Parenting Interventions for Refugees and Forcibly Displaced Families: A Systematic Review

Globally, an estimated 79.5 million individuals have been displaced, nearly 40% of whom are children. Parenting interventions may have the potential to improve outcomes for displaced families. To investigate this, we conducted a systematic review to identify the types of caregiver or parenting interventions that have been evaluated among displaced families, to assess their efficacy across a range of contexts, and to describe their cultural and contextual adaptations. The review followed PRISMA guidelines. At stage one, all articles describing caregiver/parenting interventions for forcibly displaced families were included to provide a scoping review of the state of the literature. At stage two, only randomized controlled trials (RCTs) and quasi-experimental designs were included, allowing for quantitative analysis of program effects. A total of 30 articles (24 studies) were identified in stage one. 95.8% of these articles were published in the past 10 years. Of these, 14 articles (10 studies) used an RCT or quasi-experimental design to assess program efficacy or effectiveness. Relative to control groups, those assigned to caregiving programs showed significant, beneficial effects across the domains of parenting behaviors and attitudes, child psychosocial and developmental outcomes, and parent mental health. Cultural adaptations and recruitment and engagement strategies are described. The evidence base for caregiving programs for displaced families has expanded in recent years but remains limited. Caregiving/parenting programs show promise for reducing the negative effects of forced displacement on families, but future studies are needed to understand which programs show the greatest potential for scalability.

     

Reducing depression among at-risk early adolescents: three-year effects of a family-centered intervention embedded within schools

The Adolescent Transitions Program (ATP) is a family-focused multilevel prevention program designed for delivery within public middle schools to target parenting factors related to the development of behavior problems in early adolescence. The current study examines the effects of the ATP on the development of youth depressive symptoms across early adolescence in a sample of 106 high-risk youths. Youths were recruited in 6th grade, and selected as high risk based on teacher and parent reports of behavioral or emotional problems. Depression symptoms were based on youth and mother reports in 7th, 8th, and 9th grades. Receipt of the family-centered intervention inhibited growth in depressive symptoms in high-risk youths over the 3 yearly assessments compared with symptoms in high-risk youths in the control group. Results support the notion that parental engagement in a program designed to improve parent management practices and parent-adolescent relationships can result in collateral benefits to the youths' depressive symptoms at a critical transition period of social and emotional development.     

A Randomized Controlled Trial of the Impact of a Family-Based Adolescent Depression Intervention on both Youth and Parent Mental Health Outcomes

This paper presents findings from a multi-centre, double-blind, randomized controlled trial that tested the hypothesis that parent and youth mental health improvements would be superior in a family-based intervention for adolescent depression (BEST MOOD) compared to a treatment-as-usual supportive parenting program (PAST). Eligible participants were families with a young person aged between 12 and 18 years who met diagnostic criteria for a depressive disorder (major, minor or dysthymic). Participating families (N = 64; 73.4% of youth were female) were recruited in Victoria, Australia and allocated to treatment condition using a block randomization procedure (parallel design) with two levels of blinding. This paper reports on the trial’s secondary outcomes on youth and parent mental health. General linear mixed models were used to examine the longitudinal effect of treatment group on outcome. Data were analyzed according to intention-to-treat; 31 families were analyzed in BEST MOOD, and 33 families in PAST. Parents in the BEST MOOD group experienced significantly greater reductions in stress and depressive symptoms than parents in the PAST group at 3-month follow-up. A greater reduction in parental anxiety was observed in the BEST MOOD group (d = 0.35) compared with PAST (d = 0.02), although the between-group difference was not significant. Both groups of youth showed similar levels of improvement in depressive symptoms at post-treatment (d = 0.83 and 0.80 respectively), which were largely sustained at a 3-month follow-up. The family-based BEST MOOD intervention appeared superior to treatment-as-usual (PAST) in demonstrating greater reductions in parental stress and depression. Both interventions produced large reductions in youth depressive symptoms.     

Therapist, Parent, and Youth Perspectives of Treatment Barriers to Family-Focused Community Outpatient Mental Health Services

This exploratory qualitative study describes treatment barriers to receiving family-focused child mental health services for youths with disruptive behavior problems from multiple perspectives. Data were collected during a series of focus groups and interviews, including: 4 therapist focus groups (n = 26), 3 parent focus groups (n = 14), and 10 youth (10–13 years) semi-structured interviews. Data analysis followed inductive, iterative processes typical of qualitative research using an editing style and thematic content analysis approach. Therapist, parent, and youth stakeholder participants discussed perceived barriers to effective treatment, the problems with current child outpatient therapy, and desired changes (i.e., policy, intervention, etc.) to improve mental health services. Results indicate similar themes around treatment barriers and dissatisfaction with services within and across multiple stakeholder groups, including inadequate service system support, lack of family involvement and feeling overwhelmed with the complexities of families’ needs; however, parents and therapists, in particular, identified different contributing factors to these barriers. Therapists highly endorse using family-focused therapy and desire parent participation; however, parents feel unsupported by their child’s therapist. Parents’ report feeling blamed and not heard by service providers which negatively impacts their attitude about service delivery, causing discomfort and resistance to participation in their youth’s treatment. Youth also discussed dissatisfaction with mental health services, specifically related to their direct experiences in therapy, and desired more active, directive family-focused approaches. Overall, stakeholders reported much frustration and dissatisfaction with current community-based outpatient child therapy services. Study findings can inform service provision, intervention development, and future research.     

Associations of Parent–Child Anxious and Depressive Symptoms When a Caregiver Has a History of Depression

We examined the associations between parent and child anxious and depressive symptoms controlling for co-occurring symptoms in both. One hundred and four families participated, including 131 9–15 year old children considered at risk for anxiety and/or depression due to a history of depression in a parent. Parents and children completed questionnaires assessing depressive and anxious symptoms. Linear Mixed Models analyses controlling for the alternate parent and child symptoms indicated that both parent and child depressive symptoms and parent and child anxious symptoms were positively associated. Parental depressive symptoms were not positively associated with child anxious symptoms, and parental anxious symptoms were not positively associated with child depressive symptoms. The findings provide evidence for positive specific links between parent and child development of same-syndrome, but not cross-syndrome, symptoms when a caregiver has a history of depression.     

A Review of Pediatric Nonpharmacological Sleep Interventions: Effects on Sleep,Secondary Outcomes,and Populations With Co-occurring Mental Health Conditions

Sleep problems are common in school-age children and linked to numerous negative outcomes. Sleep disturbances are particularly common in children with mental health disorders, such as attention-deficit/hyperactivity disorder, depression, and anxiety. Despite frequent use of nonpharmacological pediatric sleep interventions to treat common sleep problems, there is a paucity of research on whether these interventions are effective. Further, it is unclear whether by targeting sleep, these interventions lead to broader improvements in the domains of functioning that are commonly affected by poor sleep. The present review includes 20 studies that evaluated nonpharmacological sleep treatments for school-aged youth, including 5 studies specifically focused on youth with externalizing or internalizing problems. Multimodal approaches consisting of psychoeducation and sleep hygiene in combination with other components were effective at treating insomnia and general sleep problems in typically developing samples. The addition of behavioral parent training to sleep interventions was effective for youth with externalizing problems, whereas incorporating cognitive strategies into sleep interventions for youth with internalizing problems was found to be ineffective. A variety of secondary outcomes were examined, with the strongest support emerging for improvement in anxiety and behavioral problems. Implications for clinical practice and future research directions are discussed.     

Interpersonal Skills Training to Reduce Aggressive and Delinquent Behavior: Limited Evidence and the Need for an Evidence-Based System of Care

The prevention of aggressive and delinquent behavior during childhood and adolescence is one of the highest priorities for public health and crime prevention. The most common approach to preventing or treating these conduct problems has been to provide interpersonal skills training to the affected youth. This paper reviews all randomized controlled trials evaluating interpersonal skills training programs as an intervention to reduce conduct problems. Research shows that such programs have weak empirical support as isolated interventions. An alternative evidence-based system of care is described. Such a system would include behavioral parent training and behavioral classroom-based interventions for young children at risk of developing problems, as well as multisystemic family therapy or multidimensional treatment foster care for chronic delinquents. Within such a network of services, interpersonal skills training could play an important supportive role. Such a system holds the greatest promise for reducing the prevalence of aggressive and delinquent behavior in communities.     

Implementation and Evaluation of Evidence-Based Psychotherapeutic Practices for Youth in a Mental Health Organization

The current initiative and program evaluation study is a demonstration of the research to practice process in youth-focused psychotherapy. We collaborated within a community-university partnership to create practice and research infrastructure in order to develop, implement, and evaluate two new models of service founded on evidence-based psychotherapeutic practice parameters. The two new service models incorporated validated interventions to address behavior problems in elementary age children, and depression in adolescents, which were delivered in separate but similarly run intensive outpatient programs within a mental health setting. We utilized a rigorous training, technical assistance, fidelity monitoring, and outcome measurement strategy to promote the integrity and quality of services provided. The resultant programs were delivered with acceptable to high fidelity and effects on youth and parenting measures collected during program and from pre to post showed a decrease in targeted problems in youth and positive benefits for families. This initiative and program evaluation adds to the accumulating research-to-practice literature in children’s mental health.     

How Do Family-Focused Prevention Programs Work? A Review of Mediating Mechanisms Associated with Reductions in Youth Antisocial Behaviors

The development and evaluation of family-focused preventive interventions has grown significantly in recent decades, but the degree to which these interventions produce anticipated improvements in the family environment, and the extent to which such changes are associated with reductions in youth antisocial behaviors (ASB), is unclear. This article seeks to answer these questions by reviewing evidence from tests of mediation conducted in evaluations of family-focused interventions. Interventions are drawn from family-focused interventions rated as Model Plus, Model, or Promising on the Blueprints for Healthy Youth Development Web site (http://www.colorado.edu/cspv/blueprints/) based on evidence of their effectiveness in reducing child externalizing behaviors, substance use, and/or delinquency. Of the 19 such interventions listed on Blueprints, seven programs (37 %) were evaluated using mediation analyses which met study criteria. Two-thirds (67 %) of these analyses indicated significant improvements in the targeted family processes for intervention versus control group participants. Over half (62 %) of all tests of mediation were statistically significant and indicated that improvements in the family environment were associated with reductions in ASB. The results support prior theoretical and empirical literature identifying the family as an important context for preventing ASB and promoting healthy youth development. The findings also provide information that can be used to refine current family-focused interventions in order to increase their efficiency and potency, and to develop new interventions in order to expand the number and types of families who can benefit from such services.     

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child’s anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children’s anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.     

Mother and Child Depressive Symptoms in Youth with Spina Bifida: Additive, Moderator, and Mediator Models

The purpose of the study was to examine the extent to which parenting behaviors influence the relation between maternal and child depressive symptoms in youth with spina bifida and a comparison sample. Previous research has found that maternal depression not only negatively impacts the mother–child relationship, but also places the child at risk for developing depressive symptoms. However, certain parenting behaviors might buffer the association between maternal and youth depression. The influence of maternal depressive symptoms and parenting behavior (i.e., acceptance, behavioral control, psychological control) on youth depressive symptoms were examined in the context of three models: (1) an additive/cumulative risk model, (2) a moderator model, and (3) a mediator model. Data were examined longitudinally at five time points when youth were 8–9 through 16–17 years of age. Results supported an additive/cumulative risk model, but did not support the moderator or mediator models. Low maternal acceptance, high behavioral control, and high psychological control were risk factors for child depressive symptoms at several time points, with maternal depressive symptoms exerting an additional risk at later time points. A group difference between the spina bifida and comparison youth was not supported. Findings indicate that in general, maternal parenting behavior is salient throughout childhood and early adolescence, but maternal depressive symptoms do not exert an influence until mid-adolescence. Family interventions should aim to promote maternal mental health and maternal parenting behaviors to reduce the risk of the development of depressive symptoms in adolescence.     

Effects of Brief Interventions on Internalizing Symptoms and Substance Use in Youth: A Systematic Review

Internalizing problems (e.g., depression, anxiety) and substance use are common among young people and often co-occur. However, youths face myriad barriers to access needed treatment, and existing evidence-based interventions tend to focus on internalizing problems or substance use, rather than both simultaneously. Brief interventions that target both problems may, therefore, be an efficient and accessible resource for alleviating youth difficulties; however, this possibility has been insufficiently evaluated. This systematic review evaluated the intervention characteristics and quality of six studies spanning 2015 to 2019 that examined intervention effects on internalizing and substance use outcomes. Based on independent calculations and author reports (respectively), 3–4 interventions significantly reduced youth internalizing symptoms; 3–5 reduced youth substance use; and 2–3 reduced symptoms in both domains. All six interventions identified substance use as a primary target. Four interventions were administered by interventionists to youths in inpatient, outpatient, primary care, or school settings. The remaining two studies delivered content through voicemail messages or an online design. Interventions ranged from?~?15 to 240 min. Results highlight the sparsity and heterogeneity of youth-focused brief interventions that have evaluated program effects on both internalizing problems and substance use outcomes, suggesting a clear need for integrated supports that are also designed for accessibility. Future investigations of brief youth-focused interventions should assess program effects on both internalizing and substance use outcomes; examine mechanisms driving the varied efficacy of identified interventions; and create, refine, and test interventions with potential to address co-occurring internalizing problems and substance use in young people.

     

Parent–Child Cultural Value Gaps and Depressive Symptoms Among Mexican American Youth

Cultural value gaps between Mexican American parents and their children are hypothesized to place youth at risk for poor mental health outcomes. While most studies examine these gaps on broad measures of acculturation, the present study examined value gaps in affiliative obedience, a cultural value that has at its core the belief that respect and deference must be shown to parents and adults. The present study hypothesized that adolescents would exhibit greater depressive symptoms when youth demonstrated lower levels of affiliative obedience than their mothers. Moreover, we examined whether gender, nativity status, and age predicted cultural value gaps and moderated the relationship between gaps and depressive symptoms. These questions were evaluated in a school-based sample of 159 Mexican American families whose children were either US born (n = 82) or foreign-born (n = 77). Twenty-five percent of the sample demonstrated a cultural value gap where youth endorsed lower levels of affiliative obedience than their parents, and this group reported the greatest depressive symptoms. Age moderated this relationship, and the greatest association between cultural value gaps and depression was found among the older group of early adolescents.     

Implementation and Dissemination of Military Informed and Evidence-Based Interventions for Community Dwelling Military Families

Community dwelling military families from the National Guard and Reserve contend with deployment-related stressors in relative isolation, living in communities where mental health providers may have little knowledge of military culture. When they are community residents, active duty service members and families tend to live in close proximity to their military installations. This article will focus primarily on the challenges to quality mental health care for reserve component (RC) families. Where studies of RC families are absent, those of active component (AC) families will be highlighted as relevant. Upon completion of a deployment, reintegration for RC families is complicated by high rates of symptomatology, low service utilization, and greater barriers to care relative to AC families. A paucity of providers skilled in evidence-based treatments (EBTs) limits community mental health capacity to serve RC military families. Several emergent programs illustrate the potential for better serving community dwelling military families. Approaches include behavioral health homes, EBTs and treatment components, structured resiliency and parent training, military informed schools, outreach methods, and technology-based coping, and psychoeducation. Methods from implementation science to improve clinical skill acquisition and spread and sustainability of EBTs may advance access to and quality of mental health treatment and are reviewed herein. Recommendations related to research methods, military knowledge and treatment competencies, and transition to a public health model of service delivery are discussed.     

Bending the Curve: A Community-Based Behavioral Parent Training Model to Address ADHD-Related Concerns in the Voluntary Sector in Denmark

Limited access to evidence-based behavioral parent training (BPT) for addressing attention deficit/hyperactivity disorder (ADHD) has been a growing concern internationally. Models to improve access to BPT are needed, particularly those that can be readily implemented in community settings and that leverage the potential workforce to increase capacity to deliver BPT. The purpose of this study was to evaluate a BPT model which included oft-used content, methods, processes of BPT (common-elements), non-professionally delivered (task-shifted/shared) BPT intervention, and an efficient ancillary support system (training, fidelity, and supervision methods) for families of youth with parental concerns about ADHD. In a randomized controlled trial of 161 families of children (79% male; mean age 7.04 [1.55]), the Caring in Chaos (CiC) BPT model, delivered by community volunteers across 12 community-based sites in Denmark, was compared to a wait-list control condition on key child and parent outcomes at immediate post-treatment and 4-month follow-up assessment points. Results suggested that the CiC model led to significantly greater improvement in parenting behavior, parenting sense of competence, child functional impairment, parental stress and parental depressive symptoms compared to the wait list condition at immediate post-treatment, with maintenance of gains in most of these areas at follow-up assessment. No effect of intervention was found on ADHD symptoms. The results of this study suggest that developing efficient BPT intervention models, such as the CiC model, can result in readily implemented interventions by a variety of individuals in community settings. Such models are necessary to bend the curve on addressing unmet needs of families of youth with concerns about ADHD.     

Associations Among Body Mass Index,Depression, and Family Factors Across Two Generations

In this pilot study, we examined the relationship between health factors, sociodemographic factors, and body mass index (BMI) across two generations (n = 41 parent-child pairs). Generation 1 study variables included parent- and family-focused characteristics and health variables, the Generation 2 variables included child demographic factors, and the outcome variable was youths’ physical health (operationalized as BMI). Regression models revealed that Generation 1 variables, taken together, accounted for 26% of the variance in youth BMI. However, only the parent’s mental health symptoms (i.e., depression symptoms) made a unique contribution to the variance in youth BMI. Logistic regression analysis revealed that the youths’ race and age—but no other demographic factor—were significantly related to youth BMI-for-age. Our findings suggest that youth race, age, and parent mental health are each associated with youth physical health (i.e., BMI), confirming previous study findings that parental factors and demographic factors should be considered when exploring youth health outcomes.     

Emotional, behavioral, and cognitive factors that differentiate obsessive-compulsive disorder and other anxiety disorders in youth

Abstract The current study examined specific emotional, behavioral, and cognitive variables that may distinguish obsessive-compulsive disorder (OCD) from generalized anxiety disorder (GAD), social phobia (SoP), and separation anxiety disorder (SAD) in youth. Youth with OCD (n=26) and other anxiety disorders (ADs; n=31), aged 7-12 years (56.1% males), and their parents participated. The study compared the two anxious groups on levels of emotional, behavioral, and cognitive functioning, as well as impairment associated with the disorder. Results indicated that in comparison to youth with GAD, SoP, or SAD, youth with OCD were found to have poorer emotion regulation skills, as well as greater oppositionality, cognitive problems/inattention, and parent impairment associated with the disorder. The findings suggest that there are unique characteristics of OCD that may differentiate this disorder from other ADs in youth. Potential clinical implications and directions for future research are discussed.     

Developing preventive mental health interventions for refugee families in resettlement

In refugee resettlement, positive psychosocial outcomes for youth and adults depend to a great extent on their families. Yet refugee families find few empirically based services geared toward them. Preventive mental health interventions that aim to stop, lessen, or delay possible negative individual mental health and behavioral sequelae through improving family and community protective resources in resettled refugee families are needed. This paper describes 8 characteristics that preventive mental health interventions should address to meet the needs of refugee families, including: Feasibility, Acceptability, Culturally Tailored, Multilevel, Time Focused, Prosaicness, Effectiveness, and Adaptability. To address these 8 characteristics in the complex environment of refugee resettlement requires modifying the process of developmental research through incorporating innovative mental health services research strategies, including: resilience framework, community collaboration, mixed methods with focused ethnography, and the comprehensive dynamic trial. A preventive intervention development cycle for refugee families is proposed based on a program of research on refugees and migrants using these services research strategies. Furthering preventive mental health for refugee families also requires new policy directives, multisystemic partnerships, and research training.     

Clinician Perspectives of Diagnosis and Perceived Client Change in “Real World” Psychotherapy for Youth Emotional and Behavioral Disorders

We investigated the extent to which clinician-assigned diagnoses of emotional and behavioral disorders and clinicians’ perceptions of client change are consistent with structured measures of youth clinical functioning and parent/family characteristics within the context of usual care or “real world” psychotherapy. A total of 54 therapists from two publicly-funded youth outpatient mental health clinics and 128 youths and parents from the therapists’ combined caseloads were included in the study. Clinician-assigned diagnosis and youth and family demographics were collected at the initial visit, clinician-reported perceived client change was collected at 6-month follow-up, and structured measures of youth clinical functioning and parent/family characteristics were collected at both time points. Results indicate some overlap between clinician-assigned diagnosis, clinician-reported perceived client change, and structured measures of youth clinical functioning and parent/family characteristics after controlling for demographic factors. Results are discussed in terms of implications for the implementation of evidence-based practices in real world community settings.     

Eating disorder pathology among overweight treatment-seeking youth: clinical correlates and cross-sectional risk modeling

Preliminary research suggests that pediatric overweight is associated with increased eating disorder pathology, however, little is known about which overweight youth are most vulnerable to eating disorder pathology. We therefore investigated 122 overweight treatment-seeking youth to describe eating disorder pathology and mental health correlates, and to identify psychopathological constructs that may place overweight youth at increased risk for eating disorder pathology. Youth participated in a comprehensive assessment of eating disorders, mood and anxiety disorders, general psychopathology, and risk variables involving semi-structured clinical interviews and self- and parent-report questionnaires prior to the initiation of weight-loss treatment. Ten youth met criteria for an eating disorder, and over one-third endorsed recent binge eating. Eating disorder pathology was associated with depressive and anxious symptoms (p's<0.001). Structural equation modeling indicated increased negative affect, teasing experience, and thin-ideal internalization, and decreased perfectionism were associated with increased eating disorder pathology. Findings corroborate earlier work indicating that eating disorder pathology is elevated and clinically significant in overweight treatment-seeking youth, bolstering the need for mental health assessment of such individuals. Cross-sectional modeling proposed key variables that relate to eating disorder pathology in overweight treatment-seeking youth, which following prospective replication, may inform the development of effective interventions for overweight and eating disorders.