Serving families who have served: providing family therapy and support in interdisciplinary polytrauma rehabilitation

Family Needs After Traumatic Brain Injury: A VA TBI Model Systems Study

OBJECTIVE

To describe the self-reported needs of family caregivers of service members and veterans (SMVs) who sustained a traumatic brain injury (TBI) and to identify predictors of the unmet family caregiver needs.

SETTING

Five Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs).

PARTICIPANTS

Family caregivers of SMVs enrolled in the VA PRC TBI Model Systems (TBIMS) national database who were within their first 5 years post-TBI (n = 427).

DESIGN

Observational study.

MAIN OUTCOME MEASURE

The Family Needs Questionnaire-Revised (FNQ-R) was completed by each SMV's designated caregiver.

ANALYSES

Descriptive analyses were conducted on the FNQ-R responses at the item, domain, and total score levels. Unadjusted univariable and adjusted multivariable regression models were fitted to identify predictors of total unmet needs and unmet family need domains.

RESULTS

FNQ-R item-level and domain-level descriptive results indicated that health information was the most frequently met need domain. In contrast, emotional and instrumental support domains were the least often met. On average, family caregivers reported that 59.2% of the 37 FNQ-R needs were met at the time of the follow-up assessment. Regression models indicated that both the number of SMV-perceived environmental barriers and whether the SMV received mental health treatment within the past year predicted the number of unmet FNQ-R needs. SMV-reported environmental barriers predicted increased unmet needs in all 6 family caregiver domains, and SMV mental health treatment in the past year predicted more unmet family caregiver emotional support, community support, and professional support needs.

CONCLUSIONS

The current findings can be used to inform policy and programming for VA and Department of Defense to proactively address the specific needs of families and caregivers experienced in the first 5 years post-TBI.

Do emotional distress and functional problems in persons with traumatic brain injury contribute to perceived sleep-related impairment in caregivers?

OBJECTIVE

The goal of this study was to examine the association between characteristics of persons with traumatic brain injury (PwTBI) and perceived sleep-related impairment of the caregivers.

METHOD

Fifty-two dyads (n = 23 civilians, n = 29 service members/veterans [SMVs]) were enrolled. Caregivers completed the Patient-Reported Outcomes Measurement Information System Sleep-Related Impairment computer adaptive test, and PwTBI completed Quality of Life in Neurological Disorders measures of depression, anxiety, anger, cognitive functioning, and upper and lower extremity functioning. Hierarchical linear regression models, stratified by civilian/SMV group, were employed to assess prediction of caregiver-perceived sleep-related impairment from emotional distress of the PwTBI (anxiety, depressed mood, and anger) and perceived functional status of the PwTBI (cognitive, upper extremity, lower extremity functioning).

RESULTS

Compared with caregivers of civilians, caregivers of SMVs reported higher perceived sleep-related impairment. Regression results showed that characteristics of the PwTBI accounted for moderate amounts of variance in the sleep-related impairment of caregivers of both civilians and SMVs. Within-group analyses showed that the strongest predictor of sleep-related impairment of caregivers of civilians was self-reported cognitive function of the PwTBI (β = -0.82, p = .08); the strongest predictor of sleep-related impairment of caregivers of SMVs was self-reported anger of the PwTBI (β = 0.54, p = .07).

CONCLUSIONS

In both caregivers of civilians and SMVs with TBI, characteristics of the PwTBI were related to perceived caregiver sleep-related impairment. These preliminary data can inform future research with larger samples that examine the impact of multiple characteristics of the caregiver and care recipient on caregiver sleep. Findings highlight the potential importance of considering the dynamics of the dyad in rehabilitation programming not only for the PwTBI but for caregivers as well. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

TBI-CareQOL family disruption: Family disruption in caregivers of persons with TBI

PURPOSE

Family disruption is often an indirect consequence of providing care for a person with traumatic brain injury (TBI). This article describes the development and preliminary validation of a Family Disruption scale designed for inclusion within the TBI-CareQOL measurement system.

METHOD/DESIGN

Five hundred thirty-four caregivers of persons with TBI (service member/veteran n = 316; civilian n = 218) completed the Family Disruption scale, alongside several other measures of caregiver strain and health-related quality of life. Classical test theory and item response theory (IRT)-based analyses were conducted to develop, and establish reliability and validity of, this scale.

RESULTS

Exploratory and confirmatory factor analysis, as well as Samejima's graded response model-related IRT fit analyses, supported the development of a 3-item scale. This final scale is scored on a T score metric (M = 50; SD = 10); higher scores are indicative of more family disruption. Reliability (internal consistency; test-retest stability) was supported for both caregiver groups, and average administration times were under 10 s. Convergent and discriminant validity were supported by strong correlations between Family Disruption and measures of caregiver burden, and smaller correlations with positive aspects of caregiving. As evidence of known-groups validity, caregivers of lower-functioning persons with TBI experienced more family disruption than caregivers of higher functioning individuals.

CONCLUSIONS

The TBI-CareQOL Family Disruption scale is a brief, reliable, and valid assessment of caregiver perceptions of how caring for an individual with a TBI interferes with family life. This measure is well-suited for inclusion in studies seeking to support family functioning in persons with TBI. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Investigating Relations between Traumatic Brain Injury and Relationship Functioning among OIF/OEF Veterans

Traumatic brain injury (TBI) is one of the most common injuries among Veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). TBI can negatively affect Veterans' close relationships, undermining an important source of support to aid recovery and rehabilitation. Given the complex symptom profile of TBI, the present research aimed to pinpoint key mediators of the link between TBI and marital functioning to help identify targets for intervention. Data from married OIF/OEF Veterans (N=188) were drawn from a larger sample. Mediation analyses simultaneously examined the potential roles of depressive, posttraumatic stress disorder (PTSD), and post-concussive symptoms in the association between TBI and Veterans' marital satisfaction. Results revealed associations between TBI and all three types of symptoms; however, only depressive symptoms independently mediated the association between TBI and marital satisfaction. These findings suggest depression as a mechanism by which TBI may interfere with healthy relationship functioning and highlight targets for intervention.

Relationship Stability After Traumatic Brain Injury Among Veterans and Service Members: A VA TBI Model Systems Study

OBJECTIVE

To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma.

SETTING

Five Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRCs).

PARTICIPANTS

A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury.

DESIGN

Prospective, longitudinal, multisite.

MAIN MEASURES

Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment.

RESULTS

At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change.

CONCLUSIONS

The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

Outcomes of a Therapeutic Fly-Fishing Program for Veterans with Combat-Related Disabilities: A Community-Based Rehabilitation Initiative

The purpose of this study was to examine the outcomes of a therapeutic fly-fishing program for veterans with combat-related disabilities. A total of 40 veterans participated in the 4-day therapeutic fly-fishing program and this study. The outcomes examined included reducing symptoms of posttraumatic stress (PTS), depression, perceived stress, functional impairment (i.e., work, relationships, physical, and everyday life), increasing self-determination, and leisure satisfaction. Each research participant completed pretest, posttest, and 3-month follow-up questionnaires. Repeated measures MANOVA and ANOVA were conducted to examine the differences between the three time points on each outcomes. The results indicated significant decreases from the pretest to posttest for symptoms of PTS, depression, perceived stress, and functional impairment, and an increase in leisure satisfaction from pretest to 3-month follow-up. These results highlight the use of therapeutic recreation programming for veterans with disabilities as a holistic approach to treatment and recovery.

The Relationship between Training and Mental Health among Caregivers of Individuals with Polytrauma

This was a hypothesis-generating exploration of relationships between caregiver training during TBI/polytrauma rehabilitation and caregiver mental health. In this cross-sectional study, 507 informal caregivers to US service members with TBI who received inpatient rehabilitation care in a Veterans Affairs' Polytrauma Rehabilitation Center from 2001 to 2009 completed a retrospective, self-report survey. Embedded in the survey were measures of caregiver mental health, including the National Institutes of Health's Patient Reported Outcome Measurement Information System (PROMIS) Anxiety and Depression Short Forms, the Rosenberg Self-Esteem scale, and the Zarit Burden Short Form. Though no groups endorsed clinical levels, mental health symptoms varied by caregiver training category (Trained, Not Trained, and Did Not Need Training). Caregivers who did not receive training on how to navigate healthcare systems endorsed higher depression and burden and lower self-esteem than those who did. Caregivers who did not receive training in supporting their care recipients' emotions endorsed higher anxiety, depression, and burden and lower self-esteem than those who did. Analyses also suggested a different association between training and mental health based on caregivers' relationship to the care recipient and the intensity of care recipient needs. Potential hypotheses for testing in future studies raised by these findings are discussed.

An integrative review of the mental health of partners of veterans with combat-related posttraumatic stress disorder

The aim of this article is to present an integrative review of the mental health of veteran partners living with veterans with combat-related posttraumatic stress disorder (PTSD). Living with a veteran with PTSD affects the psychological well-being and health outcomes of a veteran partner. Fourteen research articles that focused on the mental health of military partners, which directly influence the psychological well-being of veteran partners, were reviewed. Findings indicate that a range of mental health concerns exist among veteran partners living with veterans with PTSD. The mental well-being of veteran partners is affected by the emotional strain of living and caring for veterans with PTSD. For years, the partner's presence has been overlooked in the PTSD treatment. However, to promote the comprehensive health of veterans with PTSD, it is paramount to understand the mental health state of veteran partners. Understanding the mental health state of veteran partners will provide a broader perspective to the plight of veteran partners.

The impact of war on Puerto Rican families: challenges and strengthened family relationships

We describe the impact of war on Puerto Rican Veterans and family members. We used qualitative research methods to collect and analyze data. We interviewed 8 Veterans and 8 family members. We used the constant comparison method to review data to identify prominent themes. Two categories emerged: (1) Challenges associated with post-deployment family reintegration, and (2) A positive aftermath of war on the family. Overall, findings indicate that OEF/OIF Veterans and family members were not prepared for the changes they encounter post-deployment. Despite these challenges, some Veterans and family members strengthened their relationships and renewed their appreciation for one another.

A case report of gunshot terror attack in pregnancy: implications for forensic nursing

We present a case report of a third trimester pregnant woman who endured a gunshot terror attack. We demonstrate the complexity involved in the treatment of mother-infant, and suggest implementing the role of forensic nurse in Israel as a way to enhance the treatment of trauma patients within the hospital setting.

Practice changes associated with the Department of Veterans Affairs' Family Care Collaborative

BACKGROUND

The Department of Veterans Affairs (VA) provides rehabilitation for veterans with moderate to severe war injuries through four regional Polytrauma Rehabilitation Centers (PRCs). To standardize and improve care provided to these veterans' family members, health services researchers partnered with program leaders and rehabilitation specialists to implement a family care quality improvement collaborative.

OBJECTIVE

To describe practice changes associated with the Family Care Collaborative's intervention.

DESIGN

Cross-site, mixed-method evaluation.

PARTICIPANTS

Rehabilitation interdisciplinary team members (n = 226) working at the four participating sites.

INTERVENTIONS

The collaborative developed and implemented in a 6-month pilot a web-based tool to standardize and promote family-centered care.

OUTCOMES

Provider survey of family care, satisfaction with family care, and perceived competence in working with families; specific practice changes at each site; provider and facilitator perceptions of the collaborative work; and a validated measure to predict likelihood of success of the selected intervention.

MAIN RESULTS

Family-centered practices and satisfaction improved at sites with lower baseline scores (P < 0.05) and was equivalent across sites after the pilot. Providers initiated specific family-centered practices that often began at one site and spread to the others through the collaborative. Sites standardized family education and collaboration. Providers believed that the collaborative produced a "culture change" from patient-centered to family-centered care and viewed program leadership and health services researchers' involvement as crucial for success. Scores on the measure to predict successful implementation of the intervention beyond the pilot were promising.

CONCLUSIONS

Collaboratives that bring together clinicians, program leaders, and researchers may be useful for fostering complex change involving interdisciplinary teams.

Military deployment: the impact on children and family adjustment and the need for care

PURPOSE OF REVIEW

Over a million children and their families have now experienced the stress of the deployment of a family member during the recent wars in Iraq and Afghanistan. Whereas there is an extensive clinical literature about the developmental challenges facing children and issues of family adjustment, there is a lack of systematic research. This review summarizes the findings of recent publications.

RECENT FINDINGS

Some veterans develop posttraumatic stress disorder as a consequence of their experiences. This condition drives many of the adverse changes in the families of returning veterans through the effects on intimacy and nurturance in their families of withdrawal, numbing and irritability that are components of posttraumatic stress disorder. There is the more general challenge that all families and children face when a partner/parent deploys of role ambiguity consequent on anxiety that is provoked by the threat that deployed family members experience. A study of Kuwaiti military showed that mothers' anxiety had the greatest impact on the children of deployed fathers, although absence of posttraumatic stress disorder in mothers could mitigate the effects of their fathers' posttraumatic stress disorder. Intervention programs are described, but there is a poverty of their evaluation.

SUMMARY

A substantial advantage of focusing on family adjustment is that it can facilitate access to mental healthcare for veterans while assisting families' positive adaptation.

Psychological services for returning veterans and their families: evolving conceptualizations of the sequelae of war-zone experiences

The provision of effective and timely behavioral health care for veterans returning from the conflicts in Iraq and Afghanistan has become the focus of national attention. In this special issue, attempts to provide psychological care for service members and their families are examined in light of three key constructs. First, it is contended that at no other time in history has more attention been paid to the psychological consequences of engaging in combat. Second, for the first time in recorded warfare, psychological morbidity is likely to far outstrip physical injury associated with combat. Finally, although posttraumatic stress disorder and traumatic brain injury are serious concerns, most service members return without significant physical or psychological injury and will be able to return to functioning without notable problems. Accurate diagnosis, a focus on resilience, and the expectation of readjustment are essential precepts that should guide clinical efforts and resource allocation.