Mental health promotion and prevention interventions in families with parental depression: A randomized controlled trial

Family Talk versus usual services in improving child and family psychosocial functioning in families with parental mental illness: a randomised controlled trial and cost analysis

Background

Parental mental illness (PMI) is common and places children at high risk of developing psychological disorders. Family Talk (FT) is a well-known, whole-family, 7-session intervention designed to reduce the risk of transgenerational psychopathology. However, very few larger-scale evaluations of FT (across only a limited number of settings) have been conducted to date while there have been no cost analyses. This study aimed to assess the effectiveness and costs of delivering FT in improving child and family psychosocial functioning in families with PMI within routine mental health settings.

Methods

A total of 83 families with PMI, with children aged 5-18 years, were randomly assigned on a 2:1 ratio to receive either the FT intervention (n=55 families) or usual services (n=28 families) across 10 adult, child and primary care mental health sites in Ireland. Parental disorders included anxiety/depression (57%), Bipolar Disorder (20%), Borderline Personality Disorder (12%), Post-Traumatic Stress Disorder (8%) and psychosis (2%). Detailed assessments with parents were conducted at baseline and 6-month follow up.

Results

FT led to significant improvements in family functioning and child behaviour at 6-month follow up when compared to usual services, with medium effect sizes indicated. Parent participants with lower mental health literacy at baseline also showed significant post-intervention improvements. Those parents with less severe mental illness at baseline, and families with more partner and economic supports, reported additional significant post-intervention improvements in child depression/anxiety and parental mental health symptoms. The cost of FT amounted to €761.50 per family, although this decreased to €415.31 when recurring costs only were included.

Conclusion

The findings from this study, which was conducted within the context of a national programme to introduce family-focused practice in Ireland, demonstrate that FT is a low-cost intervention that improved child and family psychosocial functioning across different mental health disorders within routine adult, child and primary care mental health services. The findings contribute to the growing evidence base for FT, and provide a robust basis to inform practice and policy development for families with parental mental illness both in Ireland and elsewhere.

Clinical trial registration

https://www.isrctn.com/ISRCTN13365858, identifier ISRCTN13365858.

Exposure to parental depression in adolescence and proinflammatory phenotypes 20 years later

Although the biological embedding model of adversity proposes that stressful experiences in childhood create a durable proinflammatory phenotype in immune cells, research to date has relied on study designs that limit our ability to make conclusions about whether the phenotype is long-lasting. The present study leverages an ongoing 20-year investigation of African American youth to test research questions about the extent to which stressors measured in childhood forecast a proinflammatory phenotype in adulthood, as indicated by exaggerated cytokine responses to bacterial stimuli, monocyte insensitivity to inhibitory signals from hydrocortisone, and low-grade inflammation. Parents reported on their depressive symptoms and unsupportive parenting tendencies across youths' adolescence. At age 31, youth participants (now adults) completed a fasting blood draw. Samples were incubated with lipopolysaccharide and doses of hydrocortisone to evaluate proinflammatory processes. Additionally, blood samples were tested for indicators of low-grade inflammation, including IL-6, IL-8, IL-10, and TNF-α, and soluble urokinase plasminogen activator receptor. Analyses revealed that parental depression across youths' adolescence prospectively predicted indicators of proinflammatory phenotypes at age 31. Follow-up analyses suggested that unsupportive parenting mediated these associations. These findings suggest that exposure to parental depression in adolescence leaves an imprint on inflammatory activity that can be observed 20 years later.

'Let's Talk About Children' family focused practice for children of parents with schizophrenia and bipolar disorder: protocol for a randomized controlled trial

INTRODUCTION

'Let's Talk About Children' is a brief family focused intervention developed to improve mental health outcomes of children of parents with mental illness (COPMI). This study aims to assess the efficacy of LTC in improving mental health of children of parents with schizophrenia or bipolar disorder in China.

METHODS

The planned study is a multicentre parallel group randomized wait-list controlled trial. A total of 400 eligible families with children aged 8 to 18 years will be recruited, 200 each for families with parental schizophrenia or bipolar disorder. The intervention group will receive Let's Talk About Children delivered by a trained therapist, while the control group will receive treatment as usual. The primary outcomes are child mental health measured by the strengths and difficulties questionnaire and parent-child communication measured using the parent-adolescent communication scale. Parental mental health and family functioning are secondary outcomes. This study also plans to explore mediating factors for the effect of Let's Talk About Children on child mental health, as well as conduct a cost-effectiveness analysis on using Let's Talk About Children in China.

CONCLUSION

The present study will provide evidence for the efficacy of Let's Talk About Children in families with parental schizophrenia and bipolar disorder in China. In addition, it will evaluate potential mechanisms of action and cost-effectiveness of Let's Talk About Children, providing a basis for future implementation.

TRIAL REGISTRATION

ChiCTR2300073904.

Talking and making meaning about parental mental health problems: The role of children's family caregivers

When a parent is less able to meet their children's needs due to a severe and enduring mental health problem (MHP), other adult family members often help with childcare. We present a Grounded Theory of how children's family caregivers construct meaning about the parental MHP and communicate about it with children. Nineteen caregivers participated in qualitative interviews. Each supported at least one related child aged 4-17 years with a parent with MHPs. We found that caregivers engaged in a Core Social Process of providing protection in uncertainty. This comprised three categories as follows: shaping the interactional space, communicating through the developmental process, and engendering a sense of safety. Caregivers appeared to act from a Key Social Positioning of developing a caregiver identity. The findings implicate family-focused provision of mental health and social care. Clinical recommendations are made for whole-family interventions and the role of marital and family therapists.

The "Let's Talk about Children" intervention in a Finnish school context: fidelity, parents' experiences, and perceived benefits

The Let's Talk about Children intervention is a tool for parents and professionals to work together to promote children's positive development, resilience, and psychosocial well-being in social and healthcare services, at school, and in day care. The aim of this study was to evaluate the fidelity, parents' experiences, and perceived benefits of using the Let's Talk about Children intervention in a school context. Participants (N = 65 first-grader parents) completed an online questionnaire after the intervention. The results show that the intervention was delivered as designed and conducted with high fidelity. Parents' experiences of the Let's Talk about Children discussions were positive, parents felt that the atmosphere was good during the discussion, and the participants reported benefits from the intervention. Clinical trial registration:ClinicalTrials.gov, identifier NCT05038280.

The science of child and adolescent mental health in Greece: a nationwide systematic review

Evidence-based information is essential for effective mental health care, yet the extent and accessibility of the scientific literature are critical barriers for professionals and policymakers. To map the necessities and make validated resources accessible, we undertook a systematic review of scientific evidence on child and adolescent mental health in Greece encompassing three research topics: prevalence estimates, assessment instruments, and interventions. We searched Pubmed, Web of Science, PsycINFO, Google Scholar, and IATPOTEK from inception to December 16th, 2021. We included studies assessing the prevalence of conditions, reporting data on assessment tools, and experimental interventions. For each area, manuals informed data extraction and the methodological quality were ascertained using validated tools. This review was registered in protocols.io [68583]. We included 104 studies reporting 533 prevalence estimates, 223 studies informing data on 261 assessment instruments, and 34 intervention studies. We report the prevalence of conditions according to regions within the country. A repository of locally validated instruments and their psychometrics was compiled. An overview of interventions provided data on their effectiveness. The outcomes are made available in an interactive resource online [ https://rpubs.com/camhi/sysrev_table ]. Scientific evidence on child and adolescent mental health in Greece has now been cataloged and appraised. This timely and accessible compendium of up-to-date evidence offers valuable resources for clinical practice and policymaking in Greece and may encourage similar assessments in other countries.

A study protocol for the randomized controlled trial SAFIR FAMILY TALK: a selective primary preventive intervention vs. service as usual for children of parents with mental illness

BACKGROUND

Children of parents with mental illness have an increased risk of developing mental illness themselves throughout their lifespan. This is due to genetic factors but also environmental disadvantages during childhood associated with parental mental illness. Selective primary preventive interventions for the children are recommended to mitigate risk factors and strengthen protective factors, but large-scale, longitudinal studies are needed. This study aims to investigate the effect of the Family Talk Preventive Intervention in a cohort of children and their parents with mental illness.

METHODS

The study is a randomized controlled trial with 286 planned families with at least one parent with any mental illness and at least one child aged 7 to 17 years. It will be carried out in the mental healthcare system in the Capital Region of Denmark. Families will be referred from hospitals and municipalities. The children and parents will be assessed at baseline and then randomized and allocated to either the Family Talk Preventive Intervention or service as usual. The intervention group will be assigned to Family Talk Preventive Intervention, a manualized programme consisting of ~ seven sessions for the family, including psychoeducation about parental mental illness and resilience in children, stimulating dialogue between family members and creating a common family narrative. The study period for both groups will be 12 months. Follow-up assessments will be conducted after 4 months and 12 months. The primary outcomes are the children's level of functioning, parental sense of competence and family functioning.

DISCUSSION

Given the prevalence of transgenerational transmission of mental illness, a systematic approach to prevention is needed in the mental healthcare setting. This study provides valuable knowledge on the Family Talk Preventive Intervention with a large sample size, inclusion of any parental mental illness and examination of the primary outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05615324. Registered on 26 October 2022. Retrospectively registered.

Preventing eating disorders and disordered eating in genetically vulnerable, high-risk families

OBJECTIVE

To close the chasm between theory about families containing a parent with an eating disorders (EDs) history and lack of selective or indicated prevention programming for such families with an older child or adolescent who is, genetically, at high risk.

METHOD

A search of four major databases for January 2000 through September 2022 yielded no publications that (a) identified genetically high-risk families with offspring ages 10 through 18; (b) devised a prevention program for the family; and (c) evaluated program effects on risk/protective factors. To rectify this gap, research on three lines of family-based prevention is reviewed: (1) programs for adolescents at genetic risk for depression or anxiety; (2) the Stanford-Dresden project for adolescents at high risk for anorexia nervosa; and (3) Sadeh-Sharvit et al.'s work concerning the Parent-Based Prevention program for mothers with an EDs history and a child under age 5.

RESULTS

The significant challenges for innovative prevention programming should be addressed by experts in effective EDs, depression, and anxiety prevention, and in family-based treatment (FBT) for EDs, collaborating with people from genetically vulnerable families. Innovative programming should focus on robust risk factors for EDs, adaptive expression of non-specific risk factors (e.g., temperament), and strengthening family functioning.

DISCUSSION

The field is overdue for development of prevention programs designed for older children or adolescents who are at risk because a parent has an ED. Evidence-based prevention programs for EDs and for depression and anxiety, as well as parent-based prevention informed by FBT, provide a springboard for addressing this gap.

PUBLIC SIGNIFICANCE

The foundation of theory and research is available for stakeholders to develop prevention programming that closes the huge gap between theory and research about families that are genetically vulnerable for eating disorders versus the complete lack of prevention programming for such families that have an older child or adolescent at high risk.

Preventive interventions for children of parents with depression, anxiety, or bipolar disorder: A quasi-experimental clinical trial

AIM

To investigate the effectiveness of preventive interventions for 8-17-year-old children of patients diagnosed with depression, anxiety, or bipolar disorder.

METHODS

Sixty-two families including 89 children received either the more extensive Family Talk Intervention (FTI; n = 35), the brief Let's Talk about Children (LTC; n = 16), or Interventions as Usual (IAU; n = 38) in routine care in adult psychiatry. Parent-rated questionnaire data were collected at baseline, after 6 and 12 months. We used growth curve models to investigate the effect of intervention on child mental health problems (SDQ-P Total Difficulties) and perceived parental control of child behaviour (PLOC-PPC).

RESULTS

Parents in the FTI and LTC groups, versus the IAU group, reported more favourable development in terms of preventing increase in child mental health problems with standardised intervention effects of d = -0.86 and -0.88 respectively, by study end, and reported improved perceived parental control, d = 1.08 and 0.71, respectively, by study end. No significant differences in effect were found when FTI and LTC were compared.

CONCLUSIONS

The results support continued use of FTI and LTC in adult psychiatry, and since LTC is a brief intervention, it might be useful as a minimum-level preventive intervention.

Promoting Self-Determination in Parents With Mental Illness in Adult Mental Health Settings

This article reports a strengths-based intervention to support parents with mental illness and their children in adult mental health settings: "Let's Talk About Children" (LTC) intervention. A qualitative methodology was adopted with parent participants receiving LTC in adult mental health and family services. The benefits for parents receiving LTC were described through in-depth interviews with 25 parents following the delivery of the program. Interview data identified an impact on parental self-regulation-mainly through a change in a sense of agency as a parent-and skill building, once a clearer picture of their child's everyday life was understood. This study outlines the benefits of talking with parents about the strengths and vulnerabilities of their children during routine mental health treatment. The role for self-determination of parents in preventive interventions for children is an important consideration for mental health recovery, and it also helps to break the cycle of transgenerational mental illness within families.

The ParentingWell Practice Approach: Adaptation of Let's Talk About Children for Parents With Mental Illness in Adult Mental Health Services in the United States

Background

Despite the importance of family and parent-focused practice, there has been a dearth of research on interventions for parents with mental illness. This paper describes the process and outcome of adapting an evidence-based intervention, Let's Talk about Children (LTC), in the context of adult mental health services in Massachusetts, United States.

Methods

Specific objectives included: (1) to specify the core components, functions, and principles of LTC essential to adapting the intervention (i.e., program theory), (2) to consider contextual factors related to the new setting; (3) to pre-test the adapted materials with diverse practitioners; and (4) to compile the program model and materials (i.e., the practice profile) for use by adult mental health service providers in Massachusetts. The Adaptation Team included individuals with expertise in psychiatric rehabilitation and clinical care, policymaking, program development and research, and parents. Activities occurred between 2015-2019 and included: (1) consulting with experts to specify the core elements and theory behind the selected intervention (i.e., with the LTC purveyor and international experts); (2) consulting with key stakeholders for input regarding the Massachusetts target population and context to inform adaptations (i.e., individual and group key informant interview sessions); (3) pretesting the initial adapted materials (i.e., training and coaching sessions with adult mental health practitioners); and (4) using feedback to refine and compile the final intervention manual (i.e., the ParentingWell Practice Profile). Participants reflected diverse, oftentimes multiple roles and perspectives, including those of parents with mental illness, adult children, and family members.

Results

ParentingWell is practitioner- and setting-agnostic, addresses parenting across the lifespan, fits into the routine workflow, and builds on practitioners' existing skills. Eight themes emerged, which were translated into four core elements (engage, explore, plan, access and advocate) consistent with Self-Determination Theory and four underlying principles (trauma-informed, strengths-based, family-focused, culturally sensitive) in keeping with the LTC model. The ParentingWell Practice Profile operationalizes each core element and addresses the underlying principles.

Conclusion

ParentingWell makes talking about parenting and family experiences a routine part of the therapeutic conversation with adults with mental illness. Future research will test the adaptation, implementation, and impact of ParentingWell.

The ParentingWell Learning Collaborative Feasibility Study: Training Adult Mental Health Service Practitioners in a Family-Focused Practice Approach

This study investigates the feasibility and impact of the ParentingWell Learning Collaborative (PWLC) model in supporting mental health practitioners in implementing the family-focused ParentingWell practice approach with adults with mental illness. An exploratory design and qualitative methods were employed. Practitioners (n = 29) participated in in-person orientation, training and debriefing sessions; virtual coaching sessions; and via an interactive online hub. Researchers obtained data on participant engagement and satisfaction, and participants' reports of use, helpfulness, intention to use and impact. Participants were engaged in and highly satisfied with the PWLC. They deployed PWLC skills, tools and resources with parents. Evidence of impact was provided at the personal, practice and organizational levels. This study provides preliminary support for the feasibility and impact of the PWLC. Clear specification of a theoretically-based training model for practitioners is an essential step in adapting, implementing and testing interventions in new contexts .

Developing and Initially Validating the Youth Mental Health Literacy Scale for Ages 11-14

Despite rising rates of youth mental health disorders and suicides, most youth lack access to accurate, non-stigmatized mental health information. Instead, many describe people with mental illness as violent and incompetent. Mental health literacy aligns with resilience theory. It assumes that youth that have accurate mental health information will have less stigmatized views of mental illness and will be more likely to seek help earlier should mental health symptoms arise. Accurate, non-stigmatized mental health information is especially needed for Children of a Parent or other Family Member that has a mental illness (COPFMI) since they are more likely to acquire a mental illness than children who do not have a family member with a mental illness. COPFMI youth are in need of the same mental health information as general population youth but they can also benefit from knowing how to deal with a family member's mental health disorder. Based on many foundation studies and key stakeholder input from parents, educators, mental health providers, child welfare providers, and especially youth, an emerging Youth Mental Health Literacy (YMHL) scale was developed and validated for measuring the mental health literacy levels of youth ages 11-14. The scale provides a full scale score of youth mental health literacy. It has subscales of knowledge of mental illness and recovery; stigma, help seeking for self/others; coping with stress; and dealing with family mental health challenges. The validation study indicated support for a unidimensional structure for each of the refined subscales. The subscales showed suitable reliability as evaluated by several measures of internal consistency. While the scale needs further study with larger samples of youth, it is hoped that the scale can yield mental health literacy outcome data that can help mental health literacy programs to build evidence-based programs that may, in turn, help prevent, delay, or ameliorate mental health disorders among youth.

An Evidence-Based Practice Developed in-situ: Let's Talk About Children and a Consolidation of Its Evidence Base

BACKGROUND

Traditional models of evidence-based practice assume knowledge is developed in research settings before being installed in practice settings. The role practice settings can play in enhancing effectiveness and enabling sustainability is not therefore acknowledged. Developing interventions in-situ alongside developing their evidence base, provides another pathway to evidence-based practice. One example is Let's Talk about Children (LTC), a brief family-focused intervention that promotes parent, family and child wellbeing. Let's Talk about Children has been developed and adapted to respond to the context into which it has been established, leading to different descriptions reported in its 20 year collection of evidence. Collating the diverse literature on LTC, this paper showcases an evidence-based practice developed in-situ in order to guide future innovation.

METHOD

Using an integrative review, key literature using LTC were identified through electronic databases and snowballing techniques. Constant comparison analysis synthesized the data to develop patterns and themes.

FINDINGS

From the 26 records, three forms of LTC were identified and outcomes related to parents, family and child wellbeing, implementation and sustainability were collated. Consolidated outcomes show overall agreement in effectiveness and acceptability outcomes across different settings and populations. Implementation and sustainability impacts are entwined with the context, and influenced by its development in-situ.

CONCLUSIONS

The study documents that the in-situ model is effective at developing sustainable evidence-based practice. In consolidating the evidence, the review clarified LTC's forms and outcomes, and draws attention to the importance of research on mechanisms of change.

A Family-Focused Intervention for Parental Mental Illness: A Practitioner Perspective

Background: Parental mental illness (PMI) is common and can lead to children developing mental disorders. Family Talk (FT) is a well-known and widely implemented intervention designed to reduce the risk of transgenerational psychopathology. However, given the research to practise "gap," very little qualitative research, to date, has investigated practitioner experiences in implementing FT. This study aimed to explore the practitioner-perceived barriers and facilitators to the implementation and sustainability of FT within mainstream mental health settings. Methods: This qualitative study was nested within a randomised controlled trial (RCT) of Family Talk [N = 86 families (139 parents, 221 children)] within 15 adult (AMHS), child (CAMHS), primary care mental health, and child protection sites in Ireland. Semi-structured interviews and focus groups were undertaken with a purposive sample of clinicians (n = 31) and managers (n = 10), based on their experiences of implementing FT. Interview data were transcribed verbatim, analysed using constructivist grounded theory, and informed by Fixsen's implementation science framework. Results: Service providers highlighted a number of benefits for approximately two thirds of families across different diagnoses and mental health settings (AMHS/CAMHS/primary care). Sites varied in their capacity to embed FT, with key enablers identified as acquiring managerial and organisational support, building clinician skill, and establishing interagency collaboration. Implementation challenges included: recruitment difficulties, stresses in working with multiply-disadvantaged families, disruption in delivery due to the COVID-19 global pandemic, and sustainability concerns (e.g., perceived fit of FT with organisational remit/capacity, systemic and cultural barriers to change). Conclusion: This study is only the second qualitative study ever conducted to explore practitioner experiences in implementing FT, and the first conducted within the context of an RCT and national research programme to introduce family-focused practise (FFP) for families living with PMI. The findings illuminate the successes and complexities of implementing FFP in a country without a "think family" infrastructure, whilst highlighting a number of important generalisable lessons for the implementation of FT, and other similar interventions, elsewhere.

Preventive interventions in offspring of parents with mental illness: a systematic review and meta-analysis of randomized controlled trials

Children with parents suffering from a psychiatric disorder are at higher risk for developing a mental disorder themselves. This systematic review and meta-analysis of randomized controlled trials aims to evaluate the efficacy of psychosocial interventions to prevent negative mental health outcomes in the offspring of parents with mental illness. Eight electronic databases, grey literature and a journal hand-search identified 14 095 randomized controlled trials with no backward limit to June 2021. Outcomes in children included incidence of mental disorders (same or different from parental ones) and internalizing and externalizing symptoms at post-test, short-term and long-term follow-up. Relative risks and standardized mean differences (SMD) for symptom severity were generated using random-effect meta-analyses. Twenty trials were selected (pooled n = 2689 children). The main therapeutic approaches found were cognitive-behavioural therapy and psychoeducation. A significant effect of interventions on the incidence of mental disorders in children was found with a risk reduction of almost 50% [combined relative risk = 0.53, 95% confidence interval (CI) 0.34-0.84]. Interventions also had a small but significant effect on internalizing symptoms at post-test (SMD = -0.25, 95% CI -0.37 to -0.14) and short-term follow-up (-0.20, 95% CI -0.37 to -0.03). For externalizing symptoms, a decreasing slope was observed at post-test follow-up, without reaching the significance level (-0.11, 95% CI -0.27 to 0.04). Preventive interventions targeting the offspring of parents with mental disorders showed not only a significant reduction of the incidence of mental illness in children, but also a diminution of internalizing symptoms in the year following the intervention.