http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2015; 29(4): 481–489 ! 2015 Informa UK Ltd. DOI: 10.3109/02699052.2014.984758

ORIGINAL ARTICLE

Parents and teachers reporting on a child’s emotional and behavioural problems following severe traumatic brain injury (TBI): The moderating effect of time Tamar Silberg1,2*, Dana Tal-Jacobi1*, Miriam Levav2, Amichai Brezner2, & Yuri Rassovsky1 1

Department of Psychology, Bar Ilan University, Ramat-Gan, Israel and 2Department of Pediatric Rehabilitation, the Edmond and Lily Safra Children’s Hospital, Tel Hashomer Medical Center, Ramat-Gan, Israel Abstract

Keywords

Background: Gathering information from parents and teachers following paediatric traumatic brain injury (TBI) has substantial clinical value for diagnostic decisions. Yet, a multi-informant approach has rarely been addressed when evaluating children at the chronic stage post-injury. In the current study, the goals were to examine (1) differences between parents’ and teachers’ reports on a child’s emotional and behavioural problems and (2) the effect of time elapsed since injury on each rater’s report. Methods: A sample of 42 parents and 42 teachers of children following severe TBI completed two standard rating scales. Receiver Operating Characteristic (ROC) curves were used to determine whether time elapsed since injury reliably distinguished children falling above and below clinical levels. Results: Emotional–behavioural scores of children following severe TBI fell within normal range, according to both teachers and parents. Significant differences were found between parents’ reports relatively close to the time of injury and 2 years post-injury. However, no such differences were observed in teachers’ ratings. Conclusions: Parents and teachers of children following severe TBI differ in their reports on a child’s emotional and behavioural problems. The present study not only underscores the importance of multiple informants, but also highlights, for the first time, the possibility that informants’ perceptions may vary across time.

Assessment, behaviour, caregiver, paediatric, traumatic brain injury

Introduction Behavioural and emotional problems among children and adolescents following traumatic brain injuries (TBIs) are a major concern for parents and teachers, as they may have detrimental effects on a child’s long-term adaptation [1–3]. Linda and Jianghong [4], in a recent review, reported that paediatric patients with TBI are at increased risk for various behavioural and psychological problems, with prevalence rates ranging from 10–50%, as compared to a non-referred population. As suggested by the authors, this wide range of reported problems may be due to child and/or environmental characteristics, as well as injury-related factors. Among children, school and home are the two major environmental contexts which affect behaviour. Parents and teachers closely interact with children and the level of proximity and the amount of time spent with them are bound to influence their perceptions regarding the child’s

*Tamar Silberg and Dana Tal-Jacobi are shared first co-authors. Correspondence: Tamar Silberg, Department of Psychology, Bar Ilan University, Ramat-Gan, Israel. Tel: +97235302043. Fax: +97235302045. E-mail: [email protected]

History Received 2 November 2013 Revised 15 September 2014 Accepted 3 November 2014 Published online 9 December 2014

psychological state [5, 6]. In the literature concerning childhood psychopathology it has been widely acknowledged that reports by different informants, such as parents and teachers, convey meaningful information about the child’s psychological condition, such as behavioural consistencies, responsiveness to challenges and the like [7, 8]. These studies also emphasize that informants cannot be substituted one for another, since they reflect variations in perceptions regarding the child’s states [9]. Moreover, in many cases these perceptions combine child’s characteristics (such as age, gender, type of problem, etc.), as well as informants characteristics (e.g. type of relationship with child, level of psychological distress, etc.) to provide a more comprehensive ‘picture’ of the child’s capabilities. Proxy reports on a child’s emotional and behavioral state become even more complicated when evaluating children and adolescents with acquired difficulties such as TBI, as the child and his or her social environment need to re-adjust to the new circumstances [10]. Furthermore, the injury itself may cause a possible halo effect or a bias toward perceiving a second problem (i.e. emotional and/or behavioural) in the presence of another (i.e. brain injury) [11]. This halo effect may affect the rater’s level of confidence in being able to hold

482

T. Silberg et al.

and manage the challenges accompanying the child’s injury and influence their reports on the child’s behaviour [12]. Another major consequence related to childhood injuries is that specific symptoms might decrease, persist or even increase over time. For instance, Taylor et al. [13] have reported that, from baseline to an average of 4 years after injury, emerging behavioural problems decreased in an orthopaedic injury comparison group, remained stable in cases of moderate TBI and increased in cases of severe TBI. Anderson et al. [14], in a more recent study, examined longterm outcomes following childhood TBI. The authors reported higher rates of educational and occupational problems, as well reduced quality-of-life 13 years post-injury among childhood severe TBI survivors. These findings underscore the need to examine the long-term effect of childhood TBI, as an integral component in the assessment of the child’s psychological functioning. Given that there is no biological marker that definitively indicates the presence of an emotional or a behavioural problem following TBI, collecting data from multiple sources should be considered a gold standard in assessing a child’s psychological state. Such perspective is in accordance with the ICF-CY (International Classification of Functioning Health and Disability–Children and Youth) framework [15], in which the child’s status is not considered only a ‘medical’ or ‘biological’ dysfunction, but rather consists of the physical as well as psychological surroundings in which the child functions. Since information collected from multiple informants often reflects the different circumstances in which children’s symptoms are manifested (i.e. child–rater–injury triad), it should be recognized as representing the interaction between the child and his or her environment [16]. Thus, only a multiple-informant approach can help capture the complexity of the emotional and behavioural aspects of the child’s functioning in the context of the traumatic injury and his or her personal environment. This child–rater–injury interaction might also change across time and, thus, should be routinely addressed in follow-up evaluations. Among the most common tools used to evaluate children’s emotional and behavioural state are the Child Behaviour Checklist (CBCL)–Teacher’s Report Form (TRF) [17–19] and the Behaviour Rating Inventory of Executive Function (BRIEF) [20]. These measures have been widely used in research with different clinical populations, including TBI, and are reported to provide reliable and valid assessments of symptoms among children at different ages [21, 22]. These measures also allow a comparison by different observers, covering a wide range of behavioural and emotional symptoms. Interestingly, studies reporting on children’s emotional and behavioural status following TBI tend to use single measures to evaluate outcomes [21, 22]. Yet, single measures, as in the case of a single rater, can rarely fully quantify the complexity of behaviours related to the traumatic injury. The current study aimed to examine variations in parents’ and teachers’reports on a wide range of emotional and behavioural problems among children and adolescents who sustained severe TBI. Most studies reporting on relatively elevated levels of behavioural and emotional problems following childhood severe TBI (see review by Linda and Jianghong [4]) generally failed to address the possibility that

Brain Inj, 2015; 29(4): 481–489

Table I. Description of child characteristics (n ¼ 42; 36% girls).

Mean (SD) Median Range

Age at injury (years)

Age at assessment (years)

Time since injury (months)

LoC (days)

9.4 (3.4) 8.8 4–16.8

11.4 (3.2) 10.5 5.4–17.9

24.6 (15.2) 22 10–73

8.1 (14.2) 2 1–56

LoC, Length of Coma.

these reports might be biased due to child or rater characteristics, as well as their interaction. Furthermore, to the authors’ knowledge no study has addressed the impact of the time elapsed since injury on the different rater’s reports, raising the possibility that the above-mentioned findings are affected by changes in rater’s status over time. Thus, the goals were 2-fold: (I) to examine differences between parents and teachers reports on child’s emotional and behavioural problems via two commonly used questionnaires; and (II) to examine the effects of time elapsed since injury on each rater’s report.

Methods Participants The study employed a retrospective cross-sectional design in which archival data were collected on 42 parents and 42 teachers of children following severe TBI (36% girls, age range at assessment ¼ 5.4–18 years). The study was conducted at a Paediatric Rehabilitation Department at a hospital in central Israel. The children enrolled in the study were 2–17 years at the time of the injury and were all evaluated at least 1 year post-injury (see Table I). All study procedures were approved by the hospital’s Institutional Review Board. Measures During a routine neuropsychological assessment of children following TBI, the Child Behaviour Check List (CBCL) and the Behaviour Rating Inventory of Executive Function (BRIEF) questionnaires were completed by both parents and teachers. These measures allow the comparison by different observers covering a range of behavioural and emotional symptoms. The CBCL questionnaire is a 113-item caregiver-report and/or self-report used to evaluate a child’s emotional and behavioural status [23]. The CBCL has frequently been used to measure levels of internalization and externalization problems observed among children, including those with chronic physical illness [17, 18]. Raters score each item on a 3-point scale: 0 ¼ not true, 1 ¼ somewhat or sometimes true and 2 ¼ very true or often true for the past 6 months. According to the CBCL scoring system, raw scores are converted into T-scores and generate a Total Problems Scale, broadband Internalizing and Externalizing Syndrome Scales and eight narrow band syndrome scales (e.g. anxiousdepressed, aggressive behaviour, etc.). Scores in narrow band syndrome scales range between Normal (T565), Clinical Band (T ¼ 65–70) and Clinical (T470). Scores in

DOI: 10.3109/02699052.2014.984758

summary scales range from Normal (T560), Clinical Band (T ¼ 60–63) and Clinical (T464). There is extensive research evidence supporting the reliability, validity and clinical utility of the CBCL [19]. The checklist has been translated into 26 languages, including Hebrew [24]. In this study, the Somatic Complaints scale in the CBCL was omitted from the analysis, because it potentially presents a considerable bias when applied to children with chronic disabilities [25]. The BRIEF questionnaire assesses executive function (EF) abilities in school and the home environment as reported by parents and/or teachers of school-age children (5–18 years). In addition, a self-report version exists for children above 11 years. Both forms contain 86 items that generate eight clinical scales (Inhibit; Shift; Emotional Control; Initiate; Working Memory; Plan/Organize; Organization of Materials; and Monitor) and three index scales (Behavioural Regulation; Meta-cognition; and an overall total score, the Global Executive Composite). Informants rate child’s behaviour during the preceding 6 months on a 3-point scale in which the behaviour (N ¼ never, S ¼ sometimes or O ¼ often) causes a problem. Cut-off scores for clinical groups on all BRIEF scales (clinical and index scales) range between Normal (T565) and Clinical (T465). In addition to the emotional and behavioural data, demographic data and injury severity measures were collected from children’s medical files. Duration of Loss of Consciousness (LoC) was used for the evaluation of injury severity level. Data analysis According to the CBCL and BRIEF scoring guidelines, in order to enable comparisons between the current sample and population norms, T-scores were computed out of each questionnaire’s scaled scores. Receiver Operating Characteristic Curves (ROC) were used in order to determine the ability of the time elapsed since injury to discriminate between those parents and teachers that reported above and below clinical levels of child emotional and behavioural problems [26–28]. CBCL and BRIEF total score cut-offs were established to classify children into the time elapsed since injury categories. Score cut-offs were determined a priori based on the clinical scoring of both questionnaires [19, 20]. Total scores of below clinical band were placed in the ‘Non-clinical’ category, while scores above the clinical band were classified into the ‘Clinical’ category. To assess agreement between raters, response bias and response precision was examined at the individual and group levels [29]. Mean differences between raters in the three Summary scales of each questionnaire (CBCL: Internalizing, Externalizing, Total; BRIEF: Meta-cognition (MA), Behaviour Regulation (BR), Global Executive Composite (GEC)) were assessed using paired t-tests. For each questionnaire a 3  2  2 ANOVA with repeated measures was conducted, using the three summary indexes as the within-subject variable and rater (parents vs. teachers) and the 2 years since injury ‘cut-off’ groups (below vs. above) as the between-subject variables. Finally, as the current study employed a retrospective design using medical files, multiple imputation technique

Emotional–behavioural problems after childhood TBI

483

(one time stochastic regression) was used to complete missing data, which was lower than 8% for all measurements collected. As long as the imputation is done completely at random [Missing Completely at Random (MCAR)] it allows using the full sample and provides an unbiased parameter estimate [30]. Little’s [31] test for MCAR showed: 2(68)¼64.36, p ¼ 0.603, indicating that data was imputed completely at random. All statistical analyses were performed using the Statistical Package for the Social Sciences version 19.0 for Windows (SPSS-19).

Results Zero-order correlations Correlations between parents’ and teachers’ scores and between child’s injury characteristics are reported in Tables II (for CBCL) and III (for BRIEF). Among all measures, the time elapsed since injury correlated with the parents BRIEF as well as with the CBCL summary indexes. Time elapsed since injury correlated positively with parents’ reports on the CBCL Externalizing and Total scales. In addition, child’s injury severity level, as measured by loss of consciousness (LoC) duration, negatively correlated with teachers’ reports on the CBCL Externalizing scale and on the CBCL Internalizing and Total scales, respectively (see Table II). As in the CBCL, time elapsed since injury correlated positively with parents’ reports on the BRIEF Meta Cognition Index and Behaviour Regulation Index scales. Age at injury, as well as age at assessment, correlated with teachers’ reports on all BRIEF indexes (see Table III). The overall CBCL emotional–behavioural scores according to both teachers’ and parents’ reports fell within the normal range, with teachers’ reports approaching clinical band scores of 605T564 in several sub-scales (Figure 1a). Furthermore, significant differences were found between parents and teachers’ reports on the attention (t(41) ¼ 2.6, p ¼ 0.01) and rule breaking behaviour (t(41) ¼ 3.54, p ¼ 0.001) sub-scales of the CBCL, with parents reporting significantly higher on the former and teachers reporting significantly higher on the latter. In addition, the difference in the Externalization summary scale approached significance (t(41) ¼ 1.96, p ¼ 0.055). However, since all scores fell within the normal range, these differences should be interpreted cautiously. Parents’ reports on the BRIEF also fell within the normal range (i.e. T565), while teachers’ reports on the BRIEF Working Memory scale and Shifting scale fell within the clinical range (see Figure 1b). Teachers reported on significantly higher problems on the Inhibit (t(41) ¼ 2.8, p ¼ 0.008), Shift (t(41) ¼ 3.8, p ¼ 0.001), Emotional control (t(41) ¼ 2.9, p ¼ 0.005), Initiate (t(41) ¼ 2.52, p ¼ 0.02), Working memory (t(41) ¼ 2.1, p ¼ 0.04) and Monitor (t(41) ¼ 2.9, p ¼ 0.007) scales, as well as on the Metacognition (MI) (t(41) ¼ 2.3, p ¼ 0.03) and General executive composite (GEC) index scales (t(41) ¼ 2.3, p ¼ 0.03). However, as in the CBCL, since most scores fell within normal range, these results should be interpreted accordingly.

484

T. Silberg et al.

Brain Inj, 2015; 29(4): 481–489

Table II. Correlations between parents’ and teachers’ reports on the CBCL and between child’s injury characteristics. Parent

a

Age at injury Age at assessmenta Time since injuryb LoC

Teacher

Total

Internalizing

Externalizing

Total

Internalizing

Externalizing

0.04 0.07 0.32* 0.11

0.11 0.02 0.28 0.11

0.08 0.04 0.32* 0.12

0.17 0.21 0.07 0.29

0.01 0.01 0.05 0.44*

0.25 0.27 0.01 0.07

*p50.05. Years; bMonths; LoC, Length of Coma (days).

a

Table III. Correlations between parents’ and teachers’ reports on the BRIEF and between child’s injury characteristics. Parent

a

Age at injury Age at assessmenta Time since injuryb LoC

Teacher

GEC

Meta cognition

Behavioural regulation

GEC

Meta cognition

Behavioural regulation

0.03 0.12 0.31* 0.07

0.01 0.11 0.33* 0.07

0.07 0.13 0.24 0.08

0.51** 0.48** 0.14 0.11

0.48** 0.45** 0.14 0.04

0.40** 0.35* 0.12 0.05

*p50.05; **p50.001. Years; bMonths. GEC, General Executive Composite; LoC, Length of Coma duration (days).

a

Figure 1. Differences between parents and teachers reports on the (a) CBCL and (b) BRIEF. Dashed lines at T-value ¼ 65 indicate borders of the clinical cut-off scores for CBCL sub-scales as well as for all BRIEF scales and indexes; and dashed lines at T-value ¼ 60 indicate borders of the clinical cut-off scores of the CBCL summary scales. Scores above clinical cut-off are considered as indicators of significant emotional and behavioural problems.

Comparison between raters according to the time elapsed since injury As the time interval between injury and assessment positively correlated with parents’ reports on both CBCL

and BRIEF, but not with the teachers reports, this study aimed to further examine the possible effect of the time elapsed since injury on the reports of both raters using both questionnaires.

DOI: 10.3109/02699052.2014.984758

Discriminant validity The C statistic or the area under the receiver operating characteristic (ROC) curve was 0.71 for the time elapsed until clinical levels of the CBCL and 0.68 for the time elapsed until clinical levels for the BRIEF were reached according to parents’ reports (p50.02; p50.05, respectively). These results indicate that the time elapsed provides fair discrimination for both scales (C statistic values greater than 0.50 indicate that the discrimination is better than chance [32]). The ‘optimal’ cut-off point for time elapsed—calculated as the point closest to the ROC curves’ 0,1 co-ordinate for the CBCL—was 22 months and for the BRIEF 24 months. For teachers the area under the ROC curve was 0.59 and 0.57 for the CBCL and the BRIEF, respectively (p ¼ 0.24; p ¼ 0.4, respectively) indicating that time elapsed poorly discriminates among teachers’ responses on both questionnaires. To this end, a ‘cut-off point’ was determined according to the spontaneous recovery period described in the literature [21] and the ROC time criterion value and divided the sample into two groups: above and below 2 years since injury. Independent t-tests were conducted in order to examine differences in child’s characteristics between the two ‘cut-off’ groups. No significant differences were found between the below and above ‘cut-off’ groups on any of the collected characteristics including gender 2 ¼ 2.8, ns; age at injury t(41) ¼ 1.8, ns; age at evaluation t(41) ¼ 0.295, ns; and injury severity level (LoC) t(41) ¼ 0.703, ns. Teachers and parents reports on the CBCL according to the time elapsed since injury The 3  2  2 interaction between the three CBCL summary scales as the within-subject variable and between rater and time since injury ‘cut-off’ groups as the between-subjects variables did not reach significance repeated measures, F(2, 162) ¼ 0.6, p ¼ 0.27, 2 ¼ 0.016. In addition, no significant differences were found between the overall CBCL reports of parents (M ¼ 56.4, SD ¼ 1.7) and teachers (M ¼ 56.8, SD ¼ 1.8), (F(1,82) ¼ 0.027, p ¼ 0.87, 2 ¼ 0.001). The comparison between raters on the CBCL in the two ‘cut-off’ groups revealed a significant main effect for the three summary scales, F(2, 162) ¼ 8.62, p50.001, 2 ¼ 0.095. Paired comparisons (with Bonferroni correction) between the three index scores revealed that scores on the Externalizing summary scale (M ¼ 54.50, SD ¼ 8.04) were significantly lower than scores on the Internalizing summary scale (M ¼ 57.55, SD ¼ 7.69) and the Total summary scale (M ¼ 57.38, SD ¼ 7.64), t(83) ¼ 2.76, p ¼ 0.007; t(83) ¼ 4.08, p50.001, respectively. No significant difference was found between the Internalizing and the Total summary scores, t(83) ¼ 0.32, ns. However, this main effect should be interpreted in light of the significant interaction found between the three summary scales and rater (i.e. parent vs. teacher) (F(1,162) ¼ 5.23, p ¼ 0.01, 2 ¼ 0.06). This interaction revealed that, whereas significant differences were observed between parents’ reports on the Externalizing summary scale and on the Internalizing and Total scales, t(41) ¼ 4.49, p50.001; t(41) ¼ 4.69, p50.001, respectively, no significant difference was found in teachers reports on any of the CBCL summary scales.

Emotional–behavioural problems after childhood TBI

485

In addition, a significant main effect was found for the 2 years ‘cut-off’ groups, in which children and adolescents in the above 2 years group received higher scores by both raters (M ¼ 58.95, SD ¼ 15.3) compared to children and adolescents in the below 2 years group (M ¼ 54.23, SD ¼ 14.18), F(1,82) ¼ 3.96, p ¼ 0.03, 2 ¼ 0.06. However, this main effect should be cautiously interpreted since the interaction between rater and the 2 years ‘cut-off’ groups was found to be significant F(1,82) ¼ 3.85, p ¼ 0.04, 2 ¼ 0.04. Paired comparisons (with Bonferroni correction) between parents and teachers revealed that, while parents of children in the below 2 years group reported significantly lower scores (M ¼ 51.65, SD ¼ 12.2) than parents of children in the above 2 years group (M ¼ 60.8, SD ¼ 11.65), t(41) ¼ 2.44, p ¼ 0.02, no significant difference was found between teachers of children in the below 2 years group (M ¼ 56.9, SD ¼ 9.1) and teachers of children in the above 2 years group (M ¼ 57.1; SD ¼ 8.5), t(41) ¼ 0.72, p ¼ 0.05 (see Figure 2a and b, respectively). Teachers and parents reports on the BRIEF according to the time elapsed since injury The comparison between raters on the BRIEF in the two ‘cutoff’ groups revealed that only the interaction between rater and the 2 years since injury ‘cut-off’ groups reached significance, F(1,82) ¼ 8.38, p ¼ 0.005, 2 ¼ 0.095. When examining the source of the interaction, a significant difference was found between the reports of parents in the below 2 years (M ¼ 55.9; SD ¼ 10.9) and of parents in the above 2 years (M ¼ 64.7; SD ¼ 9.6) groups, t(42) ¼ 2.68, p ¼ 0.01. No such difference was found between teachers in the below 2 years group (M ¼ 63.1; SD ¼ 10.8) and those in the above 2 years group (M ¼ 59.6; SD ¼ 9.2), t(42) ¼ 1.1, p ¼ 0.42 (see Figure 3a and b, respectively).

Discussion The current study examined variations in parents’ and teachers’ reports regarding a wide range of emotional and behavioural problems, among children and adolescents following severe TBI. Overall it was found that the emotional and behavioural profiles of this sample fell within the normal range in all scales of both CBCL and BRIEF questionnaires, with slightly higher reports on EF problems by teachers on the working memory and shift indexes of the BRIEF. These results support previous findings in which following childhood TBI there is variability in the appearance of emotional and behavioural problems (see recent review by Linda and Jianghong [4]). However, although it is suggested that such variability might be related to a range of contributing factors (related to the child, injury and the environment), none of the studies addressed the possibility that such variability might be related to the source of the information and to the point in time at which these evaluations were conducted. Furthermore, although not clinically significant according to the CBCL scoring system (i.e. T565 for most BRIEF scales), teachers reported on relatively higher problems on the BRIEF, as compared to parents. The results are in accordance with the reports of Mares et al. [33], who examined differences between teachers and parents reports on child’s EF in a sample of children with

486

T. Silberg et al.

Brain Inj, 2015; 29(4): 481–489

Figure 2. Differences between reports of (a) parents and (b) teachers in the ‘below’ and in the ‘above’ 2 years cut-off groups on the CBCL summary scales. INT, Internalizing summary scale; EXT, Externalizing summary scale; Total, Total summary scale. Dashed lines at T-value ¼ 60 indicate borders of the clinical cut-off scores of the CBCL summary scales. Scores above clinical cut-off are considered as indicators of significant emotional and behavioural problems.

Figure 3. Differences between reports of (a) parents and (b) teachers in the ‘below’ and ‘above’ 2 years cut-off groups on the BRIEF summary indexes. BRI, Behavioural regulation index; MC, Metacognition index; GEC, General executive composite. Dashed lines at T-value ¼ 65 indicate borders of the clinical cut-off scores of the BRIEF summary indexes. Scores above clinical cut-off are considered as indicators of EF dysfunction.

ADHD using the BRIEF and found that teachers consistently reported higher executive dysfunction compared to parents. The authors’ suggest that the school environment is more demanding, less tolerant and flexible than the home environment, resulting in the possible higher rates of behavioural problems reported by teachers. Finally, they conclude that the observations made by teachers were more reliable and less confounded than those made by the parents. The findings indicate that, among children and adolescents after severe TBI, teachers reported on relatively more behavioural

problems as compared to parents. This might be related to the fact that teachers have more access to a comparison ageappropriate group and are, thus, more qualified in recognizing difficulties in executive aspects of behaviour among schoolaged children. However, it should be emphasized that differences between raters, rather than being considered a weakness, often represent the value of obtaining information from several sources [34, 35] and frequently indicates that contextual variability in children’s behaviour is authentic and not simply an artifact of rater characteristics [36]. Hence, it

DOI: 10.3109/02699052.2014.984758

appears that, in such cases, each source may provide distinctive information that is potentially valuable for diagnostic decision-making [9, 37, 38]. Moreover, in light of the ICF framework, in the case of paediatric TBI, teachers’ and parents’ perceptions, interactions and reports on different levels of emotional and behavioural problems shed light on the child’s broad ability to participate in his or her environment. Further, this study aimed to examine the possible effect of the time elapsed since injury on the reports of both raters. To this end, the sample was divided into two groups according to the ROC validated time criterion value of 24 months and in agreement with the possible spontaneous recovery period suggested by Armstrong-Betts [21]. This comparison yielded significant differences between parents and teachers reports on both questionnaires at the time close to injury and relatively similar reports at the chronic phase, i.e. above 2 years since injury. The results suggest that a single evaluation of emotional and behavioural reports of different raters relatively close to the time of the child’s injury might be misleading and represent a single characteristic of the child–rater–injury triad. In addition, the results suggest that examining potential moderator variables, such as time elapsed since injury, is highly recommended. The findings support the results of Armstrong-Betts [21], regarding EF problems among young children following TBI (mostly mildto-moderate), during four time periods (shortly after injury, 6-months, 12-months and 18-months post-injury). Similar to the present study, parent’s and teachers reported on relatively similar levels of EF problems within 2 years from the time of injury. However, the results elaborate on these previous findings and suggest that parents’ reports of child’s emotional and behavioural state following TBI change over time, with higher levels of emotional and behavioural problems reported at the chronic stage following injury. Such effect was not observed for any of the teachers’ reports, which were substantially higher and more stable across time. Notably, this pattern was observed on both questionnaires, indicating that this tendency may not be limited to a circumscribed behavioural component, but rather represents a general perspective of children with TBI across diverse psychological contexts. It might be suggested that the higher rates of emotional and behavioural problems in the reports of parents’ of children at the chronic stage following TBI, compared to their reports within 2 years post-injury, may be related to the ‘latent effects’ of TBI on the developing brain [39]. However, the fact that such effect was found only among parents and not among the teachers implies that other processes might be involved in parents’ evaluation of their child’s problems following TBI. A possible explanation might be related to the psychological adjustment process parents of injured children go through as a result of the traumatic event. Research shows that mothers of children following TBI, aged 5–15 years at the time of injury, experienced high levels of stress, weakening their ability to adjust to the demands of their child’s condition [40]. The relatively low number of problems reported by parents in the below 2 years group might indicate they were still within the first stages of adjustment to the child’s injury, comprised of distinct psychological features such as denial as

Emotional–behavioural problems after childhood TBI

487

well as hope for improvement [41, 42]. It is also possible that, within a time-frame relatively close to the injury, parents might ‘idealize’ their child’s capabilities and report on more, what they perceive as, ‘normative’ levels of emotional and behavioural problems [43]. However, during the chronic stage, despite all the external support available for families, it is the family that ultimately becomes the long-term case manager for their child, co-ordinating school meetings, friendships, social events and, thus, becoming more and more familiar with the child’s status [44]. According to the current results, it seems that, especially during the relatively early stage following severe TBI (up to 2 years), when evaluating child’s emotional and behavioural state, professionals should seek information from multiple informants and insist on receiving external reports from teachers or other healthcare providers. Yet, it should be acknowledged that, although teachers’ reports tend to be more stable following child’s TBI, they cannot substitute parents’ evaluations, since these reports may reflect on diverse psychological symptoms within the child’s family. Furthermore, understanding the possible differences in informant’s perspectives is an important aspect of any applied intervention; as such disagreements might be a major source of conflict between the family and the different health professionals [45]. By this, the results call for a family-based intervention framework following childhood TBI in order to support the adjustment of the child and his or her personal environment. It is important to note that studies assessing a child’s outcomes following TBI commonly use longitudinal designs, in which the child is repeatedly evaluated over time. As many factors may intervene between repeated assessments, it is not possible to isolate the effect of time on the informants’ report. The current study employed a cross-sectional design, in which no other child- or injury-related factors, other than the time elapsed since injury, differed between the two ‘cut-off’ groups. This design, therefore, provided a further insight into the possible bias in using reports from a single informant (most often the parent), especially during the first phase of post-injury adjustment. To the authors’ knowledge, this is the first study to address these methodological aspects in evaluating proxy reports of children following TBI. In addition to the above, the fact that both questionnaires revealed a relatively similar pattern of results indicates that they represent a wider illustration of raters’ perspectives on children post-TBI and is another contribution of the current study’s design. This study has several limitations. First, the findings reported here are based on a relatively small sample of children and, therefore, require replication in larger datasets. It is, thus, recommended that the results be addressed as preliminary patterns which might help reveal what should be studied with a larger sample size. Second, no additional data was available on raters’ characteristics (teachers’ seniority level, age, etc.) and the majority of the parents reporting on a child’s emotional and behavioural status were mothers; thus, this study was unable to examine the possible sources that might explain the differences between raters. Follow-up studies should further examine variables related to raters’ characteristics (such as emotional distress, gender, age and

488

T. Silberg et al.

experience). Future studies should also incorporate the child’s self-report measures, as several studies have documented incongruence in the way children and caregivers perceive a given state of affairs [34]. Finally, it would be important to examine whether reports of different informants change across time, as demands of the environment increase and children may find themselves in more difficult situations and show other behavioural or emotional difficulties. In sum, the present study underscores the importance of using reports from multiple informants when assessing complex behavioural issues of children following TBI over time. As suggested by the ICF-CY framework, incorporating contextual features into the evaluation may contribute to a better understanding regarding diverse psychological problems often reported on childhood TBI survivors.

Acknowledgements We thank the families that participated in this study, the research assistant Adi Zakay, MA, for data entering and to the professional team at the Neuropsychological Unit at the Pediatric Rehabilitation Department, the Edmond and Lily Safra Children’s Hospital, for the proficient data collection along the years. Finally, we thank S. Barak, PhD, for assistance with the data analysis as well as J. Ahonniska-Assa, E. Shadmi, PhD, and T. Krasovsky, PhD, for the helpful comments and advice which contributed to the manuscript.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Anderson V, Brown S, Newitt H, Hoile H. Educational, vocational, psychosocial, and quality-of-life outcomes for adult survivors of childhood traumatic brain injury. Journal of Head Trauma Rehabilitation 2009;24:303–312. 2. Barker-Collo SL. Behavioral profiles and injury severity following childhood traumatic brain injury. Brain Impairment 2007;8:22–30. 3. Poggi G, Liscio M, Adduci A, Galbiaty S, Massimino M, Sommovigo M, Zettin M, Figini E, Castelli E. Psychological and adjustment problems due to acquired brain lesions in childhood: a comparison between post-traumatic patients and brain tumor survivors. Brain Injury 2005;19:777–785. 4. Linda LI, Jianghong LIU. The effect of pediatric traumatic brain injury on behavioral outcomes: A systematic review. Developmental Medicine & Child Neurology 2013;55:37–45. 5. Randazzo KV, Landsverk J, Ganger W. Three informants’ reports of child behavior: Parents, teachers, and foster parents. Child Adolescent Psychiatry 2003;42:1343–1350. 6. Treutler CM, Epkins CC. Are discrepancies among child, mother, and father reports on children’s behavior related to parents’ psychological symptoms and aspects of parent–child relationships? Journal of Abnormal Child Psychology 2003;31:13–27. 7. Achenbach TM. As others see us: Clinical and research implications of cross-informant correlations for psychopathology. Current Directions in Psychological Science 2006;15:94–98. 8. De Los Reyes A, Thomas SA, Goodman KL, Kundey SMA. Principles underlying the use of multiple informants’ reports. Annul Review of Clinical Psychology 2013;9:123–149. 9. Achenbach TM, McConaughy SH, Howell CT. Child/adolescent behavioral and emotional problems: Implications of cross-informant correlations for situational specificity. Psychological Bulletin 1987;101:213–232.

Brain Inj, 2015; 29(4): 481–489

10. Hawley CA. Reported problems and their resolution following mild, moderate and severe traumatic brain injury amongst children and adolescents in the UK. Brain Injury 2003;17:105–129. 11. Biederman J, Mick E, Faraone SV. Normalized functioning in youths with persistent attention-deficit/hyperactivity disorder. Journal of Pediatric 1998;133:544–551. 12. Mohr JD, Bullock LM. Traumatic brain injury: Perspectives from educational professionals. Preventing School Failure: Alternative Education for Children and Youth 2005;94:53–57. 13. Taylor HG, Yeates KO, Wade SL, Drotar D, Stancin T, Minich N. A prospective study of short and long term outcomes after traumatic brain injury in children: Behaviour and achievement. Neuropsychology 2002;16:15–27. 14. Anderson V, Brown S, Newitt H, Hoile H. Long-term outcome from childhood traumatic brain injury: Intellectual ability, personality, and quality of life. Neuropsychology 2011;25:176–184. 15. World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland: World Health Organization; 2001. 16. Dirks MA, De Los Reyes A, Briggs-Gowan M, Cella D, Wakschlag LS. Annual Research Review: Embracing not erasing contextual variability in children’s behavior–theory and utility in the selection and use of methods and informants in developmental psychopathology. Journal of Child Psychology & Psychiatry 2012;53:558–574. 17. Barlow JH, Ellard DR. The psychosocial well-being of children with chronic disease, their parents and siblings: An overview of the research evidence base. Child: Care Health & Development 2006; 32:19–31. 18. Lavigne JV, Faier-Routman J. Psychological adjustment to pediatric physical disorders: A meta-analytic review. Pediatric Psychology 1992;17:133–157. 19. Achenbach TM, Rescorla LA. Manual for the ASEBA school age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, and Families; 2001. 20. Gioia GA, Isquith PK, Guy SC, Kenworthy L. Behavior Rating Inventory of Executive Function. Odessa, FL: Psychological Assessment Resources, Inc.; 2000. 21. Armstrong-Betts AE. Perceptions of executive functioning in young children following traumatic brain injury [thesis]. Dayton, OH: The School of Education and Allied Professions of the University of Dayton; 2011. 22. Hayman-Abello SE, Rourke BP, Fuerst DR. Psychosocial status after pediatric traumatic brain injury: A subtype analysis using the Child Behavior Checklist. Journal of the International Neuropsychological Society 2003;9:887–898. 23. Achenbach TM. Manual for the Child Behavior Checklist/4-18 and Profile. Burlington, VT: University of Vermont; 1991. 24. Zilber N, Auerbach J, Lerner Y. Israeli norms for the Achenbach child behavior checklist: Comparison of clinically and non-referred children. The Israel Journal of Psychiatry & Related Sciences 1994; 31:5–12. 25. Friedman D, Bryant FB, Holmbeck GN. Brief report: Testing the factorial invariance of the CBCL somatic complaints scale as a measure of internalizing symptoms for children with and without chronic illness. Pediatric Psychology 2007;32:512–516. 26. McFall RM, Treat TA. Quantifying the information value of clinical assessments with signal detection theory. Annul Review of Psychology 1999;50:215–241. 27. Pintea S, Moldovan R. The Receiver-Operating Characteristic (ROC) analysis: Fundamentals and applications in clinical psychology. Journal of Cognitive and Behavioral Psychotherapies 2009;1:49–66. 28. Streiner DL, Cairney J. What’s under the ROC? An introduction to receiver operating characteristics curves. Canadian Journal of Psychiatry 2007;52:121–128. 29. Snow AL, Cook KF, Lin P, Morgan RO, Magaziner J. Proxies and other external raters: Methodological considerations. Health Services Research 2005;40:1676–1693. 30. Enders CK. Applied missing data analysis. New York: Guilford Press; 2010. 31. Little RJA. A test of missing completely at random for multivariate data with missing values. Journal of the American Statistical Association 1988;83:1198–1202. 32. Hosmer DW, Lemeshow S. A goodness-of-fit test for the multiple logistic regression model. Communications in Statistics 1980;A10: 1043–1069.

DOI: 10.3109/02699052.2014.984758

33. Mares D, McLuckie A, Schwartz M, Saini M. Executive function impairments in children with attention-deficit hyperactivity disorder: Do they differ between school and home environments? Canadian Journal of Psychiatry 2007;52:527–534. 34. Nelson JM, Harwood HR. A Meta-Analysis of parent and teacher reports of depression among students with learning disabilities: Evidence for the importance of multi-informant assessment. Psychology in Schools 2011;48:371–385. 35. Smith SR. Making sense of multiple informants in child and adolescent psychopathology. Journal of Psychoeducational Assessment 2007;25:139–149. 36. De Los Reyes A, Goodman KL, Kliewer W, Reid-Quinones K. The longitudinal consistency of mother-child reporting discrepancies of parental monitoring and their ability to predict child delinquent behaviors two years later. Journal of Youth Adolescence 2010;39: 1417–1430. 37. Kolko DJ, Kazdin AE. Emotional/behavioral problems in clinical and nonclinic children: Correspondence among child, parent and teacher reports. Journal of Child Psychology & Psychiatry 1993;34: 991–1006. 38. Stanger C, Lewis M. Agreement among parents, teachers, and children on internalizing and externalizing behavior problems. Journal of Clinical Child Psychology 1993;22:107–116.

Emotional–behavioural problems after childhood TBI

489

39. Brenner LA, Dise-Lewis JE, Bartles SK, O’Brien SE, Godleski M, Selinger M. The long-term impact and rehabilitation of pediatric traumatic brain injury: A 50-year follow-up case study. Journal of Head Trauma Rehabilitation 2007;22:56–64. 40. Hawley CA, Ward AB, Magnay AR, Long J. Parental stress and burden following traumatic brain injury amongst children and adolescents. Brain Injury 2003;17:1–23. 41. Lezak MD. Brain damage is a family affair. Journal of Clinical & Experimental Neuropsychology 1988;10:111–123. 42. Waaland PK. Family response to childhood traumatic brain injury. In: Kreutzer J, Wehman P, editors. Community reintegration following traumatic brain injury. Baltimore, MD: Brookes; 1990. 43. Anderson VA. Traumatic brain injury in children. In: Anderson VA, Northam E, Hendy J, Wrennall J, editors. Developmental neuropsychology: A clinical approach. Hove, East Sussex: Psychology Press Ltd; 2001. p 125–184. 44. Williams J, Savage R. Family, culture, and child development. Head Injury: A family matter. Baltimore, MD: Brookes; 1991. 45. Ravelli A, Viola S, Migliavacca D, Pistorio A, Ruperto N, Martini A. Discordance between proxy-reported and observed assessment of functional ability of children with juvenile idiopathicarthritis. Rheumatology 2001;40:914–919.

Copyright of Brain Injury is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.