What is the Impact of Acquired Brain Injuries on Children s Play

1. What is the Impact of Acquired Brain Injuries on Children’s Play? Silvia Bernal, Brenda Dorey, Zahra Jamal, Alda Melo, Victoria Prooday & Shira Tenenbaum

2. Presentation Outline Research Process Key Definitions Initial Model Critical Analyses Gaps and Research Suggestions Discussion

3. Research Process How we came to our research question Brainstormed ideas Chose a topic of interest Final question What is the Impact of ABI on Children’s Play? CHOSE TOPIC OF INTEREST SAY SOME STATS ON ABI in CHILDREN!CHOSE TOPIC OF INTEREST SAY SOME STATS ON ABI in CHILDREN!

4. Research Process Cont’d… Search interfaces OVID, Cambridge Scientific, Pubmed Databases Medline, CINHAL, Psychinfo, EMBASE, ERIC, Education: A SAGE Full-Text Collection, Psychology: A SAGE Full-Text Collection Internet searches Keywords ABI, play, playing, children, education, traumatic brain injury, social participation, disability, social interaction, play ground, quality of life

5. Key Definitions Acquired Brain Injury (ABI) – damage to the brain which occurs after birth and is not related to a congenital disorder, a progressive disease or a developmental disease that damages the brain. (Toronto Acquired Brain Injury Network, 2004) Play – “more internally than externally motivated, controlled by the player, safe, fun, unpredictable, spontaneous, involves non-obligatory active engagement, and activity that involves movement and manipulation in relation to the environment” (Stagnitti, et al., 2000, pp 292) Talk to Notes: The brain damage may be due to a traumatic injury to the head, or a medical problem or disease process which causes injury to the brainTalk to Notes: The brain damage may be due to a traumatic injury to the head, or a medical problem or disease process which causes injury to the brain

6. Initial Model

7. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: a follow-up study(Bedell & Dumas, 2004) Purpose To describe the level of participation in the home, school and community life as well as child related problems of children and youth with ABI after discharge from an inpatient rehabilitation programme To identify factors that were associated with the children and youths’ participation

8. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: a follow-up study Methods Participants: 60 caregivers of children and youth Age range of children: 3.05 – 21.33 years; mean 12.97 Types of brain injuries (moderate to severe): TBI, brain tumor, stroke, seizure disorder, infection & anoxia Procedure: Mailed survey to caregivers of children who had been discharged from an in-patient rehabilitation program

9. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: a follow-up study Instruments: Survey consisted of 3 scales: Child and Adolescent Scale of Participation Child and Adolescent Scale of Environment Child and Adolescent Factors Inventory Examined discharge Paediatric Evaluation of Disability Inventory (PEDI) scores Design Analysis: Descriptive Statistics Correlation Analysis Multiple Regression

10. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: a follow-up study Results Children were rated most restricted in participating in structured community events and activities, social and play activities with peers at school and in the community and managing their schedule Two main reported environmental problems were: inadequate information about brain injury and intervention programmes, and inadequate services/programmes at school

11. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: a follow-up study Paradigm and Level of Question Quantitative Level 2 - Relational Type Question (DePoy & Gitlin,1998) Strengths Showed relationships between ABI and play Looked at participation in the home, school and community and found that children's restriction in participation was related to environment for activities including play

12. Social participation of children and youth with acquired brain injuries discharged from inpatient rehabilitation: a follow-up study Limitations Had an underlying motive to develop measurement tools (no psychometric analysis available) Both children and youth were considered in the same study Caregiver report; child’s perspective not accounted for Sample of convenience

13. Social and Behavioural Effects of Traumatic Brain Injury in Children(Andrews, Rose, & Johnson, 1998) Purpose To measure social effects of traumatic brain injury (TBI) in children by examining self-ratings of self-esteem, and loneliness These findings were examined together with behavioural impairments such as adaptive, maladaptive and aggressive antisocial behaviour

14. Social and Behavioural Effects of Traumatic Brain Injury in Children Methods Participants: 54 children involved (ages 6.6-17.8; mean age 12.5) Experimental group 27 children (ages 6.6-15.6; mean age=10.9) Admitted to department of neurosurgery Sub-divided by mild, moderate, and severe TBI diagnoses Control group 27 children Age, sex and socioeconomic status (SES) matched to experimental group Recruited from local primary and secondary schools

15. Social and Behavioural Effects of Traumatic Brain Injury in Children Methods Cont’d… Procedure Non-directive semi-structured interview conducted with primary caregiver of each child to assess the nature and extent of behavioural effects Directive semi-structured interview with each child was conducted to assess the incidence of social effects Assessments were conducted half a year later to ensure behaviours were result of TBI and not just temporary reaction to the accident itself

16. Social and Behavioural Effects of Traumatic Brain Injury in Children Instruments: Vineland Adaptive Behaviour Scale (VABS) DeBlois Aggressive and Antisocial Behaviour Scales (DAABS) Coppersmith Self Esteem Inventory (CSEI) Children’s Loneliness Scale (CLS) Instrument Details Vineland Adaptive Behaviour Scale (VABS) Used to measure levels of adaptive and maladaptive behaviour DeBlois Aggressive and Antisocial Behaviour Scales (DAABS) Used to measure degree of aggressiveness, non-compliance, reactivity, antisocial behaviour, depression, anxiety and egocentricity Employed Coppersmith Self Esteem Inventory (CSEI) Children’s Loneliness Scale (CLS) These instruments (CSEI and CLS) were both used to assess self ratings of self esteem, loneliness and social functioning Instrument Details Vineland Adaptive Behaviour Scale (VABS) Used to measure levels of adaptive and maladaptive behaviour DeBlois Aggressive and Antisocial Behaviour Scales (DAABS) Used to measure degree of aggressiveness, non-compliance, reactivity, antisocial behaviour, depression, anxiety and egocentricity Employed Coppersmith Self Esteem Inventory (CSEI) Children’s Loneliness Scale (CLS) These instruments (CSEI and CLS) were both used to assess self ratings of self esteem, loneliness and social functioning

17. Social and Behavioural Effects of Traumatic Brain Injury in Children Results Significantly higher levels of loneliness, maladaptive behaviour, aggressive, antisocial behaviour, and lower levels of self esteem and adaptive behaviour in children with TBI No significant difference between three TBI experimental groups in terms of adaptive behaviour, aggressive/antisocial behaviour, loneliness and self esteem

18. Social and Behavioural Effects of Traumatic Brain Injury in Children Paradigm and Level of Question Quantitative Level 2 – Relational Type Question (DePoy & Gitlin, 1998) Strengths Takes into account child’s perception of self-concept Used standardized measures that were applicable to population Level 2: Compares levels of self-esteem, loneliness, and social interaction between children with TBI and children without TBI Level 2: Compares levels of self-esteem, loneliness, and social interaction between children with TBI and children without TBI

19. Social and Behavioural Effects of Traumatic Brain Injury in Children Strengths Cont’d … Employed two measurements to assess aspects of behaviour in children (VABS and DAABS) Aware that VABS had limitations and subsequently used DAABS for broader assessment of social functioning

20. Social and Behavioural Effects of Traumatic Brain Injury in Children Limitations Direct relation between effects of TBI on children’s play not identified Children, youth, and adolescents were considered together (capability of self-assessment) There is no cause and effect relationship Are social and behavioural effects directly related to TBI? Proxy bias Parental expectations may affect findings on behavioural and social functioning

21. What Do We Know From Other Studies? Only one study looked at play performance All studies were quantitative Research results are conflicting Studies reviewed suggest that ABI negatively influences physical, cognitive, behaviour, and affective components 1:but was not study’s objective, rather play performance was a means of measuring social competence; 2: QT studies don’t address meaning children attribute to play; 3:leave us with more questions than answers about what the play of children with ABI might look like; + there is debate in the research literature over how significant the deficits are and for how long they last 1:but was not study’s objective, rather play performance was a means of measuring social competence; 2: QT studies don’t address meaning children attribute to play; 3:leave us with more questions than answers about what the play of children with ABI might look like; + there is debate in the research literature over how significant the deficits are and for how long they last

22. What Does The Research Literature Say? Gagnon et al., (1998) found that some children that have sustained a mild TBI present with significant deficits in motor performance 2-3 weeks post injury In contrast, Coster et al., (1993) found that brain injured children as a group did not display statistically significant deficits in discrete functional or motor skills at one or six months post injury, and that the deficits observed at one month had decreased at six months such as running speed and agility, response speed and balance at two to three weeks post injury if these deficits persists they may impact on the group play that some children participate in within a school environment (gym class, sports during recess) such as running speed and agility, response speed and balance at two to three weeks post injury if these deficits persists they may impact on the group play that some children participate in within a school environment (gym class, sports during recess)

23. What Does The Research Literature Say? Cont’d… Social and cognitive functioning has also been found to be negatively influenced by ABI (Landry et al., 2004; Stancin et al., 2002; Lewis et al., 2000) Pre-injury and family factors have been suggested to predict the outcomes of the components (Stancin et al., 2002) that may influence play Pre-injury and family factors predict outcomes of well-being in physical, mental and social domains thus as perceived by child and others in child’s environment in children with ABI –Implication: Pre-injury and family factors predict outcomes of well-being in physical, mental and social domains thus as perceived by child and others in child’s environment in children with ABI –Implication:

24. Summary of Analysis so Far Based on these findings one might hypothesize that the component impairments reported would pose barriers for engagement and performance in play, When we consider the findings in these studies we are inclined to think that the play of children with ABI may be compromised because the components assessed are all required for play, thusWhen we consider the findings in these studies we are inclined to think that the play of children with ABI may be compromised because the components assessed are all required for play, thus

25. But … Landry et al (2004) found that children with moderate to severe brain injuries performed comparably to the comparative group on independent play Only when the children had to coordinate attention around toys and the researcher interacting with them did they display difficulty in play performance suggesting that play performance may be affected by the environment

26. Initial Model

27. Final Model

28. Gaps in the Research Lack of occupational perspective in research literature reviewed Child’s meaning of play Play was not looked at specifically Emphasis on components Need to define play as an occupation and examine it in relation to children with ABI Lack of attention to environmental influence on children with ABIs’ play

29. Gaps in the Research - Cont’d Most studies used caregiver report; perspective of the child was not considered In the literature, children and youth are often considered together Time as a variable

30. Suggestions for Research Occupational Science: Examine play performance in a naturalistic setting from a qualitative paradigm Longitudinal studies Occupational Therapy: Develop performance based assessment tools to measure play in children with ABI that are age-appropriate

31. Conclusion Research on the play of children with ABI is limited The research reviewed suggests that ABI negatively influences components that are potentially required for engagement in play No clear picture of what the play of children with ABI looks like Research should also examine the environmental impact on play Play is the primary of occupation of childhood thus research should examine play within the environmental context not only on the person component level Play is the primary of occupation of childhood thus research should examine play within the environmental context not only on the person component level

32. Facilitated Discussion Do you think the perspectives of children with ABI should be considered when conducting research of children with ABI and play (i.e. not only caregiver report)? If so, do you have any suggestions of ways to accomplish this? Should future research examine children’s play using a top-down approach or a bottom up approach?