- Email: [email protected]
Jack Fell Down and Broke His Crown: Not Unusual and So Why the Skype?
EDITORIAL Jack Fell Down and Broke His Crown: Not Unusual and So Why the Skype? Jeffrey E. Max,
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n the article “Randomized Clinical Trial of Online Parent Training for Behavior Problems After Early Brain Injury” by Wade et al.,1 the authors have reported that brief online parent skills training via Skype showed a main effect in reducing parents’ report of how much their child’s behavioral symptoms were bothersome to them. In addition, manualized parent skills training as opposed to provision of Internet resources reduced behavioral symptoms best when pretreatment symptom levels were high. Furthermore, where pretreatment behavioral symptoms were higher, there was evidence that reduction in symptoms was mediated by improved parent skills. The study sample included young children (n ¼ 113) who had a history of hospitalization for mild to severe traumatic brain injury (TBI) between ages 3 and 8 years. The researchers studied the children a mean of 10.8 months (SD ¼ 16.7 months) after the TBI, and the children were a mean age of 5.4 years (SD ¼ 2.2 years) at the time of the clinical trial. Inclusion in the study did not require the presence of psychopathology, and this limited change in pretreatment to posttreatment levels of symptoms. The work is innovative in at least 3 respects. First, the children were selected because of their TBI; second, some measures of parenting involved direct observation and not merely self-report; and third, the treatment arms were all characterized by online provision of therapy or educational resources. The 3 specific arms of the treatment trial were Internet-based Interacting Together Everyday: Recovery After Childhood TBI (I-InTERACT) versus abbreviated parent training (Express) versus access to online resources (IRC). The effectiveness of the Express arm was especially encouraging, because of the hope that effective treatments for disruptive behavior problems in children with TBI can be treated with a relatively brief intervention and remotely via telemedicine. Furthermore, the parent-training arms are not particularly abstruse and are modifications of widely implemented and studied Parent Child Interaction Therapy (PCIT).2 In an age of limited resources, a creative approach such as this furthers the goal of providing needed relief to a large population of children and families who are the face of the major public health problem that is pediatric TBI. This is a wake-up call for child and adolescent psychiatrists and other pediatric mental health professionals that we need not feel uncomfortable working with children with a history of TBI; rather, we are among the professionals most well equipped to have a positive impact on children’s mental health, which is a highly relevant issue in children with a history of TBI. The high prevalence of preinjury lifetime psychiatric disorder (up to 50%) and the high risk of
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new-onset or “novel” psychiatric disorders in children after hospitalization for TBI (severe TBI 54%63%; mild/moderate TBI 10%36%, versus orthopedic injury, 4%14%) or “reliable change” or worsening of behavioral symptoms scream out for our involvement.3-6 The positive treatment effect ought not to be surprising because of the high prevalence of preinjury behavioral problems and psychiatric disorders that cannot be attributed to the TBI and that should respond to standard validated therapies.3 The current study, which did not attempt to discern which behavioral symptoms were due to TBI, is nevertheless encouraging because it suggests that the TBI did not completely block a positive treatment effect. Amelioration specifically of postinjury behavioral sequelae remains to be studied. Research of risk factors for postinjury behavioral complications may provide clues for viable treatments, and this study was an excellent example thereof. The relationship of family function and child behavior/ psychiatric disorder after TBI is very strong, replicated multiple times, and has been shown to be bidirectional in terms of one influencing the other.7 Other risk factors for new-onset psychiatric disorders that could guide future intervention studies have been identified. These include a variety of psychosocial and biological variables, which, although not necessarily modifiable, could identify a subgroup of individuals who should be monitored closely.4 Psychiatric morbidity caused by TBI can be profound. However, an ironic scenario occurs when the level of function in the child sometimes improves postinjury compared to preinjury, once the TBI becomes a signal event leading to identification and treatment of untreated preinjury problems. No single study can answer all questions. This study does not address treatment of internalizing problems in children with a history of TBI. Anxiety and depression are important problems in children with TBI and affect overall function, and should be identified and treated.8 School programming interventions are also crucial for re-entry of the student to the system after hospitalization, and, when necessary, for the long term in some cases of severe TBI.9 Pharmacological intervention research targeting externalizing or internalizing symptom domains or clinical diagnoses lags behind psychosocial approaches. Of particular interest would be research on psychopharmacological treatment of attentiondeficit/hyperactivity disorder. Combined psychosocial treatments together with psychopharmacological treatments should be tested as this field matures. A broadening of the mission of established research units in pediatric psychopharmacology (RUPP) to include multisite medication trials JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 11 NOVEMBER 2017
EDITORIAL
is an option to facilitate these difficult-to-accomplish studies. Finally, injury prevention is superior to any treatment.10 In summary, the following are key issues. (1) The study demonstrated effectiveness of a psychosocial intervention, delivered via the Internet, targeting parenting behavior to reduce disruptive behavior in children with a history of hospitalization for TBI. (2) There is a high rate of psychopathology in a pediatric TBI population including preinjury psychopathology. (3) Pediatric mental health professionals should more confidently take their rightful place as core members of the team of professionals striving to improve the lives of children at high risk for psychopathology that increased the risk of the child’s injury and that, in turn, increased the risk of additional psychopathology. & REFERENCES
1. Wade SL, Cassedy AE, Schultz EL, et al. Randomized clinical trial of online parent training for behavior problems after early brain injury. J Am Acad Child Adolesc Psychiatry. 2017;56:930-939. 2. Thomas R, Abell B, Webb HJ, Avdagic E, Zimmer-Gembeck MJ. Parent-child interaction therapy: a meta-analysis. Pediatrics. 2017;140: e20170352. 3. Max JE. Neuropsychiatry of pediatric traumatic brain injury. Psychiatr Clin North Am. 2014;37:125-140. 4. Max JE, Wilde EA, Bigler ED, et al. Neuroimaging correlates of novel psychiatric disorders after pediatric traumatic brain injury. J Am Acad Child Adolesc Psychiatry. 2012;51:1208-1217. 5. Yeates KO, Kaizar E, Rusin J, et al. Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med. 2012;166:615-622.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 11 NOVEMBER 2017
Accepted September 13, 2017. Dr. Max is with the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Max is supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant 1R-01 HD088438-01. Disclosure: Dr. Max has provided expert testimony in cases of traumatic brain injury on an ad hoc basis for plaintiffs and defendants on a more or less equal ratio. This activity constitutes approximately 5% to 10% of his professional activities. Correspondence to Jeffrey Max, MBBCh, Rady Children’s Hospital, 3020 Children’s Way, MC 5018, San Diego, CA 92123; e-mail: [email protected] 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry https://doi.org/10.1016/j.jaac.2017.09.416
6. Max JE, Schachar RJ, Landis J, et al. Psychiatric disorders in children and adolescents in the first six months after mild traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2013;25:187-197. 7. Taylor HG, Yeates KO, Wade SL, Drotar D, Stancin T, Burant C. Bidirectional child-family influences on outcomes of traumatic brain injury in children. J Int Neuropsychol Soc. 2001;7:755-767. 8. Vasa RA, Gerring JP, Grados M, et al. Anxiety after severe pediatric closed head injury. J Am Acad Child Adolesc Psychiatry. 2002;41:148-156. 9. Ylvisaker M, Todis B, Glang A, et al. Educating students with TBI: themes and recommendations. J Head Trauma Rehabil. 2001;16:76-93. 10. Cheng TA, Bell JM, Haileyesus T, Gilchrist J, Sugerman DE, Coronado VG. Nonfatal playground-related traumatic brain injuries among children, 2001-2013. Pediatrics. 2016;137. pii: e20152721. https:// doi.org/10.1542/peds.2015-2721. Epub 2016 May 2.
www.jaacap.org
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I
n the article “Randomized Clinical Trial of Online Parent Training for Behavior Problems After Early Brain Injury” by Wade et al.,1 the authors have reported that brief online parent skills training via Skype showed a main effect in reducing parents’ report of how much their child’s behavioral symptoms were bothersome to them. In addition, manualized parent skills training as opposed to provision of Internet resources reduced behavioral symptoms best when pretreatment symptom levels were high. Furthermore, where pretreatment behavioral symptoms were higher, there was evidence that reduction in symptoms was mediated by improved parent skills. The study sample included young children (n ¼ 113) who had a history of hospitalization for mild to severe traumatic brain injury (TBI) between ages 3 and 8 years. The researchers studied the children a mean of 10.8 months (SD ¼ 16.7 months) after the TBI, and the children were a mean age of 5.4 years (SD ¼ 2.2 years) at the time of the clinical trial. Inclusion in the study did not require the presence of psychopathology, and this limited change in pretreatment to posttreatment levels of symptoms. The work is innovative in at least 3 respects. First, the children were selected because of their TBI; second, some measures of parenting involved direct observation and not merely self-report; and third, the treatment arms were all characterized by online provision of therapy or educational resources. The 3 specific arms of the treatment trial were Internet-based Interacting Together Everyday: Recovery After Childhood TBI (I-InTERACT) versus abbreviated parent training (Express) versus access to online resources (IRC). The effectiveness of the Express arm was especially encouraging, because of the hope that effective treatments for disruptive behavior problems in children with TBI can be treated with a relatively brief intervention and remotely via telemedicine. Furthermore, the parent-training arms are not particularly abstruse and are modifications of widely implemented and studied Parent Child Interaction Therapy (PCIT).2 In an age of limited resources, a creative approach such as this furthers the goal of providing needed relief to a large population of children and families who are the face of the major public health problem that is pediatric TBI. This is a wake-up call for child and adolescent psychiatrists and other pediatric mental health professionals that we need not feel uncomfortable working with children with a history of TBI; rather, we are among the professionals most well equipped to have a positive impact on children’s mental health, which is a highly relevant issue in children with a history of TBI. The high prevalence of preinjury lifetime psychiatric disorder (up to 50%) and the high risk of
916
www.jaacap.org
MBBCh
new-onset or “novel” psychiatric disorders in children after hospitalization for TBI (severe TBI 54%63%; mild/moderate TBI 10%36%, versus orthopedic injury, 4%14%) or “reliable change” or worsening of behavioral symptoms scream out for our involvement.3-6 The positive treatment effect ought not to be surprising because of the high prevalence of preinjury behavioral problems and psychiatric disorders that cannot be attributed to the TBI and that should respond to standard validated therapies.3 The current study, which did not attempt to discern which behavioral symptoms were due to TBI, is nevertheless encouraging because it suggests that the TBI did not completely block a positive treatment effect. Amelioration specifically of postinjury behavioral sequelae remains to be studied. Research of risk factors for postinjury behavioral complications may provide clues for viable treatments, and this study was an excellent example thereof. The relationship of family function and child behavior/ psychiatric disorder after TBI is very strong, replicated multiple times, and has been shown to be bidirectional in terms of one influencing the other.7 Other risk factors for new-onset psychiatric disorders that could guide future intervention studies have been identified. These include a variety of psychosocial and biological variables, which, although not necessarily modifiable, could identify a subgroup of individuals who should be monitored closely.4 Psychiatric morbidity caused by TBI can be profound. However, an ironic scenario occurs when the level of function in the child sometimes improves postinjury compared to preinjury, once the TBI becomes a signal event leading to identification and treatment of untreated preinjury problems. No single study can answer all questions. This study does not address treatment of internalizing problems in children with a history of TBI. Anxiety and depression are important problems in children with TBI and affect overall function, and should be identified and treated.8 School programming interventions are also crucial for re-entry of the student to the system after hospitalization, and, when necessary, for the long term in some cases of severe TBI.9 Pharmacological intervention research targeting externalizing or internalizing symptom domains or clinical diagnoses lags behind psychosocial approaches. Of particular interest would be research on psychopharmacological treatment of attentiondeficit/hyperactivity disorder. Combined psychosocial treatments together with psychopharmacological treatments should be tested as this field matures. A broadening of the mission of established research units in pediatric psychopharmacology (RUPP) to include multisite medication trials JOURNAL
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 11 NOVEMBER 2017
EDITORIAL
is an option to facilitate these difficult-to-accomplish studies. Finally, injury prevention is superior to any treatment.10 In summary, the following are key issues. (1) The study demonstrated effectiveness of a psychosocial intervention, delivered via the Internet, targeting parenting behavior to reduce disruptive behavior in children with a history of hospitalization for TBI. (2) There is a high rate of psychopathology in a pediatric TBI population including preinjury psychopathology. (3) Pediatric mental health professionals should more confidently take their rightful place as core members of the team of professionals striving to improve the lives of children at high risk for psychopathology that increased the risk of the child’s injury and that, in turn, increased the risk of additional psychopathology. & REFERENCES
1. Wade SL, Cassedy AE, Schultz EL, et al. Randomized clinical trial of online parent training for behavior problems after early brain injury. J Am Acad Child Adolesc Psychiatry. 2017;56:930-939. 2. Thomas R, Abell B, Webb HJ, Avdagic E, Zimmer-Gembeck MJ. Parent-child interaction therapy: a meta-analysis. Pediatrics. 2017;140: e20170352. 3. Max JE. Neuropsychiatry of pediatric traumatic brain injury. Psychiatr Clin North Am. 2014;37:125-140. 4. Max JE, Wilde EA, Bigler ED, et al. Neuroimaging correlates of novel psychiatric disorders after pediatric traumatic brain injury. J Am Acad Child Adolesc Psychiatry. 2012;51:1208-1217. 5. Yeates KO, Kaizar E, Rusin J, et al. Reliable change in postconcussive symptoms and its functional consequences among children with mild traumatic brain injury. Arch Pediatr Adolesc Med. 2012;166:615-622.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 56 NUMBER 11 NOVEMBER 2017
Accepted September 13, 2017. Dr. Max is with the University of California, San Diego, and Rady Children’s Hospital, San Diego. Dr. Max is supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development Grant 1R-01 HD088438-01. Disclosure: Dr. Max has provided expert testimony in cases of traumatic brain injury on an ad hoc basis for plaintiffs and defendants on a more or less equal ratio. This activity constitutes approximately 5% to 10% of his professional activities. Correspondence to Jeffrey Max, MBBCh, Rady Children’s Hospital, 3020 Children’s Way, MC 5018, San Diego, CA 92123; e-mail: [email protected] 0890-8567/$36.00/ª2017 American Academy of Child and Adolescent Psychiatry https://doi.org/10.1016/j.jaac.2017.09.416
6. Max JE, Schachar RJ, Landis J, et al. Psychiatric disorders in children and adolescents in the first six months after mild traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2013;25:187-197. 7. Taylor HG, Yeates KO, Wade SL, Drotar D, Stancin T, Burant C. Bidirectional child-family influences on outcomes of traumatic brain injury in children. J Int Neuropsychol Soc. 2001;7:755-767. 8. Vasa RA, Gerring JP, Grados M, et al. Anxiety after severe pediatric closed head injury. J Am Acad Child Adolesc Psychiatry. 2002;41:148-156. 9. Ylvisaker M, Todis B, Glang A, et al. Educating students with TBI: themes and recommendations. J Head Trauma Rehabil. 2001;16:76-93. 10. Cheng TA, Bell JM, Haileyesus T, Gilchrist J, Sugerman DE, Coronado VG. Nonfatal playground-related traumatic brain injuries among children, 2001-2013. Pediatrics. 2016;137. pii: e20152721. https:// doi.org/10.1542/peds.2015-2721. Epub 2016 May 2.
www.jaacap.org
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