A Comparison of 2 Online Parent Skills Training Interventions for Early Childhood Brain Injury: Improvements in Internalizing and Executive Function Behaviors.

OBJECTIVE: To examine the effectiveness of a web-based parenting intervention (Internet-Based Interacting Together Everyday: Recovery After Childhood TBI [I-InTERACT]) and an abbreviated version (Express) in reducing executive dysfunction and internalizing problems among young children following traumatic brain injury (TBI). METHOD: Parents of 113 children (ages 3-9 years) who had sustained a TBI were randomized to 1 of 3 treatment groups: I-InTERACT, Express, or an Internet Resource Comparison (IRC) group. Parents who participated in either I-InTERACT or Express completed self-guided web sessions and received live coaching of their parenting skills via videoconferencing with a therapist. I-InTERACT included additional psychoeducation, stress management, and family communication skills (eg, marriage, grief, pain, and sleep). Analyses of covariance were utilized to compare the groups on parent-reported executive function behaviors (ie, Behavior Rating Inventory of Executive Function) and internalizing symptoms (ie, Child Behavior Checklist) at baseline and 6 months. RESULTS: Parents who participated in Express reported significantly lower levels of executive dysfunction than those in I-InTERACT, ß = -0.49; t(2, 73) = -2.47, P = .048, and significantly lower levels of withdrawal than those in the IRC group, ß = -0.44; t(2, 74) = -2.22, P = .03. The Express group did not significantly differ from the IRC group on executive function behaviors or the I-InTERACT group on internalizing problems, all P > .05. Children with more problems at baseline, families with lower education levels, and parents with more symptoms of depression benefited most. CONCLUSION: A brief, online parent training intervention may be efficacious in improving executive dysfunction and internalizing problems following early TBI, particularly among children of lower socioeconomic status or with existing behavioral concerns.

Effects of Web-Based Parent Training on Caregiver Functioning Following Pediatric Traumatic Brain Injury: A Randomized Control Trial.

OBJECTIVE: To examine the effects of a Web-based parenting intervention (I-InTERACT), and an abbreviated version (Express), on caregiver depression, psychological distress, parenting stress, and parenting efficacy following pediatric traumatic brain injury (TBI). SETTING: Four children's hospitals and 1 general hospital in the United States. PARTICIPANTS: 148 caregivers of 113 children aged 3 to 9 years with a moderate to severe TBI. DESIGN: Multicenter randomized controlled trial. Participants were randomly assigned to I-InTERACT, Express, or an active control condition. Caregiver data were collected at baseline and postintervention (6 months later). INTERVENTION: I-InTERACT (10-14 sessions) and Express (7 sessions) combine live coaching of parenting skills and positive parenting strategies. MAIN MEASURES: Center for Epidemiologic Studies Depression Scale (CES-D); Global Severity Index of the Symptom Checklist-90-R (GSI), Parenting Stress Index (PSI), and Caregiver Self-Efficacy Scale (CSES). RESULTS: Analyses revealed no main effects of treatment on caregiver distress (GSI), parenting stress (PSI), or parenting efficacy (CSES). However, analyses examining baseline severity as a moderator found that caregivers with elevated levels of depression in I-InTERACT experienced significantly greater reductions in CES-D scores compared with caregivers in the active control condition. CONCLUSIONS: I-InTERACT reduced caregiver depression but no other facets of caregiver psychological functioning. Modifications to the treatment content may be necessary to reduce parenting stress and improve caregiver efficacy.

Family estimates of risk for neurocognitive late effects following pediatric cancer: From diagnosis through the first three years of survivorship.

BACKGROUND: Families often express a need for additional information about neurocognitive late effects (NCLE) after a pediatric cancer diagnosis. Therefore, we examined: (i) differences in parent, child, and oncologist estimates of risk for NCLE; (ii) whether the estimates of parents and/or children change over time; and (iii) whether estimates are different for children treated with central nervous system (CNS) directed therapies. PROCEDURE: Mothers, fathers, and children (initial age: 5-17, self-report: >10) from 258 families reported their perceived likelihood of the child developing "thinking/learning problems" on a visual analog scale (0-100%) at 2 months (T1), 1 year (T2), and 3 years (T3) following cancer diagnosis/relapse. Oncologists estimated the likelihood of NCLE at T1. Children were separated into groups based on CNS-directed treatment (n = 137; neurosurgery, intrathecal chemotherapy, and/or craniospinal radiation) or no CNS treatment. RESULTS: Mother, father, and child estimates of risk for NCLE were similar to oncologists and to one another around diagnosis (T1). Although there were no significant mean differences, a considerable subset of family members either underestimated their child's risk for NCLE (>40%) or overestimated the risk for NCLE (20%) in comparison to oncologists. At T2 and T3, the estimates of mothers were significantly higher than children. Linear growth curves indicated that mothers' estimates for children with CNS-directed treatment significantly increased throughout the first 3 years of survivorship. CONCLUSIONS: Considering that accurate understanding of NCLE is essential to seeking appropriate assessment and intervention, healthcare providers should focus on implementing family-based education early in treatment and throughout survivorship care.

Parent-Child Communication and Adjustment Among Children With Advanced and Non-Advanced Cancer in the First Year Following Diagnosis or Relapse.

Objectives: To examine parent-child communication (i.e., openness, problems) and child adjustment among youth with advanced or non-advanced cancer and comparison children. Methods: Families (n = 125) were recruited after a child's diagnosis/relapse and stratified by advanced (n = 55) or non-advanced (n = 70) disease. Comparison children (n = 60) were recruited from local schools. Children (ages 10-17) reported on communication (Parent-Adolescent Communication Scale) with both parents, while mothers reported on child adjustment (Child Behavior Checklist) at enrollment (T1) and one year (T2). Results: Openness/problems in communication did not differ across groups at T1, but problems with fathers were higher among children with non-advanced cancer versus comparisons at T2. Openness declined for all fathers, while changes in problems varied by group for both parents. T1 communication predicted later adjustment only for children with advanced cancer. Conclusions: Communication plays an important role, particularly for children with advanced cancer. Additional research with families affected by life-limiting conditions is needed.

Multiple Perspectives of Symptoms and Suffering at End of Life in the NICU.

BACKGROUND: Despite technological advances in the neonatal intensive care unit, not all infants survive. Limited research has focused on infants' symptoms and suffering at end of life (EOL) from multiple perspectives. PURPOSE: To compare retrospective parent report and electronic medical record (EMR) documentation of symptoms and to examine associations with parent perceptions of infants suffering at EOL. METHODS/SEARCH STRATEGY: Bereaved parents of 40 infants (40 mothers and 27 fathers) retrospectively reported on their perceptions of infant symptoms and suffering during the last week of life. EMRs were also reviewed. FINDINGS/RESULTS: Parents were asked about their observations of 23 symptoms. Within the 27 parental dyads, mothers reported 6.15 symptoms (standard deviation = 3.75), which was not significantly different from fathers' report of 5.67 symptoms (standard deviation = 5.11). Respiratory distress, agitation, and pain were most common according to mothers and EMR, whereas respiratory distress, agitation, and lethargy were most common according to fathers. Few differences were found between mothers, fathers, and EMRs. However, missing data (range: 0%-20%) indicated that some parents had challenges assessing symptoms. Parents reported that the worst symptom was respiratory distress. In addition, parents reported moderate infant suffering, which was correlated with the total number of symptoms. IMPLICATIONS FOR PRACTICE: Parents demonstrate awareness of their infant's symptoms at EOL, and these observations should be valued as they closely parallel EMR documentation. However, some parents did have difficulty reporting symptoms, highlighting the importance of education. IMPLICATIONS FOR RESEARCH: Future larger sample research should prospectively examine parent perceptions of infant symptom burden, suffering, and associations with other infant and parent outcomes (eg, decision making and grief).

Longitudinal associations among maternal depressive symptoms, child emotional caretaking, and anxious/depressed symptoms in pediatric cancer.

Research has shown that children experience increased emotional distress when engaging in emotional caretaking of a parent. The current study is the first to examine this process in families in which the source of the stress is the child's illness. Prospective associations were tested among mothers' depressive symptoms near the time of their child's cancer diagnosis, mothers' expressed distress and their child's emotional caretaking during an interaction task, and child anxious/depressed symptoms at 1 year postdiagnosis. Families (N = 78) were recruited from two pediatric hospitals soon after their child's (Ages 5-18) new diagnosis or relapse of cancer. Mothers reported on their own depressive symptoms and their child's anxious/depressed symptoms near the time of diagnosis or recurrence (Time 1) and 1 year later (Time 3). At Time 2 (4 months after Time 1), mother-child dyads completed a video-recorded discussion of their experience with cancer that was coded for observed maternal expressed distress (anxiety, sadness) and observed child emotional caretaking. Maternal expressed distress during the interaction was significantly related to more emotional caretaking behaviors by both boys and girls. Results of a moderated mediation model showed that child emotional caretaking at Time 2 significantly mediated the relation between maternal depressive symptoms at Time 1 and child anxious/depressed symptoms at Time 3 for girls but not for boys. The findings suggest that children's emotional caretaking behaviors contribute to subsequent anxious/depressed symptoms for girls, but not for boys, with cancer. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Technology-assisted rehabilitation interventions following pediatric brain injury.

INTRODUCTION: Following traumatic brain injury (TBI), children experience a variety of physical, motor, speech, and cognitive deficits that can have a long-term detrimental impact. The emergence and popularity of new technologies has led to research into the development of various apps, gaming systems, websites, and robotics that might be applied to rehabilitation. The objective of this narrative review was to describe the current literature regarding technologically-assisted interventions for the rehabilitation of motor, neurocognitive, behavioral, and family impairments following pediatric TBI. EVIDENCE ACQUISITION: We conducted a series of searches for peer-reviewed manuscripts published between 2000 and 2017 that included a technology-assisted component in the domains of motor, language/communication, cognition, behavior, social competence/functioning, family, and academic/school-based functioning. EVIDENCE SYNTHESIS: Findings suggested several benefits of utilizing technology in TBI rehabilitation including facilitating engagement/adherence, increasing access to therapies, and improving generalizability across settings. There is fairly robust evidence regarding the efficacy of online family problem-solving therapy in improving behavior problems, executive functioning, and family functioning. There was less compelling, but still promising, evidence regarding the efficacy other technology for motor deficits, apps for social skills, and computerized programs for cognitive skills. Overall, many studies were limited in the rigor of their methodology due to small heterogeneous samples and lack of control groups. CONCLUSIONS: Technology-assisted interventions have the potential to enhance pediatric rehabilitation after TBI. Future research is needed to further support their efficacy with larger controlled trials and to identify characteristics of children who are most likely to benefit.

Parent Distress and the Decision to Have Another Child After an Infant's Death in the NICU.

OBJECTIVE: To examine associations among parent perceptions of infant symptoms/suffering, parent distress, and decision making about having additional children after an infant's death in the NICU. DESIGN: Mixed-methods pilot study incorporating mailed surveys and qualitative interviews. SETTING: Midwestern Level IV regional referral NICU. PARTICIPANTS: Participants were 42 mothers and 27 fathers whose infants died in the NICU. METHODS: Parents reported on infant symptoms/suffering at end of life and their own grief and posttraumatic stress symptoms. Qualitative interviews explored decision making about having additional children. RESULTS: Approximately two thirds of bereaved parents had another child after their infant's death (62% of mothers, 67% of fathers). Mothers who had another child reported fewer infant symptoms at end of life compared with mothers who did not (p = .002, d = 1.28). Although few mothers exceeded clinical levels of prolonged grief (3%) and posttraumatic stress symptoms (18%), mothers who had another child endorsed fewer symptoms of prolonged grief (p = .001, d = 1.63) and posttraumatic stress (p = .009, d = 1.16). Differences between fathers mirrored these effects but were not significant. Parent interviews generated themes related to decision making about having additional children, including Impact of Infant Death, Facilitators and Barriers, Timing and Trajectories of Decisions, and Not Wanting to Replace the Deceased Child. CONCLUSION: Having another child after infant loss may promote resilience or serve as an indicator of positive adjustment among parents bereaved by infant death in the NICU. Prospective research is necessary to distinguish directional associations and guide evidence-based care.

Randomized Clinical Trial of Online Parent Training for Behavior Problems After Early Brain Injury.

OBJECTIVE: To evaluate the effectiveness of Internet-based Interacting Together Everyday: Recovery After Childhood TBI (I-InTERACT) versus abbreviated parent training (Express) or access to online resources (internet resources comparison [IRC]) in improving parenting skills and decreasing behavior problems after early traumatic brain injury (TBI). METHOD: In this randomized, controlled, clinical trial, 113 children 3 to 9 years old previously hospitalized for moderate to severe TBI were randomly assigned to receive Express (n = 36), I-InTERACT (n = 39), or IRC (n = 38). Express included 7 online parent skills sessions, and I-InTERACT delivered 10 to 14 sessions addressing parenting skills, TBI education, stress, and anger management. The 2 interventions coupled online modules with therapist coaching through a Health Insurance Portability and Accountability Act-compliant Skype link. The IRC group received access to online TBI and parent skills resources. Co-primary outcomes were blinded ratings of parenting skills and parent report of behavior problems and problem intensity on the Eyberg Child Behavior Inventory (ECBI). Outcomes were assessed before treatment and 3 and 6 months after treatment, with the latter constituting the primary endpoint. RESULTS: The Express and I-InTERACT groups displayed higher levels of positive parenting at follow-up. Only the I-InTERACT group had lower levels of negative parenting at 6 months. The Express group had lower ECBI intensity scores than the IRC group. Baseline symptom levels moderated improvements; children in the Express and I-InTERACT groups with higher baseline symptoms demonstrated greater improvements than those in the IRC group. Changes in parenting skills mediated improvements in behavior in those with higher baseline symptoms. CONCLUSION: Brief online parent skills training can effectively decrease behavior problems after early TBI in children with existing behavioral symptoms. Clinical trial registration information-Internet-based Interacting Together Everyday, Recovery After Childhood TBI (I-InTERACT)-RRTC; http://clinicaltrials.gov/; NCT01214694.

Adaptive functioning following pediatric traumatic brain injury: Relationship to executive function and processing speed.

OBJECTIVE: Pediatric traumatic brain injury (TBI) may affect children's ability to perform everyday tasks (i.e., adaptive functioning). Guided by the American Association for Intellectual and Developmental Disabilities (AAIDD) model, we explored the association between TBI and adaptive functioning at increasing levels of specificity (global, AAIDD domains, and subscales). We also examined the contributions of executive function and processing speed as mediators of TBI's effects on adaptive functioning. METHOD: Children (ages 8-13) with severe TBI (STBI; n = 19), mild-moderate TBI (MTBI; n = 50), or orthopedic injury (OI; n = 60) completed measures of executive function (TEA-Ch) and processing speed (WISC-IV) an average of 2.7 years postinjury (SD = 1.2; range: 1-5.3). Parents rated children's adaptive functioning (ABAS-II, BASC-2, CASP). RESULTS: STBI had lower global adaptive functioning (η2 = .04-.08) than the MTBI and OI groups, which typically did not differ. Deficits in the STBI group were particularly evident in the social domain, with specific deficits in social participation, leisure, and social adjustment (η2 = .06-.09). Jointly, executive function and processing speed were mediators of STBI's effects on global adaptive functioning and in conceptual and social domains. In the STBI group, executive function mediated social functioning, and processing speed mediated social participation. CONCLUSIONS: Children with STBI experience deficits in adaptive functioning, particularly in social adjustment, with less pronounced deficits in conceptual and practical skills. Executive function and processing speed may mediate the effects of STBI on adaptive functioning. Targeting adaptive functioning and associated cognitive deficits for intervention may enhance quality of life for pediatric TBI survivors. (PsycINFO Database Record