The experiences of parenting a child with an acquired brain injury: A meta-synthesis of the qualitative literature

Strategies supporting parent-delivered rehabilitation exercises to improve motor function after paediatric traumatic brain injury: A systematic review

AIM

To identify and analyse ways in which parents are supported to deliver rehabilitation exercises to their child after traumatic brain injury (TBI), conceptualized as strategies.

METHOD

A systematic search was completed using seven online databases and three grey literature databases, from inception to November 2021. The included studies focused on physical rehabilitation in children after TBI with the involvement of parents as hands-on deliverers or facilitators of rehabilitation (e.g. supervising the exercise). Intervention descriptions were reviewed to identify strategies; this was followed by fine-grained analysis using the Behaviour Change Wheel to identify intervention components. Risk of bias was analysed using the revised Cochrane Risk-of-Bias Tool for Randomized Trials or the Risk Of Bias In Non-randomized Studies - of Interventions.

RESULTS

Six interventions including 211 participants and one trial protocol met the inclusion criteria. All studies included a proportion of children diagnosed with TBI and four studies included mixed samples of acquired brain injury or cerebral palsy. All interventions included elements of goal setting and instruction.

INTERPRETATION

Interventions focus heavily on the initiation of physical rehabilitation, but focus less on the longer-term maintenance of rehabilitation delivery. Further research should integrate perspectives from parents to inform the development of new interventions.

WHAT THIS PAPER ADDS

Parents need support to deliver or supervise rehabilitation exercises. The interventions identified in this review supported goal setting, action planning, and learning rehabilitation exercises. Interventions focused primarily on the initiation of exercises but less on maintenance. Rehabilitation is complex and new approaches are needed to better support parents.

Parents' experience of children with acquired brain injury undergoing neurorehabilitation: a systematic review

BACKGROUND

This systematic review aims to synthesise the qualitative evidence exploring parents' experiences of children with acquired brain injury (ABI) undergoing neurorehabilitation during the first year post-injury.

METHODS

A systematic review of qualitative research was conducted using thematic synthesis with Thomas and Harden's approach. The population, exposure and outcome model was used for the search strategy. The electronic databases Ovid Embase, Ovid MEDLINE, CINAHL, Scopus and PsycINFO were searched from 2009 to 2023. The review included qualitative and mixed-method studies published in English only. Grey literature was excluded. There were no geographical restrictions. Reporting within the review followed the Enhancing Transparency in Reporting the Synthesis of Qualitative Research guideline. The studies' quality was appraised using the Critical Appraisal Skills Programme tool.

RESULTS

Three studies met the inclusion criteria and were included in the synthesis, representing the experiences of 30 parents. The quality assessment showed that the three included studies met most quality indicators. Following thematic synthesis, four analytical themes were identified: school unpreparedness, parents as advocates and navigators, parents as monitors, and parents recognising the impact of ABI on their child. The reviewers proposed a group of recommendations for services reviewing their parental support.

CONCLUSION

This review highlights some challenges parents of children diagnosed with ABI experience during their child's neurorehabilitation journey. This review has suggested potential improvements that could be made in paediatric neurorehabilitation services when reviewing their parental support and care pathways. These will ultimately influence parents' and children's experience of paediatric neurorehabilitation services.

A meta-ethnographic synthesis of the experiences of stigma amongst people with functional neurological disorder

PURPOSE

Functional neurological disorder (FND) causes many neurological symptoms and significant disability. It is often misunderstood by medical professionals and the public meaning stigma is regularly reported. The aim of this review was to synthesise the qualitative findings in the literature to develop a more in-depth understanding of how people with FND experience stigma to inform future interventions.

METHOD

This review used a meta-ethnography approach. Five databases were searched (PsycINFO, Web of Science, CINAHL, MEDLINE, and EMBASE) in February 2021 and updated in July 2022 for qualitative papers in FND. Included papers were critically assessed using the critical appraisal skills programme (CASP) checklist. Data were analysed and synthesised utilising meta-ethnography.

RESULTS AND CONCLUSION

Sixteen papers were included in the final synthesis. Four major themes emerged: stigmatized by delegitimization; stigmatized by social exclusion and rejection; coping with stigma; and stigma and identity. The results identified negative, stigmatizing attitudes towards people experiencing FND symptoms in a variety of contexts including healthcare and other social institutions. The effects of stigma led to further exclusion for participants and appeared to trigger coping styles that led to additional difficulty. Stigma is a key part of the illness experience of FND and needs to be addressed.

Perspectives of parents partnering with physical therapists to deliver intensive rehabilitation for their young children with perinatal stroke: A qualitative study

BACKGROUND

Parental participation in their young children's rehabilitation has been promoted to increase intervention intensity, but parents' perspectives on increased involvement remain unclear. The objective of this study was to explore parents' experiences partnering with physical therapists (PTs) to administer early, intensive rehabilitation to their young children with cerebral palsy (CP).

METHODS

Twelve mothers and one father of children between 8 months and 3 years old with CP were interviewed. Semistructured interviews were conducted before and after parents partnered with a PT to deliver a 12 week activity-based intervention targeting their child's lower extremities. The intervention occurred in the child's home and in PT clinical sites. Interviews were audio recorded and transcribed verbatim. Interpretive description was used as the methodological framework.

RESULTS

The three themes were (1) focus on maximizing the child's potential, (2) participation in intensive rehabilitation is challenging, and (3) the importance of a positive experience with therapy. Families discussed a number of barriers and facilitators to participating in intensive rehabilitation.

CONCLUSIONS

These results provide considerations for clinicians and researchers to facilitate meaningful engagement of parents in their young children's rehabilitation. This is especially important with increasing evidence for early, activity-based interventions for young children with CP.

Returning to education after childhood acquired brain injury: Learning from lived parental experience

BACKGROUND

Returning to education (RtE) after an acquired brain injury (ABI) can be stressful for children/young people (CYP) and families. While much can be done to support RtE, there has been limited exploration of the lived experience of parents/carers about what can both help and hinder the process.

OBJECTIVE

The aim was to understand more about RtE from parents' perspectives to inform best practice and facilitate improvements in service delivery.

METHODS

A service evaluation explored parent/carer views about the RtE process and the support received from healthcare professionals at a regional centre in the UK. Questionnaires (n = 59) were sent to parents of patients treated for an ABI in the last two years.

RESULTS

31 parents (response rate = 51%) completed the survey. Results highlight the many challenges of RtE. Thematic analysis of responses revealed six key themes: Parental mindset and growth; What do they need know?; Specialist support and information; Talk and share; Challenges of new and hidden needs; and Don't forget them!

CONCLUSION

Parents offer crucial insight into the challenges of the RtE process. Their feedback highlights important factors for service development and reminds professionals of the key components of an effective return.

Parents' experience of children with acquired brain injury undergoing neuro-rehabilitation: thematic synthesis protocol

INTRODUCTION

Children with moderate to severe acquired brain injury frequently require a period of demanding medical and rehabilitative care to optimise their long-term capabilities and quality of life. Usually, the initial acute care is provided in tertiary centres and can last up to 12 months following the original injury. Parents of children with acquired brain injury share that experience with their child and face many different challenges encountered as their child's long-term needs become apparent. Parents are essential partners in care, hence there is a need to better understand their experiences to support them as they face those challenges and adapt to the needs of their child. We aim to synthesise the qualitative evidence exploring parents' experiences of children undergoing neuro-rehabilitative care.

METHODS AND ANALYSIS

The Enhancing Transparency in Reporting the Synthesis of Qualitative Research guideline was used in the design of this protocol. The Population, Exposure and Outcome model was used to define inclusion and exclusion criteria and refine search terms. The databases Ovid Embase, Ovid MEDLINE, CINAHL, Scopus and PsychINFO will be searched from 2009 to 2022. Two independent reviewers will review studies, assess quality using the Critical Appraisal Skills Programme and scrutinise and extract the data. Disagreements will be resolved after discussion with the third reviewer. Thematic synthesis using Thomas and Harden's approach will be undertaken to provide the evidence to develop a model for parental support during the first year of their child's neuro-rehabilitation.

ETHICS AND DISSEMINATION

Ethical committee approval will not be required as no new data will be collected. The findings will be disseminated through presentations at professional conferences, publications in peer-reviewed journals and shared with the public through relevant charities and local family support groups and networks.

PROSPERO REGISTRATION NUMBER

CRD42022333182.

Factors that support and hinder recovery and adjustment after traumatic brain injury: a qualitative multiple case study

Background/Aims

The numbers of individuals acquiring brain injuries in childhood is increasing. The deficits caused by brain injury can often have long-term implications that require support from caregivers, friends and the community. This study was conducted to gain an understanding of the shared perspectives of parental caregivers and their adolescent children as to what factors supported and hindered recovery and adjustment after traumatic brain injury.

Methods

In this qualitative multiple case study, semi-structured interviews were conducted with a purposive sample of four individuals with traumatic brain injury and their five parental caregivers. A thematic, cross-case analysis was used to identify factors that support and hinder recovery and adjustment.

Results

Seven themes were identified from the interviews: lack of educational resources about traumatic brain injury; poor consistency of care; caregiver stress and guilt; disconnection and isolation; connection, empathy and social support; being high achieving and resourceful; and authentic relationships between adolescents with traumatic brain injury and their parents.

Conclusions

The findings highlight the need for improved access to follow-up or community-based services for adolescents with traumatic brain injury who do not experience a hospital or inpatient rehabilitation stay. Additionally, healthcare providers should capitalise on the relationships between adolescents with traumatic brain injury and their parents to support recovery. The information gained from this study can be used to inform allied health professionals when developing and implementing interventions to support recovery in adolescents with traumatic brain injury and their parental caregivers.

Coping and wellbeing in families with a child with acquired brain injury compared with families in the community

PURPOSE

Paediatric acquired brain injury (ABI) negatively impacts parental wellbeing and family functioning. Adaptive coping, that is behaviours promoting emotional wellbeing and addressing distressing problems, may support wellbeing and family functioning. This study compared wellbeing, coping, and family functioning between parents of a child with ABI and parents in the community, and examined coping as a predictor of wellbeing and family functioning.

METHODS

Forty parents of a child with ABI and 40 parents in the community participated in this cross-sectional survey using the Personal Wellbeing Index, Coping Scale for Adults Short Form, McMaster Family Assessment Device (General Functioning Subscale).

RESULTS

The ABI group had statistically significantly lower wellbeing, t(68.70) = -4.01, p < 0.001, lower adaptive coping, t(73.95) = -3.27, p = 0.002, and poorer family functioning, t(77) = 4.26, p < 0.001. Family composition (single-parent/couple), having a child with ABI, adaptive coping, and non-productive coping predicted 47.7% of the variance in wellbeing, F(5, 70) = 12.75, p < 0.001. Parental education, having a child with ABI, and non-productive coping predicted 35.9% of the variance in family functioning, F(5, 69) = 7.71, p < 0.001.

CONCLUSIONS

Adaptive coping may contribute to better family outcomes in paediatric ABI.Implications for rehabilitationPaediatric ABI may have a significant impact on the child with ABI and the family, leading to poorer outcomes for some families.This study suggested that parents of a child with ABI use adaptive coping less than parents in the community but do not differ in the use of non-productive coping.Families need long-term targeted support to meet the challenges paediatric ABI presents and may benefit from interventions which actively seek to change parental coping strategies.

Perfectionism, Big Five and biopsychosocial functioning among parents of children with and without acquired brain injury (ABI)

BACKGROUND AND OBJECTIVE

Personality factors are often investigated in the context of parenting but are rarely studied in relation to coping with child disabilities like pediatric acquired brain injury (pABI). This study (1) compares Biopsychosocial functioning (BPSF), Big Five personality traits, and dimensions of perfectionism of parents of children with and without pABI, and (2) examines the role personality factors play in parental BPSF in each group.

METHOD

57 parents of children who sustained a significant pABI and 50 parents of typically developing children participated in this cross-sectional study. Parents completed scales measuring Multidimensional Perfectionism, Big Five inventory, and BPSF.

RESULTS

Among the pABI group, multivariate analysis indicated significantly poorer BPSF, higher levels of neuroticism, socially prescribed perfectionism, and lower levels of openness, than controls. Regression analysis showed that personality explained 60.5% of the variance in parental BPSF post pABI. In both samples, neuroticism and socially prescribed perfectionism appeared as two prominent personality factors with a significant negative effect on parental BPSF, while self-perfectionism appeared prominent only in the pABI group, indicating a significant positive effect.

IMPLICATIONS

pABI may result in changes to parents` personality. Personality characteristics significantly contribute to parental BPSF post-injury and should be addressed in clinical practice.

The experience of families following traumatic brain injury in adult populations: A meta-synthesis of narrative structures

BACKGROUND

Traumatic brain injury has a significant effect on uninjured family members. Typically, this has been examined with a focus on psychopathological outcomes including stress, depression and anxiety. However, in recent years there has been increasing interest in the subjective experiences of families post-injury leading to a plethora of qualitative studies. Therefore, an in-depth examination and synthesis of this literature is now relevant and timely.

OBJECTIVE

To examine the subjective experiences of families following traumatic brain injury in adult populations in the sub/post-acute period through the synthesis of original qualitative research.

DESIGN

This paper presents a meta-synthesis using Thomas and Harden's framework of 'thematic synthesis' rooted in a critical realist philosophy.

DATA SOURCES

In July 2019 five electronic databases, were searched for the terms 'traumatic brain injury', 'family' and 'qualitative'. Studies were included if the primary research reported qualitative data about the subjective experiences of family members of adults with traumatic brain injury and had been published in a peer reviewed journal. Studies with mixed brain injury samples, child or adolescent traumatic brain injury or disorders of consciousness were excluded. Hand searching and citation searches were also completed.

REVIEW METHODS

Two reviewers screened titles, abstracts and full text and reached consensus through critical discussion. Thirty papers were finally agreed for inclusion in this review. Each study was then assessed for relevance, resonance and rigour using the Critical Appraisal Skills Programme (CASP) tool. Line by line coding of the findings in each paper was conducted as the basis for a thematic analysis and synthesis.

RESULTS

Descriptive themes were identified followed later by analytical themes. This final stage was informed by a narrative lens and from these, eight narrative functions belonging to four dimensions were identified from the subjective experiences of families post-traumatic brain injury. Specifically, these were: (1) Displacing and Anchoring; (2) Rupturing and Stabilising; (3) Isolating and Connecting; (4) Harming and Healing.

CONCLUSIONS

The interpretation of the narrative functions revealed the substantial existential work involved in negotiating lives, maintaining family system equilibrium and moving forward. As such, family members have their own unique narrative needs. Despite contemporary service models built around the injured person, service providers are well placed to support families in this everyday narrative work through actively attending to narrative structures and understanding the implications of these for family experience. The study protocol was registered with PROSPERO (International prospective register of systematic reviews) in July 2018 (Registration number: CRD42018085824). Tweetable abstract: This synthesis showed the immense and invisible work required for family members to maintain family system equilibrium and negotiate their lives post-TBI.

"Concurrent Ropes and Ladders": Mapping and Conceptualizing the Emotional Loss Experience of Parents Following Pediatric Acquired Brain Injury

This grounded theory study aims to map, conceptualize, and theorize the emotional loss experienced by parents following their child's pediatric acquired brain injury (pABI). Data were obtained from 47 semi-structured interviews conducted with parents (72% mothers) at least 1 year following pABI. The study's theory of "concurrent ropes and ladders" emerged from a process of initial in vivo coding followed by focused and thematic coding. Codes were consolidated into five thematic categories capturing parents' emotional continuous loss experience: (a) comparing life before and after, (b) struggling to construct new realities, (c) recognizing instability and permanency, (d) adjusting and readjusting, and (e) grieving as an emotional shadow. These categories are at work simultaneously in parents' accounts, thus supporting a model of dynamic concurrency within and across their lived experiences. Recommendations for practitioners were derived from the theory to support parents' emotional coping with living loss throughout the chronic stage.

A mixed-methods analysis examining child and family needs following early brain injury

Purpose:To understand child and family needs following TBI in early childhood, 22 caregivers of children who were hospitalized for a moderate to severe TBI between the ages of 0 and 4 within the past 10 years (M = 3.27 years; Range = 3 months to 8 years) participated in a needs assessment.Methods: Through a convergent study design, including focus groups (FG), key informant interviews (KII), and standardized questionnaires, caregivers discussed challenges and changes in their child's behaviors and functioning in addition to resources that would be helpful post-injury. Standardized questionnaires assessing current psychological distress and parenting stress in addition to open-ended questions about their general experience were completed.Results: Results indicated some families continue to experience unresolved concerns relating to the child's injury, caregiver wellbeing, and the family system after early TBI, including notable variation in caregiver reported psychological distress and parenting stress. Caregivers noted unmet needs post-injury, such as child behavior management and caregiver stress and coping.Conclusion: Early TBI can have a long-term impact on the child, caregivers, and family system. Addressing the needs of the whole family system in intervention and rehabilitation efforts may optimize outcomes following early TBI. Study results will inform intervention development to facilitate post-injury coping and positive parenting.IMPLICATIONS FOR REHABILITATIONEarly TBI can result in unmet needs that have a lingering impact on the child, caregiver, and family.Caregivers need information and resources that address their own distress and stressors related to changes in the child post-injury.Our study suggests that stress management and self-care skills are possible targets of intervention for caregivers of children who experienced an early TBI.

Parental Caregiving Burden, Depression, Social Support, and Life Satisfaction: A Multigroup Analysis of Social Support for Parents of Young Children Suffering From Brain Lesions

Social support refers to people’s interpersonal relationships and is a potentially powerful mediator for caregivers’ life satisfaction. This study examined the relationships between parental caregiver burden, depression, social support, and life satisfaction. It compared these relation variables between parents of preschool- and school-aged children, as mediator effects of social support may differ across age ranges. Data were used from the Ministry of Health and Welfare of Korea’s research on support services and policies for people with brain lesions. Parental caregivers of preschool- ( n = 93) and school-aged ( n = 91) children participated in this study. A multigroup analysis indicated a significant negative relationship between caregiving burden and depression with social support and parental life satisfaction and a significant positive relation for social support with life satisfaction for the overall group, preschool- and school aged. Social support was a mediator for each group; however, the regression weight differed between preschool- and school-aged children’s parents. The study confirms the importance of caregivers’ social support and suggests a need for family support strategies that account for children’s ages.

Exploring the role of perceived vs. observed behavioral outcomes in parental grief reaction following pediatric acquired brain injury

BACKGROUND

Pediatric acquired brain injury may result in a significant gap between the "pre" and "post-injury" child.

OBJECTIVE

We aimed to quantitatively explore the mechanism underlying parents' loss experience by examining the mediating role of behavioral outcomes (observed-problems and perceived-change) in the relationship between injury severity and grief.

METHOD

The study employed a cross-sectional retrospective design and comprised 40 parents of children (aged 3-18 years) with moderate-severe brain injury. Data for each parent included an adapted version of the Two-Track Bereavement Questionnaire and Socio-demographics; Data for each child included the child's Information Processing Speed Index; the Child Behavioral Checklist and Parental Perception of Behavioral Changes scale.

RESULTS

Slowed information processing speed was significantly associated with elevated ratings on both measures of behavioral outcomes and with intensified grief. Mediation analyses revealed that parental perceived behavioral change, significantly mediate the relationship between information processing speed and grief; the Child Behavioral Checklist total score also mediated the same relationship but only in 90% confidence interval.

CONCLUSIONS

Findings reveal the adverse impact of behavioral outcomes on grief and suggest parents' loss experience to be stemming primarily from their subjective perception over their "changed-child", rather than the observed problems. Implications for clinical practice are discussed.

Factors associated with parental grief reaction following pediatric acquired brain injury

The present study investigated factors associated with parental grief reaction (PGR) following pediatric acquired brain injury (ABI), and compared PGR to the one exhibited following child death. Fifty-seven parents of 51 children (aged 3-18) whose ABI occurred 1-14 years before participation, completed the multi-scale Two-Track Bereavement Questionnaire; a socio-demographic questionnaire; and a scale assessing perceived behavioural changes in the child. Results from regression analysis indicated that time since injury had no impact on parents' grief other than having an adverse impact on their overall coping and functioning; A higher amount of weekly caring hours predicted only a greater traumatic perception of the loss; Older children's ages but mostly greater parental-perceived behavioural changes, predicted greater PGR on most scales. PGR was compared with the pre-existing data of bereaved parents who completed the same grief questionnaire. Although grief response patterns and intensity were similar in both groups, significant differences were found on scales assessing the continuing bond with the child: relational active grief, close and positive relationship, and conflictual relationship. Our findings indicate that parental grief is multi-dimensional following pediatric ABI and illuminate the interplay between elements characterizing parents' nonfinite vs. finite loss experience.

Understanding parental perspectives on outcomes following paediatric encephalitis: A qualitative study

Background

Encephalitis, characterised as inflammation of the brain tissue, is an important cause of acquired brain injury in children. Objective clinical outcomes vary significantly between affected patients, however they do not always correlate with quality of life as reported by parents. The aim of this study was to explore how parents experience and interpret outcomes in relation to their child who has been affected by encephalitis.

Methods

Data were derived from in-depth, semi-structured interviews, with 15 parents of 12 children and young people affected by encephalitis. Paediatric cases were identified from the retrospective arm of the research programme ‘ENCEPH-UK-Understanding and Improving the Outcome of Encephalitis’, and from the prospective UK childhood meningitis and encephalitis cohort study (UK-ChiMES, 2012 to 2016). Data were analysed thematically.

Results

Parents’ perspectives on important outcomes for their child and family changed during the different stages of the encephalitis illness trajectory: from acute illness, recovery and rehabilitation, then reintegration into everyday life. Parents’ understanding of their children’s overall outcome was informed by their own experiences, involving comparisons with other children and reflections on their child’s problems before, during and after the acute illness.

Conclusion

Outcomes in paediatric encephalitis need to be understood in terms of the context of the patient and family experience as well as the timeframe of recovery. The research highlights the need to include more patient, parent and/or carer reported outcome measures during patient assessment, and that assessment should be repeated during recovery as family concerns change. In the longer term, these parameters could be included in clinical and rehabilitation practice to further support child recovery.

Putting the person in person-centered care: Stakeholder experiences in pediatric traumatic brain injury

PURPOSE

This pilot study sought to describe the perspectives and experiences of survivors of pediatric traumatic brain injury (pTBI), their caregivers, and the medical professionals who serve them.

METHODS

Thirteen people participated in semi-structured interviews: five survivors of pTBI, their primary caregivers, and three medical professionals who work with persons who have sustained pTBI. The study involved a prospective, qualitative, participatory action research model with convenience sampling. All interviews were transcribed and thematic analysis identified central concepts within and between groups. Additionally, the Consolidated Criteria for Reporting Qualitative Research (COREG) were applied.

RESULTS

This study found that survivors of pTBI and their caregivers commonly noted later developing issues, social challenges, and difficulty in post-rehabilitation transitions. In addition, both caregivers and medical professionals reported the need for improved follow-up with survivors, evidence-based research, and medical and therapy providers with specific training on pTBI.

CONCLUSIONS

The perspectives provided by key stakeholders in this pilot study identify common themes that should be central to driving innovation in rehabilitation research and clinical care.