A Systematic Review of Parenting Interventions for Traumatic Brain Injury

LWW/JHTR HTR200217 April 27, 2012 22:30

J Head Trauma RehabilVol. 00, No. 00, pp. 1–12

Copyright c© 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

A Systematic Review of ParentingInterventions for Traumatic BrainInjury: Child and Parent Outcomes

Felicity Louise Brown, BSc (Hons); Koa Whittingham, PhD; Roslyn Boyd, PhD;Kate Sofronoff, PhD

Objective: To evaluate the efficacy of parenting interventions on child and parent behavioral and emotionaloutcomes for parents of children with traumatic brain injury (TBI). Methods: Systematic searches of 5 databases.Included studies were assessed for quality, and relevant data were extracted and collated. Results: Eight articlesmet inclusion criteria, reporting 6 trials of interventions involving parent training for parents of children with TBI.Only 1 pre-post study trialed a version of a traditional parenting intervention. The remaining studies involved amulticomponent family problem-solving intervention. Each trial found a statistically significant intervention effectfor at least 1 outcome measure. Conclusions: Interventions that train parents may be a useful approach to alleviatebehavioral and emotional disturbances after pediatric TBI. Some evidence suggests that these interventions mayhelp to improve parenting skill and adjustment. However, all identified studies included interventions with multipletreatment components, so the effects attributable to parent training alone remain undetermined. Further qualitytrials are needed to assess the unique effectiveness of parenting interventions in this population. Key words: braininjury, intervention outcome, parenting, systematic review

TRAUMATIC BRAIN INJURY (TBI) is a leadingcause of acquired disability in the pediatric age

group.1,2 Numerous studies have identified persistentdisabilities after TBI in children and adolescents,including impairments in intellectual functioning,attention and hyperactivity, memory and learning, psy-chomotor skills, language, and executive functioning,as well as higher incidences of postinjury psychiatric,emotional, behavioral, academic, occupational, andsocial functioning difficulties.3,4 While improvementsin neuropsychological and motor deficits often occurover time, behavioral, emotional, academic, andadaptive functioning deficits are commonly viewed as

Author Affiliations: School of Psychology (Ms Brown, Drs Whittinghamand Sofronoff); Queensland Cerebral Palsy and Rehabilitation ResearchCentre, School of Medicine (Ms Brown and Drs Whittingham and Boyd);and The Queensland Children’s Medical Research Institute (Ms Brownand Drs Whittingham and Boyd), The University of Queensland,Brisbane, Australia.

Ms Brown received a Queensland Children’s Medical Research Institute PhDscience scholarship. Dr Whittingham received a National Health and MedicalResearch Council Training fellowship. Dr Boyd received a National Healthand Medical Research Council Career Development award.

The authors declare no conflict of interest.

Corresponding Author: Felicity Louise Brown, BSc (Hons), The Universityof Queensland, School of Psychology, Brisbane, Queensland, 4072, Australia([email protected]).

DOI: 10.1097/HTR.0b013e318245fed5

more enduring, and there is some evidence that theycan develop and worsen over time.4,5

Understandably, parents of children with TBI ex-perience high levels of caregiver and injury-relatedburden, as well as a high incidence of psychologi-cal symptoms.6–8 There is evidence of a reciprocalrelation between child behavior and parent adjust-ment, where the initial impact of the injury on childbehavioral outcomes may disrupt family adjustment,negatively influencing child outcomes through im-paired parenting effectiveness and a detrimental familyenvironment.6,9

Given the chronicity of deficits after TBI and the cu-mulative disability experienced, it is pertinent to identifyeffective intervention options in pediatric TBI that canimprove outcomes in this population. Several studieshave investigated clinician-, teacher-, or parent-deliveredrehabilitation programs for deficits such as cognitiveor social skills.10 A systematic review of the litera-ture indicated that behavioral intervention, includingcontingency management and positive behavior sup-ports, is considered an evidence-based treatment optionfor this population.11 However, the majority of stud-ies in the area are uncontrolled trials or case studieswith limitations identified in experimental methodol-ogy, objective outcome measurements, and treatmentdefinitions, thereby calling into question their widerapplicability.11–13

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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On the basis of knowledge of the literature andclinical experience, several authors recommend thatbehavioral rehabilitation actively involve the family.However, the majority of behavioral interventions re-viewed to date have involved the implementation of be-havior management techniques by therapists, teachers,or residential setting workers rather than parents.11–14

An empirical study has supported the importanceof parent involvement by demonstrating that family-delivered cognitive and physical rehabilitation programsappear more effective than standard clinician-deliveredprograms.15 Furthermore, observational studies haveshown that children’s cognitive and behavioral recov-ery after TBI is influenced significantly by the familyenvironment, including parenting characteristics andresponsiveness.16,17 It seems likely that interventionsthat optimize the family environment through alter-ing parenting practices will lead to improved child out-comes.

Parenting interventions teach parents to alter parent-ing practices and the family environment in order to in-fluence child development and behavior.18 On the basisof the theories of operant conditioning, social learningtheory, and coercion theory, parenting interventions en-courage parents to examine the antecedents of and con-sequences for children’s behaviors, and the potentialrole of social modeling.18,19 Through psychoeducation,therapist modeling of specific strategies, behavioral re-hearsal, practice, and feedback, these interventions aimto improve the skills, knowledge, and confidence ofparents; improve couple communication; and reduceparental stress to treat and prevent child behavioral andemotional difficulties.19

Specific evidence-based parenting interventions thathave been manualized and disseminated include theTriple P-Positive Parenting Program,19 Parent-Child In-teraction Therapy,20 the Incredible Years Program,21

and Parent Management Training Oregon.22 These pro-grams have been implemented in the general populationwhere parents may be concerned about their child’s be-havioral and emotional development, as well as in spe-cific clinical populations. Treatments are delivered viagroup, self-directed, or individual format, and lengthcan vary from a very brief intervention for a specificissue to a comprehensive intervention that considersadditional factors affecting the family such as parentalpsychopathology or the couple relationship.19

There is strong support for the efficacy of such parent-ing interventions in improving child outcomes in chil-dren developing typically, especially those with conductproblems.18,23,24 Parenting interventions have also beenimplemented successfully with parents of children withdisabilities, with trials showing effectiveness for parentsof children with mixed disabilities and autism spectrumdisorders.25,26 It is known that children with disabili-

ties are more likely to experience behavioral and emo-tional problems than their peers,27 so the knowledge ofefficacious treatments is particularly valuable in thesepopulations.

PURPOSE OF CURRENT REVIEW

Determining effective interventions for families withchildren with TBI is important to allow clinicians to ap-propriately address common child behavioral and emo-tional problems and related and reciprocal parent ad-justment difficulties. Given the vital role that the familyplays in recovery from TBI,16,17 and the established ef-fectiveness of parent training in the general population,as well as in families of children with disabilities,23,25

this review seeks to determine the evidence supportingthe use of parenting interventions in the pediatric TBIpopulation. The primary aim was to evaluate the effi-cacy of parent training in enhancing child behavior andemotional outcomes. The secondary aim was to evaluatethe efficacy of parent training with respect to parentalskills, confidence, and adjustment.

METHODS

Search strategy

A systematic literature search was conducted onthe following databases: CINAHL (1982-April 2011),EMBASE (1947-April 2011), MEDLINE (1950-April2011), PsycINFO (1840-April 2011), PubMed (1951-April 2011), and Web of Science (1900-April 2011).The searches used exploded Medical Subject Headings(MeSH) terms, where relevant, and the following keywords:

1. Traumatic brain injur∗ or TBI or Brain Injur∗ orHead Injur∗ and

2. Paediatric or pediatric or child or children oryouth∗, and

3. Parent∗ training or parent∗ program or parent∗

intervention or parent∗ support or parent∗ psy-choeducation or parent∗ effectiveness training orbehavior∗ family intervention or behaviour∗ familyintervention or family therapy or family interven-tion or family support or family life education orfunctional communication training or behaviour∗

analysis or behavior∗ analysis or functional analysisor parent∗ programme or family program or fam-ily programme or behaviour∗ therapy or behavior∗

therapy or functional assessment or behaviour∗

support or behavior∗ support or behaviour∗ man-agement or behavior∗ management or parent∗ ed-ucation, and

4. Behaviour∗ or behavior∗ or stress or parent∗ styleor parent∗ skill or parent∗ behavior or parent∗



A Systematic Review of Parenting Interventions for TBI 3

behaviour or parent∗ attitude or anxiety or de-pression or child behaviour or child behavioror parenting or emotion∗ or suffering or depres-sive symptom∗ or anxiety symptom∗ or depres-sive disorder∗ or anxiety disorder∗ or behavioralsymptom∗ or behavioural symptom∗.

Searches were limited to English language articles andthose using human subjects. Results were initially re-stricted to randomized controlled trials (RCTs); how-ever, this yielded insufficient studies, so the criterionwas broadened to include quasi-RCTs, controlled trials,and pre-to-post designs. Single case studies or case serieswere excluded.

Inclusion criteria

Studies were included in this systematic review if theymet the following criteria.

1. The participants were parents of children (up to 18years old) with TBI.

2. The intervention was a parenting intervention.This could include any program (group or indi-vidual) that taught parenting skills such as im-proving parenting style or managing child behav-ior and/or emotions. Studies were not excludedif the intervention included other components oftreatment or if it involved the child’s participationas well.

3. The study measured child behavioral or emo-tional outcome and/or the study assessed parent-ing style or skill and/or parental coping and ad-justment, and the tools of assessment were ei-ther direct observation of frequency of behav-ior or standardized parent- or child-report mea-sures. Studies that assessed only the child’s attain-ment of a skill or cognitive outcomes were notincluded.

Consequently, studies were excluded if they:1. included adults with TBI or children with other

forms of brain injury such as tumor or stroke,2. involved interventions that targeted only parents’

own psychological well-being, employed thera-pists working only with the children, or providedonly TBI education (ie, did not involve parenttraining).

3. did not provide adequate measures of child or par-ent behavioral or emotional outcome or measuredspecific child skill attainment rather than changesin behavior.

The full search yield was initially reviewed for inclu-sion by 2 independent reviewers (FB and KW) on the ba-sis of title and abstract. Both reviewers then assessed thefull text of the remaining articles to ensure adherence tothe inclusion criteria, and discrepancies were resolved bydiscussion.

Methodological quality assessment

Methodological quality of the included studies wasassessed by 2 independent reviewers (FB and KW) us-ing the PEDro (Physiotherapy Evidence Database) scalefor RCTs and a version of the STROBE (Strengtheningthe Reporting of Observational Studies in Epidemiol-ogy) statement for pre-post designs, which was adaptedspecifically for this review to reflect important reportingcriteria for studies in this area. Discrepancies were solvedthrough discussion.

Data extraction

Data extracted from each study included study design,participant characteristics, and intervention characteris-tics. The first author extracted data on relevant outcomemeasures, with queries clarified with the second author.Where results were provided for a global scale of a stan-dardized measure, as well as for individual subscales, allscores were collected to retain the maximum amount ofinformation.

Data synthesis

Quantitative analysis was conducted on the relevantoutcome data from each study to determine a mea-sure of intervention effect size. For RCTs, the standard-ized mean difference was calculated with postinterven-tion scores for treatment and control groups by usingHedges’ g, as illustrated in Equation 1. For pre-post stud-ies, a measure of relative change between baseline andfollow-up scores, was calculated using a version of Co-hen’s d,28 as illustrated in Equation 2. Where decreasesin the scores of a measure reflected improvement, effectmeasures were multiplied by −1 to ensure consistencyin direction of effect sizes. Effect sizes were classified assmall (0.2), medium (0.5), and large (0.8) according toguidelines suggested by Cohen.28

MpostT − MpostC√[SDpostT

2(nT −1)+SDpostC2(nC−1)]/(nT +nC−2)

[1]SDpreT − MpostT

MpreT[2]

It was our intention to conduct a meta-analysis on thecollated outcome data. However, this was not done be-cause of the following reasons: (i) the majority of studieswere pre-post designs and therefore their inclusion in ameta-analysis would be questionable because of the po-tential for bias29; (ii) there was substantial variation inthe outcomes assessed and the measures used; (iii) therewas heterogeneity in the study participants, with some


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Figure. Flow diagram of search strategy of systematic review.TBI, traumatic brain injury.

studies including only adolescents or only younger chil-dren; and (iv) all of the identified studies included mul-ticomponent interventions and hence a meta-analysiswould not directly answer our research question aboutthe effects of parenting interventions.

RESULTS

Descriptions of studies

The search strategy yielded 522 unique references(Figure). Of these articles, 473 were excluded on ex-amination of the title and abstract as clearly not meet-ing inclusion criteria. The remaining 49 articles wereaccessed for detailed review, of which 8 met inclusioncriteria. Four articles detailed 3 RCTs,30–33 and 4 articlesdescribed 3 pre-post studies.34–37

Participant characteristics

As shown in Table 1, all participants were parentsof children with moderate to severe TBI, and samplesizes ranged from 5 to 40 families. The age range ofthe children varied across studies, with 1 study focusingspecifically on younger children34 and 2 focusing specif-ically on adolescents.30,36 Time since injury also variedacross studies; the majority required that the injury hadoccurred within the last 18 to 24 months; however, 1pre-post study required that the injury had occurred15 months or more prior to intervention.35,37 For eachof the RCTs, participants in the treatment and controlgroups did not differ on demographic or injury charac-teristics.

Types of intervention

Two broad categories of intervention were iden-tified: online parenting intervention and problemsolving interventions (see Table 1). All interven-tions included a component of training parents inbehavior management (ie, a component of parentingintervention), although in the problem solving interven-tions, this was not the primary focus. All interventionswere conducted by clinical psychologists or graduatestudents in clinical psychology.

In a pre-post design, Wade et al34 trialed an onlineprogram, “Internet-based INteracting Together Every-day, Recovery After Childhood Traumatic Brain Injury”(I-INTERACT), which was based on parent-child in-teraction therapy (PCIT) and involved comprehensiveparent training, including psychoeducation, live obser-vation, and feedback over Web-based video links. The

TABLE 1 Participant characteristics and study designs of included studiesa

Mean (SD)

Study Design Child age, yLowest

GCS scoreMonths

postinjuryTreatmentmodality n Control n

Wade et al, 200632,33 RCT 11.00 (3.27) 11.40 (4.52) 13.65 (7.15) Online FPS 20 Internetresources

20

Wade, Michaud,et al, 200631

RCT 10.83 (2.94) 10.97 (4.63) 8.73 (4.34) FPS 16 Usual care 16

Wade et al, 201030 RCT 14.26 (2.29) 9.98 (4.62) 9.54 (4.97) TOPS 16 Internetresources

19

Wade et al, 200535,37 Pre-post 10.5 (3.62)b NR- 2 mod 18.67 (4.93)b Online FPS 6 Nil . . .Wade et al, 200836 Pre-post 15.04 (11.8-18.2)c 10.89 (4.01) 9.33 (2-20)c TOPS 9 Nil . . .Wade et al, 200934 Pre-post 6.5 (4.7-8.3)c NR-9 mod 12.9 (2-21)c I-INTERACT 5 Nil . . .

Abbreviations: FPS, family problem solving; GCS, Glasgow Coma Scale; I-INTERACT, Internet-based INteracting Together Everyday,Recovery After Childhood Traumatic Brain Injury; mod, moderate traumatic brain injury; NR, not reported; RCT, randomized controlledtrial; TOPS, teen online problem solving.aSample sizes given are numbers of families included in analyses.bAs reported in Wade, Brown et al, 2005, Wade, Wolfe et al, 2005, reported slightly different figures.cMean (range), SD not reported.




TABLE 2 Methodological quality assessment of included randomized controlled trialsusing the PEDro scalea

Items

Study 1 2 3 4 5 6 7 8 9 10 11 Total

Wade et al, 200632,33 1 1 0 1 0 0 0 0b 0 1 1 5Wade et al, 200631 1 1 0 1 0 0 0 1 0 1 1 6Wade et al, 201030 1 1 0 1 0 0 0 1 0 1 1 6

aScale of item score: 0 = absent/unclear, 1 = present. The PEDro scale criteria are as follows: (1) specification of eligibility criteria; (2)random allocation; (3) concealed allocation; (4) prognostic similarity at baseline; (5) subject blinding; (6) therapist blinding; (7) assessorblinding; (8) greater than 85% follow-up of at least 1 key outcome; (9) intention-to-treat analysis; (10) between-group statisticalcomparison for at least 1 key outcome; and (11) point estimates and measures of variability provided for at least 1 key outcome.bStudy had outcome data for 84.7% of participants.

intervention consisted of up to 13 videoconferences,held fortnightly, and also included self-guided Web ses-sions with family problem solving (FPS) componentsand modules on stress and anger management.

The remaining studies investigated variants of an FPSintervention trialed in face-to-face format31 and onlineformat32,33,35,37 for families of children with TBI. Twoother studies trialed a similar intervention, teen onlineproblem solving (TOPS), for families of adolescents withTBI.30,36 Each of these interventions involved the en-tire family; core sessions focused primarily on problem-solving skills, but they also included a psychoeducationcomponent and behavior management strategies. Up to4 supplemental sessions were offered to families cov-ering various issues relevant to them (eg, stress man-agement and marital communication) and hence theinterventions were quite broadly focused. The face-to-face version consisted of up to 11 sessions, and onlineversions offered between 12 and 14 self-guided Web-based sessions combined with synchronous fortnightlyvideoconferencing with a therapist.

Outcomes investigated

All studies used standardized parent-reported mea-sures of aspects of child behavior. A range of mea-sures, including global measures of behavior as wellas more specific aspects of cognition and behavioraland emotional adjustment (eg, depression, executivefunctioning, and antisocial behavior), was used acrossstudies. Some studies included child-reported measuresof depression35–37 and executive functioning,30 Onestudy30 reported results separately for children with se-vere versus moderate injuries. However, to present re-sults concisely in this review, pooled means and pooledstandard deviations were calculated.

Several studies also investigated the effects of theintervention on parent adjustment by using standard-ized measures.31,32,35,36 One study34 objectively mea-

sured parenting skill through blinded observers ratingthe number of positive and negative parenting behav-iors during a parent-child interaction. Although somestudies reported additional variables such as parent-child interaction, problem-solving skill, and familyadjustment,31–33,35–37 these were considered beyond thescope of this review and therefore are not reported.

Qualitative assessment

Three RCTs30–33 scored 5 to 6 points on the PEDroscale (Table 2). No studies used masking to group allo-cation and hence several points were lost for each studybecause of the increased risk of bias. It must be notedthat blinding is often difficult in psychological interven-tions for practical and ethical reasons. Another sourceof potential bias in each study was the lack of adequateintention-to-treat analyses; no study included data for allrandomized participants in analyses. In addition, studiesdid not clearly describe the randomization procedure,so it was not clear whether allocation concealment wasused.

The 3 prospective pre-post studies34–37 scored be-tween 16.6 and 21.8 of a possible 32 on the STROBEscoring system (Table 3). Common reasons for loss ofpoints were lack of power analysis to determine samplesize, lack of independent raters of outcome, and failureto report certain details from the study.

Study findings

Data for child behavioral and emotional outcomesand parent adjustment and skill outcomes are tabulatedin Table 4 for RCTs and Table 5 for pre-post studies.The effect sizes shown in the tables are those calculatedspecifically for this review.

Child behavioral and emotional outcomes

Evidence for I-INTERACT was limited to a sin-gle small (N = 5) pre-post study that showed mixed





TABLE 3 Methodological quality assessment of included pre-post studies using theSTROBE

Study

Section CriterionWade et al,

200535,37Wade et al,

200836Wade et al,

200934

Title, abstract,introduction

1a. Indicate a study’s design with a commonlyused term in the title or the abstract

0 0 0

b. Provide in the abstract an informative andbalanced summary of what was done andwhat was found

1 1 1

Background 2. Explain the scientific background and rationalefor the investigation being reported

1 1 1

Methods 3. State specific objectives, including anyprespecified hypotheses

1 1 1

Study design 4. Present key elements of study design early inthe article

0 0 0

Setting 5. Describe the setting, locations, and relevantdates:0.2 points awarded to each component to total

maximum score of 1a. Setting of sessions 0.2 0.2 0.2b. Setting of assessments 0 0 0.2c. Dates of recruitment 0 0 0d. Location of recruitment 0.2 0.2 0.2e. Specified when follow-up data collected 0.2 0 0.2

Participants 6. Give the eligibility criteria, and the sources andmethods of selection of participants

1 1 1

Variables 7. Clearly define all outcomes, exposures,predictors, potential confounders, and effectmodifiers:a. Outcomesb. Exposures 1 1 10.33 points awarded to each component to

total maximum score of 1:i. Number sessions 0.33 0.33 0.33ii. Length sessions 0.33 0 0.33iii. Frequency sessions 0.33 0.33 0.33

c. Effect modifiers, predictors, confounders0.50 points awarded to each component to

total maximum score of 1:i. Acknowledgement of brain injury severity 0.5 0.5 0.5ii. Acknowledgement of concurrent

treatments0.5 0 0.5

8. For each variable give sources of data andassessment methods

1 1 1

Bias 9. Describe any efforts to address potentialsources of bias:0.5 points awarded to each component to total

maximum score of 1a. Independent raters 0 0 0.5b. Selection bias 0 0.5 0.5

Study size 10. Explain how the study size was arrived at 0 0 0Quantitativevariables

11. Explain how quantitative variables werehandled in the analyses

1 1 1

Statisticalmethods

12a. Describe all statistical methods, includingthose used for confounding

0 1 1

b. Describe any methods used to examinesubgroups and interactions

NA 1 0

c. Explain how missing data were addressed 0 0 0d. If applicable, explain how loss to follow up

was addressedNA NA 1

e. Describe any sensitivity analyses NA NA NA(continues)




TABLE 3 Methodological quality assessment of included pre-post studies using theSTROBE (Continued)

Study

Section CriterionWade et al,

200535,37Wade et al,

200836Wade et al,

200934

Results 13a. Report number of individuals at each stage ofstudy

0 0 0

Participants b. Give reasons for nonparticipation at eachstage

0 1 1

c. Use of a flow diagram 0 0 0Descriptivedata

14a. Give characteristics of study participants:Awarded 0.20 per component to total

maximum score of 1i. Age 0.2 0.2 0.2ii. Sex 0.2 0.2 0.2iii. Injury severity 0.2 0.2 0.2iv. Time since injury 0.2 0.2 0.2v. Preexisting behavioral or learning

difficulties0.2 0.2 0.2

b. Indicate the number of participants withmissing data for each variable of interest

0 0 0

c. Cohort study—summarize follow-up time (eg,average and total amount)

0 0 0

Outcome data 15. Outcomes and exposures:0.5 points awarded to each component to totalmaximum score of 1

a. Report number of participants analyzed 0.5 0.5 0.5b. Report summary measures of treatment dose 0.5 0.5 0.5

Main results 16a. Give unadjusted estimates and their precision 1 1 1b. Report category boundaries when continuous

variables were categorizedNA NA NA

c. If relevant, consider translating estimates ofrelative risk into absolute risk for a meaningfultime period

NA NA NA

Other analyses 17. Report other analyses done 0 1 1Discussion 18. Summarize key results with reference to study

objectives1 1 1

Limitations 19. 0.5 points awarded to each component to totalmaximum score of 1:

a. Discuss limitations of the study taking intoaccount sources of potential bias orimprecision

0.5 0.5 0.5

b. Discuss both direction and magnitude ofpotential bias

0.5 0.5 0.5

Interpretation 20. Give a cautious overall interpretation of resultsconsidering objectives, limitations, multiplicityof analyses, results from similar studies andother relevant evidence

1 1 1

Generalizability 21. Discuss the generalizability of the study results 1 1 0Otherinformation

22. Give the source of funding 0 1 1

Abbreviation: NA, not applicable.

results.34 No statistically significant differences werefound for number or intensity of child problem behav-iors pre- to postintervention; however, a trend towardimprovement in number of child problem behaviors wasfound, with large effect size.

Similarly, evaluation of FPS also showed mixed re-sults. In investigating the face-to-face version of thisintervention in an RCT, Wade et al31 found signifi-cant treatment group effects for child internalizing be-haviors in general and also specifically for anxious and





TABLE 4 Results of randomized controlled trials reporting on child and parent adjust-ment following parenting interventions

Treatment Control

Study Outcome measure n Mean (SD) n Mean (SD) ESa

Child outcomeWade et al, 201030 Behavior regulation: BRIEF(C) 16 47.25 (11.16) 19 49.95 (13.26) 0.22

Metacognitive: BRIEF(C)b 16 48.19 (11.55) 19 53.05 (13.42) 0.39Global EF: BRIEF(C)b 16 47.44 (11.64) 19 63.29 (14.13) 1.21Behavior regulation: BRIEF (P) 16 52.24 (9.18) 19 55.16 (12.50) 0.26Metacognitive: BRIEF(P) 16 54.00 (10.77) 19 58.10 (13.75) 0.33Global EF: BRIEF (P) 16 53.56 (10.58) 19 62.43 (14.03) 0.70

Wade et al, 200631 Behavior problem: CBCL 16 53.40 (8.71) 16 51.44 (14.41) − 0.16Internalizing: CBCLc 16 51.00 (8.74) 16 50.94 (13.53) − 0.01Externalizing: CBCL 16 51.60 (10.06) 16 50.19 (14.41) − 0.11Anxiety and depression: CBCLc 16 52.20 (3.99) 16 55.25 (12.22) 0.34Withdrawn: CBCLc 16 54.13 (6.02) 16 54.75 (9.87) 0.08Attention difficulties: CBCL 16 57.20 (5.06) 16 56.31 (9.59) − 0.11

Wade et al, 200633 Behavior problem: CBCL 19 47.78 (11.43) 20 56.06 (11.82) 0.71Internalizing: CBCL 19 47.39 (10.30) 20 56.72 (12.42) 0.82Externalizing: CBCL 19 48.17 (10.68) 20 52.00 (11.02) 0.35Social skill: HCSBS 19 53.15 (9.89) 20 45.50 (11.50) 0.71Compliance: HCSBSc 19 52.35 (10.48) 20 45.50 (11.37) 0.63Peer relations: HCSBS 19 53.55 (9.07) 20 46.50 (10.31) 0.72

Parent outcomeWade et al, 200631 Global symptoms: BSI 16 53.13 (12.03) 16 55.13 (14.09) 0.15

Depression: BSI 16 52.62 (10.24) 16 56.19 (12.59) 0.31Anxiety: BSI 16 50.38 (11.44) 16 53.14 (14.09) 0.22

Wade et al, 200632 Global symptoms: SCLc 20 52.33 (10.69) 20 58.37 (11.49) 0.54Depression: CES-Dc 20 9.25 (7.09) 20 18.15 (13.49) 0.83Anxiety: AIc 20 9.25 (4.99) 20 14.05 (7.50) 0.75

Abbreviations: AI, Anxiety Inventory; BRIEF(C), Behavior Rating Inventory of Executive Function—child report; BRIEF(P), BehaviorRating Inventory of Executive Function—parent report; BSI, Brief Symptom Inventory; CBCL, child behavior checklist; CES-D, Centerfor Epidemiologic Studies Depression Scale; ES, effect size; EF, executive functioning; HCSBS, Home and Community Social BehaviorScales; SCL, Symptom Checklist-90, Revised.aEffect sizes calculated specifically for this review.bP < .05, ANCOVA on postintervention scores for severe traumatic brain injury only.cP < .05, ANCOVA on postintervention scores.

depressive symptoms and withdrawn behavior. How-ever, the calculated effect sizes for these measures weresmall. Furthermore, no differences were seen in exter-nalizing child behaviors. When tested through a smallpre-post design,37 the online version resulted in signif-icant improvements from pre- to postintervention onchild antisocial behavior, with a large effect size. Nosignificant differences in child executive functioning,social functioning, or depressive symptoms were seen.The RCT of the same intervention found a significanttreatment effect for child self-management and compli-ance, with a moderate effect size.33 However, changes inother measures of child behavioral and emotional out-comes were not significant. These authors also foundthat demographic variables moderated treatment effectssuch that children of lower socioeconomic status andolder age who received the intervention showed greaterimprovements on measures of outcomes.

The pre-post study investigating TOPS demonstratedsignificant improvements in internalizing symptomsgenerally, and also improvements specifically in depres-sive symptoms, with moderate effect sizes.36 Changes onmeasures of adolescent externalizing behaviors and ex-ecutive functioning did not reach significance. The RCTof the same intervention30 found that adolescents withsevere TBI reported significantly greater improvementsthan the comparison group on a measure of global exec-utive functioning, as well as the more specific metacog-nitive skills index. No treatment group effects were seenfor adolescents with moderate TBI or for parent-reportedoutcomes. The effect sizes calculated for this review, us-ing pooled means and standard deviations across sever-ity levels, were large for the global measure but small formetacognitive skills.

It must be noted here that it is not possible to de-termine the specific impact of parent training (ie, the




TABLE 5 Results of pre-post studies reporting on child and parent adjustment followingparenting interventions

Pre PostStudy Outcome measure n Mean (SD) Mean (SD) ESa

Child outcomeWade et al, 200537 Global EF: BRIEF 6 62.17 (11.70) 54.83 (3.31) 0.63

Social: HCSBC 6 43.83 (9.35) 48.33 (7.76) 0.48Antisocial behavior: HCSBCb 6 51.67 (7.50) 45.50 (6.74) 0.82Depression: CDI 6 4.40 (4.16) 5.20 (5.36) − 0.19

Wade et al, 200836 Behavior problem: CBCL 9 54.22 (9.78) 50.11 (10.78) 0.42Internalizing: CBCLc 9 57.00 (9.68) 50.22 (13.41) 0.70Externalizing: CBCL 9 51.56 (9.98) 49.67 (10.20) 0.19Global EF: BRIEF 9 61.56 (9.32) 56.78 (10.84) 0.51Depression: CDIc 9 1.56 (1.51) 0.67 (0.71) 0.59

Wade et al, 200934 No. behaviors: ECBI 5 65.20 (7.80) 55.80 (8.90) 1.21Behavior intensity: ECBI 5 60.50 (10.17) 56.92 (5.14) 0.35

Parent outcomeWade et al, 200535 Stress: PSIb 8 102.38 (22.88) 84.75 (27.02) 0.77

Burden of injury: FBIId 8 51.25 (25.04) 16.25 (8.17) 1.40Global symptoms: SCLb 8 63.63 (8.97) 57.00 (12.97) 0.74Depression: CES-Db 8 22.75 (10.98) 16.38 (11.16) 0.58Anxiety: AI 8 14.38 (7.09) 11.88 (7.40) 0.35

Wade et al, 200836 Global symptoms: SCL 12 53.00 (12.66) 50.83 (10.51) 0.17Depression: CES-Dc 12 13.17 (9.11) 6.92 (6.36) 0.69

Wade et al, 200934 Positive behavior: Obsb 6 3.09 (2.51) 17.29 (10.11) 5.66Negative behavior: Obsd 6 31.64 (10.58) 6.29 (5.31) 2.40

Abbreviations: AI, Anxiety Inventory; BRIEF, Behavior Rating Inventory of Executive Function; CDI, Child Depression Inventory; CES-D,Center for Epidemiologic Studies Depression Scale; ECBI, Eyberg Child Behavior Inventory; ES, effect size; FBII, Family Burden ofInjury Inventory; HCSBS, Home and Community Social Behavior Scales; Obs, observation via live Web camera; PSI, Parenting StressIndex; SCL, Symptom Checklist-90, Revised.aEffect sizes are those calculated specifically for this review.bP < .05, 2-tailed, for paired t test pre- to postintervention.cP < .05, 1-tailed, for paired t test pre- to postintervention.dP < .01, 2-tailed, for paired t test pre- to postintervention.

behavioral management component of the intervention)on outcomes, as the interventions were comprehensiveand multidimensional in nature.

Parenting skill and parent adjustment

The pre-post study investigating I-INTERACT34

demonstrated significant increases in positive parentingbehaviors (eg, giving praise) and decreases in negativeparenting behaviors (eg, asking questions during child-directed interactions), and the corresponding effect sizeswere large.

Wade et al31 found no significant group differencesfor reductions in parent depression, anxiety, or generalsymptoms after the face-to-face FPS intervention, andeffect sizes were small. This may have been due to base-line means generally falling in the nonclinical range;hence, there may have been a floor effect. These authorsalso found that time since injury was positively corre-

lated with reductions in parental stress in the treatmentgroup.

Conversely, the online FPS intervention studies in-volving families of children with TBI demonstrated pos-itive results in terms of parent outcomes. The pre-poststudy35 found significant improvements on burden ofinjury, parenting stress, depression, and general symp-toms, with moderate to large effect sizes. The RCT32

also showed significant group effects for measures ofdepression, anxiety, and general symptoms, again withmoderate to large effects. These authors found that fewerparents in the treatment group reported clinically signif-icant symptoms at follow-up than parents in the controlgroup; however, χ2 analyses did not reach significanceat P < .05.

Parent outcomes were not assessed in the RCT of theTOPS intervention30; however, the pre-post study36 in-dicated significant improvements in parental depressivesymptoms, with a moderate effect size. No differencewas seen on overall symptoms.





Again, it must be noted that the specific effect ofparent training on parent adjustment cannot be deter-mined from these studies, as all interventions involvedadditional components and were broad in scope.

Parent satisfaction with programs

Four studies reported parent satisfaction measures forthe programs. All parents in the I-INTERACT pro-gram reported that the training in behavior manage-ment strategies was helpful.34 Satisfaction with the face-to-face FPS program was also high, and most parentsreported that they understood their child’s injury bet-ter and knew strategies to help their child.31 Similarly,satisfaction with the online FPS intervention was high,with the behavior management strategies generally ratedas very helpful.32,35,37

DISCUSSION

Given the increased risk of child behavioral and emo-tional difficulties, as well as parent adjustment problemsafter pediatric TBI, and evidence of a reciprocal relationbetween these difficulties,9 knowledge of effective fam-ily interventions in this population is vital. Althoughthere is strong empirical support for the value of par-enting interventions for child behavioral problems inchildren developing typically and children with disabili-ties in general,23,25 this systematic review of the literatureyielded only a small number of studies that evaluatedparent training for parents of children with TBI. In ad-dition, all included studies had the same first author,indicating that this is currently a sparse field of research.

Each of the 3 identified RCTs of problem solving in-terventions demonstrated efficacy in improving aspectsof child or adolescent outcomes.30,31,33 Similarly, eachof the pre-post studies reported significant improve-ments in child or adolescent behavior or emotions afterintervention.34,36,37 In terms of our second outcomeof interest, parent adjustment, 1 RCT32 and 2 pre-poststudies35,36 found significant improvements in at least1 aspect of parent coping. One RCT31 did not reportsignificant improvements, likely due to a floor effect atbaseline.

It should be noted that only one of the interventionsevaluated in these studies could be considered a compre-hensive parenting intervention that primarily focusedon parenting skills—the I-INTERACT program based onPCIT.34 The remaining studies tested multifaceted fam-ily interventions, with parent skills training forming arelatively small component of the program.

The I-INTERACT program showed promising resultsin a very small sample of families, with clinically impor-tant increases in the use of positive parenting behaviors,decreases in the use of negative parenting behaviors, anddecreases in the number of problem child behaviors

(although not all statistically significant).34 However,like other interventions, this program also involved ad-ditional components such as problem solving and stressmanagement and therefore the specific effect of par-enting interventions on child and parent outcomes re-mains unknown. Through satisfaction ratings relatingto the behavior management strategies, these studies dosuggest that parenting intervention components may beuseful, but this is yet to be explicitly tested.

A major strength of the identified literature is thepresence of RCTs and multiple-subject prospective stud-ies. Reviews of the TBI literature consistently iden-tify limited numbers of controlled trials,11,12,38,39 pre-sumably due to recruitment challenges inherent in thispopulation,40 and these studies are therefore an impor-tant contribution to this field of research. An additionalstrength of the studies reviewed is the exploration ofthe Internet as an avenue for treatment. This greatly in-creases accessibility for families living outside of majormetropolitan areas and may reduce barriers to atten-dance at a clinical setting. The positive results, and gen-erally high consumer satisfaction when reported, suggestthat online delivery may be an acceptable and effectivemeans of treatment.

Moreover, each of the RCTs investigated variablesthat may affect treatment response, such as the child’sage, time since injury, socioeconomic status, or injuryseverity.30–33 This is an important line of enquiry forfuture studies to elaborate on to effectively target treat-ment toward subgroups of the population and deter-mine intervention timing.

There are several limitations of the existing studiesthat should be addressed in future research. First, a lackof follow-up data beyond the immediate postinterven-tion phase precludes knowledge of maintenance of gainsbeyond the intervention period. Particularly, as the in-terventions are quite intensive, it would be useful to de-termine whether treatment gains can be sustained oncetreatment concludes, and, also, whether less intensivetreatment leads to similar outcomes. Consideration ofclinically relevant change, beyond statistically signifi-cant group differences, will also be important.

Methodologically, future research should focus onreducing potential bias to increase reliability of results.All studies reviewed here used only parent- or child-reported outcomes for child and parent adjustment, withonly 1 study using independent observation for parent-ing skill assessment.34 Objective measures of outcomewould avoid potential social desirability or placebo ef-fects, strengthening the results. No studies in this reviewused an adequate intention-to treat-analysis, which leadsto the possibility that only the most motivated familiesremained in the treatment, increasing the chances ofpositive results. As all studies included in this reviewwere conducted in the United States, it will be useful




for future reviews to consider articles in languages otherthan English to determine the generalizability of find-ings to other countries and cultures.

Although this review has identified that studiesinvolving teaching parents behavior management tech-niques appear to positively affect parent and childoutcomes in the pediatric TBI population, these inter-ventions were composed of multiple components andtherefore it is not clear exactly which component(s)is(are) the catalyst(s) for change. As in other areas ofclinical psychology,41 it will be important for futureresearch to identify the necessary and sufficient com-ponents of family interventions within this populationto improve theoretical understanding of the mecha-nisms of change and to ensure that evidence-based andcost-effective treatments are delivered. Furthermore, itwill be important to determine the efficacy of existingmainstream parenting interventions (such as Triple P,19

PCIT,20 the Incredible Years Program,21 or Parent Man-

agement Training Oregon22) in this population, as theseare more likely to be widely disseminated and accessiblein clinical practice, thereby potentially reaching a greaterportion of parents.42

CONCLUSIONS

Given the important role parents play in childoutcome,9,16,17 and the effectiveness of parent-implemented rehabilitation programs for other skills,15

parenting interventions may be a powerful tool for re-ducing child behavioral and emotional problems afterTBI and improving long-term outcomes for child andfamily. This systematic review has identified a limitednumber of studies in this area. While our results suggestthe potential usefulness and feasibility of such programsin this population, further studies involving high-qualityrandomized trials that isolate the unique effects of par-enting interventions are required to specifically validatetheir use in this population.

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A Systematic Review of Parenting Interventions for Traumatic Brain Injury

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