The Impact of TBI on Parenting

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The Impact of TBI on Parenting

• Mary R. Hibbard, Ph.D., ABPP (RP)
• Professor
• Department of Rehabilitation Medicine
• Mount Sinai School of Medicine
• New York New York
• Rehabilitation Research and Training Center on
  Traumatic Brain Injury Interventions
• Mount Sinai School of Medicine, New York NY
• Supported in part by Grant No. H133B040033, from
  the National Institute on Disability and
  Rehabilitation Research, U.S. Department of
  Education

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Objectives

• Review of research on parenting and TBI
• Highlight challenges identified in parenting for
  similar disability groups
• Challenges in assessing the impact of TBI on
  parenting and the family
• Suggested research agenda

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Need for Parenting Research in TBI

• Majority of adult TBIs occur prior to the age of
  35
• Children with TBI become adults who marry and
  have children
• Many children are (or will be) raised in families
  where one parent has experienced a TBI
• TBI challenges may selectively impact cognitive
  and behavioral abilities needed for effective
  parenting

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Parenting After TBI

• Urbach and Culbert (1991)
• 3 case studies of impact of fathers TBI on
  children
• On interviews, children presented with
• Increased emotional and conduct disturbances
  (somatic symptoms, levels of activity, increased
  dependence, school failure)
• Feelings of abandonment
• Difficulties adapting to changes in parent and
  family roles

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Parenting After TBI

• Pezzar et al (1993)
• Spousal report of own and mate with TBIs
  parenting abilities, impact of parenting on
  childrens behaviors
• Findings
• Negative changes - parent with TBI
• Decreased parental role fulfillment
• Increased frequency negative behaviors
• Fewer positive behaviors
• Negative changes - parent without TBI
• Increased feeling overwhelmed
• Increased impatience and arguing
• Decreased activities with children
• Negative changes for children
• Increased acting out behaviors
• Increased emotional problems
• Relationship problems with parent with TBI
• 
  

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Suggested impacts of TBI on Children

• Children mirror or react to cognitive, emotional
  and behavioral styles of parent with TBI
• Higher risk of emotional, cognitive and
  behavioral problems in children
• Changing roles and expectations of child
• Lack of support in time of need
• Stigmatization of having a different parent
• Increased depression in children
• From Uysal, et al., 1998

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Parenting After TBI

• Uysal, Hibbard, et al (1998)
• Self report parenting skills parents with TBI
• Self report parenting skills mates without TBI
• Childrens ratings of parenting skills
• Impact parental TBI on family members levels of
  depression
• Comparison group of non-disabled families (16
  families with TBI/16 families without TBI)
• Families equivalent in terms of age and sex of
  parents and children interviewed
• On average, parents with TBI 9 years post injury

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Parenting Measures (Uysal et al., 1998)

• Parents Battery
• Self rating of parenting abilities
• Parent Behavior Form
• Parent Practices Questionnaire
• Parenting Dimension Inventory
• Ratings of childrens behaviors
• Childrens Problem Checklist
• Behavior Rating Profile
• Self report depression
• BDI

• Childs Battery
• Parenting abilities of both parents
• Parent Behavior Form
• Parent Practices Questionnaire
• Rating of own behavior
• Behavior Rating Profile
• Self report depression
• CDI

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Impact of TBI on Parenting Skills(Uysal et al,
l998)

• Parents with TBI and their spouses were similar
  to parents in the comparison group in
• Egalitarian treatment
• Encourage of independent thinking
• Parental strictness
• Use of punishment and anger
• Demands for maturity
• Frequency of favorable and unfavorable parental
  practices
• Reports of stress related to child rearing

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Impact of TBI on Parenting Skills(Uysal et al,
1998)

• Parents with TBI reported less
• Goal setting
• Encouragement of skill development
• Emphasis on obedience to rules and orderliness
• Promotion of work values
• Nurturance
• Involvement in activities with children
• Non-TBI parent reported less
• Feelings of warmth for children
• Loving of children
• Accepting of children

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Impact of Parental TBI on Children(Uysal et al,
1998)

• Childrens reports did not support differences
  reported by their parents in TBI households
• Children in TBI households did report
• both parents using lax control more frequently
• non-TBI parent was less actively involved in
  parenting roles
• The frequency of self reported behavioral
  problems were equivalent in children from TBI and
  non-TBI families

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Impact of TBI on Familys Mood(Uysal, et al,
1998)

• Parents with TBI reported
• higher frequency of depressive symptoms
• greater met criteria for depression (BDI 15)
• Spouses of mates with TBI endorsed more symptoms
  of depression
• Children in TBI families reported more depressive
  symptoms

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Lack of congruence Parents and children
reports?(Uysal, et al, 1998)

• Parents in TBI families overly critical of their
  parenting abilities
• A halo effect .children rate parents as doing
  well despite TBI
• A minimization effectchildren downplay the
  impact of TBI on parents skills
• A time effectchildren accept the parents
  current abilities as normal since it was now 9
  years on average post injury

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Parenting challenges in other disability groups

• Fathers with marked ADHD symptoms tended to be
  more over-reactive and use authoritarian
  discipline strategies (Arnold, OLeary Edwards
  (1997)
• Mothers with ADHD were poorer at monitoring child
  behaviors and less consistent disciplinarians
  (Murray Johnson, 2006)
• Children of fathers with alcoholism display
  increasing levels of externalizing behavior
  problems from an early age leading to antisocial
  behavior in later years
• (Eiden, Edwards Leonard, 2006
  Puttler,Zucker, Fitzgerald Bingham, l998, Wong,
  Zucker, Fitzgerald Puttler, 1999)

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Parenting challenges in other disability groups

• Parents with co-morbid Axis I and II disorders
  (Johnson, Cohen, Kasen et al, 2006)
• Parental depression associated with
• Low parental affection
• Low parental assistance
• Low parental time with child
• Parental anxiety associated with
• Low parental possessiveness
• Low parental affection
• Low parental assistance

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Parenting challenges in other disability groups

• Parents with co-morbid Axis I and II disorders
  (Johnson, Cohen, Kasen et al, 2006)
• When effects of parent and offspring gender and
  co-occurring Axis II conditions controlled for
• Only Axis I association remaining
• Parental anxiety disorder associated with high
  parental possessiveness
• Parental personality disorders were associated
  with
• Parental possessiveness
• Inconsistent parental discipline
• Low parental communication
• Low parental praise and encouragement
• Parents with personality disorders were 3x more
  likely to engage in problematic child rearing
  behaviors

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Next steps???

• Expanded evaluation
• Broaden domains of inquiry
• Prospective studies
• Determine nature and scope of parental
  interventions needed

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Assessment of Family Functioning Post TBI (Wade,
et al, 1995)

• Avoid observations based on a single individual
  in the family to draw conclusions about the
  functioning of the family
• Integrate self report measures with direct
  observation of family interactions
• Differentiate generic family impact and stressors
  from changes unique to TBI
• ? construct structured interviews of family
  stress and adaptation geared to specific stresses
  of TBI which combine, open-ended and structured
  probes, e.g.,
• Family Interview Rating Scale (Rivera et al,
  1992)
• Family Burden of Injury Interview (Taylor, in
  press)

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Evaluating Parenting Impacts within the TBI
Family System
Potential Impacts
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Parental Adjustment Post TBI
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Parental Adjustment Post TBI
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Child Adjustment Post TBI
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Design Considerations

• Discrepancies extent of potential discord
  within members of the family
• Discrepancies will highlight needed intervention
  for parents and children
• Prospective studies will identify
• Shifts in family adjustment and adaptation
• Time periods when interventions are most critical
  

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Thank you