Lived experiences: Growing up with a seriously mentally ill parent.

INTRODUCTION: Individuals with serious mental illness often have persistent and disruptive symptoms. These can profoundly affect their children's lives, exposing them to adverse social and psychological conditions. Such conditions can result in traumatic lived experiences during childhood, which can carry over into adulthood, influencing their self-perceptions and shaping their attitudes toward themselves and society. To gain insights into this phenomenon, this study explored the lived experiences of adults who grew up with a parent with serious mental illness and their perceptions of their lives in adulthood. DESIGN: This study used an interpretive phenomenological design. METHODS: Participants were invited to voluntarily participate in the study through a call posted on social media. Semi-structured interviews were conducted with 30 adults (age range, 20-55 years) who grew up with a parent with serious mental illness. The interviews were recorded and transcribed, and inductive thematic analysis was used to identify main and overarching themes. RESULTS: The overarching theme of transition from childhood survival to adulthood survival emerged and included four main themes: (1) a traumatic childhood, (2) perceived control, (3) resilience and general self-efficacy, and (4) adult quality of life. A traumatic childhood consisted of experiences of neglect and abuse, while participants used perceived control to achieve personal growth, self-care, and care of others. Resilience and general self-efficacy emerged during the transition to adulthood and helped participants further their social status and strengthen family bonds. Lastly, adult quality of life was described as being disturbed by feelings of loneliness and being burdensome, stemming from an inherent tendency to rely solely on themselves, leading to trust issues and mental health complications. Therefore, these adults found it difficult to reach out and get help or treatment for their concerns, as they initially did not want to appear dysfunctional or in need. CONCLUSION: This study has illuminated the lived experiences of a specific, vulnerable population that has not been intentionally explored until now. To delve into these experiences, we employed a distinctive qualitative approach, merging the interpretive phenomenological perspective with an inductive thematic analysis. This allowed for rich insight with a relatively large group of participants and enabled an in-depth exploration within this methodological framework. Consequently, this study constitutes a notable contribution to the extant body of knowledge, exploring the intricacies of personal growth and its impact on participants' quality of life. It uncovers the essence of resilience and general self-efficacy, revealing how these elements intertwine with the negative results observed. However, the study findings emphasize the need for healthcare professionals, including nurses and other caregivers, to be mindful of the long-lasting effects of the adverse experiences of children of patients with serious mental illness. Prioritizing active clinical assessment and implementing tailored interventions to address such children's specific needs and difficulties across different developmental stages is imperative. Such comprehensive and targeted approaches are crucial in providing appropriate support and promoting the well-being of these individuals. CLINICAL RELEVANCE: Enhanced clinical attention in holistic psychiatric care is crucial for individuals and their relatives, especially children. Comprehensive assessments of children and adults raised by seriously mentally ill parents can enable tailored and preventive interventions, positively impacting overall quality of life.

Mindfulness-based cognitive therapy for children and adolescents with anxiety disorders at-risk for bipolar disorder: A psychoeducation waitlist controlled pilot trial.

AIM: Previous studies suggest that Mindfulness-Based Cognitive Therapy for Children (MBCT-C) is feasible and may improve anxiety and emotion regulation in youth with anxiety disorders at-risk for bipolar disorder. However, controlled studies are warranted to replicate and extend these findings. METHODS: In the current study, 24 youth with anxiety disorders who have at least one parent with bipolar disorder participated in a MBCT-C treatment period (n = 24; Mage = 13.6, 75% girls, 79% White) with a subset also participating in a prior psychoeducation waitlist control period (n = 19 Mage = 13.8, 68% girls, 84% White). Participants in both the waitlist and MBCT-C periods completed independently-rated symptom scales at each time point. Participants in the waitlist period received educational materials 12 weeks prior to the beginning of MBCT-C. RESULTS: There were significantly greater improvements in overall clinical severity in the MBCT-C period compared to the waitlist period, but not in clinician- and child-rated anxiety, emotion regulation or mindfulness. However, increases in mindfulness were associated with improvements in anxiety and emotion regulation in the MBCT-C period, but not the waitlist period. CONCLUSIONS: Findings suggest that MBCT-C may be effective for improving overall clinical severity in youth with anxiety disorders who are at-risk for bipolar disorder. However, waitlist controlled designs may inflate effect sizes so interpret with caution. Larger studies utilizing prospective randomized controlled designs are warranted.

[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.

Evaluation of the mindfulness-augmented "Trampoline" programme - a German prevention programme for children from substance-involved families tested in a cluster-randomised trial.

BACKGROUND: Children of substance-abusing parents are at a substantial risk of developing substance-use and other mental disorders. Children involved in substance abuse - not diagnosed with substance-use problems but integrated in psychiatric treatment or youth welfare services - constitute a particular high-risk group that is in need of substance use prevention. Emerging evidence indicates that self-regulatory determinants of substance use and other mental disorders, particularly stress reactivity, are modifiable by mindfulness-based interventions, such as mindfulness-based stress reduction. METHODS: In this ongoing cluster randomised-controlled trial, a mindfulness-augmented version of the modularised evidence-based "Trampoline" programme for children affected by parental substance use problems is evaluated in a sample of 420 children who are from substance-involved families, aged from 8 to 12 and receiving non-substance-specific care in psychiatric or youth welfare services. Larger effects on adaptive stress-coping strategies (primary outcome), internalising and externalising problem behaviours and distress due to parental substance use are expected compared to the standard "Trampoline"-programme version. Mindfulness components will be added and regularly practiced for 30 min in each validated "Trampoline" module. Moreover, the feasibility of mindfulness-based interventions in psychiatric care and youth welfare services for children suffering from emotional and behavioural problems will be investigated in this study. DISCUSSION: Despite recruitment challenges, this study provides a unique opportunity to develop and test a promising addiction-specific, mindfulness-based intervention for a target group at risk, i.e. children from substance-involved families. TRIAL REGISTRATION: The trial was registered in the German Clinical Trials Register on July 16th 2018 (trial registration number (TRN): DRKS00013533 ). Any important protocol modifications are to be reported immediately. Protocol version v.2.1, 15th April 2019.

["I Would Never have done it Without Coercion " - Experiences with Coercion and Compulsion in a Family Psychiatric and Psychotherapeutic Day Clinic]. / "Freiwillig hätt' ich's nicht gemacht " ­ Erfahrungen mit Zwangskontexten und erzwungenen Aufenthalten in einer familienpsychiatrischen und -psychotherapeutischen Tagesklinik.

"I Would Never have done it Without Coercion …" - Experiences with Coercion and Compulsion in a Family Psychiatric and Psychotherapeutic Day Clinic Coercion and compulsion have negative connotations, especially in psychiatric therapy. But in families, children are always also affected if parents do not want or are not able to make use of therapy. The avoidance of therapy can be a symptom of illness, e. g. separation anxiety. Perceived or real external coercion, e. g. from the youth welfare office or school, can be used to initially open up access to therapy and to allow parents to become capable of acting again. Coercion can initially reduce the ambivalence of the parents. The Family Therapeutic Centre (FaTZ) is a psychiatric and psychotherapeutic day clinic for parents and children. Family constellations are described in which initial coercion was a door-opener to therapy. During courses of treatment therapeutic alliances could be established, hope for positive change emerged, and the outcome was favourable. School avoidance of the child (e. g. due to separation anxiety) in combination with mentally ill parents is an exemplary constellation in which initial coercion can pave the way to therapy for families that otherwise wouldn't get access. Afterwards, voluntary cooperation should be intended, as the overriding objective is to reduce coercive measures to a minimum.

Association of Constellations of Parental Risk With Children's Subsequent Anxiety and Depression: Findings From a HUNT Survey and Health Registry Study.

Importance: The research focus on children of parents with alcohol use disorder has eclipsed the potentially wider-reaching detrimental effects of subclinical parental drinking, both alone and in combination with other parental risk factors. Objective: To identify constellations of early parental risk characterized by variations in drinking, mental health, and education in both parents and examine their prospective associations with children's contact with the health care system for anxiety and/or depression (ie, diagnoses or treatment). Design, Setting, and Participants: This prospective study was based on linked survey and health registries data. The sample included 8773 children from 6696 two-parent families in Norway who participated in the Nord-Trøndelag Health Study (HUNT) survey in 1995 to 1997 or 2006 to 2008, when the children were aged 13 to 19 years. Data were analyzed from January to September 2018. Exposures: Five constellations of early parental risks, characterized by variations in drinking frequencies and amounts, mental health, and education for both parents, as identified through latent profile analysis. Main Outcomes and Measures: Children's diagnoses or treatment of anxiety and/or depression from 2008 to 2016 were recorded in 3 health registries. The primary outcome was the total number of registries where participants presented (ranging from 0 to 3). Results: Of the 8773 included children, 4404 (50.2%) were boys, and the mean (SD) age at the time of participation in the Nord-Trøndelag Health Study was 16.1 (1.8) years. Prevalence of anxiety and/or depression, as evidenced in at least 1 registry record, was 24.3% (2132 of 8773). Early parental risk profiles risks marked by (1) the lowest parental education (adjusted relative risk, 1.13; 95% CI, 1.01-1.25) and (2) elevated drinking in both parents and elevated mental health symptoms in fathers (adjusted relative risk, 1.52; 95% CI, 1.03-2.22) were associated with a significant increase in risk of anxiety and/or depression in children from those families compared with children from no-risk families. Conclusions and Relevance: Studies seeking to understand prospective associations of parental drinking with children's mental health need to consider additional risk factors in combination with one another as well as parental behaviors and characteristics below clinically defined levels. When accumulated at a family level, even seemingly innocuous characteristics contributed to meaningful increases in risk of anxiety and/or depression among children, potentially translating into poorer mental health outcomes for many young people.

A THERAPEUTIC PLAYGROUP FOR DEPRESSED MOTHERS AND THEIR INFANTS: FEASIBILITY STUDY AND PILOT RANDOMIZED TRIAL OF COMMUNITY HUGS.

Symptoms of depression negatively impact on mother-infant relationships and child outcomes. We evaluated a novel, 10-session mother-infant therapeutic playgroup-Community HUGS (CHUGS)-which combines cognitive and experiential components through psychoeducation, play, music, and movement. Participants were mothers experiencing a range of postnatal mental health difficulties, including depression, with infants ≤12 months of age. However, the aim was not to treat maternal depression but to ameliorate associated problems in the mother-infant interaction. In the feasibility study, all participants received CHUGS. In the pilot randomized controlled trial (RCT), participants were randomized between intervention and a wait-list. Outcomes were the Parenting Stress Index (PSI; R.R. Abidin, 1995), Parenting Sense of Competency Scale (Self-Efficacy subscale; J. Gibaud-Wallston & L.P. Wandersman, 1978), and the Depression, Anxiety, Stress Scales (P.F. Lovibond & S.H. Lovibond, 1995). In the feasibility study (n = 74), PSI scores dropped on all subscales, all ps < .01. Depression, p < .001, anxiety, p = .01, stress, p = .01, and self-efficacy, p < .001, all showed improvements, as did observer-rated mother-infant interactions, p < .001. In the RCT, depression, p < .001, anxiety, p = .005, and stress, p < .001, symptoms were significantly reduced for intervention participants (n = 16), as compared to wait-list participants (n = 15). The CHUGS program had high participant satisfaction and produced improvements in self-efficacy, depression, anxiety, stress, and mother-infant interactions that supported the program's acceptability and the utility of further rollout.

Benefits to Children Who Participate in Family Therapy with their Substance-Using Mother.

It is rare that family members other than the identified patient are followed over time in studies of therapy effectiveness. Family therapy is believed to be effective because it targets processes within the system that maintain symptoms. If these processes are changed, then all family members can benefit. Using a sample of 183 mother-child dyads from a study comparing family therapy for adult substance use versus an attention control, change in child's substance use (tobacco, alcohol, and marijuana) was estimated. Children who participated in family therapy with their mothers showed greater decreases in alcohol and tobacco use and were less likely to begin using compared to children whose mothers participated in the attention control condition.

Adverse Childhood Experiences and Child Health Outcomes: Comparing Cumulative Risk and Latent Class Approaches.

Objectives This study seeks to further the work exploring adverse childhood experiences (ACEs) by proposing a novel approach to understanding the impact of ACEs through applying advanced analytical methods to examine whether combinations of ACEs differentially impact child health outcomes. Methods Using National Survey of Children's Health data, we use latent class analysis to estimate associations between classes of ACEs and child health outcomes. Results Class membership predicts child poor health, with differences found for specific ACE combinations. A subgroup of children exposed to poverty and parental mental illness are at higher risk for special healthcare needs than all other groups, including children exposed to 3 or more ACEs. Conclusions Different combinations of ACEs carry different risk for child health. Interventions tailored to specific ACEs and ACE combinations are likely to have a greater effect on improving child health. Our findings suggest children who experience specific ACE combinations (e.g., poverty and parental mental illness) are at particularly high risk for poor health outcomes. Therefore, clinicians should routinely assess for ACEs to identify children exposed to the most problematic ACE combinations; once identified, these children should be given priority for supportive interventions tailored to their specific ACE exposure and needs.

An open trial of equine-assisted therapy for children exposed to problematic parental substance use.

Children exposed to problematic parental substance use (PPSU) often face a number of deleterious developmental outcomes, yet these children are less likely to become known to child protection and welfare services. Although there is a growing evidence base for equine-assisted therapy (EAT) as an effective treatment modality for atypically developing children and adolescents, scant research has explored the benefit of EAT for children exposed to PPSU. The current study is the first to explore the benefit of EAT for children exposed to PPSU in Victoria, Australia. Five 12-week EAT programmes were delivered from 2012 to 2015 with a total of 41 children (mean age of 10.26 years) taking part. Children's parents (n = 41) and schoolteachers (n = 31) completed the Strengths and Difficulties Questionnaire pre- and post-intervention. Parents reported that children's total difficult behaviour and emotional problems decreased following the 12-week EAT programme. In addition, parents and teachers observed a significant decrease in children's hyperactivity. The findings obtained highlight the benefit of EAT for children exposed to PPSU and thus, extends the existing evidence base for this treatment modality.

Down on the upside: redemption, contamination, and agency in the lives of adult children of alcoholics.

We investigated differences in the nature and implications of Adult Children of Alcoholics (ACOAs; n = 53) and non-ACOAs' (n = 80) narrative identities. Participants described six autobiographical narratives and completed measures of emotional functioning. Narratives were coded for redemptive (bad things turning good), contaminated (good things turning bad), and agentic (perceived control) imagery. ACOAs exhibited similar levels of redemptive and contaminated imagery, and lower levels of agency in their narratives, relative to non-ACOAs. In addition, themes of redemption, contamination, and agency corresponded divergently with emotional functioning. Among ACOAs, narrative redemption and agency were related to poorer emotional functioning whereas, among non-ACOAs, narrative contamination predicted poorer emotional functioning. These findings provide indication of the manner in which ACOAs story their lives. They also align with the emerging area of research noting that, among certain vulnerable populations, redemptive and agentic imagery serve as predictors of maladaptive functioning.

From early family systems to internalizing symptoms: The role of emotion regulation and peer relations.

Research has demonstrated the importance of early family characteristics, such as the quality of caregiving, on children's later mental health. Information is, however, needed about the role of more holistic family systems and specific child-related socioemotional mechanisms. In this study, we conceptualize families as dynamic family system types, consisting of both marital and parenting trajectories over the transition to parenthood. First, we examine how early family system types predict children's anxiety, depression, peer exclusion, and emotion regulation. Second, we test whether couples' infertility history and other family related contextual factors moderate the effects of family system types on child outcomes. Third, we test whether children's emotion regulation and peer exclusion mediate the effects of family system types on anxiety and depression. The participants were 452 families representing cohesive, distant, authoritative, enmeshed, and discrepant family types, identified on the basis of relationship autonomy and intimacy from pregnancy to the child's age of 2 and 12 months. Children's anxiety, depression, emotion regulation, and peer exclusion were assessed at the age of 7-8 years. Structural equation modeling showed that distant, enmeshed, and discrepant families similarly predicted children's heightened anxiety and depression. Infertility history, parental education, and parity moderated the associations between certain family system types and child outcomes. Finally, emotion regulation, but not peer exclusion, was a common mediating mechanism between distant and enmeshed families and children's depression. The results emphasize the importance of early family environments on children's emotion regulation development and internalizing psychopathology. (PsycINFO Database Record

[Unseen Suffering - Therapy for Traumatized Refugee Children]. / Unsichtbares Leiden ­ Therapie traumatisierter Kinder mit Fluchterfahrung.

Unseen Suffering - Therapy for Traumatized Refugee Children In March 2015 the psychological counselling service (Psychologische Familien- und Lebensberatung) of Caritas Ulm initiated a psychotherapy project for traumatized minor refugees. Besides individual and group therapy, networking and qualification of qualified personnel and volunteers, in autumn 2015 we started offering our services on-site in a large collective accommodation for asylum seekers in Ulm. This was mainly because - in contrast to unaccompanied, mostly adolescent, minor refugees - our services appeared to reach children only by chance. In our opinion this is mostly due to the fact that children's suffering is often far less noticed. This paper describes our first year's project work, followed by reports on the use of psychodrama groups with refugee children and on the therapeutic work in a collective accommodation for asylum seekers.

Effectiveness of Mindfulness Intervention on Psychological Behaviors Among Adolescents With Parental HIV Infection: A Group-Randomized Controlled Trial.

This study aims to identify the effectiveness of mindfulness intervention on the psychological behaviors of adolescents with parental HIV infection and its associated factors in Myanmar. A total of 80 adolescents from 2 intervention townships and 80 adolescents from 2 control townships were enrolled in a group randomized controlled trial with assessments at baseline and 6 months follow-up. The mindfulness intervention involved monthly group sessions for 3 consecutive months led by an experienced mindfulness trainer. Three domains of psychological behaviors-namely, emotional, conduct, and social behaviors-were assessed at baseline and compared after 6 months. Multilevel regression analysis was used to determine the effectiveness of the intervention and associated factors for psychological behaviors. The intervention significantly improved emotional and conduct behaviors at 6 months (P < .001) but had no effect on social behavior. The significant effect of the intervention existed after adjusting for gender, family type, child age, and orphan status.

Family systems therapy for substance-using mothers and their 8- to 16-year-old children.

Family systems therapy has shown to be a powerful adjunct to substance use treatment for couples and for adolescent substance users (Rowe, 2012). However, studies including children (8-16 years of age) in the treatment of their substance using mothers have been overlooked and are essentially nonexistent. Addressing the quality of the mother-child relationship and communication through family systems therapy may prove to be a potent intervention focus for improving mothers' substance use outcomes and parent-child interaction. As such, the current study recruited 183 mothers who sought outpatient treatment through a local substance use treatment facility and randomly assigned them to also receive family systems therapy or Women's Health Education. Self-report and observational data were collected, and assessment interviews were completed at baseline and 3, 6, 12, and 18 months postbaseline. Findings showed that women assigned to family systems therapy showed a quicker decline in alcohol, marijuana, and cocaine use, supporting the efficacy of family therapy as an important addition to mother's substance use treatment plans. Data also revealed an association between change in observed autonomy-relatedness and substance use, though mediation was not found. To our knowledge this is the first effort to successfully document a family systems therapy for substance using mothers with minor children in their care. (PsycINFO Database Record

Outcomes of programs serving mothers with psychiatric disabilities and their young children: a multisite case file abstraction study.

OBJECTIVE: This multisite study examined outcomes of mothers with mental illnesses receiving integrated clinical, rehabilitation, and parenting services for their preschool-age children. Mothers' outcomes included independent living and employment status, custody loss and reunification, psychiatric hospitalization, and substance abuse. METHOD: Retrospective case file abstraction yielded data regarding 104 mothers served over 12-month periods during 1995-1999 at 4 programs located in 3 different states. Multivariable logistic regression (MLR) analysis explored associations between outcomes and predictors from prior research, controlling for study site. RESULTS: During their first 12 months of program participation, significant increases were found in the proportions of mothers employed and living independently. Significant decreases were noted in the proportion of mothers abusing substances. Although 10% of the women served lost formal custody during their first year of participation, 22% were reunited with 1 or more children. In MLR analysis, mothers who abused substances were more likely to have experienced childhood sexual abuse and custody loss; those who were psychiatrically hospitalized were more likely to have abused substances, lost custody of 1 or more children, and had more disabling forms of mental illness; and those who lost custody of 1 or more children were more likely to have experienced a psychiatric hospitalization and less likely to be residing with 3 or more children. CONCLUSIONS: Programs for mothers with mental illness and their preschool children address service needs in an integrated fashion that appears to improve clinical and rehabilitation outcomes, while preventing custody loss and supporting reunification.

Nonprofit Charity Impacts Wounded Combat Veterans And Children Facing Adversity.

Mental and physical health challenges, especially for returning war veterans and their families, is a growing national concern. A grassroots program featuring equine therapy for these patients and their families shows promise in increasing self-esteem and self-confidence, reducing isolation and depression, and improving speaking and writing skills.

The shroud: ways adolescents manage living with parental chronic pain.

PURPOSE: The purpose of this article is to describe a substantive theory that details how adolescents manage living with a parent experiencing chronic noncancer pain (CNCP). DESIGN: Grounded theory methods were used to recruit 30 young adults, ages 18 through 21 years, from community settings. METHODS: During open-ended interviews, participants were asked to look back on their adolescence and talk about how they managed living with parental chronic pain. Interview transcripts and field notes were analyzed using constant comparative methods. FINDINGS: Participants who lived with heavily shrouded parents (a) endured hardships; (b) distanced themselves; (c) lamented losses; and (d) held back on revealing their authentic selves. Those who lived with minimally shrouded parents (a) received nurturance and parenting; (b) empathized with their parents' pain situations; (c) lamented losses; and (d) revealed to their parents how parental pain affected them. Participants who connected with significant others "filled the gaps" created by parental pain disability, while those who did not connect with significant others "cooped up" their thoughts, feelings, and needs. CONCLUSIONS: Findings shed light on psychosocial processes and behavior within families experiencing CNCP and serve as the basis for the development of personalized family interventions. CLINICAL RELEVANCE: Nursing interventions should focus on helping adolescents and parents build interpersonal relationship and communication skills. Aggressive diagnosis and treatment of mood disturbance in the parent with CNCP should be part of a holistic treatment plan.

[Support for families with a parent diagnosed with cancer and children under the age of five--delineation of a counselling concept]. / Unterstützung von Familien mit einem an Krebs erkrankten Elternteil und Kindern unter fünf Jahren--Darstellung eines Beratungskonzeptes.

Parents of infants and young children, who have been diagnosed with cancer wish to protect their child from the emotional strains of their illness. They wonder, what the child can understand about the illness and how it is able to process or assimilate the experience of the illness. In fact, infants and young children are particularly sensitive to the degree of emotional burden and the mental state of their parents and will experience varying degrees of insecurity due to even small changes in their relationship with their parents. On the basis of psychological development parameters specific to this age group as well as scientific findings on risk and protection factors an integrated interaction based counseling approach was developed. Within this approach, support for the communication between parent and child in view of the specific strains of their illness, both non-verbal and in the child's early stages of verbal communication, is central. In the present article the counselling concept is described and illustrated by case studies. Application and limits are discussed.