Family stress plays part in children’s TBI recovery

But access to resources makes a difference

A recent study has found that children ages 6 to 12 who sustained a moderate-to-severe traumatic brain injury (TBI) were prone to having difficulty in school and behavioral problems long after their recovery.1

One of the more interesting aspects of the research was the finding that TBI children had less favorable post-injury outcomes when their families scored high on various stress measures.

"Severely injured children from relatively unstressed families had good recovery in math abilities in that first-year follow-up," says Gerry Taylor, PhD, professor of pediatrics at Rainbow Babies and Children’s Hospital, University Hospitals of Cleveland and Case Western Reserve University in Cleveland. Taylor is a co-author of the study, which was published in Neuropsychology this year.

The family’s level of stress was measured using the Socioeconomic Composite Index, computed by averaging sample scores for the Duncan Socioeconomic Index, the annual family income as coded on the Life Stressors and Social Resources Inventory - Adult Form, and years of maternal education. The family stressors score also was determined by scores on measures of health, work, spouse, extended family, and friends.

The study included 53 children with severe TBI, 56 children with moderate TBI, and a comparison group of 80 children who had orthopedic injuries that did not involve TBI. Investigators measured the children’s and families’ pre-injury status and post-injury achievement skills shortly after the injuries occurred and followed the children’s progress at three assessments over an average of four years.

Among their findings were that children with severe TBI were able to maintain the same progress as the children who suffered orthopedic injuries on socialization measures, but this was only true if they were from families of relatively higher socioeconomic status, Taylor says.

Investigators first met with families when the TBI children were medically stable but still in the hospital, Taylor says.

"We asked parents how they viewed their child’s behavior before injury and about the family’s functioning before injury," Taylor says. "We then scheduled them for a first formal assessment at about three weeks after injury, and in most cases the children were still in the hospital."

Follow-up assessments were done at six months after baseline, 12 months after, and then a final time about four years post-injury, Taylor adds.

"We had this long-term follow-up, and we could then track their recovery or lack of recovery over that period of time," Taylor says. "We subsequently saw them again annually two more times at five and six years out."

However, the last two assessments were not included in the published report. There had been a significant study drop-out by participants at that point, whereas the attrition at four years post-injury was more reasonable, Taylor adds.

Among the outcomes measures studied were measures of the child’s IQ and other cognitive ability, academic achievement in reading and math, and measures of behavior as rated by parents and teachers.

The group of children with severe TBI tended to do poorly on most outcome measures and had the most difficulty with recovery, continuing to have behavioral and learning problems long after the injury, Taylor says.

"Fifty percent of those with severe TBI were in some kind of special education program four years after injury," Taylor says. "And about 30% of the children with severe TBI had a behavior problem."

Although rehab professionals who work with TBI children will not find these results surprising, the study does provide a sophisticated methodological demonstration of what they may have understood intuitively.

The study’s more interesting findings are that children with severe TBIs can grow and improve in their abilities, socialization, and behavior over time, but this improvement is dependent on the child’s environment, Taylor says.

"Children from families with lower socioeconomic status failed to maintain the same progress as the orthopedic group in terms of socialization six to 12 months after injury," Taylor says. "Those trends became more evident the further you got away from the average level of socioeconomic status, and we saw differences from conditions of disadvantage relative to conditions of advantage."

Also, teachers rated academic performance lower in severe TBI children who were from families of lower socioeconomic status, Taylor says.

"Only under conditions of disadvantage did we see that effect, and it applies to a longer-term follow-up interval," Taylor notes. "What we conclude is that the environment can either facilitate or retard recovery, and thus the family environment is important to consider in facilitating recovery."

Taylor says he hopes the research will help rehab providers identify high-risk children and provide an impetus for their receiving family treatment and environmental modification as a component of rehab services.

"TBI kids may need more support," Taylor says. "We may do some things that may help the process along the way."

Some strategies that rehab providers can employ include:

  • teaching families how to provide a supportive environment for the child to help optimize the child’s recovery;
  • suggesting families become involved in TBI support groups where they can receive information and emotional support;
  • referring families to web-based support and information about TBI;
  • providing counseling and neuropsychology services to the entire family;
  • working with schools to provide TBI children with tutors and homework assistance.

While this study looked only at TBI’s impact on children, there could be some broader-reaching implications for TBIs and adults, Taylor suggests.

"There is evidence that the effect of severe TBI on adults and their families is similar to the effects on children with severe TBI and their families," Taylor says. "You would expect to see similar kinds of neurocognitive and behavioral problems, and thus the need for behavioral support and facilitation of recovery would be similar, I think."

The general take-home message of this research is that the impact of TBIs is not entirely physiological, and rehab providers need to be aware of the impact of the child’s environment on recovery, Taylor says.

"It should encourage rehab centers to do even more with the families and provide even more intensive interventions," Taylor says. "It encourages us to look at injury in terms of the context of family and environment."


1. Taylor HG, Yeates KO, Wade SL, et al. A prospective study of short- and long-term outcomes after traumatic brain injury in children: Behavior and achievement. Neuropsychology 2002; 16:15-27.

Need More Information?
  • Gerry Taylor, PhD, Professor of Pediatrics, Rainbow Babies and Children’s Hospital, University Hospitals of Cleveland, Case Western Reserve University, 11100 Euclid Ave., Cleveland, OH 44106-6038. Telephone: (216) 844-6227.