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Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

Aim

The psychological and psychiatric outcome of children with acquired brain injury is influenced by many variables. A review was undertaken to clarify the contribution of family function, how it relates to injury severity, and what particular aspects of family function influence psychological outcome in this group.

Method

A systematized review of the literature of studies published between 1970 and 2012 from OvidMedline, PsychoInfo, PsycARTICLES, and Cochrane was undertaken focusing on family function, injury severity, and psychiatric outcome.

Results

Thirty-six papers met the inclusion criteria. Injury severity was linked to the development of organic personality change. Family function before injury, measured by the Family Assessment Device or the Clinical Rating Scale, had a statistically significant effect on general psychological functioning in six out of eight studies. Family function had a significant effect for oppositional defiant disorder and secondary attention-deficit–hyperactivity disorder. The effects of family function may differ depending on the age of the child and the severity of the injury. Some styles of parenting moderated recovery. After injury, family function was related to the child's contemporaneous psychiatric symptoms. The level of evidence for these papers was 3 or 4 (Oxford Centre for Evidence-based Medicine criteria).

Interpretation

Screening for some aspects of family functioning before injury and family function during the rehabilitation phase may identify children at risk of psychiatric disorders.

Abbreviations
ABI

Acquired brain injury

CBCL

Child Behavior Checklist

FAD-GF

Family Assessment Device, General function

GCS

Glasgow Coma Scale

ODD

Oppositional defiant disorder

PAS

Psychosocial Adversity Scale

PTA

Post-traumatic amnesia

SADHD

Secondary attention-deficit-hyperactivity disorder

Acquired brain injury (ABI) is a leading cause of mortality and morbidity in children. It often has long-term effects on their physical, cognitive, and emotional well-being. Between 5% and 72% of children are reported to have significant emotional, behavioural, and cognitive changes after ABI, with most studies reporting a prevalence of between 40% and 70%.[1] Cognitive outcome seems to be strongly related to severity of injury,[2] but the factors influencing psychiatric outcome seem to be more varied. Studies have suggested that the behavioural, emotional, and psychiatric outcome of children depends on injury variables (e.g. severity, immediate complications), child factors (e.g. age, pre-injury functioning), and environmental aspects (e.g. socio-economic status, family function); however, their relative contribution is debated.

From the clinical perspective, it is important to focus on aspects that are modifiable by intervention. Family function may be amenable to change. There are, however, different points of view regarding its importance in influencing the psychiatric outcome of children after brain injury. The difference of opinion may be due to methodological differences in various papers. First, the child's psychiatric outcome and family function influence each other,[3-6] therefore, finding a significant association between the two variables does not prove causality. In addition, family function changes over time[7-9] and, therefore it is important to know whether family function was measured pre-injury or, if post injury, how long after injury it was measured. Other methodological issues such as the aspect of family function being measured (overprotection, parenting style, communication, adaptability), as well as how these aspects interact with child factors (age, child function) and injury factors (severity), are dealt with differently by the researchers in the field and may explain the different results.

In a systematic review of psychological interventions in ABI, Ross et al.[10] noted that some interventions targeting families have shown encouraging results on children's functioning.[11-14] It is, therefore, clinically important to establish (1) in which cases family function should be a focus for intervention, and in what aspects; (2) whether it is possible to identify at an early stage which families are likely to need help; and (3) when the interventions should be offered.

Given the relevance of this topic from the clinical point of view, we undertook a systematized review of predictors of psychiatric, behavioural, or emotional outcome, looking particularly at family function before injury and its interaction with severity of injury.

To organize the data the following questions seem to be important: (1) Is severity of injury always a predictor of psychiatric outcome? If not, what are the differences between the studies that find a correlation and those that do not? For example, could the association be confounded by another variable such as pre-injury psychiatric disorder, length of follow-up, age of the child, or measures used? (2) What is the relationship between family function and post-injury psychiatric disorder? Moreover, is post-injury family function or pre-injury family function more important in the prediction of outcome? (3) Is there any interaction between family function and injury severity that affects psychiatric outcome? (4) Is there any particular aspect of family function that is more important in terms of psychiatric disorder?

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

Search strategy

A literature search of studies published between 1970 and 2012 was conducted of OvidMedline, PsychoInfo, PsycARTICLES, Ovid Nursing, and Cochrane by using the following text words: (1) acquired brain injur* or acquired head injur* or traumatic brain injur* or traumatic head injur*; (2) family; and (3) behav* outcome or psych* outcome or emotional disorder or depression or anxiety or post-traumatic stress disorder or ADHD or OCD or PTSD or psychosis or schizo*. A second search with the text words (1) acquired brain injur* or acquired head injur*; (2) children; (3) family; and (4) outcome was carried out.

Both searches were limited to children (aged 0–18y) and to the years 1970 to 2012. The two searches gave 338 references. The abstracts of the references were examined. The inclusion criteria were as follows: (1) all participants in the sample were children (18y or younger); (2) the number of participants in the sample was specified; (3) standardized measures or assessments of psychological/psychiatric outcomes and of family functioning were used; (4) one of the outcome measures of the study was a measure of psychiatric/psychological outcome in children with ABI; and (5) a pre-injury assessment of family functioning was carried out. The following types of studies were excluded: (1) studies with a mixed sample of adults and children; (2) studies described in review articles or book chapters but that did not include the data from the original studies; and (3) studies that reported outcomes only of cognitive function.

Thirty-six papers were examined in detail and are summarized in Tables 1, 2, and 3. We looked at the methodological issues and the level of evidence following the scheme suggested by the Oxford Centre for Evidence Based Medicine.[15] The level of evidence for each paper is reported in Tables 1, 2, and 3. A detailed analysis of the sources of bias for each paper is given in Appendix SI (online supporting information).

Table 1. Predictors of psychiatric outcome: novel psychiatric disorder
AuthorAge atinjury, y n Outcome measureLength of follow-upSeverity measure and significance levelPre-injury family function measure and significance levelOther predictors of psychiatric outcomeLevel of evidence (see Appendix SI)
  1. A brief description of these measures can be found online in Appendix SII. aNew psychiatric disorder after acquired brain injury. GCS, Glasgow Coma Scale; CRS, Clinical Rating Scale (McMasters Model); FAD, Family Assessment Device; PTA, post-traumatic amnesia; PAS, Psychosocial Adversity Scale; NS, not significant; mod, moderate; sev, severe.

Max et al.[16]6–1450 (mild=17, mod=9, sev=11)Novel psychiatric disorder0–3moLowest GCS score, p=0.02CRS and FAD combined, p=0.02Pre-injury psychiatric disorder, family history of psychiatric disorder, socio-economic status4
Max et al.[17]6–14 (including cases from previous study and additional cases)41 (mild=20, mod=9, sev=12)Novel psychiatric disorder3–6moLowest GCS score, p=0.012p=0.019Family history of psychiatric disorder4
Max et al.[18]Follow-up from Max et al.[17]43 (mild=21, mod=9, sev=13)Novel psychiatric disorder6–12moLowest GCS score, p=0.059p=0.02Family history of psychiatric disorder, Vineland Adaptive function, socio-economic status4
Max et al.[19]Follow-up from Max et al.[17]42 (mild=20, mod=9, sev=13)Novel psychiatric disorder12–24moLowest GCS score, p=0.009p=0.01Pre-morbid psychiatric disorder4
Brown et al.[20]5–1460 (PTA<1wk, n=29; PTA>1wk, n=31)Psychiatric disorder12mo and 30moPTA severe vs orthopaedic control comparison: 12mo, p=0.02; 30mo, p=0.09; mild vs orthop controls 12mo NS 30mo NSPAS significant for severe head injury group but not for mild head injury group at 12mo and 30moPre-injury behaviour, intellectual impairment4
Table 2. Predictors of change in measures of psychological functioning
AuthorAge atinjury, y n Outcome measureLength of follow-upSeverity measure and significance levelPre-injury family function measure and significance levelOther predictors of psychiatric outcomeLevel of evidence
  1. For information regarding all measures in this table, see Appendix SII. CBCL, Child Behaviour Checklist; CBCL-T, Child Behaviour Checklist Teachers form; PTA, post-traumatic amnesia; FAD-BC, Family Assessment Device – behaviour control subscale; FBII, Family Burden of Injury Interview; GCS, Glasgow Coma Scale; LSSRI, Life Stressors and Social Resources Inventory; FAD-GF, Family Assessment Device – general functioning subscale; BSI, Brief Symptom Inventory; TRF, Teachers Report form; NS, not significant; SCI, Socio-economic Composite Index (including occupational status, income and resources); FAD, Family Assessment Device; Vineland Socialization, Vineland Adaptive Behaviour checklist Socialization Subscale; PIC, Personality Inventory for Children; FFS, family functioning Scales Intimacy factor; FFQ, Family Functioning Questionnaire; BRI, Rowe Behavioural Rating Inventory; PKBS-2, pre-school and kinder garden behaviour scales; HCSBS, home and community social behaviour scales; HOME, home observation of measures of environment; TRF-CBCL, Teachers Report Form of CBCL; NYU-SO, New York University Problem Checklist for Significant Other; FIRS, Family Interview Rating Scale (GF-FIRS, general subscale; Behaviour-FIRS, subscales of child behaviour); Social CBCL, social subscale of CBCL; Behaviour CBCL, behaviour subscale of CBCL; HBI, Health Behaviour Inventory; PCI, post-concussive symptoms interview; LISRES-A, Life Stressors and Social Resources Inventory – Adult Form; FGAS, Family Global Assessment Scale; mod, moderate; sev, severe.

Taylor et al.[21]6–1242 (mod, sev)CBCL, CBCL-T6moPTA p<0.05FAD-BC pre-injury, p<0.01Pre-injury behaviour, FBII at 6mo, p<0.014
Yates et al.[22]6–12109 (mod=53, sev=56), orthopaedic injuries=80CBCL, CBCL-T6 and 12moLowest GCS score sev/mod, p<0.01Combined measure of LSSRI, FAD-GF, FBII, parent BSI, pre-injury predicted behaviour problems at 6mo and 12mo, p=0.001Pre-injury behaviour3
Taylor et al.[23]Follow-up from Yeates et al.[22]94 (mod=52, sev=42), orthopaedic injuries=80CBCL, CBCL-T6 and 12moLowest GCS score; sev/mod 6mo, p<0.001; 12mo, p<0.001BSI, family status pre-injury relationship to outcome not analysedFBII and/or parental distress on BSI at 6mo and 12mo predicted concurrent child function3
Taylor et al.[24]Follow-up from Yeates et al.[22]109 (mod=56, sev=53), comparison=80CBCL, TRF6mo, 12mo, and 4y 1mo (range 2y 5mo to 5y 10mo)6mo, p<0.01; 12mo, p<0.01; 4y 1mo, p<0.01Family Stressors Score, Family Resources Score, pre-injury, NSSCI (composite socio-economic status) (low stress facilitates the recovery of severe head injury from 6mo 12mo)4
Schwartz.[25]Follow-up from Yeates et al.[22]83 (mod=42, sev=41), comparison=50CBCL, TRF4y 1mo (range 2y 8mo to 5y 10mo)GCS score, sev/mod, p<0.05FAD pre-injury, NS; FBII, NSPre-injury CBCL, SCI, concurrent FAD-GF and FBII4
Yeates et al.[26]Follow-up from Yeates et al.[22]109 (mod=56, sev=59), comparison=80Social competence CBCL, Vineland socialization6mo, 12mo, and 4y 1moGCS score; 6mo, significant; 12mo, significant; 4y 1mo, significantFAD-GF interacted with severity at 6mo and 12mo, p<0.01; at 4y, NSSCI, pre-injury social competence, family resources4
Fay et al.[27]Follow-up from Yeates et al. [22]77 (mod=40, sev=37)Total behaviour score in CBCL vs no deficit, p<0.054yGCS score, p<0.05FAD, NSSevere group more likely than moderate injury to show deterioration over time p=0.03, pre-injury CBCL, socio-economic status4
Anderson et al.[28]2–6.1184 (mild=14, mod=26, sev=24)PIC30moGCS score at 24 h, NSFFS, p=0.094Pre-injury behaviour, FBII at 30mo, p<0.001; FFQ at 30mo, p=0.0013
Anderson et al.[29]2–12112 (mild=31, mod=52, sev=29)PIC, BRI6moGCS score at 24 h, NSFFS (intimacy factor) pre-injury NSFFS at 6mo, p=0.0074
Anderson et al.[31]3–12.11150PIC, BRI30mop=0.06FFS pre-injury, NSAge, pre-injury adaptive behaviour, FBII at 6mo, p=0.014
Anderson et al.[30]2–748, (mild=11, mod=22, sev=15)PIC5yGCS score, p=0.01FFQ (intimacy), NSPre-injury behaviour4
Yeates et al.[32]3–699 (mod=79, sev=20)CBCL, PKBS-2, and HCSBS combined6, 12, and 18moGCS, CBCL, NS; PKBS-2 and HCSBS combined, p=0.003FAD-GF pre-injury predicts behaviour at 18mo, p<0.04; HOME, NSPre-injury behaviour, socio-economic status, partner at home, specific aspects of parenting (see Table 3)4
Rivara et al.[33, 34]6–1594 (mild=50, mod=25, sev=19)TRF-CBCL, CBCL, NYU-SO, Behaviour- FIRS, GF-FIRS3moAdaptive TRF NS, social CBCL p=0.002, GF-FIRS p=0.008   
    1yBehaviour CBCL NS, TRF-CBCL NS, NYU-SO NS, social CBCL p=0.005, behaviour-FIRS p<0.01Relationship–FIRS p<0.001, FGAS p<0.01Pre-injury child functioning, family function at 1y correlated with child function at 1y4
Yeates et al.[35]8–15186 (mild), comparison group (orthopaedic injury)=89PCI (somatic, cognitive, emotional), CBCL, HBI3 wk, 1, 3, and 12moGCS score (13–14) with loss of consciousness vs orthopaedic injury, p<0.001; in measures of PCI and HBI, GCS score (3–14) with no loss of consciousness vs orthopaedic injury, NSFGA-GF: better family function predicted more parent-rated PCI somatic symptoms, p=0.02; LISRES-A: more family resources predicted more parent-rated PCI somatic symptomsPre-morbid CBCL, pre-morbid symptoms, sex (female)4
Table 3. Predictors of outcome for specific psychiatric disorders and specific psychological symptoms
AuthorAge atinjury, y n OutcomeLength of follow upSeverityFamilyfunctionOtherLevel of evidence
  1. NS, not significant; FAD Family Assessment Device; n/a, not applicable; PAS, psychosocial adversity composite measure of environment and family factors; GCS, Glasgow Coma Scale; CRS, Clinical Rating Scale (McMasters Model); CBCL, Child Behaviour Checklist; FAD-GF, Family Assessment Device General Functioning Subscale; ODD, oppositional defiant disorder; ADHD, attention-deficit–hyperactivity disorder; mod, moderate; sev, severe.

Max et al.[36]5–14177 (mild=64, mod=27, sev=56)Anxiety disorder definite and probable, yes/no6moNSFAD, NSYounger age, lesions in superior frontal gyrus, concomitant depression or personality change4
Vassa et al.[37]4–1997 (all sev)Anxiety disorders1ySevere only, n/aPAS, NSAge (younger), pre-injury anxiety4
Grados et al.[38] (parent study Gerring et al. 2002[64])6–1880 (all sev)Obsessive–compulsive symptoms Severe only, n/aPAS, p<0.005Female gender4
Max et al.[39] (from Max et al. 1997[19])6–1450 (mild=26, mod=9, sev=15)Post-traumatic stress symptoms3, 6, 12, and 24moLowest GCS score; 3mo, NS; 6mo, p=0.003; 12mo, p=0.001; 24mo, NSCRS: 3mo, p=0.034; 6mo, NS; 12mo, p=0.054; 24mo, p=0.057Internalizing disorders pre-injury4
Kirkwood et al.[40] (parent study Taylor et al. [21]) 89 (mod=51, sev=38), orthopaedic=55Depression, child depression inventory, CBCL6mo and 1yLowest GCS; 6mo, NS; 1y, NSFAD, NSSocio-economic status was significantly related to depression in all groups4
Max et al.[41, 42]5–1494 (mild–mod=57, sev=37)Persistent personality change2yLowest GCS, p=0.007CRS, NSIQ, child function4
Max et al.[43]5–14177, mean lowest GCS=10.8 (4.2)Personality change6moLowest GCS, p<0.001FAD-GF, NSAssociated with other disorders, significantly associated with some locations4
Max et al.[44]Follow-up from Max et al.[44]177, mean lowest GCS=10.8 (4.2)Personality change6–12mo and 12–24mo6–12mo, p=0.03; 12–24mo, p=0.026–12mo, NS; 12–24mo, NSPre-injury psychosocial adversity trend, associated with white matter lesions in the frontal lobe4
Max et al.[45]6–1450 (mild=26, mod=9, sev=15)ODD symptoms3mo, 6mo, 12mo, and 24moLowest GCS score: 3mo, NS; 6mo, NS; 12mo, N; 24mo, F<0.004CRS: 3mo, F<0.04; 6mo, F≤0.0002; 12mo; F<0.001; 24mo, NSPre-injury oppositional symptoms and socio-economic status significant at 6mo and 12mo4
Max et al. [46]6–1450 (mild=17, mod=12, sev=17)ODD and ADHD5y (SD 4y)Lowest GCS score: novel ODD vs never ODD, p<0.05; novel ADHD vs no ADHD, NSCRS; novel ODD vs never ODD, p<0.001; novel ADHD vs non-ADHD, NS 4
Gerring et al.[47] 99 (mod=10, sev=89)Secondary ADHD1yNSPAS, p<0.01 4
Max et al.[48]6–1450 (mild=26, mod=9, sev=15)New secondary ADHD3mo, 6mo, 12mo, and 24moLowest GCS score: 3mo, p=0.001; 6mo, p=0.001; 12mo, p=0.001; 24mo, p=0.001CRS, p<0.03Socio-economic status NS4
Max et al. [49]5–1498New secondary ADHD, yes/no6mo–42moLowest GCS score, p=0.009CRS, p=0.001Socio-economic status, family psychiatric history4
Max et al. [50]5–14143Secondary ADHD6moLowest GCS score, NSPre-injury FAD-GF, NS; PAS, p=0.07Socio-economic status, p=0.007; orbitofrontal gyrus lesions4
Max et al. [51]Follow-up from Max et al. [51]143Secondary ADHD6–12mo and 12–24mo6–12mo, NS; 12–24mo, NSPre-injury FAD- GF, NS; PAS, p=0.01 (for both 6–12mo and 12–24mo)Pre-injury function Vineland, socio-economic status4

In addition, with regard to question 4, a further search of the same databases was carried out using the following keywords: (1) brain injury or head injury; and (2) parent–child interaction or disciplinary practice* or discipline or parenting. The search had the same limits as the previous search. This search gave a total of 10 references. Inclusion and exclusion criteria were the same as in the previous search. In total, five references were obtained, and these will be discussed in the last section of this paper.

Results

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

The 36 studies were divided into three groups. This gave five studies that looked at the existence of any psychiatric diagnosis in general using a dichotomous outcome measure (Table 1),[16-20] 15 studies that looked at psychopathological outcome using continuous measures of emotion and behaviour (Table 2),[20-35] and 16 studies that looked at specific psychiatric conditions or psychological symptoms (Table 3).[36-51] Of the 15 papers that looked at general psychopathology, seven (Taylor et al.,[21, 23, 24] Yeates et al.,[22, 26] Schwartz et al.,[25] and Fay et al.[27]) studied different aspects of psychological functioning at different points of follow-up in one cohort; the papers on psychiatric diagnosis (Table 2) included four studies (Max et al.[16-19]) that followed up one cohort of patients.

Is severity of injury always a predictor of outcome?

Children with severe head injury are more likely to experience deterioration in behaviour over time; the behaviour of children with mild to moderate head injury has a more fluctuating course.[26-29]

The relative importance of severity changes with time, and it depends on the outcome being measured. It was found to be a statistically significant predictor of a psychiatric diagnosis in four of the five papers that looked at this (Table 1). The exception was the 12-month follow-up by Max et al.,[18] in which severity approached significance.

Severity was also significantly related to outcome in 13 of the 15 studies that looked at psychological disturbance. The exceptions were the studies by Anderson et al.,[29, 31] in which the proportion of children with psychological disturbance was around 20%, which is much less than in other studies. In Anderson et al.,[28] although the Glasgow Coma Scale (GCS) score was not significantly predictive of behavioural outcome at 30 months of age in the regression analysis, it was clear that children with severe injuries were significantly more impaired than children with mild and moderate injuries and that their condition deteriorated more over time. Interestingly, some studies[32-34] found that the severity of injury was a statistically significant predictor of some measures of outcome but not others. The only study that was confined to mild head injuries[35] found that loss of consciousness was associated with a greater persistence of symptoms.

Most studies use the lowest GCS score as the measure of severity. One study[20] used post-traumatic amnesia (PTA) as a measure of severity and related it to the prediction of psychiatric disorder. It found no difference in the rate of psychiatric disorder between children who had suffered a mild head injury and a comparison group with orthopaedic injuries, but a large increase in the prevalence of psychiatric disorder was noted in children in whom PTA lasted more than 1 week; after that point there was a dose–response relationship between severity and the frequency of psychiatric disorder in their sample. Another study[21] found PTA to be a predictor of psychological adjustment as measured by the Child Behavior Checklist (CBCL).

After head injury, the most frequent diagnoses are organic personality change, oppositional defiant disorder (ODD), and secondary attention-deficit- hyperactivity disorder (SADHD).[18] Children may also suffer from anxiety,[36, 37] obsessive–compulsive symptoms,[38] post-traumatic symptoms,[39] and other emotional problems.[40] The factors that predict the development of various disorders vary. Persistent organic personality change[41-44] occurs only in children who have suffered a severe brain injury; however, severity is not a statistically significant influence when the outcome is depression or anxiety. Indeed, Max et al.[36] found higher rates of anxiety disorder in children with mild head injury than in those with severe head injury at the 6-month follow-up. The results regarding the influence of severity on development of ODD are mixed,[45, 46] with the suggestion that ODD symptoms improve in the mild/moderate group after 1 year, but persist in the severe group.

Five studies have looked at SADHD[47-51] (ADHD that was not present before injury and was a new diagnosis after injury). Severity of injury was found to be a predictor in two studies, but others, such as Gerring et al.[47] and Max et al.,[50, 51] did not find a significant association. This may be because of the narrower range of severity of injury in these studies: Gerring et al. mainly focused on children with severe brain injury and in the study by Max et al.[50, 51] the sample was skewed towards severe brain injury. Max et al.[50] also found that the development of SADHD was related to regions in the orbitofrontal gyrus in the first 6 months and was related to psychosocial variables in the 24-month follow-up. Interestingly, SADHD may not be a permanent complication and may resolve in some cases after about 18 months.

In summary, severity of injury seems to be related to psychopathology in general, and to particular types of psychiatric disorder such as organic personality change, but not to others, such as depression and anxiety. Methodological issues, however (see below), preclude reaching firm conclusions.

What is the relationship between family function (pre and post-injury) and post-injury psychiatric disorder?

Of the 20 studies in Tables 1 and 2, 13 used measures of pre-injury rating derived from the McMaster model, the Family Assessment Device General function (FAD-GF), or the Clinical Rating Scale on their own or in combination with other measures. The five studies of psychiatric disorder in general found that family function had a significant effect.

The results of the 15 studies in which psychological distress was the outcome (Table 2) varied depending on the measure of family function used and the length of follow-up. Of the nine studies using the FAD alone or in combination, seven found a significant effect; Schwartz et al.[25] found no significant effect of pre-injury FAD-GF on psychological outcome when the length of the follow-up was 2 years or more, and Yeates et al.[26] found a significant effect of pre-injury family function at 12 months but not at 4 years. The study by Yeates et al.[35] was the only one that looked at the relationship between mild head injury (defined as a GCS score between 13 and 15 with or without loss of consciousness) and post-concussional symptoms (somatic, emotional, cognitive). This was the only study that found a significant negative effect, with better functioning predicting more symptoms. The authors relate this to the parents being more sensitive to functional change.

Studies that have looked at family functioning after injury with the Family Burden of Injury Interview, the Family Functioning Scales, or FAD have found a significant effect on children's contemporary psychological measures.

Family functioning before injury predicts the development of some psychiatric disorders but not others. Poor pre-injury family functioning seems to be particularly related to ODD after injury and also to post-traumatic symptoms at 3 months. The association with SADHD is more doubtful. If children with mild to severe injuries are included in the study,[48, 49] family function measured by FAD or the Clinical Rating Scale is a predictor and it has a moderate effect size[49]; however, the effect of family function is lost if the sample analysed contains mainly children with severe head injury.[49-51] In the latter case, a high percentage of children suffer from SADHD. Overall, the studies suggest that family function before injury may be more influential in the development of SADHD when children experience mild to moderate head injuries. If the injury is severe, the likelihood of developing SADHD is high, even if the family function is good. The development of SADHD seems to be influenced by socio-economic status. The Psychosocial Adversity Scale (PAS) includes measures of socio-economic status and family function; pre-injury PAS is a significant predictor of the development of SADHD.[47]

Brown et al.[20] studied the rate of any psychiatric disorder at 12 months and at 30 months after injury. High psychosocial adversity, as measured by the PAS, significantly increased the risk of psychiatric disorder in children with severe brain injury but not in children with mild brain injury, in whom the psychiatric disorder after injury was mainly influenced by psychiatric disorder before the injury. This would appear to be in contradiction to the studies of SADHD specifically, either because Brown et al.[20] used a different measure of family function or because they looked at all psychiatric disorders including ODD, which seems to be particularly influenced by family function.

In summary, the effects of pre-injury family function on outcome depend on the measure of family function being used and the outcome being studied, together with other issues such as the length of follow-up and the severity of injury. It would seem that poor family functioning before injury influences short-term (<2y) psychological distress and the development of some psychiatric disorders such as ODD. In the case of mild head injury, the effect was in the opposite direction to that of severe injury, with better-functioning families reporting more symptoms. Poor concurrent family functioning has an adverse effect on children's psychological adjustment. Conclusions need to be provisional in the light of methodological issues.

Methodological issues

There are significant difficulties in the methodology of some of the papers. Some studies are cohort studies and use children with orthopaedic injuries but no central nervous system involvement as a comparison group, but some are case series. The level of evidence attached to studies that look at prognostic factors is, according to the Oxford Centre for Evidence Based Medicine,[15] never the highest and such studies are sometimes prone to bias. We have followed the Cochrane Collaboration's tool[52] for assessing risk of bias in each study. The summary is given in Appendix SI.

A further source of confusion is that seven papers refer to one sample of participants (Taylor et al.,[21, 23, 24] Yeates et al.,[22, 26] Schwartz et al.,[25] and Fay et al.[27]), four papers to another sample (Max et al.[16-19]), and Anderson et al.[30, 31] to another sample. The possible bias in the selection of the initial sample becomes perpetuated at follow-up; for example, in the studies by Max et al. more of the patients with severe head injury agreed to participate. If, as it seems, severity is related to outcome, it is possible that the frequency of psychiatric disorder in children with head injury could be overestimated in each study that uses this sample.

Measurement issues are a source of concern for most of the studies. When there has been a particular issue in a paper, this is noted in the column headed ‘other methodological issues’ in Appendix SI. A description of the measures is given in Appendix SII (online supporting information). Studies generally use GCS or PTA as the measure of severity. These measures are correlated and have been found to relate to functional outcome in other papers.[53]

The measures of pre-injury family and child function are carried out after injury. This introduces a source of bias. In addition, when the measure of pre-injury family functioning is unpublished,[28-31] it is difficult to ascertain its validity. Psychiatric disorder before injury was assessed as soon as possible after the injury. Some of the psychiatric problems rated as ‘new’ may not have been so apparent before injury because of the child's younger age, milder symptoms, or recall issues. It is well known that children with psychiatric disorders have high levels of unintentional injuries.[54] Recall issues and social desirability may also affect the measures of family function.

Except for the studies by Yeates et al.[22] and Rivara et al. 1994[33], the studies selected did not have the issue of pre-injury family functioning in relation to psychiatric outcome as their primary aim; they all examined this issue using a variety of methods of analysis and comparisons with different groups (sometimes a comparison group of orthopaedic patients, sometimes mild vs severe) that made meta-analysis impossible.

In summary, the evidence from most papers is only at level 3 or 4, which does not allow firm conclusions to be drawn regarding the effect of pre-injury family functioning on outcome. Nevertheless, the evidence from most papers seems to be that severity is an important predictor and that pre-injury family function affects the development of some types of psychiatric disorder or affects recovery.

Is there any interaction between family function and injury severity that affects psychiatric outcome?

Yeates et al.[26] found that the effects of family dysfunction on measures of social competence were different depending on the severity. Social competence in children with severe injury deteriorated from 6 to 12 months whatever the level family function. Children with moderate brain injury with good family functioning experienced an improvement in their social scale of CBCL from 6 to 12 months, although if they had poor family function they experienced a deterioration.

The effects of family functioning may be different depending on the age of the child. Yeates et al.[32] studied the effects of family environment and severity of illness in a group of 3- to 6-year-old children and compared this with studies by the same authors of 6- to 12-year-old children.[22-24] They concluded that, in children with severe head injury, the moderating effects of family environment were more apparent in older children; the younger group with severe injury showed a high frequency of deficits by 18 months, regardless of the family environment. In the younger age group, family environment had more effect on the outcome of children with moderate brain injury than on children with severe brain injury, although the reverse was true in the older group.

In summary, the effects of family function are particularly relevant for some measures of outcome and for the children with moderate head injury, with some evidence of particular effects depending on the age of the child.

Is there any particular aspect of family function that is more important in terms of psychiatric disorder?

Wamboldt and Wamboldt[55] reviewed the role of the family in chronic illness and they suggested that families manage the extra burden and stress by increasing organization and structure, sometimes at the expense of emotional warmth. There is some evidence that high levels of conflict and criticism may lead to poor adherence in chronic illness and that the mental health of children is mediated by how well the family functions in general.

High parental distress and psychiatric disorder in parents have been found to be predictors of poor psychiatric outcome in children in various studies.[16-18, 56] The study by Yeates et al.[32] of 3- to 6-year-old children looked at parenting style and how this may affect outcome. They used the Parenting Practices Questionnaire, which classifies parenting into authoritarian, authoritative, and permissive parenting. Authoritarian parents are directive, highly demanding and non-responsive; authoritative parents are directive and responsive; and permissive or indulgent parents are more responsive than demanding. The effect of the different styles differed depending on the time since injury and severity of the injury. Authoritative parenting led to a better outcome over time. For children with severe head injury, the family environment was particularly important in determining the outcome in the short term, but by 18 months children with severe head injury showed deficits regardless of the family environment. Authoritarian parenting was associated with better behavioural outcomes at 6 months but worse outcomes at 18 months. The same group of children was studied by Chapman et al.,[57] who found deficits in social competence increasing at 18 months after injury and this was linked to family dysfunction and permissive parenting.

Woods et al.[58] looked at disciplinary practices in parents of 3- to 12-year-old children using the Parenting Scale, which measures the aspects of laxness, over-reactivity, and verbosity. Compared with the parents of children with orthopaedic injuries, the parents of children with mild and severe head injury were more likely to engage in dysfunctional, over-reactive disciplinary strategies, whereas the parents of children with moderate head injury engaged in lax disciplinary practices more frequently than the parents of children with orthopaedic injuries. Laxness was related to internalizing symptoms and laxness and over-reactivity were related to externalizing symptoms in the CBCL. Parents may be influenced in their parenting by the severity of injury and their own mental state. Parents who engaged in highly dysfunctional practices had children with more severe ABI, more depressive symptoms, more adversity, and more behavioural problems.

Other studies[58, 60] have observed the interaction of parents and children soon after the head injury[59] and followed them up for 6 months.[61] Immediately after the injury, parents of children with brain injury were found to be more directive in a structured task than the parents of comparison children with orthopaedic injuries. Children's cooperation was less related to parental warmth and responsiveness in the head injury group than in the orthopaedic injury group. Six months later, parental distress was related to the outcome in the CBCL. Family function measured by FAD-GF was predictive of internalizing symptoms at 6 months. Parental negativity shortly after brain injury was related to externalizing problems 6 months later, particularly for the severe head injury group. Warm responsiveness initially did not predict outcome for children with a severe injury at 6 months, but the children of parents who were rated as warm-reactive at 6 months had less externalizing, internalizing, and ADHD symptoms.

In a study with older children (mean age 9y) Wade et al.[61] found that the level of conflict in the parent–child interaction did not differ across severity. High levels of conflict were related to depression and high CBCL total scores.

Discussion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

The aim of this review was to look at the relationships between injury severity, family function, and psychiatric outcome in children with acquired brain injury. Severity is an important predictor of outcome; family function before injury affects psychiatric outcome possibly up to 2 years after head injury and also affects recovery. The effects of family function may, at times, be overshadowed by the catastrophic effect of a severe injury, but this does not mean that family function is not important in helping recovery. These conclusions need to be viewed with caution in view of the methodological limitations. We were surprised to find no study attempting to measure overprotection, overindulgence after injury, parental guilt after injury, or parental post-traumatic stress disorder, as clinical studies in other types of injury[63] have indicated that these variables seem to affect psychiatric outcome.

Practical implications

The results of this study indicate that it would be useful to screen for certain aspects of pre-injury family function in the acute period after a brain injury, perhaps using the PAS or FAD-GF, and families above cut-off points should be offered intervention.

Children with a severe brain injury are at high risk of a psychiatric disorder. These families, in particular, should be offered intervention. Family burden and family function should be measured regularly at follow-up because of its relationship with psychiatric disorder and intervention should be offered if needed.

The intervention may be aimed at screening parents for a psychiatric disorder and referral for treatment if needed, in order to promote warmth, reduce criticism, and engage families in sensitive, authoritative parenting.

Future researchers should include measures of the effect size in the prediction of outcome, investigate the effects of different aspects of family function on outcome depending on the age of the child and the stage of recovery, and take into account that the causative insult may not be independent of both child and family factors.

Limitations and conclusions

The studies selected for this review had to include measures of child psychiatric outcome and family function before injury; some well-known psychiatric outcome studies were excluded as they did not meet this inclusion criterion. We acknowledge that the relationship between family function after injury and children's psychiatric disorder is bidirectional.[4, 7, 9, 62]

We specifically looked at family function and its relationship to psychiatric outcome because it may be modifiable by intervention. Other variables, such as child pre-injury function and age, emerge in the literature as important and may interact with severity and family function, but these issues were beyond the scope of this review.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information

This research is part of the doctoral thesis of the first author at the Department of Psychiatry and Forensic Medicine, Bellatera (Barcelona), Universitat Autonoma de Barcelona, Spain.

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  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Acknowledgements
  7. References
  8. Supporting Information
FilenameFormatSizeDescription
dmcn12237-sup-0001-AppendixS1.docWord document108K

Appendix SI: Methodological issues.

Table SI Predictors of psychiatric outcome: novel psychiatric disorder.

Table SII: Predictors of change in measures of psychological functioning.

Table SIII: Predictors of outcome for specific issues.

dmcn12237-sup-0002-AppendixS2.docWord document69KAppendix SII: Description of measures.

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.