The Integrated Family Approach in Mental Health Care Services: A Study of Risk Factors.

BACKGROUND: Parental mental disorders in families are frequently accompanied with other problems. These include family life, the development of children, and the social and economic environment. Mental health services often focus treatments on the individual being referred, with little attention to parenting, the family, child development, and environmental factors. This is despite the fact that there is substantial evidence to suggest that the children of these parents are at increased risk of developing a mental disorder throughout the course of their lives. Young children are particularly vulnerable to environmental influences given the level of dependency in this stage of development. OBJECTIVE: The main objective of this study was to identify whether there were a complexity of problems and risks in a clinical sample of patients and their young children (0-6) in mental health care, and, if so, whether this complexity was reflected in the integrated treatment given. METHODS: The data were collected for 26 risk factors, based on the literature, and then subdivided into the parental, child, family, and environmental domains. The data were obtained from the electronic case files of 100 patients at an adult mental health service and the corresponding 100 electronic case files of their infants at a child mental health service. RESULTS: The findings evidenced a notable accumulation of risk factors within families, with a mean number of 8.43 (SD 3.2) risk factors. Almost all of the families had at least four risk factors, more than half of them had between six and ten risk factors, and a quarter of them had between eleven and sixteen risk factors. Furthermore, two-thirds of the families had at least one risk factor in each of the four domains. More than half of the families received support from at least two organizations in addition to the involvement of adult and child mental health services, which is also an indication of the presence of cumulative problems. CONCLUSION: This study of a clinical sample shows clearly that the mental disorder among most of the patients, who were all parents of young children, was only one of the problems they had to deal with. The cumulation of risk factors-especially in the family domain-increased the risk of the intergenerational transmission of mental disorders. To prevent these parents and their young children being caught up in this intergenerational cycle, a broad assessment is needed. In addition, malleable risk factors should be addressed in treatment and in close collaboration with other services.

An integrated family approach in the practice of adult and child mental health care.

This paper describes the practice of an integrated family approach to treatment in mental health care in which the focus is on the whole family and treatment is carried out by professionals of adult and child mental health services together. It is presented as an example of a best practice in finding a way to overcome barriers in implementing an integrated family approach in treatment for the benefit of families with a variety of interrelated problems. Even though there is a lot of knowledge about the importance of a family approach in mental health care with specific attention to the patients' parental role, the children, family relationships, and the social economic context, this is worldwide rarely implemented in the practice of mental health care. Barriers to keep the whole family in mind are identified on different levels: organizational policy, interagency collaboration, professionals, and patients themselves. As a solution, a model of an integrated family approach in mental health care is presented: how it is defined; which domains in the family are targeted; which key elements it contains; what the treatment consists of; and which procedures are followed in practice. A case illustrates how this approach might work in practice.

The Patient's Voice as a Parent in Mental Health Care: A Qualitative Study.

OBJECTIVE: This study is an evaluation of patients in mental health care who have undertaken treatment with an integrated family approach. The treatment focuses on the mental disorders of patients, their role as parents, the development of their young children, and family relationships. The treatment was conducted by professionals from an adult and a child mental health service in the Netherlands. The aim of the study was to identify the key elements and processes of this approach in order to develop a theoretical model. BACKGROUND: Parental mental disorders have an impact on parenting and child development. To stop detrimental cascade effects and prevent parents and children from being caught up in the intergenerational transmission of psychopathology, a family approach in mental health care is needed. METHODS: A qualitative design was adopted using thematic analysis. Data were collected through 18 interviews with patients. The themes in the interviews were which outcomes the patients experienced and which key elements of the treatment contributed to these outcomes. RESULTS: In general, patients were satisfied with the treatment offered. Improved outcomes were within the domain of the family, the parent-child relationship, individual symptoms, and the functioning of the parent and the child. Patients mentioned six key elements of success in treatment: focus on the whole family, flexible treatment tailored to the situation of the family, components of the whole treatment reinforcing each other, multi-disciplinary consultation among involved professionals, a liaison between adult and child mental health services, and attention to the social and economic environment. CONCLUSIONS: According to the majority of patients, treatment with an integrated family approach in mental health care is of value for themselves, their children, and family relationships, especially the parent-child relationship.

Integrated Family Approach in Mental Health Care by Professionals From Adult and Child Mental Health Services: A Qualitative Study.

Objective: A multiple case-study in which each case was evaluated by adult and child mental health professionals who used an integrated family approach in their treatments. In this approach, treatment focuses on the mental disorders of the parents as well as on the development of the young child and family relationships. This study evaluated the experiences of professionals from adult and child mental health services using this approach. The aim of the study is identifying key elements of this approach, processes involved in treatment, and barriers to its success, with the aim of contributing to the development of practice based integrated mental health care for the whole family. Background: Parental mental disorders have an impact on parenting and child development. To stop detrimental cascade effects and prevent parent and child from being caught up in the intergenerational transmission of psychopathology, an integrated family approach in mental health care is needed. Methods: A qualitative case study design using a grounded theory approach. Data were collected through 19 group interviews of professionals (N = 37) from adult and infant mental health teams who worked together in the treatment of a family. Results: Professionals from the two services were comfortable coping with complexity and felt supported to perform their treatments by staying in touch with each other in multi-disciplinary consultations. They indicated that by attuning the treatment components to each other and tailoring them to the capabilities of the family, their treatments had more impact. A flexible attitude of all involved professionals and commitment to the interest of all family members was essential. Conclusion: According to professionals, treatment with an integrated family approach in mental health care is of value for families by addressing the distinct roles, positions and relationships, by implementing a flexible complementary treatment plan, and by empowering professionals by multi-disciplinary consultations.

Effectiveness of a high-intensive trauma-focused, family-based therapy for youth exposed to family violence: study protocol for a randomized controlled trial.

BACKGROUND: Family violence is a common problem with direct adverse effects on children as well as indirect effects through disruption of parenting and parent-child relationships. The complex interrelationships between family violence, parenting, and relationships make recovery from psychological responses difficult. In more than half of the families referred to mental health care after family violence, the violence continues. Also, the effect sizes of "golden standard" treatments are generally lower for complex trauma compared to other forms of trauma. In the treatment of complex trauma, trauma-focused therapies including cognitive restructuring and imaginal exposure are most effective, and intensifying therapy results in faster symptom reduction. Furthermore, there is promising evidence that adding a parental component to individual trauma treatment increases treatment success. In family-based intensive trauma treatment (FITT), these factors are addressed on an individual and family level in a short period of time to establish long-term effects on the reduction of trauma symptoms and recovery of security in the family. This randomized controlled multicentre study tests if FITT is an effective treatment for concurrent reduction of trauma symptoms of children, improvement of parenting functioning, and increasing emotional and physical security in children, through the improvement of parent-child relationships. METHODS: The effectiveness of FITT will be tested by a RCT design. A total of 120 adolescents with a history of family violence and PTS symptoms will be randomized to (a) an intensive trauma treatment with a parent and systemic component (FITT), (b) an intensive trauma treatment without these components (ITT), and (c) treatment as usual (TAU, low-frequency trauma treatment with parent therapy and family sessions). Changes in children's trauma symptoms, child and parent functioning, and emotional and physical security in the family will be monitored before, during, after, and at 3 months follow-up. DISCUSSION: Comparing these interventions with and without a high intensive frequency and parenting and family components can help to understand if and how these interventions work and can contribute to the ambition to recover from the impact of family violence and restore emotional and physical security for children and young people. TRIAL REGISTRATION: Netherlands Trial Register Trial NL8592 . Registered on 4 May 2020.

How to Support Parents of Infants and Young Children in Mental Health Care: A Narrative Review.

Objective: The aim of this narrative review is to gain insight into the appropriate intervention targets when parents of infants and young children suffer from psychopathology. Background: Psychopathology in parents is a risk factor for maladaptive parenting and is strongly related to negative cascade effects on parent-child interactions and relations in the short and long term. Children in their first years of life are especially at risk. However, in adult mental health care, this knowledge is rarely translated into practice, which is a missed opportunity for prevention. Methods: Electronic databases were searched for reviews and meta-analysis. In addition, sources were obtained via manual search, reference mining, expert opinion, and communications from conferences. In total, 56 papers, whereof 23 reviews and 12 meta-analyses were included. Results: Findings regarding targets of intervention were identified in different interacting domains, namely the parental, family, child, and environmental domains as well as the developing parent-child relationship. A "one size fits all" intervention is not appropriate. A flexible, tailored, resource-oriented intervention program, multi-faceted in addressing all modifiable risk factors and using different methods (individual, dyadic, group), seems to provide the best results. Conclusion: To address the risk factors in different domains, adult and child mental health care providers should work together in close collaboration to treat the whole family including mental disorders, relational, and contextual problems. A multi-agency approach that includes social services is needed.

Exploring the Impact of Child Maltreatment and Interparental Violence on Violent Delinquency in an International Sample.

Young people are exposed to violence regularly in their homes, schools, and communities. Such exposure can cause them significant physical, mental, and emotional harm, with long-term effects lasting well into adulthood. Of particular concern is violence within the family, where children are victimized by their parents. Research shows that direct and indirect childhood exposure to violence and maltreatment within the family increases the risk of subsequent violent delinquent behavior. Social learning theory and attachment theory place parenting at the center of the "cycle of violence," and "intergenerational transmission of violence" claims that experiencing violence in childhood will lead to the perpetration of violence in adolescence. Although much research has been done, these assertions have never been tested on a large international sample of young people. The current article fills this void by analyzing surveys completed by 57,892 students who were 12 to 16 years old from 25 countries as part of the International Self-Report Delinquency Study (ISRD3). Structural equation modeling (SEM) is used to test the direct and indirect effects of child maltreatment and interparental violence on self-reported violent delinquency. Mediating effects are proposed for attachment to parents, parental social control (measured by parental knowledge, parental monitoring, and child disclosure), and parental moral authority. Analysis suggests direct effects of child maltreatment and interparental violence, as well as mediating effects of parental monitoring, parental knowledge, and parental moral authority. Child disclosure and attachment to parents do not affect violent juvenile offending. Being a victim of both child maltreatment and interparental violence is found to exacerbate the effect on violent offending. The results support the cross-national generalizability of the "cycle of violence" argument that children tend to reproduce the behavior of their parents.

Domestic violence in families in the Netherlands during the coronavirus crisis: A mixed method study.

BACKGROUND: The consequences of the coronavirus crisis are considerable for everyone in the Netherlands. Although there were concerns about the many vulnerable families who were forced to stay at home because of the measures taken by the government to contain the coronavirus in the Netherlands, there has been no increase in the number of reports of domestic violence or child abuse. OBJECTIVE: To gain insight by a mixed method study on what has happened during the lockdown within families who were already known to social services. METHODS: A quantitative study was performed among 159 families recruited before the coronavirus crisis, and 87 families recruited during the lockdown in the Netherlands through child protection services. Family members (parents, children) completed questionnaires about interparental violence, (historical) child abuse and neglect, and emotional security. In a qualitative study 39 of these respondents and 13 professionals were interviewed. RESULTS: No difference was found in violence between families who participated before and after the lockdown. The level of violence is still high in most families. The absence of assistance promoted the self-reliance of children and parents to deal with this difficult period. Professionals found new ways of connecting to families at risk. Every form of support is important to these families because it made children feel seen and heard. Isolation of families where domestic violence and child abuse occurred, remains a risk factor, even outside the coronavirus crisis.

Trajectories of traumatic stress reactions in children exposed to intimate partner violence.

BACKGROUND: Understanding different longitudinal patterns of traumatic stress reactions in children exposed to intimate partner violence (IPV) can promote early identification of at-risk children. OBJECTIVE: Our study aims to explore trajectories of traumatic stress reactions following childhood IPV exposure, and their relation with parental traumatic stress and child emotional security in the interparental subsystem. PARTICIPANTS AND SETTING: The sample comprised 303 children (age 3-10, M = 6.20) from families referred to institutions for IPV. Data were collected at home. METHODS: Three waves of parent-reported questionnaire data were analyzed using latent class growth analysis and linear regression. RESULTS: Five trajectories were identified: 'resilient', 'moderate stable', 'struggling', 'improving', and 'elevated adjusting'. Only the 'struggling' trajectory had dysfunctional symptom levels at the final wave. Higher parental traumatic stress predicted 'improving' trajectory membership (ß = 0.17, p = .033), whereas lower parental traumatic stress (ß = -0.20, p = .003) and child emotional insecurity (ß = -0.45, p = < .001) predicted 'resilient' trajectory membership. Higher child emotional insecurity predicted membership in trajectories with higher initial traumatic stress (improving: ß = 0.26, p < .001; struggling: ß = 0.31, p < .001; elevated adjusting: ß = 0.27, p < .001). Child emotional security did not buffer the effect of parental traumatic stress on likelihood of dysfunctional trajectory membership (ß = 0.04, p =.380). CONCLUSIONS: Children exposed to IPV show different trajectories of traumatic stress reactions, partly corresponding to trajectories identified in other populations. Child emotional security and parental traumatic stress predict trajectory membership.

Interparental Violence: Similarities and Discrepancies Between Narratives of Mothers and Their Children.

Previous studies and intervention programs on interparental violence have relied largely on reports either solely from parents or solely from children. Nevertheless, the literature and the theoretical background provide indications of the existence of discrepancies between the narratives of parents and those of children. This study therefore focuses on similarities and differences between the narratives of mothers and those of their children with regard to the children's exposure to interparental violence and its impact on child and parental functioning. In depth open interviews were conducted to assess the narratives of 36 mothers (27-59 years of age) and 43 of their children (17 boys and 26 girls; 9-25 years of age) who had experienced interparental violence in their past. A hierarchical coding system was used to code the interviews. Thereafter, the differences between mother and child narratives were analyzed based on the coded fragments. Few differences were found between the narratives with regard to parental functioning. We did find discrepancies, however, with regard to the children's exposure to interparental violence and its impact on child functioning. Exploratory analyses showed relationships between the discrepancies and the severity of the violence and age of the children. More attention to these differences is essential in order to enhance our knowledge concerning the complex impact of violence on family members and to improve support geared to their specific needs.

Community variation in adolescent alcohol use in Australia and the Netherlands.

To investigate the cross-national relevance of community health promotion, this paper compared community variation in alcohol use and risk and protective factors for adolescents in Australia (State of Victoria, 2009) and the Netherlands (2007/2008). Multi-level analyses examined community variation in heavy episodic (binge) alcohol use [≥5 drinks in a session ≥once in the prior fortnight (>63 ml of ethanol)] and associations with predictors. Representative community samples of adolescents (12-17 years) were recruited. The participants were 7812 students from 36 Australian communities and 15 082 adolescents from 124 Dutch communities. Predictors included adolescent reports of family, school, peer and neighbourhood environments and community predictors (rural, disadvantage). The overall prevalence of alcohol use prevalence was similar in both nations. Australia had higher use at younger ages and no difference between genders. In the Netherlands older adolescents and males used alcohol at significantly higher rates. Although individual predictors were mostly similar, binge drinking was more strongly associated with poor family management, friends' use of drugs and community disorganization in Australia. Significant community variation in adolescent heavy alcohol use was observed in both countries, but was higher in the Netherlands [inter class correlation 6.1%, (95% CI: 4.5-8.3%)] than Australia (ICC 2.4%, 1.3-4.5%). Youth from rural areas drank at a higher level, especially in the Netherlands. Targeting community level adolescent alcohol use appears feasible in both countries. Although behavioural patterns and risk and protective influences are similar in the Netherlands and Australia, important differences should be taken into account in tailoring community interventions.

Transforming prevention systems in the United States and the Netherlands using Communities That Care Promising prevention in the eyes of Josine Junger-Tas.

Josine Junger-Tas introduced the Communities That Care (CTC) prevention system to the Netherlands as a promising approach to address the growing youth violence and delinquency. Using data from a randomized trial of CTC in the United States and a quasi-experimental study of CTC in the Netherlands, this article describes the results of a comparison of the implementation of CTC in 12 U.S. communities and 5 Dutch neighborhoods. CTC communities in both countries achieved higher stages of a science-based approach to prevention than control communities, but full implementation of CTC in the Netherlands was hampered by the very small list of prevention programs tested and found effective in the Dutch context.

A Cross-national Comparison of Risk and Protective Factors for Adolescent Drug Use and Delinquency in the United States and the Netherlands.

The present study compared associations between risk and protective factors and adolescent drug use and delinquency in the Netherlands and the United States. Data were collected from students between the ages of 12 and 17 using the same school-administered survey instrument in both countries. Levels of exposure to risk and protective factors were generally similar in both countries. The same risk and protective factors shown to be associated with U.S. adolescents' drug use and delinquency were related significantly to Dutch youth's drug use and delinquency. One important exception was that Dutch students perceived their parents' attitudes to be more favorable toward alcohol use; these attitudes also were more predictive of adolescents' regular drinking in the Netherlands compared to the United States. The findings indicate that the risk and protective factors measured in this study can be important targets for prevention of health-compromising behaviors among young people in the Netherlands and the United States.