Paediatric acquired brain injury (ABI) detrimentally impacts the child, parents, and entire family system. Increased rates of child behaviour difficulties, parent distress, and family dysfunction have been documented. However, there is a paucity of research investigating effective methods to support families following ABI. Since parents play an essential role in rehabilitation, and parent adjustment and child functioning are reciprocally related, this is a vital avenue for investigation. This thesis evaluates the use of an evidence-based behavioural family intervention, Group Stepping Stones Triple P (SSTP), plus an Acceptance and Commitment Therapy (ACT) workshop for parents of children with an ABI.
Firstly, the rationale for studies contained in this thesis will be provided through a brief review of pertinent issues relating to paediatric ABI, interventions trialed to date, and a description and review of the evidence for the interventions used in this project.
Secondly, a paper published in Brain Injury will detail a qualitative inquiry with parents and health professionals to explore the experiences, challenges, and support needs of parents of children with ABI. Thematic analysis indicated that parents experienced a range of intense and persistent emotions and relationship difficulties, and commonly used coping styles of disengagement and avoidance, each of which could pose further challenges to the parenting role. Parents also felt isolated, with a distinct lack of support and information. It is therefore suggested that intervention research focus not only on rehabilitation programs for the child, but also on providing information, skills, and support to parents in managing their child’s behaviour, and their own emotions and stress.
Next, a systematic review published in Journal of Head Trauma Rehabilitation reports on the efficacy of parenting interventions on child and parent behavioral and emotional outcomes in paediatric ABI. Eight eligible papers were identified, reporting on six trials of interventions involving parent training. Only one pre-post study trialed a version of a traditional, evidence-based parenting intervention. While remaining trials successfully implemented multi-component interventions including behaviour management, this review highlights the need for further quality trials assessing the unique effectiveness of evidence-based parenting interventions in this population.
A protocol paper published in Brain Impairment will then be presented to outline the plan of a wait-list randomised controlled trial (RCT) of Group SSTP plus an ACT workshop for paediatric ABI. The paper outlines the rationale, outcome measures, study procedures, study hypotheses and planned statistical analyses. Publication of a protocol prior to publication of study results allows for transparency in research methods, informs the research and clinical community of work in progress, and allows peer-review of study processes prior to study completion.
The results of this RCT will be reported across the two subsequent chapters, consisting of a manuscript accepted for publication at Journal of Child Psychology and Psychiatry, and a manuscript under review at Journal of Head Trauma and Rehabilitation. Fifty-nine parents were randomly assigned to either a treatment (SSTP and ACT program over 10 weeks) or a waitlist control condition (care as usual over 10 weeks). Post-intervention, treatment families showed significant improvements relative to the waitlist families on self-report measures of: child behavioural and emotional problems, parenting styles; parent confidence in managing behaviours; family adjustment; parent anxiety and stress symptoms; parent psychological flexibility; and number of disagreements between parents. The majority of improvements were maintained at 6-month follow-up. These results indicate that a combination of parent skills training and Acceptance and Commitment Therapy may be an effective intervention to improve child and parenting outcomes following paediatric ABI.
Finally, a paper currently under review at Journal of Contextual Behavioral Science will consider the benefits of adding ACT interventions to parenting interventions, based on available data in the RCT. Parent satisfaction results indicate high satisfaction with the ACT intervention and 83% of parents indicated a preference to receive ACT. Assessment of change from baseline to a mid-intervention timepoint (i.e. after ACT but before SSTP) for parent adjustment and psychological flexibility indicated a significant but small increase in parent stress, however this decreased significantly by the end of the full intervention). Correlational analyses showed a strong relationship between parent psychological flexibility (as targetted by ACT) and parenting style and parent psychological symptoms both cross-sectionally (at baseline) and longitudinally (from post-intervention to follow-up). Additional analyses suggest that changes in psychological flexibilty mediate the effects of treatment on parenting style and parent adjustment, however further trials assessing the proposed mediator and outcome variables at multiple time-points are needed to clarify the direction of these effects.
Results from this thesis suggest that behavioural family interventions, such as SSTP, are viable interventions to assist in improving outcomes for families in which a child has sustained an ABI. ACT-based interventions may provide valuable additional support to parents and should be further explored in this population. Future research directions and clinical implications will be discussed.