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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Rehabil Psychol. Author manuscript; available in PMC 2013 August 28.
Published in final edited form as:
PMCID: PMC3755597
NIHMSID: NIHMS501414

Mothers Report More Child-Rearing Disagreements Following Early Brain Injury Than Do Fathers

Abstract

Objective

To investigate differences between mother’s and father’s perceptions of marital relationship quality, child rearing disagreements, and family functioning over the initial 18 months following traumatic brain injury (TBI) in early childhood relative to an orthopedic-injury comparison group.

Methods

Participants included 147 parent-dyads of children with TBI (n = 53) and orthopedic injuries (OI; n = 94) who were between the ages of 3 and 7 years at injury. Family functioning, marital quality, and child-rearing disagreements were assessed shortly after injury and at 6, 12, and 18-month follow-ups, with ratings at the initial assessment completed to reflect preinjury functioning. Mixed model analyses were used to examine mother and father’s reports of family functioning, marital quality, and child-rearing disagreements over time as a function of injury severity and parent gender.

Results

We found a significant Group x Gender interaction for ratings of love and parenting disagreements. As hypothesized, mothers of children with severe TBI rated the relationship as significantly less loving than did their partners, and mothers of children with both moderate and severe TBI endorsed more parenting disagreements than did their partners. However, fathers reported higher levels of family dysfunction than their partners, regardless of injury type or severity.

Conclusions

Implications for treatment based on differences in mothers’ and fathers’ perceptions of family and marital functioning, and future directions for research, are discussed.

Keywords: brain injury, family functioning, marital relationship, parental perceptions

Childhood traumatic brain injury (TBI) results in a number of negative consequences, including elevated rates of behavioral, psychiatric, adaptive, and academic problems in these children postinjury (e.g., Fletcher, Ewing-Cobbs, Miner, Levin, & Eisen-berg, 1990; Semrud-Clikeman, 2010; Taylor et al., 2001). Moderate to severe TBI also adversely impact the entire family (e.g., Wade, Taylor, Drotar, Stancin, & Yeates, 1996). For instance, Taylor et al. (2001) found that child behavior problems 6 months postinjury predicted higher family burden and parent psychological distress at 12 months. Clinical observations indicate that families of children with TBI are more likely to experience strain in family roles, lack of social support outside of the family, and low levels of support or communication within the family (Brooks, 1991; Conoley & Sheridan, 1996; Waaland & Kreutzer, 1988). In addition, the transition from the hospital to the child’s home can become even more stressful if the family experiences challenges beyond the TBI (Semrud-Clikeman, 2010). Reactions of other family members, including one’s spouse, are another source of stress for parents of children with moderate to severe TBI (Wade et al., 2002). Such reactions may represent one underlying reason why parents of children with severe TBI report higher levels of psychological distress than do parents of children with mild TBI or orthopedic injuries (Rivara et al., 1992). Furthermore, mothers of children with TBI typically experience and express more of the subjective burden (e.g., frustration, anger, depression) following TBI than other family members, and this subjective burden tends to increase over time (see Semrud-Clikeman, 2010, for review).

The pediatric psychology literature underscores the importance of using both maternal and paternal self-report data in order to gain a more comprehensive view of marital and family functioning in families with a chronically ill child. For example, Holmbeck et al. (1997) examined functioning in families of 8- to 9-year-old children with spina bifida using data from mothers and fathers in comparison to a control group. Their findings showed that relations between coping strategies and adjustment differed as a function of parent gender. Specifically, coping through positive reinterpretation and growth was associated with high levels of marital and parenting satisfaction among fathers but not mothers. Chaney et al. (1997) explored parent–child transactional aspects of adjustment among families of children/adolescents with insulin-dependent diabetes mellitus. Findings indicated that variations in fathers’ adjustment were inversely related to mothers’ adjustment; however, child adjustment was positively related to fathers’ adjustment. Such differences highlight the value of assessing both mothers and fathers in studies of pediatric chronic illness populations.

Most pediatric TBI studies focusing on family functioning postinjury have relied solely on mother self-reports. Therefore, less is known about fathers’ perceptions of marital and family functioning postinjury. However, two studies of maternal versus paternal responses to brain injury derived differing conclusions from their findings (Benn & McColl, 2004; Wade et al., 2010). The study conducted by Wade and colleagues (2010) focused on maternal and paternal self-reports of coping styles, injury-related burden, and distress following pediatric TBI. Their findings indicated that coping styles differed as a function of parent gender and, in some cases, time since injury. Specifically, mothers of children with severe TBI were more likely to use cognitive reframing/acceptance as a coping strategy whereas fathers tended to use denial. The reported use of active coping strategies following severe TBI varied as a function of parental gender and time, with fathers reporting greater use of active coping than did mothers, and mothers reporting more active coping with increasing time since injury. Fathers also reported significantly higher levels of burden and distress, suggesting that their responses to the injury may be less adaptive than mothers. The investigators speculated that the difference in coping styles in response to injury might contribute to parental disagreements and place a strain on the marital relationship. In other words, fathers may be less likely to share their concerns with others if they are employing denial, and as a result, mothers may perceive fathers as unconcerned about the injured child. In contrast, a study conducted by Benn and McColl (2004) found that both mothers and fathers use active coping strategies; however, mothers were more likely to endorse perception-oriented coping strategies and cognitive reframing than fathers. Benn and McColl (2004) postulated that differences between maternal and paternal coping strategies are complimentary rather than problematic, as indicated by Wade and colleagues (2010). The differing conclusions of these studies may be attributable to differences in the samples themselves (Benn & McColl, 2004, included a range of acquired brain injuries while Wade et al., 2010, was limited to TBI), how coping was assessed, and the inclusion of measures of burden and distress in the Wade et al. (2010) but not the Benn & McColl (2004) study. Nonetheless, these limited findings underscore the need for further research regarding differences in maternal and paternal response to injury.

While an extensive literature supports the negative impact of pediatric TBI on family functioning, surprisingly little is known about the effect of pediatric TBI on the quality of the marital relationship. Furthermore, it is unclear whether gender differences exist between mothers’ versus fathers’ appraisal of their relationship. As family-centered interventions are developed for pediatric TBI, it is important to investigate potential problems within the marital relationship that may place a strain on the entire family and exacerbate the symptoms of the injured child.

The present report is an extension of the study reported by Wade and colleagues (2010). The major goal of the current study was to investigate marital relationship quality, as well as family functioning, over the initial 18 months following TBI in early childhood relative to an orthopedic-injury comparison group using self-reports from both mothers and fathers. We hypothesized that the injury-related burdens associated with severe TBI, coupled with differences in coping between mothers and fathers, would contribute to greater differences between partners following severe TBI, with fathers reporting lower levels of disagreements and marital/family dysfunction and higher levels of love within the marriage than mothers following severe TBI. This study represents one of the first investigations to examine the effects of pediatric TBI on mother’s versus father’s perceptions of family functioning, relationship quality, and shared parenting.

Method

The study used a prospective, concurrent cohort research design to examine recovery from TBI in young children over the first 18 months post-TBI in comparison to children with orthopedic injuries (OI). As part of a larger investigation, this study’s sample was the same as the sample of dyads of parents of children with TBI and OI children who were described in previous reports (e.g., Wade et al., 2010). We sought to understand changes in marital and family functioning following injury. Using a sample of children with OI as a comparison group allowed us to contrast the effects of TBI to the effects of traumatic injuries not involving the central nervous system (CNS). Both groups shared stress of child hospitalization for a traumatic injury. In addition, both the TBI and the OI groups were likely to share preinjury behavioral characteristics and the related risk factors. For example, the child’s behavioral regulation, as well as parenting behaviors such as the level of parental supervision and monitoring, have been associated with the risk for injury and may also relate to preinjury parent–child interactions (Goldstrohm & Arffa, 2005). Approval was obtained from the institutional review boards at participating institutions prior to the start of the study, and informed consent was obtained from participating caregivers.

Recruitment Criteria

Between January 2003 and September 2007, consecutive admissions of children with TBI or with OI not involving the brain were screened at three tertiary care children’s hospitals and a general hospital (all with Level 1 trauma centers) in Ohio. Eligibility requirements for both groups included age between 36 to 84 months at the time of injury and English as the primary spoken language in the home. In addition, eligibility for the TBI group included a TBI requiring overnight admission to the hospital with a Glasgow Coma Scale (GCS) score of 12 or less, or a higher score accompanied by evidence of abnormalities on neuroimaging (MRI or CT scan). Children with nonblunt head trauma (e.g., projectile wounds, strokes, drowning) were excluded. Inclusion in the OI group required documented bone fracture (other than the skull), an overnight hospital stay, and the absence of any evidence of loss of consciousness or other findings suggestive of brain injury (e.g., symptoms of concussion). Children were excluded if they had any of the following: previous history of brain injury, preexisting neurological disorder or medical problem affecting the nervous system, documentation in the medical chart or in the parent interview of child abuse as the case of injury, or history of severe psychiatric disorder requiring hospitalization. Preexisting neurological or medical problems included autism, seizure disorder, pervasive developmental disorder, significant developmental delay, and other less common neurological conditions. Given that children were less than 7 years old at the time of injury, relatively few children had been diagnosed with attention deficit hyperactivity disorder (ADHD) or learning disabilities, and these children were not excluded. Relatively few children were excluded based on these criteria. The most common reasons for exclusion were speaking a primary language other than English in the home (e.g., Spanish) or preinjury autism or developmental delay. Parents of all children meeting the study criteria were contacted either during the child’s hospital stay or subsequently by letter and follow-up phone calls to conduct further screening and recruit the family for participation.

Procedures

Assessments were administered to parents shortly after the injury and then again at 6, 12, and 18 months postinjury. Parents were asked to complete the initial ratings of marital relationship quality, family functioning, and child-rearing disagreements with respect to functioning prior to the injury. Both parents were asked to complete the parent-report measures in two-parent families.

Sample Characteristics

Baseline data were collected on 204 children and their caregivers (87 with TBI and 117 with OI) after they completed informed consent and were enrolled in the study. About 54% of potentially eligible children with TBI and 35% of eligible children with OI were included in this sample. Consistent with previous investigations, the TBI group was categorized based on the severity of injury. GCS scores of 8 or less were considered to reflect severe TBI, and complicated-mild to moderate TBI was classified as a GCS score of 9 to 12 or a higher GCS score with abnormal neuroimaging. The GCS score assigned to the child was the lowest score recorded postresuscitation.

There were 64 primary caregivers in the TBI group (74%) and 101 primary caregivers in the OI group (85%) who had spouses or partners. Out of these individuals, 141 dyads (88%) completed self-report measures of child-rearing disagreements and marital and family functioning. Fifty-three (83%) of the spouses/partners from the TBI group and 94 (93%) of the spouses/partners from the OI group completed the necessary measures. Within the TBI group, 14 were categorized as severe and 39 as mild/moderate. Demographic or child characteristics (including race, income, education level, child age, and injury severity) did not differ between participating fathers and fathers who did not participate. Eleven parent-dyads of children with severe TBI (79%), 27 parent-dyads of children with moderate/complicated mild TBI (69%), and 64 parent-dyads of children with OI (68%) completed all four assessments, and this was not significantly different across groups. However, use of mixed models analyses allowed us to retain all 141 dyads with data from one or more of the assessments in the final analyses.

As reported in Table 1, children with severe TBI were hospitalized significantly longer and had significantly higher injury severity scores. Relatively few families received any type of behavioral treatment for the child or individual therapy for the parent, and this did not differ significantly by group. Specifically, only one of 14 children with severe TBI (7%), one child with moderate/complicated mild TBI (3%), and two children with OI (2%) received behavioral treatment at any point postinjury. Similarly, two parents of children with severe TBI (14%), three parents of children with moderate/complicated mild TBI (8%), and five parents of children with OI (6%) reported receiving individual therapy. None of the participants reported receiving family therapy at any point following injury.

Table 1
Demographic and Injury Characteristics of Participating Families

Both mothers and fathers reported changes in employment status over the course of the study with four of 14 (29%) in the severe TBI group, nine of 39 (23%) of those in the moderate/complicated mild group, and 29 of 94 (31%) in the OI group reporting one or more changes over the initial 18 months postinjury. Of those with changes, 50% of the severe group, 44% of the moderate/complicated mild group, and 65% of the OI group reported increases in their level of employment (e.g., unemployed to part or full time).

Measures

Assessment of parent and family functioning

Both mothers and fathers completed the 12-item General Functioning (GF) scale from the Family Assessment Device (FAD; Miller, Bishop, Epstein, & Keitner, 1985) to assess global preinjury family functioning at baseline and current functioning at the follow-up assessments. The FAD-GF has demonstrated reliability and validity, and correlates highly with other FAD subscales. Higher scores on the FAD-GF indicate greater family dysfunction. For our sample, the standardized Cronbach’s alpha for the FAD-GF was .71.

Assessment of love and conflict within marriage

Mothers and fathers also completed the Braiker and Kelley Partnership Questionnaire (Braiker & Kelley, 1979). This is a 25-item self-report measure that assesses love and conflict in the marital relationship. In addition, the partnership questionnaire generates two separate subscales: love (e.g., caring and emotional attachment) and conflict (e.g., problems and arguments). Each item is rated on a 9-point Likert scale ranging from not at all/very little (1) to very much/frequently (9). Higher scores indicate more love and more conflict (Braiker & Kelley, 1979). Cronbach’s alpha, using a married sample of participants, ranged from .81 to .84 for the Love Scale (Johnson & Huston, 1998). In addition, Gryl, Stith, and Bird (1991) reported a Cronbach’s alpha of .81 for the conflict negativity scale using a college sample. Belsky, Lang, and Rovine (1985) reported on internal consistency across three time points and found that the Braiker and Kelley Relationship Questionnaire scales ranged from .61 to .90 for husbands and wives. Within a sample of married couples transitioning to parenthood, Belsky and colleagues (1985) found significant decreases in feelings of love between the last trimester of pregnancy and the third postpartum month, whereas conflict scores remained consistent.

Assessment of child-rearing disagreements

Participants also completed the Child-Rearing Disagreements (CRD) questionnaire (Jouriles et al., 1991). The CRD is a 21-item self-report measure that assesses common topics of child rearing disagreements. For each item, parents rate the frequency of the disagreements during the past 6 months on a 6-point Likert scale ranging from never (0) to daily (5). Cronbach’s alpha for the CRD was .86 (Jouriles et al., 1991).

Data Analyses

Mixed model analyses were used to examine parent reports of family functioning, marital quality, and child-rearing disagreements over time as a function of injury severity and parent gender. Mixed model analyses were employed because they allow flexible longitudinal modeling of the pattern of change in outcomes over time. In particular, mixed model analysis makes use of all the data for a given participant, even if that individual is not seen at all assessments or if assessment intervals are unevenly spaced. A separate analysis was conducted for each of the primary dependent variables: the FAD-GF, love and conflict, and child-rearing disagreements, for a total of four analyses. The initial model for each of these analyses was the same and included family socioeconomic status (SES) and race as covariates; the main effects of injury severity, parent gender, and time since injury; and interactions of group, parent gender, and time. SES was calculated using the average of the z-scores for maternal education and median income from the family’s census tract. The effects of injury severity in each model were examined using two dummy variables, one comparing severe TBI versus OI and one comparing the complicated mild/moderate TBI versus OI. Both linear and quadratic terms representing time postinjury were included in each model. Subjects were considered a random effect, so that each subject was initially modeled with independent slopes and intercepts with respect to time. After fitting an initial model, we reduced model complexity to achieve the most parsimonious model. We followed an iterative process, eliminating predictors for which the F tests for fixed effects were not significant, starting with three-way interactions, and then reestimating the model before examining lower-level interactions and, finally, main effects. For any significant interaction, all of the main effects and lower-level interactions upon which the significant interaction was based were retained in the model. The standardized coefficient was calculated to provide an estimate of effect sizes. Analyses were conducted using SAS 9.2©. In accordance with previous research, alpha in each domain (family functioning, parenting disagreements, marital relationship) was set at .05. Because there were two analyses within the marital relationship domain examining love and conflict, alpha for these analyses was set at .025.

Results

Family Functioning

Table 2 provides the trimmed models for the FAD-GF and other dependent variables. In contrast to the hypothesis, fathers endorsed higher levels of global family dysfunction, F(1, 144) = 24.34; p < .001, regardless of the nature or severity of the childhood injury than mothers (standardized coefficient = 0.23). However, no group differences in family dysfunction were found. See Table 3 for the FAD-GF means by group, parent, and time. Time since injury and race were also not significantly related to family functioning, suggesting that perceptions of family functioning did not change as a consequence of the injury.

Table 2
Mixed-Models Analysis of Group and Gender Differences in Family Functioning, Marital Quality, and Child-Rearing Disagreements
Table 3
Means and Standard Deviations of Child-Rearing Disagreements, Family Functioning, and Marital Conflict and Love for Mothers and Fathers by Group at Each Time Period

Marital Love and Conflict

As reported in Table 2, the interaction between parent gender and injury group was a significant predictor of reported love in the relationship, F(2, 134) = 4.93; p < .01. Mother’s and father’s ratings of love differed significantly following severe TBI, with fathers endorsing significantly higher levels of love in the marriage than mothers (standardized coefficient = −0.25). However, no significant difference existed between mothers’ and fathers’ ratings of love within the moderate/mild TBI group or the orthopedic injuries group (see Figure 1). After correcting for multiple comparisons, there was a trend for parental perceptions of love to vary as a function of time since injury, F(1, 727) = 5.00; p < .05. Ratings of love decreased over time, as rated by mothers and fathers across injury groups. Conversely, parent perception of conflict within the marriage did not differ by parent gender, injury group, or time since injury (see Table 3 for means).

Figure 1
Mean scores on Child-Rearing Disagreements questionnaire in the three comparison groups separated by parent gender.

Child-Rearing Disagreements

When the frequency of child-rearing disagreements was analyzed, the results revealed a significant interaction between parent gender and group, F(2, 140) = 3.93; p < .05. Mothers and fathers differed in their perceptions of disagreements, with mothers in both the severe and moderate TBI groups reporting more disagreements than their spouses (standardized coefficient = 0.399). As depicted in Figure 2, mothers from the severe TBI group endorsed the highest frequency of child-rearing disagreements overall (standardized coefficient = 0.25). Mothers from the severe TBI group differed from mothers in the other groups; however, fathers across groups did not differ in their perception of child-rearing disagreements. Interestingly, fathers from the mild/moderate TBI group endorsed the lowest number of disagreements.

Figure 2
Mean scores on the love subscale from the Braiker and Kelley Partnership Questionnaire in the three comparison groups separated by parent gender.

Discussion

The current findings provide preliminary evidence regarding differences in parent perceptions of marital and family functioning following childhood TBI. Consistent with hypotheses, difference in parental perceptions of the marital relationship and parenting was amplified following TBI. Specifically, when rating the marital relationship, fathers of children with a severe TBI endorsed significantly higher levels of love than did mothers. Conversely, mothers of children with both moderate and severe TBI reported higher levels of child-rearing disagreements than did fathers. However, we found no support for Group x Parent x Time interactions, raising the possibility that differing parental perceptions of the marital relationship and parenting disagreements preceded the TBI. The initial ratings of preinjury functioning were completed as much as 3 months postinjury and thus may have been biased by changes in the family following injury. Contrary to this possibility, there were no differences between mother’s and father’s preinjury ratings of child-rearing disagreements in the severe TBI, moderate TBI, and OI groups (all ps > .30), and only the parents of children with OI differed on ratings of love at preinjury, with mothers reporting significantly lower levels than fathers. Moreover, significant differences emerged between mother’s and father’s ratings of child-rearing disagreements in the moderate TBI at 6 and 18 months postinjury (p < .05), and there was a trend for differences among the parents of children with severe TBI at Visit 2. Taken together, these findings suggest that the observed differences in parental perceptions following TBI were not solely an artifact of premorbid status.

Contrary to our hypotheses, in general, fathers reported more family dysfunction than mothers. In other words, regardless of the type of childhood injury, fathers tend to perceive more dysfunction in the family than mothers. However, even though fathers, as a group, reported higher levels of family dysfunction, they perceived the relationship with their wives as loving. In addition, there was a general trend indicating that mothers’ and fathers’ ratings of love within the marriage decreased over time regardless of the type or severity of the injury. Interestingly, we failed to find differences in marital conflict as either a function of the severity of injury or parent gender. These findings suggest a substantial gulf between mothers’ and fathers’ perceptions of some, but not all, aspects of marital and family functioning, particularly following severe TBI.

The Effects of TBI on Parental Perceptions of Their Relationship

Pediatric TBI has been shown to adversely affect caregiver and family functioning (e.g., Wade et al., 1996), but less is known about its impact on the marital relationship and shared parenting. The current findings suggest that severe TBI and, to a lesser extent, moderate TBI may accentuate difference in parental perceptions, with mothers of children with severe TBI perceiving both more disagreements with their spouses and less love in the relationship. Given evidence that fathers of children with severe TBI are more likely to cope through denial (Wade et al., 2010), they may be less likely to acknowledge or accept changes in the relationship. The fact that mothers of children with severe TBI are rating more disagreements around parenting but not greater conflict in general suggests that changes in the relationship may center on the child’s injury. In addition, because mothers are more likely to experience subjective burden following TBI (Semrud-Clikeman, 2010), they may be more likely to have child-rearing disagreements with their spouse.

Researchers have also suggested that the parent–child relationship postinjury is reciprocal in nature, such that child behavior influences parent behavior and vice versa (Wade et al., 2008). More specifically, parental distress resulting from the child’s condition may result in changes in parenting behaviors (Quittner, Opipari, Regoli, Jacobsen, & Eigen, 1992). In addition, the child’s behavior postinjury, such as the child’s need for cognitive support, may lead to changes in the behavior of parents (Keogh, Garnier, Bernheimer, & Gallimore, 2000; Landry, Chapieski, Richardson, Palmer, & Hall, 1990). Wade and colleagues (2008) found that differences in child behavioral regulation partially mediated differences in observer ratings of parental responsiveness and directiveness. Parents of children with TBI exhibited less warm responsiveness than parents of children with OI. Overall, Wade and colleagues (2008) suggested that parent and child behavior influence one another post-TBI. Because a child’s behavior following TBI may be particularly challenging, parents may be more likely to engage in child-rearing disagreements.

Disagreements following TBI regarding how to manage the child’s behavior may serve to exacerbate behavior problems. Although general marital conflict can spill over into the parenting relationship (Bradford & Barber, 2005), specific conflicts regarding how to manage the child’s behavior may be of even greater consequence for the child’s behavior. The lack of a parenting coalition may undermine discipline strategies, thereby contributing to escalating behavior problems. In addition, children may be particularly aware when their parents disagree about child-rearing (O’Leary & Vidair, 2005). Frequently, disagreements with child-related themes occur with the child present and can be particularly distressing for the child (Papp, Cummings, & Goeke-Morey, 2002). It has been widely shown that children with severe TBI have elevated behavior problems following injury (Bloom et al., 2001; Chapman et al., 2010; Schwartz et al., 2003), and these behavioral issues can be exacerbated by aspects of the social environment, including parenting (Wade et al., 2011; Yeates, 2010). Thus, following severe TBI, there is the potential for a complex interaction between changes in the child’s behavior resulting from the injury, a resultant increasing gulf in parental perceptions regarding their shared parenting, and further escalations in child behavior problems.

Importance of Family Functioning

As stated previously, marital disagreements and conflict tend to negatively impact parenting practices and increase family dysfunction (Bradford & Barber, 2005). In addition, research supports that family functioning is negatively impacted by moderate to severe childhood TBI (Wade et al., 1996). Therefore, it was hypothesized that higher levels of family dysfunction would be perceived by parents from either of the childhood TBI groups. In contrast to this hypothesis, similar levels of family dysfunction were perceived across groups. Furthermore, in general, fathers indicated higher levels of dysfunction than mothers, suggesting that fathers may be more distressed postchildhood injury.

The Effects of Time Since Injury

The current results suggest that the course of recovery has relatively little effect on mothers’ and fathers’ perceptions of their relationship. We found only a single trend for the effects of time on parental ratings of love in their relationship, with a reduction over time across groups. There are limited published data regarding the stability of the Braiker and Kelley Partnership Questionnaire over time. In a sample of couples followed before and after the birth of their first child, Belsky and colleagues (1985) reported findings similar to those in the current study, with significant declines in love over the course of the study. In light of such a paucity of evidence, it is difficult to determine whether changing perceptions of love are an artifact of repeated administration of the questionnaire over time or whether they reflect changes in the nature of the relationship that occur during times of transition. With this single exception, parental perceptions remained stable over the course of 18 months, indicating that recovery does not close the gap in perceptions between mothers and fathers.

Limitations

The current findings must be considered in the context of the limitations of this study. First, all results were based on parent reports of their own functioning. Observational data of the family and marital relationship or diagnostic interviews may provide a more unbiased assessment of parent and family functioning and could yield different results. In addition, larger samples of parents within the severe TBI group are needed in order to address issues of parent and family functioning postinjury. The fact that there were only 14 parent dyads in the severe TBI group suggests that there may not be sufficient power to detect subtle group differences. Therefore, caution should be taken when interpreting these results. However, most TBI researchers struggle to include subjects of varying levels of brain injury severity (see Semrud-Clikeman, 2010, for review). Future investigations that incorporate additional demographic and family characteristics, such as changing employment status and treatment history, may further enhance our understanding of factors that shape parental perceptions post-TBI. Although this investigation is one of the first studies to examine both mother’s and father’s perceptions of family functioning following early TBI, replication with a larger sample is necessary.

Implications for Intervention and Future Recommendations

Rehabilitation professionals providing treatment to families of injured children should be aware of differences in parent perceptions of marital and family functioning. Both marital and family counseling may be beneficial for families of injured children. It is striking that none of the families in the current study reported receiving any marital or family therapy, and only a small proportion received any type of psychological intervention at all. These findings suggest that parent disagreements and conflict that may appropriately be addressed in marital counseling are not currently being treated. It would be important for each parent to understand the concerns of the other and how the other is currently coping with those concerns. Furthermore, because ratings of love within the marriage decrease over time postinjury, parents need to be encouraged to set aside some time to spend together. Doctor’s appointments and other engagements related to the child’s recovery are time-consuming, leading to less time to devote to the marital relationship. Therapists providing treatment to families following childhood injury need to help the family change mal-adaptive coping strategies, such as denial, and work together to cope with the impact of the injury. Furthermore, it is important for rehabilitation professionals to intervene with families early. The results indicate that parent perceptions of love within the marriage decrease over time; therefore, it may be beneficial to begin counseling soon after the injury.

The current findings provide preliminary evidence regarding differences in parent perceptions of marital and family functioning following childhood TBI over time. These results suggest a number of important clinical implications, such as targeting the inclusion of fathers in treatment following TBI. Replication of the study is necessary, given the small sample size for the severe TBI group. Future research with larger samples of children with severe TBI would help to better explain the differences in parent perception of family and marital functioning. In addition, studies need to include other non-self-report measures in order to obtain a more accurate measurement of functioning postchildhood TBI. Finally, because child functioning is significantly related to the quality of family functioning (Kazak, 1997), the relationship between parent perceptions and the child’s recovery must be examined in future studies. Subsequent analyses will help to refine and alter treatment methods for families following TBI.

Acknowledgments

This work is supported by Grant R01 HD42729 from NICHD and by Trauma Research grants from the State of Ohio Emergency Medical Services. This publication was also supported by an Institutional Clinical and Translational Science Award, NIH/NCRR Grant Number 1UL1RR026314. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The authors wish to acknowledge the contributions of Christine Abraham, Andrea Beebe, Lori Bernard, Anne Birnbaum, Beth Bishop, Tammy Matecun, Karen Oberjohn, Elizabeth Roth, and Maegan Swarthout in data collection and coding. The Cincinnati Children’s Medical Center Trauma Registry, Rainbow Pediatric Trauma Center, Rainbow Babies & Children’s Hospital, Columbus Children’s Hospital Trauma Program, and MetroHealth Center Department of Pediatrics and Trauma Registry provided assistance with recruitment.

Contributor Information

Emily A. Bendikas, Department of Psychology, Miami University.

Shari L. Wade, Department of Pediatrics, University of Cincinnati College of Medicine.

Amy Cassedy, Department of Pediatrics, University of Cincinnati College of Medicine.

H. Gerry Taylor, Department of Pediatrics, Case Western Reserve University, Rainbow Babies & Children’s Hospital, and University Hospitals Case Medical Center, Cleveland, Ohio.

Keith Owen Yeates, Department of Pediatrics, Nationwide Children’s Hospital, Ohio State University.

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