A Randomized Trial of Teen Online Problem Solving:
Efficacy in Improving Caregiver Outcomes After Brain Injury
Shari L. Wade, Nicolay C. Walz, JoAnne Carey, and
Kendra M. McMullen
Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
and College of Medicine, University of Cincinnati
Jennifer Cass, Erin Mark, and Keith Owen Yeates
The Ohio State University and Center for Biobehavioral Health,
The Research Institute at Nationwide Children’s Hospital,
Objective: To examine the results of a randomized clinical trial (RCT) of Teen Online Problem Solving
(TOPS), an online problem solving therapy model, in increasing problem-solving skills and decreasing
depressive symptoms and global distress for caregivers of adolescents with traumatic brain injury (TBI).
Method: Families of adolescents aged 11–18 who sustained a moderate to severe TBI between 3 and 19
months earlier were recruited from hospital trauma registries. Participants were assigned to receive a
web-based, problem-solving intervention (TOPS, n ? 20), or access to online resources pertaining to TBI
(Internet Resource Comparison; IRC; n ? 21). Parent report of problem solving skills, depressive
symptoms, global distress, utilization, and satisfaction were assessed pre- and posttreatment. Groups
were compared on follow-up scores after controlling for pretreatment levels. Family income was
examined as a potential moderator of treatment efficacy. Improvement in problem solving was examined
as a mediator of reductions in depression and distress. Results: Forty-one participants provided consent
and completed baseline assessments, with follow-up assessments completed on 35 participants (16 TOPS
and 19 IRC). Parents in both groups reported a high level of satisfaction with both interventions.
Improvements in problem solving skills and depression were moderated by family income, with
caregivers of lower income in TOPS reporting greater improvements. Increases in problem solving
partially mediated reductions in global distress. Conclusions: Findings suggest that TOPS may be
effective in improving problem solving skills and reducing depressive symptoms for certain subsets of
caregivers in families of adolescents with TBI.
Keywords: acquired brain injury, telehealth, adolescent, problem solving, caregiver
Traumatic brain injury (TBI) is a leading cause of death and
disability in children (Langlois, Rutland-Brown, & Thomas, 2006)
and contributes to persistent deficits in child functioning particu-
larly among children with more severe injuries (Anderson et al.,
2006; Bloom et al., 2001; Ewing-Cobbs, Prasad, Landry, Kramer,
& DeLeon, 2004; Schwartz et al., 2003). Parents report increased
burden associated with the child’s recovery, the reactions of other
family members, and unmet needs for services (Aitken et al., 2009;
Wade, Taylor, Drotar, Stancin, & Yeates, 1998). Parents also
experience elevated psychological distress and rates of disorders
such as depression (Wade et al., 1998). Family functioning may
deteriorate, particularly in the initial months following the injury
(Rivara et al., 1992; Wade et al., 1998).
Injury severity has been shown to consistently predict parental
burden and distress, with parents of children with severe TBI
reporting substantially higher levels of injury-related stress and
rates of clinically significant symptoms (Wade et al., 1998; Wade
et al., 2006). However, a variety of other factors have been linked
to caregiver and family response including how one copes with the
injury, the presence of chronic stresses versus supportive relation-
ships, and the existence of unmet health care needs (Aitken et al.,
2009; Wade et al., 2001; Wade et al., 2004). The latter factors are
potentially modifiable and could thus be addressed through inter-
vention; however, as discussed subsequently, very few family
interventions have been empirically tested.
TBI during adolescence may be particularly burdensome for
caregivers and families for a variety of reasons. First, the teen
years result in normative reductions in parental satisfaction and
concomitant increases in parental distress (Silverberg & Steinberg,
1987, 1990). Adolescents take on increased responsibility for
self-management and self-care that ranges from assuming sole
responsibility for schoolwork to driving, after school employment,
and preparing for college. TBI at this age may disrupt these
normative transitions contributing to further exacerbation of
parent-teen conflict. However, the literature on TBI and adoles-
cence is limited by the fact that most research studies lump teens
with younger children or with adults, including the elderly.
This article was published Online First July 2, 2012.
Department of Pediatrics, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio and College of Medicine, University of Cincinnati; Jennifer
Cass, Erin Mark, and Keith Owen Yeates, Department of Pediatrics, The Ohio
State University and Center for Biobehavioral Health, The Research Institute
at Nationwide Children’s Hospital, Columbus, Ohio.
This work was supported by grant #H133G050239 from the National
Institute of Disability and Rehabilitation Research, U.S. Department of
Education. This study is registered at www.clinicaltrials.gov. Clinicaltrials
.gov identifier: NCT00409058
Correspondence concerning this article should be addressed to Shari L.
Wade, PhD, Division of Physical Medicine and Rehabilitation, Cincinnati
Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH
45229. E-mail: email@example.com
2012, Vol. 31, No. 6, 767–776
© 2012 American Psychological Association
0278-6133/12/$12.00 DOI: 10.1037/a0028440
Families with limited social and economic resources may be
particularly vulnerable to the burdens associated with TBI (Wade
et al., 2004). In the context of economic disadvantage, caregivers
may be unable to access needed services for their child or them-
selves, thus resulting in further exacerbations of injury-related
stresses (Slomine et al., 2006). Given their added risks and limited
access to services, families that lack economic and social resources
may be particularly able to benefit from behavioral interventions
(Wade, Carey, & Wolfe, 2006a).
The evidence base regarding interventions to improve family
adaptation following pediatric TBI is scant (see Boschen, Gerber,
Gan, Brandys, & Gargaro, 2005). However, a small but growing
literature suggests that interventions designed to increase the care-
giver’s understanding of TBI and facilitate coping with the atten-
dant burdens can be effective in reducing caregiver stress and
burden as well (Aitken et al., 2005; Wade, Carey, & Wolfe,
2006b). Two recent reports describe preliminary findings from
interventions for families of adolescents with TBI (Gan, Gargaro,
Brandys, Gerber, & Boschen, 2010; Wade, Walz, Carey, & Wil-
liams, 2008). Gan and colleagues adapted a family centered inter-
vention for adults with TBI that incorporated education, training in
specific skills, and emotional support for use with adolescents.
Results from a pilot with eight adolescents and their families
revealed high levels of satisfaction. However, no data regarding
clinical outcomes were reported. Wade, Walz, Carey, and Wil-
liams (2008) reported findings from a preliminary study of web-
based problem-solving training, Teen Online Problem Solving
(TOPS), for adolescents with moderate to severe TBI. Using a
pre/post design involving nine adolescents and their families, these
investigators reported significant improvements in caregiver de-
pression and parent-teen conflict, but not global caregiver distress.
Thus, to date, despite promising pilot data, findings from random-
ized clinical trials designed to improve caregiver functioning fol-
lowing TBI in adolescence are lacking.
TOPS was rooted in previous family problem-solving ap-
proaches for pediatric TBI (Wade, Michaud, & Brown, 2006;
Wade, Carey, & Wolfe, 2006ab) but was expanded to more thor-
oughly address the issues of self-regulation, autonomy, and social
problem solving in the context of TBI. As conceptualized by Nezu
and colleagues (Nezu, Nezu, & D’Zurilla, 2007), problem solving
therapy is based on the theory that one’s approach to the problem,
known as problem orientation, and his or her characteristic
problem-solving style determine the individual’s success in coping
with life’s challenges. Problem-solving therapy helps individuals
to adopt a more positive approach to life stresses and to develop
and implement systematic plans to address problems or achieve
goals. The problems arising from TBI are diverse, multifaceted,
and vary substantially from family to family and over time. Thus,
problem-solving therapy provides a flexible approach to facilitat-
ing family coping. Moreover, the steps of problem solving also
provide an executive function heuristic for the adolescent whose
ability for rationale reflection and planned action may have been
impaired as a result of the TBI. In response to the needs of the
families, the basic problem-solving content was expanded to ad-
dress the attendant issues of TBI such as impaired anger control,
nonverbal communication, and social skills.
Research on family centered interventions for TBI has been
hindered by the small numbers of families available at any one
location and difficulties engaging families in follow-up care over
prohibitively long distances. Interventions that make use of emerg-
ing technology such as the Web may allow both clinicians and
researchers to overcome some of these barriers (Sander, Clark,
Atchison, & Rueda, 2009; Wade et al., 2006a; 2006b; Wade et al.,
2008). Reported levels of satisfaction with web-based interven-
tions for pediatric TBI have been high; however, limited prior
experience with computers may limit their efficacy in reducing
caregiver distress (Carey, Wade, & Wolfe, 2008). The current
article seeks to expand the findings of Wade, Walz, Carey, and
Williams (2009) by reporting findings from a small randomized
trial comparing the efficacy of TOPS to access to web-based
resources regarding TBI (Internet Resource Comparison; IRC) in
improving caregiver problem solving and reducing caregiver de-
pression and distress. Findings regarding ease of use, utility, and
satisfaction are also reported. We hypothesized that parents of
adolescents in the TOPS group would report greater reductions in
depression and distress and greater improvements in problem
solving than those in the IRC. Based on results from prior inves-
tigations of family problem solving interventions (Wade et al.,
2006a) and given evidence that families of lower SES have higher
levels of symptoms to ameliorate, we further hypothesized that
socioeconomic status would moderate treatment effects with fam-
ilies of lower SES showing greater improvements following
TOPS. Finally, we tested the hypothesis that reductions in depres-
sion and global distress were mediated by improvements in prob-
Potential participants were identified from the trauma registries
and the inpatient rehabilitation units of two urban children’s hos-
pitals. Eligibility criteria included age at enrollment between 11
and 18 years and hospitalization for a moderate to severe traumatic
brain injury (TBI) in the previous 18 months. Injury severity was
defined based on the lowest, postresuscitation Glasgow Coma
Scale score (GCS; Teasdale & Jennett, 1974). GCS scores are
determined by the best eye, verbal, and motor response and range
from 3 (not present) to 15 (normal) A severe TBI was defined as
a GCS score of 8 or less; a moderate TBI was defined as a GCS
score between 9 to 12, or a GCS score ? 12 accompanied by
abnormal imaging or other evidence of neurological impairment.
Adolescents were excluded if the primary language spoken in the
home was not English; there was documentation of child abuse as
a cause of the injury and the perpetrator remained in the home; or
if the teen or primary caregiver had a psychiatric hospitalization
prior to the injury. Teens were also excluded if they were unable
to communicate sufficiently to participate in the sessions. As
presented in Figure 1 depicting the CONSORT flowchart, a total of
137 children were identified as potentially eligible. We success-
fully contacted 121 of these families (88%) regarding their partic-
ipation. Forty-one consented and completed baseline assessments.
However, one participant was subsequently excluded due to sig-
nificant cognitive limitations in the primary caregiver. Participants
were representative of the broader sample with respect to age and
race. However, participants showed a trend toward more severe
injuries, as reflected by lower GCS scores (Participants M ? 9.58,
WADE ET AL.
SD ? 4.56, nonparticipants M ? 11.07, SD ? 4.09), t(86) ? 1.81,
p ? .07.
was sought and obtained at each study site. Families were con-
tacted by letter and then by phone regarding possible participation.
Before participating parents and teens were enrolled, informed
consent from the parent and assent from the teen was obtained by
a trained research coordinator. Families were then randomly as-
signed to either TOPS or IRC using a randomization scheme that
stratified participants based on sex and race/ethnicity. This was
done to ensure that the groups were equivalent with respect to
these characteristics. Both participants and research staff were
aware of group assignment. However, the primary outcome mea-
Institutional Review Board approval
sures were based on parent report and therefore not dependent on
the judgments by the research staff. Both treatments were pre-
sented as active and potentially helpful treatments and families
assigned to the IRC group were encouraged to spend an hour or
more per week accessing the resources provided on the Web.
Therapist and interviewer training.
was delivered by a staff psychologist and doctoral students in
clinical psychology. All therapists received training prior to be-
ginning the project. A treatment manual (available upon request
from the first author) provided detailed instructions regarding the
content and implementation of each session. The therapists and
supervising psychologists at each site participated in weekly su-
pervision calls to maintain fidelity among therapists and sites. The
therapist and families completed checklists at the end of each
session providing further verification of the correspondence be-
tween actual session content and intervention objectives. Research
The TOPS intervention
Depicts the CONSORT flow chart of the TOPS study. CONSORT Flow Chart.
IMPROVING CAREGIVING OUTCOMES AFTER BRAIN INJURY
assistants at each site participated in a group training session in
recruitment strategies, interviewing techniques, and questionnaire
administration prior to beginning the study.
Baseline and follow-up assessments.
the research assistant administered the baseline assessment and
trained participating family members on how to turn on the com-
puter and log onto the Web site. To address disparities in Internet
access and utilization, all participating families were provided with
high speed Internet access through the project, when available.
Additionally, any family without an existing home computer was
given one to use for the duration the study. Follow-up assessments
were completed 7.83 months (SD ? 1.05) following baseline in the
TOPS group and 7.92 months (SD ? 2.88) following baseline in
the IRC group; t(34) ? .12.
During the initial visit,
Description of the TOPS Intervention
The TOPS intervention involved an initial home visit by the
therapist and 9–13 subsequent web-based sessions (Wade, Walz,
Carey, & Williams, 2009). The content for each session was
covered in two separate parts: in the first part, the teen, primary
caregiver, and other participating family members completed a
self-guided module that could be accessed at a password-protected
Web site; and then, in the second part, participating family mem-
bers reviewed the Web site content with the therapist during a
synchronous videoconference. Sessions 2 and 3 focused on devel-
oping a positive approach to problems and the steps of problem
solving, respectively. Beginning with the third session, the thera-
pist also aided the family in implementing the problem-solving
process with a goal or problem that they had identified. Similar to
Nezu, Nezu, and D’Zurilla (2007), the problem-solving heuristic
consisted of five steps: Aim (goal identification), Brainstorm (so-
lution generation), Choose (evaluation of the various solutions),
Do It (detailed implementation plan), and Evaluate (did it work).
Each portion of the sessions required 45–60 minutes to com-
plete. Beyond training in social problem solving skills, the Web
site modules also included didactic information about the conse-
quences of TBI and the targeted skills, videoclips of teens talking
about TBI and modeling the targeted skill (i.e., cognitive refram-
ing), and interactive exercises giving the family additional practice
with the concepts. Although the content was directed to the teen,
all participating family members were encouraged to learn the
skills and apply them in their daily lives.
The TOPS Web site had 10 core sessions. The principles of
problem-solving were addressed in the first three sessions and
provided the foundation for all subsequent sessions. Sessions 4–9
covered issues that were frequently concerns following TBI in-
cluding planning and organization, self-regulation, anger manage-
ment, nonverbal communication and pragmatics, and social rela-
tionships. A final session addressed planning for future challenges.
Six supplemental sessions addressed less common concerns such
as pain management and post-high school transitions. The core
session content was assigned to all families in the TOPS group;
whereas the supplemental sessions were only assigned to families
with concerns in those areas. At the end of the ninth session, each
family member completed a brief self-assessment of their
problem-solving, communication, and social skills. They also in-
dicated their interest in receiving additional online content. Fam-
ilies received up to four supplemental sessions based on their
needs and interests indicated in the self assessment. Supplement
session content focused on (a) caregiver stress, taking care of
yourself, marital communication; (b) working with the school; (c)
planning for after high school; (d) sibling concerns; (e) pain
management; and (f) talking with your adolescent.
Description of the IRC Intervention
Families in the IRC group also received high-speed Internet
access and a computer and printer if they did not currently have
them. Additionally, IRC families received access to a home page
of brain injury resources and links to online resources but were not
able to access specific session content. Resources included links to
local, state, and national brain-injury associations and to sites
specific to pediatric brain injury, such as the Center on Brain
Injury Research and Training, Brain Injury Partners and the Na-
tional Database of Educational Resources on Traumatic Brain
Injury. Families were encouraged to spend at least an hour each
week accessing information regarding pediatric brain injury on the
Web throughout the 6-month intervention period. At follow-up,
parents provided information about the Web sites visited and the
time spent at each site.
Web site utilization, ease of use, and satisfaction.
qualitative and quantitative methods were used to assess the care-
giver’s experience with the TOPS and IRC websites, associated
technology, and intervention content. Caregivers in both groups
completed a satisfaction survey (Wade et al., 2006), and those
receiving TOPS completed a companion questionnaire regarding
ease of use and helpfulness of specific aspects of the TOPS Web
site (Web site Evaluation Questionnaire; WEQ). The WEQ con-
tains 23 questions regarding the ease of use and helpfulness of the
videoconferences and the components of the Web site rated on a
5-point Likert scale (1 ? not at all; 2 ? a little; 3 ? moderately;
4 ? very; 5 ? extremely). Five questions pertained to Web site
ease of use (e.g., logging on, navigating). Six questions addressed
the helpfulness of specific Web site content. Six additional ques-
tions addressed the ease of use and helpfulness of the videocon-
ferences. Previous analyses of the WEQ indicated that the items
pertaining to Web site and videoconference ease of use and help-
fulness possessed high-internal consistency (Cronbach’s a’s rang-
ing from 0.87 to 0.92; Carey et al., 2008). Caregivers also provided
open-ended feedback regarding aspects of the intervention that
were most and least helpful and suggested areas of change.
Because problem-solving skills
was a primary target of the TOPS intervention, the Social
Problem Solving Inventory—Revised Short Form (SPSI-R:S,
D’Zurilla & Nezu, 1990) was used to assess changes in care-
giver problem solving from pre to post treatment. The SPSI-R:S
is a 25 item self-report questionnaire that yields a score of
overall problem solving as well as subscale scores assessing:
Positive Problem Orientation, Negative Problem Orientation,
Rational Problem Solving, Impulsivity/Carelessness Style, and
Avoidance Style. The SPSI-R normative sample included 1,928
participants ranging in age from adolescents to elderly adults.
The measure possesses acceptable psychometric properties in-
cluding evidence of predictive and discriminant validity.
WADE ET AL.
Parental distress and depression.
dex (GSI) of the Symptom Checklist-90-R (SCL-90–R), a 90-item
self-report inventory, provided a measure of global psychiatric
symptoms and parental distress. The SCL-90–R has well-
documented reliability and validity. The GSI score is reported as a
T score with a mean of 50 and a standard deviation of 10. Scores
greater or equal to 63 are considered to be indicative of clinically
significant levels of distress (Derogatis & Lazarus, 1994). The
Center for Epidemiologic Studies Depression Scale (CES-D) was
used to assess specific symptoms of depression. It has well-
established psychometric properties and is useful for screening
individuals at risk for developing clinical depression. A raw score
of 16 is typically used as a cutoff to indicate clinically significant
depressive symptoms (Radloff, 1977).
The Global Severity In-
T tests and chi square analyses or Fisher’s exact tests were con-
ducted to compare the TOPS and IRC groups on continuous and
dichotomous background and injury characteristics, respectively.
Similar analyses were conducted to examine baseline differences
between those who completed the study and those who dropped out.
Overall group differences were examined using analysis of covari-
ance, in which the baseline score on the measure of interest served as
a covariate thereby allowing us to assess change over time. Multiple
regression analyses were used to examine the potential role of family
income in moderating treatment response. The model tested con-
trolled for the baseline score on the dependent variable of interest
and the group ? income interaction. Family income was dichoto-
mized in these analyses to minimize the effects of outliers. Regression
analyses were also used to examine the hypothesis that reductions in
depression and global distress were mediated by improvements in
problem solving. In these analyses, the residualized change in rational
problem-solving scores was entered into the model before group or
the interaction of group with SES, if significant. If the problem-
solving variable accounted for significant variance, it provided evi-
dence that changes in problem solving were associated with changes
in depression and distress. If the problem-solving variable was both
group or group ? SES interactions, this could be considered evidence
of mediation. R2change provided an estimate of effect size in these
Demographic information about participants is reported in Table
1. Follow-up data were obtained from 35 of the 41 original
participants. Completers did not differ from noncompleters with
respect to sex, race, age at injury, injury severity, time since injury,
or caregiver ratings of problem solving at baseline. However,
dropouts reported significantly higher levels of depression on the
CES-D, dropout M ? 26.80 (14.76) versus completer M ? 12.54
(8.75), t(38) ? 3.12, p ? .003, and global caregiver distress on the
SCL-90, dropout M ? 65.20 (10.76) versus completer M ? 54.06
(10.80), t(38) ? 2.16, p ? .04.
Caregivers who completed both the baseline and follow-up
assessment ranged in age from 29 to 58 years at baseline (M ?
41.23; SD ? 6.11). Twenty-five were married (71.4%) and four
were living with someone (11.4%). Nearly two thirds (n ? 23) had
some postsecondary education and 77% (n ? 27) were working
full or part-time. The adolescents ranged in age from 11.47 to
17.90 years at baseline and 40% had severe TBI. Participants in the
TOPS and IRC groups did not differ significantly with respect to
demographic characteristics such as age or SES nor did they differ
on measures of parent problem solving, depression, or psycholog-
ical distress at pretreatment (all ps ? .20).
Participants in both groups received high speed Internet access
for approximately 7 months at an average cost of $50 per month
($350/participant). Participants in the TOPS group had an average
of 10 synchronous meeting with the therapist and each meeting
involved approximately 1 hour of direct contact and 1 hour of
scheduling and charting. The average therapist salary was $30 per
hour, resulting in an additional $600 per patient costs for a total of
$350 per family in IRC and $950 per family in TOPS. Families
Demographic and Injury Characteristics by Treatment Group
t/chi squareMean/n SD/%Mean/n SD/%
Caregiver age at baseline
Child’s age at injury
Months from injury to baseline
Caregiver education ? High school
was coded in $5,000?$10,000 increments with 1 corresponding to incomes of less than $20,000 and 9
corresponding to incomes of $70,000 or greater. A rating of 5 corresponds to an income between $35,000 and
$39,999 whereas a rating of 6 corresponds to an income between $40,000 and $49,999. No significant group
differences were found.
GCS ? Glasgow Coma Scale. Income was assessed using a Likert item regarding family income. Income
IMPROVING CAREGIVING OUTCOMES AFTER BRAIN INJURY
lived an average of 28.93 miles from the medical center (range
1.7–106). As a consequence, the telehealth approach resulted in
considerable savings in travel time and fuel costs.
Due to administration error, satisfaction surveys were only
completed by participants in the IRC group at one of the two sites.
Table 2 presents ratings of global satisfaction and specific behav-
ioral improvements by group. Respondents in the TOPS group
rated the program as significantly more helpful overall as well as
more helpful in working with their child than did respondents in
the IRC group. Additionally, TOPS participants rated the program
as more enjoyable than IRC participants. Nearly all participants in
both groups endorsed increased knowledge regarding TBI, but
significantly higher proportions of TOPS participants endorsed
understanding their child better and feeling less stressed.
On the WEQ, which was completed only by those receiving
TOPS, all but one participant rated the TOPS Web site as moder-
ately to extremely helpful overall and when compared to other
Web sites regarding pediatric TBI. Ratings of specific components
of the website were also rated favorably, with 100% of parents
who responded rating the materials on problem solving, commu-
nication, behavior management, and anger control as moderately
to extremely helpful (range 3–5 on a 5-point rating scale). Ratings
of the brain injury content were somewhat lower, with 31% of
respondents rating them as only a little helpful. Qualitative feed-
back suggested that parents who felt that their teen had already
recovered fully found the information on TBI unnecessary, while
parents of adolescents with more severe injuries wanted more
detailed information about long-term issues and prognosis.
Qualitative feedback indicated that parents found the training in
problem solving and communication skills to be particularly help-
ful. Several parents also noted that they liked learning about the
experiences of others with brain injury through the website videos
and content. Parents’ suggestions for change centered on reducing
the number of questionnaires administered at baseline and
follow-up and addressing technological issues with the Web site,
including sound issues with some of the videos. Several parents
also recommended lengthening the program. Consistent with this
qualitative feedback, 20% of parents agreed with the statement that
the program was to short. Conversely, 80% of the parents rated the
program as neither too short nor too long.
Improvements in Problem Solving
The TOPS intervention specifically targeted having a positive
attitude or problem orientation when problem solving and engaging in
a rational problem solving process. Given this focus, we examined
change on these two positive problem-solving subscales as well as the
total of the SPSI. As reported in Table 2, SES significantly moderated
treatment-related improvements in positive problem orientation and
rational problem solving, both ps ? .05. To examine the nature of
these interactions, ANCOVAS were run separately for the high and
low income groups. As depicted in Figure 2, post hoc analyses
indicated that only parents of lower income in the TOPS group
reported significant improvements in rational problem solving from
baseline to follow-up. For the positive problem orientation subscale,
group and parents of higher income in the IRC group both reported
significant improvements from baseline to follow-up.
Parental Satisfaction Survey Responses by Treatment Group. Global Satisfaction Ratings
(1 ? Not at all; 10 ? Extremely)
TOPS (n ? 15)IRC (n ? 8)
Mean (SD) Mean (SD)
Helpful in working
with my child?
Endorsement of Specific Changes
8.52 (2.2) 6.25 (3.41)
9.13 (1.92) 6.00 (3.82)
TOPS (n ? 15)IRC (n ? 8)
DisagreeAgree Disagree Agree
Reached my goals
Understand child’s injury better
Understand child better?
Get along with child better
Feel less stressed?
Plan for crises
Group differences for the global satisfaction ratings were analyzed using independent sample t tests. Group
differences in the proportion endorsing behavioral changes were examined using Fischer’s exact test.
?indicates a significant difference, p ? .05.
Due to administration error, IRC participants at one of the sites did not receive Satisfaction Surveys.
WADE ET AL.
Improvements in Depression and Global Distress
As depicted in Figure 3, improvements in depressive symp-
toms on the CES-D were also moderated by SES. Post hoc
analyses revealed that parents of lower SES in the TOPS group
reported significant reductions in depressive symptoms from
baseline to follow-up, as did parents of higher SES in the IRC
group (see Table 2). SES did not moderate treatment effects on
the SCL-90, nor did the groups differ on the SCL-90 at
follow-up after controlling for baseline scores, F(1, 32) ? 3.05,
Summary of the Hierarchical Regression Analyses Testing Hypothesized Moderation Effects
B SE B
Step 1: BL RPS
Step 2: Group
Step 3: Income
Step 4: Income ? Group
Step 1: BL PPO
Step 2: Group
Step 3: Income
Step 4: Income ? Group
Step 1: BL Total
Step 2: Group
Step 3: Income
Step 4: Income ? Group
Step 1: BL CES-D
Step 2: Group
Step 3: Income
Step 4: Income ? Group
Step 1: BL SCL-90
Step 2: Group
Step 3: Income
Step 4: Income ? Group
Problem Orientation scale; SPSI total ? Social Problem Solving Inventory total; CES-D ? Center for Epidemiology Depression scale total; SCL-90 GSI ?
Global Severity Index of the Symptom Checklist 90 revised. Income was dichotomized to minimize the effects of extreme values.
?p ? .05.
Bl ? BL; SPSI RPS ? Social Problem Solving Inventory Rational Problem Solving scale; SPSI PPO ? Social Problem Solving Inventory Positive
??p ? .01.
???p ? .001.
Inventory from baseline to follow-up for caregivers in the TOPS and IRC groups at high and low levels of family
income. Post hoc analyses revealed that caregivers in TOPS with low income reported significantly greater
improvements in rational problem solving than those with low income in the IRC group, F(1, 16) ? 5.93; partial
eta2?31, whereas there was no difference between the groups at high levels of income. Rational Problem
Solving at Baseline and Follow-up by Treatment Group and Family Income.
Depicts improvements in the Rational Problem Solving score of the Social Problem Solving
IMPROVING CAREGIVING OUTCOMES AFTER BRAIN INJURY
p ? .09, [(TOPS M ? 48.85 (SE ? 1.98) vs. IRC M ? 54.03
(SE ? 2.16)].
Associations Between Problem Solving and Reductions
in Depression and Distress
A final set of regression analyses (see Table 3) was conducted
to examine the relationship between improvements in global prob-
lem solving and reductions in depressive symptoms and global
distress. Change in overall problem solving, as defined by the
standardized residuals from the regression of problem solving at
Time 1 on problem solving at Time 2, accounted for significant
variance in both depression and distress at Time 2, explaining 16%
of the variance in depression, F(1, 30) ? 7.70, p ? .01 and 7% of
the variance in global distress, F(1, 31) ? 4.75, p ? .04, after
controlling for baseline scores. The absence of a decrease in the
significance of the group ? SES interaction in the CES-D model
failed to support the hypothesis that problem solving mediated
treatment-related reductions in depression. However, for the SCL-
90, the variance accounted for by treatment group was reduced
from 5% to 2% when problem solving was in the model, thus
providing partial support for the mediation hypothesis.
The results provide evidence that TOPS was well received by
parents and may contribute to improvements in parental problem
solving, depression, and distress, particularly among those of
lower SES. Although a trend was found for greater reductions in
global distress in the TOPS versus IRC group, this difference did
not achieve statistical significance. However, SES moderated the
effects of TOPS on rational problem solving, positive problem
orientation, and depressive symptoms, with parents of lower SES
who received TOPS reporting significant improvement from base-
line to follow-up on each of these measures, whereas parents of
lower SES in the IRC group did not report improvements. Inter-
estingly, parents of higher SES in the IRC treatment also reported
significant increases in their positive problem orientation and
concomitant reductions in depression, whereas those of higher SES
in TOPS failed to report improvements on these measures. Thus,
the findings provide some evidence that while TOPS may be
effective in reducing depression among parents of lower SES, IRC
may be as effective for parents of higher SES.
There are several possible explanations for the differential effi-
cacy of TOPS and IRC as a function of varying levels of family
income. Although both TOPS and IRC were active treatments
providing access to web-based information about pediatric TBI,
they differed in several key respects. Unlike IRC, TOPS presented
information in a structured format with a trained therapist to
explain and reinforce that information, whereas IRC required that
the parent follow the links and seek out information on their own.
The latter approach may have proved more daunting for families of
lower SES, who may have less experience seeking and interpreting
information on the Internet. Conversely, higher SES families may
more readily access the available information to address questions
and allay fears, without guidance or therapist support. Lower
income families who lack resources and other supports may have
also found the relationship with the therapist to be more valuable,
whereas that aspect may be less relevant for higher income fam-
ilies with access to other resources.
The current study design did not allow examination of the
efficacy of web-based training in problem-solving in reducing
caregiver distress following TBI in the absence of therapist sup-
port. Recent meta-analyses of telehealth interventions (Spek et al.,
2007) for depression and anxiety suggest that therapist-supported
interventions result in substantially larger treatment effects than
those without therapist involvement, however, comparable meta-
analyses with health-related conditions such as TBI. In the current
study, qualitative feedback suggested that the therapist’s involve-
ment may be particularly important for lower SES families. Spe-
cifically, many parents identified the Skype sessions with the
therapist as the most valuable aspect of the program because it
helped them to understand and communicate with their adolescent.
This type of parent-teen communication may not have occurred in
the absence of therapist involvement, especially in more chaotic,
lower-income households. However, the potential value of thera-
pist involvement must be weighed against its costs as well as the
limited availability for many families, especially those of lower
SES. Thus, although perhaps not as efficacious, web-based
problem-solving without therapeutic support may prove to be a
needed option for families lacking in services, and this possibility
should be examined in future studies.
TOPS also placed emphasis on learning and employing specific
problem solving skills in managing TBI-related and other life
concerns. Caregivers of lower SES showed a trend to report lower
levels of rational problem solving prior to treatment. As a conse-
quence, they may be more likely to benefit from specific training
in this area. Moreover, they may be more likely to experience a
sense of empowerment as they are encouraged to approach prob-
lems in a constructive and positive manner.
Families of adolescents with TBI are often limited in their
follow-up care options due to time and distance from knowledge-
able providers. Delivering an intervention directly to families in
their homes via the Internet through the use of online modules and
synchronous coaching sessions greatly reduces these barriers to
care. It is noteworthy that participants in the current study lived an
average of 29 miles from the hospital with the majority having a
from baseline to follow-up for caregivers in the TOPS and IRC groups at
high and low levels of family income. Post hoc analyses revealed that
caregivers in TOPS with low income reported a significant reduction in
depression t(7) ? 2.17, one-tailed p ? .04; as did caregivers in the IRC
with high incomes t(10) ? 2.65, one-tailed p ? .01. CES-D Depression
Scores at Baseline and Follow-up by Treatment Group and Income.
Depicts improvements in depression as assessed by the CES-D
WADE ET AL.
50 ? mile roundtrip commute. Factors such as distance and time
are particularly important when working with families of adoles-
cents who often have busy schedules and families of lower SES
who may be limited in their access to care or transportation.
Satisfaction with the program was quite high and did not vary by
SES. This high level of satisfaction is evidence that a problem
solving therapy model can be delivered online with success in
improving problem solving skills for some families and with high
levels of satisfaction for most families.
A previous study of online family problem solving for TBI
found that families with limited prior computer use showed fewer
improvements in depression and distress (Carey et al., 2008).
However, in this study, families of lower SES in TOPS showed the
most improvements in problem solving orientation and parental
distress, indicating that previous conclusions regarding the effects
of technology on families of lower SES may need to be modified.
This may be due to a number of factors including changes in the
level of computer and Internet use among families of lower SES
and improvements in ease of use and Web site accessibility.
Nonetheless, replication is warranted to determine which aspects
of an online problem solving intervention provide the most favor-
able outcomes for families of adolescents with TBI.
The study is limited by the relatively small and heterogeneous
sample. Only 34% of families contacted agreed to participate.
Because recruitment criteria targeted all adolescents with TBI
rather than only those experiencing cognitive or behavioral con-
sequences from their injury, the majority of families declined
participation due to a lack of current TBI-related problems. Thus,
those enrolled likely reflect a subgroup of adolescents experienc-
ing persistent sequelae from their injuries. The study design also
precluded distinguishing improvements due to the specific ele-
ments of the treatment (i.e., training in problem solving) from
those arising from supportive involvement with a skilled therapist.
Assessment of problem solving skills and parent distress relied
solely on self report, and thus improvements may have been
inflated by social desirability biases. Additionally, utilization data
were not collected from the IRC group thus precluding comparison
of the groups with respect to time spent on the intervention.
However, parents in both groups reported increased knowledge of
TBI, suggesting that both the TOPS and IRC groups perceived
benefits from the treatment received. Future studies would benefit
from extended follow-up and objective measures of parent prob-
lem solving skills and depressive symptoms and global distress.
Larger studies employing multifactorial designs would enable re-
searchers to evaluate the relative importance of the therapist’s
involvement as well as the added value of the additional content on
anger management, communication, and social skills, beyond that
of standard problem-solving therapy. However, such multicell
designs would necessitate a large, multi-site trial.
The current study presents the first significant evidence of the
potential efficacy of an online family problem solving intervention
for families of adolescents with TBI. The findings add to the
literature supporting the utility of web-based interventions to im-
prove outcomes following TBI. Web-based interventions may be
especially appropriate for families of lower SES who may not have
access to traditional office-based therapy due to time, distance,
financial burden, or other factors. Large, randomized clinical trials
with longer-term follow-up will be necessary to fully establish the
efficacy of TOPS.
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Received June 2, 2011
Revision received December 19, 2011
Accepted December 20, 2011 ?
WADE ET AL.