The importance of clinicians' and parents' awareness of suicidal behaviour in adolescents reaching the upper age limit of their mental health services in Europe.

BACKGROUND: To study clinicians' and parents' awareness of suicidal behaviour in adolescents reaching the upper age limit of their Child and Adolescent Mental Health Service (CAMHS) and its association with mental health indicators, transition recommendations and mental health service (MHS) use. METHODS: 763 CAMHS users from eight European countries were assessed using multi-informant and standardised assessment tools at baseline and nine months follow-up. Separate ANCOVA's and pairwise comparisons were conducted to assess whether clinicians' and parents' awareness of young people's suicidal behaviour were associated with mental health indicators, clinician's recommendations to continue treatment and MHS use at nine months follow-up. RESULTS: 53.5 % of clinicians and 56.9 % of parents were unaware of young people's self-reported suicidal behaviour at baseline. Compared to those whose clinicians/parents were aware, unawareness was associated with a 72-80 % lower proportion of being recommended to continue treatment. Self-reported mental health problems at baseline were comparable for young people whose clinicians and parents were aware and unaware of suicidal behaviour. Clinicians' and parents' unawareness were not associated with MHS use at follow-up. LIMITATIONS: Aspects of suicidal behaviour, such as suicide ideation, -plans and -attempts, could not be distinguished. Few young people transitioned to Adult Mental Health Services (AMHS), therefore power to study factors associated with AMHS use was limited. CONCLUSION: Clinicians and parents are often unaware of suicidal behaviour, which decreases the likelihood of a recommendation to continue treatment, but does not seem to affect young people's MHS use or their mental health problems.

Leaving child and adolescent mental health services in the MILESTONE cohort: a longitudinal cohort study on young people's mental health indicators, care pathways, and outcomes in Europe.

BACKGROUND: The configuration of having separate mental health services by age, namely child and adolescent mental health services (CAMHS) and adult mental health services (AMHS), might be a barrier to continuity of care that adversely affects young people's mental health. However, no studies have investigated whether discontinuity of care in the transition period affects mental health. We aimed to discern the type of care young people receive after reaching the upper age limit of their CAMHS and examine differences in outcomes at 24-month follow-up between young people receiving different types of care. METHODS: To assess mental health in young people from 39 CAMHS in eight European countries (Belgium, Croatia, France, Germany, Italy, Ireland, the Netherlands, and the UK), we did a longitudinal cohort study. Eligible young people were CAMHS users up to 1 year younger than the upper age limit of their CAMHS or up to 3 months older, if they were still in CAMHS. Information on mental health service use, mental health problems (ie, using the Health of the Nation Outcome Scale for Children and Adolescents, Youth Self-Report and Adult Self-Report, DSM-5, and ICD-10), and sociodemographic characteristics were collected using self-reported, parent-reported, and clinician-reported interviews and questionnaires. Mixed models were applied to assess relationships between baseline characteristics, mental health service use, and outcomes. FINDINGS: The MILESTONE cohort included 763 young people. The participants were 60·0% female (n=458) and 40·0% male (n=305), 90·3% White (n=578), and had a mean age of 17·5 years (range 15·2-19·6 years). Over the 24-month follow-up period, 48 young people (6·3%) actively withdrew from the study. For young people, the higher their scores on the Health of the Nation Outcome Scale for Children and Adolescents (p=0·0009) and Youth Self-Report and Adult Self-Report (p=0·046), and who had a clinical classification of severe mental illness (p=0·0033), had suicidal thoughts or behaviours or self-harm (p=0·034), used psychotropic medication (p=0·0014), and had a self-reported or parent-reported need for continued treatment (p<0·0001) at baseline, were more likely to transition to AMHS or stay in CAMHS than to have care end. Overall, over the 24-month follow-up period, the mental health of young people improved, but 24·4% of young people reported an increase in problems calculated using the reliable change index, of whom 5·3% had a clinically relevant increase in problems. At 24-month follow-up, no differences in change in mental health problems since baseline were found between young people who used different types of care (CAMHS, AMHS, or no care). INTERPRETATION: Although approximately half of young people reaching the upper age limit of their CAMHS stop using mental health services, this was not associated with a deterioration in their mental health. Young people with the most severe mental health problems are more likely to receive continued care. If replicated, our findings suggest investments in improving transitional care for all CAMHS users might not be cost-effective in times of rising health-care costs, but might be better targeted at a subgroup of young people with increasing mental health problems who do not receive continued treatment. FUNDING: European Commission's 7th Framework Programme.

Quality of Mother-child Dialogue About Emotional Events, Coping and Posttraumatic Stress Symptoms Among Children Exposed to Interpersonal Trauma.

Children exposed to traumatic events are at increased risk for developing symptoms of a Post-Traumatic Stress Disorder. Children often discuss emotional, and therefore also traumatic, events in their lives with their parents, and the quality of these discussions can facilitate coping and further development. The study aim was 1) to explore whether the association between the quality of dialogue between mothers and children about emotional events and children's posttraumatic stress symptoms (PTSS) might be indirectly linked through children's adaptive coping skills, and 2) whether this association differed when discussing different negative emotions. 169 mother-child dyads with interpersonal trauma-exposure (86% domestic violence, 14% mother and/or child sexually abused) participated in the Autobiographical Emotional Events Dialogue (AEED). Quality of mother-child emotion dialogue, captured in maternal sensitive guidance and child cooperation, and approach-oriented coping were coded from transcripts. PTSS was measured with the Child Behavior Checklist. Lower quality of mother-child emotion dialogue was associated with less approach-oriented coping and more symptoms of posttraumatic stress. There was an indirect effect of approach-oriented coping with angry feelings linking quality of mother-child emotion dialogue and child PTSS. Children's symptoms of posttraumatic stress were reflected in the quality of mother-child dialogues about traumatic and other emotional events. Findings support that dialogues about emotional events may be a promising target for intervention with children exposed to trauma.

Cohort profile: demographic and clinical characteristics of the MILESTONE longitudinal cohort of young people approaching the upper age limit of their child mental health care service in Europe.

PURPOSE: The presence of distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) impacts continuity of mental health treatment for young people. However, we do not know the extent of discontinuity of care in Europe nor the effects of discontinuity on the mental health of young people. Current research is limited, as the majority of existing studies are retrospective, based on small samples or used non-standardised information from medical records. The MILESTONE prospective cohort study aims to examine associations between service use, mental health and other outcomes over 24 months, using information from self, parent and clinician reports. PARTICIPANTS: Seven hundred sixty-three young people from 39 CAMHS in 8 European countries, their parents and CAMHS clinicians who completed interviews and online questionnaires and were followed up for 2 years after reaching the upper age limit of the CAMHS they receive treatment at. FINDINGS TO DATE: This cohort profile describes the baseline characteristics of the MILESTONE cohort. The mental health of young people reaching the upper age limit of their CAMHS varied greatly in type and severity: 32.8% of young people reported clinical levels of self-reported problems and 18.6% were rated to be 'markedly ill', 'severely ill' or 'among the most extremely ill' by their clinician. Fifty-seven per cent of young people reported psychotropic medication use in the previous half year. FUTURE PLANS: Analysis of longitudinal data from the MILESTONE cohort will be used to assess relationships between the demographic and clinical characteristics of young people reaching the upper age limit of their CAMHS and the type of care the young person uses over the next 2 years, such as whether the young person transitions to AMHS. At 2 years follow-up, the mental health outcomes of young people following different care pathways will be compared. TRIAL REGISTRATION NUMBER: NCT03013595.

Trauma Exposure in Relation to the Content of Mother-Child Emotional Conversations and Quality of Interaction.

Parent-child conversations contribute to understanding and regulating children's emotions. Similarities and differences in discussed topics, quality of interaction and coherence/elaboration in mother-child conversations about emotional experiences of the child were studied in dyads who had been exposed to interpersonal trauma (N = 213) and non-trauma-exposed dyads (N = 86). Results showed that in conversations about negative emotions, trauma-exposed children more often discussed trauma topics and focused less on relationship topics than non-trauma-exposed children. Trauma-exposed dyads found it more difficult to come up with a story. The most common topics chosen by dyads to discuss for each emotion were mostly similar between trauma-exposed dyads and non-trauma-exposed dyads. Dyads exposed to interpersonal traumatic events showed lower quality of interaction and less coherence/elaboration than dyads who had not experienced traumatic events. Discussion of traumatic topics was associated with lower quality of mother-child interaction and less coherent dialogues. In conclusion, the effect of the trauma is seen at several levels in mother-child interaction: topics, behavior and coherence. A focus on support in developing a secure relationship after trauma may be important for intervention.

A Systematic Review of the Literature on Parenting of Young Children with Visual Impairments and the Adaptions for Video-Feedback Intervention to Promote Positive Parenting (VIPP).

Secure parent-child attachment may help children to overcome the challenges of growing up with a visual or visual-and-intellectual impairment. A large literature exists that provides a blueprint for interventions that promote parental sensitivity and secure attachment. The Video-feedback Intervention to promote Positive Parenting (VIPP) is based on that blueprint. While it has been adapted to several specific at risk populations, children with visual impairment may require additional adjustments. This study aimed to identify the themes that should be addressed in adapting VIPP and similar interventions. A Delphi-consultation was conducted with 13 professionals in the field of visual impairment to select the themes for relationship-focused intervention. These themes informed a systematic literature search. Interaction, intersubjectivity, joint attention, exploration, play and specific behavior were the themes mentioned in the Delphi-group. Paired with visual impairment or vision disorders, infants or young children (and their parents) the search yielded 74 articles, making the six themes for intervention adaptation more specific and concrete. The rich literature on six visual impairment specific themes was dominated by the themes interaction, intersubjectivity, and joint attention. These themes need to be addressed in adapting intervention programs developed for other populations, such as VIPP which currently focuses on higher order constructs of sensitivity and attachment.

Mediators and Treatment Factors in Intervention for Children Exposed to Interparental Violence.

Changes in children's emotion differentiation, coping skills, parenting stress, parental psychopathology, and parent-child interaction were explored as mediators of treatment factors in two selective preventive group interventions for children exposed to interparental violence (IPV) and their parents. One hundred thirty-four IPV-exposed children (ages 6-12 years, 52% boys) and their parents were randomized to an IPV-focused or common factors community-based group intervention and completed baseline, posttest, and follow-up assessments for posttraumatic stress (PTS). A multilevel model tested mediators that included children's ability to differentiate emotions and coping skills, parenting stress, parental psychopathology, and parent-child interactions. In both conditions, exposure to nonspecific factors, specific factors unrelated to IPV and trauma-specific intervention factors was coded from videotaped child and parent sessions. Improved parental mental health mediated the link between greater exposure to nonspecific treatment factors and decreases in PTS symptoms. In addition, an increase in emotion differentiation and a decrease in parenting stress were associated with a decrease in PTS symptoms. Greater exposure to trauma-specific factors in child sessions was associated with a small decrease in emotion differentiation, an increase in coping skills, and a decrease in PTS symptoms over time. Greater exposure to nonspecific treatment factors in child and parent sessions was associated with more positive parent-child interaction. Parental mental health appears to be an important mechanism of change that can be promoted through exposure to nonspecific factors in parent intervention. For children, the effect of greater exposure to trauma-specific factors in intervention is less clear and may not have clear benefits.

Family Functioning and Children's Post-Traumatic Stress Symptoms in a Referred Sample Exposed to Interparental Violence.

This study examined the association between interparental violence (IPV), child abuse and neglect, other traumatic experiences, and children's post-traumatic stress (PTS) symptoms and explored the moderating role of family functioning in the aftermath of IPV. One hundred and twenty IPV-exposed children (53.3 % male, M age = 9.85) and parents who were referred to community mental health centers participated in the study. Combined, IPV, child abuse and neglect, and other traumatic experiences were associated with PTS symptoms. For family functioning, higher levels of parenting stress were associated with higher levels of PTS symptoms. No moderating effects were found. To understand the variability in PTS symptoms among children exposed to IPV, other traumatic and stressful experiences need to be taken into account.

The effectiveness of VIPP-V parenting training for parents of young children with a visual or visual-and-intellectual disability: study protocol of a multicenter randomized controlled trial.

BACKGROUND: Visual or visual-and-intellectual disabilities of children make daily interactions more difficult for their parents and may impact the quality of the parent-child relationship. To support these parents, an existing intervention (Video-feedback Intervention to promote Positive Parenting; VIPP; Juffer F, Bakermans-Kranenburg MJ, van IJzendoorn MH, 2008. Promoting positive parenting; an attachment-based intervention. Mahwah, NJ: Lawrence Erlbaum Associates; 2008) was adapted for use with parents of children with a visual or visual-and-intellectual disability (VIPP-V). This attachment-based intervention was hypothesized to support parents' interpretation and understanding of the behavior of their child with a visual or visual-and-intellectual disability and respond to their child's signals in a sensitive way to improve parent-child interaction quality. METHODS/DESIGN: A randomized controlled trial (RCT) will be conducted to assess the effectiveness of the adapted intervention VIPP-V (Video-feedback Intervention to promote Positive Parenting in parents of children with Visual or visual-and-intellectual disabilities). Parent-child dyads will be randomized into two groups: 50 dyads will receive VIPP-V in combination with care-as-usual and 50 dyads will receive care-as-usual. Families with a child (1-5 years of age) with a visual or visual-and-intellectual disability will be recruited for participation in the study. Primary outcome measures are parental sensitivity and the quality of parent-child interaction. Secondary outcome measures are parental self-efficacy, and parenting stress. To assess feasibility of implementation of the intervention the experiences of early intervention workers with regard to using VIPP-V are assessed. Moderator variables are the child's developmental age, working alliance between parent and VIPP-V intervention worker and empathy of the VIPP-V intervention worker. Data will be collected approximately one week before the intervention starts (T1), one week (T2) and three months (T3) after the intervention. Parent-child dyads in the care-as-usual-only condition will be assessed at the same time points. Both intention-to-treat and completer analyses will be performed. DISCUSSION: Descriptive findings in pilot cases suggest benefits from VIPP-V, and compatibility with existing services for parents of children with a visual or visual-and-intellectual disability. The current study will provide insight into the effectiveness of this intervention for parents of children with a visual or visual-and-intellectual disability, and, if the intervention is effective, prepare the field for broad-scale implementation. TRIAL REGISTRATION: Nederlands Trial Register NTR4306 (registered 5 December 2013).

Risk factors as moderators of recovery during and after interventions for children exposed to interparental violence.

High family risk was tested as an impediment to recovery in children exposed to interparental violence (IPV) participating in community-based intervention. Characteristics of IPV were also explored as moderators for the effect of an IPV-focused intervention over a common factors intervention. Baseline, posttest and follow-up measurements of 155 parents and children (aged 6 to 12 years; 55.5% boys) were fitted in a multilevel model. Outcomes were clinical classifications of internalizing and externalizing problems, and posttraumatic stress symptoms. Tested moderators were child maltreatment, symptoms of disordered attachment, parental psychopathology, parenting stress, poverty, and IPV characteristics. Children without symptoms of disinhibited social engagement disorder, children of parents with high levels of psychopathology, and children of parents with high levels of parenting stress showed strongest recovery. Participation in an IPV-focused intervention was not more effective than in a common factors intervention, irrespective of the nature of the IPV. Based on rate of recovery, participation in community-based group interventions does not need to be contraindicated for children facing high family risk after being exposed to IPV, except for children with symptoms of disinhibited social engagement disorder.

Effectiveness of specific factors in community-based intervention for child-witnesses of interparental violence: a randomized trial.

A community-based intervention with specific factors for children and parents exposed to interparental violence (IPV) was compared with a control intervention based on non-specific factors. We hypothesized that participation in an intervention with specific factors, focused on IPV, parenting and coping, would be associated with better recovery. IPV exposed children and parents were group randomized over a specific factors- and control intervention. Baseline, posttest and follow-up measurements of 155 parents and children (aged 6-12 years, 55.5% boys) were fitted in a multilevel model. Outcomes were parent and teacher reported children's internalizing and externalizing problems (CBCL, TRF), child self-reported depressive symptoms (CDI) and parent and child reported children's post-traumatic stress symptoms (TSCYC, TSCC). Based on intention-to-treat and completer analyses, children in the specific factors intervention did not show better recovery than children in the control intervention. Children in both interventions decreased significantly in parent-reported children's internalizing and externalizing problems and post-traumatic stress symptoms. Children reported a decrease in their mean level of depressive and post-traumatic stress symptoms. Teachers reported a decrease in internalizing problems, but not in externalizing problems. No association between time since exposure and level and course of symptoms was found. Treatment differentiation was assessed and both programs were significantly different on hypothesized effective factors. Higher treatment adherence in both programs did not result in a larger difference in recovery. IPV exposed children improve over the course and after participating in a community-based child- and parent program, but specific factors in intervention may not carry additional benefits when implemented in community settings.

The effectiveness of a trauma-focused psycho-educational secondary prevention program for children exposed to interparental violence: study protocol for a randomized controlled trial.

BACKGROUND: Children who witness interparental violence are at a heightened risk for developing psychosocial, behavioral and cognitive problems, as well as posttraumatic stress symptoms. For these children the psycho-educational secondary prevention program 'En nu ik...!' ('It's my turn now!') has been developed. This program includes specific therapeutic factors focused on emotion awareness and expression, increasing feelings of emotional security, teaching specific coping strategies, developing a trauma narrative, improving parent-child interaction and psycho-education. The main study aim is to evaluate the effectiveness of the specific therapeutic factors in the program. A secondary objective is to study mediating and moderating factors. METHODS/DESIGN: This study is a prospective multicenter randomized controlled trial across cities in the Netherlands. Participants (N = 140) are referred to the secondary preventive intervention program by police, social work, women shelters and youth (mental health) care. Children, aged 6-12 years, and their parents, who experienced interparental violence are randomly assigned to either the intervention program or the control program. The control program is comparable on nonspecific factors by offering positive attention, positive expectations, recreation, distraction, warmth and empathy of the therapist, and social support among group participants, in ways that are similar to the intervention program. Primary outcome measures are posttraumatic stress symptoms and emotional and behavioral problems of the child. Mediators tested are the ability to differentiate and express emotions, emotional security, coping strategies, feelings of guilt and parent-child interaction. Mental health of the parent, parenting stress, disturbances in parent-child attachment, duration and severity of the domestic violence and demographics are examined for their moderating effect. Data are collected one week before the program starts (T1), and one week (T2) and six months (T3) after finishing the program. Both intention-to-treat and completer analyses will be done. DISCUSSION: Adverse outcomes after witnessing interparental violence are highly diverse and may be explained by multiple risk factors. An important question for prevention programs is therefore to what extent a specific focus on potential psychotrauma is useful. This trial may point to several directions for optimizing public health response to children's exposure to interparental violence.