Parent-child Interaction Therapy Following Pediatric TBI
Parent-child Interaction Therapy Following Pediatric TBI
Objective To present a case study illustrating the application of parent–child interaction therapy (PCIT) for management of a child's externalizing behaviors related to a severe traumatic brain injury (TBI).
Methods An 11-year-old boy's history and injury are described, followed by a description of PCIT and the course of therapy.
Results After 9 sessions of PCIT, the child displayed fewer negative behaviors, and his mother's distress was reduced.
Conclusions This case demonstrates the feasibility of using PCIT with a child older than the recommended age range to address behavior problems associated with TBI.
Traumatic brain injury (TBI) occurs at a rate of 70 per 100,000 in children under 18 years of age, is a leading cause of death and disability, and accounts for more than $1 billion in hospital expenses annually (Langlois, Rutland-Brown, & Thomas, 2006; Schneier, Shields, Hostetler, Xiang, & Smith, 2006). Pediatric TBI symptom severity and duration are highly variable and can have long-term sequelae for the child that includes cognitive, academic, social, functional, and behavioral components (Fletcher, Ewing-Cobbs, Miner, Levin, & Eisenberg, 1990; Taylor et al., 2002; Yeates et al., 2004). Up to 50% of children with severe TBI experience problem behaviors that can persist well beyond the postacute recovery phase (Brown, Chadwick, Shaffer, Rutter, & Traub, 1981; Fay et al., 2009; Yeates, 2010), which poses an important treatment challenge to pediatric psychologists and neuropsychologists. Children with more severe brain injuries, with greater socioeconomic disadvantage, and with a preinjury history of behavior problems are at greatest risk for developing persistent postinjury behavior problems (see Taylor, 2010; and Yeates, 2010 for reviews). Pediatric TBI also has significant impact on the family system. In the initial year following injury, there can be significant family dysfunction coupled with caregiver stress, burden, anxiety, and depression (Wade, Taylor, Drotar, Stancin, & Yeates, 1998). The effects on the family often last for >6 years following the injury (Wade et al., 2006) and exceed the burden faced by families of children with injuries outside the central nervous system (CNS). Furthermore, there appears to be a complex but important relationship between family functioning and functioning of the child recovering from TBI, highlighting the importance of taking a systemic approach to treatment of postinjury behavior problems (Kinsella et al., 1999; Taylor et al., 2001).
Behavioral and emotional changes following TBI are fairly common in pediatric TBI, although there is no specific behavioral profile uniquely attributed to TBI (Brown et al., 1981). In fact, a wide range of problems can be observed, including depressed or anxious mood, personality changes, inattention and hyperactivity, and oppositional behaviors. Externalizing problems, such as disinhibition and oppositional defiance, occur more frequently in pediatric TBI than the general population (Brown et al., 1981) and can negatively affect a child's functioning both at home and school. Although it is well-established that children with pre-existing behavior problems (e.g., attention deficit/hyperactivity disorder, ADHD) are at greater risk for postinjury behavioral sequelae, it has been suggested that TBI can exacerbate preinjury behavior problems in some children and increase the risk for additional, novel behavior problems (Max et al., 1998). Furthermore, even children with no history of behavioral or emotional problems are at risk for developing post-TBI behavior problems, particularly those more severely injured (Brown et al., 1981; Bloom et al., 2001; Fletcher et al., 1996). Research has also supported the notion that family factors such as socioeconomic disadvantage, and family burden, distress, and dysfunction are risk factors for poor postinjury functioning of the child, and better family functioning may moderate some of the effects of brain injury (Anderson, Catroppa, Morse, Haritou, & Rosenfeld, 2005; Taylor et al., 1995, 2001). Thus, there is an acute need not only to treat behavior problems arising after pediatric TBI through interventions directed at the child, but also to target important outcome moderating factors, such as family burden and stress.
Existing treatment approaches targeting behavior problems after severe pediatric TBI include structuring the child's environment to provide positive behavioral supports (Ylvisaker, Jacobs, & Feeney, 2003), implementing cognitive behavioral approaches with the injured child (Selznick & Savage, 2000; Suzman, Morris, Morris, & Milan, 1997; Ylvisaker, 2006), and training parents to be stronger advocates for their injured child's needs in the school setting (Glang, McLaughlin, & Schroeder, 2007). However, despite strong evidence for family factors affecting pediatric TBI outcome, only a few evidence-informed, family-centered interventions have been developed and successfully applied to pediatric TBI (see Wade, 2010 for review), and interventions directly targeting parent–child interactions have been limited to work with very young children.
Over the past decade, Wade and colleagues have been developing and refining a family problem-solving approach that seeks to improve functioning for not on the injured child, but their family members as well (Wade, 2010). Although their treatment program targeted the whole family and evidence suggested a reduction in behavior problems of school-age children, parent–child interactions were not a specific intervention target. Recently, the group extended some of their early work with families of school-age children and adolescents with TBI to provide a web-based parenting skills program for families of very young (ages 3–8 years) children (Wade, Oberjohn, Burkhardt, & Greenberg, 2009). The program consisted of 10 web-based sessions that included self-guided didactic information, video modeling skills, and exercises, with related in vivo coaching of target skills by a trained therapist. Preliminary data from nine participating families indicated significant improvement in targeted parenting behaviors, which were maintained at follow-up, but only five families completed treatment. Among this small group of treatment completers, there was a noted trend for reductions in child behavior problems, providing tantalizing evidence that interventions targeting parent–child interactions may have positive effects on child behaviors after severe TBI. Positive interpersonal interactions within the home are important for creating a supportive family environment. In turn, a supportive family environment protects the family against additional stress and burden and improves the child's adaptation to the injury (Wade, 2006). Although the research being conducted by Wade and colleagues suggests that intervention programs targeting parent–child interactions may be a viable treatment approach for pediatric TBI, it is unclear whether these methods would work well with older children. Furthermore, it is unclear whether already existing, manualized parent–child interaction treatments (e.g., Parent–Child Interaction Therapy; PCIT) can be applied to this population. In this case study, we present PCIT outcomes for behavior problems and family functioning of a severely brain-injured adolescent 19 months postinjury.
PCIT is an empirically supported intervention designed for families with young children with disruptive behavior disorders. After completing PCIT, children's disruptive behavior is reduced to within normal limits both in the home (Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998) and classroom (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991), and these changes are maintained in both settings over time (Funderburk et al., 1998; Hood & Eyberg, 2003). PCIT has also been applied successfully to the treatment of children experiencing a broad range of behavioral, emotional, and family problems (Zisser & Eyberg, 2010) as well as externalizing behavior problems in the context of medical conditions (e.g., Bagner, Fernandez, & Eyberg, 2004). Although PCIT was designed for the treatment of young children (i.e., ages 2–7 years), it has been implemented for treatment of physically abusive parenting with dyads in which children ranged up to 12 years of age (Chaffin et al., 2004). To our knowledge, however, child outcomes have not been reported for children at this age.
PCIT sessions incorporate parent–child interactions that are coached from an observation room (via wireless "bug" in the ear) to aid the parent in building positive interaction patterns with the child. The direct and concrete interaction patterns coached during PCIT may be particularly beneficial for children with TBI who have deficits in working memory (Levin et al., 2002) and executive control (Ornstein et al., 2009). For example, rather than saying "clean up your toys when you're done," a parent would be coached to use the more concrete, direct command "please put the blue truck in the toy box," and the child would be praised following compliance to each simple command. Alternatively, one might argue that frontal lobe injury (which is common in severe TBI) would impair a child's ability to learn from consequences and adapt their behavior based on parental response, such that behavioral interventions relying on operant conditioning through discipline would be ill-suited to this population (Ylvisaker, Turkstra, & Coelho, 2005). This issue may be particularly relevant in the second phase of PCIT in which the child's compliant behaviors are reinforced through positive attention and praise, and noncompliant behaviors discouraged by contingent application of a time-out procedure. Although prior research has shown that child behavior change occurs in both phases of treatment (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993), it is unknown whether frontal lobe pathology would specifically interfere with the effectiveness of the second phase of PCIT. This case study provides a preliminary opportunity to explore these issues because the child had extensive frontal lobe damage.
In PCIT, parents are taught skills to establish a nurturing and secure relationship with their child, while also increasing their child's prosocial skills and reducing disruptive behaviors. Treatment focuses on establishing Baumrind's (1976) authoritative parenting style in which parents are taught to be empathic and supportive while using clear communication and setting firm limits. PCIT consists of two phases: the child-directed interaction (CDI), which focuses on increasing parental warmth and strengthening the parent–child relationship, and the parent-directed interaction (PDI), which teaches parents a structured and consistent approach to discipline. In CDI, parents learn to follow their child's lead in a play situation and use differential social attention to give positive attention to prosocial behaviors and ignore negative behaviors. Parents also model appropriate play behaviors (such as sharing) for their children. At the completion of PCIT, parents typically show decreases in negative, critical talk, and increases in prosocial talk and physical warmth toward their child (Eisenstadt et al., 1993).
In the PDI phase of PCIT, parents learn to give specific, age-appropriate, direct commands to their children and to follow each command with a clear, consistent contingency plan for compliance and noncompliance. Parents are taught to provide positive reinforcement for compliance and to begin a time-out sequence following noncompliance (Eyberg & Bussing, 2010). Several randomized controlled trials have shown that children participating in PCIT increase their compliance to parental commands and decrease their disruptive behaviors in comparison to wait-list controls (Bagner & Eyberg 2007; Schuhmann et al., 1998). Consistent pairing of child compliance with parental reinforcement is presumed to underlie the behavioral changes that occur during the PDI phase of treatment. It is possible that cognitive impairments post-TBI could dampen the effects of this type of operant conditioning. However, the immediate, direct, and concrete interaction style of PCIT may be particularly beneficial for children with TBI who have cognitive deficits (Levin, 2002; Ornstein et al., 2009).
In this case report, we aim to show that PCIT may be an effective treatment for managing the behavior problems that can result from pediatric TBI and improving the quality of the child's relationship with his or her parents, thus relieving stress on the family system. We applied this intervention with an 11-year-old boy with a preinjury diagnosis of ADHD-combined type from a socioeconomically disadvantaged family who was the unfortunate victim of a severe traumatic brain injury. These characteristics (severe TBI, preinjury behavior problems, low socioeconomic level) are all negative predictors of long-term behavior problems following pediatric TBI (Schwartz et al., 2003). If the intervention is successful for a high-risk family with multiple negative predictors of postinjury behavior problems and for whom PCIT is not traditionally targeted, the effectiveness of PCIT may also be indicated for children with lesser TBI severity and for whom PCIT is a more traditional fit (e.g., younger children). Thus, the purpose of this case study was to demonstrate (a) the feasibility of treating the family of a child with TBI and negative prognostic indicators using PCIT, (b) a quantitative reduction in the number of problem behaviors after PCIT, and (c) a qualitative and quantitative reduction in parental distress after PCIT.
Abstract and Introduction
Abstract
Objective To present a case study illustrating the application of parent–child interaction therapy (PCIT) for management of a child's externalizing behaviors related to a severe traumatic brain injury (TBI).
Methods An 11-year-old boy's history and injury are described, followed by a description of PCIT and the course of therapy.
Results After 9 sessions of PCIT, the child displayed fewer negative behaviors, and his mother's distress was reduced.
Conclusions This case demonstrates the feasibility of using PCIT with a child older than the recommended age range to address behavior problems associated with TBI.
Introduction
Traumatic brain injury (TBI) occurs at a rate of 70 per 100,000 in children under 18 years of age, is a leading cause of death and disability, and accounts for more than $1 billion in hospital expenses annually (Langlois, Rutland-Brown, & Thomas, 2006; Schneier, Shields, Hostetler, Xiang, & Smith, 2006). Pediatric TBI symptom severity and duration are highly variable and can have long-term sequelae for the child that includes cognitive, academic, social, functional, and behavioral components (Fletcher, Ewing-Cobbs, Miner, Levin, & Eisenberg, 1990; Taylor et al., 2002; Yeates et al., 2004). Up to 50% of children with severe TBI experience problem behaviors that can persist well beyond the postacute recovery phase (Brown, Chadwick, Shaffer, Rutter, & Traub, 1981; Fay et al., 2009; Yeates, 2010), which poses an important treatment challenge to pediatric psychologists and neuropsychologists. Children with more severe brain injuries, with greater socioeconomic disadvantage, and with a preinjury history of behavior problems are at greatest risk for developing persistent postinjury behavior problems (see Taylor, 2010; and Yeates, 2010 for reviews). Pediatric TBI also has significant impact on the family system. In the initial year following injury, there can be significant family dysfunction coupled with caregiver stress, burden, anxiety, and depression (Wade, Taylor, Drotar, Stancin, & Yeates, 1998). The effects on the family often last for >6 years following the injury (Wade et al., 2006) and exceed the burden faced by families of children with injuries outside the central nervous system (CNS). Furthermore, there appears to be a complex but important relationship between family functioning and functioning of the child recovering from TBI, highlighting the importance of taking a systemic approach to treatment of postinjury behavior problems (Kinsella et al., 1999; Taylor et al., 2001).
Behavioral and emotional changes following TBI are fairly common in pediatric TBI, although there is no specific behavioral profile uniquely attributed to TBI (Brown et al., 1981). In fact, a wide range of problems can be observed, including depressed or anxious mood, personality changes, inattention and hyperactivity, and oppositional behaviors. Externalizing problems, such as disinhibition and oppositional defiance, occur more frequently in pediatric TBI than the general population (Brown et al., 1981) and can negatively affect a child's functioning both at home and school. Although it is well-established that children with pre-existing behavior problems (e.g., attention deficit/hyperactivity disorder, ADHD) are at greater risk for postinjury behavioral sequelae, it has been suggested that TBI can exacerbate preinjury behavior problems in some children and increase the risk for additional, novel behavior problems (Max et al., 1998). Furthermore, even children with no history of behavioral or emotional problems are at risk for developing post-TBI behavior problems, particularly those more severely injured (Brown et al., 1981; Bloom et al., 2001; Fletcher et al., 1996). Research has also supported the notion that family factors such as socioeconomic disadvantage, and family burden, distress, and dysfunction are risk factors for poor postinjury functioning of the child, and better family functioning may moderate some of the effects of brain injury (Anderson, Catroppa, Morse, Haritou, & Rosenfeld, 2005; Taylor et al., 1995, 2001). Thus, there is an acute need not only to treat behavior problems arising after pediatric TBI through interventions directed at the child, but also to target important outcome moderating factors, such as family burden and stress.
Existing treatment approaches targeting behavior problems after severe pediatric TBI include structuring the child's environment to provide positive behavioral supports (Ylvisaker, Jacobs, & Feeney, 2003), implementing cognitive behavioral approaches with the injured child (Selznick & Savage, 2000; Suzman, Morris, Morris, & Milan, 1997; Ylvisaker, 2006), and training parents to be stronger advocates for their injured child's needs in the school setting (Glang, McLaughlin, & Schroeder, 2007). However, despite strong evidence for family factors affecting pediatric TBI outcome, only a few evidence-informed, family-centered interventions have been developed and successfully applied to pediatric TBI (see Wade, 2010 for review), and interventions directly targeting parent–child interactions have been limited to work with very young children.
Over the past decade, Wade and colleagues have been developing and refining a family problem-solving approach that seeks to improve functioning for not on the injured child, but their family members as well (Wade, 2010). Although their treatment program targeted the whole family and evidence suggested a reduction in behavior problems of school-age children, parent–child interactions were not a specific intervention target. Recently, the group extended some of their early work with families of school-age children and adolescents with TBI to provide a web-based parenting skills program for families of very young (ages 3–8 years) children (Wade, Oberjohn, Burkhardt, & Greenberg, 2009). The program consisted of 10 web-based sessions that included self-guided didactic information, video modeling skills, and exercises, with related in vivo coaching of target skills by a trained therapist. Preliminary data from nine participating families indicated significant improvement in targeted parenting behaviors, which were maintained at follow-up, but only five families completed treatment. Among this small group of treatment completers, there was a noted trend for reductions in child behavior problems, providing tantalizing evidence that interventions targeting parent–child interactions may have positive effects on child behaviors after severe TBI. Positive interpersonal interactions within the home are important for creating a supportive family environment. In turn, a supportive family environment protects the family against additional stress and burden and improves the child's adaptation to the injury (Wade, 2006). Although the research being conducted by Wade and colleagues suggests that intervention programs targeting parent–child interactions may be a viable treatment approach for pediatric TBI, it is unclear whether these methods would work well with older children. Furthermore, it is unclear whether already existing, manualized parent–child interaction treatments (e.g., Parent–Child Interaction Therapy; PCIT) can be applied to this population. In this case study, we present PCIT outcomes for behavior problems and family functioning of a severely brain-injured adolescent 19 months postinjury.
PCIT is an empirically supported intervention designed for families with young children with disruptive behavior disorders. After completing PCIT, children's disruptive behavior is reduced to within normal limits both in the home (Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998) and classroom (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991), and these changes are maintained in both settings over time (Funderburk et al., 1998; Hood & Eyberg, 2003). PCIT has also been applied successfully to the treatment of children experiencing a broad range of behavioral, emotional, and family problems (Zisser & Eyberg, 2010) as well as externalizing behavior problems in the context of medical conditions (e.g., Bagner, Fernandez, & Eyberg, 2004). Although PCIT was designed for the treatment of young children (i.e., ages 2–7 years), it has been implemented for treatment of physically abusive parenting with dyads in which children ranged up to 12 years of age (Chaffin et al., 2004). To our knowledge, however, child outcomes have not been reported for children at this age.
PCIT sessions incorporate parent–child interactions that are coached from an observation room (via wireless "bug" in the ear) to aid the parent in building positive interaction patterns with the child. The direct and concrete interaction patterns coached during PCIT may be particularly beneficial for children with TBI who have deficits in working memory (Levin et al., 2002) and executive control (Ornstein et al., 2009). For example, rather than saying "clean up your toys when you're done," a parent would be coached to use the more concrete, direct command "please put the blue truck in the toy box," and the child would be praised following compliance to each simple command. Alternatively, one might argue that frontal lobe injury (which is common in severe TBI) would impair a child's ability to learn from consequences and adapt their behavior based on parental response, such that behavioral interventions relying on operant conditioning through discipline would be ill-suited to this population (Ylvisaker, Turkstra, & Coelho, 2005). This issue may be particularly relevant in the second phase of PCIT in which the child's compliant behaviors are reinforced through positive attention and praise, and noncompliant behaviors discouraged by contingent application of a time-out procedure. Although prior research has shown that child behavior change occurs in both phases of treatment (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993), it is unknown whether frontal lobe pathology would specifically interfere with the effectiveness of the second phase of PCIT. This case study provides a preliminary opportunity to explore these issues because the child had extensive frontal lobe damage.
In PCIT, parents are taught skills to establish a nurturing and secure relationship with their child, while also increasing their child's prosocial skills and reducing disruptive behaviors. Treatment focuses on establishing Baumrind's (1976) authoritative parenting style in which parents are taught to be empathic and supportive while using clear communication and setting firm limits. PCIT consists of two phases: the child-directed interaction (CDI), which focuses on increasing parental warmth and strengthening the parent–child relationship, and the parent-directed interaction (PDI), which teaches parents a structured and consistent approach to discipline. In CDI, parents learn to follow their child's lead in a play situation and use differential social attention to give positive attention to prosocial behaviors and ignore negative behaviors. Parents also model appropriate play behaviors (such as sharing) for their children. At the completion of PCIT, parents typically show decreases in negative, critical talk, and increases in prosocial talk and physical warmth toward their child (Eisenstadt et al., 1993).
In the PDI phase of PCIT, parents learn to give specific, age-appropriate, direct commands to their children and to follow each command with a clear, consistent contingency plan for compliance and noncompliance. Parents are taught to provide positive reinforcement for compliance and to begin a time-out sequence following noncompliance (Eyberg & Bussing, 2010). Several randomized controlled trials have shown that children participating in PCIT increase their compliance to parental commands and decrease their disruptive behaviors in comparison to wait-list controls (Bagner & Eyberg 2007; Schuhmann et al., 1998). Consistent pairing of child compliance with parental reinforcement is presumed to underlie the behavioral changes that occur during the PDI phase of treatment. It is possible that cognitive impairments post-TBI could dampen the effects of this type of operant conditioning. However, the immediate, direct, and concrete interaction style of PCIT may be particularly beneficial for children with TBI who have cognitive deficits (Levin, 2002; Ornstein et al., 2009).
In this case report, we aim to show that PCIT may be an effective treatment for managing the behavior problems that can result from pediatric TBI and improving the quality of the child's relationship with his or her parents, thus relieving stress on the family system. We applied this intervention with an 11-year-old boy with a preinjury diagnosis of ADHD-combined type from a socioeconomically disadvantaged family who was the unfortunate victim of a severe traumatic brain injury. These characteristics (severe TBI, preinjury behavior problems, low socioeconomic level) are all negative predictors of long-term behavior problems following pediatric TBI (Schwartz et al., 2003). If the intervention is successful for a high-risk family with multiple negative predictors of postinjury behavior problems and for whom PCIT is not traditionally targeted, the effectiveness of PCIT may also be indicated for children with lesser TBI severity and for whom PCIT is a more traditional fit (e.g., younger children). Thus, the purpose of this case study was to demonstrate (a) the feasibility of treating the family of a child with TBI and negative prognostic indicators using PCIT, (b) a quantitative reduction in the number of problem behaviors after PCIT, and (c) a qualitative and quantitative reduction in parental distress after PCIT.
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