Familial support becomes a critical role in the child’s recovery and development following an ABI (Braga et al. 2005). It is thought that family-centered interventions will help to improve parents, child and sibling adaptation following injury (Wade, Carey, et al. 2006). It has been demonstrated that family functioning is a significant moderator of child outcome following brain injury (Yeates & Taylor 2005) which becomes an issue as an increase in family dysfunction following an ABI has been well-documented (Cole et al. 2009). Throughout the acute and post-acute stages of recovery, families remain a constant presence for the child (Savage et al. 2005). It has been noted that families provide four unique roles in a child’s recovery from brain injury: (1) as observers of the child’s care, (2) as experts with insightful pre- and post-injury information regarding the child’s abilities, (3) as communicators with professional caregivers and (4) as advocates for the child (Savage et al. 2005).
Unfortunately, being a parent for a child with an ABI can be a demanding and stressful experience. For example, parents expierence feelings of isolation, distress, relationship discord, and anxiety, and engage in negative coping mechanisms such as avoidance and disengagment behaviours (Brown et al. 2013). Parental psychiatric symtpoms impact child’s care, as 22-26% of parents with internalizing issues post pediatric ABI positively correlated to their child’s internalizing issues (Peterson et al. 2013). There is a bi-directional relationship between parent and child function: improvements in paretnal function is likely to have an effect on child adjustment and outcomes following an ABI (Taylor et al. 2001). Therefore it is important to target both child and parental outcomes for optimal recovery after a child has sustained a brain injury.
Web-Based Family Supported Interventions
Family based interventions delivered online have gained popularity due to the appeal of easier accessibility to treatment. Families can access online treatment programs from their home and teleconference in with a therapist over the phone/internet (Narad et al. 2015). Online programs remove barriers to care and treatment, such as distance, time, and proximity of knowledge providers (Wade et al. 2006). Together, online family supported interventions aim to not only improve child outcomes, but also parental outcomes and communication between family members.
Therapy provided with the assistant of a counsellor was examined for a population of children with a mean age greater than 10 years and around 1 year or less post-ABI. Counsellor assistance to complete psychoeducational modules did not significantly improve family function, such as communication and transactions between family members, compared to an internet resource comparison group (IRC) (Narad et al. 2015). However, children improved in self-management and compliant behaviours from pre- to post-treatment in the online counsellor assisted therapy group (Wade, Michaud, et al. 2006). Upon analyzing parental outcomes post-intervention, parents had a reduction in depressive symptoms, anxiety, and distress, but not problem solving compared to the IRC (Wade, Michaud, et al. 2006). The reduction in depressive symptoms was particularly evident when participants completed more than four sessions (Wade et al. 2014). However, long term analysis 18 months post-intervention revealed that online counsellor assisted therapy only reduced caregiver psychological distress, not depression and self-efficacy (Petranovich et al. 2015).
Some benefits from counsellor assisted online therapy were evident for a subset of individuals. For example parental self-efficacy improved for non-frequent compared to frequent computer users (Wade, Kurowski, et al. 2015) and self-management improved for older children (>11yrs) in the intervention compared to older children in the IRC (Wade, Carey, et al. 2006). Other benefits were found for individuals with severe versus moderate TBI, however the effect sizes were small and reports were inconsistent between parents and adolescents (Narad et al. 2015).
An important moderating variable that was found within counsellor assisted online therapy was socioeconomic status (Petranovich et al. 2015; Wade et al. 2012). Parental distress levels were reduced for low income parents compared to the IRC (Petranovich et al. 2015). Within groups, low income parents significantly reduced depressive symptomology post-treatment. Within high income parents the control group (IRC) reduced their depressive symptoms post-treatment, whereas there was no significant difference observed within the online intervention group (Wade et al. 2012). Authors hypothesize that counsellor assisted therapy may be more beneficial for a subset of individual based on socioeconomic status, and future research is warranted.
Within group, online counsellor assisted therapy improved adolescent behavioural problems, parental depression and parent-child conflicts from pre- to post-treatment (Wade et al. 2008). Additionally, there were improvements within intervention and IRC groups on several outcomes, such as the transactional family characteristics and effective communication (Narad et al. 2015), distress (Wade et al. 2014), and depression (Petranovich et al. 2015). Although the differences between groups are not significant, authors suggest that both interventions may be beneficial to reduce caregiver burden and family functioning post-ABI.
An online parenting skills program, Internet-Based Interacting Together Everyday (I-InTERACT), instructed parents on management of children post-ABI. I-InTERACT was compared to an IRC to determine the effects on caregiver strain and parent-child interactions (Antonini et al. 2014; Mast et al. 2014; Raj et al. 2015). The I-InTERACT parenting skills program did not reduce depression or stress, or improve self-efficacy and distress levels (Raj et al. 2015). However, within this population, 92% of caregivers were mothers and may not be representative towards other caregivers such as fathers or grandparents (Raj et al. 2015). Furthermore, I-InTERACT treatment increased the frequency of positive parental statements and praise compared to the IRC group (Antonini et al. 2014). This improvement was also present in a subset of children that had sustained abusive head trauma (Mast et al. 2014). The number of sessions completed by families correlated with the frequency of positive parenting skills (Antonini et al. 2014). Other significant differences were evident upon sub-analyses of parental income. Parental distress was significantly reduced in low-income, but not high income, families following the I-InTERACT program compared to pre-intervention (Raj et al. 2015). Additionally, parental income predicted child’s behaviour following the intervention as children from low-income families had a significant reduction in behavioural problems, which was not apparent with high-income families (Antonini et al. 2014).
There is Level 1a evidence that online problem solving program with therapist assistance is not superior to an internet resource comparison group at improving parent-teen communications and conflict.
There is Level 2 evidence that online problem solving with audio support is not superior to without audio support with regards to improving adolescent behavioural issues and depression.
There is Level 1b evidence that an online parenting skills workshops (I-InTERACT) improves positive parental involvement towards children, when compared with an internet resource group.
There is Level 2 evidence that an online parenting skills program (I-InTERACT) is not superior to an internet resource comparison group at improving caregiver stress, distress, depression, and self-efficacy.
Online parenting skills workshops are not superior to internet resource comparison groups in reducing caregiver stress, depression, and self-efficacy. However, such workshops are efficient at improving positive parental behaviours towards children.
Web-based teen problem solving intervention programs are effective in reducing parental depression, anxiety, and distress compared to an internet resource comparison group.
Family-based interventions benefit children or adolescents and their families following brain injury.
Alternative Family Supported Interventions
A few non-web-based interventions have been evaluated for children that have sustained an ABI. Contrary to web-based programs, face to face interventions can provide social support for parents through the rehabilitation process (Brown & Whittingham 2015). However similarly to web-based, the main focus of therapy continues to be on family dynamics and improving long term outcomes in families with a child that has sustained an ABI.
The Stepping Stone Triple P and acceptance and commitment therapy combined aimed to improve family outcomes and communication within a pediatric ABI population (Brown & Whittingham 2015; Brown et al. 2014). Behavioural problems were reduced in children that underwent the intervention; however these reductions were not maintained by the 6 month follow-up (Brown et al. 2014). There is the potential of both cumulative and delayed deficits following a brain injury that can lead to long term deterioration. Thus authors hypothesize these children may have experienced such a phenomenon and perhaps maintaining interventions for longer time periods may be more beneficial (Brown et al. 2014). In terms of parental outcomes, confidence, disagreements between couples, and psychological distress were significantly improved following the intervention (Brown & Whittingham 2015). Such improvements were not found in the usual care control group, therefore results cannot be attributed to spontaneous recovery (Brown & Whittingham 2015). No significant changes were found for parental relationship satisfaction and depression as both control and intervention groups improved by post-treatment (Brown & Whittingham 2015).
A family problem solving therapy that was delivered face to face was compared to usual care to determine effects on behavioural problems and parental outcomes following a pediatric ABI (Wade, Michaud, et al. 2006). Children within one year post-injury improved in behavioural outcomes following the family problem solving intervention compared to children in the usual care group. Particularly, improvements were reported for internalizing and withdrawal behaviours, and depression and anxiety. Parental distress was not improved following therapy, which is contrary to other studies (Wade, Michaud, et al. 2006). However, rather than parental distress influencing the child’s behaviour changes, authors hypothesize that parental practices from the satisfaction survey, such as better understanding and relationship with child, contributed to the magnitude of changes reported (Wade, Michaud, et al. 2006).
Family rehabilitation consisting of home based activities improved both cognitive and physical abilities for children following a TBI, compared to standard clinician based therapy (Braga et al. 2005). Specifically, IQ, motor development, and functional independence were improved within children receiving the family rehabilitation. Parents were able to be effectively trained to deliver the intervention and this result was unrelated to their education status. Therefore, children in the chronic phase of recovery (mean time post injury 1 year) can benefit from family driven rehabilitation at home and may be easily accepted and learned across families (Braga et al. 2005).
There is Level 2 evidence that Stepping Stone Triple P combined with Acceptance and Commitment Therapy improves parental distress, confidence, psychological flexibility, and conflict, but not depression, when compared to usual care.
There is Level 2 evidence that a face to face family problem solving therapy is superior to usual care in terms of reduction of child behavioural problems, but not parental distress or relationship satisfaction.
There is Level 2 evidence to suggest that family based therapy is superior to standard clinician-directed care for children post-TBI to improve cognitive and physical outcomes.
Stepping Stone Triple P with Acceptance and Commitment Therapy improves parental outcomes and children’s short-term behavioural problems post-ABI.
Family problem solving therapy face to face improves child behavioural problems post-TBI, but not parental distress or relationship satisfaction.
Family based rehabilitation is superior to clinician-directed care to improve cognitive and physical outcomes in children following a TBI.