Chapter 31. The Family System

Marie M. Cavallo, Ph.D.; Thomas Kay, Ph.D.
DOI: 10.1176/appi.books.9781585624201.685691



Traumatic brain injury (TBI) is an event that affects and alters an entire family, not only the person with the injury. It is our hope that this chapter will serve as an introduction to service providers across disciplines to sensitize them to the needs of families so that the role of family intervention can be spread out and shared across the rehabilitation team and into the community.

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Figure 31–1. Concentric circles of intervention.

Figure 31–2. Levels of intervention.

Figure 31–3. Stages of intervention.
Table Reference Number
Table 31–1. A model of family assessment and intervention after traumatic brain injury
Table Reference Number
Table 31–2. New York University Head Injury Family Interview


Aitken ME, Korehbandi P, Parnell D, et al: Experiences from the development of a comprehensive family support program for pediatric trauma and rehabilitation patients. Arch Phys Med Rehabil 86:175–179, 2005
Albert SM, Im A, Brenner L, et al: Effect of a social worker liaison program on family caregivers to people with brain injury. J Head Trauma Rehabil 17:175–189, 2002
Anderson MI, Parmenter TR, Mok M: The relationship between neurobehavioural problems of severe traumatic brain injury (TBI), family functioning and the psychological well-being of the spouse/caregiver: path model analysis. Brain Inj 16:743–757, 2002
Anderson VA, Catroppa C, Haritou F, et al: Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children. J Neurol Neurosurg Psychiatry 76:401–408, 2005
Armstrong K, Kerns KA: The assessment of parent needs following paediatric traumatic brain injury. Pediatr Rehabil 5:149–160, 2002
Barringer F: For 32 million Americans, English is a second language. New York Times, April 28, 1993, p A18
Benn KM, McColl MA: Parental coping following childhood acquired brain injury. Brain Inj 18:239–255, 2004
Bishop DS, Miller IW: Traumatic brain injury: empirical family assessment techniques. J Head Trauma Rehabil 3:16–30, 1988
Blais MC, Boisvert JM: Psychological and marital adjustment in couples following a traumatic brain injury (TBI): a critical review. Brain Inj 19:1223–1235, 2005
Blais MC, Boisvert JM: Psychological adjustment and marital satisfaction following head injury: which critical personal characteristics should both partners develop? Brain Inj 21:357–372, 2007
Boschen K, Gargaro J, Gan C, et al: Family interventions after acquired brain injury and other chronic conditions: a critical appraisal of the quality of the evidence. NeuroRehabilitation 22:19–41, 2007
Brooks N: The head-injured family. J Clin Exp Neuropsychol 13:155–188, 1991
Cantor JB, Ashman TA, Schwartz ME, et al: The role of self-discrepancy theory in understanding post-traumatic brain injury affective disorders: a pilot study. J Head Trauma Rehabil 20:527–543, 2005
Carnevale GJ: Natural-setting behavior management for individuals with traumatic brain injury: results of a three-year caregiver training program. J Head Trauma Rehabil 11:27–38, 1996
Carnevale GJ, Anselmi V, Busichio K, et al: Changes in ratings of caregiver burden following a community-based behavior management program for persons with traumatic brain injury. J Head Trauma Rehabil 17:83–95, 2002
Carnes SL, Quinn WH: Family adaptation to brain injury: coping and psychological distress. Fam Syst Health 23:180–203, 2005
Cavallo MM: Subjective burden in caregivers of persons with traumatic brain injury: the influence of family relationship. Unpublished doctoral dissertation, New York University, 1997
Cavallo MM, Saucedo C: Traumatic brain injury in families from culturally diverse populations. J Head Trauma Rehabil 10:66–77, 1995
Cavallo MM, Kay T, Ezrachi O: Problems and changes after traumatic brain injury: differing perceptions between and within families. Brain Inj 6:327–335, 1992
Curtiss G, Klemz S, Vanderploeg RD: Acute impact of severe traumatic brain injury on family structure and coping responses. J Head Trauma Rehabil 15:1113–1122, 2000
Davis JR, Gemeinhardt M, Gan C, et al: Crisis and its assessment after brain injury. Brain Inj 27:359–376, 2003
DeJong G, Batavia AI, Williams JW: Who is responsible for the lifelong well-being of a person with a head injury? J Head Trauma Rehabil 5:9–22, 1990
Department of Veterans Affairs: Veterans Health Administration Directive 2005-024: Polytrauma Rehabilitation Centers. Washington, DC, Veterans Health Administration, June 8, 2005
Digre PG, Kamen D, Vaughn S, et al: Selected states' public policy responses to traumatic brain injury. J Head Trauma Rehabil 9:12–26, 1994
Ergh TC, Rapport LJ, Coleman RD, et al: Predictors of caregiver and family functioning following traumatic brain injury: social support moderates caregiver distress. J Head Trauma Rehabil 17:155–174, 2002
Ergh TC, Hanks RA, Rapport LJ, et al: Social support moderates caregiver life satisfaction following traumatic brain injury. J Clin Exp Neuropsychol 25:1090–1101, 2003
Fitzgerald MH: Multicultural clinical interactions. J Rehabil 58:388–342, 1992
Forsyth RJ, Kelly TP, Wicks B, et al: "Must try harder?": a family empowerment intervention for acquired brain injury. Pediatr Rehabil 8:140–143, 2005
Gan C, Schuller R: Family system outcome following acquired brain injury: clinical and research perspectives. Brain Inj 16:311–322, 2002
Gervasio AH, Kreutzer JS: Kinship and family members' psychological distress after traumatic brain injury: a large sample study. J Head Trauma Rehabil 12:14–26, 1997
Grafman J, Schwab K, Warden D, et al: Frontal lobe injuries, violence, and aggression: a report of the Vietnam Head Injury Study. Neurology 46:1231–1238, 1996
Groom KN, Shaw TG, O'Connor ME, et al: Neurobehavioral symptoms and family functioning in traumatically brain-injured adults. Arch Clin Neuropsychol 13:695–711, 1998
Hart T, O'Neil-Pirozzi TM, Williams KD, et al: Racial differences in caregiving patterns, caregiver emotional function, and sources of emotional support following traumatic brain injury. J Head Trauma Rehabil 22:122–131, 2007
Hawley CA, Ward AB, Magnay AR, et al: Parental stress and burden following traumatic brain injury amongst children and adolescents. Brain Inj 17:1–23, 2003
Kay T: The Unseen Injury: Minor Head Trauma. Framingham, MA, National Head Injury Foundation, 1986
Kay T: Neuropsychological diagnosis: disentangling the multiple determinants of functional disability after mild traumatic brain injury, in Rehabilitation of Post-Concussive Disorders: Physical Medicine and Rehabilitation: State of the Art Reviews. Edited by Horn L, Zassler N. Philadelphia, PA, Hanley and Belfus, 1992, pp 109–127
Kay T, Cavallo MM: Evolutions: research and clinical perspectives on families, in Head Injury: A Family Matter. Edited by Williams JM, Kay T. Baltimore, MD, Paul H Brookes, 1991, pp 121–150
Kay T, Cavallo MM, Ezrachi O: Administration Manual, New York University Head Injury Family Interview (Version 1.2). New York, New York University Medical Center, Research and Training Center on Head Trauma and Stroke, 1988
Kay T, Cavallo MM, Ezrachi O, et al: The head injury family interview: a clinical and research tool. J Head Trauma Rehabil 10:12–31, 1995
Kiser LJ, Black MM: Family processes in the midst of urban poverty: what does the trauma literature tell us? Aggress Violent Behav 10:715–750, 2005
Kosciulek JF: Relationship of family coping with head injury to family adaptation. Rehabil Psychol 39:215–230, 1994
Kosciulek JF: Dimensions of family coping with head injury: a replication and extension. Rehabil Couns Bull 41:43–53, 1997a
Kosciulek JF: Relationship of family schema to family adaptation to brain injury. Brain Inj 11:821–830, 1997b
Kosciulek JF, Lustig DC: Predicting family adaptation from brain injury-related family stress. Journal of Applied Rehabilitation Counseling 29:8–12, 1998
Kosciulek JF, Pichette EF: Adaptation concerns of families of people with head injuries. J Appl Rehabil Counsel 27:8–13, 1996
Koskinen S: Quality of life 10 years after a very severe traumatic brain injury (TBI): the perspective of the injured and the closest relative. Brain Inj 12:631–648, 1998
Kozloff R: Networks of social support and the outcome from severe head injury. J Head Trauma Rehabil 2:14–23, 1987
Kreutzer JS, Gervasio AH, Camplair PS: Patient correlates of caregivers' distress and family functioning after traumatic brain injury. Brain Inj 8:211–230, 1994a
Kreutzer JS, Gervasio AH, Camplair PS: Primary caregiver's psychological status and family functioning after traumatic brain injury. Brain Inj 8:197–210, 1994b
Kreutzer JS, Kolakowsky-Hayner SA, Demm SR, et al: A structured approach to family intervention after brain injury. J Head Trauma Rehabil 17:349–367, 2002
Kübler-Ross E: On Death and Dying. New York, Macmillan, 1969
Lanham RA Jr, Weissenburger JE, Schwab KA, et al: A longitudinal investigation of the concordance between individuals with traumatic brain injury and family or friend ratings on the Katz Adjustment Scale. J Head Trauma Rehabil 15:1123–1138, 2000
Lefebvre H, Pelchat D, Levert MJ: Interdisciplinary family intervention program: a partnership among health professionals, traumatic brain injury patients, and caregiving relatives. J Trauma Nurs 14:100–113, 2007
Lew HL, Poole, JH, Vanderploeg, RD, et al: Program development and defining characteristics of returning military in a VA Polytrauma Network Site. J Rehabil Res Dev 44:1027–1034, 2007
Lezak MD: Psychological implications of traumatic brain damage for the patient's family. Rehabil Psychol 31:241–250, 1986
Livingston MG, Brooks N: The burden on families of the brain injured: a review. J Head Trauma Rehabil 4:6–15, 1988
Machamer J, Temkin N, Dikmen S: Significant other burden and factors related to it in traumatic brain injury. J Clin Exp Neuropsychol 24:420–433, 2002
Maitz EA: The psychological sequelae of a severe closed head injury and their impact upon family systems. Unpublished doctoral dissertation, Temple University, Philadelphia, PA, 1989
Malec JF, Machulda MM, Moessner AM: Differing problem perceptions of staff, survivors, and significant others after brain injury. J Head Trauma Rehabil 12:1–13, 1997
Marsh NV, Kersel DA, Havill JH, et al: Caregiver burden at 1 year following severe traumatic brain injury. Brain Inj 12:1045–1059, 1998
Marsh NV, Kersel DA, Havill JA, et al: Caregiver burden during the year following severe traumatic brain injury. J Clin Exp Neuropsychol 24:434–447, 2002
Max JE, Castillo CS, Robin DA, et al: Predictors of family functioning after traumatic brain injury in children and adolescents. J Am Acad Child Adolesc Psychiatry 37:83–90, 1998
Miller FE: Grief therapy for relatives of persons with serious mental illness. Psychiatr Serv 47:633–637, 1996
Minnes P, Graffi S, Nolte ML, et al: Coping and stress in Canadian family caregivers of persons with traumatic brain injury. Brain Inj 14:737–748, 2000
Moore A, Stambrooke M, Peters L: Centripetal and centrifugal family life cycle factors in long-term outcome following traumatic brain injury. Brain Inj 7:247–255, 1993
Muir CA, Rosenthal M, Diehl LN: Methods of family intervention, in Rehabilitation of the Adult and Child With Traumatic Brain Injury. Edited by Rosenthal M, Griffith ER, Bond MR, et al. Philadelphia, PA, FA Davis, 1990, pp 433–448
Nabors N, Seacat J, Rosenthal M: Predictors of caregiver burden following traumatic brain injury. Brain Inj 16:1039–1050, 2002
Okie S: Reconstructing lives: a tale of two soldiers. N Engl J Med 355:2609–2615, 2006
Olshansky S: Chronic sorrow: a response to having a mentally defective child. Soc Casework 43:190–193, 1962
Olson DH: Circumplex model of marital and family services, in Normal Family Processes. Edited by Walsh F. New York, Guilford, 1993, pp 104–137
Olson DH, Portner J, Bell RQ: FACES-II: Family Adaptation and Cohesion Evaluation Scales. St. Paul, University of Minnesota, Family Social Science, 1982
Peters LC, Stambrook M, Moore AD, et al: Psychosocial sequelae of closed head injury: effects on the marital relationship. Brain Inj 4:39–47, 1990
Ponsford J, Olver J, Ponsford M, et al: Long-term adjustment of families following traumatic brain injury where comprehensive rehabilitation has been provided. Brain Inj 17:453–468, 2003
Prigatano GP, Gray JA: Parental concerns and distress after paediatric traumatic brain injury: a qualitative study. Brain Inj 21:721–729, 2007
Rape RN, Busch JP, Slavin LA: Toward a conceptualization of the family's adaptation to a member's head injury: a critique of developmental stage models. Rehabil Psychol 37:3–22, 1992
Ridley B: Family response in head injury: denial or hope for the future? Soc Sci Med 29:555–561, 1989
Robinson L, Clare L, Evans K: Making sense of dementia and adjusting to loss: psychological reactions to a diagnosis of dementia in couples. Aging Mental Health 9:337–347, 2005
Rosen B, Reynolds WE: The impact of public policy on persons with traumatic brain injury and their families. J Head Trauma Rehabil 9:1–11, 1994
Rosenthal M, Hutchins B: Interdisciplinary family education in head injury rehabilitation, in Head Injury: A Family Matter. Edited by Williams JM, Kay T. Baltimore, MD, Paul H Brookes, 1991, pp 273–282
Rosenthal M, Dijkers M, Harrison-Felix C, et al: Impact of minority status on functional outcome and community integration following traumatic brain injury. J Head Trauma Rehabil 11:40–57, 1996
Sander AM, Davis LC, Struchen MA, et al: Relationship of race/ethnicity to caregivers' coping, appraisals, and distress after traumatic brain injury. NeuroRehabilitation 22:9–17, 2007
Schmitt E: Census data show a sharp increase in living standard. New York Times, August 6, 2001, pp A1, A10
Serio CD, Kreutzer JS, Gervasio AH: Predicting family needs after brain injury: implications for intervention. J Head Trauma Rehabil 10:32–45, 1995
Sinnakaruppan I, Downey B, Morrison S: Head injury and family carers: a pilot study to investigate an innovative community-based educational programme for family carers and patients. Brain Inj 19:283–308, 2005
Spearman RC, Stamm BH, Rosen BH, et al: The use of Medicaid waivers and their impact on services. J Head Trauma Rehabil 16:47–60, 2001
Struchen MA, Atchison TB, Roebuck TM, et al: A multidimensional measure of caregiving appraisal: validation of the Caregiver Appraisal Scale in traumatic brain injury. J Head Trauma Rehabil 17:132–154, 2002
Trudeau DL, Anderson J, Hansen LM, et al: Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion. Neuropsychiatry Clin Neurosci 10:308–313, 1998
Wade SL, Taylor G, Drotar D, et al: A prospective study of long-term caregiver and family adaptation following brain injury in children. J Head Trauma Rehabil 17:96–111, 2002
Wade SL, Stancin T, Taylor HG, et al: Interpersonal stressors and resources as predictors of parental adaptation following pediatric traumatic injury. J Consult Clin Psychol 72:776–784, 2004a
Wade SL, Wolfe CR, Pestian JP: A Web-based family problem-solving intervention for families of children with traumatic brain injury. Behav Res Methods Instrum Comput 36:261–269, 2004b
Wade SL, Carey J, Wolfe CR: An online family intervention to reduce parental distress following pediatric brain injury. J Consult Clin Psychol 74:445–454, 2006a
Wade SL, Michaud L, Brown TM: Putting the pieces together: preliminary efficacy of a family problem-solving intervention for children with traumatic brain injury. J Head Trauma Rehabil 21:57–67, 2006b
Wade SL, Taylor GH, Yeates KO, et al: Long-term parental and family adaptation following pediatric brain injury. J Pediatric Psychol 31:1072–1083, 2006c
Warden D: Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil 21:398–402, 2006
Wells R, Dywan J, Dumas J: Life satisfaction and distress in family caregivers as related to specific behavioural changes after traumatic brain injury. Brain Inj 19:1105–1115, 2005
Wikler L: Chronic stresses of families of mentally retarded children. Fam Relat 30:281–288, 1981
Williams JM, Kay T: Head Injury: A Family Matter. Baltimore, MD, Paul H Brookes, 1991
Williams JM, Savage RC: Family culture and child development, in Head Injury: A Family Matter. Edited by Williams JM, Kay T. Baltimore, MD, Paul H Brookes, 1991, pp 219–238
Wood RL, Liossi C, Wood L: The impact of head injury neurobehavioural sequelae on personal relationships: preliminary findings. Brain Inj 19:845–851, 2005
Yeates G, Henwood K, Gracey F, et al: Awareness of disability after acquired brain injury and the family context. Neuropsychol Rehabil 17:151–173, 2007
Yeates KO, Taylor HG, Drotar D, et al: Preinjury family environment as a determinant of recovery from traumatic brain injuries in school-age children. J Int Neuropsychol Soc 3:617–630, 1997
Yeates KO, Taylor HG, Woodrome SE, et al: Race as a moderator of parent and family outcomes following pediatric traumatic brain injury. J Pediatr Psychol 27:393–403, 2002
Yeoman B: When wounded vets come home. AARP The Magazine, July/August 2008, pp 60–64, 80
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