Abstract Objective The present study sought to examine adolescents’ perceptions of their interpersonal stressors and resources across parent, sibling, friend, and school relationships, and the longitudinal associations with self-reported adjustment after traumatic brain injury (TBI) over a 12-month period. Methods We examined the main effects of stressors and resources on internalizing and externalizing symptoms in 152 adolescents who had sustained complicated mild-to-severe TBI. We also investigated the conjoint effects of stressors and resources and the moderating effects of TBI severity with stressors and resources on outcomes. Results High stressors consistently predicted worse adjustment. High resources were generally only associated with fewer internalizing symptoms. Main effects were qualified by interactions between school stressors and resources in predicting externalizing symptoms and between friend stressors and resources in predicting internalizing and externalizing symptoms. For school stressors, the effects of resources on externalizing symptoms functioned as a buffer. In comparison, the buffering effects of friend resources on internalizing and externalizing symptoms disappeared at moderate-to-high levels of friend stress. Moderating effects of TBI severity were also observed, such that as family resources increased, only adolescents with complicated mild-to-moderate TBI, but not those with severe TBI, experienced decreases in internalizing and eternalizing symptoms. Conclusion Interpersonal stressors and social support have important implications for adolescent adjustment after TBI. Adolescents with low levels of school resources, with high levels of friend stress, and who sustain severe TBI are at greatest risk for difficulties with adjustment. adjustment, adolescence, closed head injury, social support, stress Rates of traumatic brain injury (TBI) spike during adolescence, with about 300,000 youth seen annually in hospital settings (Coronado et al., 2015). Following TBI, adolescents are at increased risk for developing a variety of novel emotional and behavioral problems (Max et al., 1997). The risk for internalizing problems and externalizing disorders increases (Chapman et al., 2010; Peterson et al., 2013; Sesma, Slomine, Ding, & McCarthy, 2008). Less is known about how contextual factors, or the broader environment in which youth exist, impact functioning after pediatric TBI (Ciccia & Threats, 2015). Interpersonal relationships are a kind of contextual factors that are directly modifiable and have the potential to shape adjustment following TBI (Ciccia & Threats, 2015). In the general population, interpersonal stressors and resources are associated with overall adolescent health (Moos, 2002). Notably, adolescents with TBIs endorse elevated stressors after injury, and those stressors subsequently predict worse functioning in adulthood (Taylor, Barrett, McLellan, & McKinlay, 2015). However, existing research on stress among youth with TBIs has relied upon retrospective reporting. To our knowledge, no studies have concurrently examined adolescents’ interpersonal stressors or resources when attempting to understand adjustment after TBI. The present study sought to examine adolescent self-report of stressors and resources across parent, sibling, friend, and school relationships, and their longitudinal associations with adjustment after injury over a 12-month period following study enrollment. Family Stressors and Resources Following Pediatric TBI For parents, interpersonal stressors (i.e., conflict and criticism among spouses, close family members, and friends) and social support (i.e., encouragement and understanding) influence family adjustment after pediatric TBI (Wade et al., 2004). Indeed, family stress and marital strain are associated with greater parent psychological distress following a child’s injury, whereas support from friends and spouses is associated with less distress (Wade et al., 2004). Among families of children with severe TBIs, only those with low social resources reported worse functioning, compared with families of children in an orthopedic injury comparison group (Wade et al., 2006). Resources can impact child adjustment as well, with fewer family resources associated with worse child executive functioning (Potter et al., 2011). Stressors and resources can also have important conjoint effects on functioning by increasing risks for adverse family outcomes in either an additive or synergistic manner. In a previous study of caregivers of children with severe TBI, only those who reported both high stressors and high resources experienced decreases in injury-related distress over time, indicating that resources buffered the negative impact of stress (Wade et al., 2004). This pattern underscores the need for studies to consider both stressors and resources concurrently, as well as the interplay between the two, to better understand outcomes following TBI. Stressors and Resources for Adolescents With TBI Relationships are redefined during adolescence, with normatively elevated levels of interpersonal stress associated with changes in parent–child relationships (Silverberg & Steinberg, 1987) and peer social networks (Vernberg, 1990). Theories offer varying hypotheses regarding the role that social support plays during this time: Some posit that support functions as a main effect and is beneficial to all adolescents, whereas others propose that support acts as a buffer and is uniquely important for those who have high levels of stress by tempering its impact (Rubin et al., 1992; Wade et al., 2004). Studies that examine the associations between stress and adjustment in the general adolescent population suggest that a favorable family environment, as measured by family structure, cohesion, routines, and parenting style, can attenuate the impact of stress (Grant et al., 2006). Likewise, higher friendship quality is another factor that can buffer youth from adverse effects of stress (Grant et al., 2006; Rubin et al., 1992). However, relatively little research has examined how adolescents’ own interpersonal stressors and resources relate to adjustment following TBI. Self-reported stressors and resources have been associated with psychosocial outcomes in adolescents with other chronic conditions, such as Type 1 diabetes and juvenile rheumatic disease (Farrell, Hains, Davies, Smith, & Parton, 2004; Timko, Stovel, Baumgartner, & Moos, 1995). For adolescents with TBIs, four types of interpersonal relationships are particularly salient in predicting adjustment, including those with parents (Wade et al., 2003), siblings (Swift et al., 2003), friends (Heverly-Fitt et al., 2014; Hung et al., 2017), and teachers (Ciccia & Threats, 2015). TBI severity is another uniquely important factor to consider when examining adjustment outcomes after brain injury (Janusz, Kirkwood, Yeates, & Taylor, 2002): More severe injuries are associated with an increased vulnerability to peer-related stressors (Yeates et al., 2013), lower social participation, and lower social competence (Rosema, Crowe, & Anderson, 2012). Moreover, studies that use adolescents’ self-reports of stressors, resources, and adjustment can provide an informative snapshot of adolescents’ own perceptions of their functioning. When examining adolescents’ stressors and resources with peers, parents, siblings, and school, self-reports have important advantages and disadvantages. On the one hand, self-reports are valuable subjective assessments that capture the current perspective of the individual who is involved in multiple relationships. Furthermore, other reporters, such as parents, may not be fully aware of the extent of stressors and resources that their adolescent experiences, particularly depending on the nature of the parent–child relationship. On the other hand, adolescents may have different motivations in reporting, and some may be impacted by what others might think of their relationship or of themselves, resulting in underreporting (Florsheim & Moore, 2008). Adolescents with TBIs may also have deficits in self-awareness following injury, and as such, they may minimize their symptoms. However, self-reports are an important first step in understanding adolescents’ perceptions of their own stressors and resources, as well as their own adjustment after injury. The Present Study Taken together, the nature and quality of interpersonal relationships have important implications for adjustment among youth who have experienced TBI. The present study sought to examine direct and moderating associations of these relationships with adjustment, as measured by adolescents’ self-reports of interpersonal stressors and resources and self-ratings of adjustment outcomes (internalizing symptoms and externalizing symptoms). Within each relationship domain (parent, sibling, peer, and school), we hypothesized that higher stress would be associated with worse adjustment, whereas higher resources would be associated with better adjustment. Consistent with a buffering model, we anticipated that the negative effects of high stressors on adjustment would be lessened in the context of high resources. Based on previous findings (Janusz, Kirkwood, Yeates, & Taylor, 2002; Taylor et al., 2015), our final hypothesis was that associations of stressors and resources with adjustment would be more pronounced for children with severe TBI. Method Participants Participants were recruited as part of a multisite randomized control trial from four tertiary care children’s hospitals and one general hospital, all with Level 1 trauma units. Participants were recruited between March 2010 and August 2014, and follow-up assessments were completed between December 2010 and July 2015. The study was approved by institutional review boards of all participating institutions and was registered with clinicaltrials.gov (assigned number: NCT01042899). In all, 45 female and 107 male individuals of age 11–18 years (M = 14.9, SD = 2.0, range = 11.1–18.9) were assessed at a baseline visit at study enrollment and at 6- and 12-month post-baseline visits. Baseline visits were conducted within 18 months of injury (M = 5.7 months, SD = 4.0 months post-injury). Eligible participants had sustained a complicated mild-to-severe TBI within the past 18 months. Inpatient admissions and trauma registries at participating institutions were screened for potentially eligible participants between the ages of 11 and 18 years. Inclusion criteria included the following: (1) hospitalization of at least one night due to TBI in the previous 18 months; (2) sustaining a moderate-to-severe TBI as characterized by a lowest Glasgow Coma Scale (GCS) score of less than 13, or evidence of brain injury visible on computerized tomography or magnetic resonance imaging; (3) completion of inpatient rehabilitation; (4) adolescent residing with parent/primary caregiver; and (5) English as the main language in the home. Adolescents were excluded if the primary language spoken at home was not English, if there was documentation of child abuse as cause of injury and the perpetrator still lived in the home, if the adolescent had a previous psychiatric hospitalization, if the adolescent was unable to communicate sufficiently to participate, or if the adolescent had a history of autism or other severe developmental disability or neurological disorder. A total of 625 adolescents were screened to participate. Of this group, 222 either could not be contacted or timed out of eligibility before contact, 170 declined to participate, and 80 did not meet inclusion criteria. The remaining 153 adolescents and their primary caregivers consented, and 152 participants completed the baseline assessment. Comparisons of those who consented versus declined revealed that participants were older than nonparticipants but did not differ on other demographic or injury characteristics. After obtaining informed consent/assent, trained research coordinators administered questionnaires and interviews. Procedure Soon after enrollment, study personnel visited families in their home to complete baseline measures with adolescents and their self-identified primary caregiver. As part of the larger multisite study, participants were then randomized (stratified by sex and race) to one of three 6-month intervention conditions: (1) family-centered online problem-solving (TOPS-Family, n = 49), a problem-solving intervention designed to support adolescent and family outcomes after injury; (2) teen-only online problem-solving (TOPS-TO, n = 51), a condition similar to the family intervention but directed specifically at the teen rather than the family; or (3) an Internet resources comparison condition (n = 52), in which the family was given access to online resources only but not the problem-solving intervention (see Wade et al., 2017 for description of these conditions). Families in all three groups were provided with Internet service for the duration of the study, and families without a computer were provided one. Forty-one participants did not complete the follow-up assessment. Attrition did not vary by group. All participants with follow-up data, regardless of the number of sessions completed, were included in the analyses. Measures Injury and Demographic Variables Severe TBI was defined based on lowest post-resuscitation GCS score of ≤ 8 (N = 66), and complicated mild-to-moderate TBI was defined as a GCS score > 8 (N = 85). Complicated mild TBI reflects that those with mild TBI (GCS score 13–15) were included in the study only if they had trauma-related intracranial findings on neuroimaging. Participants with mild TBI without intracranial findings were not included in the study. Injury severity, age, sex, and socioeconomic status (SES) have been identified in the literature as related to adjustment following injury and were controlled for in all analyses, along with treatment group (Geraldina et al., 2003; Taylor & Alden, 1997; Wade et al., 1998; Yeates, 2010). The amount of time from the date of injury to baseline assessment was also calculated and included as a control variable in all analyses. Life Stressors and Social Resources Inventory At each assessment, participants completed the Life Stressors and Social Resources Inventory—Youth (Moos, Fenn, & Billings, 1988) to assess stressors and resources within relationships. Items on stressor scales assess negative interactions, defined as criticism, conflict, irritation, anger, and high expectations from individuals within each domain. Items on the social resource scales assess the supportiveness of parent, sibling, friendships, and school relationships, defined as being understanding, respectful, reliable, and encouraging. The stressors and resources within the four domains of parent, sibling, friendships, and school relationships have moderate-to-high internal consistencies (Cronbach’s α ranging from .68 to .93; Moos et al., 1989). Youth Self-Report Achenbach’s Youth Self-Report (YSR; 1991) assessed participants’ adjustment. The YSR is a well-validated questionnaire assessing both internalizing and externalizing symptoms in youth of age 11–18 years as standardized t-scores, normalized for age and sex (M = 50, SD = 10). Internalizing symptoms measure symptoms of anxiety/depression, withdrawal, and somatization. Externalizing symptoms measure symptoms of conduct problems and disruptive behaviors (Achenbach, 1991). Higher scores reflect more problems. Analyses All data were examined to ensure they had acceptable distributions (Behrens, 1997). Outliers were winsorized to ±3 SDs from the sample mean. Hierarchical linear modeling was then used to test a series of multilevel models (HLM Version 6.0; Raudenbush, Bryk, & Congdon, 2004). HLM takes into account the nested nature of the data in a longitudinal study and permits missing data by using full information maximum likelihood to estimate parameters. For longitudinal models, time is nested within the individual; in our models, age at each of the three time points (baseline, 6 months, and 12 months) was included as the index of time. Models resembled the following: Yi = γ00 + γ01 (Sex) + γ02 (Treatment Condition) + γ03 (Race) + β1ti(Age) + β2i(TBI Severity) + β3i(SES) + β4i(Time From Injury) + β5i(Parent Stressors) + β6i(Parent Resources) + β7i(Parent Stressors × Parent Resources) + u0+ ri Models initially determined whether the adjustment outcomes—internalizing symptoms and externalizing symptoms—varied by several control variables (sex, treatment condition, race, age, TBI severity, SES, and time from injury). Both the stressor and the resource from within a particular interpersonal domain (parent, sibling, friend, or school) were included in the models to determine associations with adjustment, followed by interactions of the stressor or resource with TBI severity. Subsequent analyses of the conjoint stressor by resource interactive effects were conducted using Preacher, Curran, and Bauer’s (2006) computational tools. Results A total of 456 observations across three time points were available from participants over 12 months. Control variables (sex, treatment condition, race, age, SES, and time from injury) were included in all analyses. Higher SES was significantly associated with lower externalizing symptoms. Sex, treatment condition, race, age, TBI severity, and time from injury were not associated with internalizing or externalizing symptoms. Table I displays demographic information according to injury severity. The number of participants with missing data was as follows: initial assessment = 12, 6-month follow-up = 48, and 12-month follow-up = 62. At Time 3, those who did not participate at Time 3 were more racially diverse and had lower GCS, lower parent resources, higher internalizing symptoms, and higher externalizing symptoms at Time 1 as compared with those who participated. Table I. Demographic Information for Individuals With Complicated Mild-to-Moderate and Severe TBIs Complicated mild-to-moderate TBI Severe TBI N 85 67 Mean (SD) age at injury 14.08 (1.94) 14.78 (2.19) Mean (SD) GCS score 13.66 (1.80) 3.73 (1.44) Sex (% male) 72.0 69.0 Race (% Caucasian) 87.0 79.0 Biological mother: Education (%) Did not complete high school 5.0 5.3 High school diploma/GED 26.3 40.4 At least 2 years of college 37.5 33.3 Bachelor/Advanced degree 31.2 21.1 Family income (%) <20,000 2.4 3.0 $20,000–$39,999 7.0 8.9 $40,000–$69,999 40.0 59.7 >$70,000 48.2 28.4 SES (z score) 0.18 (1.00) −0.23 (0.97) Family composition (% two-parent households) 72.0 67.0 Time since injury (in months) 5.85 (4.46) 5.58 (3.52) Complicated mild-to-moderate TBI Severe TBI N 85 67 Mean (SD) age at injury 14.08 (1.94) 14.78 (2.19) Mean (SD) GCS score 13.66 (1.80) 3.73 (1.44) Sex (% male) 72.0 69.0 Race (% Caucasian) 87.0 79.0 Biological mother: Education (%) Did not complete high school 5.0 5.3 High school diploma/GED 26.3 40.4 At least 2 years of college 37.5 33.3 Bachelor/Advanced degree 31.2 21.1 Family income (%) <20,000 2.4 3.0 $20,000–$39,999 7.0 8.9 $40,000–$69,999 40.0 59.7 >$70,000 48.2 28.4 SES (z score) 0.18 (1.00) −0.23 (0.97) Family composition (% two-parent households) 72.0 67.0 Time since injury (in months) 5.85 (4.46) 5.58 (3.52) Table I. Demographic Information for Individuals With Complicated Mild-to-Moderate and Severe TBIs Complicated mild-to-moderate TBI Severe TBI N 85 67 Mean (SD) age at injury 14.08 (1.94) 14.78 (2.19) Mean (SD) GCS score 13.66 (1.80) 3.73 (1.44) Sex (% male) 72.0 69.0 Race (% Caucasian) 87.0 79.0 Biological mother: Education (%) Did not complete high school 5.0 5.3 High school diploma/GED 26.3 40.4 At least 2 years of college 37.5 33.3 Bachelor/Advanced degree 31.2 21.1 Family income (%) <20,000 2.4 3.0 $20,000–$39,999 7.0 8.9 $40,000–$69,999 40.0 59.7 >$70,000 48.2 28.4 SES (z score) 0.18 (1.00) −0.23 (0.97) Family composition (% two-parent households) 72.0 67.0 Time since injury (in months) 5.85 (4.46) 5.58 (3.52) Complicated mild-to-moderate TBI Severe TBI N 85 67 Mean (SD) age at injury 14.08 (1.94) 14.78 (2.19) Mean (SD) GCS score 13.66 (1.80) 3.73 (1.44) Sex (% male) 72.0 69.0 Race (% Caucasian) 87.0 79.0 Biological mother: Education (%) Did not complete high school 5.0 5.3 High school diploma/GED 26.3 40.4 At least 2 years of college 37.5 33.3 Bachelor/Advanced degree 31.2 21.1 Family income (%) <20,000 2.4 3.0 $20,000–$39,999 7.0 8.9 $40,000–$69,999 40.0 59.7 >$70,000 48.2 28.4 SES (z score) 0.18 (1.00) −0.23 (0.97) Family composition (% two-parent households) 72.0 67.0 Time since injury (in months) 5.85 (4.46) 5.58 (3.52) Main Effects of Stressors and Resources for Adjustment For internalizing problems, both self-reported resources and stressors uniquely contributed to symptoms across all four domains (parent, sibling, friend, and school). Higher stressors were associated with higher internalizing symptoms and higher resources with lower symptoms. For externalizing problems, higher parent, sibling, and friend stressors predicted higher symptoms, but associations with resources were not significant. For school relationships, higher stressors predicted higher externalizing symptoms and higher resources predicted lower symptoms. Interactions With TBI Severity There were no significant interactions between stressors and GCS. For resources, there was an interaction between GCS and sibling resources and between GCS and parent resources for internalizing symptoms, B = −0.02, t(283) = −2.19, p < .05; B = −0.03, t(297) = −2.54, p < .05, respectively. As parent and sibling resources increased, decreases in symptoms occurred in the complicated mild-to-moderate TBI group but not the severe TBI group. Similar patterns were observed for interactions between GCS and sibling resources and between GCS and parent resources for externalizing symptoms, B = −0.02, t(283) = −2.14, p < .05; B = −0.02, t(297) = −2.18, p < .05, respectively. As parent and sibling resources increased, externalizing symptoms decreased for individuals in the complicated mild-to-moderate TBI group; those in the severe TBI group had consistently higher levels of externalizing symptoms regardless of resources. Conjoint (Interactive) Effects of Stressors and Resources Following methods described by Preacher et al. (2006), significant interactions between stressors and resources were explored by plotting the estimated effects of stress on adjustment for three levels of resources: below average (1 SD below average level of resource), average (at the mean level of resource), and above average (1 SD above average level of resource). For internalizing and externalizing problems, friend stressors and friend resources interacted to predict symptoms (internalizing: B = 0.01, t(294) = 2.27, p < .05; Figure 1; externalizing: B = 0.01, t(294) = 2.31, p < .05, Figure 2). For both outcomes, increased symptoms were associated with higher levels of friend stressors. Association of symptoms with lower levels of friend stressors was weakened in the context of average and above average friend resources, but this moderating effect was not evident at a high level of friend stressors. Figure 1. View largeDownload slide Interaction between friend stressors and friend resources on internalizing symptoms. Figure 1. View largeDownload slide Interaction between friend stressors and friend resources on internalizing symptoms. Figure 2. View largeDownload slide Interaction between friend stressors and friend resources on externalizing symptoms. Figure 2. View largeDownload slide Interaction between friend stressors and friend resources on externalizing symptoms. School-related stressors and resources also interacted to predict externalizing symptoms, B = −0.01, t(290) = −2.65, p < .01 (Figure 3). For all individuals, externalizing symptoms increased as school-related stressors increased, but with weaker associations between stressors and symptoms for children with high resources. Figure 3. View largeDownload slide Interaction between school stressors and school resources on externalizing symptoms. Figure 3. View largeDownload slide Interaction between school stressors and school resources on externalizing symptoms. Discussion The present study examined how interpersonal relationships can shape adolescent outcomes after TBI. In general, adolescents’ self-reports of both interpersonal stressors and resources contributed to adjustment after injury, and combinations of stressors and resources were important for understanding functioning in some domains. Results also showed that associations between resources and adjustment varied according to injury severity: Among youth with complicated mild-to-moderate TBI, resources played an important buffering role, but this was less true for youth with severe TBI. Main Effects of Stressors and Resources Consistent with our predictions, each interpersonal stressor was consistently associated with adjustment. Adolescents are particularly sensitive to social cues; as such, stressful social interactions can carry significant weight (Somerville, 2013). We also examined whether social resources were protective factors for adolescents with TBIs. This was true for internalizing symptoms, as higher levels of all four resources were associated with fewer internalizing symptoms. Parents, siblings, peers, and school may provide different types of support that could reduce worries or irritability after injury. Peers or parents may be emotionally supportive, whereas school support may be more instrumental in nature. Contrary to hypotheses, there were generally no significant main effects of resources for externalizing symptoms when main effects of stressors were also considered. However, main effects of friend and school resources for externalizing symptoms were qualified by an interaction with the corresponding stressor, suggesting that it is important to consider the interplay between resources and stressors for this domain. Interactions Between Stressors and Resources Consistent with previous findings that resources have a moderating effect on adjustment after pediatric TBI (Rivara et al., 1996; Wade et al., 2004), we found a moderating effect for friend and school resources. As friend stress increased, internalizing and externalizing symptoms increased regardless of the level of resources. However, at low-to-moderate levels of friend stress, adolescents with average and above average friend resources had fewer symptoms, demonstrating that peer support buffers the impact of low-to-moderate friend stress. At high levels of friend stress, this protective role of friend resources was not apparent, and regardless of resources, adolescents had elevated symptoms. Of note, adolescents with the lowest friend resources showed the fewest externalizing symptoms at high levels of friend stress. These adolescents may exhibit their symptoms in other ways, and it is possible that they could be withdrawn or irritable. For adolescents with other chronic illnesses, peers have often been identified as the primary source of support during adolescence (La Greca et al., 1995). Thus, targeting peer social support in general could be beneficial to adolescents with TBIs, particularly if it focuses on helping the adolescent with the TBI to learn more effective coping strategies from their peers. At very high levels of friend stress, different strategies and resources may be needed to cope with the taxing nature of friend stressors. Very high levels of friend stress could be linked to lower social competence, and these youth may be unsure how to navigate peer relationships. Adolescents with high friend stress could be bullied or victimized, or could be bullies themselves, and as such, having some peer support would not mitigate all of the negative peer interactions. It would be informative to learn more qualitative information regarding what high levels of peer stressors entail to determine if other factors can distinguish these adolescents from their peers (e.g., social competence or agreeableness). However, interventions should prioritize working with adolescents with high levels of friend stress, as their prognosis is consistently worse. With regard to school stressors, across all individuals, as school stress increased, externalizing symptoms increased. Increases were greatest in the low school resource group, followed by the average and high resource groups. Spanning these findings, we note that those with high resources experienced the lowest increases in symptoms, and resources functioned as a buffer. In comparison, youth with low resources had worse adjustment and were particularly vulnerable to increases in school stress. These findings are consistent with the transactional stress and coping model, which posits that stress emerges when a demand is placed on an individual and that individual does not have adequate resources to cope with the demand (Lazarus & Folkman, 1984). Furthermore, school resources may in fact reflect overall school quality or general school climate: Higher resources could reflect that teachers have the time to focus their attention on particular students. School resources could also reflect appropriate accommodations upon returning to school, which would engender feelings of support. Existing research demonstrates that when school administrations receive training in concussion management practices, youth receive more academic accommodations upon returning to school (Glang et al., 2014). As such, rehabilitation could place a greater emphasis on identifying at least one person at school who could provide support during the transition back to the classroom. TBI Severity Injury severity also had a significant interaction with family resources when predicting adjustment. Parent and sibling resources were associated with decreases in internalizing and externalizing symptoms for adolescents with complicated mild-to-moderate TBI. For adolescents with complicated mild-to-moderate TBI, problems may only emerge in the absence of supportive resources. In comparison, for adolescents with severe TBI, resources were less strongly associated with symptoms. The state of the field is currently mixed regarding whether the environment affects adjustment outcomes for individuals with severe TBI. The present findings are consistent with studies indicating that individuals with severe TBI are less responsive to the environment (Yeates et al., 2010). Severe TBI is a significant enough insult that adjustment difficulties may be pervasive regardless. Clinical Implications Previous work has shown that children with TBI are more susceptible to experiencing stressors after injury (Taylor et al., 2002), and the present study links interpersonal relationships to self-perceived adjustment outcomes. Interventions could target interpersonal relationships with a focus on reducing peer interpersonal stressors and enhancing school resources. Although interpersonal relationships are associated with adjustment outcomes, it is also likely that adjustment impacts interpersonal relationships. Thus, interventions that simultaneously target interpersonal stressors, social support, and adjustment may be the most beneficial. Specifically, research has shown that brain injuries can influence social competence, which is one possible mechanism that might make it more difficult for youth to initiate and navigate social interactions, and which could be associated with adjustment outcomes. Group interventions such as Interpersonal Psychotherapy for Adolescents with an emphasis on Skills Training (IPT-AST) could be particularly valuable for adolescents who have sustained TBI, with a focus on communication skills and problem-solving, factors that impact social competence. IPT-AST is centered on the idea that relationships impact mood, and if relationships are improved, mood will improve (Young, Kranzler, Gallop, & Mufson, 2012). This is one possible therapy modality that could appropriately target adolescents’ perceived interpersonal stressors, resources, and adjustment. Limitations and Future Directions Several limitations in the present study warrant consideration. First, although we used a longitudinal design to examine associations between stressors, resources, and adjustment, causal inferences cannot be made. We discussed how stressors and resources are associated with adjustment, but it is also likely that adjustment impacts relationships. For example, depression is linked to withdrawal, and individuals who are isolated are less likely to have social support. In addition, although we controlled for the amount of time since injury, data collected immediately following injury may yield different findings. Although the present study demonstrated that interpersonal relationships are important, we did not thoroughly delve into which stressors or resources are important, such as conflict compared with criticism or satisfaction with versus supportiveness of the relationship. It would also be informative to complement adjustment ratings with other reporters’ ratings. An additional limitation is that we used adolescents’ self-reports on stressors, resources, and adjustment, and thus, associations may be partly due to shared method variance. There have also been discrepancies in adolescent and parent ratings for functioning after TBI, including health-related quality of life and executive functioning, and adolescents tend to underreport their own difficulties (Green et al., 2012; Wilson, Donders, & Nguyen, 2011). Including multiple reporters’ perceptions of stressors, resources, and adjustment will be an integral component of subsequent research studies. Finally, our study examined adolescence overall as the period spanning ages 11–18 years. Future studies could explore subgroups and compare adjustment and stressors among early adolescents, mid-adolescents, and late adolescents. Despite these limitations, the present study makes several important contributions to the literature. First, the interpersonal relationships that were examined in the present study are important contextual factors that are modifiable and can shape adjustment following injury. Notably, stressors, resources, and the interplay between the two have various implications for adjustment outcomes after injury. Adolescents with severe TBIs, adolescents with low school resources, and adolescents with high friend stress generally have worse adjustment outcomes following TBI. Interventions should thus be targeted accordingly and focus on helping adolescents to navigate challenging interpersonal interactions. Funding Supported in part by the National Institute on Disability, Independent Living, and Rehabilitation Research, formerly known as the National Institute on Disability and Rehabilitation Research (grant no. H133B090010), and the National Institutes of Health/National Institute of Child Health and Human Development (grant no. K23HD074683). Clinical Trial Registration No.: NCT01042899. References Achenbach T. M. ( 1991 ). Manual for the child behavior checklist/4-18 and 1991 profile . Burlington, VT : Department of Psychiatry, University of Vermot . Behrens J. T. ( 1997 ). Principles and procedures of exploratory data analysis . Psychological Methods , 2 , 131 – 160 . Google Scholar CrossRef Search ADS Chapman L. A. , Wade S. L. , Walz N. C. , Taylor H. G. , Stancin T. , Yeates K. O. ( 2010 ). Clinically significant behavior problems during the initial 18 months following early childhood traumatic brain injury . 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Journal of Pediatric Psychology – Oxford University Press
Published: Mar 29, 2018
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