Web-based integrated bipolar parenting intervention for parents with bipolar disorder: a randomised controlled pilot trial

The Triple P System of Evidence-Based Parenting Support: Past, Present, and Future Directions

Triple P is an integrated, multi-level system of evidence-based parenting support designed to promote the well-being of children and families to reduce prevalence rates of social, emotional, and behavioral problems in children and adolescents and to prevent child maltreatment. The system developed gradually over four decades to address the complex needs of parents and children from diverse family, socioeconomic and cultural backgrounds. It blends universal and targeted programs, a focus on developing parental self-regulation capabilities, and adopts a life span perspective with a population health framework. The Triple P system is used as a case example to discuss the past, present and future challenges, and opportunities involved in developing, evaluating, adapting, scaling and maintaining a sustainable system of evidence-based parenting intervention. Seven stages of program development are outlined from initial theory building and development of the core parenting program through to the sustained deployment of the intervention system delivered at scale. The importance of ongoing research and evaluation is highlighted so that different programs within the system evolve and adapt to address the contemporary concerns and priorities of families in diverse cultural contexts. A well-trained workforce is essential to deliver evidence-based programs, in a need-responsive manner that blends both fidelity of delivery and flexibility and is tailored to respond to the needs of individual families and local context. Programs need to be gender-sensitive, culturally informed, and attuned to the local context including relevant policies, resources, cultural factors, funding, workforce availability and their capacity to implement programs.

The efficacy of online parenting interventions in addressing emotional problems in children and adolescents: A meta-analysis of randomized controlled trials

BACKGROUND

Parenting interventions offer opportunities for reducing emotional problems in children and adolescents, based on addressing parental risk and protective factors. Online parenting interventions were developed more recently to increase access to interventions for parents, and the aim of this systematic review and meta-analysis is to investigate their efficacy.

METHODS

We conducted a meta-analysis pooling studies that tested online parenting interventions having as outcome emotional problems in children/adolescents. We considered as secondary outcome parent mental health and moderation effects for the type of population, intervention characteristics, and risk of bias.

RESULTS

Thirty-one studies met the inclusion criteria and were included in the meta-analysis. For child/adolescent emotional problems, at post-intervention, 13 studies were pooled, yielding an ES of g = -0.26 (95% CI [-0.41, -0.11]; p < .001) favoring the online parental interventions over wait-list, while at follow-up five RCTs were pooled, yielding an ES of g = -0.14 (95% CI [-0.25, -0.02]; p = .015) favoring the parental online interventions over wait-list. Moderation analyses suggest that longer online parenting programs are more effective in improving child emotional problems.

CONCLUSIONS

Online parent programs have positive effects on reducing emotional symptoms in children and adolescents. Future research will need to develop and investigate the efficacy of the programs that can personalize their contents and delivery methods.

Reduced parenting stress following a prevention program decreases internalizing and externalizing symptoms in the offspring of parents with bipolar disorder

BACKGROUND

Offspring of parents with bipolar disorder (OBD) are at risk for developing mental disorders, and the literature suggests that parenting stress may represent an important risk factor linking parental psychopathology to offspring psychopathology. We aimed to investigate whether improvements in parenting stress mediated the relationship between participation in a prevention program and offspring internalizing and externalizing symptoms at follow-up.

METHODS

Families having a parent with BD (N = 25) underwent a 12-week prevention program. Assessments were conducted at pre-intervention, post-intervention, and at 3- and 6-month follow-ups. Families of parents with no affective disorders (i.e., control families) served as a comparison sample (N = 28). The Reducing Unwanted Stress in the Home (RUSH) program aimed to teach communication, problem-solving, and organization skills to improve the rearing environment. Measures included the Parenting Stress Index-4th Edition, the Behaviour Assessment Scales for Children-2nd Edition, and the UCLA Life Stress Interview.

RESULTS

Families having a parent with BD reported more parenting stress at pre-intervention, and more change across time, than control families. Improvements in parenting stress mediated the relationship between participation in the intervention and reduced offspring internalizing and externalizing symptoms. While families having a parent with BD reported more chronic interpersonal stress at pre-intervention, no intervention effects were found.

CONCLUSIONS

The findings demonstrate that a preventative intervention targeting parenting stress in families may serve to prevent the development of mental disorders in at-risk children.

Decreased Psychological Well-Being in Patients With Bipolar Disorder in Remission

BACKGROUND

The goals of this study were to introduce psychological well-being as an important subject of inquiry in bipolar disorder, to compare well-being in a cohort of patients with bipolar disorder with that of a normative sample, and to assess whether common measures of well-being and mood measure empirically distinct phenomena.

METHODS

Participants were outpatients with bipolar I disorder in remission (N=37) from the Enhancing Emotion Regulation in Bipolar Disorder (EERBD) study and a matched community normative sample from the Midlife in the United States (MIDUS) survey (N=6297). The Psychological Well-Being Scale (PWBS) was used to measure psychological well-being. We calculated means and SD of scores on the PWBS and evaluated the differences between the scores of the bipolar I and community samples. We also tested the association between raw and change scores in depression [Hamilton Rating Scale for Depression (HAM-D)] and eudaimonic well-being (PWBS) using Spearman correlation coefficients.

RESULTS

The MIDUS survey sample (N=6297) was 48% male, with a mean age of 47 years (SD=13 y). The EERBD sample (N=37) was 27% male, with a mean age of 41 years (SD=11 y). In the bipolar sample, the baseline mean score on the HAM-D was 12.7 (SD=6.0) and the mean score on the Young Mania Rating Scale was 6.1 (SD=6.2). The baseline mean sum score on the PWBS in the normative community MIDUS sample was 100 (SD=14), while that of the bipolar I EERBD sample was 79 (SD=15) at baseline, 84 (SD=13) posttreatment, and 84 (SD=12) at the 3-month follow-up assessment. The effect sizes of the differences at all timepoints were large (Hedges g=1.42 at baseline, 1.11 at the end of treatment, and 1.06 at the 3-mo follow-up). No association was found between the PWBS and depression scores.

CONCLUSIONS

Outpatients with bipolar disorder in remission demonstrated substantially impaired psychological well-being, despite low levels of depressive symptoms, compared with a normative community sample.

The Triple P Positive Parenting Program for Parents With Psychosis: A Case Series With Qualitative Evaluation

Although many people with psychosis are parents, managing the dual demands of poor mental health and parenting can be stressful and may contribute to poorer outcomes for both parent and child. Parenting interventions have the potential to improve outcomes for the whole family but need evaluation of feasibility in this context. The Triple-P Self-Help Workbook was implemented with guidance and support with 10 parents experiencing psychosis in a multiple baseline case series study. Sessions were weekly and home-based. Outcome measures examined facets of parenting, child behavior, self-efficacy and parental mental health. Follow up interviews explored parents' perspectives of the perceived impact of the intervention and apparent mechanisms of change. The program resulted in clinically significant change (>25% improvement) in mental health, parenting and child behavior measures post-intervention for the 50% who completed all 10 sessions and improvements were maintained at 3 and 6 month follow up. Interviews with those who completed the program revealed it to have been transformative: parents reported positive changes in parenting style; they were empowered with regard to their parenting and had a greater sense of control over their mental health. This study provides preliminary evidence that self-directed Triple P might be able to reduce the symptoms of psychosis by improving family functioning. Findings could inform the future development or adaptation of evidence-based parenting interventions for parents with psychosis in order to improve their mental health, aid recovery, and intervene early in the lives of children at risk of poor long-term outcomes.

Promoting Mental Health in Parents of Young Children Using eHealth Interventions: A Systematic Review and Meta-analysis

Parent stress and mental health problems negatively impact early child development. This study aimed to systematically review and meta-analyze the effect of eHealth interventions on parent stress and mental health outcomes, and identify family- and program-level factors that may moderate treatment effects. A search of PsycINFO, Medline, CINAHL, Cochrane and Embase databases was conducted from their inception dates to July 2020. English-language controlled and open trials were included if they reported: (a) administration of an eHealth intervention, and (b) stress or mental health outcomes such as self-report or clinical diagnosis of anxiety and depression, among (c) parents of children who were aged 1–5 years old. Non-human studies, case reports, reviews, editorials, letters, dissertations, and books were excluded. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Random-effects meta-analyses of standardized mean differences (SMD) were conducted and meta-regressions tested potential moderators. 38 studies were included (N = 4360 parents), from 13 countries (47.4% USA). Meta-analyses indicated eHealth interventions were associated with better self-reported mental health among parents (overall SMD = .368, 95% CI 0.228, 0.509), regardless of study design (k = 30 controlled, k = 8 pre-post) and across most outcomes (k = 17 anxiety, k = 19 depression, k = 12 parenting stress), with small to medium effect sizes. No significant family- or program-level moderators emerged. Despite different types and targets, eHealth interventions offer a promising and accessible option to promote mental health among parents of young children. Further research is needed on moderators and the long-term outcomes of eHealth interventions. Prospero Registration: CRD42020190719.

Improving the Assessment Process of Family Functioning in Adult Bipolar Disorders: A PRISMA Systematic Review

In order to determine family functioning in the treatment of adults with bipolar disorders, guidelines are needed regarding the way family functioning may be assessed. The present systematic review aims to investigate how family functioning is assessed in this context. Following PRISMA guidelines, a total of 29 studies were reviewed. Results showed that although there was no consensual family functioning assessment across studies, 27 studies (93%) relied on self-report questionnaires, 12 studies (41%) relied on one family member as an informant (adult with bipolar disorder or other) and the adult considered was mostly a woman in the acute phase of bipolar I disorder. Significant heterogeneity was observed in the assessment of family functioning. Methodological considerations regarding the assessment of family functioning are discussed.

The Use of Information and Communication Technologies in Family Support across Europe: A Narrative Review

The COVID-19 pandemic has accelerated the use of information and communication technology (ICT) to deliver parenting and mental health support services to families. This narrative review illustrates the diverse ways in which ICT is being used across Europe to provide family support to different populations. We distinguish between the use of ICT in professional-led and peer-led support and provide implementation examples from across Europe. We discuss the potential advantages and disadvantages of different ways of using ICT in family support and the main developments and challenges for the field more generally, guiding decision-making as to how to use ICT in family support, as well as critical reflections and future research on its merit.

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.

Effectiveness of a Web-Based Intervention on Parental Psychological Flexibility and Emotion Regulation: A Pilot Open Trial

"Parenting Forest" is an informed contextual therapy parenting program for improving parental emotion regulation strategies and psychological flexibility. The aim of this study was to evaluate the preliminary effectiveness of a self-guided web-based intervention of the Parenting Forest program. The intervention program consists of six self-applied sequential modules that use strategies from contextual therapies for providing a parenting style open to experience, mindful and committed to its actions. A pilot controlled open trial was conducted. Eligible parents (n = 12) enrolled in the web-based intervention completed baseline (T1) and post-intervention (T2) assessment instruments. Parental psychological flexibility, avoidance, emotional regulation, parental stress, satisfaction with life, children's psychological adjustment and client satisfaction were measured to assess the effects of the intervention. Mood, coping, and value-related actions were assessed as measures of progress. The results showed positive effects on the parents' psychological flexibility and emotion regulation. Parents' mood and coping skills improved throughout the intervention program. These results provide preliminary evidence of the web-based Parenting Forest's efficacy, although further research is needed to assess its effectiveness for prevention and in clinical populations.

Exploring Staff Implementation of a Self-directed Parenting Intervention for Parents with Mental Health Difficulties

Parents with mental health difficulties face significant barriers in accessing evidence-based parenting interventions. Self-directed approaches may be a destigmatising, accessible alternative. Evidence has suggested that Triple P Positive Parenting Programme's self-directed format is as effective as more time- and cost-intensive delivery methods. The aim of the current study was to establish whether staff were able to use this intervention with parents with mental health difficulties and to explore staff experiences of implementation. Triple P self-help workbooks were provided to practitioners across three teams. Data were collected regarding workbook uptake and use. Interviews with staff exploring their experiences of implementation were analysed using thematic analysis. Overall, 41 participants were recruited, of which 12 (29.27%) also consented to interviews. Overall, six practitioners (14.63%) reported that they utilised the workbook. Uptake and utilisation were varied, but practitioners who used the workbook reported positive outcomes. Interviews revealed themes regarding practitioner concerns, views of the intervention and implementation issues. Self-directed Triple remains a promising intervention but its feasibility is dependent on addressing barriers to implementation and facilitating a family-focused approach to meet the needs of these parents and their children.

Online parent programs for children's behavioral problems: a meta-analytic review

A recent increase in the development of online parent programs calls for the need to understand how effective these strategies are for improving children's mental health. We meta-analyzed the effects of online parent programs on children's behavioral problems. Moreover, we explored the combinations of program components to yield stronger program effects. Medline, PsycINFO, Web of Science, and the Cochrane Library were searched. We included peer-reviewed randomized studies evaluating the effect of an online parent program. Effect sizes (Hedges' g) were calculated from post intervention means and standard deviations. We used Qualitative Comparative Analysis (QCA) to identify pathways to effectiveness and individual content and delivery components that seem sufficient or necessary for yielding high effectiveness. Of 2941 articles, 12 articles with a total of 2025 participants met the inclusion criteria. Online parent programs have significant effects on children's behavioral problems (g =   - 0.32; 95% CI, - 0.47 to - 0.17), emotional problems (g =  - 0.22; 95% CI, - 0.31 to - 0.13), and parental mental health problems (g =  - 0.30; 95% CI, - 0.42 to - 0.17). In the QCA, sending parents reminders to work on the program was the only one sufficient component. In conclusion, online support programs reduce children's behavioral and emotional problems and improve parental mental health. Sending parents reminders to work on the program seems to contribute to high effectiveness. Review Registration This study was registered with PROSPERO, number CRD42017080051.

An internet-delivered self-management programme for bipolar disorder in mental health services in Ireland: Results and learnings from a feasibility trial

Bipolar disorder (BD) is a chronic condition that requires continued care. Psychological interventions are recommended by clinical guidelines but there are treatment barriers that prevent patients to access these services. Internet-delivered self-management interventions are promising alternatives to improve treatment accessibility in patients with BD. Several studies indicate that these interventions are acceptable and beneficial for patients with BD, but no studies have been conducted in routine care settings. This trial aimed to examine the feasibility, acceptability, and preliminary efficacy of implementing an internet-delivered, clinician-supported intervention for BD as an adjunct to treatment as usual at two secondary-care services in Ireland. This study used an uncontrolled design with mixed-methods evaluation. Feasibility and acceptability were assessed in terms of recruitment, use of the intervention, and satisfaction from both clinicians and patients' perspectives. Personal recovery, quality of life, and severity of symptoms were measured at baseline and post-intervention. Fifteen patients signed consent and used the programme for 10 weeks. Usage of the intervention was adequate with high frequency of tool usage. There was a significant improvement in patients' sense of personal recovery (z = 2.38, p = .017). The intervention was found acceptable and easy-to-use; however, implementation barriers will need to be overcome for scaling the intervention. This is the first study testing the feasibility of a digital intervention for patients with BD in public mental health services in Ireland. More research is needed in order to increase the understanding of how to promote the integration and the uptake of digital interventions for individuals with BD.

Family Functioning and Psychological Health of Children with Mentally Ill Parents

Parental mental illness can be linked to reduced family functioning, which is associated with more conflicts, less adaptability and cohesion as well as a disorganized pattern of everyday planning. Concurrently, family functioning is an important moderator for the influence of parental mental disorders on the development of the children. Consequently, the current study addresses the correlation of family functioning in families with mentally ill parents and the psychological health of the children. The sample consists of 67 mentally ill parents. Both parents and therapists completed questionnaires related to family functioning and the psychological health of the children. Family functioning was rated as dysfunctional in 38% of the families. The psychological health of the children was classified as clinical or subclinical in 43% of the cases. 52% of the children were rated to have no psychological problems. In families with good family functioning, children were assessed to have less psychological problems than in families with poor functioning. Children outside the clinical range lived in families with good family functioning and vice versa. Significant positive correlations were found between the FB-A scales, the CBCL/4-18 syndrome scales and the CBCL/4–18 total score. Results indicate that family functioning and psychological health of children in families with mentally ill parents correlate closely and represent potential targets for future family interventions.

Harnessing the Power of Positive Parenting to Promote Wellbeing of Children, Parents and Communities Over a Lifetime

Evidence-based parenting support (EBPS) programs derived from social learning theory, cognitive behavioural principles, and developmental theory are among the most successful innovations in the entire field of psychological intervention. EBPS programs have been at the cutting edge of global dissemination efforts to increase community access to evidence-based parenting programs. Despite the widely recognised success of these efforts, existing models of parenting intervention are not a panacea, and much can be done to improved outcomes. Efforts to improve outcomes have included the emergence of a population-based approach to increase reach of intervention. This has included the development of flexible delivery modalities, including online parenting interventions, the incorporation of strategies to enhance cultural relevance and acceptability of programs, and more recently, applications with parents in very low resource settings. Further enhancements of outcomes are likely to be forthcoming as we gain a better understanding of the mechanisms that explain positive intervention effects and non-response to interventions. More cost-effective online professional training models are needed to disseminate and promote the sustained use of EBPS programs. New interventions are required for the most vulnerable parents when parenting concerns are complicated by other problems such as trauma, addictions, relationship conflict, family violence, mental health problems and intergenerational poverty. However, to scale effective programs, Commonwealth and state government policies and funding priorities need to respond to evidence about what works and make sustained investments in the implementation of parenting programs. Possible strategies to enhance the policy impact of intervention research are discussed.

Basic science and treatment innovation

The idea of trans-diagnostic and modular treatments highlighted in this Editorial points the way beyond self-contained 'branded' therapies to a more flexible intervention science responsive to advances in basic science and relevant also to personalisation of therapies. For such approaches to be rigorous, there need to be empirically identified trans-diagnostic target mechanisms. The Editorial reviews two studies of potential mechanisms of this kind in the developmental neurobiology of stress response in children at risk from prenatal maternal stress and post natal neglect and maltreatment. A number of treatment trials are also reviewed illustrating the common method of digitally-aided therapy; a common theme is the difficult in sustaining adherence to such treatment delivery methods. Finally it reviews a useful independent investigation of a commonly used autism screening instrument, suggesting improvements for greater specificity.