Siblings of children with severe emotional disturbances: risks, resources, and adaptation

'No one else understands', 'I wouldn't want to pity myself over something that's not really my problem': siblings' experiences of their adolescent brothers and sisters' inpatient treatment for mental health difficulties

BACKGROUND

Family life is disrupted when a child experiences mental health difficulties. This can have long-standing effects on sibling relationships. This study explores the lived experiences of young people who have an adolescent sibling hospitalised for treatment of a mental health difficulty.

METHOD

Semi-structured interviews of 45-60 min were conducted to explore the experiences of 10 siblings (6 sisters/4 brothers aged 13-22) of nine patients (5 sisters/4 brothers aged 15-17) receiving treatment for a mental health difficulty in a child and adolescent inpatient unit (IPU). Interpretative phenomenological analysis was used to analyse the data.

RESULTS

Two superordinate themes were identified: 'Who am I if I'm not supporting them?' and 'On the fringes: actively involved but from the outside'. The interplay of these two super-ordinate themes was found to influence the five sub-ordinate themes: 'Confusion and disbelief', 'Don't worry about me, focus on them.', 'Powerless when I need to be powerful.', 'Helping or hindering- what is this place??' and 'Knowledge is power.'

CONCLUSION

Siblings described experiencing conflicting and confusing emotions which may impact their attendance in IPU and engagement in siblings' treatment. Siblings of adolescents in inpatient treatment for mental health difficulties may be at increased risk of experiencing psychological distress. The mental well-being of siblings must be borne in mind by child and adolescent inpatient services supporting families in crisis.

All in the Family: Living With ADNP Syndrome

PURPOSE

The overarching purpose of this research was to examine the experiences of 1 family living with a child with Helsmoortel-Van Der Aa syndrome or activity-dependent neuroprotective protein (ADNP) syndrome.

DESIGN

A retrospective qualitative design was used for this study.

METHODS

Two primary caregivers for a 5-year-old child with ADNP syndrome completed background questionnaires to provide context for semistructured interviews. Each caregiver completed 2 interviews, approximately 2 months apart. Field notes, member checks, and triangulation were used to enhance the credibility of the study.

RESULTS

This article summarizes the theme "All in the Family." Having a child with ADNP syndrome affected all aspects of family life. Participants revealed that family dynamics were shaped by experiences stemming from their living arrangements and caregiving responsibilities.

CONCLUSIONS

Findings from this research highlighted the need for increased support for families faced with ADNP syndrome, as well as the role clinical nurse specialists can play in the lives of caregivers faced with such a rare diagnosis. Furthermore, given the paucity of ADNP syndrome information, the need for more research is warranted.

Experiencing the relationship with a sibling coping with mental health problems: Dilemmas of connection, communication, and role

Prolonged mental health problems of one family member influences the whole family system, including sibling relationships. The current research focuses on the way siblings of persons with mental health problems experience the relationship. The findings identify the challenges and difficulties these siblings face and can help mental health practitioners support siblings as well as their brothers and sisters with mental health problems. This qualitative research employs the Interpretative Phenomenological Analysis method. Data were collected through in-depth semi-structured interviews with 14 adult siblings of persons coping with prolonged mental health problems. The sample included seven men and seven women, between the ages of 20-55. Three main themes were identified: (a) Connection: Between involvement and distance; (b) Communication: Controlled confrontation or cautious vagueness; (c) Role: Positioning in the sibling relationship. The discussion introduces the Relational Dialectics Theory in order to understand contradictory statements that arise from the interviewees' experience of dialectal tensions between: involvement versus distancing; direct confrontation versus cautious vagueness; and opposing positions in relation to the sibling coping with mental health problems. A multi-voiced discourse allows for dialogue that incorporates the contradictory poles of the dialectic, thus enabling the siblings to balance the tension in the relationship. In addition, the concept of ambiguous loss is used to interpret the findings. The study is limited by the small homogeneous sample. The results highlight the need for practitioners to give special attention to siblings of persons with mental health problems in order to help them process and cope with the challenges in the relationship, thus providing an opportunity for growth and empowerment.

Consensus statement on preventive and symptomatic care of leukodystrophy patients

Leukodystrophies are inherited disorders whose primary pathophysiology consists of abnormal deposition or progressive disruption of brain myelin. Leukodystrophy patients manifest many of the same symptoms and medical complications despite the wide spectrum of genetic origins. Although no definitive cures exist, all of these conditions are treatable. This report provides the first expert consensus on the recognition and treatment of medical and psychosocial complications associated with leukodystrophies. We include a discussion of serious and potentially preventable medical complications and propose several preventive care strategies. We also outline the need for future research to prioritize clinical needs and subsequently develop, validate, and optimize specific care strategies.

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.



Interventions for family members of adolescents with disruptive behavior disorders

PROBLEM

The family members of adolescents diagnosed with disruptive behavior disorders (DBDs) experience profound stress and burden. Despite the need for empirically supported interventions that address the challenges faced by these family members, few such interventions are available.

METHODS

In this qualitative descriptive study, we conducted in-depth interviews with 15 families of adolescents diagnosed with DBD. We asked the family members to identify what types of mental health services they needed and to describe the "ideal" program that would best address their concerns.

FINDINGS

Family members identified several intervention modalities that would fit their needs, including multifamily groups, family therapy, individual therapy, and community-based hotlines. They indicated that programs should address the following topics: family communication, conflict resolution, education about DBD, and strategies to improve interactions with child service agencies.

CONCLUSIONS

Clinicians should recognize that all family members may need support to manage the stressors associated with caring for or living with adolescents with DBD. When working with families, clinicians should provide information about the etiology and management of DBD, help navigate interactions with child service agencies, and employ strategies to improve family communication and functioning.

Sustaining and expanding systems of care to provide mental health services for children, youth and families across America

The Substance Abuse and Mental Health Services Administration has been instrumental in supporting the development and implementation of systems of care to provide services to children and youth with serious mental health conditions and their families. Since 1993, 173 grants have been awarded to communities in all 50 states, Puerto Rico, Guam, the District of Columbia, and 21 American Indian/Alaska Native communities. The system of care principles of creating comprehensive, individualized services, family-driven and youth-guided care and cultural and linguistic competence, supported by a well-trained and competent workforce, have been successful in transforming the field of children's mental health and facilitating the integration of child-serving systems. This approach has achieved positive outcomes at the child and family, practice and system levels, and numerous articles have been published using data collected from system of care communities, demonstrating the effectiveness of this framework. This article will describe lessons learned from implementing the system of care approach, and will discuss the importance of expanding and sustaining systems of care across the country.

Systems of care: new partnerships for community psychology

For almost two decades, the federal government has supported the development of integrated models of mental health service delivery for children and families, known as systems of care (SOCs), that strive to be child-centered, family-focused, community-based, and culturally competent. These efforts align well with the values and principles (e.g., empowerment, collaboration, strengths emphasis, focus on macro-level social/system change) central to community psychology (CP; Kloos et al. in Community psychology, Cengage Learning, Belmont, 2012). Despite the convergence of many core values, CPs have historically been underrepresented in key roles in SOC initiatives. However, this has changed in recent years, with increasing examples of community psychology skills and principles applied to the development, implementation, and evaluation of SOCs. Because successful and sustainable implementation of SOCs requires community and system-level change, and SOCs are increasingly being urged to adopt a stronger "public health" orientation (Miles et al. in A public health approach to children's mental health: a conceptual framework, Georgetown University Center for Child and Human Development, National Technical Assistance Center for Children's Mental Health, Washington, DC, 2010), there is great potential for CPs to play important roles in SOCs. This paper discusses opportunities and roles for CPs in SOCs in applied research and evaluation, community practice, and training.

Moving forward with systems of care: needs and new directions

The articles in this Special Issue on system change within systems of care (SOCs) provide guidance regarding strategies for modifying SOCs to address the needs of different populations, and ways for changing systems to support more positive child and family outcomes. This paper frames central needs, unanswered questions, and issues that remain for those working to implement SOCs. Specific needs and new directions considered include: (1) rigorous implementation-focused research to identify the necessary and sufficient elements of SOCs and the primary practice approach currently used in SOCs, wraparound; (2) applied research to assess SOCs and document their effectiveness in non-standard or non-traditional settings (i.e., non-mental health settings, including child welfare, juvenile justice, local housing authorities); (3) controlled outcome studies for school-based wraparound initiatives; (4) research to document the effectiveness of the family support efforts that are part of most SOCs; and (5) attention to context, for families, service providers, and collaborative implementation efforts, by researchers and providers alike. Progress in these areas can inform well-targeted system change efforts in the context of SOCs, a critical need given changes in federal funding for these initiatives.

The effects of caregiver social connections on caregiver, child, and family well-being

This study examines the degree to which caregiver social connectedness influences the effects of strain associated with caring for a child with severe emotional disturbance (SED) on caregiver well-being. We propose a model describing the relationships among the variables of interest and investigate elements of this model. Caregiver strain and social connections were significantly associated with caregiver well-being. Although, no significant interaction effects of caregiver strain and social connections were detected, study findings suggest that caregiver well-being can affect child progress and adjustment. Implications for child- and family-serving systems are considered.

Educational outcomes in a system of care for children with emotional disturbance

In North Carolina, only 69% of high school students graduate in 4 years; however, recent data suggest that only 42% of students with mental and emotional disabilities graduate. MeckCARES, a system of care (SOC) in Mecklenburg County, North Carolina, is designed to serve youth with severe emotional disturbances and their families. The SOC philosophy is a prominent family-focused approach intended to provide comprehensive, coordinated networks of services, tailored to the needs of the child and family, while emphasizing the strengthening of natural community supports. In addition to other mental health objectives, a particular goal of MeckCARES is to address specific school-based needs of system-identified youth to improve educational outcomes and reduce the risk of dropping out. This study sought to assess empirically the impact that enrollment in MeckCARES has on graduation precursors; namely, grades, suspensions, and absences. This study found that, on average, enrollment in MeckCARES is not associated with positive changes in educational variables. Implications of these findings are discussed, as are future directions. For example, additional research is needed with more sensitive measurement and data collection procedures (i.e., access to graduation rates and Medicaid information) to adequately assess the impact of enrollment in MeckCARES on educational outcomes.

Moving from principles to practice: recommended policy changes to promote family-centered care

This paper emphasizes the value of family-centered care. Discussion highlights family-centered philosophies (e.g., Systems of Care [SOCs]) and practice models (i.e., wraparound) and identifies discrepancies between conceptualizations and actual practice. Data from multiple sources detail issues in fidelity to family-centered values and needs and risks experienced by siblings of children with severe emotional disturbance and their caregivers. This discussion provides a springboard for policy recommendations to strengthen family support programming and enhance family-centered care, from modifying funding streams such that systems extend their reach beyond children with full-blown, diagnosable problems (those meeting standards of "medical necessity), to supporting prevention and early intervention initiatives that address families as targets for intervention. Recommendations include ensuring that communities with SOC funding address the needs of families; broadening Medicaid rules and definitions; expanding the range of reimbursable activities and services; and increasing funding for evaluating family-centered care models and family support programming.

Factors associated with positive adjustment in siblings of children with severe emotional disturbance: the role of family resources and community life

This study builds on the scant research involving siblings of children with severe emotional disturbances (SED) and examines: associations between adversity experiences and adjustment among 5- to 10-year-old siblings, and relations among family resources, community life, and sibling adjustment. Caregivers from 100 families completed standardized indicators of sibling adjustment and scales reflecting multiple contextual variables. Results document negative associations between stress exposure and sibling adjustment. Regression models also indicate positive associations between the caregiver-child relationship and broader family resources on sibling behavioral and emotional strengths, even after accounting for adversity experiences; adversity exposure was the prime correlate in regression models involving sibling oppositional behavior. Analyses also suggest that strain related to parenting a child with SED is associated with sibling adjustment. This work documents the needs of these siblings and their family systems and highlights the relevance of not only core proximal influences (e.g., child-caregiver relationship) but also elements of their broader contexts. Implications and recommendations are described, including the need to support plans of care that involve services, supports, or preventive strategies for these siblings.

Defining the scope of systems of care: an ecological perspective

The definition of a system of care (SOC) can guide those intending to develop and sustain SOCs. Hodges, Ferreira, Israel, and Mazza [Hodges, S., Ferreira, K., Israel, N., & Mazza, J. (in press). Systems of care, featherless bipeds, and the measure of all things. Evaluation and Program Planning] have emphasized contexts in which services are provided to families, plus the adaptive, dynamic, complex nature of systems and multiple components that comprise SOCs. However, two areas need additional clarification: (1) the nature of the "system" of concern in a "system of care," and how it should differ from a "service delivery system"; and (2) the degree to which intended, or desired, outcomes of a SOC extend beyond increased access to "necessary" services and supports. These prime issues in the conceptualization of SOCs are addressed, drawing on ecological theory to underscore the need for broader systems--including factors in the proximal and distal contexts of children and families--to be engaged in the process of promoting well-being and helping children and families function and participate fully in their communities. A revised definition is proposed, with implications for the implementation of SOCs.

The importance of context in fostering responsive community systems: supports for families in systems of care

The importance of helping families of children with severe emotional disturbances (SED) connect with informal or natural supports-that is, individuals who are part of their ongoing communities and daily lives-has been widely recognized. Utilization of informal supports has thus become a core element within systems of care (SOCs) designed to improve services for children with SED and their families. However, research demonstrates that implementation of wraparound, the key practice approach within SOCs, often does not include involvement of informal supports. Using a measure of social connectedness (SC), developed to augment the instruments used for the SOC national evaluation, this study assessed parents' and caregivers' views of their connections to and support from their community within a SOC. Overall, parents and caregivers reported low levels of support across multiple sources as well as a desire for more support. Greater levels of perceived support related positively to caregiver strain, types of and satisfaction with services received, and views of their communities as supportive and safe. Greater attention to families' contexts and the identification of effective ways to connect families to their communities are recommended.

Responding to the needs of children and families after a disaster: linkages between unmet needs and caregiver functioning

Disasters may negatively influence caregivers' ability to respond to the needs of their families. In this context, service organizations' response to families' needs may affect caregivers' symptoms and parenting. Interviews were conducted with caregivers affected by Hurricane Katrina approximately 1 year (T(1); N = 68) and 2 years posthurricane (T(2); N = 52). Caregivers reported high levels of service needs and unmet needs for themselves and their child(ren) and family at both time points. Regression analyses indicated that after accounting for hurricane exposure: (a) child unmet service needs significantly contributed to T(1) caregiver distress, (b) caregiver service needs and child unmet needs were associated with higher levels of posttraumatic stress symptoms, and (c) caregiver unmet needs related to greater strain at T(1). At T(2), after accounting for T(1) scores, service need variables did not contribute to distress or posttraumatic stress symptoms. Caregiver strain at T(1) and T(1) child service needs were associated with greater T(2) strain. These findings highlight the importance of extending the availability of services beyond the initial postdisaster recovery period to better meet the needs of caregivers and families.

Caregiving by teens for family members with Huntington disease

The purpose of this report is to describe caregiving by teens for family members with Huntington disease (HD). Thirty-two teens in HD families in the United States and Canada participated in focus groups from 2002 to 2005 in a study to identify concerns and strategies to manage concerns. An unexpected finding was 24 (77%) described caregiving activities. Descriptive analysis of caregiving statements identified themes of Tasks and Responsibilities, Subjective Burden, Caregiving in Context of Personal Risk for HD, and Decisional Responsibility. Teens took an active part in nearly all aspects of care with the exception of contacting health care providers and attending doctors' appointments. Some described emotional distress, and many provided care knowing they had the potential to develop HD. Teens recognized the need for decisions but lacked the authority to make these decisions. Findings may be relevant for other teens who strive to meet caregiver and student roles and developmental tasks.