Different perspectives in psychiatry: how family-oriented are professionals in Germany?

ΒACKGROUND: Children of parents with a mental illness have up to 50% chance of developing a mental illness themselves. Numerous studies have shown that preventive family-oriented interventions can decrease the risk by 40% and that professionals are a decisive factor influencing family-oriented practice. There are also substantial differences between professions in terms of their family-oriented practices. This study examines the level of family-oriented practice for different professional groups in Germany. METHODS: Data were used from the baseline assessment of the two-group randomized controlled multicenter trial ci-chimps as a subproject of CHIMPS-NET, which took place from January 2020 to May 2021 in 18 clinical centers in Germany. Child and adolescent mental health systems as well as adult mental health systems took part and every professional involved in the treatment was invited to participate. Data was used from 475 mental health professionals including physicians, psychologists, psychotherapists for adults and for children and adolescents, occupational/ music/ physio/ art therapists/ (social) education workers and nursing/ education service. Family-oriented mental health practice was examined using the translated version of the Family-Focused Mental Health Practice Questionnaire (FFMHPQ) with means and standard deviations calculated for each of the 18 FFMHPQ-GV subscales. ANOVAs were computed to compare professions and significant differences were examined via post hoc analyses (Scheffé). Additionally, effect sizes were calculated (Omega squared). RESULTS: Differences were seen between the professions in all aspects of family-oriented practice: Both regarding organizational policy and support aspects, issues concerning working with parent-clients, as well as professional skills and knowledge aspects. Psychotherapists for children and adolescents scored the highest family-oriented practices compared to all other professional groups on almost all subscales. CONCLUSION: This study examines the level of family-oriented practice for different professional groups in Germany. Apart from skills and knowledge about the impact of mental illness and parenting, psychotherapists for children and adolescents had the highest scores and engaged most in family-oriented practice. Psychotherapists for adults got the least workplace support for family-oriented practice but were competent providing resources and referral information to the concerned families and feel confidence working with them. Due to these results, a training need exists to improve skills and knowledge about the impact of mental illness and parenting. Additionally, there is still potential for institutional support in promoting family-oriented work. TRIAL REGISTRATION: The CHIMPS-NET-study was registered with the German Clinical Trials Register on 2019-12-19 (DRKS00020380) and with Clinical Trials on 2020-4-30 (NCT04369625), the ci-chimps-study was registered with the German Clinical Trials Register (DRKS00026217) on 2021-08-27 and with Clinical Trials on 2021-11-04 (NCT05106673).

Clinical Trial Data: Both Parents Having Psychiatric Symptoms as Risk Factor for Children's Mental Illness.

Children of mentally ill parents represent a particularly vulnerable risk group for the development of mental illness. This study examines whether there is a predictive association between children's psychiatric symptomatology and (1) the clinical diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of their mentally ill parent as well as (2) to families both parents showing psychiatric symptoms. The study is part of the multicenter controlled trial project "Children of Mentally Ill Parents" (CHIMPS). For this purpose, the psychiatric symptomatology of the mentally ill parent (N = 196) and his or her partner (N = 134) as well as the psychiatric symptomatology of their children aged 4 to 18 years (N = 290) was measured using clinical rated ICD-10-diagnosis, self-rated Brief Symptom Inventory (BSI), and Child Behavior Checklist (CBCL). Using multilevel analyses, the severity of the parental psychiatric symptomatology (BSI) was identified as a significant predictor of children's psychiatric symptomatology (CBCL). Children of parents with a personality disorder (ICD-10) were not more affected than children of parents with another ICD-10-diagnosis. However, children with two parents showing psychiatric symptoms (CBCL) were significantly more affected than children with one mentally ill parent. The results of this study support the well-known view that parental mental illness is a risk factor for children's psychiatric symptoms. Therefore, increased support, especially in high-risk families, both parents having psychiatric symptoms, is highly necessary and should be implemented in the future psychotherapeutic family care.

Clinical Implementation and Evaluation of Three Implementation Interventions for a Family-Oriented Care for Children of Mentally Ill Parents (ci-chimps): Study Protocol for a Randomized Controlled Multicenter Trial.

Background: In Germany, approximately three million children under the age of eighteen have a mentally ill parent. These children are at an increased risk of developing a mental illness themselves (1) as well as a physical illness (2). While research has identified numerous evidence-based family-oriented interventions, little is known about how to implement such interventions effectively and efficiently in clinical practice in Germany. This implementation study (ci-chimps) evaluates three clinical implementation projects with three different implementation interventions for the optimal implementation of the tailored family-oriented preventive and therapeutic interventions in the CHIMPS-NET (children of mentally ill parents-research network) with an implementation model for children of mentally ill parents. Methods: A two-group randomized controlled multicenter trial will examine changes in family-oriented practice and aspects of implementation at baseline as well as at 12- and 24-months follow-up. The CHIMPS-Network consists of 20 clinical centers. The centers in the intervention group receive the support of all of the three implementation interventions: (1) optimal pathways to care, (2) education and a training program for professionals, and (3) systematic screening for children. The centers in the control group do not receive this specific implementation support. Discussion: While we know that children of mentally ill parents are an important target group to be addressed by preventive and therapeutic interventions, there is often a lack of structured implementation of family-oriented interventions in clinical practice in Germany. Using a randomized controlled multicenter trial design with a large and wide-ranging sample (clinics for adult psychiatry and clinics for child and adolescent psychiatry, university clinics and clinics at the real health care) will provide a robust understanding of implementing family-oriented changes in German clinical practice. Trial Registration: The CHIMPS-NET-study was registered with the German Clinical Trials Register on 2019-12-19 (DRKS00020380) and with Clinical Trials on 2020-4-30 (NCT04369625), the ci-chimps-study was registered with the German Clinical Trials Register (DRKS00026217) on 2021-08-27, the Clinical Trials registration is in review process.

[Treatment of mentally ill parents-Strengthen awareness for children]. / Behandlung psychisch erkrankter Eltern ­ Awareness für Kinder stärken.

To raise awareness that families with a mentally ill parent face special challenges and the correct handling of it, need to be considered more in health care. The simple question "how are you as a parent and your children?" is often not asked but this question is important so as not to endanger the healing process, to identify the need for assistance and to break the potential vicious circle for children. Awareness of the problem in the psychiatry of adults can support the care of affected persons and their children.

Identification of Children of Mentally Ill Patients and Provision of Support According to the Norwegian Health Legislation: A 11-Year Review.

BACKGROUND: According to amended legislation implemented in Norway in 2010, personnel in healthcare services for adults are obligated to identify patients' minor children and to assess the family situation. Health personnel is also obligated to contribute to adequate support to families affected by parental mental illness or substance use disorders. The intention behind the amendment was to support and protect children of mentally ill parents, as they are at risk of developing problems of their own. The aim of the present study was to evaluate health personnel's practice during the years 2010-2020, more specifically; (a) to what extent children of patients with mental illness and substance use disorders are registered in patient records, and (b) to what extent activities relating to the assessment and support of patients' minor children are documented in patient records. METHOD: The participants in the study are patients admitted to Division for Mental Health and Substance Use at the University Hospital of North Norway in the years 2010-2020. The data was drawn from patient records during October 2021. RESULTS: The registration of patients' minor children is considerably strengthened since the introduction of the new Norwegian Health Personnel Act in 2010, and estimates show that 56% of patients' minor children are identified. However, only 31% of cases where patients have identified minor children this result in health personnel performing activities to support the children. DISCUSSION: Based on the rising proportion of identified minor children throughout the 10-year period, it seems evident that the dissemination efforts have contributed to the development of some new skills among health personnel. However, compared with the national estimation that 35% of mentally ill and substance abusing patients have minor children, a large proportion of children remains unidentified. After identification, there seem to still be a long way to go before minor children are systematically offered support. Different solutions to strengthen the implementation of new skills in clinical practice, to ensure the identification of minor children and provision of necessary support for them is discussed.

[Preventive and therapeutic interventions for children of mentally ill parents]. / Präventive und therapeutische Interventionen für Kinder psychisch belasteter Eltern.

Preventive and therapeutic interventions for children of mentally ill parents Abstract. The risk of developing mental disorders increases markedly in children of mentally ill parents. Several risk factors have been identified and become possible targets of preventive and therapeutic interventions. Numerous studies investigated the efficacy of these interventions, which are very heterogeneous regarding content and methodology. One part of these studies focuses on infants of depressed and substance-addicted mothers; the other part focuses on children and adolescents of parents suffering from various mental disorders. Today, we have several meta-analyses at our disposal which yielded small effect sizes concerning the development of psychological symptoms or disorders in these affected children. The current review reveals a lack of high-quality studies, and analyses on cost-effectiveness are also needed. The preventive and therapeutic interventions now available show inadequate efficacy to effectively improve the situation of these children and adolescents. Future research is needed to develop and implement cost-effective interventions as well as high-quality studies to investigate the efficacy of these interventions.

[Shared Responsibility!? Interdisciplinary Care for Children of Mentally Ill Parents From the Perspective of Child and Youth Welfare]. / Gemeinsam Verantwortung tragen!? Interdisziplinäre Versorgung von Kindern psychisch kranker Eltern aus Sicht der Kinder- und Jugendhilfe.

Shared Responsibility!? Interdisciplinary Care for Children of Mentally Ill Parents From the Perspective of Child and Youth Welfare Families with at least one mentally ill parent require professional help from several support systems considering the different burdens and complex needs. When designing help and care programs, it is important to focus on the quality of interdisciplinary cooperation and communal networking. Case-related and cross-case cooperation requires binding work structures as well as an overall strategy at the local level. The recent final report to the German Bundestag by the working group "The Children of Mentally Ill Parents" emphasized the relevance of the topic while putting forward recommendations. This article outlines the current academic discussion as well as developments in the design process of interdisciplinary care programs from the perspective of child and youth welfare.

Evaluation of a Family-Based Intervention Program for Children of Mentally Ill Parents: Study Protocol for a Randomized Controlled Multicenter Trial.

Background: Children of mentally ill parents have a three to seven times higher risk of developing mental disorders compared to the general population. For this high-risk group, specialized prevention and intervention programs have already been developed. However, there has been insufficient sytematic evaluation to date. Moreover, effectiveness and the cost-effectiveness data of the respective programs until today is very scarce and at the same time constitutes the pre-condition for the program's implementation into regular health care. Methods: The study consists of a two-group randomized controlled multicenter trial conducted at seven study sites throughout Germany and Switzerland. Participants are families with mentally ill parents and their children aged from 3 to 19 years. The intervention comprises 6 to 8 semi-structured sessions over a period of about 6 months. Topics discussed in the intervention include parental mental illness, coping, family relations and social support. Families in the control condition will receive treatment as usual. The children's mental health, assessed using the K-SADS-PL by blinded external raters will constitute the primary efficacy outcome. Further outcomes will be assessed from the parents' as well as from the children's perspectives. Participants are investigated at baseline, 6, 12, and 18 months after baseline assessment. In addition to the assessment of various psychosocial outcomes, a comprehensive health-economic evaluation will be performed. Discussion: This paper describes the evaluation of a family-based intervention program for children of mentally ill parents (CHIMPs) in the regular health care system in Germany and Switzerland. A methodically sophisticated study design has been developed to reflect the complexity of the actual health care situation. This trial will contribute to the regular health care for the high-risk group of children of mentally ill parents. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

Retinal function anomalies in young offspring at genetic risk of schizophrenia and mood disorder: The meaning for the illness pathophysiology.

BACKGROUND: Visual defects are documented in psychiatric disorders such as schizophrenia, bipolar disorder and major depressive disorder. One of the most consistent alterations in patients is a change in cone and rod electroretinographic (ERG) responses. We previously showed a reduced rod b-wave amplitude in a small sample of young offspring born to an affected parent. A confirmation of the patients ERG anomalies in young offspring at high genetic risk would offer a new approach to the neurodevelopmental investigation of the illness. We thus investigated cone and rod responses in a larger sample of young healthy high-risk offspring. METHODS: The ERG was recorded in 99 offspring of patients having DMS-IV schizophrenia, bipolar or major depressive disorder (mean age 16.03; SD 6.14) and in 223 healthy controls balanced for sex and age. The a- and b-wave latency and amplitude of cones and rods were recorded. RESULTS: Cone b-wave latency was increased in offspring (ES = 0.31; P = 0.006) whereas rod b-wave amplitude was decreased (ES = -0.37; P = 0.001) and rod latency was increased (ES = 0.35; P = 0.002). CONCLUSIONS: The ERG rod and cone abnormal response previously reported in adult patients having schizophrenia, bipolar disorder or major depressive disorder are detectable in genetically high-risk offspring as early as in childhood and adolescence. Moreover, a gradient of effect sizes among offspring and the three adult diagnoses was found in the cone response. This suggests that ERG waveform as a risk endophenotype might become part of the definition of a "childhood risk syndrome".

[Family Psychiatry - The Attachment-Focused, Systemic-Oriented, Integrative Concept of the Family Therapy Centre (FaTC), an Acute Multi-Family Day Clinic]. / Familienpsychiatrie ­ bindungsorientiert, systemisch ausgerichtet, integrativ im akut-tagesklinischen Mehrfamiliensetting: Das FaTZ-Konzept.

Family Psychiatry - The Attachment-Focused, Systemic-Oriented, Integrative Concept of the Family Therapy Centre (FaTC), an Acute Multi-Family Day Clinic Up to three quarters of the children of mentally ill parents develop a mental disorder during their lifetime. The transmission occurs essentially through dysfunctional interaction and disturbed attachment. Parent-child interaction is characterized by a vicious circle of escalating symptoms in the child and increasing helplessness in the parents. For this family psychiatric approaches are helpful, which address the interaction in addition to the individual disorders. The Family Therapy Centre (FaTC) Neckargemünd offers family psychiatric, integrated therapy for parents and children in an acute day clinic multi-family setting. The basic therapeutic principles are attachment orientation, mentalisation and systemic perspective with a multi-family therapy approach. Typical family psychiatric case constellations are presented, for which the concept seems particularly helpful: (1) Early childhood regulatory disorders in interaction with mentally ill parents, (2) mother with PTSD and expansive-aggressive preschool child and (3) adolescents with separation anxiety and depressive-anxious mother. The previous experiences are reflected by a moderated focus group of the entire FaTC team. The FaTC concept was evaluated as very helpful. It was positively judged that the family system is visibly present on site (and not only virtually). The focus is on interaction, therefore causal therapy can be offered rather than symptomatic treatment. Limitations of the concept are therapy of severely aggressive adolescents or parents who do not want to participate. The concept of the FaTC is currently being scientifically evaluated.

Children of Mentally III Parents at Risk Evaluation (COMPARE): Design and Methods of a Randomized Controlled Multicenter Study-Part I.

Objectives: Mental disorders are frequent, associated with disability-adjusted life years, societal, and economic costs. Children of parents with a mental illness (COPMI) are at an increased risk to develop disorders themselves. The transgenerational transmission of mental disorders has been conceptualized in a model that takes parental and family factors, the social environment (i.e., school, work, and social support), parent-child-interaction and possible child outcomes into account. The goal of the "Children of Mentally Ill Parents At Risk Evaluation" (COMPARE) study will thus be twofold: (1) to establish the efficacy and cost-effectiveness of a high-quality randomized controlled trial (RCT) with the aim of interrupting the intergenerational transmission of mental disorders in COPMI, (2) to test the components of the trans-generational transmission model of mental disorders. Methods: To implement a randomized controlled trial (RCT: comparison of parental cognitive behavioral therapy/CBT with CBT + Positive Parenting Program) that is flanked by four add-on projects that apply behavioral, psychophysiological, and neuro-imaging methods to examine potential moderators and mediators of risk transmission (projects COMPARE-emotion/-interaction/-work/-school). COMPARE-emotion targets emotion processing and regulation and its impact on the transgenerational disorder transmission; COMPARE-interaction focuses especially on the impact of maternal comorbid diagnoses of depression and anxiety disorders and will concentrate on different pathways of the impact of maternal disorders on socio-emotional and cognitive infant development, such as parent-infant interaction and the infant's stress regulation skills. COMPARE-work analyzes the transmission of strains a person experiences in one area of life to another (i.e., from family to work; spill-over), and how stress and strain are transmitted between individuals (i.e., from parent to child; cross-over). COMPARE-school focuses on the psychosocial adjustment, school performance, and subjective well-being in COPMI compared to an adequate control group of healthy children. Results: This study protocol reports on the interdisciplinary approach of COMPARE testing the model of the transgenerational transmission of mental disorders. Conclusion: The combination of applied basic with clinical research will facilitate the examination of specific risk transmission mechanisms, promotion, dissemination and implementation of results into a highly important but largely neglected field. Clinical Trial Registration: DRKS-ID: DRKS00013516 (German Clinical Trials Register, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013516).

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.

COMPARE Family (Children of Mentally Ill Parents at Risk Evaluation): A Study Protocol for a Preventive Intervention for Children of Mentally Ill Parents (Triple P, Evidence-Based Program That Enhances Parentings Skills, in Addition to Gold-Standard CBT With the Mentally Ill Parent) in a Multicenter RCT-Part II.

Background: Mental health problems are highly frequent, as well as being associated with enormous societal and economic costs and significant disability-adjusted life years. Children of parents with a mental illness (COPMI) are at a tremendously increased risk to develop disorders themselves. According to the literature, parental mental disorders launch a wave of risk factors that in turn predict the emergence of psychological problems in the offspring, and effective treatment of the parental disorder has been associated with reduced child psychopathology (launch and grow assumption). Furthermore, studies focusing on parent-child interaction demonstrate generally poorer parenting skills in parents with mental disorders, and the enhancement of such skills has been a significant mediator in improving child outcomes (parenting assumption). Objective: To implement a preventive intervention for COPMI with the aim of interrupting the transmission of mental disorders in children of a parent with mental disorders. An RCT will compare state-of-the-art cognitive behavioral therapy (CBT) for a parent with mental disorders to CBT plus the Positive Parenting Program (Triple-P), a well-established and evidence-based program that enhances parenting skills. Methods: A total of 634 patients seeking treatment in 8 outpatient clinics in Germany and their children will be included between January 2018 and April 2021 in the study. We use (clinical) interviews and self- as well as other-report questionnaires to assess the families at four main measurement points [T1: beginning of waiting period for psychotherapy treatment (duration of waiting period depends on usual waiting period in the study center: multiple baselines), T2: begin of parental psychotherapy, T3: post-assessment, T4: 6 months follow-up]. The total observation period will be 39 months. The patients will be randomly assigned to either the control condition (25 to 45 CBT sessions) or the experimental condition (25 to 45 CBT sessions + 10 Triple-P sessions). For evaluating the treatment process, the patients and clinicians will also be assessed after each treatment session. Furthermore, there will be a continuous assessment and report of adverse events during treatment. Discussion: This trial will be the first ever to address the launch and grow as well as the parenting assumption in one study and to establish effects of the two different interventions on children's health. Our study will also likely be the first one to provide data on the comparative cost-effectiveness and will therefore provide essential information relevant for the potential implementation of such programs. The structure of the RCT will allow us to establish effects of the parental disorder(s) with/without comorbidities on children's health, to test assumptions of the trans-generational transmission model of mental disorders and bi-directional influences of different treatments on the model and to analyze specific transmission mechanisms. A deeper understanding of risk mechanisms will reveal specific transmission profiles that will result in the early detection of and effective reduction in risk factors and thus improve the health of the children at risk. Ethics: The study is carried out according to the Good Clinical Practice (GCP) guidelines, the Declaration of Helsinki and its later supplements and local legal requirements. The lead ethics committee at the department of psychology at Philipps-University Marburg approved the study procedure and all study documents. A positive ethics committee vote is required at a study site, before the inclusion of a first patient at the respective site. Dissemination: Via peer-reviewed publications in scientific journals, the results of this study will be made available to the scientific community. Using PsychData all primary data will be made available for re- and meta-analyses. Politicians, public health services, and stakeholders will be informed throughout the study and beyond, thus, improving public policy and health care decisions concerning preventive interventions and treatments for COPMI. Trial Registration: DRKS-ID: DRKS00013516 (German Clinical Trials Register, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013516).

["Nicht von schlechten Eltern - NischE": A Family Orientated Collaborative Care Approach to Support Children in Families with Mentally Ill Parents]. / Nicht von schlechten Eltern ­ NischE: Ein Brückenkonzept familienorientierter Versorgung von Kindern mit psychisch oder suchtbelasteten Eltern.

"Nicht von schlechten Eltern - NischE": A Family Orientated Collaborative Care Approach to Support Children in Families with Mentally Ill Parents The present work describes the setting- and multi-professional offer "NischE" in Gütersloh, a systemic approach for the care of children and their mentally ill parents. Children of mentally ill parents are a special risk group for developing their own mental illness. The aim of the collaborative care model between child and adolescent psychiatry, youth services and adult psychiatry is to enable affected families in terms of family-focused practice a low threshold access to different services. For this purpose, two positions have been created to advise the affected families and support access to the help system in the sense of a systemic case management in a project. The article describes the background and the need for the development of the offer, the current scientific knowledge base on the subject and illustrates the procedure using a case study from practice.

[Do Attachment Styles of Mentally Ill Parents Impact on the Health-related Quality of Life of their Children?]. / Beeinflusst der elterliche Bindungsstil die gesundheitsbezogene Lebensqualität der Kinder psychisch kranker Eltern?

Do Attachment Styles of Mentally Ill Parents Impact on the Health-related Quality of Life of their Children? Parents with a mental disorder often display a problematic attachment style which may impact on their children's health related quality of life (HrQoL). The current study cross-sectionally examines attachment styles (BEPE) in mentally ill parents with underage children (n = 62) and the effect of attachment on their children's HrQoL (KINDL-R). Results show that secure attachment is less represented in parents with a mental health condition than in a healthy reference group. Within the clinical sample, children of mentally ill parents with a secure attachment style exhibit a higher HrQoL than children of mentally ill parents with ambivalent or avoidant attachment styles. These findings indicate not only that problematic attachment styles frequently occur in families with a mentally ill parent, but also suggest that this negatively affects the children's HrQoL. Appropriate interventions should include attachment oriented concepts.

Knowledge transfer in the field of parental mental illness: objectives, effective strategies, indicators of success, and sustainability.

BACKGROUND: Mental health problems are often transmitted from one generation to the next. However, transferring knowledge about interventions that reduce intergenerational transmission of disease to the field of parental mental illness has been very difficult. One of the most critical issues in mental health services research is the gap between what is generally known about effective treatment and what is provided to consumers in routine care. DISCUSSION: In this article we discuss several aspects of knowledge transfer in the field of parental mental illness. Effective strategies and implementation prerequisites are explored, and we also discuss indicators of success and sustainability. SUMMARY: Altogether, this article presents a rationale for the importance of preventive strategies for children of mentally ill parents. Furthermore, the discussion shows how complex it is to change clinical practice.