The relation between therapeutic processes and outcomes following Online

Family Problem-Solving Therapy for pediatric traumatic brain injury

Allison P. Fisher, B.S., Aimee Miley, B.A., B.S., Nori Minich, B.S., Amy Cassedy, Ph.D., Nanhua Zhang, Ph.D., Shari L. Wade, Ph.D.

Introduction Method Results

• Pediatric traumatic brain injury (TBI) can negatively impact Procedure: • For a 1-point increase in homework completion, caregiver-
behavioral and emotional functioning • Therapists rated caregiver and child in-session involvement and reported externalizing problems decreased by 2.71 points, but
homework completion after each session, Likert scale 1-5 this failed to reach significance
• Online family problem-solving therapy (OFPST) represents a
promising treatment for addressing post-injury deficits CHILD EXTERNALIZING PROBLEMS
• Caregivers completed measures of child behavior at baseline,
reflecting current functioning 0-24 months post-injury Estimate F P
• Although therapeutic processes (e.g., homework participation, Caregiver
0.89 0.70 0.41
engagement) relate to outcomes in family-based therapy, little is • Completed same measures immediately posttreatment (6 months) Involvement
known about them in videoconference-based therapy or individuals Child
0.27 0.02 0.90
with neurocognitive deficits Involvement
Outcome Homework -2.71 2.79 0.10
Construct Rater Time Point Scale
• We examined the relation between therapeutic processes and Measure
outcomes in 5 trials of OFPST • For a 1-point increase in child involvement, caregiver-reported
Child Behavior
Behavior Baseline & 6 T-score
Checklist (CBCL) Caregiver perceived treatment benefits increased by 0.28 points
Problems months (M = 50, SD = 10)
– Externalizing

Child Behavior CAREGIVER-REPORTED PERCEIVED BENEFITS

Method Checklist (CBCL)
Behavior
Problems
Caregiver
Baseline & 6
months
T-score
(M = 50, SD = 10)
– Internalizing Estimate F P
Behavioral Caregiver
-0.11 1.48 0.23
Participants: Rating Inventory Executive
Caregiver
Baseline & 6 T-score Involvement
• 112 children and their caregivers of Executive Function months (M = 50, SD = 10)
Child
Function (BRIEF) 0.28 14.91 <0.001
• Children on average 14.3 years old (range = 5-18) Involvement
Home and
• Complicated Mild to Severe Traumatic Brain Injury Community Social Baseline & 6 T-score
Homework -0.01 0.05 0.83
Caregiver
• 0 – 24 months post injury Social Behavior Competence months (M = 50, SD = 10)

• 63% male, 85% Caucasian Scale (HCSBS) • For a 1-point increase in child involvement, child-reported
Online Perceived
Caregiver and
perceived treatment benefits increased by 0.14 points, but this
Satisfaction Treatment 6 months only 10-point scale failed to reach significance
Procedure: Survey Benefits
Child
• Data from 5 randomized clinical trials of OFPST between 2002
and 2015 CHILD-REPORTED PERCEIVED BENEFITS
Data Analysis Plan:
Estimate F P
• All therapies involved self-guided online modules and video • Mixed effect models were used to examine the relationship
between homework completion, caregiver and child involvement Caregiver
conference with therapist to review module content and problem Involvement
-0.13 2.02 0.16
solve surrounding family goals and outcomes
Child
0.14 3.13 0.08
Involvement
• Therapies focused on problem solving, communication, • Controlled for baseline score, site (proxy for therapist) caregiver
Homework -0.07 1.51 0.22
cognitive reframing and behavior management education, race, age at baseline, and injury severity

• Controlled for study via random effects • Therapeutic factors did not contribute to child social
Example of OFPST Sessions competence or internalizing problems

Session 1: Getting Started

Session 2: Staying Positive Results Discussion
Session 3: Steps of Problem Solving
• Therapists rated child (M = 4.1/5, SD = 0.77) and caregiver in- • We found partial support that therapeutic processes during
Session 4: Cognitive Challenges session participation (M = 4.4/5, SD = 0.65) as well as homework OFPST contribute to outcomes following TBI
Session 5: Staying in Control participation (M = 3.4/5, SD = 0.87) as high
• Study limited by lack of heterogeneity in race and ethnicity and
Session 6: Communication Skills reliance on therapist-reported measures of involvement and
homework completion
Session 7: Anger – Crisis Management
We would like to thank the families who participated and our
Final Session: Putting It All Together funding source, NIMH. Correspondence to: • Future research should explore whether child and caregiver
perceived therapeutic alliance impacts treatment outcomes
Allison.fisher@cchmc.org