Family Support in Children’s Mental Health: A Review and Synthesis

A comprehensive review of structured family support programs in children’s mental health was conducted in collaboration with leadership from key national family organizations. The goals were to identify typologies of family support services for which evaluation data existed and identify research gaps. Over 200 programs were examined; 50 met criteria for inclusion. Programs were categorized by whether they were delivered by peer family members, clinicians, or teams. Five salient components of family support were identified: (a) informational, (b) instructional, (c) emotional, (d) instrumental, and (e) advocacy. Clinician-led programs were heavily represented (n = 33, 66%), followed by family-led (n = 11, 22%), and team-delivered (n = 6, 12%) programs. Key differences between programs delivered by clinicians or by peer family members were found in the degree of emphasis, research methodology, and outcomes. However, the content of the components was similar across all three program types. There are both important differences in emphasis across typologies of family support provided by clinicians, family members, or teams as well as important similarities in content. Family-delivered support may be an important adjunct to existing services for parents, although the research base remains thin. A research agenda to promote more rigorous evaluations of these services especially those delivered by peer family members is critical.     

A family-based approach to adult mental disorders

Recent research studies have provided strong support for a collaborative approach between families and mental health services in the clinical management of major mental disorders. A comprehensive approach to adult mental health care that employs cognitive-behavioural family therapy as the basis for clinical assessment and treatment is described. This model emphasizes home-based intervention, collaboration with primary care, targeted specific interventions, achievement of the personal goals of index patients and their family members, long-term rehabilitation, and assessment of benefits and costs.     

Family-Involved Mental Health Care Among OEF/OIF Veterans With and Without PTSD Using VHA Administrative Records

Prior research indicates that veterans are interested in including family members in health care and that family-inclusive mental health treatment can improve treatment outcomes. Consequently, the Veterans Health Administration’s (VHA) directive requires providers to offer family-inclusive mental health services to veterans. However, the extent to which veterans engage in family-inclusive mental health services at the VHA remains unclear. Using data from a longitudinal registry of male and female veterans with and without posttraumatic stress disorder, we examined the extent to which veterans included family members in their mental health care and predictors of engagement in family-involved therapy visits using VHA administrative records over a 5-year time span. Of the 1,329 veterans who received mental health care during the study, 8.4% received a family therapy visit—the number of visits per veteran ranged from 1 to 34. Results from logistic regressions indicate that relative to White veterans, Black veterans were 61.0% less likely to receive a family-involved therapy visit. Married veterans or veterans living with a partner, and veterans with poor romantic relationship functioning, were more likely to receive a family-involved therapy visit. These findings indicate that only a small percentage of veterans received a family therapy visit across 5 years. Efforts to understand barriers to family-involved therapy visits and strategies to increase engagement in family-involved visits may improve clinical outcomes and promote patient-centered care.     

Involving Family in Psychosocial Interventions for Chronic Illness

ABSTRACT— Interactions with close family members have consequences for the emotional and physical well-being of individuals who are dealing with a chronic physical illness. Therefore, inclusion of a close family member in psychosocial interventions for chronic illnesses is a logical treatment approach that has the potential to boost the effects of intervention on the patient and also benefit the family member. However, randomized, controlled studies indicate that such family-oriented interventions generally have small effects. The efficacy of these treatment approaches might be enhanced by targeting specific interactions that emerging research identifies as promoting or derailing healthy behaviors and by better incorporating strategies from family caregiver interventions. In addition, family-oriented interventions should be more fully evaluated, by assessing the benefits for both patients and family members. Future research in this area can tell us much about how and when to involve family in treatment of specific chronic illnesses and, in turn, may inform conceptual models of the impact of family interactions on health.     

Important Elements of Aftercare Services for Youth Departing Group Homes

Aftercare services have been suggested to improve the outcomes of youth who depart group homes. The purpose of this study was to collect views from social service agency leaders about the aftercare supports they believed were most important for youth departing group homes. This project used a survey method and gathered views from 38 agency leaders who were 28–66 years of age, with an average of 21 years of experience working with residential care programs in 23 states across the United States. Participants ranked seven support domains (i.e., family, education, mental health, relationships, physical health, safety, and independent living) and rated 56 specific aftercare supports based on importance for youth who were departing group homes and returning to their homes/schools prior to high school graduation. Results suggested family, safety, and mental health supports were the most important domains of support for aftercare. Specific aftercare items that were rated critically important included support for self-harm/suicidal thoughts, accessing mental health services, coping with trauma, and managing medication for behavior/mental health. Tables are provided for the complete list of 56 specific support ratings. The findings are summarized and limitations are discussed. Also included are the implications the findings could have regarding future research on the design of aftercare services.     

Determinants of Children's Primary Health Care Use

We review factors that influence children's use of primary health care services. Predictors of pediatric health care use include child health status, child mental health, parent and family functioning, demographic characteristics, and access to health care services. Health services research is marked by inconsistencies due to varying approaches to measurement, population sampling, and analysis, and models that do not incorporate situational factors. We present recommendations for practicing clinicians and discuss suggestions for future research to help identify additional factors that may influence a parent's decision to seek help from pediatric physicians. Health care use is determined by multiple factors, and complex models will lead to improved strategies for maximizing health status and establishing optimal pediatric care.     

Innovations in the Identification and Referral of Mothers at Risk for Depression: Development of a Peer-to-Peer Model

This paper describes a feasibility study of a peer-delivered prevention intervention to identify mothers at high risk for depression and facilitate engagement in mental health services for their emotional health. Sixteen family peer advocates and their supervisors partnered with academic researchers over a period of 6 months to develop a four-session intervention that focused on identifying symptoms of depression, providing education about depression and treatment, actively linking caregivers to treatment for their own emotional health, and assisting caregivers in becoming active participants in their mental health care. Collaborating with peers to develop the model enhanced its perceived relevance and utility, and resulted in an intervention that was complimentary to their roles and the mission of peer-delivered support services. Peer/professional partnerships may be beneficial for enhancing the feasibility and acceptability of research efforts; the impact of peers’ participation in the current project and the need for future research to develop and study peer-delivered models is discussed.     

Youth Mental Illness and the Family: Parents’ Loss and Grief

Parents and family members whose adult child or relative has a mental illness endure significant losses, to which they respond with grief. Such grief may negatively affect family members’ physical and psychological health and also the relationship with their relative. Yet, research in this field is sparse. Very few studies have examined parents’ loss and grief in the context of the patient being a child or teen. It is not clear the extent to which parents’ loss and grief in response to their child or adolescent’s mental illness is similar or different to the accounts of older parents and family members caring for an adult relative with major psychopathology (e.g., Schizophrenia, Bipolar disorder). Parental loss and grief is not often addressed in child and adolescent mental health services’ provision of care; alarmingly, little is known about how best to support parents who access these services. The present study aimed to bridge this knowledge gap and identify the therapeutic needs of this younger parent population. Comprehensive interviews were conducted with 14 parents and one custodial grandparent of a youth aged 18 years or younger who was currently attending a child and adolescent mental health service. An inductive thematic analysis identified six themes; parents’ narrative of finding out, profound and pervasive loss, complex grief, waning support, the challenges of caregiving and a call for assistance. It can be inferred from these results that youth mental illness can constitute a source of loss and grief for parents. Participants’ loss and grief was largely consistent with the experience of families caring for an adult relative with major psychopathology. Opportunities for mental health practitioners to support families’ loss and grief were identified. Further studies are needed to enhance understanding of this complex and, to a large extent, ignored familial experience. Results do underscore the importance of clinicians acknowledging parents’ loss and grief and working directly with this experience over the course of youths’ treatment, perhaps in conjunction with family psychoeducation approaches.     

Differentiation of Self in Family Members’ of SUD Loved Ones: An Analysis of Prefrontal Cortex Activation

Substance use disorders (SUDs) are a chronic disease that impacts the individual with a SUD as well as an entire family system. While family members of those with SUDs are one of the most important support networks in the recovery process, impacted family members have been found to experience more adverse health outcomes and altered functioning of the prefrontal cortex (PFC). These impacts negatively influence not only family members’ personal health but also the health of the family unit, which limits the family’s capability of providing its most effective support. Bowen’s conceptualization of differentiation of self can help explain the perspective of SUDs as a “family disease” and associated impacts on family members. Using functional near-infrared spectroscopy with a sample of 26 SUD-impacted family members, the present study examined associations between PFC activation in response to images of a loved-one seeking abstinence from a SUD and various components of differentiation of self (i.e., emotional cutoff, emotional reactivity, fusion with others, and I-position). Activation of the left dorsomedial PFC in response to SUD loved-one images associated negatively with emotional reactivity and positively with fusion with others. These findings did not replicate in a control group and have important implications for research and clinical practice.

     

Asian American families' collectivistic coping strategies in response to 9/11

Our study investigated the use of individualistic and collectivistic coping strategies among Asian American family members of victims of the World Trade Center (WTC) attacks on September 11th, 2001. Interviews were conducted with 11 Asian Americans who had lost a member of their family in the WTC attacks. Using the Discovery-Oriented Research analysis (Mahrer, 1988), results indicated that Asian Americans utilized the following collectivistic coping methods to deal with their losses: individualistic coping, familial coping, intracultural coping, relational universality, forbearance, fatalism/ spirituality, and indigenous healing methods. Additionally, our research found that cultural stigmata, privacy issues, and lack of culturally responsive counselors were factors in participants not utilizing available mental health services. Implications for culturally appropriate services, counseling, and research are discussed.     

Building a research base for community services for children and families: What we know and what we need to learn

We examine the knowledge base for community-based mental health services for youth and their families. A brief historical perspective on the development of community services is presented, and the fundamental components of a comprehensive child mental health service system are described. Outcome studies for service components as well as the service system as a whole are summarized. Research related to the context of treatment, i.e., service setting, cost, is presented. The authors conclude that a research base for child and family services is emerging, but there is still a paucity of well designed studies that address the complexities of a community-based system as well as the critical outcome questions that need to be addressed. Finally, promising service system developments are described and recommendations for future research are presented.     

The Age of Uncertainty: Parent Perspectives on the Transitions of Young People with Mental Health Difficulties to Adulthood

For young people aged 16–24, the transition from adolescence to young adulthood involves predictable and unpredictable changes and they may encounter challenges in their roles, relationships, and responsibilities. Young people with mental health difficulties face additional challenges as they and their families navigate this transition. As a result, families commonly experience anxiety, uncertainty, frustration, and turbulent relationships. After learning to become advocates to secure appropriate services for their children, in late adolescence and young adulthood, parents are likely to find themselves excluded from their children’s treatment planning and services. This article reports findings from a recent qualitative study of the experiences and perceptions of 42 family members supporting their children with mental health difficulties during the transition years. Family members described their goals for their children, their frustrations trying to access appropriate services for their children, and their strategies to provide the support their children needed. Recommendations are for service providers to connect transition age youth with practical assistance and supportive mentoring relationships. Family members requested service providers to consider them as resources and potential collaborators in supporting young people with mental health difficulties to live successful lives in the community.     

Mental Health Services in Juvenile Correctional Facilities: A National Survey of Clinical Staff

This study determined the use of best practices in providing mental health services to youth within juvenile correctional facilities. A national sample of 94 (49.7 %) lead clinical staff from all available and qualifying facilities responded to a mail and on-line survey. There were no statistically significant differences across respondents versus nonrespondents for security level, gender served, or census region of facilities. Specifically, we examined the provision of facility-wide mental health programming, individual, group, and family counseling, and case management services. Examination of these services included the use of evidence-based interventions provided through an established curriculum and methods used to evaluate the effectiveness of the interventions. We also examined staff involvement, and the perceived quality of services and barriers to providing interventions. Participants reported using a variety of evidence-based interventions; however, participants also acknowledged using other approaches that may not have empirical support. Additionally, although at least half of the participants reported mandatory individual and group counseling, less than a third of the participants reported that their facilities required family counseling. Clinical staff also reported a variety of methods used for evaluating the effectiveness of mental health services. Additional findings, as well as implications for research and practice, are discussed.     

An exploration of alcohol services’ staff experiences of providing support to relatives of alcohol-dependent individuals from the Sikh community

The present study investigated the experiences of alcohol services’ staff providing support to Sikh family members of alcohol-dependent individuals. Ten staff members agreed to take part in semi-structured interviews. Thematic analysis of the interview data elicited themes illustrating the nature of familial support provided and attitudes to alcohol use. Participants identified Sikh family members as lacking an understanding of addiction and the treatment options available for addiction. Participants describe inter-generational differences between Sikh family members when accessing alcohol services for support. Lastly, participants highlighted ways in which alcohol services target and tailor their services to meet the needs of Sikh family members. Methodological limitations of the present study are highlighted and recommendations for future research offered.     

The Critical Need to Recognize That Families Matter for Adult Health: A Systematic Review of the Literature

A systemic approach to researching families and health should capture the complex network within which family members are embedded, including multiple family relationships and larger systems of health care. However, much of the families and health research focused on adult family members has focused solely on intimate partnerships, usually the marital relationship. This neglects the remainder of the powerfully influencing family relationships adults retain, and may increasingly focus on as they age. We conducted a systematic review of the families and adult health literature, retaining 72 articles which were subsequently thematically coded to highlight main foci of this area of research. Results highlight six themes, which include family relationship quality, family composition, behavioral factors in health and health care, psychophysiological mediators, caregiving, and aging health. Findings support an underrepresentation of family members, other than the intimate partner, in research on adult health.     

What is the Impact of Placement Type on Educational and Health Outcomes of Unaccompanied Refugee Minors? A Systematic Review of the Evidence

Record numbers of unaccompanied refugee minors have been arriving in high-income countries since 2015. Child welfare agencies and non-governmental organisations tasked with providing services have struggled to cope with demands on their services as a result. Despite this, there is little research on how best to meet their needs and in particular what services can mitigate the psychological difficulties they face. As a result, the evidence base for social services for refugee children remains very limited. This paper is a systematic review and meta-analysis of the evidence on the relationship between care placement type and the educational, mental health and physical health outcomes of unaccompanied refugee minors. We searched ten databases and identified 3877 citations which were screened for inclusion. Nine studies were included in the final review, with seven included in the meta-analysis. Eight studies examined the link between accommodation type and mental health outcomes, and two analysed the relationship between accommodation type and education. There were no studies looking at physical health outcomes. Included studies suggest that foster care and placements that are culturally sensitive may be associated with better mental health outcomes. This review highlights the paucity of research on the impact of services provided by child welfare agencies and non-governmental organisations.     

Impact of Caregiver Factors on Youth Service Utilization of Trauma-Focused Cognitive Behavioral Therapy in a Community Setting

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is an increasingly available evidence-based therapy that targets the mental health symptoms of youth who have experienced trauma. Limited research has examined how to engage and retain families in TF-CBT services in community settings. Using a mixed-methods approach, the goal of this exploratory study was to identify caregiver factors that impact youth enrollment and completion of community-delivered TF-CBT. The study included 41 caretakers of youth referred to therapy at a local child advocacy center following a forensic assessment substantiating youth trauma exposure. Caregiver factors examined include caregiver demographics, trauma exposure, and mental health symptomology. Results from multivariate logistic regressions indicate that caregivers reporting more children residing in the household were significantly more likely to enroll youth in therapy (OR 2.27; 95 % CI 1.02, 5.03). Qualitative analyses further explicate that parents with personal trauma or therapy experiences expressed positive opinions regarding therapy services for youth, and were more likely to enroll in or complete services. Findings suggest that caregivers with personal traumatic experience and related symptomatology view therapy as important and are more committed to their child receiving therapy. Future research on service utilization is warranted and should explore offering parental psychoeducation or engagement strategies discussing therapy benefits to parents who have not experienced trauma and related mental health symptomatology.     

Serving the mental health needs of families with children under three: A comprehensive program

This paper describes a pregnancy and infant/parent program that was developed to provide comprehensive mental health services to families with children under 3 years of age. Because either the infant or parent can be the identified patient, we are able to treat families who define their problems in a variety of ways. The program has four basic premises: (1) the mental health of all family members should be addressed, (2) treatment of family members should be provided with minimum fragmentation of services, (3) the treatment plan must be individualized for each family, and (4) modes of therapy must be changed as the needs of the family change over time. This paper presents the rationale and techniques necessary for integrated services to families with children under 3 years of age. Two cases are presented: one with the infant as the identified patient, and one with the mother as the identified patient.