Abstract
Objective: To examine changes in parent-adolescent interactions after traumatic brain injury (TBI) and their relationship to parent and adolescent adjustment.
Design: Concurrent cohort, cross-sectional study. Analysis of variance was used to examine group differences and regression analysis to assess associations between interactional measures and concurrent adjustment.
Setting: Four hospitals in north-central Ohio.
Participants: Adolescents with severe TBI (25), moderate TBI (22), and orthopedic injuries (35) and their parents.
Main outcome measures: Observer ratings of parent-adolescent interactions, Conflict Behavior Questionnaire (CBQ), Family Burden of Injury Interview (FBII), Brief Symptom Inventory (BSI), Family Assessment Device (FAD), Child Behavior Checklist, Vineland Adaptive Behavior Scale, and Children's Depression Inventory.
Results: No group differences were found on ratings of parent-adolescent interaction or the parent or child CBQ. However, observed criticism/coldness and self-rated conflict had stronger associations with the FBII, BSI, and FAD in the severe TBI group than in the orthopedic injury group, suggesting that conflict is more disruptive after TBI. Ratings of criticism/coldness and parent and adolescent CBQ scores were also associated with parent and adolescent adjustment.
Conclusions: Results support the utility of observational measures in assessing dyadic interactions after TBI.
TRAUMATIC BRAIN injury (TBI) in children leads to a wide range of adverse consequences for children and their caregivers, including: cognitive and behavior problems in the injured child, elevated levels of caregiver burden and distress, and family dysfunction. 1-12 Although not the focus of previous investigations, TBI may also contribute to increased criticism and conflict in parent-child interactions.
Programmatic research investigations by Patterson and other members of the Oregon Social Learning Center have provided evidence that parents experiencing economic or personal stress are more likely to respond punitively to their children who in turn react with escalating anger and acting-out behaviors. 13-15 The documented stress upon caregivers arising from pediatric TBI, 2,3,5,7,9-12 coupled with deterioration in the child's behavior, 3,6,8 have the potential to initiate this coercive cycle resulting in increasing worsening in the child's behavior and mounting family distress over time.
Thus adverse changes in parent-child relations precipitated by TBI may, in turn, result in further deterioration of the child's behavior. Parental criticism and conflict (both family and dyadic) appear to be particularly potent predictors of child adjustment. 16 Parental criticism has been associated with externalizing behaviors among children with medical conditions and developmental disabilities. 17,18 High levels of parent-adolescent conflict have been linked to delinquency 13 and substance use. 19 Deficits in maternal or family problem-solving skills have also been linked to delinquency, more frequent family crises, and poorer child social skills. 13,20
Understanding the association between parent-child interactions and child recovery after TBI has important implications for developing interventions to improve child outcomes via improved parent-child relationships. Several investigations have linked both pre- and postinjury family adjustment to the child's cognitive and behavioral recovery. 3,4,8,21,22 Perhaps of greater relevance, differences in cognitive recovery between children with severe TBI and those with orthopedic injuries were greater in the context of an adverse pre- and postinjury family environment. 8,22 These findings raise the possibility that the influence of parent-child interactions on the child's recovery and subsequent adjustment may vary as a function of the severity of the injury, with severe TBI amplifying the deleterious effects of conflict and criticism on child adjustment.
To begin to more fully understand the impact of childhood TBI on the quality of the parent-child relationship, researchers need to go beyond self-report by obtaining observation-based measures or by collecting data from multiple family members. 23 To address this need, the present study examined the effects of traumatic injury on parent-adolescent interaction from the perspectives of the parent, adolescent, and trained observer. We also examined the relationship of parent-adolescent interactional patterns to longer term parent and adolescent outcomes and tested the possibility that the relationship of parent-adolescent interactions to adolescent and parent adaptation might be stronger after severe TBI.
We hypothesized that parent-adolescent interactions would differ between families of children with TBI and families of children with orthopedic injuries not involving the central nervous system (CNS). Based on evidence that elevated caregiver stress contributes to increasingly negative interactions with children, 14,15 we anticipated that parents of adolescents who had experienced a TBI would display higher levels of criticism and conflict in their interactions and less problem solving than parents of adolescents with orthopedic injuries. Additionally, based on evidence regarding the behavioral effects of TBI, 1 we anticipated that adolescents with TBI would evidence less positive behavior while interacting with their parents (e.g., less effective problem solving) than did adolescents with orthopedic injuries.
Second, we hypothesized that the quality of the interaction would be associated with parent and family functioning and the child's behavioral adjustment even after taking injury severity into account, and that this relationship would be particularly strong after severe TBI. Based on Patterson's coercion model of parent-child interactions, 13,14 we predicted that greater parental criticism and parent-adolescent conflict and less effective problem solving would be associated with more adverse parent and adolescent outcomes.
The current report differs from previous investigations in its focus on the parent-adolescent relationship from multiple perspectives and longer term outcomes (on average, 4 years after the injury). This cross-sectional investigation represents the first use of observational measures of parent-adolescent interaction to assess family functioning after TBI. Although exploratory in nature, it provides preliminary validation for our observational measure and an initial test of the hypotheses outlined previously, thus establishing a foundation for subsequent hypothesis generation and investigation.