problem-solving training effects on family caregivers and care recipients

43
Problem-Solving Training Effects on Family Caregivers and Care Recipients Timothy R. Elliott, Ph.D.

Upload: benny

Post on 22-Feb-2016

24 views

Category:

Documents


0 download

DESCRIPTION

Problem-Solving Training Effects on Family Caregivers and Care Recipients . Timothy R. Elliott, Ph.D . Acknowledgements. National Institute for Disability Research and Rehabilitation National Institutes of Health National Institute of Child Health and Development - PowerPoint PPT Presentation

TRANSCRIPT

Page 1: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Problem-Solving Training Effects on Family Caregivers and Care Recipients

Timothy R. Elliott, Ph.D.

Page 2: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Acknowledgements• National Institute for Disability Research and

Rehabilitation

• National Institutes of Health– National Institute of Child Health and Development

• Centers for Disease Control and Prevention– National Center for Injury

Prevention and ControlCollaborators

Jack Berry, Ph.D., Joan Grant, Ph.D.

Page 3: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Policy Perspective National Scope of Caregiving• Currently, 44 million Americans over the age of 18 are

in caregiver roles

• Caregivers likely have more influence on care recipient health than any single health care provider

• Yet they do not receive ongoing training or routine

access to support commiserate with their roles, tasks and responsibilities

Page 4: Problem-Solving Training Effects on Family Caregivers and Care Recipients

• High rates of acquired disability– Disproportionate number of these are men– Numbers increasing with wounded from OIF/OEF

• Life expectancy for persons with disability continues to increase

• Health and well-being of family caregivers – and their ability to assist their care recipients – is now a public health priority Talley & Crews, 2007

Family Caregiving And Disability

Page 5: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Clinical Perspective Consistent with Chronic Care (cf. Wagner, et

al.)and Family-Centered Care (cf. Weihs, et al.),

Partnership Models • Help family caregivers to be more expert in self-

regulation, managing demands• Help family caregivers operate competently as formal

extensions of health care systems• Help them address tasks and routines “…essential to

family functioning”

Page 6: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Partnership Models• Provide training and support to family

caregivers in the community• Tailor services to meet the needs of

each individual family• Promote use of long-distance

technologies to provide training in the home

Page 7: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Theoretical Perspective Social Problem Solving Training for Family Caregivers of Persons with

Acquired Disabilities

Page 8: Problem-Solving Training Effects on Family Caregivers and Care Recipients

The Social Problem Solving Modelof Adjustment

D’Zurilla & Goldfried, 1971 • General Orientation to Problem Solving• Problem Definition• Generation of Alternatives• Decision Making and Implementation• Verification

Page 9: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Effective Problem-Solvers– Ward Off Negative Emotions – Promote Positive Emotions– Inhibit Impulsive Reactions– Motivated toward Solving Problems – Generate Solutions– Make and Implement Choices– Evaluate Progress and Outcome

Page 10: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Caregiver Problem-Solving Abilities Predict Adjustment• Caregivers with ineffective styles report

increasing levels of depression, anxiety, ill health over time– Elliott et al. 2001, Grant et al. 2006

• Effective problem-solving ability – adjustment association independent of stress– Noojin & Wallander, 1997

• Care recipients who have caregivers who possess dysfunctional styles are more likely to develop secondary complications – Elliott et al., 1999, Kurylo et al. 2004

Page 11: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST teaches skills necessary to be an effective problem solver

PST can be used to help caregivers:

• Develop a positive, proactive orientation to problem situations

• Have a better understanding of the components involved in interpreting a problem situation

• Increase their actual problem solving skills

Problem Solving Training for Caregivers

Page 12: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Problem-Solving Training (PST) for Family Caregivers• Stroke caregivers Review by Lui et al., 2005• Mothers of children with cancer Sahler et al.

2005 • Parents of children with traumatic brain

injuries (TBI) Wade et al., 2006a, 2006b• Individuals with cancer and their caregivers

Bucher et al., 1999; Nezu et al., 2003http://www.apa.org/pi/about/publications/caregivers/index.aspx

http://www.apa.org/pi/about/publications/caregivers/practice-settings/intervention/individual.aspx

Page 13: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Problem Solving Training for Family Caregivers Works Results from RCTs

Family Caregivers of Persons with Traumatic Brain Injuries Rivera, Elliott et al. Archives of Physical Medicine and Rehabilitation, 2008

Family Caregivers of Persons with Spinal Cord InjuriesElliott, Brossart et al., Behaviour Research & Therapy, 2008

Family Caregivers of Persons with Recent-Onset Spinal Cord Injuries Elliott & Berry, Journal of Clinical Psychology, 2009

Family Caregivers of Women with Severe Disabilities Elliott, Berry, & Grant, Behaviour Research & Therapy, 2009,

Family Caregivers of Stroke Survivors Grant, Elliott et al., Stroke, 2002

Page 14: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Tailoring PST to Specific ProblemsItems Identified by Caregivers in a Focus Group

1 2 3 4 5 6 7Least Important Most Important

SexualRelations 21

Saying “No” 16

Bowel and Bladder Acc. 24

Lack of Time

6

HatefulAttitude

1

Patient Cries

5

Lack of Appreciation

18

Page 15: Problem-Solving Training Effects on Family Caregivers and Care Recipients

• http://main.uab.edu/tbi/show.asp?durki=110890&site=2988&return=66594

This interactive program is designed to offer caregivers 3 techniques to help improve their health and quality of life.

1 - Card Sort 2 - Problem Solving

3 - Stress Relief

Page 16: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Methodological Perspective We Use Modeling Techniques

• Theoretical and Methodological Reasons

– What is the outcome? A single point in time? – For us, the trajectory of the response to PST over

time is important– Literature mixed about the response to PST – Concerns about pre-existing characteristics

resources, etc., that might not be equally distributed by randomization (particularly with small Ns)

– Use of all available data

Page 17: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Therapeutic Responses: Three Common Trajectories of Change in Response to Counseling

J.-P. Laurenceau et al. Clinical Psychology Review 2007

Page 18: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Does Problem-Solving Training for Family Caregivers Benefit Care Recipients? • We know that caregiver problem-solving styles

are associated with care recipient secondary complications – e.g., depression, pressure sores

• Care recipients reported less depression and improvements in QoL as their caregiver received PST – SCI; Elliott et al. 2008

• But we do not know the mechanisms by which PST for caregivers would influence care recipient adjustment

Page 19: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Would the Effects of Problem-Solving Training for Family Caregivers Benefit Care Recipients with TBI? • Prior study revealed that caregivers of persons with TBI

experienced a non-linear response to PST over time– Their depression scores first increased before decreasing

significantly in response to PST; Rivera et al. 2008• Other caregivers have often shown a more linear

trajectory in response to PST• We do not know if care recipients with TBI

would differ in their response to PST for caregivers• We need to know if effects are isolated to specific

conditions, and determine if the effects of PST are portable and generalizable across caregiver scenarios

Page 20: Problem-Solving Training Effects on Family Caregivers and Care Recipients

• Caregivers– 87.7% female– 74.8% Caucasian, 23.8% African American– Mean Age = 56.6 yrs.– Median duration caregiving = 55 months (Mean=132 mo.)– Relationship to recipient: 52% parents, 12% spouses, 5% siblings

• Care Recipients– 55.1% female– 76.8% Caucasian, 22.5% African American– Mean Age = 44.9 yrs.

PROJECT CLUES: MODELING EFFECTS OF PST ON FAMILY

CAREGIVERS AND CARE RECIPIENTS N = 147

Page 21: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST for Caregivers of Persons with Severe Disabilities

CLUES• Problem Solving Training

– Four face-to-face sessions in the caregiver residence with the interventionist• Baseline and at months 4, 8, 12

– Telephone sessions in other months• Interventionist adhered to a script

PST tailored to address specific problems identified by each caregiver at each session

Page 22: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Education “Control” Group• Monthly telephone calls• 10 minutes minimum each• CGs received a folder with information

to be read before each telephone contact

• Topics included: aging, dental health, disaster preparedness, relaxation, physical fitness, respite, pain

Page 23: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Exclusion Criteria• CGs had to be 18 years or older • Be clearly identified as a caregiver (by the caregiver

and the care recipient)• Live in the same household as the person with a

disability • Provide part-time or full-time care• CR had a diagnosed disability • Had to have a telephone at home to be in the project• Agree to random assignment group• Were knowledgeable of our duty to report any

possible abuse observed in or reported by the CR

Page 24: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Caregivers assessed for eligibilityn = 411

Excluded n = 264 Did not meet inclusion criteria

n = 122 Refused to participate

n = 58 No response to calls or letters

n = 67 Erratic behavior, did not keep

initial home appointment n = 17

Page 25: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Treatment Allocation

Groups did not differ significantly in• Caregiver or care recipient demographics

• Outside help or financial assistance• Caregiver burden or mental status

• Care Recipient mental status or functional independence

Page 26: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Care Recipient Medical Conditions

PSTN = 74

TBI = 35Cerebral Palsy = 10

Stroke = 14Mental Retardation = 5

Alzheimer's Disease = 2Multiple Sclerosis = 1

Autism = 1Angelman's Syndr. = 1

Polio = 1Fetal Hydantoin = 1

Tubular Sclerosis = 1Rett's Syndrome = 1

Prader-Willi = 1

ControlN = 73

TBI = 34Stroke = 12

Mental Retardation = 8Cerebral Palsy = 6

Dementia = 3Alzheimer's Disease = 2

Aneurysm = 1SCI = 1

Chronic Pain = 1Down's syndrome = 1Seizure disorder = 1

Arthritis = 1Scoliosis = 1

Muscular dystrophy = 1

Page 27: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Follow-Up

PSTLost to follow-up (n = 14) Unable to contact n = 2

Care recipient moved out of caregiver residence n = 2 Care recipient died n = 1 Care recipient placed in residential facility n = 3

Caregiver no longer interested

n = 2 Caregiver had a stroke n = 1 Caregiver inappropriate to

staffn = 1

No reasons recorded n = 2

Control

Lost to follow-up (n = 7) Unable to contact n = 1

Care recipient moved outn = 1

Care recipient died n = 2

Care recipient placed in residential facility n = 2 No reasons recorded

n = 1

Page 28: Problem-Solving Training Effects on Family Caregivers and Care Recipients

AnalysisN = 147 dyads

PSTAll four assessments = 44

Baseline only = 5 First and second assessments

only = 4 First, second and third

assessments only = 1 First, second and final

assessments only = 4 First and final assessments

only = 3 First and third assessments

only = 2 First, third and final

assessments only = 5 First and second assessments complete,

partial third only = 2

First, second and third complete, final partial

only = 2 First assessment complete,

second partial only = 1 First, third and final

assessments complete, second partial only = 1

ControlAll four assessments = 49

Baseline only = 2 First and second assessments

only = 3 First, second and third

assessments only = 1 First, second and final

assessments only = 6 First and final assessment

only = 3 First, third and final

assessments only = 4 First, second and third

assessments, and partial final only = 2

First and second assessments, third and final partials

only = 1 First, second and final

assessments, and third partial only = 1

First, third and final assessments, and second

partial only = 1

Page 29: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Outcome Measures• Caregiver Depression (CES-D)• Caregiver Physical Symptoms (PILL)• Caregiver Satisfaction with Life (SWL)• Caregiver Constructive PS (SPSI-R)

– Composite of Positive Problem Orientation and Rational Style

• Caregiver Dysfunctional PS (SPSI-R)– Composite of Negative Problem Orientation and Impulsive & Avoidant Styles

• Care Recipient depression (HAM-D)Assessments made by a data collection technician -- with no

knowledge of group assignment -- at pretreatment baseline, 4th month, 8th month, and 12th month

Page 30: Problem-Solving Training Effects on Family Caregivers and Care Recipients

OutcomeT1

OutcomeT2

OutcomeT3

OutcomeT4

TreatmentTx=1 Cn=0

Int Slope

A Latent Growth Model to Predict Outcomes

Page 31: Problem-Solving Training Effects on Family Caregivers and Care Recipients

LGM Results: Caregiver Outcomes

Caregiver Outcomes Slope SE t χ2 CFI RMSEA

Depression (CESD) -1.37 0.69 -1.99* 9.30 .99 .041

Physical Symptoms 0.08 0.35 0.24 8.32 .99 .036

Satisfaction with Life -0.29 0.37 -0.81 12.5 .98 .073

Constructive PS 2.21 0.86 2.57** 7.80 1.00 .028

Dysfunctional PS -1.40 0.61 -2.30* 10.2 .99 .056

Note. All χ2 ns, p>.05 * p<.05 ** p<.01

Page 32: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST Reduces Caregiver Depression Over 12 Months

1 2 3 410

11

12

13

14

15

16

17

18

19

20

ControlPST

Page 33: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST Produces Similar Effects on Depression for TBI and non-TBI Caregivers

1 2 3 410

12

14

16

18

20

22

24

PST (Other)CT (Other)PST (TBI)CT (TBI)

TBI

Other

Chi-sq. Difference tests: Significant intercepts between TBI and non-TBI (p<.01); Treatment effect on slopes not significantly different for TBI and non-TBI (p=.60).

Multiple Group Analysis (TBI vs Other)

Page 34: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST Reduces Caregiver Dysfunctional Problem Solving Over 12 Months

1 2 3 415

17

19

21

23

25

27

29

ControlPST

Page 35: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST Increases Caregiver Constructive Problem Solving Over 12 Months

1 2 3 452

54

56

58

60

62

64

66

ControlPST

Page 36: Problem-Solving Training Effects on Family Caregivers and Care Recipients

LGM Results: Care Recipient Depression

Slope SE t χ2 CFI RMSEA

Care Recipient

Depression (HAMD) -0.32 0.14 -2.37* 1.82 1.00 .000 Note. χ2 ns, p>.05 * p<.05

Page 37: Problem-Solving Training Effects on Family Caregivers and Care Recipients

PST Reduces Care Recipient Depression (HAMD) Over 12 Months

1 2 3 40

0.5

1

1.5

2

2.5

ControlPST

Page 38: Problem-Solving Training Effects on Family Caregivers and Care Recipients

How does PST for caregiversaffect care recipient

depression?• May be possible that caregiver mood (which was improving due

to treatment) can affect care recipient mood.• This phenomenon goes by many names: Emotional Contagion, Affective “Mirroring,” Emotional Convergence, Co-regulation, Emotional Transmission, and Social Entrainment (among others).• Many experience-sampling and diary studies find emotional

congruence in couples and families over time (Larsen & Almeida, 1999).

Page 39: Problem-Solving Training Effects on Family Caregivers and Care Recipients

HAMDT1

HAMDT2

HAMDT3

HAMDT4

HAMDInt

HAMDSlope

Overall Model FitChi-sq = 19.04, p=.94

CFI = .99RMSEA = .00

* p<.05

Parallel Process Mediation Model: Caregiver Depression (CES-D) and Care-Recipient Depression (HAMD)

CES-DT1

CES-DT2

CES-DT3

CES-DT4

CES-DInt

CES-DSlope

.04*.24*

TreatmentTx=1 Cn=0

-1.40*

Indirect Path (red arrows)Est. = -.33 (SE=.11), p < .01

Page 40: Problem-Solving Training Effects on Family Caregivers and Care Recipients

CES-DT1

CES-DT2

CES-DT3

CES-DT4

TreatmentTx=1 Cn=0

Int Slope

HAMDT1

HAMDT2

HAMDT3

HAMDT4

- 1.34*

.039** .038† .055** .059***

Overall Model FitChi-sq = 26.1, p=.46

CFI = .99RMSEA = .004

† p<.10 * p<.05 ** p<.01 *** p<.001

Direct Effects of Caregiver Depression (CES-D) on Care-Recipient Depression (HAMD)

Page 41: Problem-Solving Training Effects on Family Caregivers and Care Recipients

What We Have Learned

Caregivers benefit from tailored PST provided to them in the home via telephone sessions and face-to-face sessions

….but these benefits may occur for reasons that are not theoretically apparent

Care recipients may also benefit over time as their caregivers experience less distress in response to PST

Contemporary modeling techniques are necessary for understanding the apparent mechanisms of change and the nature of the therapeutic responses of caregivers and care recipients to PST

Page 42: Problem-Solving Training Effects on Family Caregivers and Care Recipients

Issues• Concerns about how clinically meaningful the

improvements may be for both caregiver and care recipients

• May be difficult to replicate “tailored” PST to caregivers, essential in the partnership model, in a multi-site clinical trial

• Reconsider inclusion criteria