What is the Impact of Acquired Brain Injuries on Children ’ s Play? Silvia Bernal, Brenda Dorey,...

What is the Impact of Acquired Brain Injuries on

Children’s Play?

Silvia Bernal, Brenda Dorey, Zahra Jamal, Alda Melo, Victoria Prooday &

Shira Tenenbaum

November 29th, 2004

Presentation Outline

Research Process Key Definitions Initial Model Critical Analyses Gaps and Research Suggestions Discussion

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?

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

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)

Initial Model

Children’s Play

Behavioural Factors

ABI

Cognitive Factors

Physical Factors

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

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

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


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

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


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

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

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


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


– Instruments:• Vineland Adaptive Behaviour Scale (VABS)• DeBlois Aggressive and Antisocial Behaviour

Scales (DAABS)• Coppersmith Self Esteem Inventory (CSEI)• Children’s Loneliness Scale (CLS)


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


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


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


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

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

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

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

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,

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

Children’s Play

Behavioural Factors

ABI

Cognitive Factors

Physical Factors

Initial Model

ABIABI

EnvironmentEnvironment

•FamilyFamily

•HomeHome

•CommunityCommunity

•SocialSocial

PersonPerson

• Cognitive FactorsCognitive Factors

•Physical FactorsPhysical Factors

•Affective FactorsAffective Factors

•Behavioural FactorsBehavioural Factors

PLAYPLAY

Pre-injury Pre-injury statestate

Final Model

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

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

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

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

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?

What is the Impact of Acquired Brain Injuries on Children ’ s Play? Silvia Bernal, Brenda Dorey,...

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