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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
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
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
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
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
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
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)
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
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
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
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
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?