How does family functioning contribute to child externalizing and internalizing behavior problems after childhood TBI? Evidence from a prospective cohort study

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BACKGROUND AND OBJECTIVES: Despite a well-documented association between childhood traumatic brain injury and elevated risk for internalizing and externalizing behavior problems, the mechanisms through which family functioning contributes to individual variation in these behavioral outcomes remains poorly understood. This prospective cohort study aimed to assess the respective contribution of family functioning and child emotion regulation (ER) to post-injury behavior problems at 1-year follow-up, with a specific focus on evaluating the role of ER problems in mediating the effects of familial affective responsiveness and communication on child behavioral outcomes. METHOD: The study included 129 participants, comprising 86 children with medically confirmed mild-to-severe TBI, identified from consecutive hospital admissions, and 43 typically developing (TD) control children, of similar age and sex. Participants ranged in age from 6 to 15 years (mean age = 11.2 years). Parents completed validated assessments of post-acute family functioning and child emotion regulation problems at 6 months post-injury, as well as measures of child behavior problems at 1-year post-injury. RESULTS: Although group differences in internalizing behaviors did not reach statistical significance, the TBI group exhibited significantly higher overall externalizing symptoms and was significantly more likely to display clinically elevated symptoms than TD controls at 1-year post-injury. Compared to TD controls, the TBI group displayed significantly greater ER problems, which mediated the effects of lower familial affective responsiveness and communication on child behavior problems 1-year-post-injury. CONCLUSIONS: Evidence for these robust, prospective associations suggests that child emotion regulation problems play a key role in mediating the effect of post-acute family functioning on long-term behavior problems in children with TBI. Early assessment and screening for relevant risk factors may help identify those children and families who could benefit from therapeutic interventions designed to address emotional dysregulation and mitigate risk for post-injury behavioral problems. Importantly, these findings underscore the value of adopting family-centred care approaches in rehabilitation, where involving families in therapeutic processes and addressing family dynamics may enhance child emotion regulation and improve long-term behavioral outcomes.

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