The Vermont Family Based Approach: Family Based Health Promotion, Illness Prevention, and Intervention

Widening Our Lane: How Child and Adolescent Psychiatrists Can Embrace the Full Spectrum of Mental Health

The majority of a psychiatrist's training and clinical attention is devoted to mental illness rather than mental health. This article suggests a broader understanding and application of mental well-being that can benefit both those already struggling with mental health challenges and those trying to stay well. Recommendations for being a well-being-oriented psychiatrist include increasing one's knowledge about well-being and health promotion and adjusting one's practice to incorporate these principles. Recommendations at the level of the field of psychiatry include revising the definition of a psychiatrist, increasing research on well-being and health promotion, improving financial incentives, expanding efforts in schools and community settings, and providing additional training.

A Pilot Randomized Controlled Trial of the Family Assessment and Feedback Intervention (FAFI): Effects on Mental Health Literacy and Attitudinal Engagement with Health Supports and Services

This randomized controlled trial tested the Family Assessment and Feedback Intervention (FAFI), a new intervention to enhance family engagement with emotional and behavioral health services. The FAFI is a guided conversation with families about results of their multidimensional assessment that is set in the context of motivational enhancement. It differs from other assessment-with-feedback interventions by extending the focus of assessment beyond the target child to parents and the family environment, addressing parental emotional and behavioral problems and competencies, spanning a broad range of children's and parents' strengths and difficulties, and being generalizable to many settings and practitioners. Participants were 81 families in primary care pediatrics. The FAFI was associated with a significant increase in parental mental health literacy and with an increase in parental attitudinal engagement with health supports and services that closely approached statistical significance (p = .052), while controlling for children's age and gender and family socioeconomic status.

Family-Based Treatment for Anxiety, Depression, and ADHD for a Parent and Child

Children with mental illness commonly live with caregivers who suffer from mental illness. Integrated mental-health-treatment approaches can provide more convenient and comprehensive care for families. This case report describes family-based treatment (FBT) for one parent/child dyad. The parent was a 37-year-old female with a history of anxiety and major depressive disorder and concern for symptoms of attention-deficit/hyperactivity disorder (ADHD). The child was an 8-year-old female with generalized anxiety disorder and concern for ADHD and behavioral problems. The parent received individual cognitive behavioral therapy (CBT) and parent management training. The child received CBT. Both also received medication management. The FBT team met regularly for coordinated treatment planning. Self-reported assessments via the Child Behavior Checklist showed meaningful improvement; anxiety decreased to nonclinical range week 12 and depression decreased to nonclinical range week 8. Clinician assessments showed improvement for both patients. Though more time intensive, FBT can yield significant improvement, particularly for children. Pragmatic approaches to treatment planning are important to minimize barriers to FBT.

The Vermont Family Based Approach in Primary Care Pediatrics: Effects on Children's and Parents' Emotional and Behavioral Problems and Parents' Health-Related Quality of Life

This randomized controlled trial tested the Vermont Family Based Approach (VFBA) in primary care pediatrics. The VFBA is a model of healthcare delivery that shifts the focus from the individual to the family, emphasizes emotional and behavioral health, and uses evidence-based health promotion/prevention along with the treatment of emotional and behavioral problems. Participants were 81 families of 3-15-year-olds. For children, the VFBA was associated with greater reductions than the Control condition on the Child Behavior Checklist Emotionally Reactive, Withdrawn, Sleep Problems, Aggressive Behavior and Total Problems scales. For parents, the VFBA was associated with greater reductions than the Control condition on the Adult Self-Report Anxious/Depressed, Rule-Breaking Behavior, Internalizing Problems and Total Problems scales. The VFBA was also associated with greater improvement than the Control condition in the parents' health-related quality of life, as indicated by all scales of the Medical Outcomes Study Health Survey.

Details of Cancer Education Programs for Adolescents and Young Adults and Their Effectiveness: A Scoping Review

The purpose of this review was to establish what cancer education programs have been carried out aimed at adolescents and young adults (AYAs) and what outcomes they achieved. The databases used were MEDLINE, CINAHL, and Web of Science, and the search period was set as 2011-2020. The extracted literature was evaluated for quality using the Joanna Briggs Institute's critical appraisal tools. The subjects of the analysis were 29 studies: 10 randomized controlled trials and 19 quasi-experimental designs. Regarding the varieties of cancers found in the data, in descending order, 10 documents looked at cervical cancer, 9 looked at cancer in general, and 4 looked at breast cancer. Most studies focused on AYAs exclusively, with just three studies involving their parents simultaneously. Many studies used lecture-based intervention, with information technology-based interventions using websites and cell phones. Topics included in the program were cancer epidemiology, cancer risk factors, cancer warning signs and symptoms, prevention methods, and screening methods. After the intervention, all studies showed statistically significant improvements in at least one outcome measure, which included knowledge and awareness of cancer, health beliefs, and intent to take preventive action, demonstrating a basis for educational intervention. Educating AYAs about cancer at a time when their ways of life are becoming more concrete can be expected to have a positive impact on cancer preventing behaviors in adulthood, increase their parents' awareness of cancer, and have a positive impact on behavior around screening.

The impact of maternal depression on child mental health treatment and models for integrating care: a systematic review

Maternal depression negatively impacts child mental health and is a well-known risk factor for child psychopathology. However, maternal depression treatment and child mental health treatment are rarely integrated. The purpose of this review was to assess the impact of maternal depression on child mental health treatment, including (1) how treatment of maternal depression affects child mental health outcomes, (2) the impact of maternal depression on children receiving mental health care, and (3) emerging models that address maternal depression in primary-care pediatrics and child mental health settings. A systematic literature review was conducted using PubMed and PsycInfo. Initial search yielded 224 records, and after exclusion, 29 papers were reviewed. Effective treatment of maternal depression is associated with a significant decrease in child psychiatric symptoms. Maternal depression negatively affects child mental health treatment in that there is a high rate of untreated mental illness among mothers of psychiatrically ill children, and maternal depression impedes effective child mental health treatment. Current models to address maternal depression in child settings include screening in pediatric primary care, psychotherapy for depressed mothers of psychiatrically ill children, and emerging models that integrate maternal and child mental health treatment. Effective treatment of maternal depression significantly improves child mental health and should be better integrated into child treatment. Opportunities to improve care include more robust screening for parental mental illness, supports to refer parents to psychiatric care, and on-site services for parents. Such interventions hold promise, but require significant support from a multidisciplinary team.

A Pilot Trial of a Health Promotion and Illness Prevention Paradigm in the Perinatal Period

OBJECTIVES

This is a pilot study of the Vermont Family Based Approach, an innovative health promotion program designed to address behavioral health prevention in primary care, adapted for perinatal women. We aimed to determine the acceptability of the intervention across socioeconomic strata, and to identify if participation improves perinatal mental health.

METHODS

Recruitment occurred at a general obstetrics practice. Women 12-25 weeks gestation were paired with a wellness coach who administered a wellness assessment and used motivational interviewing to facilitate individualized plans based on evidence-based domains of health promotion. Participants were offered access to free, co-located wellness activities through the peripartum, and referred to behavioral health services if appropriate.

RESULTS

93 women consented; 16 Medicaid Insured women (MI) and 30 Privately Insured (PI) were randomized to the intervention. Of all activities, yoga and parenting activities were most appealing, with 58% of women attending. PI (M = 12.30, SD = 11.71) attended significantly more activities than MI (M = 3.81, SD = 12.30; p = .001). Trauma exposure was inversely associated with attendance (p = .004). Randomization to the intervention was not associated with improvements in internalizing symptoms or perceived stress at 12 months postpartum, however, attending three or more wellness activities was associated with a decrease in perceived stress between baseline and 12 months postpartum.

CONCLUSION

This program appeared acceptable and engaging to women with private insurance, but less so with Medicaid. The trial failed to demonstrate improvement in internalizing scores, but of those randomized to the intervention, higher engagement was associated with decreased stress one year after giving birth.

The Family is the Patient: Promoting Early Childhood Mental Health in Pediatric Care

Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children's mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent-child and family relationships, parents' emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.

Preventing the Onset of Anxiety Disorders in Offspring of Anxious Parents: A Six-Year Follow-up

This study examined the effects of a family-based intervention Coping and Promoting Strength (CAPS) relative to a control condition, information-monitoring (IM), to prevent the onset of anxiety disorders in offspring of anxious parents six years after their initial assessment. One hundred thirty six families participated in the original randomized trial; 113 (83%) completed the one time follow-up assessment. Presence of anxiety disorders and severity of symptoms in offspring were assessed by masked evaluators using the Anxiety Disorders Interview Schedule; parents and offspring also completed questionnaires assessing offspring anxiety. Using the intention to treat sample from the original trial, Cox regression models showed significant intervention main effects in the rate of onset of anxiety disorders from baseline to follow-up (anxiety disorder: hazard ratio (HR) = 2.55, 95% CI: 1.54, 4.21) but growth curves suggest effects occurred within the first year after program completion. No group differences were found in the cumulative incidence of anxiety disorders at the six-year follow-up. Additional intervention appears needed to maintain the initial positive effects long-term to reduce the risk for downstream disability.Clinical Trials Registration: NCT00847561.

The Parents Are Not Alright: A Call for Caregiver Mental Health Screening During the COVID-19 Pandemic

Nearly a year into the COVID-19 pandemic, conversations about the impact of COVID-19 on children and families have shifted. Initial advice for parents stressed topics such as how to talk about the pandemic with children or cope with illness-related distress. They now focus on youth adjustment to a heavily disrupted school year and on strategies for building long-term resilience. Although these conversations often center on youth adjustment, they have-at last-started to consider the well-being of parents (and other caregivers) as well. This shift in focus is crucial given the enormous challenges that parents face right now and the direct links between their well-being and that of their children. What continues to lag, even well into the pandemic, however, is the provision of workable solutions for addressing parents' mental health. While we applaud the renewed focus on parenting stress and well-being, we remain deeply concerned by the absence of a plan for intervening.

Accentuate the Positive: Strengths-Based Therapy for Adolescents

Purpose

The field of psychiatry has conventionally employed a medical model in which mental health disorders are diagnosed and treated. However, the evidence is amassing that using a strengths-based approach that promotes wellness by engaging the patient's assets and interests may work in synergy with the medical model to promote recovery. This harmonizes with the patient-centered care model that has been promoted by the Institute of Medicine.

Methods

The article uses a clinical case to highlight the attributes of a strength-based model in the psychiatric treatment of adolescents.

Results

Outcome metrics from a number of studies have demonstrated enhanced youth and parent satisfaction and decreased use of hospital level of care with the implementation of strengths-based therapeutic modalities.

Implications

Incorporating strengths-based interventions into conventional psychiatric practice provides a multi-faceted treatment approach that promotes recovery in children and adolescents with psychiatric disorders.

Comparing the genetic architecture of childhood behavioral problems across socioeconomic strata in the Netherlands and the United Kingdom

Socioeconomic status (SES) affects the development of childhood behavioral problems. It has been frequently observed that children from low SES background tend to show more behavioral problems. There also is some evidence that SES has a moderating effect on the causes of individual differences in childhood behavioral problems, with lower heritability estimates and a stronger contribution of environmental factors in low SES groups. The aim of the present study was to examine whether the genetic architecture of childhood behavioral problems suggests the presence of protective and/or harmful effects across socioeconomic strata, in two countries with different levels of socioeconomic disparity: the Netherlands and the United Kingdom. We analyzed data from 7-year-old twins from the Netherlands Twin Register (N = 24,112 twins) and the Twins Early Development Study (N = 19,644 twins). The results revealed a nonlinear moderation effect of SES on the contribution of genetic and environmental factors to individual differences in childhood behavioral problems. The heritability was higher, the contribution of the shared environment was lower, and the contribution of the nonshared environment was higher, for children from high SES families, compared to children from low or medium SES families. The pattern was similar for Dutch and UK families. We discuss the importance of these findings for prevention and intervention goals.

Better than Better: The New Focus on Well-Being in Child Psychiatry

Training and practice within child psychiatry has focused predominantly on mental illness rather than mental health. A growing body of evidence, however, is demonstrating the importance for clinicians also to be able to focus directly on enhancing positive traits and emotions and increasing well-being and health promotion in their patients. This complementary aspect of mental health care has been called well-being and positive psychiatry, among other terms. Being able to apply these principles to standard practice requires new knowledge, skills, and attitudes that are not part of traditional psychiatric training.

Where Do We Go from Here? Additional Opportunities to Address Well-Being in Child Psychiatry Clinical Practice and Advocacy for Children and Families

Child psychiatrists should play an active role in helping parents and children to develop healthy media use habits and can introduce uses of technology including mobile applications and telepsychiatry to enhance clinical care. Strength-based approaches in clinical assessment and treatment build patient and family engagement and enhance outcomes in child psychiatry. Focusing on supporting youths' strengths and enhancing emotional and behavioral well-being are critical strategies for child psychiatrists working in consultation with schools and other community settings, and in advocating for optimal environments for children and families.

The Neuroscience of Happiness and Well-Being: What Brain Findings from Optimism and Compassion Reveal

Increasing behavioral data support the value of developing positive traits and attitudes to promote mental health and human flourishing. A neuroscience approach to understanding the mechanisms of the key constructs of optimism and compassion is relevant toward improving identification and measurement of relevant traits, progress and barriers to cultivating these traits, and identifying which mental health-promoting practices are most effective in promoting growth of optimism and compassion.

Health Promotion in Primary Care Pediatrics: Initial Results of a Randomized Clinical Trial of the Vermont Family Based Approach

The Vermont Family Based Approach (VFBA) is an innovative approach to healthcare delivery that addresses challenges of the healthcare system in the United States. The authors conducted a randomized controlled trial of the VFBA at a primary care pediatric clinic. The goal of the trial was to test the feasibility of the VFBA in pediatrics and to improve healthcare engagement and health outcomes for families. This article presents initial results of the trial on feasibility and engagement. The VFBA was found feasible and was associated with a significant increase in engagement with health and wellness supports and services.

Parental Psychiatric Symptoms and Children's Outcomes: Toward Understanding and Responding to Intergenerational Risk in Child Psychiatry

Family history of psychiatric illness is a core feature of any competent clinical history taken in a child and adolescent psychiatry clinical setting, and this history is often limited to reviewing caregivers' reports of diagnosed or suspected mental disorders in biological parents and relatives across several generations. Less commonly included is a detailed inquiry into parents' and caregivers' current mental health, including psychiatric symptoms at the time that their child is presenting for evaluation. Recent evidence is a strong reminder that parental mental illness is an important adversity that critically affects lifelong mental well-being in offspring, and that maternal depression in particular is an established factor influencing offspring mental health.^1-3 In this issue of the Journal, Wesseldijk et al. present their article "Do Parental Psychiatric Symptoms Predict Outcome in Children With Psychiatric Disorders? A Naturalistic Clinical Study," an effort to examine relationships between parental psychiatric symptoms and clinical outcomes in child psychiatric patients.⁴ The study moves beyond a focus on maternal depression as a risk factor for offspring psychopathology to include a range of active psychiatric symptomatology in both mothers and fathers at the time that children are presenting for clinical evaluation, and again at follow-up over a year and a half later.

Childhood aggression: A synthesis of reviews and meta-analyses to reveal patterns and opportunities for prevention and intervention strategies

This study provides a synthesis of meta-analyses and systematic reviews on non-pharmacological treatments for childhood aggression. Treatments referred to universal prevention, selective prevention, indicated prevention, or intervention (Mrazek and Haggerty, 1994). Seventy-two meta-analyses and systematic reviews met the inclusion criteria. We describe their characteristics, effect sizes across types of treatments, and the effects of various moderators. For universal and selective prevention, effects were mostly absent or small; for indicated prevention and interventions, effects were mostly small or medium. Only two moderators had a positive effect on treatment effectiveness, namely pre-test levels of aggression and parental involvement. These results identified similarities between indicated prevention and intervention treatments, on the one hand, and universal prevention and selective prevention, on the other. Our findings suggest that research distinguishing between targets of treatments (i.e., factors associated with childhood aggression vs. present aggressive behaviors) would be promising. Moreover, to further increase effectiveness of treatments for childhood aggression, individual differences warrant scientific attention.

The Future of Preschool Prevention, Assessment, and Intervention

Preschoolers are in the most rapid period of brain development. Environment shapes the structure and function of the developing brain. Promoting brain health requires cultivation of healthy environments at home, school, and in the community. This improves the emotional-behavioral and physical health of all children, can prevent problems in children at risk, and can alter the trajectory of children already suffering. For clinicians, this starts with assessing and treating the entire family, equipping parents with the principles of parent management training, and incorporating wellness prescriptions for nutrition, physical activity, music, and mindfulness.

Neuroscience-Inspired, Behavioral Change Program for University Students

It is clear that environmental influences impact the structure and function of the human brain, and thus, thoughts, actions, and behaviors. These in turn influence whether an individual engages in high-risk (drugs, alcohol, violence) or health-promoting (exercise, meditation, music) activities. The developmental mismatch between cortical and subcortical maturation of the transitional age brain places college students at risk for negative outcomes. This article argues that the prescription of incentive-based behavioral change and brain-building activities simply make good scientific, programmatic, and financial sense for colleges and universities. The authors present University of Vermont Wellness Environment as an example.