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. 2019 Mar 29;44(8):914–923. doi: 10.1093/jpepsy/jsz016

A Prospective Examination of Child Avoidance Coping and Parental Coping Assistance After Pediatric Injury: A Mixed-Methods Approach

Alyssa C Jones 1,✉, Nancy Kassam-Adams 2, Jeffrey A Ciesla 3, Lamia P Barakat 2, Meghan L Marsac 1,2,4
PMCID: PMC6705713  PMID: 30925586

Abstract

Objective

Millions of children experience injuries annually, and avoidance coping increases risk of negative emotional and physical outcomes after injury. Little is known about how children select avoidance coping strategies. Parents may help their children cope with an injury by encouraging or discouraging the use of specific strategies, such as avoidance coping. The present study examined parental influence of child use of avoidance coping post-injury.

Methods

Children ages 8–13 (65% male; 50% White) hospitalized for pediatric injury and their parents (N = 96 child-parent dyads) participated in an interview and discussion task about coping at baseline, and then completed coping/coping assistance measures at three time points: T1 (within 2 weeks post-injury), T2 (6-weeks post-injury), and T3 (12-weeks post-injury).

Results

When presented with an ambiguous situation in the observational interview and discussion task, the number of avoidance coping solutions offered by children independently as well as during a discussion with their parent predicted the child’s ultimate avoidance versus non-avoidance coping choice. The number of avoidance coping solutions offered by parents did not predict children’s final choice to use avoidance coping. Longitudinal data suggest that parent encouragement of avoidance coping predicted child avoidance coping within the first 6-weeks post-trauma.

Conclusions

Our study suggests that child avoidance coping is multifaceted and may result from both parent encouragement as well as independent decisions by children. Future research may explore additional factors that influence child avoidance coping, outside of parental suggestion, in response to trauma exposure.

Keywords: accidents and injuries, coping skills and adjustment, parents, posttraumatic stress

According to the Centers for Disease Control and Prevention (CDC), millions of children experience potentially traumatic injuries each year (CDC, 2014). Injuries may be accompanied by physical and psychological difficulties, such as chronic pain, impaired motor functioning, and challenging emotional reactions [e.g., post-traumatic stress disorder (PTSD); Martin-Herz, Zatzick, & McMahon, 2012]. For instance, estimates of children who develop PTSD after hospitalization for an injury range from 5 to 28% (e.g., see Nelson & Gold, 2012). PTSD symptoms (PTSS) include difficulties related to re-experiencing or intrusions of a traumatic event, avoidance of internal or external reminders of the event, hyperarousal, and changes in mood or cognitions (American Psychiatric Association [APA], 2013). PTSS are commonly reported in the immediate aftermath of a trauma (i.e., peri-trauma period) but often resolve within 3 months after the trauma (i.e., post-trauma). For some, however, PTSS persist, resulting in prolonged emotional challenges in children (APA, 2013). A better understanding of mechanisms that lead to these negative consequences can inform prevention and treatment efforts to facilitate recovery.

One mechanism to consider, particularly with regard to addressing challenging emotional reactions, is avoidance coping. Avoidance coping can involve both cognitive efforts (e.g., wishful thinking, refusing to think about the problem) and behavioral efforts (e.g., staying away or leaving problems; Ayers, Sandier, West, & Roosa, 1996). Avoidance coping has been frequently associated with symptoms of anxiety, depression, and PTSD, somatic complaints, and lower social competence (Compas, Jaser, Dunn, & Rodriguez, 2012; Marsac, Donlon, Winston, & Kassam-Adams, 2013a; Marsac et al., 2016, 2017; Stallard, Velleman, Langsford, & Baldwin, 2001).

Avoidance coping may become problematic if it prevents individuals from learning adaptive appraisals and from gaining confidence in their ability to tolerate or overcome stressful situations and distressing emotions (Ehlers & Clark, 2000). In cognitive models of PTSD, individuals who avoid thoughts, feelings, or external reminders (e.g., people, places, situations) of a trauma may continue to perceive these reminders as threatening. Continued avoidance may then maintain negative appraisals and preclude incorporation of adaptive appraisals, and in the case of PTSD, may serve to maintain or worsen symptoms (Bryant, Salmon, Sinclair, & Davidson, 2007; Ehlers & Clark, 2000). If negative appraisals are strengthened by avoidance coping, and the ability to tolerate trauma reminders is threatened, a better understanding of how children develop and utilize avoidance coping could inform interventions.

One method by which children may learn to use avoidance coping is through their parents. For instance, Marsac, Kassam-Adams, Delahanty, Widaman, and Barakat (2014) proposed a bio-psycho-social model for the development of PTSS following pediatric trauma, suggesting that parent coping assistance may influence how children learn and continue to cope throughout the peri- and post-trauma period. This notion is supported by research suggesting that parents may influence children’s interpretations of ambiguous stimuli (Barrett, Rapee, Dadds, & Ryan, 1996), detection of threat (Creswell, Shildrick, & Field, 2011), fear beliefs (Remmerswaal, Muris, & Huijding, 2016), reluctance to approach new stimuli (Remmerswaal, Muris, & Huijding, 2013), and use of adaptive coping strategies (Marsac, Mirman, Kohser, & Kassam-Adams, 2011; Marsac et al., 2013a). Less work has examined trauma-specific reactions among parents and children. In one study, 132 parent-child dyads were recruited from the emergency department after an acute trauma (e.g., motor vehicle accident, serious falls, acute medical episode) and assessed at two time points (i.e., 1 month and 6 months posttrauma; Hiller et al., 2018). Dyads completed a trauma narrative observational task where they were asked to describe the trauma together, and then parents answered prompts about the child’s thoughts and feelings during and after the event. Then, parents and children completed self-report measures to assess trauma-related appraisals, trauma-related coping, and child PTSS. The authors found that parent encouragement of avoidance coping within 1 month of the trauma was associated with increased child-reported PTSS 6 months later. The aforementioned association was mediated by child cognitive avoidance coping, suggesting the important impact of parental suggestion on child coping and ultimately PTSS. This research study did not assess child behavioral avoidance coping and only parent utterances to the observational task were reported. These findings are consistent with prior work demonstrating the association between parent avoidance coping assistance and PTSS (e.g., Prinstein, La Greca, Vernberg, & Silverman, 1996). Additional longitudinal research is needed to further understand the impact of parent coping assistance on children’s cognitive and behavioral avoidance coping throughout the peri- and post-trauma periods.

The present study examined parental influence on child avoidance coping among children hospitalized for an injury using a mixed method, longitudinal design. The design involved presenting parents and children with an ambiguous situation discussion task in the peri-trauma period and collecting self-report data at three time points: peri-trauma (i.e., within 2 weeks of injury), 6 weeks post-trauma, and 12 weeks post-trauma. We hypothesized that, during the peri-trauma period, children’s and parents’ coping tendencies would influence a child’s response to an ambiguous situation (neutral compared to threat). We also hypothesized that parents’ self-reported avoidance coping assistance (i.e., encouragement of avoidance coping), in the peri-trauma period and at later time points, would predict subsequent child avoidance coping in the months following the traumatic injury. Better understanding these relationships may help in determining a potential role for interventions that target parent coping assistance in preventive and/or early intervention following exposure to acute traumatic events.

Method

Participants

The present study was part of a larger longitudinal study (see Marsac et al., 2017) that explored various predictors (e.g., biological, psychological, environmental) of PTSS in children after an injury. Participants were enrolled at a Level-I pediatric trauma center in the northeastern United States and included 96 children (Mage = 10.60 years; SD = 1.71; 65% male) and their parents (Mage = 40.60; SD = 6.75; 81% mothers). Eligibility requirements included that the child: (1) was between ages 8 and 13, (2) had an injury within the past 2 weeks that required hospitalization and was perceived by the child as potentially traumatic, (3) had a Glasgow Coma Score greater than 12, and 4) was physically well enough to complete study tasks. Children ages 8–13 were selected for participation due to the developmental changes (e.g., cognitive, language, social, and emotional) in middle childhood that may enhance communication abilities, making it a ripe period to study independent and parent-assisted coping. Participants were excluded if the preferred language was not English, the child’s injury was related to family violence, or there were legal proceedings related to the injury. Child and parent participants reported their race/ethnicity as: White (50%; 52%), Black/African American (39%; 39%), Native Hawaiian/Pacific Islander (1%; 1%), Bi-racial or Multi-racial (2%; 1%), and Other (4%; 1%). About 4% of child participants and 1% of parent participants identified as Hispanic. Injury circumstances included recreational activity (57.3%), sports (16.7%), motor-vehicle crash (15.6%), injured by animal (5.2%), gunshot wound (2.1%), and kitchen incidents (3.1%).

There were no significant differences in child sex, race, or age between study participants and individuals who were eligible but were missed by the research team. There were no differences in child age or sex between those who participated and those who chose not to participate. There were differences in child race between those who chose to participate and those who elected not to participate. A higher proportion of children identifying as White declined to participate compared to those who identified as Black/African American (71.3% vs. 51.9%, χ2(1) = 9.2, p < .01). There were no differences between child participants who completed the baseline assessment only and those who also completed assessments at T2 (n = 84, 87.5%) and T3 (n = 75, 78.1%). However, children who completed the T2 6-week follow-up (i.e., T2), but not the T3 12-week (i.e., T3), were on average slightly younger (10.5 vs. 11.6 years, t(94) = 2.2, p < .05).

Procedure

All study procedures were approved by the hospital’s Institutional Review Board. After identifying potentially eligible children via hospital records, a research assistant (RA) approached the child and their parent(s) during their hospitalization. Parents provided informed consent; children provided assent. Children were then asked to complete a four-item screen (derived from the Acute Stress Checklist for Children; Kassam-Adams, 2006) to determine if the injury event was perceived as potentially traumatic. Based on this screener, if children perceived the event as potentially traumatic, they were asked to provide assent (consent provided by parents) for the full study. Children and their parents then participated in the Trauma Ambiguous Situations Task (TAST;Marsac & Kassam-Adams, 2016). Next, children completed the How I Coped Under Pressure Scale (HICUPS; Ayers et al., 1996) to assess avoidance coping, and parents completed the Parental Socialization of Coping Questionnaire (PSCQ; Miller, Kliewer, Hepworth, & Sandler, 1994) to assess parent avoidance coping assistance. RAs contacted participants via telephone 6-weeks and 12-weeks post trauma to repeat self-report measures. Thus, three measurements of self-reported child avoidance coping and parent avoidance coping assistance were obtained: T1 (baseline; within 2 weeks post trauma), T2 (6-weeks post trauma), and T3 (12-weeks post trauma).

Measures

Observed Child and Parent Avoidance Coping

The TAST (Marsac & Kassam-Adams, 2016) is an observational interview and discussion task during which children and parents participate in three modules facilitated by a RA. Module 1 takes an average of 12 min for children and 13 min for parents to complete. Module 2 takes about 4–6 min. Module 3 takes less than 1 min. Participants completed the TAST as an assessment of parents’ encouragement of and children’s decisions to engage in avoidance coping. In Module 1, children and their parents are interviewed separately, during which they are presented with several ambiguous situations (e.g., “When you wake up tomorrow morning, you notice your tummy feels funny”) and asked to appraise the situation (i.e., “What could be happening?”) and provide coping responses (i.e., “What are some things you could do?”). After the independent interviews, children and parents participate in Module 2 together, where they engage in a 5-min discussion about two of the ambiguous situations (i.e., “You wake up tomorrow and your tummy feels funny,” “Your doctor comes in and asks to talk to your mom/dad”). For Module 3, the child provides a final appraisal and final coping response. All modules are audio recorded, transcribed, and coded. In the present study, we limited analyses to a single ambiguous situation (i.e., “Your doctor comes in to talk to your mom/dad”), as the other discussion situation had limited variability (0.02% selecting an avoidance coping solution). Five variables were derived: parent count of avoidance coping solutions in Module 1, child count in Module 1, parent count in Module 2, child count in Module 2, child final coping solution in Module 3. For more information on the TAST, see Marsac and Kassam-Adams (2016).

Self-Reported Child Avoidance Coping

The HICUPS (Ayers et al., 1996) was used to assess self-reported child avoidance coping. The HICIPS was developed and validated via confirmatory factor analysis, and it has demonstrated acceptable use across age and gender (Ayers et al., 1996). Only the avoidance coping subscale was used for the present study. The self-reported avoidance coping subscale includes 12 items related to children’s use of strategies that employ behavioral and cognitive avoidance. Items ask about how often a strategy was used, rated on a scale of 1 (Never) to 4 (Most of the time). Internal consistency for the HICUPS was good across all time points, α = .84–92.

Self-Reported Parent Coping Assistance

The PSCQ (Miller et al., 1994) assesses the extent to which parents self-report their encouragement or discouragement of their child’s use of specific coping strategies after experiencing a stressful event. The PSCQ contains 52 items to measure 12 domains of coping. Parents rated the extent to which they encouraged or discouraged their child’s use of specific strategies since the child’s injury on a scale of 1 (Strongly discouraged) to 7 (Strongly encouraged). In the current study, the cognitive avoidance and behavioral avoidance coping subscales were combined to create one parent coping assistance variable, reflecting parent encouragement of avoidance coping, which had a total of 12 items. Internal consistency for parent coping assistance was acceptable across all time points, α = .83–86.

Injury Severity

Overall injury severity was determined via the Injury Severity Score (ISS; Baker, O’Neill, Haddon, & Long, 1974). The ISS calculates injury severity using standard ratings across the three most severely injured body regions. Scores were abstracted from the institution’s trauma registry data. Scores range from 1 to 75; scores greater than 16 indicate severe injury. The current sample had an average ISS of 5.82 (SD = 4.38, range = 1–22).

Data Analytic Approach

We first examined bivariate relationships between selected demographic characteristics (i.e., sex, age, injury severity) and study variables of interest (i.e., child avoidance coping, parent coping assistance). We then conducted a logistic regression to test our first hypothesis—that more avoidance coping strategies reported by a child and their parent in the observed TAST would predict the child’s final coping solution in response to an ambiguous situation. These analyses were conducted using SPSS 24 (IBM, 2016).

A three time-point cross-lagged panel design was used to assess the second hypothesis—that parent self-reported avoidance coping assistance would predict child self-reported avoidance coping in the months after the traumatic injury. Structural Equation Modeling (SEM) was conducted with AMOS (Version 24; Arbuckle, 2016). These analyses were conducted using maximum likelihood estimation. Missing data were managed using a full-information maximum likelihood approach within the SEM. Model fit was assessed using the chi-square goodness of fit statistic, comparative fit index (CFI), and the root mean square error of approximation (RMSEA; Browne & Cudeck, 1992). Models with a non-significant chi-square value are considered to have good fit. CFI values of .95 or greater are desirable and indicate adequate fit to the data (Hu & Bentler, 1999). Models with a RMSEA of .05 or less are described as having as good fit, .08 or less as adequate fit, and .10 or more as poor fit (Hu & Bentler, 1999).

Results

Bivariate Analyses

Table I includes descriptive data and bivariate correlations for study variables. As can be seen in the table, neither injury severity nor child age were associated with child self-reported avoidance coping, parent self-reported coping assistance, or child’s use of avoidance coping during the TAST. However, injury severity was positively correlated with the number of avoidance solutions offered by parents during the TAST discussion. Independent samples t-tests indicated that there were no significant differences in child self-reported avoidance coping or parent self-reported coping assistance scores between male and female children or mother and father parent reporters. It is important to note the small number of avoidance coping counts during the TAST, as both the observed avoidance coping solutions offered by parents and children in Modules 1 and 2 have means less than one avoidance coping solution offered.

Table I.

Descriptive Data and Zero-Order Correlations Among Predictor and Criterion Variables

1 2 3 4 5 6 7 8 9 10 11 12 13 14 Range
1. Child Age 10.60 (1.71) 8–13
2. Parent Age – 40.72 (6.75) 27–54
3. Injury Severity −.09 .10 5.82 (4.38) 1–22
4. T1 Cope .04 −.06 −.09 31.66 (7.91) 12–46
5. T1 Assist .09 .001 .02 .05 48.36 (13.31) 18–84
6. T2 Cope −.15 −.05 −.07 .57** .27* 30.48 (8.62) 12–48
7. T2 Assist −.03 −.16 −.04 .06 .51** .37** 47.02 (13.60) 24–84
8. T3 Cope −.04 −.07 −.13 .55** .13 .73** .26* 30.06 (10.16) 12–48
9. T3 Assist .02 −.09 .06 .18 .38** .28* .61** .31** 46.56 (13.98) 18–82
10. Child Interview Count −.02 −.06 .02 .16 −.01 −.05 −.06 .18 .01 0.36 (.86) 0–4
11. Parent Interview Count −.14 −.05 .08 .18 −.02 .20 .14 .12 −.18 .01 0.44 (.87) 0–4
12. Discussion Child Count −.13 .06 .17 .03 .05 .08 −.04 .13 −.07 .53** .14 0.54 (1.10) 0–5
13. Discussion Parent Count −.13 .05 .35** .15 .01 .001 −.07 .07 −.07 .24* .32** .65** 0.33 (.80) 0–4
14. Child Final Solution .03 .11 −.13 −.05 .04 −.13 −.08 .03 .01 .64** .04 .58** .34** – –
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Note. N = 96; *p < .05; **p < .01.

Means are included in the diagonal with standard deviations in parentheses. T1 Cope = Child Avoidance Coping at Time 1; T1 Assist = Parent Avoidance Coping Assistance at Time 1; T2 Cope = Child Avoidance Coping at Time 2; T2 Assist = Parent Avoidance Coping Assistance at Time 2; T3 Cope = Child Avoidance Coping at Time 3; T3 Assist = Parent Avoidance Coping Assistance at Time 3; Child Interview Count = Count of avoidance solutions offered by child during the interview; Parent Interview Count = Count of avoidance solutions offered by parent during the interview; Discussion Child Count = Count of avoidance solutions offered by child during the discussion; Discussion Parent Count = Count of avoidance solutions offered by parent during the discussion; Child Final Solution = Child’s final decision to pick an avoidance solution.

Logistic Regression

To examine hypothesis 1—that more avoidance coping strategies reported by a child and their parent in the observed TAST would predict the child’s final coping solution in response to an ambiguous situation—we tested a model that included number of avoidance solutions from TAST Module 1 (parent and child individual interviews) and the number of avoidance solutions from TAST Module 2 (parent and child discussion) as predictors of the child’s final choice of an avoidance solution (1, 0) in TAST Module 3. Parent and child counts of avoidance coping solutions after the individual interviews were entered in Step 1 of the regression, and parent and child counts of avoidance coping solutions after the discussion were entered in Step 2.1Figure 1 depicts a conceptual model for this analysis. Table II depicts the results of the logistic regression model. As expected, the child’s final choice of avoidance in Module 3 was predicted by the number of avoidance solutions offered by the child during the independent interview in Module 1 (B = 1.24, SE = .48, p = .01) and the discussion in Module 2 (B = 1.13, SE = .51, p = .03). However, the child’s final choice of avoidance coping in Module 3 was not predicted by the number of avoidance coping solutions developed by parents during the independent interview in Module 1 (B = −0.15, SE = .55, p = .79) or offered during the discussion in Module 2 (B = −0.13, SE = .51, p = .85).

Figure 1.

Figure 1.

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Conceptual model for the prediction of children’s final coping solutions as assessed by TAST. The number of avoidance coping strategies that children offered during an initial interview (Module 1), the number of avoidance coping strategies that parents offered during an initial interview (Module 1), the number of avoidance solutions offered by children during a discussion (Module 2), the number of avoidance solutions offered by parents during a discussion (Module 2) would predict children’s final coping solutions (Module 3).

Table II.

Predictors of Child’s Choice of Avoidance Coping Solution After the Ambiguous Situation Task in a Logistic Regression Model

Predictors B SE Wald test p OR  (95% CI)
1. Child interview count of avoidance solutions 1.24 .48 6.65 .01* 0.88  (0.76, 1.72)
2. Parent interview count of avoidance solutions –0.15 .55 0.07 .79 0.86  (–0.70, 0.40)
3. Discussion—Child count of avoidance solutions 1.13 .51 4.86 .03* 3.10  (0.62, 1.64)
4. Discussion—Parent count of avoidance solutions –0.13 .67 0.04 .85 3.46  (–0.80, 0.54)
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Note. N = 95;

*

p < .05.

Predictors 1 and 2 were entered in Step 1 of the regression, and predictors 3 and 4 in Step 2.

Structural Model

We used a structural model to examine hypothesis 2—that parent self-reported coping assistance would predict child self-reported avoidance coping in the months after the traumatic injury. Standardized regression coefficients (β) and standard errors are reported in Figure 2. Table I includes descriptive information and zero-order correlations among all variables. The cross-lagged panel model demonstrated good fit: χ2 (22, N = 96) = 20.98, p = .52; CFI = 1.00; RMSEA = .00 with a 90% confidence interval of .00 and .08. Neither child age, child sex, parent relationship, nor injury severity were significantly associated with T1 avoidance coping or T1 parent avoidance coping assistance. As shown in Figure 2, there was only a significant concurrent relation between parent avoidance coping assistance and child avoidance coping at T2 (p = .01). Child avoidance coping demonstrated stability across time points with significant paths from T1 to T2 and from T2 to T3 (p’s < .001). Parent avoidance coping assistance also demonstrated stability across time points (p’s ≤ .001). After taking stability of child avoidance coping into account, parent avoidance coping assistance at T1 predicted subsequent child avoidance coping at T2 (p < .001). However, T2 parent avoidance coping assistance did not predict T3 child avoidance coping (p = .99). Of note, alternative models were run to examine the possibility that child coping predicts parent coping over time. While this model demonstrated that parent coping predicted child coping, as supported by the present study, child coping did not predict parent coping. Notably, results were consistent even when paths from parents to children were omitted.

Figure 2.

Figure 2.

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Cross-lagged panel model for examining prospective associations between parent self-reported avoidance coping assistance (i.e., parent encouragement of avoidance coping) and child self-reported avoidance coping. Standardized coefficients are presented. Child sex, parent relationship, injury severity, and child age were included as covariates of exogenous variables.Note. *p < .05; **p < .01; ***p < .001.

Discussion

The current study presents novel data regarding influences on children’s use of avoidance coping after experiencing a traumatic injury. To the authors’ knowledge, this is among the first studies of children’s avoidance coping utilizing a mixed methods approach, integrating data from a parent-child interaction task as well as longitudinal data over the course of 12 weeks post-injury. Data suggest that when presented with an ambiguous situation in an observational interview and discussion task, the number of avoidance coping solutions offered by children independently as well as during a discussion with their parent predicted the child’s ultimate avoidance versus non-avoidance coping choice. Contrary to our hypothesis, the number of avoidance coping solutions offered by parents during the discussion did not predict the children’s final choice to use avoidance coping. Self-reported longitudinal data suggest that parent encouragement of avoidance coping predicted subsequent child avoidance coping across 6-weeks post-trauma, but not from 6-weeks to 12-weeks posttrauma. Our results shed more light on the development of avoidance coping in trauma-exposed children. Results were consistent with prior work demonstrating parent influence on children’s interpretations and reactions to novel situations (Barrett et al., 1996; Creswell et al., 2011; Remmerswaal et al., 2013, 2016), but also suggest that children may sometimes make autonomous coping decisions.

Our finding that the number of avoidance coping strategies offered by parents during the TAST was not associated with their child’s choice of an avoidance coping strategy was surprising. Prior research suggests that parent interactions influence children’s interpretations of ambiguous stimuli and engagement in avoidant behaviors (e.g., Barrett et al., 1996; Remmerswaal et al., 2013). Several factors may have influenced this finding. For instance, it is possible that the timing of the interaction task contributed to these differences, as the TAST was completed during the peri-trauma period in the hospital. Coping outside of the hospital in daily life may differ from the acute, peri-trauma context, which the TAST may have captured. Another difference between current study findings and past research is the nature of the samples studied: for example, Barrett et al. (1996) examined children with anxious or aggressive presentations. Remmerswaal et al. (2013, 2016) recruited child participants from local schools. Our sample may have unique characteristics in that it was comprised of children hospitalized after an injury.

In examining the differences in findings from the observational TAST compared to the longitudinal, self-report assessments (i.e., parent avoidance coping assistance did not appear to influence children’s coping choice in the TAST, but parent self-reported avoidance coping assistance predicted child self-reported avoidance coping concurrently and prospectively from baseline to 6 weeks post-trauma), it is possible that the TAST may be assessing a different component of avoidance coping. For instance, the TAST involves opportunities to brainstorm potential coping responses in real-time, whereas self-reports rely on retrospective report over several weeks. Additionally, the TAST was not specific to the injury, whereas the self-report measures specifically assessed injury-related coping. The TAST also asks children and parents to offer and select strategies that they would use in a hypothetical situation, as opposed to self-report measures that ask individuals to reflect on what they actually used. Another important consideration is that perhaps the influence of parent encouragement of avoidance coping strengthens or unfolds over time and is not captured by peri-trauma assessment. In any case, the TAST results provide preliminary evidence children may act as agents of their own coping and may not respond solely in response to parental suggestion within the peri-trauma period. This finding is encouraging for situations where parents promote avoidance coping, or if providers have access to the child only (e.g., school-based interventions). Interventions that focus on the child, such as Coping Coach (Kassam-Adams et al., 2016; Marsac et al., 2013b), may facilitate recovery despite limited guidance from parents.

In the event that parents are available to facilitate their child’s coping after injury, research supports the potential role of parents. In their bio-psycho-social model for the development of child PTSD, Marsac et al. (2014) proposed that early (i.e., peri-trauma) and continued (post-trauma) parent coping assistance may impact early and continued child coping after injury, which can then lead to persistent PTSS. The present study partially supports this notion, providing evidence that within the first six weeks after a trauma, parents may influence their child’s use of avoidance coping by encouraging children not to think about the event, distracting themselves from thoughts or emotions related to the event, imagining that the situation is better, and leaving or staying away from stressful situations or problems. This finding supports other research that has demonstrated the influence of parent encouragement of avoidance coping on child avoidance coping and PTSS (Hiller et al., 2018). Contrary to hypothesis 2, the association between parent avoidance coping assistance and child avoidance coping was not maintained at the 12-week follow-up. This finding highlights the potential importance of the early post-trauma period for promoting adaptive coping. Taken together with past research, results suggest that parents may want to carefully consider how to best support their child following a potentially traumatic event, such as injury.

In addition to child-focused interventions, medical professionals may also want to consider parents when designing and implementing coping interventions. To ensure that parents are aware of their role in children’s recovery, medical teams may consider providing anticipatory guidance at the time of initial treatment for the injury about common reactions to trauma and adaptive coping strategies to promote awareness and knowledge about healthy coping. For instance, children are more likely to seek out help and use social support coping when parents are positively involved in recovery (Marsac et al., 2013a). Furthermore, research suggests that providing parents with information about potential emotional and behavioral alterations in their child after a hospitalization facilitates child recovery (Cox, Kenardy, & Hendrikz, 2010). However, evidence on adaptive coping remains mixed. For example, Hiller and colleagues (2018) and Marsac and colleagues (2017) found that parent encouragement of adaptive coping was neither helpful nor harmful. Thus, more research is needed to be able to optimize guidance provided to parents in how to best support their child.

Several study limitations should be noted in interpreting study findings. One limitation is potential self-selection in those who decided to participate; about one-third of those approached declined to participate (Marsac et al., 2017). Additionally, the TAST is a relatively new assessment tool; psychometric evidence from additional studies would strengthen our ability to generalize its findings. Variability in the children’s final coping choice during the TAST was also limited (i.e., 11 out of 95 children chose an avoidance coping solution). Other limitations include the small range of ISSs and the overall low base rate of avoidance coping as observed by the TAST. It is possible that parents and children with greater avoidance coping decided not to participate in the study, thus restricting the full range of observed avoidance. Future research with larger samples and greater variability of responses is warranted. Future research may also assess additional outcomes (e.g., psychological, physical, social) of children whose parents do and do not encourage avoidance coping as well as the mechanisms (e.g., appraisals) that influence children’s coping decisions. It is also important for future research to consider how these findings may differ across phase of child development, perhaps incorporating the importance of peer groups on coping for adolescents, and household make-up to understand the role of other sources of support (e.g., another parent, family member) who may encourage or discourage avoidance coping. Additional research can provide a larger picture about the development, use, and implications of avoidance coping in children and allow us to test whether there is a compounding effect of long-term avoidance coping and parent encouragement of avoidance coping on emotional and physical health outcomes in children with injury versus time-limited encouragement of avoidance coping (e.g., during the peri-trauma period only).

The present study found support for the role of parent peri-trauma and post-trauma coping assistance, specifically as it relates to the promotion of avoidance coping. Results also suggest that children may autonomously engage in avoidance coping. Given that avoidance is associated with negative health outcomes (Compas et al., 2012), and may be critical in the development and maintenance of PTSD in children (Marsac et al., 2013a, 2016, 2017; Stallard et al., 2001), it is important to understand the mechanisms by which children learn to use avoidance. Our study suggests that the development of child avoidance coping is multifaceted. Targeting early avoidance coping at both the individual (child) and familial (parental) levels may thus prove to be helpful in reducing associated negative psychological outcomes (e.g., PTSD). These findings support the importance of treatment approaches, such as trauma-informed cognitive behavioral therapy (for a review, see Dowd & McGuire, 2011), that target avoidance and involve both children and their parents in order to promote healthy and adaptive recovery from pediatric injury.

Funding

This work was supported by a Mentored Career Award grant 1K23MH093618-01A1 from the National Institute of Mental Health (PI: Marsac). The authors declare that they have no competing or potential conflicts of interest.

Footnotes

1

One observation was removed due to being an overly influential variable (i.e., Cook’s distance of 2.25). Therefore, the logistic regression utilized a sample of 95.

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