TBI were recruited from the trauma registry of a large children's hospital and randomly assigned to receive online family problem solving therapy (FPS; n = 20) or Internet resources (IRC; n = 20) in addition to usual care. The FPS group reported significantly less global distress, depressive symptoms, and anxiety at follow-up than did the IRC group after controlling for baseline symptoms. The FPS group also reported significant improvements in problem-solving skills, although the groups did not differ significantly at follow-up. Findings suggest that an online, skill-building approach can be effective in facilitating parental adaptation after TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Anosognosia and denial: Their relationship to coping and depression in acquired brain injury.

Objective: To evaluate relations among denial, anosognosia, coping strategies, and depression in persons with brain injury. Study Design: Correlational. Setting: A Midwest residential, post-acute brain injury rehabilitation center. Participants: Twenty-seven adults with brain injury. Measures: Clinician's Rating Scale for Evaluating Impaired Self-Awareness and Denial of Disability After Brain Injury, COPE, Beck Depression Inventory-I. Results: Denial and anosognosia were related and co-occurred. Use of process coping strategies was associated with greater use of problem-focused coping strategies. Higher levels of denial were associated with greater use of avoidant coping strategies, and greater use of these coping strategies was related to higher levels of depression. Conclusions: Individuals primarily in denial and individuals primarily anosognosic differ in the coping strategies they institute. Avoidant coping strategies are used more frequently by individuals in denial, and use of these strategies is associated with higher levels of clinical depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of short- and long-term neuropsychological outcomes after traumatic brain injury in children.

Longitudinal neuropsychological outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries only. Neuropsychological functioning was assessed at baseline, at 6- and 12-month follow-ups, and at an extended follow-up (a mean of 4 years postinjury). Mixed model analyses revealed persistent neuropsychological sequelae of TBI that generally did not vary as a function of time postinjury. Some recovery occurred during the first year postinjury, but recovery reached a plateau after that time, and deficits were still apparent at the extended follow-up. Further recovery was uncommon after the first year postinjury. Family factors did not moderate neuropsychological outcomes, despite their demonstrated influence on behavior and academic achievement after childhood TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Response to "Programming for occupational outcomes following traumatic brain injury".

Responds to an article Programming for occupational outcomes following traumatic brain injury by William J. Haffey and Frank D. Lewis (see record 1990-02644-001). The dramatic upsurge in attention paid in the past 10 years to the rehabilitation of persons with traumatic brain injury (TBI) has resulted in an accelerating proliferation of treatment programs purporting to apply specialized techniques that will "remediate" the cognitive and behavioral deficits of this population, with implicit or explicit promises of functional gain. Specifically, given the epidemiologic realities of the TBI population, returning to work is a major goal of the rehabilitation process. With the movement of TBI rehabilitation programs out of academic medical centers and into the private sector, increasing numbers of zealous professionals are ready to apply a variety of treatment approaches, thousands of families are eager to find the "best" program, and more and more nervous insurers are both mandated and requested to pay for expensive treatments that hold out the promise of return to work. Unfortunately, the field of TBI rehabilitation has been more eager to provide services than critically evaluate the effectiveness of those services. The first major contribution of the Haffey and Lewis article is to call attention both to the paucity of posttreatment vocational outcome studies, and to emphasize the need to evaluate the success of various models of vocational rehabilitation. The second major contribution of the Haffey and Lewis article is their offering of a concrete example of one approach to systematic programming for vocational outcomes. Our experience is that vocational potential—and therefore reasonable goals—only emerge as the product of a process that involves testing the client's capacities not just cognitively and behaviorally, but also his or her capacity to conform to a series of messages and procedures that will determine the viability of any given vocational plan. Readers should take from the concrete programming suggestions in this article the laudable objective of making vocational goals, obstacles, and critical events specific and public, but beware of mechanically applying the approach without appreciating the complex subtleties in enabling a brain-injured person to become a productive worker. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relationship between employment-related self-efficacy and quality of life following traumatic brain injury.

Objectives: This study examines the relative contribution of employment-related and general self-efficacy to perceptions of quality of life (QoL) for individuals with traumatic brain injury. Design: Correlational. Setting: Community-based research and training center. Participants: 427 individuals with self-reported TBI under the age of 65 were included in analysis. Main Outcome Measure: Employment-related self-efficacy, general self-efficacy, perceived quality of life (PQoL), unmet important needs (UIN). Results: Significant correlations were found between income, injury severity, age at injury, and employment and the QoL variables. In addition, employment-related and general self-efficacy correlated positively with both PQoL and UIN. Employment-related and general self-efficacy accounted for 16% of the variance in PQoL and 9.5% of the variance in UIN, over and above other variables traditionally associated with QoL. Conclusions: These findings highlight the importance of including subjective appraisals of employment, such as perceived self-efficacy at the workplace, in assessing QoL and successful return to work following TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinically significant behavior problems during the initial 18 months following early childhood traumatic brain injury.

Objective: This study looked at the emergence of clinically significant problems in behavior, executive function skills, and social competence during the initial 18 months following traumatic brain injury (TBI) in young children relative to a cohort of children with orthopedic injuries (OI) and the environmental factors that predict difficulties postinjury. Participants: Children, ages 3–7 years, hospitalized for severe TBI, moderate TBI, or OI were seen shortly after their injury (M = 40 days) and again 6 months, 12 months, and 18 months postinjury. Design: Behavioral parent self-reports, demographic data, family functioning reports, and home environment reports were collected at injury baseline and each time point postinjury. Results: Results suggest that, compared with the OI group, the severe TBI group developed significantly more externalizing behavior problems and executive function problems following injury that persisted through the 18-month follow-up. Minimal social competence difficulties appeared at the 18-month follow-up, suggesting a possible pattern of emerging deficits rather than a recovery over time. Conclusions: Predictors of the emergence of clinically significant problems included permissive parenting, family dysfunction, and low socioeconomic status. The findings are similar to those found in school-age children. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury.

Objective: The long-term consequences of traumatic brain injury affect millions of Americans, many of whom report using religion and spirituality to cope. Little research, however, has investigated how various elements of the religious and spiritual belief systems affect rehabilitation outcomes. The present study sought to assess the use of specifically defined elements of religion and spirituality as psychosocial resources in a sample of traumatically brain injured adults. Participants: The sample included 88 adults with brain injury from 1 to 20 years post injury and their knowledgeable significant others (SOs). The majority of the participants with brain injury were male (76%), African American (75%) and Christian (76%). Measures: Participants subjectively reported on their religious/spiritual beliefs and psychosocial resources as well as their current physical and psychological status. Significant others reported objective rehabilitation outcomes. Analyses: Hierarchical multiple regression analyses were used to determine the proportion of variance in outcomes accounted for by demographic, injury related, psychosocial and religious/spiritual variables. Results: The results indicate that religious well-being (a sense of connection to a higher power) was a unique predictor for life satisfaction, distress and functional ability whereas public religious practice and existential well-being were not. Conclusions: The findings of this project indicate that specific facets of religious and spiritual belief systems do play direct and unique roles in predicting rehabilitation outcomes whereas religious activity does not. Notably, a self-reported individual connection to a higher power was an extremely robust predictor of both subjective and objective outcome. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Gender differences in learning and memory after pediatric traumatic brain injury.

Thirty boys and 30 girls who sustained a traumatic brain injury (TBI) were evaluated within 1 year postinjury with the California Verbal Learning Test--Children's Version (CVLT-C; D. C. Delis, J. H. Kramer, E. Kaplan, & B. A. Ober, 1994). Boys had statistically significantly lower performance on the CVLT-C than girls in the absence of statistically significant group differences on various demographic and neurological variables. Although the effect size for this difference was modest (η=.09), gender accounted for a statistically significant amount of the variance (5%) in CVLT-C scores in addition to effects of injury severity and age. It is concluded that male gender is associated with an increased risk for retrieval deficits after pediatric TBI, possibly because of reduced speed or efficiency of information processing. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting longitudinal patterns of functional deficits in children with traumatic brain injury.

Longitudinal patterns of functional deficits were investigated in 37 children with severe traumatic brain injury (TBI), 40 children with moderate TBI, and 44 children with orthopedic injuries. They were from 6 to 12 years of age when injured. Their neuropsychological, behavioral, adaptive, and academic functioning were assessed at 6 months, 12 months, and 3–5 years postinjury. Functional deficits (     

A prospective study of short- and long-term outcomes after traumatic brain injury in children: Behavior and achievement.

Longitudinal behavior and achievement outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries not involving brain insult. Measures of preinjury child and family status and of postinjury achievement skills were administered shortly after injury. Assessments were repeated 3 times across a mean follow-up interval of 4 years. Results from mixed model analysis revealed persisting sequelae of TBI. Recovery of math skills was observed in the severe TBI group but only for children from less stressed families. Social disadvantage in children with TBI predicted more adverse behavioral sequelae and less favorable changes in some outcome measures. The findings suggest that pediatric TBI has long-term effects on behavior and achievement but that postinjury progress is influenced by the family environment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A stress process model of caregiving for individuals with traumatic brain injury.

Objective: To test a stress process model of caregiving for persons with traumatic brain injury. Design: A correlational study using path analysis. Participants: One hundred eight caregivers affiliated with community- or Web-based support groups. Main Outcome Measures: The Modified Caregiver Appraisal Scale, the World Health Organization Quality of Life-Brief Version, the Interpersonal Support Evaluation List, and the COPE. Results: The normed fit index, comparative fit index, and parsimony ratio indicated a good fit for the model, suggesting that coping, social support, and caregiving appraisal contribute to quality of life. A more parsimonious model was respecified and achieved a better fit with fewer paths and variables. Conclusions: Empirical support was found for the proposed caregiving stress process model, which appears to provide useful information for future research and clinical interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Recovery of time estimation following moderate to severe traumatic brain injury.

Objective: Accurate time estimation abilities are thought to play an important role in efficient performance of many daily activities. This study investigated the role of episodic memory in the recovery of time estimation abilities following moderate to severe traumatic brain injury (TBI). Method: Using a prospective verbal time estimation paradigm, TBI participants were tested in the early phase of recovery from TBI and then again approximately one year later. Verbal time estimations were made for filled intervals both within (i.e., 10 s, 25 s) and beyond (i.e., 45 s 60 s) the time frame of working memory. Results: At baseline, when compared to controls, the TBI group significantly underestimated time durations at the 25 s, 45 s and 60 s intervals, indicating that the TBI group perceived less time as having passed than actually had passed. At follow-up, despite the presence of continued episodic memory impairment and little recovery in episodic memory performance, the TBI group exhibited estimates of time passage that were similar to controls. Conclusion: The pattern of data was interpreted at suggesting that episodic memory performance did not play a noteworthy role in the recovery of temporal perception in TBI participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Family satisfaction predicts life satisfaction trajectories over the first 5 years after traumatic brain injury.

Objectives: Examined the influence of functional impairment, stable marital status, and family satisfaction on life satisfaction trajectories for 609 individuals (435 men, 174 women) over the first 5 years after traumatic brain injury (TBI). Measures: Participants completed the Family Satisfaction Scale (FSS), Functional Independence Measure (FIM), and the Life Satisfaction Index (LSI) at years 1, 2, 4, and 5 after sustaining a TBI. Results: Trajectory modeling revealed that higher family satisfaction was associated with increases in life satisfaction for individuals with less functional impairment. Stable marital status was not significantly associated with life satisfaction trajectories. Implications: Family satisfaction appears to have pronounced beneficial effects on life satisfaction for persons with less functional impairment after TBI regardless of marital status. In contrast, a stable marriage appears to have no apparent benefits to self-reported life satisfaction over the first 5 years post-TBI. Theoretical and clinical implications of these results are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attribution of blame in accidental and violence-related traumatic brain injury.

Objective: To study reliability and validity of blame attribution following acute moderate to severe traumatic brain injury (TBI) caused by violence versus accident. Study Design: Prospective study with test-retest component, comparing groups with violent versus accidental injuries as determined by self-report and chart review. Participants: Fifty-seven persons in acute rehabilitation for moderate to severe TBI. Measure: Eight-item Blame Attribution Questionnaire. Results: Blame attribution was reliable, even for participants with severe TBI. Violence and accident groups apportioned different amounts of blame to other people; concern with cause of injury and degree of self-blame showed less striking differences. Conclusions: Blame of others, which may increase risk of adverse psychological outcome, is strongest in those with violence-related TBI. Self-blame is not as strongly related to external circumstances and could signal a constructive coping mechanism. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Correlates of social problem solving during the first year after traumatic brain injury in children.

Effects of pediatric traumatic brain injury (TBI) on social problem-solving were examined in a longitudinal study of 103 children with moderate-to-severe TBI (n = 52) or orthopedic injury (OI; n = 51) using the Interpersonal Negotiation Strategies task (INS). Children solved age-appropriate hypothetical social conflicts, with responses for four problem-solving steps scored by developmental level. The OI group performed better than the TBI group, but rate of change in performance over time did not differ between groups, suggesting improvement in children with TBI was not due to recovery from injury. Strong relations between INS performance and memory and language skills emerged, but emotional processing was only weakly related to INS performance. Frontal focal lesions influenced INS performance in younger (but not older) children with TBI. Diffusion tensor imaging (DTI), revealed strong relationships between the INS and increased apparent diffusion coefficient (ADC) measures indexing connectivity in the dorsolateral and cingulate regions in both TBI and OI groups, and in the temporal and parietal regions in the TBI group. These findings inform studies of social problem-solving skills during the first year post TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting community integration following traumatic brain injury with health and cognitive status measures.

Objective: To examine measurement properties of the Community Integration Questionnaire (CIQ) and the Short-Form Health Survey (SF-36) and assets the contributions of cognitive functioning and health to community integration. Design: Rating scale analyses and regression analysis data on basic cognitive functioning and health collected from 289 individuals with traumatic brain injury. Results: Person reliabilities indicated substantial measurement error. Ceiling effects weakened the model (adjusted R2 = .143) specifying the contributions of age, gender, cognitive functioning, and health to community integration. Conclusions: Poor measurement properties and definitional problems associated with community integration weakened the results. The extent to which potential familial and environmental characteristics contributing to role fulfillment change across time requires further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Use of the Neuropsychiatric Inventory in traumatic brain injury: A pilot investigation.

Objective: The goal of this investigation was to pilot the Neuropsychiatric Inventory (NPI) among individuals with traumatic brain injury (TBI) and their caregivers, assessing its screen-metric approach. Design and Participants: Using the NPI, caregivers rated neurobehavioral disturbances in 51 individuals with moderate-to-severe TBI. The NPI was completed 1 or 2 years after the individuals were injured. Results: Caregivers reported the highest symptom levels for participants on Irritability/Lability, Apathy, and Agitation/Aggression, and rated greater levels of distress tied to those domains and to Dysphoria. Caregivers endorsing domain screening items endorsed significantly more metric items (vs. screen non-endorsers) within that domain, as would be expected if the screen accurately measured the psychopathology under consideration. In addition, the screen-metric yielded extremely low false-positive rates, although 5 of the 12 domains had elevated false-negative rates. Conclusions: Findings provide preliminary support for the accuracy of the NPI's screen-metric in this population and are consistent with prior work detailing common problematic neurobehavioral consequences of TBI. These results lay groundwork for research and clinical use of this measure in populations with TBI. (PsycINFO Database Record (c) 2010 APA, all rights reserved)