MODERATE TO SEVERE traumatic brain injury (TBI) in childhood has profound, and often persistent, consequences for the child's cognitive, behavioral, and social functioning.1–3,4,5 Parents and families are also adversely affected as evidenced by increased rates of injury-related burden, depression, and family dysfunction.6 Mounting evidence supports a reciprocal relationship between child and parent/family functioning following TBI.7–10 Families of children with marked behavioral and functional impairments report higher levels of injury-related burden and distress.11,12 Conversely, children of parents with higher socioeconomic status, more effective parenting strategies, and lower levels of family stressors experience fewer functional impairments.7–10 These findings suggest that intervening at a family level may support improvements in both parent/family and child functioning.
Family-problem–solving treatment (F-PST) has been increasingly used to promote family coping following pediatric TBI.13–18 As implemented in a series of 4 randomized controlled trials, F-PST provides training in step-by-step problem solving,19 communication skills, and self-regulation to the youth with TBI, their parents or caregivers, and available siblings. The problem-solving training is conceptualized as supporting family coping with varied challenges, both related to and distinct from the child's TBI, while providing the child with a heuristic for addressing executive function and problem-solving deficits arising from his or her injury. Growing evidence suggests that this approach is effective in improving executive function and externalizing behaviors among adolescents with TBI as well as reducing parental depression and improving caregiving efficacy.18,20–22
Although TBI is the leading cause of acquired disability in childhood, many children and families fail to receive needed services.23,24 E-health approaches allow mental health and behavioral treatments to be delivered remotely with comparable efficacy25 and could prove particularly beneficial following pediatric TBI where qualified local providers may be difficult to find.26 Prior trials of therapist-guided online F-PST highlight its efficacy relative to online education but fail to elucidate efficacy relative to face-to-face F-PST, which remains the standard of care.
Previous studies of therapist-guided online F-PST have highlighted heterogeneity in treatment response. Families of lower socioeconomic status may be particularly likely to benefit both due to higher levels of initial depression and poorer premorbid problem-solving skills.15,16 These findings suggest that families from higher socioeconomic status backgrounds may have resources to allow them to benefit from less intensive intervention, whereas families with lower socioeconomic status may require more therapist involvement in order to benefit. Familiarity and comfort with technology may also moderate the efficacy of therapist-guided online F-PST,15,27 although the changing nature of these effects with widespread broadband access underscores the need for continued evaluation.
In the Coping with Head Injury through Problem Solving (CHIPS) study, the efficacy of 3 modes of F-PST in improving child and family psychosocial outcomes following pediatric TBI was compared: (1) face-to-face F-PST, (2) therapist-guided online F-PST, and (3) self-guided online F-PST.28 The 3 groups covered identical content but differed on whether a therapist was involved and whether the treatment was online or in-person. This report focuses on parent outcomes of the intervention. This study hypothesized that therapist-guided online F-PST would result in better parent outcomes than other conditions, given the combination of therapist support with self-guided online content and greater accessibility. We further anticipated that families at risk due to lower socioeconomic status would be particularly likely to benefit from therapist-guided online F-PST. Comfort with technology was also examined as a potential moderator, with the expectation that those less comfortable with technology would benefit more from one of the therapist-involved treatments than self-guided online F-PST.
This study was registered with Clinicaltrials.gov NCT02368366 and approved by the institutional review boards at 5 participating hospitals (4 children's hospitals and 1 general hospital with pediatric commitment). Potentially eligible participants were identified through a variety of avenues including current hospital admissions, trauma registry information, outpatient medical visits, or via referral or letter from their clinical provider. Eligible participants were adolescents, aged 14 to 18 years, with complicated mild to severe TBI who required inhospital medical or rehabilitation care and had current, persistent behavioral impairment (>1-month duration) on the Strengths and Difficulties Questionnaire.29 Severe TBI was defined as a Glasgow Coma Scale score of 8 or less; moderate TBI as a Glasgow Coma Scale score of 9 to 12; and complicated mild TBI as a Glasgow Coma Scale score of greater than 12 accompanied by an Abbreviated Injury Severity30 score of the head region of greater than 3 or TBI-related abnormalities on neuroimaging. Exclusionary criteria included primary language other than English, moderate to severe cognitive disability prior to injury, severe TBI-related cognitive impairment that precluded participation in the therapy, parent hospitalization for psychiatric reasons during the previous year, or child hospitalization for psychiatric reasons prior to their TBI. Children with nonblunt trauma or a history of child abuse were not excluded. Participating adolescents also had to be in a stable living situation with a clearly identified parent/legal guardian who consented to participate.
Participants were randomized into 1 of 3 versions of F-PST: face-to-face F-PST; therapist-guided online F-PST; and self-guided online F-PST. Randomization was stratified on the basis of distance from the hospital. Those residing 25 miles or less from the hospital were randomized in a 2:1 ratio, with 2 children assigned to the face-to-face arm for each participant assigned to one of online treatment arms. Those residing more than 25 miles from the hospital were randomized equally among the 2 online arms (therapist-guided vs self-guided). Group assignment was provided to families in a sealed envelope at the conclusion of the baseline visit to allow interviewers to remain naïve of group assignment during the baseline data collection.
Table 1 summarizes sample characteristics for the 3 groups. Groups significantly differed in participant racial background, such that the face-to-face group comprised higher proportion of nonwhite participants than the 2 online groups. This difference is likely attributable to higher levels of racial and ethnic diversity in the geographic areas closer to the hospital locations, as these families were more likely to be randomized to the face-to-face group according to the randomization scheme (2:1 ratio). No significant group differences were evident in other participant characteristics (gender, age of injury, time since injury, and injury severity) and parent characteristics (marital status, parental education, and household income).
Procedures and Interventions
Informed parental consent and adolescent assent, baseline data collection, and randomization were conducted either in the medical clinic or the family's home, depending on family preference. Six- and nine-month follow-up questionnaire data were collected online, via mail, or in-person at a medical clinic visit or at the family's home, depending on family preference.
Treatment content was equivalent across treatment arms, though groups differed in terms of delivery mode (online vs face to face) and degree of therapist involvement (therapist-guided vs self-guided). The same therapists were trained to deliver the therapist-guided online and face-to-face treatments. (See the study by Wade et al1 for a more thorough description of therapist experience and training.) Participants and their families in all 3 treatment arms could complete up to 10 sequential sessions providing training in staying positive/cognitive reframing, problem-solving, communication, and self-regulation/anger management.18,28 After completing the initial 9 core sessions, families in the therapist-guided arms could complete up to 4 additional sessions with the therapist focusing on areas of concern for their particular family. Possible supplemental sessions included (1) Just for Siblings, 2) Parents and Siblings— for Parents, (3) Marital Communication, (4) Talking with your Teen, (5) TBI and Seizures, (6) Sleep and Your Teen, (7) After High School, (8) Pain Management, (9) Crisis Management, (10) Guilt, Grief and Caregiving, and (11) Memory Challenges. Families in both online arms had access to the Web-based content for all of the supplemental sessions. Families in the face-to-face arm could receive handouts for the supplemental sessions they did not complete at the end of treatment.
Face-to-face F-PST: Families assigned to this arm met with the therapist in person at the medical center or satellite clinics. Sessions lasted approximately 60 minutes and covered the didactic content using printed handouts provided as part of a family workbook that they could take home with them after each session. Therapists also discussed or role-played the content covered in online exercises, for example, reframing negative self-statements. Sessions were scheduled weekly for the first month and then biweekly for the next 3 months; however, there was considerable flexibility in actual delivery based on family needs.
Therapist-guided online F-PST: Families assigned to this arm were provided access to the online intervention materials throughout the course of the intervention. Each session of therapist-guided online F-PST consisted of a self-guided online portion providing didactic content regarding the desired skill (ie, problem-solving), video clips modeling the skill, and exercises and assignments giving the family an opportunity to practice the skill. New materials were released upon completion of each session with the therapist. Synchronous, videoconference sessions with the therapist were scheduled weekly for the first month and then biweekly for the next 3 months of the intervention for a total of 10 sessions.
Self-guided online F-PST: Families in the self-guided online F-PST arm received access to the online intervention materials throughout the course of the intervention. They received access to the same Web modules as the therapist-guided online F-PST group but reviewed them on their own without therapist support. Participants in this group were encouraged to complete Web modules at the same schedule (initially weekly and then biweekly) as participants in the other groups and the research coordinators helped them schedule these sessions in advance and provided electronic reminders. If the family failed to log on or complete Web modules, they received reminders via phone, text, or e-mail. They also had access to all 11 supplemental sessions.
Parental depression and distress
The Center for Epidemiological Studies Depression Scale (CES-D)31 was administered to assess for parental depression. Caregivers rated the frequency of experiencing specific depression symptoms over the past week, including depressed mood and social withdrawal. Scores on this 20-item measure range from 0 to 60, with higher scores reflecting higher levels of depression. Raw scores of 16 and higher were used as a cut-point to designate clinically significant depressive symptoms.31 The Brief Symptom Inventory (BSI)32 was also administered to parents to measure a broader range of psychiatric symptoms. The BSI is a 53-item self-report inventory in which caregivers rated the extent to which they have been bothered in the past week by a range of psychiatric symptoms. The BSI has 9 subscales designed to assess individual symptom groups and includes 3 scales that capture global psychological distress. The BSI is reported as a T-score with a mean of 50 and standard deviation of 10. Scores of 63 on the Global Severity Index were used as a cut-point to indicate clinically significant levels of psychiatric distress.
Family characteristics and sociodemographic status
Families provided information regarding race and ethnicity, marital status, parental education, and distance from the medical center during the baseline interview. Total household income was assessed using a 12-point scale that was categorized into $10 000 increments. The lowest category started at “less than $20 000 a year” and the highest category ended at “$120 000 a year or more.” A continuous income variable was created on the basis of these categories using the midrange for each category except the lowest and highest categories.
Parent computer usage prior to, during, and after the intervention was assessed using the Computer Usage Questionnaire developed for our previous investigation.27 This questionnaire assesses several types of computer usage at home and work or school including word processing, e-mail, and Web-based searches. Participants also rated their computer skills and the total number of hours spent using the computer. For the current analyses, we used responses to the following item: “I would rate my computer abilities as: extremely poor, poor, average, good, or extremely good.” This variable was dichotomized to reflect below average self-reported abilities (extremely poor, poor) versus average to superior self-reported abilities.
The primary analyses consisted of generalized linear mixed models with repeated measures. For the CES-D total and BSI—Global Severity Index, each response was modeled as a function of treatment group, time period (baseline, 6 months, and 9 months), and their interaction. In addition, time since injury, race, and study site were covariates. In addition to the primary outcome models described, variables were examined individually in these models to see whether they moderated the effect of treatment. Potential moderators included parental education and comfort with technology. All analyses were conducted using SAS statistical software version 9.4 (SAS Institute Inc, Cary, North Carolina).
Participant characteristics and attrition
As reported in Table 1, a total of 149 parents or caregivers completed the baseline assessment (see also CONSORT diagram, Supplemental Digital Content Figure 4, available at: http://links.lww.com/JHTR/A306). Time since injury ranged from 1 month to 17 years and 3 months. Almost two-thirds (n = 95; 64%) of the adolescents in this study were male. Of the primary caregivers, 127 (85%) were mothers of the participant, 83 (56%) were married, and 59 (40%) had only a high school degree. The average household income for this sample was $62 050 (SD = $36 900). One hundred twenty-two (82%) primary caregivers provided data at either the 6- or 9-month follow-ups. The number of sessions completed did not differ significantly among treatment arms. Attrition rates varied by treatment arm (χ2 = 7.42; P = .025), race (χ2 = 3.9; P = .048), completion of 3 or more therapy sessions (χ2 = 32.7; P < .001), and time since injury at baseline (t = −2.89, P = .006). Those in the face-to-face arm, people of color, those who completed fewer sessions, and those with more recent injuries were more likely to drop out prior to follow-up. Attrition between 6 and 9 months did not vary significantly across treatment arms.
Center for Epidemiological Studies Depression Scale
As reported in Table 2, parents' report of their own depressive symptoms declined significantly in the therapist-guided online group between baseline and 6 months and these improvements were maintained at 9 months. Given our interest in the contrast between the 2 online groups, we examined the post hoc analyses slopes despite the failure of the group × time interaction to achieve significance, F2,131 = 2.49; P = .087. Post hoc analyses indicated that the slopes for the online groups differed significantly, t = −2.23, P = .028. As indicated in Figure 1, parents in the therapist-guided online group had declining symptoms of depression over time, whereas symptoms in the self-guided online group did not decline between baseline and 9 months.
Brief Symptom Inventory
On the BSI Global Severity Index, the therapist-guided online group reported significant reduction in distress from baseline to 6 months that was maintained at 9 months. Conversely, the face-to-face and self-guided online groups reported significant reductions in distress between the 6- and 9-month follow-ups with corresponding large effect sizes. There were no significant group differences at any time point. However, scores in all 3 groups were consistent with population norms (mean = 50) at the 9-month follow-up (see Table 2).
Moderators of treatment efficacy
Given prior evidence of socioeconomic status and technology savvy as moderators of the efficacy of online F-PST,16,27 we were particularly interested in the contrast between the 2 online treatments. When comparing these groups, 2 interactions trended toward significance for the CES-D: whether the parent had a college degree (group × time × parent education, df: 1, 101; F: 3.70; P = .057) and whether the parent was comfortable with technology (group × time × comfort with technology, df: 1, 107; F: 3.80; P = .054). Within-group contrasts indicated that parents with less education (see Figure 2) or less comfort with technology (see Figure 3) improved more with therapist-guided online therapy treatment over time. In addition, when comparing differences in slopes, the therapist-guided online group was significantly different than the self-guided online group (see Table 3). Neither parental education nor comfort with technology moderated group differences in the BSI over time.
This study reports changes in parent-reported depression and psychological distress following family-problem–solving therapy delivered face-to-face with a therapist, online with a therapist, or online without therapist involvement. Consistent with our hypotheses, the therapist-guided online group had significant reductions in both family/parental depression and distress over time. Analyses of slopes of recovery revealed differential improvement between the 2 online groups, with no significant change in depressive symptoms following self-guided F-PST. These findings suggest that therapist involvement may be important in addressing parental depressive symptoms following childhood TBI. Also consistent with hypotheses, differences between therapist-guided online and self-guided online groups at the 9-month follow-up were more pronounced in families of lower socioeconomic status. A somewhat different pattern of group differences was evident for psychological distress on the BSI, with all 3 groups reporting significantly lower levels of symptoms at the 9-month follow-up with no evidence of significant moderation. Taken together, these findings provide further support for the utility of therapist-guided online F-PST following pediatric TBI and offer relatively limited evidence of the efficacy of self-guided online treatment for family/parental outcomes.
The current findings regarding the relative merits of therapist-guided online F-PST are consistent with prior research.13,15,16 However, findings from this project regarding improvements in parent-reported child outcomes suggest a different pattern of comparative effectiveness. Specifically, for child behavior, quality of life, and TBI-related symptoms, parents in the self-guided online group reported the greatest reductions in symptoms, suggesting that effectiveness may vary as a function of the outcome of interest. Parents with significant depression may find it difficult to navigate and benefit from the content on their own without the support and additional structure afforded by therapist's involvement. This may be particularly true for parents of lower socioeconomic status who may have fewer resources that allow them to carve out the time to truly integrate and implement the strategies. For these families, the therapist may be instrumental in helping them systematically problem-solve and subsequently address barriers to implementing their solutions. Although the effects of face-to-face and therapist-guided online treatments did not significantly differ, the therapist-guided online treatment also offers potential benefits over traditional face-to-face treatment because it exposes families to skills via a multimedia Web site that can be digested at the family's own pace, in addition to offering sessions with the therapist who can review content and support the family in problem-solving implementation. Parents with less familiarity and comfort with technology may require therapeutic support to navigate and benefit from the online resources whereas technology-savvy adolescents may derive benefit without therapist involvement.
Attrition in the current study suggests, unsurprisingly, that the additional time and travel requirements of attending face-to-face treatment are associated with greater attrition. Time since injury was also associated with greater attrition, with families of adolescents with more recent injuries more likely to drop out. These findings are consistent with results from a recently published meta-analytic examination of prior randomized clinical trials of therapist-guided online F-PST that found that longer time since injury was associated with greater improvements in parent-reported child behavior problems than shorter time since injury.33 Participation in F-PST, even when delivered online, may prove challenging for families soon after injury, given the demands of medical follow-up and outpatient physical and speech therapies. Moreover, the adolescents themselves may have difficulty engaging in the problem-solving process due to fatigue and limited attention span. Taken together, these findings suggest that post–acute delivery may minimize attrition and increase benefit.
The current findings should be considered in the context of study limitations including a relatively small face-to-face arm that was disproportionately nonwhite. Although race was included as a covariate in all analyses, this difference in group composition may have biased results. As such, findings regarding the face-to-face arm should be interpreted with caution. Given the nature of the study, concealment of group assignment was not possible and participants who worked with therapists may have rated their symptoms more favorably over time due to social desirability biases. Diagnostic interviews or clinical ratings would provide additional information about parent functioning and could be considered in future studies. Finally, the relatively short follow-up period precludes examination of long-term maintenance of reductions in depression or psychological distress.
In conclusion, findings support hypotheses and previous research regarding the utility of therapist-guided online F-PST in reducing parental depression following pediatric TBI, particularly among families of lower socioeconomic status. The lack of support for self-guided F-PST suggests that therapist involvement may be important in helping parents and caregivers address depressive symptoms post-TBI.
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