Why family functioning matters after a child’s brain injury

When a child sustains a brain injury, attention naturally turns to the child: their recovery, their therapy goals, their progress at school. It is easy to think of the family around them simply as the context in which that recovery happens. But research, including a study I carried out as part of my MSc in Neurorehabilitation, suggests that how well a family functions as a whole has a measurable relationship with how a child copes and recovers.

What we mean by ‘family functioning’

‘Family functioning’ is not a vague impression of whether a household is happy. It refers to specific, observable things: how clearly family members communicate, how well problems get solved, how roles and responsibilities are shared, and how much warmth and support is shown day to day. One of the most widely used tools for measuring this is the McMaster Family Assessment Device (FAD), which has been translated into 27 languages and is used in both research and clinical settings, including with families affected by traumatic brain injury (Epstein, Bishop and Levin, 1978; Baños, 2018).

What the research found

For my MSc dissertation, I carried out a secondary analysis of data originally collected by Tonks et al. (2011), comparing 21 children with acquired brain injury (ABI), aged nine to fifteen, with 70 healthy controls of the same age range. Families of children with ABI scored significantly higher (indicating poorer functioning) on the FAD 12 than families of healthy children, with a mean score of 24.2 compared with 17.7 among the controls. In other words, families who had been through a childhood brain injury were, on average, reporting more difficulty with communication, roles and problem-solving than families who had not.

Why this matters for recovery

The second part of the study looked at whether family functioning was linked to resilience, using the Resiliency Scales for Children and Adolescents. The results showed that poorer family functioning was significantly correlated with a reduced sense of mastery (a child’s sense of control over their own life) and resourcefulness, and with higher emotional reactivity and vulnerability. Interestingly, family functioning was not significantly linked to social relatedness, suggesting that a child’s friendships can remain a source of strength even when other internal resources are under pressure.

These findings echo what clinicians working with families have described for some time. Gracey et al. (2015) describe multiple, reciprocal interactions between a child’s emotional response to their injury and the family’s response to the child, in which maladaptive coping and changes in family functioning can, over time, become disruptive to a child’s emotional and social development.

A promising avenue for intervention

Brown and Whittingham (2015) describe the family environment as ‘a promising avenue for intervention’, and the findings from this study support that view. If family functioning and a child’s resilience are linked, then supporting the family is not separate from supporting the child. It is part of the same picture.

This is one of the reasons why, at Hawkley Rehab, case management for children does not focus solely on the child’s individual therapy goals. Assessments consider the family as a whole, using the World Health Organisation’s International Classification of Functioning, Disability and Health, and plans are reviewed and adapted as the family’s needs change over time. Our guide for families of children with brain injury says more about this approach, and our article on Immediate Needs Assessments explains how this picture is built from the outset.

If you would like to talk about what this might mean for your family, please get in touch.

References

Baños, J. H. (2018) ‘McMaster Family Assessment Device’, in Kreutzer, J., DeLuca, J. and Caplan, B. (eds) Encyclopaedia of Clinical Neuropsychology. Cham: Springer.

Brown, F. L. and Whittingham, K. (2015) ‘A Structured Behavioural Family Intervention with Parents of Children with Brain Injury’, in Neuropsychological Rehabilitation of Childhood Brain Injury. London: Palgrave Macmillan UK, pp. 60–81. doi: 10.1057/9781137388223_4.

Durish, C. L., Yeates, K. O., Stancin, T., Gerry Taylor, H., Walz, N. C. and Wade, S. L. (2017) ‘Home environment as a predictor of long-term executive functioning following early childhood traumatic brain injury’, Journal of the International Neuropsychological Society, 24(1), pp. 27–37. doi: 10.1017/S1355617717000595.

Epstein, N. B., Bishop, D. S. and Levin, S. (1978) ‘The McMaster Model of Family Functioning’, Journal of Marital and Family Therapy, 4(4), pp. 19–31. doi: 10.1111/j.1752-0606.1978.tb00537.x.

Gracey, F., Olsen, G., Austin, L., Watson, S. and Malley, D. (2015) ‘Integrating Psychological Therapy into Interdisciplinary Child Neuropsychological Rehabilitation’, in Neuropsychological Rehabilitation of Childhood Brain Injury. London: Palgrave Macmillan UK, pp. 191–214. doi: 10.1057/9781137388223_10.

Lax Pericall, M. T. and Taylor, E. (2014) ‘Family function and its relationship to injury severity and psychiatric outcome in children with acquired brain injury: a systematized review’, Developmental Medicine and Child Neurology, 56(1), pp. 19–30. doi: 10.1111/dmcn.12237.

Potter, J. L., Wade, S. L., Walz, N. C., Cassedy, A., Stevens, M. H., Yeates, K. O. and Gerry Taylor, H. (2011) ‘Parenting style is related to executive dysfunction after brain injury in children’, Rehabilitation Psychology, 56(4), pp. 351–358. doi: 10.1037/a0025445.

Tonks, J., Yates, P., Frampton, I., Williams, W. H., Harris, D. and Slater, A. (2011) ‘Resilience and the mediating effects of executive dysfunction after childhood brain injury: a comparison between children aged 9–15 years with brain injury and non-injured controls’, Brain Injury, 25(10), pp. 870–881. doi: 10.3109/02699052.2011.581641.

Wade, S. L., Zhang, N., Yeates, K. O., Stancin, T. and Gerry Taylor, H. (2016) ‘Social environmental moderators of long-term functional outcomes of early childhood brain injury’, JAMA Pediatrics, 170(4), pp. 343–349. doi: 10.1001/jamapediatrics.2015.4485.