Evaluating the effectiveness of the Family Connections program for caregivers of youth with mental health challenges, part I: A quantitative analysis

Caregivers of individuals with borderline personality disorder: The relationship between leading caregiver interventions and psychological distress/positive mental well-being

Burden and psychological distress are higher in informal caregivers (ICs) of people with severe emotional and behavior dysregulation who have been given a diagnosis of borderline personality disorder (BPD) compared with non-caregivers. The current cross-sectional study examines the difference in outcomes of ICs of people with BPD who have received the intervention Family Connections (FC) and who also led interventions for other caregivers (caregiver-leaders) compared with those who have attended FC but not led caregiver interventions (non-leader-FC participants). The sample for this research is from a larger study (Hayes et al., 2023, Borderline Personality Disorder and Emotion Dysregulation, 10, 31). Data for 347 participants who self-reported receiving FC and completed the McLean Screening Instrument for BPD-Carer Version, the Brief COPE, the Multidimensional Scale of Perceived Social Support, the Kessler Psychological Distress scale, the WHO-5 Well-being Index, and the Coronavirus Anxiety Scale were analyzed. The results found that being a caregiver-leader was associated with higher positive mental well-being and lower psychological distress compared with non-leader-FC participants. Being a caregiver-leader was also associated with significantly greater use of the coping strategy of positive reframing and lower use of behavioral disengagement and self-blame than non-leader-FC participants. The study provides preliminary evidence that for those who have received FC, becoming an intervention leader is associated with better outcomes than caregivers who do not become leaders and provides support for caregiver-led rollout of FC across services.

Group intervention for family members of people with borderline personality disorder based on Dialectical Behavior Therapy: Implementation of the Family Connections® program in France and Switzerland

BACKGROUND

Families and significant others of people with borderline personality disorder (BPD) show increased levels of psychological distress. Family Connections®, a 12-week group intervention based on the principles of Dialectical Behavior Therapy, was designed to provide families with both information about the disorder and emotion regulation skills. It has been progressively implemented in French-speaking European countries.

METHODS

We conducted an observational, multicenter study in France and Switzerland. In total, 149 participants of the Family Connections program were included among five centers. Burden, depression, coping, and emotion regulation were assessed before and after the intervention.

RESULTS

One-way repeated measures MANOVA showed that the burden, depressive symptoms, emotion regulation and coping all changed significantly after the intervention (p < 0.001, partial η2 = 0.297). T-tests showed that the burden significantly decreased after the intervention (p < 0.0001, d = -0.48), as did depressive symptoms (p < 0.0001, d = -0.36) and difficulties in emotion regulation (p < 0.0001, d =-0.32) whereas coping improved (p < 0.0001, d = 0.53). Two-way mixed ANOVA showed that burden reduction was stronger among female than male participants (p = 0.048, η2 = 0.027). Before the intervention, the burden was higher for female than male participants (p < 0.001). An initial linear regression showed the burden reduction to be associated with a decrease in the resignation of the participants (β = 0.19, p = 0.047). A second linear regression showed the burden reduction to be associated with the intensity of the relatives' symptoms at baseline (β = 0.22, p = 0.008) and improvement of emotional clarity of the participants (β = 0.25, p = 0.006).

CONCLUSION

This Dialectical Behavior Therapy-Based psychoeducational intervention is an appropriate way to support French-speaking European families of people with BPD.

The lived experience of French parents concerning the diagnosis of their children with borderline personality disorder

BACKGROUND

Psychiatrists often hesitate to diagnose borderline personality disorder (BPD). While individuals with BPD have reported both positive and negative experiences upon receiving their diagnosis, no study has specifically explored this issue among parents. Parents of children diagnosed with BPD can benefit from recently developed family-support interventions such as the Family Connections program. Our study aimed to explore the experiences of parents learning about their child's BPD diagnosis and to investigate the impact of the Family Connections program on their experiences.

METHODS

This qualitative study, conducted in France following the five-stage IPSE method, involved parents of children with BPD recruited through the Family Connections association in Versailles. We conducted semi-structured interviews and used purposive sampling for data collection until data saturation was reached. Data analysis was performed using a descriptive and structuring approach with NVivo 12 software to elucidate the structure of lived experiences.

RESULTS

The study included 21 parents. The structure of the lived experiences was characterized by three central axes: (1) the long and difficult road to diagnosis; (2) communicating the BPD diagnosis to parents: a necessary step; (3) the pitfalls of receiving the diagnosis. The Family Connections program provided significant support in these areas, particularly in understanding the diagnosis, enhancing communication with their child, and reducing social isolation.

CONCLUSION

These findings highlight the challenges parents face when receiving a BPD diagnosis for their child and underscore the need for an early, clear, and detailed explanation of the diagnosis. The specific experiences of receiving the diagnosis are indicative of the broader care experience parents undergo and highlight their need and right to be informed, supported, and guided throughout their child's treatment.

Health through the eyes of youths: a qualitative study

Background

Emerging definitions of health have suggested a shift in focus to one's ability to manage their health condition, function, and social determinants of health. The construct of health for youths with mental health and substance use disorders (MHSU) is complex and multi-dimensional with interplay between biological, behavioral, and social conditions. Expanding definitions of health is crucial in the measurement of health and evaluation of integrated youth services (IYS) systems for people with MHSU disorders. Hence, it is critical to understand the construct of health from the perspective of a young person living with a MHSU disorder.

Methods

This study was conducted using inductive thematic analysis. Three focus groups were conducted from July to August 2017.

Results

A total of 22 youths (17-24 years) took part in this study. Results showed that health is a multidimensional construct situated in the ecosystem of a person's environment. Health can be understood from two macro themes: Individual health and Determinants of health. It consisted of physical health, mental health, day-to-day functioning, and being in control of your own health condition. Systemic and social factors were factors that influenced the state of health.

Conclusion

This study contributes to a conceptualization of good health in youth with MHSU disorders. This conceptualization can aid in the development of more accurate measures of health and functioning and the evaluation of mental health services for youth with MHSU.

Perspectives of parents of adolescents with repeated non-suicidal self-injury on sharing their caretaking experiences with peers: a qualitative study

Background

The prevalence of non-suicidal self-injury among adolescents has increased over the years. Most parents, however, are poorly informed and confused about this behavior. Sharing caretaking experiences with parents in similar situations seems to be beneficial. Nevertheless, few researchers have explored the views of parents who share their caretaking experiences with peers.

Aim

This study aimed to investigate the perspectives of parents of adolescents with repeated non-suicidal self-injury on sharing their caretaking experiences with peers as well as the motivations for and barriers to this behavior.

Methods

This qualitative study adopted a purposive sampling method. Participants (16 mothers and 2 fathers) were recruited from the mental health center of a tertiary hospital in Chengdu, Sichuan, China. A total of 18 semistructured face-to-face individual interviews were conducted. All interviews were audio-recorded and analyzed thematically using NVivo 11.

Results

Three themes and nine subthemes were identified: (1) sharable caretaking experiences: reflection and transformation, self-emotional management, and diversified support; (2) motivations for sharing: empathy, reciprocity, and meaning; and (3) barriers to sharing: inadequate knowledge, low self-identity, and concerns for children.

Conclusion

Parents accumulate a wealth of experience during their long-term care of adolescents with repeated non-suicidal self-injury. Although most parents are willing to share their caretaking experiences with peers, there are several barriers. Therefore, in order to increase parents' motivation to share, psychological education is necessary.

Parent and Carer Skills Groups in Dialectical Behaviour Therapy for High-Risk Adolescents with Severe Emotion Dysregulation: A Mixed-Methods Evaluation of Participants' Outcomes and Experiences

BACKGROUND

There is an established evidence-base for dialectical behaviour therapy for adolescents (DBT-A) in the treatment of young people with severe emotion dysregulation and related problems, including repeated self-harm and suicidal behaviours. However, few studies have reported on parental involvement in such treatments. This study aims to explore the outcomes and experiences of participants of a dedicated skills group for parents and carers embedded within an adapted DBT-A programme in the United Kingdom.

METHOD

This study was conducted within a specialist outpatient Child and Adolescent Mental Health Services (CAMHS) DBT programme in the National Health Service (NHS) in London. Participants were parents and carers of adolescents engaged in the DBT-A programme. Participants attended a 6-month parent and carer skills group intervention and completed self-report measures relating to carer distress, communication and family functioning, at pre-intervention and post-intervention. Following the intervention, semi-structured interviews were also completed with a subgroup of participants to explore their experiences of the skills group and how they perceived its effectiveness. Quantitative and qualitative methods were used to analyse the data collected from participants.

RESULTS

Forty-one parents and carers completed the intervention. Participants reported a number of statistically significant changes from pre- to post-intervention: general levels of distress and problems in family communication decreased, while perceived openness of family communication and strengths and adaptability in family functioning increased. A thematic analysis of post-intervention interviews examining participant experiences identified six themes: (1) experiences prior to DBT; (2) safety in DBT; (3) experiences with other parents and carers; (4) new understandings; (5) changes in behaviours; and (6) future suggestions.

DISCUSSION

Parents and carers who attended a dedicated DBT skills groups, adapted for local needs, reported improvements in their wellbeing, as well as interactions with their adolescents and more general family functioning, by the end of the intervention. Further studies are needed which report on caregiver involvement in DBT.

The Influence of Family Intervention on the Treatment of Adolescent Patients With Borderline Personality Disorder: A Literature Review

Borderline personality disorder (BPD) is a widespread mental disorder linked to functional impairment and a high suicide rate. Adolescent BPD is now recognized as a reliable and valid diagnosis in psychiatric classification systems and national treatment guidelines. Family issues, such as parental underinvolvement or neglect, may affect the mentalization process and attachment styles. Thus, the family is crucial to understanding the etiology of BPD in adolescents. Family intervention was primarily used as a component of the psychotherapy strategy in the current treatment of BPD, including pharmacological and psychotherapy measures. The primary objective of this study is to review previous research on the effectiveness of family intervention in treating adolescents with BPD. Although there is currently little data, studies in this paper show that family intervention is a realistic treatment option for adolescents with BPD.

Family connections vs treatment at usual optimized in the treatment of relatives of people with suicidal behavior disorder: study protocol of a randomized control trial

BACKGROUND

Relatives of people diagnosed with suicidal behavior disorder (SBD) feel guilty, afraid, hopeless, depression and anxiety. It is necessary to help the relatives of people with SBD to reduce their discomfort and burden. Family Connections (FC) is a program that has been shown to be effective in reducing burden, depression, and anxiety, and increasing dominance and validating behaviors in relatives of people with borderline personality disorder. However, there are no RCTs that demonstrate the efficacy of the FC program in patients with SBD. Our research team adapted FC for relatives of people with SBD for delivery in the Spanish population (FC-SBD). The FC-SBD program contains 12 two-hour sessions held once a week. The first aim is to verify the efficacy of the FC-SBD intervention for relatives of people diagnosed with SBD in a randomized control trial with a Spanish sample. The second objective is to analyze the feasibility and acceptance of FC-SBD in relatives. The third aim is to analyze whether the changes produced in the psychological variables in the relatives after the intervention are related to changes in the psychological variables of the patients. This paper presents the study protocol.

METHODS

The study design consists of a two-arm randomized controlled trial with two conditions: FC-SBD or Treatment as usual optimized (TAU-O). Participants will be relatives of patients who meet DSM-5 criteria for SBD. The caregivers` primary outcome measures will be the BAS. Secondary outcomes will be DASS-21, FES, DERS, QoL. The patient's primary outcome measures will be the frequency of critical incidents with the family member with SBD. Secondary measures will be the INQ, PHQ-9, OASIS. Participants will be assessed at pretreatment, post-treatment, and 6-month follow-up. The intention-to-treat principle will be used when analyzing the data.

DISCUSSION

This study will provide results that confirm the efficacy of the FC-SBD in relatives of people with SBD. These results will also confirm its good acceptance by family members and help us to find out whether it is a good program to improve the prevention of suicidal behaviors in the family environment.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05157607 . Registered 15 December 2021.

Borderline personality traits mediate the relationship between low perceived social support and non-suicidal self-injury in a clinical sample of adolescents

BACKGROUND

Non-suicidal self-injury (NSSI) is a serious public health concern among adolescents, especially in clinical settings. Social support plays a critical role in the onset and maintenance of NSSI in adolescence. NSSI is closely associated with borderline personality disorder (BPD), yet no previous work has analyzed the mediating role of borderline traits in the relationship between perceived social support (PSS) and NSSI. This study aimed to address this gap.

METHODS

Participants were 228 adolescent patients (12 to 18 years old), who completed a clinical interview and self-report measures of BPD-traits, current psychological distress, emotion dysregulation and PSS. They were grouped based on the presence (vs. absence) of NSSI. Univariate and multivariate logistic regression analyses were used to identify risk factors of NSSI, and a mediation analysis was conducted to examine the intermediary role of borderline traits in the relationship between PSS and NSSI.

RESULTS

NSSI was highly prevalent in our sample (58%) and was associated with higher clinical severity. Low PSS predicted NSSI in univariate, but not multivariate regression. Mediation analyses showed that borderline traits fully accounted for the relationship between low PSS and NSSI, even when controlling for current psychological distress and gender.

LIMITATIONS

Cross-sectional design through self-report assessment.

CONCLUSIONS

Findings suggest that adolescents with low PSS are especially vulnerable for developing NSSI due to elevated BPD traits. In clinical settings, interventions aimed to reduce borderline symptoms may be a promising treatment option for adolescents with NSSI and low PSS.

Family Structure is Associated with Mental Health and Attention Deficit (Hyperactivity) Disorders in Adolescents with Type 1 Diabetes

OBJECTIVE

To analyze the cross-sectional associations of family structure with mental health and attention deficit (hyperactivity) disorders (AD(H)D) in 11- to 17-year-old adolescents with early-onset type 1 diabetes participating in one of three baseline surveys as part of an ongoing cohort study.

METHODS

Parents (n=1,631) completed the Strengths and Difficulties Questionnaire to screen for their child's mental health and answered questions about their child's diagnosis of AD(H)D. Associations between mental health or AD(H)D and family structure were analyzed using multivariable logistic regression analyses adjusted for various personal and diabetes-related variables.

RESULTS

Compared to adolescents living with both parents, adolescents living with one parent and his/her partner had 2.35 (95% confidence interval 1.32; 4.21) higher odds of abnormal screening result and 2.08 (1.09; 3.95) higher odds of a borderline screening result while adolescents living with a single parent had 1.84 (1.07; 3.17)/1.08 (0.53; 2.21) higher odds of abnormal/borderline screening results. The odds ratios for diagnosed attention deficit (hyperactivity) disorder were 2.17 (0.98; 4.84) for adolescents living with one parent and his/her partner and 1.27 (0.54; 3.01) for those living with a single parent vs. both parents.

CONCLUSIONS

Our results indicate higher odds of mental health problems and AD(H)D in adolescents with type 1 diabetes who do not live with both parents; this finding was most pronounced in individuals living with one parent and his/her partner vs. both parents. Longitudinal studies are needed to verify our results and elucidate the underlying mechanisms.

Evaluating the effectiveness of the Family Connections program for caregivers of youth with mental health challenges, part I: A quantitative analysis

INTRODUCTION

Caregivers of youth with mental health (MH) challenges are often faced with complex problems in relation to caring for their youth. Family Connections™ (FC) is a 12-week skills training program for families of individuals with MH challenges, developed originally for Borderline Personality Disorder. Research is needed to examine the effectiveness of FC for caregivers of youth with diverse MH challenges.

OBJECTIVE

To examine the effectiveness of FC for caregivers of youth with MH challenges.

METHODS

A total of 94 caregivers of youth with MH challenges participated in FC, across three sites in Ontario, Canada. Assessments occurred at baseline, 6 weeks, 12 weeks and follow-up. Primary outcomes include the Burden Assessment Scale and The Stress Index for Parents of Adolescents. Secondary outcomes included the caregiver's report of child behaviour, affect, mastery, coping and grief. Linear mixed model analyses were conducted, where time and the time × site interaction were defined as the fixed effects.

RESULTS

Statistically significant improvements over time were observed across outcome measures, including caregiver burden, grief, coping, and other measures. The time × site interaction was only significant for burden (P = .005).

CONCLUSION

This study demonstrates the effectiveness of FC for caregivers of youth with MH challenges. Future research should focus on differences across geographical sites and facilitation models.

PATIENT OR PUBLIC CONTRIBUTION

Caregivers were involved in the facilitation of FC. A person with lived experience was involved in analysing the data, reporting the results, and drafting the manuscript.

Evaluating the effectiveness of the Family Connections program for caregivers of youth with mental health challenges, part II: A qualitative analysis

Background

The Family Connections™ (FC) program is a 12‐week support and skill‐training program for caregivers of youth with mental health challenges. The intervention was originally developed with a focus on borderline personality disorder (BPD). It is important to understand the experiences of caregivers in such interventions, as well as its applicability beyond BPD, for the purposes of evaluation and ongoing program improvement.

Objective

To explore and analyse the experiences of caregivers of youth with diverse mental health challenges and who participated in FC.

Design

Semi‐structured interviews with thirteen FC‐participating caregivers of youth with mental health challenges.

Results

Thematic analysis uncovered three major themes regarding caregivers' experience with FC: (a) FC increased the caregivers' ability to manage their youth's mental health challenges; (b) participating in FC impacted their intra‐ and interpersonal spheres; and (c) improvements to the program were proposed. Following participation in FC, caregivers felt they learned a new approach to understanding themselves, their youth and mental health, and were better able to manage their youth's mental health challenges.

Discussion and conclusion

FC is a promising intervention for caregivers of youth with mental health challenges, beyond the traditional BPD focus. The intervention has the potential to provide broad‐based benefits for caregivers and should be considered for implementation and scale‐up across youth‐ and caregiver‐serving organizations. Potential areas of intervention flexibility and improvement are discussed.

Patient/public contribution

Caregivers were involved in the program development and facilitation of FC. A person with lived experience was involved with the analysis.