A telehealth intervention for families caring

for a child with traumatic brain injury (TBI)

Damith T. Woods, Cathy Catroppa, Celia Godfrey, Rebecca Giallo, Jan Matthews and
Vicki A. Anderson

Dr Celia Godfrey is based at Abstract

Child Neuropsychology, Purpose – The purpose of this paper is to determine the preliminary clinical utility of a telephone-support
Murdoch Childrens Research format of the “Signposts” (Hudson et al., 2003) behavioural intervention programme to be used with
Institute, Melbourne, Australia; a paediatric traumatic brain injury (TBI) population.
School of Psychological Design/methodology/approach – Nine families caring for a child with moderate or severe TBI,
Sciences, University of participated in a pilot study of a TBI adapted “Signposts for Building Better Behaviour” manualised
Melbourne, Melbourne, programme. The programme is designed to help parents learn positive parenting skills and strategies that
empower them to successfully manage their child’s challenging behaviour post-TBI. The programme
Australia; Department of
consists of seven core sessions and two supplemental sessions. Parents work through the sessions with an
Paediatrics, University of
accompaniment of guiding information booklets, a DVD with scenes modelling positive parenting strategies,
Melbourne, Melbourne, and a workbook containing written exercises. At the completion of each session parents receive
Australia and Royal Children’s a telephone-support call from a trained Signposts practitioner who provides assistance and feedback on
Hospital, Melbourne, Australia, programme content.
where Dr Damith T. Woods is a Findings – On average parents completed eight sessions (range seven to nine) and every family completed
Clinical Lecturer and the seven core sessions. Participation in the telephone-support calls was high with 96 per cent of calls
Professor Vicki A. Anderson is having been successfully received by families. All parents agreed that the telephone calls were a useful part
the Director, Clinical Studies. of the programme and felt that the materials were helpful for managing challenging behaviour. Paired-
Associate Professor Cathy samples t-tests showed significant reductions for challenging behaviour from pre- to post-intervention.
Parenting practices also significantly improved over the course of the intervention. In general, parents rated
Catroppa is a Psychologist/
a high level of consumer satisfaction with the Signposts programme and its content.
Research Fellow, based at
Originality/value – Overall, these preliminary findings support the potential clinical utility of a telephone-
Child Neuropsychology, support version of the Signposts programme to improve parenting skills and to reduce challenging child
Murdoch Childrens Research behaviour following TBI. This study has provided the impetus for a larger clinical research trial to be conducted.
Institute, Melbourne, Australia; Keywords Children, Telehealth, Traumatic brain injury, Behaviour intervention
School of Psychological
Paper type Research paper
Sciences, University of
Melbourne, Melbourne,
Australia and Department of
Paediatrics, University of Introduction
Melbourne, Melbourne,
Australia. Challenging externalising behaviours including impulsiveness, affective instability, disinhibition,
Dr Rebecca Giallo is a Senior social impropriety, oppositional-defiance, and aggressiveness are common sequelae of
Research Fellow and Associate traumatic brain injury (TBI) in children (Cole et al., 2008; Dooley et al., 2008; Levin et al., 2007;
Professor Jan Matthews is a Prigatano et al., 2010; Ylvisaker et al., 2007). Compared to “mild” TBI, a “moderate”, or “severe”
Principal Research Fellow, brain injury is more likely to result in these types of post-injury behavioural displays (Asarnow
both are based at Parenting et al., 1991; Schwartz et al., 2003; Max et al., 1998). In saying this, a minority of children with
Research Centre, Melbourne, mild TBI are equally susceptible to these issues (McKinlay, 2009; McKinlay et al., 2009).
Australia.
Irrespective of injury severity, challenging behaviours prevent the injured child from engaging in
activities that may enable them to function and interact with their caregivers, and more broadly
with those in the wider community (Emmerson et al., 1988). It has been reported that as many
as 70 per cent of children with severe TBI will demonstrate challenging behaviours that did not

DOI 10.1108/SCN-01-2013-0002 VOL. 5 NO. 1 2014, pp. 51-62, C Emerald Group Publishing Limited, ISSN 2042-0919 j SOCIAL CARE AND NEURODISABILITY j PAGE 51
 predate the injury (Schwartz et al., 2003; Max et al., 1998), while others may show an
exacerbation in the intensity, frequency, and duration of premorbid difficulties (Anderson et al.,
2006). In the absence of any psychosocial intervention or follow-up, prospective evidence
suggests that these problems are likely to persist (Catroppa et al., 2009), sometimes well into
adulthood (Brenner et al., 2007; Cattelani et al., 1998). This can place children at increased
risk for peer rejection, social withdrawal, and significant interruptions in academic pursuits
(Hawley, 2004, 2005).
After a child has suffered a brain injury leading to hospital admission the acute medical
needs of the child will initially dominate care. In this early period, the value of behavioural
management procedures is often limited due to diminished learning capacity (Flanagan et al.,
2008). Despite this, controlling particular aspects of the environment in this early stage such
as minimising visual and auditory stimulation, restricting visitors, establishing a consistent
sleep-wake cycle, and orientating the child to time and place can prove beneficial (Woods
et al., 2008). Additionally, a structured hospital environment often lends itself to parents being
able to successfully manage the necessary acute care of their child. However, families must
eventually return home, some to more isolated regions, and find it difficult to access services
and support (Aitken et al., 2004). A lack of systematic follow-up can add to the burden that
some families may have already experienced in the acute setting (Ganesalingham et al., 2008;
Wade et al., 1996). This is of major concern because family-parental dysfunction, as well as
burden and distress, are linked with children’s long-term behavioural prognosis (Rivara et al.,
1993, 1996; Taylor et al., 2001).
There is an alarming body of research emphasising the high frequency of unmet healthcare needs
for families caring for a child with TBI especially with respect to managing challenging behaviour
(Aitken et al., 2004; Bedell and Dumas, 2004; Greenspan and Mackenzie, 2000; Hawley et al.,
2003; Slomine et al., 2006; Prigatano and Gray, 2007; Wade et al., 1996). It is also evident from
the literature that not all families necessarily have the resources, finances, or time to engage in
intensive, and often time-consuming rehabilitation provisions that are provided in major cities and
tertiary clinics. There is a practical and real need for services that are accessible and delivered via
“user friendly” methods that does not increase the burden and stress for families.
Wade et al. (2004a) were the first to explore the internet, web-based, and teleconferencing
media as alternative forms of intervention delivery after paediatric TBI. Advantages of this
approach include flexible timetabling, the use of patient-preferred locations (e.g. home) that can
help to alleviate concerns about stigma (e.g. attending a public health clinic), ease of utilisation
as well as time efficiency (e.g. restricting travelling time) (Wade and Wolfe, 2005). In a contiguous
series of studies, Wade and colleagues have utilised an online web-based family problem
solving (FPS; Wade et al., 2004a, 2005a, b, 2006a, b) and teen online problem solving (TOPS;
Wade et al., 2008, 2010) intervention. This programme consists of eight core sessions and
up to four additional supplementary sessions depending on a family’s level of psychosocial
need. The web sessions are self-guided (e.g. completed without therapist assistance) and upon
completion are accompanied by a videoconference with a trained psychotherapist. Their
findings have demonstrated the efficacy and effectiveness of this programme to ameliorate
challenging child behaviour, improve general family functioning, lower parental stress, facilitate
knowledge gain with respect to TBI management, and expedite positive sibling adjustment.
Building on their online intervention, Wade et al. (2012) have reported on the preliminary
feasibility and efficacy findings, as well as participant satisfaction data (Antonini et al., 2012) for a
pilot study using: internet-based IN-teracting Together Everyday, Recovery after Childhood TBI
(I-InTERACT). This programme represents the authors’ adaptation of their original online FPS
treatment programme with an added component of parent-child interaction therapy (Eyberg,
1988). Incorporated within this adaptation, parents are inclusively taught positive parent-child
interaction skills (e.g. how to give clear commands, how to provide specific, and consistent
praise, restricting punitive methods of behavioural control) to help facilitate better management
of their child’s challenging behaviours post-TBI. Compared to the FPS programme, I-InTERACT
consists of ten core sessions and up to five supplemental sessions. Disseminated within the
core sessions are units directed solely at the parents to help them learn specific positive
parenting skills (see Table I).

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 Table I Outline of session content for I-InTERACTa
Session Title

1 Programme Overview and Introduction to Positive Parenting Skills

2 Positive Parenting Skills: Praise, Reflection, Imitation, Description, Enthusiasm
3 Staying Positive and Coping With Stress
4 Behavior Management Following TBI: Setting Your Child up for Success
5 Parent-Directed Interaction: Giving Good Commands
6 Dealing With Anger
7 Time-out
8 Cognitive Problems and Strategies for Addressing Them
9 Using Positive Parenting Skills in Real Life
10 Wrap Up and Planning For Future Transitions

Source: aAdapted from Wade et al. (2012)

Woods et al. (2012) similarly outlined their adaptations made to a positive parenting programme
called “Signposts for Building Better Behaviour” to meet the needs of families caring for a child
with TBI. In its original conception, Signposts was developed to provide support to families
caring for a child with intellectual disability (ID) and challenging behaviour (Hudson et al., 2003).
Families are able to access the programme in one of three formats depending on their level of
psychosocial need and family circumstances: group-support (i.e. face-to-face), telephone-
support, or self-directed (i.e. do not receive any therapist guidance or contact). Within the
telephone-support format, and similar to Wade et al’s. (2004a) original FPS design, parents
guide themselves through a manualised seven core and two supplemental session programme
with the aid of specific information booklets (see Table II). The programme also contains a DVD
with actor scenes modelling specific parenting skills, and a workbook containing written
exercises. At the completion of each session parents receive a telephone-support call from
a trained Signposts practitioner to discuss key elements of the programme and any difficulties
they may be experiencing. The length of the call is as long as is necessary to talk about the
completion of the workbook exercises and to discuss any problems or issues that may have
been encountered.
In their original Signposts implementation study, Hudson et al. (2003) compared group-support,
telephone-support, and self-directed intervention groups. All groups reported significant
changes from pre-intervention to post-intervention with reductions in parental stress and child
antisocial behaviour. The findings also suggested that all support modes were equally
efficacious. All parents reported high consumer satisfaction with the programme material and

Table II Outline of session content for adapted TBI Signposts interventiona

Session Topic Key feature

1 Introduction Psycho-education and an introduction to positive parenting intervention

2 A traumatic brain injury in the family Identifying cognitive-behavioural effects of brain injury and family-parent-sibling
adjustment issues
3 Measuring your child’s behaviour Functional assessment of challenging behaviours
4 Systematic use of daily routines Understanding triggers and consequences for challenging child behavior after
TBI
5 Replacing difficult behavior with useful Antecedent behaviour management strategies
behaviour
6 Planning for better behaviour Activities routines and planning ahead for high risk situations
7 Developing more skills in your child Teaching children functionally-adaptive skills in various domains including
communication and emotional control
8 Dealing with stress in the family Understanding and managing stress; cognitive-behavioural therapy techniques
9 Your family as a team Improving family communication; family-parent-sibling support

Sources: aAdapted from Woods et al. (2012); core sessions 1-7; supplemental sessions 8-9

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 content. Then in a much larger wide-scale implementation of the programme, Hudson et al.
(2008) again reported similar positive findings to their original research.
Parenting practices and the way parents interact with their child is inherently linked with
children’s adjustment (O’Connor, 2002). Hooper et al. (2007) assessed the impact it childhood
TBI had on parenting practices. They reported that parents often made use of pro-active
parenting strategies such as positive reinforcement, logic, and rationalisation. Conversely, some
parents endorsed the use of more negative strategies, such as punishment, force and giving in
to child behaviour. What is more, when parents reported greater psychological distress, they
were less likely to employ positive parenting approaches to manage post-TBI challenging
behaviour. Woods et al. (2011) reported similar findings and suggested that dysfunctional
parenting practices potentially exacerbate challenging child behaviours following TBI and should
be a target of post-injury behavioural interventions.
“Signposts” was chosen for use with a paediatric TBI population because of the demographic
population that the programme was originally designed to assist, that being families of children
with ID. Children with ID often present with challenging behaviours comparable to the
behaviours seen in children with moderate or severe TBI (Gavidia-Payne, 2002; Prigatano et al.,
2010). Therefore, we deemed it reasonable to assume that families who had a child with TBI may
also benefit from the strategies taught within the intervention. Moreover, positive parenting
programmes have been delivered successfully utilising a wide array of media (e.g. audiotape,
book, computer programme, leaflet, manual, videotape, web site, or combination of these)
with equal efficacy and effectiveness when compared to the more traditional face-to-face
delivery (Montgomery et al., 2009).
This study extends the line of research utilising an alternative method of intervention by investigating
a telephone-support version of the Signposts programme. We particularly wanted to target families
living in isolated settings or far from tertiary paediatric centres to eliminate previously recognised
barriers with continued follow-up such as travel distance, time restrictions, financial burden, and
reliable transportation. One objective of the research was to determine the clinical utility of
Signposts for families caring for a child with moderate or severe TBI. Linked to this objective,
we hypothesised that families receiving the programme would report reductions in challenging
child behaviour, lowered parental distress, and dysfunctional parenting practices, as well as
improved general family functioning.

Method
Study design and procedure
This single site pilot study was reviewed and approved by the Royal Children’s Hospital,
Melbourne, Australia, Human Research Ethics Committee. It used a within-subject pre-post
design to determine the behavioural outcomes of children with TBI, parental distress, general
family functioning, and parenting practices. Families were approached to take part in the study
during initial hospital admission. In line with hospital ethics guidelines, a detailed explanation of the
research was given. With written informed consent, parents met face-to-face once with the lead
researcher one-month prior to intervention delivery (approximately three-months post-TBI) to
conduct a structured assessment interview of the family. This assessment interview covered the
nature and circumstances of the child’s injury, its subsequent effects on the family, a child
neurocognitive assessment (results reported elsewhere), and what the family hoped to gain from
the telephone-support Signposts intervention, thereby providing the family with a sense of rapport
and the therapist with an idea of the family’s strengths and concerns. Parents also provided pre-
intervention ratings of child behaviour, and measures of parental distress, general family
functioning, and parenting practices. Parents then partook in the Signposts intervention lasting
five-months in duration. Data collection procedures were repeated one-month post-intervention to
determine intervention effects.

Participants
Participants were the parents of a child with moderate or severe TBI aged between the ages
of seven and 12 years. To be eligible for participation, the child needed to have a medical history

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sufficiently detailed to provide indices of brain injury severity. Consistent with previous
investigations (Anderson et al., 2006) children who had sustained a TBI were classified as
follows: first, moderate TBI – Glasgow Coma Scale (GCS; Teasdale and Jennett, 1974) score
9-12, and/or mass lesion or other evidence of specific injury on CT/MRI, and/or neurological
impairment; and second, severe TBI – GCS 3-8, mass lesion or other evidence of specific injury
on CT/MRI, and/or neurological impairment. The lowest post-resuscitation GCS score was used
to determine injury severity. There was a requirement for parents and children to speak English
and for children to reside in the family home. Families were excluded if their child had a
documented prior history of neurological disorder, documented evidence that injury was
a result of child abuse, or did not reside more than 70 kilometres from the paediatric institution in
which this study was conducted (it was determined that residing in excess of this distance
represented a significant burden with regard to travelling time, e.g. 41 hour). A total of nine
families were recruited from 23 families approached (recruitment rate of 39.1 per cent).
Demographic characteristics of the sample are provided in Table III. Reasons for not
participating in the research study included inability to contact the family (n ¼ 1), family’s
reporting their child was not experiencing any problems (n ¼ 7), and time constraints (n ¼ 6).
There was no difference between participants and non-participants in terms of their injured
child’s age, race, or gender.

Signposts resources and programme delivery

Signposts resources for the family consist of nine information booklets (each booklet
corresponds with one session), a DVD, and workbook. Parents work their way through the
materials with time allocated in between to practice the skills that they have been taught.
The DVD comprises a series of 33 scenes illustrating specific behavioural management
techniques made in the booklets. As parents work their way through the programme they can
document their thoughts and observations in the workbook in addition to completing written
exercises. Parents receive a pre-arranged telephone call (e.g. at a time that is most convenient
and suitable for the family) every three weeks from a trained Signposts practitioner. During these
telephone calls the practitioner discusses the workbook exercises, any issues or problems
the family may be experiencing and general concerns.

Measures
Social risk
Social risk was assessed with the Social Risk Index (Roberts et al., 2008), composed of six
aspects of social status: family structure (0: 2 caregivers (nuclear); 1: separated parents with
dual custody, or cared for by other intact family; 2: single caregiver); education of primary
caregiver (0: tertiary educated; 1: 11-12 years of formal schooling; 2: o11 years of formal

Table III Demographic and patient characteristics

n 9
Age at intervention (years), M (SD) 8.56 (2.50)
Time since injury, months, M (SD) 3.86 (1.50)
Distance from hospital (km), M (SD) 96.4 (32.1)
Gender: males n (%) 3 (33.3)
Lowest GCS score, M (SD) 10.8 (3.10)
Ethnicity n (%)
Anglo Australian 7 (77.8)
Other 2 (11.1)
Family structure n (%)
Intact 8 (88.9)
Single parent 1 (11.1)
High social risk n (%) 5 (55.5)

Note: GCS, Glasgow Coma Scale

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 schooling); occupation of primary income earner (0: skilled/professional; 1: semiskilled; 2:
unskilled); employment status of primary income earner (0: full-time employment; 1: part-time
employment; 2: unemployed/pension); language spoken at home (0: English only; 1: some
English; 2: no English); and maternal age at birth (0: 421 years old; 1: 18-21 years old; 2: o18
years old). Total score provided an estimated value of social risk. Each family was categorised as
low social risk (social risk score of 0 or 1) or high social risk (social risk score of 42) based on
previous paediatric research by our group (Treyvaud et al., 2009).

Child behaviour
The Child Behaviour Checklist (CBCL; Achenbach, 2001) is a standardised 113-item (six-18
years) caregiver-report measure that inventories child behaviour and emotional problems.
For the current study analyses were based on mean T-scores (M ¼ 50; SD ¼ 10) for the three
summary scales (total, internalising, externalising). A T-score of 463 indicates behaviour problems
that fall within a clinical range. The Behaviour Rating Inventory of Executive Function (BRIEF; Gioia
and Isquith, 2004) is a parent-rated scale measuring ecologically valid manifestations of
behavioural problems related to brain dysfunction. Analyses were based on mean T-scores
(M ¼ 50; SD ¼ 10) for two of the summary scales of interest (emotional control and monitor
behaviour). A T-score of 465 indicates behavioural problems that fall within a clinical range.

Parental distress, parenting practices, and family functioning

Parental psychological distress was measured using the Depression Anxiety Stress Scale
(DASS; Lovibond and Lovibond, 1995). The DASS is a 42-item self-report inventory designed to
measure the negative emotional states of depression, anxiety, and stress. The mean total score
on the stress subscale (DASS-S) was used for analyses with moderate-severe problems
identified by a score ranging between 19 and 33 (Lovibond and Lovibond, 1995). The Parenting
Scale (PS; Arnold et al., 1993) was used to measure different styles of parenting practices. The
PS is a 30-item questionnaire that yields three measures of parenting practices: laxness
(permissive discipline); overreactivity (authoritarian discipline, displays of anger, meanness, and
irritability); and verbosity (overly long reprimands or reliance on talking). The PS has successfully
been used to discriminate between groups of clinic and non-clinic families, and for this research
mean scores on each of the three subscales were used in the analyses with scores above:
3.2-laxness; 3.1-overreactivenss; and 4.1-verbosity, representing clinically dysfunctional levels
of parenting practices (Arnold et al., 1993). The McMaster Family Assessment Device (FAD; Miller
et al., 1985) was used to measure family functioning. For this research the 12-item FAD-General
Functioning (FAD-GF) scale was used to provide a summary measure of family functioning.
High family dysfunction was identified by a mean FAD-GF score 42.17 (Miller et al., 1985).

Consumer satisfaction
Parents were asked to rate their satisfaction with the programme on the Consumer Satisfaction
Scale (CSS; Hudson et al., 2003). The CSS has nine items, each rated on a six-point scale from
“strongly disagree” to “strongly agree”. It measures the extent to which parents were happy
with the content of the materials and the support that they received in working through the
programme. On a matched rating scale to the CSS, parents were also asked to rate
the usefulness of each of the seven core information booklets and two supplementary booklets.

Statistical analyses
Frequencies and percentages were used to describe the population. Paired samples t-tests
were employed to examine changes from pre-intervention to post-intervention. As this was
a pilot investigation, an a was set at 0.05 for one tailed and effect sizes were estimated on the
basis of Cohen’s d analysis in accordance with previous guidelines (Cohen, 1992): 0.2 ¼ small
effect, 0.5 ¼ medium effect, 0.8 ¼ large effect. The total minute average was used to measure
the duration of telephone calls. Frequency percentages were used to investigate programme
approval and satisfaction as well as utility ratings for each of the information booklets, DVD,
and workbook. All data were analysed using the SPSS version 19.0 statistical package (Green
et al., 2000).

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Results
Participation, satisfaction, and utility
Nine families participated in the study with a retention rate of 100 per cent for pre- and
post-intervention data collection points. A total of 52 out of a possible 54 telephone calls were
successfully placed and received during the five-month intervention. Parents spent on average
23.1 minute talking to a Signposts practitioner for each of the telephone calls. Parents
completed an average of eight sessions (SD ¼ 0.86; range seven to nine) and every family
completed all seven core sessions. Five parents strongly agreed (55.0 per cent), three agreed
(33.0 per cent), and one mildly agreed (11.0 per cent) that the telephone calls were a useful part
of the programme. All participants approved (agree or strongly agree) of the skills taught, felt that
the materials were helpful for managing challenging child behaviour, and for teaching new skills.
Overall four parents strongly agreed (44 per cent), three agreed (33.3 per cent), and two mildly
agreed (22 per cent) that they were more confident in managing their child’s challenging
behaviour. All parents reported that they understood the written materials and found the DVD to
be useful. Only one parent reported that they would have liked to receive more help throughout
the programme.
Parents rated a high level of usefulness for each of the core information and supplementary
booklets. Investigation of the ratings revealed that all parents agreed with the utility of all
materials presented. The highest rated booklets (strongly agree only) with regard to utility (e.g.
most useful) were the Your Family as a Team (n ¼ 6; 66.7 per cent), followed by Planning for
Better Behaviour, and Dealing with Stress in your Family (n ¼ 5; 55.6 per cent, respectively). No
information booklet received a negative rating.

Comparison of pre- and post-intervention functioning

As shown in Table IV, prior to intervention parents reported elevated “externalising” and “total”
child challenging behaviours as measured by the CBCL, in addition to an elevated “monitor”
subscale score of the BRIEF. Following intervention children’s challenging behaviour significantly
decreased on the internalising and total subscales of the CBCL. The corresponding effect sizes
were large (41.00). Whilst there was a non-significant reduction in children’s externalising
behaviours their scores moved from a rating within a clinical range (M ¼ 64.5, SD 7.7) to
sub-clinical levels (M ¼ 55.8, SD 11.3). This was associated with a medium effect size (d ¼ 0.55).
A similar finding can be observed for the monitor subscale of the BRIEF with a pre-intervention
clinical rating (M ¼ 63.0, SD 13.0) decreasing to a sub-clinical level post-intervention (M ¼ 53.7,
SD 8.0). Dysfunctional parenting practices also demonstrated significant decreases for all three

Table IV Pre-post differences child behaviour, parent distress, family functioning,

parenting behaviour
Pre-intervention Post-intervention Difference t-value Cohen’s “d”

CBCL
Internalising 50.2 (9.0) 44.4 (8.5) 5.8 3.25* 1.09
Externalising 64.5a (7.7) 55.8 (11.3) 8.7 1.63 0.55
Total 63.1a (6.8) 54.6 (3.3) 8.6 2.95* 1.03
BRIEF
Emotional control 57.5 (12.7) 54.8 (11.3) 2.7 0.97 0.33
Monitor 63.0a (13.0) 53.7 (8.0) 9.3 1.56 0.53
PS
Laxness 3.14 (0.8) 1.97 (0.7) 1.1 3.97* 1.27
Overreactive 2.62 (0.9) 1.76 (0.4) 0.8 2.43* 0.98
Verbosity 2.58 (0.4) 0.95 (0.4) 1.6 8.25** 3.27
DASS-S 7.44 (9.7) 3.33 (4.3) 4.1 1.96 1.17
FAD-GF 1.94 (0.2) 1.91 (0.1) 0.03 0.14 0.15

Notes: CBCL, Child Behavior Checklist; BRIEF, Behavior Rating Inventory of Executive Function; DASS,
Depression Anxiety Stress Scale. Values expressed as mean (SD). aAbove clinical range. *po0.05; **po0.01

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 subscales and correspondingly large effect sizes. Observations for parental distress and
general family functioning showed non-significant minor reductions.

Discussion
The main objective of this pilot investigation was to explore the clinical utility for a telephone-
support version of the Signposts behaviour parenting programme to ameliorate challenging
behaviours in children with TBI, and to improve general family functioning, parental distress, and
parenting practices. If left untreated, behaviour problems have the potential to become a
persistent concern after paediatric TBI (Catroppa et al., 2009). Similar to Wade’s et al. (2012)
research, this study showed that families experiencing a high level of social risk (five of nine) can
benefit from an intervention that is largely self-directed and supported via telephone contact with
a trained practitioner. Parents reported a high level of clinical utility and consumer satisfaction
with the programme which is in accordance with previous Signposts research (Hudson et al.,
2003, 2008), as well as other internet delivered TBI intervention studies (Antonini et al., 2012;
Wade et al., 2004a, 2005a, 2006a, 2008).
One of the primary aims of this research was to offer earlier access to services while overcoming
previously well documented obstacles to follow-up care. The current study demonstrates that
telephone-support has the potential to overcome the barriers of distance, time, and financial
burden. In comparison with Wade et al. (2012) who reported a significant attrition rate, this
study successfully retained all participants through to follow-up. Wade suggested that their
I-InTERACT positive parenting intervention may have been too demanding for parents with
weekly online sessions coupled with daily practicing of skills. We were cognisant of this issue
and subsequently contacted families every three weeks to ensure programme adherence.
Despite the novel nature of the treatment approach, parents openly discussed their problems
with the therapist over the telephone. Parents recounted that meeting the lead therapist for an
initial meeting face-to-face was particularly helpful and helped to put a “face to the voice”.
Another common theme that parents continued to mention throughout the telephone sessions
was the generalised implementation of the behaviour management strategies to all children and
not just their brain-injured child. Later investigation of the demographic information revealed that
eight of the nine families in this study had at least one other child aged under ten-years living in
the family home. Clinically, parents reported their child displayed significantly less challenging
behaviour after receiving the intervention thus meeting one of the study’s hypotheses. In fact,
children’s levels of behavioural disturbance dropped from levels within a clinical range at
pre-intervention to sub-clinical levels post-intervention. The corresponding effect sizes were
large which is encouraging should Signposts be delivered to a larger cohort of families caring for
children with TBI. On closer examination of the inventories it was evident that a significant
proportion of the child behaviours reported by parents were punctuated by an inability to
regulate and/or control externalising behaviours in combination with emotional dysregulation.
Notably, this research has shown that these types of behaviours can be targeted early by timely
intervention procedures. What is more, parents also reported improvements in their own
behaviour with significant large effect size reductions in dysfunctional parenting practices. This is
an important finding as research investigating the maintenance of behaviour problems in clinical
populations without TBI suggests that exposure to dysfunctional parenting practices accounts
for a significant portion of the variance when explaining long-term behavioural sequelae in
children (Loeber and Farrington, 2000).
Parental distress showed a small reduction with no elevation post-intervention. The failure to find
a statistical change with this measure may partly be attributable to the participant mothers’
reporting lowered levels of stress prior to the intervention. Equally, families also tended to report
sub-clinical levels of family dysfunction before intervention. Research has shown that some
families experience high levels of family burden and dysfunction following pediatric TBI (Wade
et al., 1998), however, this has often been measured at protracted follow-up points (e.g.
between one and four years) when longer-term consequences of the injury may have a
compounding effect such as financial difficulties, sibling adjustment issues, educational
adversities, and interpersonal stressors (Wade et al., 2004b). Families in this study participated

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in this intervention on average between three and four-months following injury and typically
preceding a time when these issues begin to appear.
During the intervention one mother reported that she would have liked more help throughout the
programme. Her child had suffered a severe TBI and at the time she was caring for not only her
brain-injured child but two other children aged less than five years. In this capacity, she reported
that she found it difficult allocating time to complete daily activities (e.g. shopping), as well as
aspects of the Signposts programme. Eventually this family was assigned a social worker from
a local health care facility who helped organise particular services for her and her family. This will
be an important point to consider for future delivery of this programme. Whilst the use of within
family supports are discussed extensively within Your Family as a Team booklet, it may be
pertinent for therapists (and participants) to consider additional outside sources of help (e.g.
district nurse, social worker, family friend).
The findings from this study are somewhat circumscribed due to the fact that there was no
control or comparison group, although, the results are in keeping with more rigorous studies
which have shown favourable outcomes for children with serious challenging behaviour (Hudson
et al., 2003, 2008). Needless to say, there are some limitations to the current investigation that
must be addressed. The first centres on the size of the recruited sample, which was small
and skewed towards moderate and severe brain injuries. As a consequence, it is difficult to
generalise to a sample of children with predominantly mild TBI, which constitute between 80 and
90 per cent of all childhood TBIs and who may experience similar behavioural sequelae
(McKinlay et al., 2009, 2010). A reliance on parent-report and a lack of follow-up add to the
limitations of the current research. The measures in this study were reliant on parents’ subjective
appraisal of either their own behaviour, their child’s or their family’s level of functioning. This can
lead to imprecision and exaggeration and so it is possible that some of the observed changes
were attributable to other factors and not the specific affects of the intervention. In future
research, it may be useful to collect data from an objective third party who is not involved with the
family (e.g. school teacher). Additionally, the data cannot prove that challenging behaviours
would not have returned without an extended follow-up. The creation of a wait-list control group
or a group receiving “usual-care” would help determine the course by which the Signposts
programme resulted in improved child, parent, and family outcomes.
It is evident from recent paediatric TBI intervention research that technology can be used to
modernise healthcare and provide the impetus for role changes. In a traditional sense, the
family/parent has been characterised as being passive in the rehabilitation process of their
qbrain-injured child. Tele-support now assigns underlying terminology that includes “self-
management”, “empowerment”, and “expert” (Finch et al., 2005). With the recognition that
families are the primary caregivers for their children it is only reasonable to assume that
intervention strategies should begin with the family and within the family home. While the small
sample in this study is likely to include biases that affect validity, meaningful information can still
be interpreted. Participants successfully completed the intervention and reported high levels of
feasibility and satisfaction with the programme. Children began the intervention with challenging
behaviours that were significantly lowered at final assessment. Thus, while it is premature to
conclude that a telephone-support version of the Signposts intervention should be used in the
delivery of clinical services, these results suggest that the programme should be evaluated in
a larger clinical trial. This research is currently being undertaken.

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Corresponding author
Dr Damith T. Woods can be contacted at: [email protected]

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