Felicity L. Brown

Improving child and parenting outcomes following paediatric acquired brain injury: A randomised controlled trial of Stepping Stones Triple P plus Acceptance and Commitment Therapy

BACKGROUND Persistent behavioural difficulties are common following paediatric acquired brain injury (ABI). Parents and families also experience heightened stress, psychological symptoms and burden, and there is evidence of a reciprocal relationship between parent and child functioning, which may be mediated by the adoption of maladaptive parenting practices. Despite this, there is currently a paucity of research in family interventions in this population. The aim of this study was to determine the efficacy of Stepping Stones Triple P: Positive Parenting Program (SSTP), with an Acceptance and Commitment Therapy (ACT) workshop, in improving child outcomes and parenting practices following paediatric ABI. METHODS Fifty-nine parents of children (mean age 7 years, SD 3 years, 1 month; 35 males, 24 females) with ABI (Traumatic injuries 58%, Tumour 17%, Encephalitis or meningitis 15%, Cardiovascular accident 7%, Hypoxia 3%) who were evidencing at least mild behaviour problems were randomly assigned to treatment or care-as-usual conditions over 10 weeks. Mixed-model repeated-measures linear regression analyses were conducted to compare conditions from pre- to postintervention on child behavioural and emotional functioning (Eyberg Child Behavior Inventory, Strengths and Difficulties Questionnaire) and dysfunctional parenting style (Parenting Scale). Assessment of maintenance of change was conducted at a 6-month follow-up. The trial was registered on Australian New Zealand Clinical Trials Registry (ID: ACTRN12610001051033, www.anzctr.org.au). RESULTS Significant time-by-condition interactions were identified on number and intensity of child behaviour problems, child emotional symptoms and parenting laxness and overreactivity, indicating significant improvements in the treatment condition, with medium-to-large effect sizes. Most improvements were maintained at 6 months. CONCLUSIONS Group parenting interventions incorporating Triple P and ACT may be efficacious in improving child and parenting outcomes following paediatric ABI.

Parenting a child with a traumatic brain injury: Experiences of parents and health professionals

Abstract Objective: To qualitatively explore the experiences, challenges and needs of parents of children with traumatic brain injury (TBI) in order to inform future intervention research through incorporation of participant knowledge and experience. Methods: Parents of children with TBI (n = 10) and experienced health professionals in paediatric rehabilitation (n = 5) took part in focus groups or individual interviews. Audio recordings were transcribed verbatim and an inductive thematic analysis performed. Findings: Participants reported that, beyond the impact of the injury on the child, TBI affects the entire family. Parents need to adjust to and manage their child’s difficulties and can also experience significant emotional distress, relationship discord and burden of care, further adding to the challenges of the parenting role. Parents can feel isolated and the importance of empowerment, support and information was emphasized. Coping styles of disengagement and avoidance were often reported, despite acknowledgement that these were not beneficial. Conclusions: Parenting interventions may provide essential support for parents in adjusting to and managing their child’s difficulties and the efficacy of existing programmes needs evaluation. Addressing parent emotional adjustment and coping strategies is vital following paediatric TBI, given the impact on parent well-being and the potential negative effects on child outcomes through reduced parenting effectiveness. Group programmes may enable connection and support.

A systematic review of parenting interventions for traumatic brain injury: Child and parent outcomes

Objective:To evaluate the efficacy of parenting interventions on child and parent behavioral and emotional outcomes 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 articles met 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 a multicomponent family problem-solving intervention. Each trial found a statistically significant intervention effect for at least 1 outcome measure. Conclusions:Interventions that train parents may be a useful approach to alleviate behavioral and emotional disturbances after pediatric TBI. Some evidence suggests that these interventions may help to improve parenting skill and adjustment. However, all identified studies included interventions with multiple treatment components, so the effects attributable to parent training alone remain undetermined. Further quality trials are needed to assess the unique effectiveness of parenting interventions in this population.

Punishing an error improves learning: the influence of punishment magnitude on error-related neural activity and subsequent learning

Punishing an error to shape subsequent performance is a major tenet of individual and societal level behavioral interventions. Recent work examining error-related neural activity has identified that the magnitude of activity in the posterior medial frontal cortex (pMFC) is predictive of learning from an error, whereby greater activity in this region predicts adaptive changes in future cognitive performance. It remains unclear how punishment influences error-related neural mechanisms to effect behavior change, particularly in key regions such as pMFC, which previous work has demonstrated to be insensitive to punishment. Using an associative learning task that provided monetary reward and punishment for recall performance, we observed that when recall errors were categorized by subsequent performance—whether the failure to accurately recall a number–location association was corrected at the next presentation of the same trial—the magnitude of error-related pMFC activity predicted future correction. However, the pMFC region was insensitive to the magnitude of punishment an error received and it was the left insula cortex that predicted learning from the most aversive outcomes. These findings add further evidence to the hypothesis that error-related pMFC activity may reflect more than a prediction error in representing the value of an outcome. The novel role identified here for the insular cortex in learning from punishment appears particularly compelling for our understanding of psychiatric and neurologic conditions that feature both insular cortex dysfunction and a diminished capacity for learning from negative feedback or punishment.

Does Stepping Stones Triple P plus Acceptance and Commitment Therapy improve parent, couple, and family adjustment following paediatric acquired brain injury? A randomised controlled trial.

OBJECTIVE To evaluate the efficacy of a behavioural family intervention, Stepping Stones Triple P (SSTP), combined with an Acceptance and Commitment Therapy (ACT) workshop in improving parent, family and couple outcomes following paediatric acquired brain injury (ABI). PARTICIPANTS AND SETTING Fifty-nine parents (90% mothers) of children (mean age 7 years; 35 males, 24 females) with ABI. INTERVENTION Participants were randomly assigned to a treatment (10-week group SSTP and ACT program) or a care-as-usual (CAU) control condition (10 weeks). Those in the CAU condition received the treatment after the waitlist period. OUTCOMES Self-report measures of parent psychological distress, parent psychological flexibility, parenting confidence, family functioning, and couple relationship, assessed at: pre-intervention, post-intervention, and 6-months post-intervention. RESULTS Post-intervention, the treatment group showed significant, small to medium improvements relative to the CAU group (at the p < .05 level) on parent psychological distress, parent psychological flexibility, parent confidence in managing behaviours, family adjustment,and number of disagreements between parents. Most improvements were maintained at 6-months. CONCLUSIONS Parent skills training and ACT may be efficacious in improving parent, family, and couple outcomes in families of children with an ABI.

A Web-Based Early Intervention Can Prevent Long-Term PTS Reactions in Children With High Initial Distress Following Accidental Injury

The present study explored the targeting of a preventative information provision intervention delivered to children following accidental injury by assessing the impact of initial traumatic distress on response to treatment. Analyses were based on baseline and 6-month outcome of child traumatic stress in a control (n = 28) and an intervention group (n = 31). Moderation of treatment outcome by initial levels of child traumatic stress was assessed through multiple hierarchical regression analyses. Results indicated the interaction between treatment provision and initial level of posttraumatic stress significantly predicted 6-month outcome (β = -.42, p = .019). When initial distress was high, children in the control group demonstrated an increase in trauma symptoms, and had significantly higher trauma symptoms at follow-up than those in the treatment group (d = 0.94, p = .008). When initial distress was not elevated, no significant differences were noted between the groups. These results indicate that a preventative early intervention may be best targeted at children presenting with the specific risk factor of high initial distress.

Parental Experiential Avoidance as a Potential Mechanism of Change in a Parenting Intervention for Parents of Children With Pediatric Acquired Brain Injury

OBJECTIVE To consider the relationship of parental experiential avoidance (EA) to psychological symptoms and problematic parenting strategies after pediatric acquired brain injury (ABI). METHODS Using available data from a randomized controlled trial of a group-based Acceptance and Commitment Therapy (ACT) workshop plus a behavioral family intervention (BFI) for parents of children with ABI (n = 59), correlational and mediational analyses were conducted to consider the role of parental EA as a process of change for parent outcomes. RESULTS Parent EA positively correlated with ineffective parenting behaviors and levels of psychological distress, both cross-sectionally and longitudinally. Reductions in EA mediated the treatment effect on reducing ineffective parenting behaviors and parent distress, but issues of temporality were present. CONCLUSIONS EA is related to parent outcomes following pediatric ABI. A larger and methodologically rigorous study is called for to further elucidate this finding and specifically determine the benefits of targeting EA with interventions such as ACT, in conjunction with evidence-based BFIs.

Pilot evaluation of a resilience training program for people with multiple sclerosis

Objective: To evaluate the feasibility and psychosocial outcomes of an Acceptance and Commitment Therapy (ACT)–based group resilience training program for people with multiple sclerosis (PwMS). Research Method/Design: The study used a pre–post group intervention design with 3-month follow-up. The intervention consisted of 8 group sessions of 2.5 hours each with 7 weekly sessions plus a booster Session 5 weeks later. Thirty-seven PwMS completed questionnaires. Primary psychosocial outcomes were resilience, quality of life (QoL), and distress. Secondary outcomes were the ACT processes: mindfulness, defusion, values and acceptance. Results: Significant improvements were observed for resilience (p = .005; Hedge’s g = .47), physical health QoL (p < .001; g = −.76), mental health QoL (p = .006; g = −.46), depression (p = .009; g = .38), stress (p = .025; g = .33), and 3 ACT processes: defusion (p = .013; g = −.54), values (p = .010; g = −.38), and acceptance (p = .006; g = −.39). Values and defusion emerged as mediators of physical health QoL and stress (90% CI), respectively. Program feasibility was supported by positive participant feedback; high rates of recruitment, attendance, retention, and homework engagement; and good intervention fidelity. Conclusions: Findings provide preliminary support for the utility and feasibility of a community organization delivered ACT-based group resilience training program for improving resilience, QoL, depression, stress, and protective factors (defusion, values, acceptance) in PwMS.

A Structured Behavioural Family Intervention with Parents of Children with Brain Injury

Child brain injury can lead to diminished quality of life and enduring sequelae, including significant emotional-behavioural, cognitive academic, occupational, physical and social deficits (Taylor et al., 2002; Jordan, 2006; Anderson et al., 2011). Improvements in neuropsychological and motor functioning are common over time postinjury; however, behavioural, emotional and adaptive functioning deficits can be more persistent (Kinsella et al., 1999; Catroppa et al., 2008; Fay et al., 2009). Approximately 50% of children will experience novel mood, anxiety or other psychiatric disorders in the first 6 months after brain injury (Luis and Mittenberg, 2002; Max et al, 2012; Pastore et al, 2013); similarly, up to 50% of children will experience significant externalising behavioural difficulties, which can persist and even worsen over time (Jordan, 2006; Li and Liu, 2013; Pastore et al., 2013). Beyond the influence of injury-specific factors such as severity of insult, behavioural and emotional symptoms after brain injury appear to be more closely related to psychosocial factors present before and after the injury. These include family material and social resources, social disadvantage, stressors, parent distress and overall family functioning (Carlson-Green et al., 1995; Kinsella et al., 1999; Taylor et al., 1999, 2002; Anderson et al., 2001, 2005, 2006; Kullgren et al., 2003; Schwartz et al., 2003; Yeates et al., 2004). Therefore, behavioural and emotional difficulties and disorders represent an important treatment target for rehabilitation professionals, with the family environment being a promising avenue for intervention.