Relationship of Preinjury Caregiver and Family Functioning to Community Integration in Adults With Traumatic Brain Injury


      Sady MD, Sander AM, Clark AN, Sherer M, Nakase-Richardson R, Malec JF. Relationship of preinjury caregiver and family functioning to community integration in adults with traumatic brain injury.


      To investigate the relationship of preinjury caregiver and family functioning to community integration outcomes in persons with traumatic brain injury (TBI).


      Inception cohort.


      Three TBI Model Systems inpatient rehabilitation facilities.


      Persons with TBI (N=141) and their caregivers admitted to inpatient rehabilitation and followed up at 1 to 2 years after injury.


      Not applicable.

      Main Outcome Measures

      Community Integration Questionnaire and the Social and Occupation scales of the Craig Handicap Assessment and Reporting Technique.


      There were significant interactions of several preinjury caregiver and family variables with injury severity. For persons with complicated mild/moderate injury, better family functioning was associated with greater home integration, and less caregiver distress was associated with better social integration. For persons with severe injuries, greater caregiver perceived social support was associated with better outcomes in productivity and social integration.


      Preinjury caregiver and family characteristics interact with injury severity to affect outcomes in persons with injury. Research on outcomes should include measures of caregiver and family functioning. Early interventions targeted toward decreasing caregiver distress, increasing support, and improving family functioning may have a positive impact on later outcomes.

      Key Words

      List of Abbreviations:

      BSI (Brief Symptom Inventory), CHART (Craig Handicap Assessment and Reporting Technique), CHocc (CHART Occupation scale), CHsi (CHART Social Integration scale), CIQ (Community Integration Questionnaire), CIQhi (CIQ Home Integration scale), CIQprod (CIQ Productivity scale), CIQsi (CIQ Social Integration scale), DRS (Disability Rating Scale), FAD (Family Assessment Device), GCS (Glasgow Coma Scale), GSI (Global Severity Index), MSPSS (Multidimensional Scale of Perceived Social Support), TBI (traumatic brain injury)
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        • Dikmen S.S.
        • Temkin N.R.
        • Machamer J.E.
        • Holubkov A.L.
        • Fraser R.T.
        • Winn H.R.
        Employment following traumatic brain injuries.
        Arch Neurol. 1994; 51: 177-186
        • Sander A.M.
        • Kreutzer J.
        • Rosenthal M.
        • Delmonico R.
        • Young M.E.
        A multicenter longitudinal investigation of return to work and community integration following traumatic brain injury.
        J Head Trauma Rehabil. 1996; 11: 70-84
        • Kreutzer J.S.
        • Marwitz J.H.
        • Walker W.
        • et al.
        Return to work and job stability after brain injury: a TBI Model System multicenter analysis.
        J Head Trauma Rehabil. 2003; 18: 128-138
        • Jacobs H.E.
        The Los Angeles head injury survey: procedures and initial findings.
        Arch Phys Med Rehabil. 1988; 69: 425-431
        • Dikmen S.
        • Machamer J.
        • Temkin N.
        Psychosocial outcome in patients with moderate to severe head injury: 2-year follow-up.
        Brain Inj. 1993; 7: 113-124
        • Kersel D.A.
        • Marsh N.V.
        • Havill J.H.
        • Sleigh J.W.
        Psychosocial functioning during the year following severe traumatic brain injury.
        Brain Inj. 2001; 15: 683-696
        • Ponsford J.L.
        • Olver J.H.
        • Curran C.
        A profile of outcome: 2 years after traumatic brain injury.
        Brain Inj. 1995; 9: 1-10
        • Sander A.M.
        • Fuchs K.L.
        • High Jr, W.M.
        • Hall K.M.
        • Kreutzer J.S.
        • Rosenthal M.
        The Community Integration Questionnaire revisited: an assessment of factor structure and validity.
        Arch Phys Med Rehabil. 1999; 80: 1303-1308
        • Uysal S.
        • Hibbard M.R.
        • Robillard D.
        • Pappadopulos E.
        • Jaffe M.
        The effect of parental traumatic brain injury on parenting and child behavior.
        J Head Trauma Rehabil. 1998; 13: 57-71
        • Bier N.
        • Dutil E.
        • Couture M.
        Factors affecting leisure participation after a traumatic brain injury: an exploratory study.
        J Head Trauma Rehabil. 2009; 24: 187-194
        • Dikmen S.
        • Ross B.L.
        • Machamer J.E.
        • Temkin N.R.
        One year psychosocial outcome in head injury.
        J Int Neuropsychol Soc. 1995; 1: 66-67
        • Sherer M.
        • Sander A.M.
        • Nick T.G.
        • High Jr, W.M.
        • Malec J.F.
        • Rosenthal M.
        Early cognitive status and productivity outcome following traumatic brain injury: findings from the TBI Model System.
        Arch Phys Med Rehabil. 2002; 83: 183-192
        • Brown A.W.
        • Malec J.F.
        • McClelland R.L.
        • Diehl N.N.
        • Englander J.
        • Cifu D.X.
        Clinical elements that predict outcome after traumatic brain injury: a prospective multi-center recursive partitioning (decision-tree) analysis.
        J Neurotrauma. 2005; 22: 1040-1051
        • Willemse-van Son A.
        • Ribbers G.M.
        • Verhagen A.P.
        • Stam H.J.
        Prognostic factors of long-term functioning and productivity after traumatic brain injury: a systematic review of prospective cohort studies.
        Clin Rehabil. 2007; 21: 1024-1037
        • Brooks N.
        • McKinlay W.
        • Symington C.
        • Beattie A.
        • Campsie L.
        Return to work within the first seven years of severe head trauma.
        Brain Inj. 1987; 1: 5-19
        • Rao N.
        • Rosenthal M.
        • Cronin-Stubbs D.
        • Lambert R.
        • Barnes P.
        • Swanson B.
        Return to work after rehabilitation following traumatic brain injury.
        Brain Inj. 1990; 4: 49-56
        • Schmidt M.F.
        • Garvin L.J.
        • Heinemann A.W.
        • Kelly J.P.
        Gender-and age-related role changes following brain injury.
        J Head Trauma Rehabil. 1995; 10: 14-27
        • McMordie W.R.
        • Barker S.L.
        • Paolo T.M.
        Return to work (RTW) after head injury.
        Brain Inj. 1990; 1: 57-69
        • Rao N.
        • Kilgore K.M.
        Predicting return to work in traumatic brain injury using assessment scales.
        Arch Phys Med Rehabil. 1992; 73: 911-916
        • Gollaher K.
        • High W.
        • Sherer M.
        • et al.
        Prediction of employment outcome one to three years following traumatic brain injury (TBI).
        Brain Inj. 1998; 12: 455-463
        • Fraser R.
        • Dikmen S.
        • McLean A.
        • Miller B.
        • Temkin N.
        Employability of head injury survivors: first year post-injury.
        Rehabil Couns Bull. 1988; 31: 276-288
        • Sherer M.
        • Levin E.
        • High W.M.
        • Oden K.E.
        • Nick T.G.
        Impaired awareness and employment outcome after traumatic brain injury.
        J Head Trauma Rehabil. 1998; 13: 44-53
        • Ip R.Y.
        • Dornan J.
        • Schentag C.
        Traumatic brain injury: factors predicting return to work or school.
        Brain Inj. 1995; 9: 517-532
        • Brandt E.N.
        • Pope A.M.
        Enabling America: assessing the role of rehabilitation science and engineering.
        National Academy Pr, Washington (DC)1997
        • Tate D.G.
        • Pledger C.
        An integrative conceptual framework of disability: new directions for research.
        Am Psychol. 2003; 58: 289-295
        • Whiteneck G.
        • Dijkers M.P.
        Difficult to measure constructs: conceptual and methodological issues concerning participation and environmental factors.
        Arch Phys Med Rehabil. 2009; 90: S22-S35
        • Rivara J.
        • Jaffe K.
        • Fay G.
        • et al.
        Family functioning and injury severity as predictors of child functioning one year following traumatic brain injury.
        Arch Phys Med Rehabil. 1993; 74: 1047-1055
        • Rivara J.
        • Jaffe K.
        • Polissar N.
        • et al.
        Family functioning and children's academic performance and behavior in the year following traumatic brain injury.
        Arch Phys Med Rehabil. 1994; 75: 369-379
        • Yeates K.
        • Taylor G.
        • Drotar D.
        • et al.
        Preinjury family environment as a determinant of recovery from traumatic brain injuries in school-age children.
        J Int Neuropsychol Soc. 1997; 3: 617-630
        • Perlesz A.
        • Kinsella G.
        • Crowe S.
        The impact of traumatic brain injury on the family: a critical review.
        Rehab Psychol. 1999; 44: 6-35
        • Oddy M.
        • Herbert C.
        Brain injury and the family: a review.
        in: Tyerman A. King N.S. Psychological approaches to rehabilitation after traumatic brain injury. Wiley, Oxford2008: 431-448
        • Kaplan S.
        Social support, emotional distress and vocational outcomes among persons with brain injuries.
        Rehab Couns Bull. 1990; 34: 16-23
        • West M.
        • Hughes T.
        Supported employment phase III: job retention techniques.
        in: Wehman P. Kreutzer J. Vocational rehabilitation for persons with traumatic brain injury. Aspen, Baltimore1990: 201-219
        • Lefebvre H.
        • Cloutier G.
        • Levert M.J.
        Perspectives of survivors of traumatic brain injury and their caregivers on long-term social integration.
        Brain Inj. 2008; 22: 535-543
        • Sander A.M.
        • Caroselli J.S.
        • High Jr, W.M.
        • Becker C.
        • Neese L.
        • Scheibel R.
        Relationship of family functioning to progress in a post-acute rehabilitation programme following traumatic brain injury.
        Brain Inj. 2002; 16: 649-657
        • Epstein N.B.
        • Baldwin L.M.
        • Bishop D.S.
        The McMaster Family Assessment Device.
        J Marital Fam Ther. 1983; 9: 171-180
        • Rappaport M.
        • Hall K.M.
        • Hopkins K.
        • Belleza K.
        • Cope D.N.
        Disability Rating Scale for severe head trauma: coma to community.
        Arch Phys Med Rehabil. 1982; 63: 118-123
        • Sander A.M.
        • Sherer M.
        • Malec J.F.
        • et al.
        Preinjury emotional and family functioning in caregivers of persons with TBI.
        Arch Phys Med Rehabil. 2003; 84: 197-203
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness: a practical scale.
        Lancet. 1974; 2: 81-84
        • Williams D.H.
        • Levin H.S.
        • Eisenberg H.M.
        Mild head injury classification.
        Neurosurgery. 1990; 27: 422-428
        • Miller I.W.
        • Epstein N.B.
        • Bishop D.S.
        • Keitner G.I.
        The McMaster Family Assessment Device: reliability and validity.
        J Marital Fam Ther. 1985; 11: 345-356
        • Kreutzer J.S.
        • Gervasio A.H.
        • Camplair P.S.
        Primary caregivers' psychological status and family functioning after traumatic brain injury.
        Brain Inj. 1994; 8: 197-210
        • Zarski J.J.
        • DePompei R.
        • Zook A.
        Traumatic head injury: dimensions of family responsivity.
        J Head Trauma Rehabil. 1988; 3: 31-41
        • Derogatis L.R.
        The Brief Symptom Inventory.
        National Computer Systems, Minneapolis1993
        • Zimet G.D.
        • Dahlem N.W.
        • Zimet S.G.
        • Farley G.K.
        The Multidimensional Scale of Perceived Social Support.
        J Pers Assess. 1988; 52: 30-41
        • Kazarian S.S.
        • McCabe S.B.
        Dimensions of social support in the MSPSS: factorial structure, reliability, and theoretical implications.
        J Community Psychol. 1991; 19: 150-160
        • Whiteneck G.G.
        • Charlifue S.W.
        • Gerhart K.A.
        • Overholser J.D.
        • Richardson G.N.
        Quantifying handicap: a new measure of long-term rehabilitation outcomes.
        Arch Phys Med Rehabil. 1992; 73: 519-526
        • World Health Organization
        International classification of impairments, disabilities, and handicaps: a manual of classification relating to the consequences of disease.
        WHO Publishing, Geneva1980
        • Whiteneck G.G.
        • Charlifue S.W.
        • Gerhart K.A.
        • Overholser J.D.
        • Richardson G.N.
        Guide for use of the CHART: Craig Handicap Assessment and Reporting Technique.
        Craig Hospital, Colorado1988
        • Willer B.
        • Rosenthal M.
        • Kreutzer J.S.
        • Gordon W.A.
        • Rempel R.
        Assessment of community integration following rehabilitation for traumatic brain injury.
        J Head Trauma Rehabil. 1993; 8: 75-87
        • Willer B.
        • Ottenbacher K.J.
        • Coad M.L.
        The Community Integration Questionnaire: a comparative examination.
        Am J Phys Med Rehabil. 1994; 73: 103-111
        • Sander A.
        • Seel R.
        • Kreutzer J.
        • Hall K.
        • High W.
        • Rosenthal M.
        Agreement between persons with traumatic brain injury and their relatives regarding psychosocial outcome using the Community Integration Questionnaire.
        Arch Phys Med Rehabil. 1997; 78: 353-357
        • Tepper S.
        • Beatty P.
        • DeJong G.
        Outcomes in traumatic brain injury: self-report versus report of significant others.
        Brain Inj. 1996; 10: 575-581
        • Cusick C.
        • Gerhart K.
        • Mellick D.
        Participant-proxy reliability in traumatic brain injury outcome research.
        J Head Trauma Rehabil. 2000; 15: 739-749
        • Gravetter F.J.
        • Wallnau L.B.
        Statistics for the behavioral sciences.
        in: 7th ed. Thomas Wadsworth, Belmont2007: 291-292
        • Muthén L.K.
        • Muthén B.O.
        Mplus user's guide.
        4th ed. Muthén & Muthén, Los Angeles2006
        • Schafer J.L.
        • Graham J.W.
        Missing data: our view of the state of the art.
        Psychol Methods. 2002; 7: 147-177
        • Sander A.M.
        • High W.
        • Hannay H.J.
        • Sherer M.
        Predictors of psychological health in caregivers of patients with closed head injury.
        Brain Inj. 1997; 11: 235-249
        • Ergh T.C.
        • Rapport L.J.
        • Coleman R.D.
        • Hanks R.A.
        Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress.
        J Head Trauma Rehabil. 2002; 17: 155-174
        • Ergh T.C.
        • Hanks R.A.
        • Rapport L.R.
        • Coleman R.D.
        Social support moderates caregiver life satisfaction following traumatic brain injury.
        J Clin Exp Neuropsychol. 2003; 25: 1090-1101
        • Hanks R.A.
        • Rapport L.J.
        • Vangel S.
        Caregiving appraisal after traumatic brain injury: the effects of functional status, coping style, social support and family functioning.
        NeuroRehabilitation. 2007; 22: 43-52

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        Archives of Physical Medicine and RehabilitationVol. 91Issue 12
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          In Sady MD, Sander AM, Clark AN, Sherer M, Nakase-Richardson R, Malec JF. Relationship of preinjury caregiver and family functioning to community integration in adults with traumatic brain injury. Arch Phys Med Rehabil 2010:91;1542-50, the authors regret that the following acknowledgment was omitted from the initial publication.
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