Parenting and family interventions in lower and middle-income countries for child and adolescent mental health: A systematic review

BACKGROUND

Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential.

METHOD

This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0-24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes.

MAIN FINDINGS

We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs.

PRELIMINARY CONCLUSIONS

Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.

Family systemic psychosocial support for at-risk adolescents in Lebanon: study protocol for a multi-site randomised controlled trial

Background

Adolescents growing up in communities characterised by adversity face multiple risk factors for poor mental health and wellbeing. There is currently a scarcity of research on effective approaches for preventing and treating psychological distress in this population, particularly in humanitarian settings. The powerful impact of the home environment and family support is well known; however, approaches targeting the family are seldom developed or evaluated in such settings. We developed a brief family systemic psychosocial support intervention to be delivered through existing child protection systems with non-specialist facilitators. This paper outlines the study protocol for a randomised controlled trial of the intervention in Lebanon.

Methods

We will conduct a single-blind hybrid effectiveness-implementation multi-site RCT comparing the locally developed systemic family intervention to a waitlist control group for families residing in vulnerable regions in North Lebanon and Beqaa governorates (including families of Syrian, Palestinian, and Lebanese backgrounds). Outcomes on a range of family, adolescent, and caregiver measures will be assessed at baseline (T0) and post-intervention (T1), and at a 3-month follow-up for the treatment arm (T2). Families will be eligible for the trial if they are identified by implementing organisations as being medium-to-high risk for child protection concerns and have one or more adolescent aged 12–17 who demonstrates significant psychological distress on a self-report brief screening tool. Families will be randomly assigned to a treatment or a waitlist control condition. Families in the waitlist condition will receive a group version of the programme after completion of the study, to allow us to assess feasibility, acceptability, and preliminary indications of intervention effects of this modality. The primary outcome is reduction in overall adolescent-reported psychological distress over time, with post-intervention (T1) as the primary endpoint. Secondary adolescent-reported outcomes include family functioning, psychosocial wellbeing, and emotional regulation difficulties. Secondary caregiver-reported outcomes include parenting style, family functioning, psychological distress, and emotional regulation difficulties.

Discussion

This trial will provide the first assessment of the effectiveness of the family systemic psychosocial support intervention for use in Lebanon, with important implications for the use of systemic, low-cost, non-specialist interventions for this age range.

Trial registration

Local registry:

National Mental Health Program, Ministry of Public Health, Lebanese Republic. Registered on 19 October 2021

Lebanese Clinical Trial Registry LBCTR2021104870. Registered on 13 October 2021

Global registry: ISRCTN ISRCTN13751677. Registered on 1 November 2021

Disseminating evidence-based research on mental health and coping to adolescents facing adversity in Lebanon: a pilot of a psychoeducational comic book 'Somoud'

Background

Despite advances in the evidence base and scaling up of mental health and psychosocial interventions for children and adolescents affected by conflict and adversity, a theory-practice gap remains, with limited translation of research findings to affected communities.

Methods

In order to disseminate findings from a review on mental health and coping for children and adolescents, a psychoeducational comic book ‘Somoud’ was developed and piloted with adolescents and their caregivers in Lebanon, using a qualitative Grounded Theory approach.

Results

In total, 10 participants (5 adolescents, 5 parents), took part in the study. Using Thematic Content Analysis, 6 themes were identified; 1) psychoeducation versus misinterpretation, 2) balancing depth with accessibility, 3) aesthetic appeal, 4) contextual relevance and realism, 5) daily stressors, and 6) parental and social relationships.

Conclusions

The findings demonstrate the importance of cultural and contextual piloting of psychoeducational content, and the potential usefulness and accessibility of a comic book format to disseminate information to adolescents. Data from the pilot was used to inform the development of a new version of ‘Somoud’ for sharing with adolescents in Lebanon. Further research is required to establish the effectiveness of the psychoeducational book as a ‘self-help’ tool, and to further improve knowledge exchange between researchers and communities.