Depressive symptoms among primary caregivers of children with mental health needs: mediating and moderating variables

A systematic review of the measurement properties of the Family Empowerment Scale

PURPOSE

To systematically review and evaluate existing psychometric evidence for the Family Empowerment Scale (FES), which has been widely used to measure empowerment across the world.

METHODS

Three databases were searched up until December 2021. Eligible studies were identified by an interdisciplinary team using the PRISMA procedure. The methodological quality of psychometrics (Risk of Bias standards) and sufficiency of each psychometric property (e.g., reliability, content validity, construct validity, responsiveness) were independently evaluated by three members, following COnsesus-based Standards for the selection of health Measurement INstruments (COSMIN).

RESULTS

Twelve studies involving 3278 caregivers were included in the review. Studies reported limited information about content validity and study sample characteristics. There is sufficient evidence with moderate methodological quality to support structural validity for a four and three-bifactor structure. Sufficient evidence with good methodological quality was found for internal consistency. No studies examined responsiveness.

CONCLUSIONS

Future psychometric studies of the FES should include diverse families and establish content validity following current COSMIN standards. Structural validity evidence does not support the original three-factor structure, which suggests the need to refine the theoretical measurement constructs. Responsiveness is needed prior to using FES as an instrument of change in applied research studies.Implications for RehabilitationThe evidence for the use of the Family Empowerment Scale (FES) is primarily with families of children with disabilities who identify as white, non-Hispanic, and live in the US.Across studies, evidence suggests the FES items work well together to measure family empowerment.Caution should be used when using the FES to measure changes in empowerment over time.

Parenting stress mediates the longitudinal effect of maternal depression on child anxiety/depressive symptoms

BACKGROUND

Evidence is lacking for the longitudinal bidirectional relationship between maternal depression and child anxiety/depressive symptoms through pre-school to adolescence and regarding parenting stress as having a mediating effect on this association.

METHODS

We performed a secondary analysis of data from the Fragile Families and Child Well-being Study (n = 1,446 child-mother dyads in 20 main U.S. cities) collected at baseline, Year-5 (T1), Year-9 (T2) and Year-15 (T3) (from 1998 to 2017). Maternal depression, child anxiety/depressive symptoms and parenting stress were assessed at three time points (T1-T3). The associations were evaluated using autoregressive cross-lagged panel models.

RESULTS

Cross-lagged models indicated that 1) maternal depression significantly predicted subsequent higher child anxiety/depressive symptoms across all time points, and 2) greater child anxiety/depressive symptoms significantly predicted subsequent maternal depression across all time points. Furthermore, T1 maternal depression was indirectly associated with T3 child anxiety/depressive symptoms via T2 parenting stress [b = 0.010 (SE=0.004), p = 0.017]. However, T2 parenting stress did not significantly mediate the association between T1 child anxiety/depressive symptoms and T3 maternal depression [b = 0.004 (SE=0.004), p = 0.256].

LIMITATIONS

The FFCWS oversampled unmarried parents and had a higher proportion of socio-economically disadvantaged racial and ethnic minority families, limiting the generalizability of findings.

CONCLUSIONS

Maternal depression is indirectly linked to child anxiety/depressive symptoms via parenting stress.

The longitudinal relationship between child emotional disorder and parental mental health in the British Child and Adolescent Mental Health surveys 1999 and 2004

BACKGROUND

Research suggests parental psychopathology has an adverse effect on child mental health. However, due to the interactional nature of parent-child relationships and with a high rate of emotional disorders reported in school-age children, it is important to know whether the effect is reciprocal.

METHODS

We explored the longitudinal relationship between child and parent mental health in the British Child and Adolescent Mental Health Surveys (N=7,100 child-parent dyads) and their three-year follow-ups. The Development and Well-Being Assessment with DSM-IV diagnostic criteria was used to measure child psychiatric diagnoses, while parental mental health was assessed using the General Health Questionnaire. Multivariable logistic regression was used to explore the longitudinal association between child emotional disorder and parent mental health.

RESULTS

Parents of children who had an emotional disorder at baseline were more likely to have poor mental health three years later compared with parents whose children had no psychiatric diagnosis (33.3% versus 16.7%; crude odds ratio=2.52; adjusted odds ratio=2.19, 95% CI=1.58 to 3.05, p<0.001). Children of parents with poor mental health at baseline were more likely to develop an emotional disorder three years later compared with children whose parents had good mental health (5.2% versus 2.5%; crude odds ratio=2.08; adjusted odds ratio=1.63, 95% CI=1.18 to 2.25, p=0.003).

LIMITATIONS

The findings of this research are limited by the survey data collected, the measures used and survey dropout.

CONCLUSIONS

We detected a bi-directional relationship between child and parent mental health, suggesting that effective intervention for one individual may benefit other family members.

Depression and associated factors among primary caregivers of children and adolescents with mental illness in Addis Ababa, Ethiopia

BACKGROUND

Mental illnesses among children and adolescents are under-recognized and under-treated problems. Depression is one of today's all-too-silent health crises in caregivers. Although primary caregivers of children and adolescents with mental illness are more frequently depressed, little attention is being given to the problem in Ethiopia. Thus, this study aimed to assess prevalence of depression and associated factors among primary caregivers of children and adolescents with mental illness in Ethiopia.

METHODS

Institution-based cross-sectional study was conducted among primary caregivers of children and adolescents with mental illness in Ethiopia. Systematic random sampling was used to recruit a total of 416 study participants. Patient Health Questionnaire-9 was used to measure depression. After descriptive statistics was conducted, binary logistic regression was employed to carry out bivariate and multivariate analysis.

RESULT

The overall prevalence of depression was 57.6% with 95% CI (53, 62.7). The prevalence of depression among female primary caregivers was 64.6% (n = 181). Female sex (AOR = 2.4, 95% CI: 1.18,4.89), duration of care > 5 years (AOR = 4.2, 95% CI: 2.02,8.70), absence of other caregiver (AOR = 2.7, 95% CI: 1.41,5.34), being mother (AOR = 3.9, 95% CI: 1.90,8.04), autistic spectrum disorder (ASD) (AOR = 4.7, 95% CI: 2.06,10.54) and attention deficit /hyperactivity disorder (ADHD) (AOR = 5.3, 95% CI: 2.14,13.23) diagnosis of children and adolescents and poor social support (AOR = 5.5, 95% CI: 2.04,15.02) were associated with depression.

CONCLUSION

The prevalence of depression among primary caregivers of children and adolescents with mental illness attending treatment in St. Paul's hospital millennium medical college (SPMMC) and Yekatit-12 hospital medical college (Y12HMC) was high. Therefore, it needs to screen and treat depression in primary caregivers of children and adolescents having follow-up at child and adolescent clinics especially for those primary caregivers who are female, mother, gave care for > five years, have no other caregiver, have children diagnosed with ASD and ADHD and have poor social support.

Developing a Multiple Caregiver Group for Caregivers of Adolescents With Disruptive Behaviors

This article describes the development of a 6-week multiple caregiver group intervention for primary caregivers of adolescents diagnosed with Oppositional Defiant Disorder or Conduct Disorder in low-income African American families. The intervention is aimed at increasing the primary caregivers' self-efficacy in managing interactions within the family and especially with child serving educational, mental health, juvenile justice, and child welfare systems. Development of the intervention involved seven iterative activities performed in a collaborative effort between an interdisciplinary academic team, community engagement specialists, members of the targeted population, and clinical partners from a large public mental health system. The intervention development process described in this article can provide guidance for teams that aim to develop new mental health interventions that target specific outcomes in populations with unique needs.

Impact of Mid-Life Symptoms of Alcoholism on the Health and Wellbeing of Aging Parents of Adults with Disabilities

The study examined the effect of adult children's disability on parents' physical health in later life and the extent to which parents' symptoms of alcoholism in mid-life moderates the link between children's disability and later life parental health. Analyses are based on data from the Wisconsin Longitudinal Study. The analytic sample included parents of children with developmental disabilities (n = 145) or mental health problems (n = 200) and 2,432 parents of unaffected children. The results showed that the negative health consequences in later life of having a child with a developmental disability were greater for those who showed more symptoms of alcoholism in mid-life. However, symptoms of alcoholism in mid-life did not significantly moderate the impact of an adult child's mental health problems on parents' later life physical health. The findings suggest a potential area where gerontological social workers could intervene, given the negative impact of symptoms of alcoholism on the health of aging parents of children with a disability who may be significantly more susceptible to the negative health impacts of alcohol compared to their younger counterparts.

The Utility of the Family Empowerment Scale With Custodial Grandmothers

The Family Empowerment Scale (FES) was developed specifically to assess empowerment in families with emotional disorders. Its relevance to custodial grandfamilies is reflected in the difficulties in grandchildren's social, emotional, and behavioral functioning, wherein such difficulties may be explained via either reactions to changes in their family structure or in their responses to the newly formed family unit. Utilizing 27 items derived from the 34-item version of the FES, which had represented differential levels of empowerment (family, service system, community) as indexed by one's attitudes, knowledge, and behavior, we explored the factor structure, internal consistency, construct, and convergent validity of the FES with grandparent caregivers. Three-hundred forty-three ( M age = 58.45, SD = 8.22, n Caucasian = 152, n African American = 149, n Hispanic = 38) custodial grandmothers caring for grandchildren between ages 4 and 12 years completed the 27 FES items and various measures of their psychological well-being, grandchild psychological difficulties, emotional support, and parenting practices. Factor analysis revealed three factors that differed slightly from the originally proposed FES subscales: Parental Self-Efficacy/Self-Confidence, Service Activism, and Service Knowledge. Each of the factors was internally consistent, and derived factor scores were moderately interrelated, speaking to the question of convergent validity. The construct validity of these three factors was evidenced by meaningful patterns of statistically significant correlations with grandmothers' psychological well-being, grandchild psychological difficulties, emotional support, and parenting practices. These factor scores were independent of grandmother age, health, and education. These findings suggest the newly identified FES factors to be valuable in understanding empowerment among grandmother caregivers.

Difficulties of familes in caring for children and adolescents with mental disorders: an integrative review

Objective To identify the difficulties of families with children and/or adolescents with mental disorder. Method This is an integrative review. In December 2013, an electronic search was performed on Latin American Caribbean Literature on Health Sciences databases (LILACS) and on Electronic Medicus Index of the National Library of Medicine (MEDLINE) indexed in the Health Virtual Library (BVS) using a combination of descriptors and boolean operators as follows: mental disorders and child or adolescent and caregivers and/not health staff. Results 557 studies were identified, of which 15 were selected for this study. The findings indicated difficulties related to the care for or to interaction with children/adolescents with mental disorder. Conclusion The studies revealed difficulties related to everyday practices of care and feelings expressed during care practices, as well as in relationships with children or adolescents with mental disorder.



The validity and reliability of the Finnish Family Empowerment Scale (FES): a survey of parents with small children

BACKGROUND

The Family Empowerment Scale (FES) is a widely used instrument which measures the parents' own sense of their empowerment at the level of the family, service system and community. It was originally developed for parents of children with emotional disabilities.

AIM

The aims of this study were to evaluate the validity and reliability of the Finnish FES and to examine its responsiveness in measuring the empowerment of parents with small children.

METHODS AND PARTICIPANTS

The English FES was translated into Finnish using back translation and modified so as to be generic and convenient for all families. The construct, convergent, discriminant and concurrent validities, reliability and responsiveness of the Finnish FES were examined. Participants (n = 955) were the parents of children aged 0-9 years who had been selected using stratified random sampling.

RESULTS

Confirmatory factor analysis proved that the Finnish FES had three subscales based on the original FES. Convergent and discriminant validities confirmed and supported the same construct. The relationship between parents' participation and empowerment was tested for concurrent validity. As in previous FES studies, the participating parents were more empowered, which supported the concurrent validity. The reliability of the Finnish FES proved acceptable for both parents. The Finnish FES could also discriminate the responses of the parents. Participation in the activities organized by the family service system influenced parents' perceptions of empowerment more than did their background characteristics.

CONCLUSIONS

The Finnish FES is a valid and reliable instrument and it is suitable for measuring the empowerment of parents. However, it is necessary to consider how the FES would identify in the best way the parents who perhaps need some help.

Problem-solving intervention for caregivers of children with mental health problems

Building Our Solutions and Connections (BOSC) focused on enhancing problem-solving skills (PSS) of primary caregivers of children with mental health problems. Aims were determining feasibility, acceptability, and effect size (ES) estimates for depression, burden, personal control, and PSS.

METHODS

Caregivers were randomized to BOSC (n=30) or wait-list control (WLC) groups (n=31). Data were collected at baseline, post-intervention, and 3 and 6 months post-intervention.

RESULTS

Three-months post-intervention, ES for burden and personal control were .07 and .08, respectively. ES for depressed caregivers for burden and personal control were 0.14 and 0.19, respectively.

CONCLUSIONS

Evidence indicates that the intervention had desired effects.

Recruitment strategies for caregivers of children with mental health problems

PURPOSE

The aim of this study was to describe strategies for recruiting participants into an intervention study that focused on improving problem-solving skills in caregivers of children with mental health problems.

BACKGROUND

Caregivers of children with mental health problems report feeling physically and psychologically overwhelmed and have high rates of depression because of the demands of caregiving. Research on the needs of these caregivers and interventions to ameliorate their stress is needed. However, recruiting this population can be particularly difficult because of the stigma of mental illness. Available literature on recruitment of caregivers of persons with physical illness cannot be transferred to caregivers of children with mental health problems because of the different caregiving situations. There is a need to identify effective recruitment strategies to reduce cost and answer research questions. Clinical nurse specialists have the skills to facilitate the recruitment of research participants. We revised and expanded health system referrals, community outreach, and recruiting advertisement (ads). When these strategies did not increase recruitment, radio ads were used. The Andersen's Behavioral Model of Health Services Utilization was selected as a guiding framework.

OUTCOME

Radio ads were the most effective strategy for recruiting caregivers of children with mental health problems for this study.

CONCLUSION

Recruitment was ultimately successful because we were flexible and made decisions consistent with the Andersen's Behavioral Model of Health Services Utilization.

IMPLICATIONS

Clinical nurse specialists who study this population of caregivers should really consider the use of radio ads and systematically track which recruitment strategies lead to the greatest number of participants screened, eligible, and enrolled into studies.

The impact of child problem behaviors of children with ASD on parent mental health: the mediating role of acceptance and empowerment

Raising a child with an autism spectrum disorder (ASD) has often been associated with higher levels of parenting stress and psychological distress, and a number of studies have examined the role of psychological processes as mediators of the impact of child problem behavior on parent mental health. The current study examined the relations among child problem behavior, parent mental health, psychological acceptance, and parent empowerment. Participants included 228 parents of children diagnosed with ASD, 6-21 years of age. As expected, psychological acceptance and empowerment were negatively related to the severity of parent mental health problems. When acceptance and empowerment were compared with each other through a test of multiple mediation, only psychological acceptance emerged as a significant partial mediator of the path between child problem behavior and parent mental health problems. As child problem behavior increased, parent psychological acceptance decreased, resulting in an increase in parent mental health problems. These findings suggest that for problems that are chronic and difficult to address, psychological acceptance may be an important factor in coping for parents of young people with ASD, in line with the growing literature on positive coping as compared with problem-focused coping.

Maternal Depressive Symptoms When Caring for a Child with Mental Health Problems

As primary caregivers of children with mental health problems, mothers face challenges that put them at risk for depression, which is rarely identified or addressed. The aims of this paper were to (a) identify mean differences among demographic, stressor, threat, and resource variables specified in a theoretical model and thought to be associated with maternal depressive symptoms and (b) determine how much variability in depressive symptoms is explained by these variables. High levels and prevalence of depressive symptoms were found within a quality of life study that these data were drawn from. Of 139 mothers participating in this study, 58% had a score of 16 or greater on the CES-D indicating moderate to high levels of depressive symptoms. Significant differences were found between mothers with higher versus lower levels of depressive symptoms for 11 of the 18 variables. Hierarchical regression was used to examine the variance explained in depressive symptoms based upon the conceptual model with 4 composite variables. Income (step 1), behavioral problems (step 2), threat appraisal (step 3), and resource appraisal (step 4) combined explained 42% of the variance.

Dynamic associations between maternal depressive symptoms and adolescents' depressive and externalizing symptoms

The current prospective study investigated transactional relations between maternal depressive symptoms and children's depressive and externalizing symptoms. Participants included 240 children (M age = 11.86 years, SD = 0.56; 53.9% female) and their mothers who were part of a 6-year longitudinal study. Measures of maternal depression (Beck Depression Inventory), child depression (Children's Depression Inventory), and children's externalizing symptoms (Youth Self-Report Form) were assessed annually. Data analyses using dynamic latent difference score structural equation models indicated that the observed relations between mothers' and adolescents' symptoms were stable across the 6 years. Higher levels of maternal depressive symptoms predicted subsequent elevations in children's depressive symptoms and in their externalizing problems over time. Among mothers with high initial levels of depression, children's depressive symptoms predicted subsequent declines in mothers' depressive symptoms. Children's externalizing problems were not related to subsequent change in maternal symptoms.