Whole-family programmes for families living with parental mental illness: a systematic review and meta-analysis.

Several interventions have been developed to support families living with parental mental illness (PMI). Recent evidence suggests that programmes with whole-family components may have greater positive effects for families, thereby also reducing costs to health and social care systems. This review aimed to identify whole-family interventions, their common characteristics, effectiveness and acceptability. A systematic review was conducted according to PRISMA 2020 guidelines. A literature search was conducted in ASSIA, CINAHL, Embase, Medline, and PsycINFO in January 2021 and updated in August 2022. We double screened 3914 abstracts and 212 papers according to pre-set inclusion and exclusion criteria. The Mixed Methods Appraisal Tool was used for quality assessment. Quantitative and qualitative data were extracted and synthesised. Randomised-control trial data on child and parent mental health outcomes were analysed separately in random-effects meta-analyses. The protocol, extracted data, and meta-data are accessible via the Open Science Framework ( https://osf.io/9uxgp/ ). Data from 66 reports-based on 41 independent studies and referring to 30 different interventions-were included. Findings indicated small intervention effects for all outcomes including children's and parents' mental health (dc = -0.017, -027; dp = -0.14, -0.16) and family outcomes. Qualitative evidence suggested that most families experienced whole-family interventions as positive, highlighting specific components as helpful, including whole-family components, speaking about mental illness, and the benefits of group settings. Our findings highlight the lack of high-quality studies. The present review fills an important gap in the literature by summarising the evidence for whole-family interventions. There is a lack of robust evidence coupled with a great need in families affected by PMI which could be addressed by whole-family interventions. We recommend the involvement of families in the further development of these interventions and their evaluation.

The Feasibility of Providing Remote Functional Family Therapy with Adolescents During the COVID-19 Pandemic: A Mixed-Method Study.

Background: Due to the recent COVID-19 pandemic, mental health care has largely transferred its services to online platforms, using videoconferencing (VC) or teletherapy. Within the field of family therapy, however, there is little evidence on the feasibility of using VC, especially when working with whole families at the edge of care. Objective: This study investigated the feasibility of remote Functional Family Therapy (FFT), using a mixed-method approach. Method: Study 1 consisted of semi-structured interviews with 23 FFT professionals (18 female) about their experience of providing remote FFT during the COVID-19 pandemic. Study 2 included monitoring data of 209 FFT clients (46% female, M age = 14.00) who participated in FFT during the pandemic. We compared families who received mainly in-person, mainly remote or a mix of remote and in-person on client-reported alliance, drop-out, therapist-rated outcomes, and treatment intensity using MANCOVA's and chi-square tests. Results: In Study 1 two themes emerged around experienced challenges, namely 'Feeling in control' and 'Engagement and alliance'. Two other themes emerged around adaptations, namely 'Being more on top' and 'Connecting in different ways'. In Study 2, we found that the therapeutic alliance was not related to using VC. Also, families had less between-session contact during the Engagement and Motivation Phase when receiving mainly VC, but had more sessions and longer therapy when receiving a mix of in-person and remote therapy. Conclusions: The current study suggests that providing systemic family teletherapy to families on the edge of care is feasible. Further development of systemic family teletherapy is warranted. Supplementary Information: The online version contains supplementary material available at 10.1007/s10566-022-09692-y.

The Development and Validation of a Subscale for the School-Age Child Behavior CheckList to Screen for Autism Spectrum Disorder.

The first aim of this study was to construct/validate a subscale-with cut-offs considering gender/age differences-for the school-age Child Behavior CheckList (CBCL) to screen for Autism Spectrum Disorder (ASD) applying both data-driven (N = 1666) and clinician-expert (N = 15) approaches. Further, we compared these to previously established CBCL ASD profiles/subscales and DSM-oriented subscales. The second aim was to cross-validate results in two truly independent samples (N = 2445 and 886). Despite relatively low discriminative power of all subscales in the cross-validation samples, results indicated that the data-driven subscale had the best potential to screen for ASD and a similar screening potential as the DSM-oriented subscales. Given beneficial implications for pediatric/clinical practice, we encourage colleagues to continue the validation of this CBCL ASD subscale.

Parental Conflicts and Posttraumatic Stress of Children in High-Conflict Divorce Families.

Parental conflicts consistently predict negative outcomes for children. Research suggests that children from high-conflict divorces (HCD) may also experience post-traumatic stress symptoms (PTSS), yet little is known about the association between parental conflicts in HCD families and child PTSS. We investigated this association, hypothesizing that parental conflicts would predict child PTSS. We also tested the moderating role of interparental contact frequency, hypothesizing that frequent contact would intensify the association between parental conflicts and child PTSS. This study was part of an observational study on the outcomes of No Kids in the Middle (NKM), a multi-family group intervention for HCD families. A total of 107 children from 68 families participated in the study with at least one parent. We used pre- (T1) and post-intervention (T2) data. Research questions were addressed cross-sectionally, using regression analyses to predict PTSS at T1, and longitudinally, using a correlated change (T1 to T2) model. The cross-sectional findings suggested that mother- and child-reported conflicts, but not father-reported conflicts, were related to the severity of child PTSS. Longitudinally, we found that change in father-reported conflicts, but not change in child- or mother-reported conflicts, were related to change in child PTSS. The estimated associations for the different informants were not significantly different from one another. The frequency of contact between ex-partners did not moderate the relationship between parental conflicts and child PTSS. We conclude that there is a positive association between parental conflicts and child PTSS in HCD families independent of who reports on the conflicts. Supplementary Information: The online version contains supplementary material available at 10.1007/s40653-021-00410-9.

Alliance Between Therapist and Multi-stressed Families During the COVID-19 Pandemic: The Effect of Family-Based Videoconferencing.

Background: A strong therapeutic alliance or working relationship is essential for effective face-to-face family-based psychotherapy. However, little is known about the use of VC on alliance in family-based therapy. The recent COVID-19 pandemic led to a national lockdown during which most family-based therapy transferred to VC. Objective: The current study analyzed the development and strength of alliance prior and during lockdown for multi-stressed families participating in Multisystemic Therapy (MST). Method: Alliance with the therapist was reported monthly by 846 caregivers (81% female). Using latent growth curve models (longitudinal approach), the development of alliance was estimated for families participating in MST prior to the lockdown, transferring to VC early in treatment or late in treatment. Using regression analyses (cross-sectional approach), lockdown (yes/no) was included as predictor of alliance. In these analyses, type of family (regular; intellectual disability; concerns regarding child abuse or neglect) and gender of caregiver were included as moderators. Results: Both analytical approaches showed that alliance was not affected by VC, except for families with concerns of child abuse, who reported lower alliances during lockdown. However, these results where no longer significant when controlling for multiple testing. Conclusions: Strong alliances can be developed and maintained during family-based VC sessions with multi-stressed families. However, for some subgroups, such as families with concerns of child abuse, VC might not be suitable or sufficient. Future research needs to investigate the potential and limitations of using VC with families.

Development of Therapist Adherence in Relation to Treatment Outcomes of Adolescents with Behavioral Problems.

Therapist adherence to the treatment manual is assumed to be crucial for adequate implementation and subsequent achievement of the intended, positive treatment outcomes. Although adherence has been mostly studied as a static factor, recent studies suggest that adherence might be dynamic and changes over time. We investigated how parent-perceived adherence to the multisystemic therapy (MST) model develops during treatment and how this development is related to treatment outcomes up to 18 months posttreatment, controlling for the effect of alliance. We used routinely collected data from 848 adolescents (66% male and 76% Western, M age = 15.25 years) and their caregivers participating in MST, a family- and community-based intervention for antisocial adolescents. Adherence and alliance were measured monthly through phone interviews with the caregivers using the Therapist Adherence Measure-Revised. Outcomes were assessed at the end of the treatment and at 18 months posttreatment using the scale Rule-Breaking Behavior of the Child Behavior Checklist and two MST Ultimate Outcomes (i.e., police contact and out-of-home placement). On average, adherence showed an increasing and then flattening slope. The initial level of adherence predicted treatment outcomes at the end of treatment but not at 18 months posttreatment. Change in adherence did not predict treatment outcomes after controlling for alliance. We advocate the need to consider the dynamic nature of adherence in research as well as clinical practice. Change in adherence during treatment, as well as its association with outcome, is likely to be dependent on the adherence measure being used.

It's not just the Therapist: Therapist and Country-Wide Experience Predict Therapist Adherence and Adolescent Outcome.

OBJECTIVE: Therapist adherence is a quality indicator in routine clinical care when evaluating the success of the implementation of an intervention. The current study investigated whether therapist adherence mediates the association between therapist, team, and country-wide experience (i.e. number of years since implementation in the country) on the one hand, and treatment outcome on the other hand. We replicated and extended a study by Löfholm et al. (2014). METHOD: Data over a 10-year period were obtained from 4290 adolescents (12-17 years) with antisocial or delinquent problem behavior, who were treated with Multisystemic Therapy (MST) by 222 therapists, working in 27 different teams in the Netherlands. Multilevel structural equation modeling was used to assess the associations between experience, therapist adherence, and post-treatment outcomes. RESULTS: Treatment outcomes were directly predicted by therapist experience, countrywide experience, and therapist adherence, but not by team experience. Moreover, therapist adherence mediated the association between therapist and country-wide experience, and treatment outcomes. The association between therapist experience and therapist adherence was not affected by the number of years of team experience or country-wide experience. CONCLUSION: The effect of country-wide experience on outcome may reflect increasing experience of training and supporting the therapists. It suggests that nation-wide quality control may relate to better therapist adherence and treatment outcome for adolescents treated with systemic therapy.

Alliance and adherence in a systemic therapy.

BACKGROUND: The client-therapist working alliance is a key contributor to effective adult psychotherapy. However, little is known about its role in family and systemic therapy. Moreover, few studies have assessed alliance longitudinally or have investigated how it interrelates with other process variables, such as therapist adherence (i.e. the extent to which the therapist adheres to the treatment protocol or manual). We hypothesised that alliance and adherence interrelate over the course of the therapy. METHOD: This study investigated the bidirectional associations between alliance and therapist adherence using cross-lagged panel analyses for a sample of 1970 adolescents and their families participating in Multisystemic Therapy (MST). A number of client characteristics were included as moderators, namely demographic characteristics, type and severity of adolescent problem behaviour, and whether or not the MST treatment was court ordered. Alliance and adherence were scored by the primary caregiver through telephone interviews at monthly intervals during treatment. RESULTS: Alliance in 1 month predicted therapist adherence in a subsequent month. Adherence only predicted subsequent alliance during the middle part of the treatment process. The results were not moderated by any of the client factors. CONCLUSIONS: The results suggest that alliance and therapist adherence may reinforce one another during therapy. Although alliance may facilitate the development of therapist adherence, adherence may subsequently deepen and consolidate the client-therapist alliance. These results are independent of client characteristics.