Problem Solving Therapy for Management of Behavior

Difficulties after Pediatric TBI

H. Gerry Taylor, Ph.D., ABPP/CNDepartment of Pediatrics

Case Western Reserve UniversityRainbow Babies & Children’s

HospitalUniversity Hospitals Case Medical

CenterCleveland, OH

H. Gerry Taylor has no relevant financial

disclosures

Collaborators Shari Wade, PhD (PI) and her colleagues at

Cincinnati Children’s Hospital, including Brad Kurowski, MD

Directors of Other Sites: H. Gerry Taylor, PhD, Case Western Reserve

University, Cleveland, OH Terry Stancin, PhD, MetroHealth Medical Center, Mike Kirkwood, PhD, The Children’s Hospital, Aurora, CO Tanya Maines Brown, PhD, The Mayo Clinic,

Rochester, MN

Funding Sources National Institutes of Health National Institute on Disability and

Rehabilitation Research Rehabilitation Medicine Scientist Training

Program Ohio Department of Public Safety Colorado Brain Injury Trust Fund Center for Clinical and Translational Science

and Training University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center

Rationale for Study of Family-Based Problem Solving

Therapy Pediatric TBI results in a range of adverse

behavioral and social consequences, including attention problems, behavioral self-control (executive function), and emotional lability.

Families also experience elevated burden and psychological distress (anxiety/depression).

Because family adaptation and child behavioral recovery have reciprocal influences on one another, both child and family outcomes need to be assessed in examining effects of intervention.

Why Family Problem Solving?

Problems after TBI are diverse and vary from family to family and over time.

Problem-solving therapy provides a flexible approach to facilitating family coping.

The steps of problem solving also provide a way for the injured child to improve self-control and executive function.

Engaging the family can facilitate family adaptation and allow the family to scaffold the injured child’s behavioral recovery.

Why Web-based? Web-based delivery eliminates barriers

to care such as distance, time, and lack of knowledgeable providers.

Teens may be particularly receptive since they are web-savvy and eager to avoid the stigma of office-based psychotherapy.

The web allows presentation of content in different formats (e.g., printed words, visual illustrations, reading of materials, videos).

Counselor Assisted Problem Solving (CAPS) Intervention

7 core sessions beginning with face-to face intro and overview and focusing on: ways to stay positive, solve problems, deal with cognitive challenges, stay in control, plan for the future.

Self-assessment and supplemental sessions as needed (e.g., dealing with sibling, marital, school issues).

Two forms of practice and reinforcement: (1) self-guided via a password protected website; and (2) with therapist via videoconference.

Illustrations of Content Session 1—Getting started:

Introduction and overview Video clips of teens talking about their TBI Self-selected family goals

Session 2—Staying positive: Common concerns and problems families

may have and skills needed to address these

Benefits of staying positive and how to do this in managing stress

Randomized Clinical Trial of CAPS

Included teens (ages 12-17 years) with moderate-severe TBI and their families.

Teens randomly assigned to Counselor Assisted Problem Solving (CAPS) or Internet Resource Comparison (IRC) condition.

Outcomes assessed at post-acute baseline and then at 6, 12, and 18 months after the baseline.

Enrollment Inclusion criteria for baseline

assessment: Injury within last 7 months (mean

3.5) Severe TBI, with lowest GCS 3-8

(40%) Moderate TBI, with lowest GCS 9-12

or 13-15 with abnormal neuroimaging

Nearly half of eligible families who were contacted consented and completed baseline assessments.

Participants 65 CAPS and 67 IRC randomized, with

57 CAPS and 61 IRC available for analysis.

Mean # months post injury at baseline = 3.6

Mean GCS score = 10. Mean age for both groups = 14½

years. 2/3’s of participants were male and

20% were nonwhite (recruitment stratified by sex and race).

Measures (partial listing) Child Behavior Outcomes

Child Behavior Checklist (CBCL) Behavioral Rating of Executive Functions (BRIEF)

Parent/Family Characteristics Parent Psychological Distress: Symptom

Checklist-90 Revised (SCL-90) Caregiving Self-Efficacy Scale Parent-Teen Conflict Questionnaire

Potential Moderators of Treatment Effects Age at injury Extent of prior computer use Family resources/income

Questions Addressed Are changes in symptoms of child

behavior problems, parent stress/distress, or parent-teen relationships more positive from pre- to post treatment for CAPS than for IRC?

Is CAPS more effective for some families than others?

Greater Decrease in Executive Dysfunction(BRIEF- GEC) for CAPS than IRC Across Follow-up in Older Teens: Kurowski et al., JAMA, 2014

Visit 1 Visit 2 Visit 3 Visit 445

47

49

51

53

55

57

59

61

63

65

GEC-CAPS GEC-IRC

Additional Findings Positive effects of CAPS in older teens

also found for ratings of externalizing problems and ADHD.

CAPS more effective than IRC in reducing family conflicts (older teens), improving caregiver self-efficacy (less experienced computer users), and decreasing parent psychological distress (lower income families).

Greater Longer-Term Reductions in Parent Psychological Distress with CAPS for Lower Income Families

Conclusions An internet-based counseling

intervention is feasible for families of teens with TBI.

Counseling results in more positive behavior changes in teens and parents than internet access alone, at least for some families.

Positive effects of internet-based counseling are not uniform but depend on child and family characteristics (child age, family income and experience with computers).

Limitations Outcomes based mainly on parent

ratings and parents aware of treatment, thus findings subject to expectation bias.

Generalization limited by low percentage of non-white participants.

Because teens were recruited even if they did not have behavior problems, the findings may under-estimate potential benefits of counseling for teens who have behavior problems after injury.

Future Directions Assess value of internet-based

intervention as more standard option in clinical practice via ongoing comparative effectiveness trial of teens with post-TBI behavior problems-- supported by Patient Centered Research Institute (PCORI).

Investigate: (a) ways to make counseling more effective for younger teens and children with TBI, (b) optimal timing of intervention, (c) characteristics of families most likely to benefit, and (d) modifications needed to fit individual family needs.