Multiproblem Families Referred to Youth Mental Health: What's in a Name?

Facilitators and Barriers in Integrated Social Care for Families Facing Multiple and Complex Problems: A Scoping Review

Introduction

Families with multiple and complex problems often deal with multiple professionals and organizations for support. Integrated social care supposedly prevents the fragmentation of care that often occurs.We identified facilitators and barriers experienced by families receiving integrated social care and by the professionals who provide it.

Method

We performed a scoping review following Arksey and O'Malley's framework, using the following databases: PsycINFO, Web of Science Core Collection, Psychology and Behavioral Sciences Collection, CINAHL, PubMed, and Medline. Furthermore, conducted a thematic analysis. The results were divided into facilitators and barriers of integrated social care.

Results

We identified 278 studies and finally included sixteen in our scoping review. We identified facilitators, including: linking formal care with informal networks, promoting collaboration among professionals e.g., working in pairs, and professionals autonomy. We identified barriers, including: time constraints, tasks outside professionals' expertise, along with resistance to integrated collaboration among organizations. These findings can enhance the advancement of social integrated care as a promising approach to support families facing multiple and complex problems.

Conclusion

To empower families, integrated social care requires a systematic approach based on trust. It involves coordinated care, shared decision-making, informal networks and the participation of all family members, including children.

Improvements in the quality of the parent-child relationship following treatment with an integrated family approach

Objective

This study investigated changes in the emotional availability of the parent and the child in the dyadic relationship, parental reflective functioning, and parental perception of the relationship with their child following treatment with an integrated family approach in adult and child mental health care services. The aim of the study was to investigate if an integrated family approach in treatment contributes to good practice in mental health care.

Background

Children of parents with a mental disorder are at increased risk for developing mental health problems themselves during lifetime. Infants are extremely vulnerable for environmental influences. Parents with mental disorders are at risk for mis-attuned behavior and non-optimal emotional availability. This increases the risk of adverse cascading effects on the parent-child relationship and child development. A secure parent-child relationship is an important protective factor against the intergenerational transmission of mental disorders. Although treatment of the parental mental disorder is important, it does not automatically change undesirable patterns in the parent-child relationship. Therefore, an integrated family approach to mental health treatment is recommended.

Methods

This study involved a mixed methods design using questionnaires, an observation instrument and semi-structured interviews. The variables examined were the quality of the parent-child interaction, the parental perspective on their relationship with the child, their problems with child upbringing, and on their parental reflective functioning. The clinical sample consisted of 50 patients with a variety of mental disorders and their young children.

Results

After finishing the integrated treatment the quality of the parent-child interaction had improved significantly. Likewise, we found a significant improvement in parental perception regarding the relationship with the child and the parental role. The majority of the parents interviewed showed that they were better able to mentalize about themselves, their child and their relationship with the child, but the data from the questionnaire showed mixed results regarding parents' reflective functioning.

Conclusion

Treatment with an integrated family approach to mental health care in which the parental role of the patient, the young child, and the parent-child relationship are integrated in treatment, can be a valuable addition to the current practice of mental health care in which patients are commonly perceived as individuals.

The Integrated Family Approach in Mental Health Care Services: A Study of Risk Factors

BACKGROUND

Parental mental disorders in families are frequently accompanied with other problems. These include family life, the development of children, and the social and economic environment. Mental health services often focus treatments on the individual being referred, with little attention to parenting, the family, child development, and environmental factors. This is despite the fact that there is substantial evidence to suggest that the children of these parents are at increased risk of developing a mental disorder throughout the course of their lives. Young children are particularly vulnerable to environmental influences given the level of dependency in this stage of development.

OBJECTIVE

The main objective of this study was to identify whether there were a complexity of problems and risks in a clinical sample of patients and their young children (0-6) in mental health care, and, if so, whether this complexity was reflected in the integrated treatment given.

METHODS

The data were collected for 26 risk factors, based on the literature, and then subdivided into the parental, child, family, and environmental domains. The data were obtained from the electronic case files of 100 patients at an adult mental health service and the corresponding 100 electronic case files of their infants at a child mental health service.

RESULTS

The findings evidenced a notable accumulation of risk factors within families, with a mean number of 8.43 (SD 3.2) risk factors. Almost all of the families had at least four risk factors, more than half of them had between six and ten risk factors, and a quarter of them had between eleven and sixteen risk factors. Furthermore, two-thirds of the families had at least one risk factor in each of the four domains. More than half of the families received support from at least two organizations in addition to the involvement of adult and child mental health services, which is also an indication of the presence of cumulative problems.

CONCLUSION

This study of a clinical sample shows clearly that the mental disorder among most of the patients, who were all parents of young children, was only one of the problems they had to deal with. The cumulation of risk factors-especially in the family domain-increased the risk of the intergenerational transmission of mental disorders. To prevent these parents and their young children being caught up in this intergenerational cycle, a broad assessment is needed. In addition, malleable risk factors should be addressed in treatment and in close collaboration with other services.

Expectant parents with intellectual disabilities in child protection: Risk factors for child safety

BACKGROUND

Newborns of parents with intellectual disabilities face higher risks in their environment for child unsafety, despite parents' good intentions. To help parents prevent unsafe circumstances, a good understanding of the risk factors faced by these parents is needed.

METHODS

This casefile study examined (1) which risk factors were present for expectant parents with intellectual disabilities in child protection, (2) which domains of risk factors, and (3) whether a cumulation of risk factors was related to child safety.

RESULTS

Expectant parents with intellectual disabilities in child protection before the child was born often experienced a cumulation of risk factors. Child, family, and care factors best predicted child safety. A cumulation of risk factors over multiple life domains increased the risks for child unsafety.

CONCLUSIONS

To reduce the risks of unsafe parenting conditions for newborns, preventive interventions for expectant parents with intellectual disabilities should address their needs from an ecological perspective.

Effectiveness of a multidisciplinary treatment with youth-initiated mentoring for youths with mental health needs from multi-problem families: a quasi-experimental study

BACKGROUND

Children from multi-problem families have an increased risk for experiencing mental health problems. These families face problems in several domains that are often found to be chronic and intergenerational. Yet, the effects of mental health care for youths from multi-problem families are small at best, urging research on new treatment programs. The InConnection approach is an integrated care program to improve resilience of youths with mental health needs from multi-problem families by connecting professional expertise from multiple disciplines with the informal social network of the youth. Youths are asked to nominate a youth-initiated mentor (YIM) from the supportive adults in their network.

METHODS

This quasi-experimental study compared the effectiveness of the InConnection approach to treatment as usual in a sample of 107 families (n = 66 intervention group, n = 41 control group) with n = 115 youths receiving treatment (cases). Youths (n = 102 reports, Mage = 15.59 years), parents (n = 85 reports) and case managers (n = 107 reports) responded to questionnaires four times over 15 months. Using these data, we measured youth resilience as the primary outcome, seven secondary outcomes, and three intermediate outcomes.

RESULTS

Latent growth models showed only one significant change in outcomes over time across conditions, namely a decrease in case manager-reported child unsafety, and only two condition effects, which were both parent-reported. Parents in the InConnection group reported improvements over time in youth's emotional and behavioral problems and their own positive parenting, whereas control parents reported no changes (ps ≤ 0.013).

DISCUSSION

The treatment conditions were not effective in improving most of the youth and parental outcomes over time, except for child safety reported by the case manager. The InConnection approach only outperformed care as usual on two parent-reported outcomes. Future research should examine for whom and under what circumstances the InConnection approach works more convincingly.

TRIAL REGISTRATION

Netherlands Trial Register NL7565. Retrospectively registered on 05/03/2019.

Resilience, well-being and informal and formal support in multi-problem families during the Covid-19 pandemic

BACKGROUND

The Covid-19 pandemic may have had negative effects on youth and parental mental health, especially in high-risk populations such as multi-problem families (i.e., families that experience problems in multiple domains, such as mental health and social network problems). Using one to four assessments during all phases of the Covid-19 pandemic up until January 2022, we examined the associations between pandemic-related stress and mental health (resilience and well-being) of youth and parents from multi-problem families. We also investigated whether experienced informal (i.e., youth informal mentoring) and formal support (i.e., therapist support) served as protective factors in this association.

METHODS

A total of 92 youth aged 10-19 years (46.7% girls; mean age 16.00 years) and 78 parents (79.5% female; mean age 47.17 years) filled in one to four questionnaires between March 2020 and January 2022. Multi-level analyses were conducted to account for the nested structure of the data.

RESULTS

For youth, pandemic-related stress was associated with lower well-being, but not with resilience. Perceived support from both mentors and therapists was positively associated with youth mental health. Furthermore, high perceived therapist support protected youth from the negative effect of pandemic-related stress on resilience. For parents, pandemic-related stress was not related to mental health, irrespective of therapist support. Yet, therapist support was directly and positively associated with parental mental health.

CONCLUSIONS

Youth from multi-problem families who experience pandemic-related stress are at risk of (elevated) mental health problems during the pandemic, specifically if they have no or weak therapist support. The mental health of parents, however, was minimally affected by pandemic-related stress, indicating strength and flexibility. Youth and parents who experienced support during the pandemic reported higher levels of resilience and well-being, demonstrating the importance of support for individuals' mental health during stressful times such as a pandemic.

Toward tailored care for families with multiple problems: A quasi-experimental study on effective elements of care

Several effective interventions have been developed for families with multiple problems (FMP), but knowledge is lacking as to which specific practice and program elements of these interventions deliver positive outcomes. The aim of this study is to assess the degree to which practice and program elements (contents of and structure in which care is provided) contribute to the effectiveness of interventions for FMP in general and for subgroups with child and/or parental psychiatric problems, intellectual disabilities, or substance use. We performed a quasi-experimental study on the effectiveness of practice and program elements provided in attested FMP interventions. Using self-report questionnaires, we measured primary (child's internalizing and externalizing problems) and secondary (parental stress and social contacts) outcomes at the beginning, end, and three months thereafter. By means of Latent Profile Analysis, we identified groups of families receiving similar combinations of practice elements ("profiles"), and we calculated propensity scores. Next, we assessed how practice element profiles and program elements affected improvement in outcomes, and whether these effects were moderated by subgroup characteristics. We found three practice element profiles (explorative/supportive, action-oriented, and their combination), which were equally effective. Regarding program elements, effects were enhanced by more frequent telephone contact between visits and more frequent intervision. Effectiveness of practice and program elements varied for specific FMP subgroups. Variations in the content of care for FMP do not affect its effectiveness, but variations in the structure of the care do. This finding can help to further improve effective interventions.

The Longitudinal Interplay Between Social Network and Psychopathology in Multi-Problem Young Adult Men; Separating Within-and Between-Person Effects

Young adulthood is characterized by many life changes. Especially for young men with problems across different life domains (i.e., multi-problem), these changes may entail obstacles. Incidences of psychopathology increase during young adulthood and at the same time important shifts in social networks - such as changing relations with peers and parents, isolation, or deviant peer affiliation - take place. The present study examined the longitudinal interplay between psychopathology and social network characteristics over the course of 1 year in multi-problem young adults, at both between-person and within-person level. A sample of 696 multi-problem young adult men (age 18-27) participated in this three wave study. We used traditional cross-lagged panel models (CLPM) to examine how social network characteristics and psychopathology are related at the between-person level, and random intercept cross-lagged panel models (RI-CLPM) to examine within-person links. Between-person associations between internalizing problems and social networks were bidirectional, and externalizing problems were related to problematic social network characteristics, but not vice versa. At the within-person level, no such cross-lagged paths were found. Overall, results indicated that in multi-problem young adults, social network characteristics and psychopathology are related. However, looking at within-person processes this relation is not reciprocal.

Development and psychometric evaluation of a Positive Health measurement scale: a factor analysis study based on a Dutch population

OBJECTIVES

The My Positive Health (MPH) dialogue tool is increasingly adopted by healthcare professionals in the Netherlands as well as abroad to support people in their health. Given this trend, the need arises to measure effects of interventions on the Positive Health dimensions. However, the dialogue tool was not developed for this purpose. Therefore, this study aims to work towards a suitable measurement scale using the MPH dialogue tool as starting point.

DESIGN

A cross-sectional study design.

PARTICIPANTS AND SETTINGS

A total of 708 respondents, who were all members of the municipal health service panel in the eastern part of the Netherlands, completed the MPH dialogue tool.

METHODS

The factor structure of the MPH dialogue tool was explored through exploratory factor analysis using maximum likelihood extraction. Next, the fit of the extracted factor structure was tested through confirmatory factor analysis. Reliability and discriminant validity of both a new model and the MPH scales were assessed through Cronbach's alpha tests.

RESULTS

Similar to the MPH dialogue tool, the extracted 17-item model has a six-factor structure but named differently, comprising the factors physical fitness, mental functions, future perspectives, contentment, social relations and health management. The reliability tests suggest good to very good reliability of the aimed measurement tool and MPH model (Cronbach's alpha values ranging from, respectively, 0.820 to 0.920 and 0.882 to 0.933). The measurement model shows acceptable discriminant validity, whereas the MPH model suggests overlap between domains.

CONCLUSION

The results suggest that the current MPH dialogue tool seems reliable as a dialogue, but it is not suitable as a measurement scale. We therefore propose a 17-item model with improved, acceptable psychometric properties which can serve as a basis for further development of a measurement scale.

Effectiveness and working mechanisms of the InConnection approach in multi-problem families: study protocol of a mixed-methods study

BACKGROUND

Multi-problem families face problems in several domains that are often found to be chronic and intergenerational. Effective mental health care for youth from these families is currently lacking, urging research on new methods. The InConnection approach is an integrated care program to improve resilience in multi-problem families by connecting the professional expertise from multiple disciplines with the informal social network of the youth. Specifically, youth are asked to nominate a youth initiated mentor (YIM) from among the supportive adults in their network. The aim of this protocol is to describe the design of a mixed-methods study to examine the effectiveness and working mechanisms of the InConnection approach.

METHOD/DESIGN

The effectiveness of the InConnection approach is studied in a quasi-experimental questionnaire study using propensity score matching, with N = 300 families with youth aged 10-23 years receiving treatment in either the intervention group (InConnection approach) or the control group (care as usual). The main outcome variables include youth resilience (primary), youth mental health, parental functioning, and the number, duration and types of out-of-home placements. Mediators, moderators, and predictors of effectiveness are examined. Assessments take place at the start of the care program and after three, nine and 15 months. Additionally, semi-structured interviews are conducted with families who have and have not nominated a YIM to understand why some families successfully nominate a YIM, whereas others do not.

DISCUSSION

Effective care for youth in multi-problem families is urgently needed. Given its flexibility and accessibility to suit all youth aged 10-23 years from multi-problem families, and its low costs compared to out-of-home placements, the InConnection approach seems an appealing approach to support these families. The current study will provide information on the effectiveness of the InConnection approach. Strengths of this study include its robust design, the ecological validity, and the inclusion of possible mediators, predictors, and moderators of treatment effects.

TRIAL REGISTRATION

Netherlands Trial Register NL7565 . Retrospectively registered on March 5, 2019.

Social Work with Families in Special Distress: Collaborative Practices

Collaborative practices have emerged as an effective approach for conducting social work interventions with families in special distress. This study aimed to ascertain the perspective of the social workers located in basic community social services, in relation to the development of a collaborative approach with families in special distress. The main objective was to find out the level of importance and the level of implementation that participants (N = 121) gave to the different intervention criteria included in an Inventory of Collaborative Practices. The results indicate that criteria related to basic issues in social case work (active listening, respect, and empathy) as well as the management and bureaucracy of the specific case are the most valued and performed by social workers. The least valued and performed criteria have to do with issues that involve reflective processes in the helping relationship, both with the family and with the rest of the professionals. Implications for practice and quality enhancement are discussed, as they are key aspects in the development of collaborative interventions in social work.

Care use and its intensity in children with complex problems are related to varying child and family factors: A follow-up study

Background

There is little evidence on the child and family factors that affect the intensity of care use by children with complex problems. We therefore wished to identify changes in these factors associated with changes in care service use and its intensity, for care use in general and psychosocial care in particular.

Methods

Parents of 272 children with problems in several life domains completed questionnaires at baseline (response 69.1%) and after 12 months. Negative binominal Hurdle analyses enabled us to distinguish between using care services (yes/ no) and its intensity, i.e. number of contacts when using care.

Results

Change in care use was more likely if the burden of adverse life events (ALE) decreased (odds ratio, OR = 0.94, 95% confidence interval, CI = 0.90–0.99) and if parenting concerns increased (OR = 1.29, CI = 1.11–1.51). Psychosocial care use became more likely for school-age children (vs. pre-school) (OR = 1.99, CI = 1.09–3.63) if ALE decreased (OR = 0.93, CI = 0.89–0.97) and if parenting concerns increased (OR = 1.26, CI = 1.10–1.45). Intensity of use (>0 contacts) of any care decreased when ALE decreased (relative risk, RR = 0.95, CI = 0.92–0.98) and when psychosocial problems became less severe (RR = 0.38, CI = 0.20–0.73). Intensity of psychosocial care also decreased when severe psychosocial problems became less severe (RR = 0.39, CI = 0.18–0.84).

Conclusions

Changes in care-service use (vs. no use) and its intensity (>0 contacts) are explained by background characteristics and changes in a child’s problems. Care use is related to factors other than changes in its intensity, indicating that care use and its intensity have different drivers. ALE in particular contribute to intensity of any care use.

How Do Health and Social Networks Compare between Low-Income Multiproblem Households and the General Population?

Multiproblem households that receive social care for multiple problems, such as debts, psychiatric disorders, and domestic violence, may also be disadvantaged in terms of health and social networks. This study examines whether low-income multiproblem households and the general population differ in self-perceived health, mental health, health behaviors, and social networks. We performed a cross-sectional survey among respondents from low-income multiproblem households (n = 105) and the general population (n = 99) in the municipality of Apeldoorn in the Netherlands. Comparisons with national statistics data indicated that our sample of multiproblem households is more disadvantaged in terms of self-perceived health and mental health than low socioeconomic groups in general in the Netherlands. A multiple logistic regression analysis showed that being part of the multiproblem household group versus the general population group was associated with a lower educational level, a lower likelihood of being in paid employment, a lower score with respect to mental health, less alcohol consumption, and less fruit consumption. There were also differences between the groups on other variables, but these were not significant in adjusted analyses. In conclusion, multiproblem households in Apeldoorn had lower scores on mental health, drank fewer alcoholic drinks per week, and ate less fruit than the general population.

Video feedback intervention to enhance parental reflective functioning in primary caregivers of inpatient psychiatric children: protocol for a randomized feasibility trial

Background

Children requiring hospitalization for psychiatric care have serious disorders, high use of psychotropic medication, and frequent readmissions. The development and implementation of therapies focused on incorporating primary caregivers or attachment figures is necessary for working with children with severe psychiatric disorders. Mentalization or parental reflective functioning (PRF) is the ability of parents to understand their children’s behaviors as an expression of internal emotional states and act accordingly to help them regulate their emotions; in this way mentalizing is a key component of sensitive parenting. Video-assisted therapies have proven to be effective in promoting change in parent–child relationships. The majority of studies have been carried out with mothers of pre-school children and in an outpatient setting. Video intervention therapy (VIT) is a flexible manualized therapy, which allows the intervention to be individualized to the context where it is applied, according to the needs and resources of the people who participate in it. The objective of the study is to evaluate the feasibility and acceptability of applying VIT to improve the PRF of the parents as primary carers of children hospitalized in a psychiatric service.

Methods

This is a pilot randomized, single-masked (outcome assessor) study with a qualitative component. It will involve a block randomization procedure to generate a 2:1 allocation (with more people allocated to the intervention arm). The intervention consists of four modules; every module has both one video-recorded play session and one VIT session per week. People assigned to the control group will receive treatment as usual plus weekly play sessions. Feasibility and acceptability of the study will be quantitatively and qualitatively assessed. Evaluation of the caregivers will include assessments of PRF, wellbeing and personality structure; assessments of children will include parent-ratings and clinician-ratings of symptomatology and general functioning. After every video feedback (VF) session, PRF, the caregiver’s wellbeing and children’s general functioning will be reassessed.

Discussion

This study will contribute to the currently scarce evidence on how to provide family attachment-based interventions in a child inpatient psychiatric unit. It will also inform the design and implementation of a future randomized clinical trial.

Trial registration

ClinicalTrials.gov, NCT03374904. Registered on 14 December 2017 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3310-y) contains supplementary material, which is available to authorized users.

Depressive symptoms and self-harm among youngsters referred to child welfare: The role of trust in caregiver support and communication

Depressive symptoms and self-harm, i.e. non-suicidal self-injury and suicidal behaviors, are highly prevalent in youngsters involved in Child Welfare System (CWS) services. Little research investigates, however, why these CWS youngsters are at risk. We explored whether trust in caregiver support and communication about experiences with primary caregivers, are associated with CWS youngsters' depressive symptoms and/or self-harm. An anonymous online survey of 271 CWS youngsters (10-21 years of age, 57.2% female) was used to assess trust and communication, and depressive symptoms/self-harm. Results showed significant negative associations between self-reported trust in maternal and paternal support, and depressive symptoms/self-harm. Communication about experiences with one's biological mother mediated the relationship between trust in maternal support and depressive symptoms/self-harm. Furthermore, the presence of an additional trustworthy caregiver buffered the impact of low trust in maternal or paternal support on depressive symptoms/self-harm. Implications for interventions targeting CWS youngsters' depressive symptoms and self-harm are discussed.