Psychiatric in-patients who are parents: what interventions are tailored to their needs and how do they experience care? A systematic review and data synthesis.

BACKGROUND: Little is known about the experiences of parents who are in receipt of in-patient psychiatric care or about what interventions are employed to support them in their parenting role. AIMS: The objective of the current study is to review two complementary areas of research: (a) research examining interventions developed to support the parent-child relationship within these settings; and (b) research focused on the experience of parents in in-patient settings. METHOD: For studies reporting on parents' experience, qualitative accounts of past or present psychiatric in-patients (child aged 1-18 years) were included. For intervention studies, the intervention had to focus on supporting the parenting role and/or the parent-child dyad of parents (child aged 1-18 years) in current receipt of in-patient care. Four bibliographic databases (PubMed, SCOPOS, Web of Science and PsychINFO) were searched for relevant published and unpublished literature from 1 January 1980 to 26 July 2022. Intervention studies were appraised using the Mixed Methods Appraisal Tool. Qualitative papers were assessed using the Critical Appraisal Skills Programme tool. Data were extracted using tools designed for the study. Qualitative data were synthesised using thematic analysis. The protocol was registered with the International Prospective Register of Systematic Reviews (reference CRD42022309065). RESULTS: Twenty-four papers (eight intervention studies and 16 studies examining parent experience) were included in the review. In-patient parents commonly reported hospital admission as having a negative impact on their parenting. Very few robust reports of interventions designed to support parents in receipt of psychiatric in-patient care were found. CONCLUSIONS: Despite the identified need for support by parents who are receiving in-patient care, there is currently no intervention of this nature running in the UK health service.

The feasibility of an objective measure of the parent-child relationship in health visiting practice: assessment of the Maternal Postnatal Attachment Scale.

Background: Positive parent infant relationships are key to achieving long term child outcomes. Identifying parents who may need support is difficult because of a lack of robust assessment tools. Working in partnership with health services we piloted the Maternal Postnatal Attachment Scale (MPAS) in a deprived, multi-ethnic urban community in Bradford, UK. The pilot aimed to assess the clinical utility of MPAS to identify need for support: Was it administered to a representative group of women? Is MPAS valid for this population? Methods: Data were linked to a cohort study in the pilot area (Born in Bradford's Better Start - BiBBS). Chi Square tests assessed sample representativeness (age, ethnicity, parity, English language, education, deprivation). Exploratory factor analysis explored MPAS' validity. Results: 563 women in BiBBS were eligible, 210 (37%) completed MPAS.  No differences were found between completers and non-completers, suggestive of a representative sample. In total, 336 women completed MPAS in the pilot.  MPAS had ceiling effects and a satisfactory factor structure could not be identified, indicating poor psychometric properties Conclusions: Health visitors were successful in administering MPAS to a representative sample, but poor psychometric robustness indicates that MPAS is unsuitable for routine use in this setting. A gap for such a measure remains.

Effectiveness of a Web-Based Intervention to Prevent Anxiety in the Children of Parents With Anxiety: Protocol for a Randomized Controlled Trial.

BACKGROUND: Anxiety is the most common childhood mental health condition and is associated with impaired child outcomes, including increased risk of mental health difficulties in adulthood. Anxiety runs in families: when a parent has anxiety, their child has a 50% higher chance of developing it themselves. Environmental factors are predominant in the intergenerational transmission of anxiety and, of these, parenting processes play a major role. Interventions that target parents to support them to limit the impact of any anxiogenic parenting behaviors are associated with reduced anxiety in their children. A brief UK-based group intervention delivered to parents within the UK National Health Service led to a 16% reduction in children meeting the criteria for an anxiety disorder. However, this intervention is not widely accessible. To widen access, a 9-module web-based version of this intervention has been developed. This course comprises psychoeducation and home practice delivered through text, video, animations, and practice tasks. OBJECTIVE: This study seeks to evaluate the feasibility of delivering this web-based intervention and assess its effectiveness in reducing child anxiety symptoms. METHODS:  This is the protocol for a randomized controlled trial (RCT) of a community sample of 1754 parents with self-identified high levels of anxiety with a child aged 2-11 years. Parents in the intervention arm will receive access to the web-based course, which they undertake at a self-determined rate. The control arm receives no intervention. Follow-up data collection is at months 6 and months 9-21. Intention-to-treat analysis will be conducted on outcomes including child anxiety, child mental health symptoms, and well-being; parental anxiety and well-being; and parenting behaviors. RESULTS: Funding was received in April 2020, and recruitment started in February 2021 and is projected to end in October 2022. A total of 1350 participants have been recruited as of May 2022. CONCLUSIONS: The results of this RCT will provide evidence on the utility of a web-based course in preventing intergenerational transmission of anxiety and increase the understanding of familial anxiety. TRIAL REGISTRATION: ClinicalTrials.gov NCT04755933; https://clinicaltrials.gov/ct2/show/NCT04755933. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40707.

The Measurement Properties and Acceptability of a New Parent-Infant Bonding Tool ('Me and My Baby') for Use in United Kingdom Universal Healthcare Settings: A Psychometric, Cross-Sectional Study.

INTRODUCTION: The National Institute for Health and Care Excellence (NICE) guidelines acknowledge the importance of the parent-infant relationship for child development but highlight the need for further research to establish reliable tools for assessment, particularly for parents of children under 1 year. This study explores the acceptability and psychometric properties of a co-developed tool, 'Me and My Baby' (MaMB). STUDY DESIGN: A cross-sectional design was applied. The MaMB was administered universally (in two sites) with mothers during routine 6-8-week Health Visitor contacts. The sample comprised 467 mothers (434 MaMB completers and 33 'non-completers'). Dimensionality of instrument responses were evaluated via exploratory and confirmatory ordinal factor analyses. Item response modeling was conducted via a Rasch calibration to evaluate how the tool conformed to principles of 'fundamental measurement'. Tool acceptability was evaluated via completion rates and comparing 'completers' and 'non-completers' demographic differences on age, parity, ethnicity, and English as an additional language. Free-text comments were summarized. Data sharing agreements and data management were compliant with the General Data Protection Regulation, and University of York data management policies. RESULTS: High completion rates suggested the MaMB was acceptable. Psychometric analyses showed the response data to be an excellent fit to a unidimensional confirmatory factor analytic model. All items loaded statistically significantly and substantially (>0.4) on a single underlying factor (latent variable). The item response modeling showed that most MaMB items fitted the Rasch model. (Rasch) item reliability was high (0.94) yet the test yielded little information on each respondent, as highlighted by the relatively low 'person separation index' of 0.1. CONCLUSION AND NEXT STEPS: MaMB reliably measures a single construct, likely to be infant bonding. However, further validation work is needed, preferably with 'enriched population samples' to include higher-need/risk families. The MaMB tool may benefit from reduced response categories (from four to three) and some modest item wording amendments. Following further validation and reliability appraisal the MaMB may ultimately be used with fathers/other primary caregivers and be potentially useful in research, universal health settings as part of a referral pathway, and clinical practice, to identify dyads in need of additional support/interventions.

Implementing the Maternal Postnatal Attachment Scale (MPAS) in universal services: Qualitative interviews with health visitors.

Background: A secure parent-infant relationship lays the foundations for children's development, however there are currently no measurement tools recommended for clinical practice. We evaluate the clinical utility of a structured assessment of the parent-infant relationship (the Maternal Postnatal Attachment Scale, MPAS) in a deprived, multi-ethnic urban community in England. This paper answers the question: what are health visitors' views on the parent-infant relationship, and experiences of piloting the MPAS? It explores the barriers and facilitators to implementation, and complements the paper on psychometric properties and representativeness reported in Dunn et al (submitted).   Methods: Semi-structured interviews were conducted with 11 health visitors and data were analysed using thematic analysis.  Results: Health visitors saw identification and support of the parent-infant relationship as an important part of their role, and reported benefits of the MPAS, including opening conversation, and identifying and reporting concerns. Challenges included timing and workload, the appropriateness of language, perceived intrusiveness and understanding of the questions, and the length of the tool. Suggestions for improvements to the tool were put forwards.  Conclusions: The experiences, benefits and challenges identified help to explain results in Dunn et al, and the wide-ranging challenges identified would hinder assessment of the parent-infant relationship in routine practice. Further work with health professionals and parents has been undertaken to co-produce an acceptable, feasible and reliable tool for clinical practice.

Reinventing Undergraduate Clinical Placements with a Switch to Delivery by Clinical Teaching Fellows.

PURPOSE: Undergraduate clinical placements have the potential for significant improvement. Previous research has shown the growing value of clinical teaching fellows (CTFs) within medical education. Changing traditional placements to a model whereby CTFs have defined roles and lead the majority of teaching can positively reinvent undergraduate clinical teaching. We wanted to see how a structured teaching programme delivered by CTFs could affect student experience and personal development within a large associate teaching hospital. We consider how such a model could be implemented and explore the opportunities for CTFs to develop in personal and professional capacities. METHODS: A mixed methods study was organised to assess student experience of a CTF-led placement. A novel structured teaching programme was delivered by 14 CTFs, who provided or were involved with the majority of teaching for all medical students. Thematic analysis was conducted on focus groups with 48 final year medical students from Queen Mary University of London following completion of their clinical placements. The same students were asked to complete an anonymous survey from which results were analysed using modified 5-point Likert scales. RESULTS: Eight themes were identified from the focus groups. Students appreciated the increased individualisation, relevance and variety of teaching and the ability to record progress. Other perceived effects were higher teacher to student ratios, more learning opportunities and increased familiarity and reliability with CTFs. Of the students surveyed, 96% felt their overall placement experience was very good in comparison to previous placements elsewhere. Survey results supported focus group themes and demonstrated perceived growth in students' personal development. CONCLUSION: Placement models where CTFs lead most teaching can improve medical undergraduate experience and training. A move towards CTF-delivered teaching can be of financial benefit to hospital trusts whilst allowing time for junior doctors to explore different clinical specialities and hone their teaching skills.

The Parenting Experience of Those With Borderline Personality Disorder Traits: Practitioner and Parent Perspectives.

BACKGROUND: Borderline Personality Disorder (BPD) is associated with challenges around emotional intensity and interpersonal difficulties. The children of parents with BPD are at risk of poorer outcomes in terms of their own mental health, educational outcomes and wellbeing. The challenges of being a parent can also exacerbate the symptoms of those with BPD traits. There is a pressing need to understand the experience of these parents and to determine what support would be appropriate and useful. AIM: To explore and compare the experiences and support needs of parents with BPD traits with the experiences and understanding of practitioners who work with them. METHODS: Interviews with 12 parents with BPD traits and 21 practitioners with experience of working with individuals with BPD. The two strands of interviews were analyzed independently using a thematic framework approach, after which the superordinate and subordinate themes were subject to comparison. RESULTS: Parents with BPD traits represent themselves as experiencing considerable challenges in their role as a parent. These included the impact of emotional intensity, social isolation and lack of a positive parenting models to draw upon. Practitioners demonstrated a strong degree of shared understanding into these difficulties. Both groups highlighted a lack of appropriate support for these parents. CONCLUSION: This research highlights the clinical need for parenting-focused support for individuals with BPD traits. Preliminary suggestions for format and content are given.

Examining the Phenomenon of Quarter-Life Crisis Through Artificial Intelligence and the Language of Twitter.

Quarter-life crisis (QLC) is a popular term for developmental crisis episodes that occur during early adulthood (18-30). Our aim was to explore what linguistic themes are associated with this phenomenon as discussed on social media. We analyzed 1.5 million tweets written by over 1,400 users from the United Kingdom and United States that referred to QLC, comparing their posts to those used by a control set of users who were matched by age, gender and period of activity. Logistic regression was used to uncover significant associations between words, topics, and sentiments of users and QLC, controlling for demographics. Users who refer to a QLC were found to post more about feeling mixed emotions, feeling stuck, wanting change, career, illness, school, and family. Their language tended to be focused on the future. Of 20 terms selected according to early adult crisis theory, 16 were mentioned by the QLC group more than the control group. The insights from this study could be used by clinicians and coaches to better understand the developmental challenges faced by young adults and how these are portrayed naturalistically in the language of social media.

Implementation evaluation of multiple complex early years interventions: an evaluation framework and study protocol.

INTRODUCTION: Implementation evaluations are integral to understanding whether, how and why interventions work. However, unpicking the mechanisms of complex interventions is often challenging in usual service settings where multiple services are delivered concurrently. Furthermore, many locally developed and/or adapted interventions have not undergone any evaluation, thus limiting the evidence base available. Born in Bradford's Better Start cohort is evaluating the impact of multiple early life interventions being delivered as part of the Big Lottery Fund's 'A Better Start' programme to improve the health and well-being of children living in one of the most socially and ethnically diverse areas of the UK. In this paper, we outline our evaluation framework and protocol for embedding pragmatic implementation evaluation across multiple early years interventions and services. METHODS AND ANALYSIS: The evaluation framework is based on a modified version of The Conceptual Framework for Implementation Fidelity. Using qualitative and quantitative methods, our evaluation framework incorporates semistructured interviews, focus groups, routinely collected data and questionnaires. We will explore factors related to content, delivery and reach of interventions at both individual and wider community levels. Potential moderating factors impacting intervention success such as participants' satisfaction, strategies to facilitate implementation, quality of delivery and context will also be examined. Interview and focus guides will be based on the Theoretical Domains Framework to further explore the barriers and facilitators of implementation. Descriptive statistics will be employed to analyse the routinely collected quantitative data and thematic analysis will be used to analyse qualitative data. ETHICS AND DISSEMINATION: The Health Research Authority (HRA) has confirmed our implementation evaluations do not require review by an NHS Research Ethics Committee (HRA decision 60/88/81). Findings will be shared widely to aid commissioning decisions and will also be disseminated through peer-reviewed journals, summary reports, conferences and community newsletters.

Integrating research and system-wide practice in public health: lessons learnt from Better Start Bradford.

Many interventions that are delivered within public health services have little evidence of effect. Evaluating interventions that are being delivered as a part of usual practice offers opportunities to improve the evidence base of public health. However, such evaluation is challenging and requires the integration of research into system-wide practice. The Born in Bradford's Better Start experimental birth cohort offers an opportunity to efficiently evaluate multiple complex community interventions to improve the health, wellbeing and development of children aged 0-3 years. Based on the learning from this programme, this paper offers a pragmatic and practical guide to researchers, public health commissioners and service providers to enable them to integrate research into their everyday practice, thus enabling relevant and robust evaluations within a complex and changing system.Using the principles of co-production the key challenges of integrating research and practice were identified, and appropriate strategies to overcome these, developed across five key stages: 1) Community and stakeholder engagement; 2) Intervention design; 3) Optimising routinely collected data; 4) Monitoring implementation; and 5) Evaluation. As a result of our learning we have developed comprehensive toolkits ( https://borninbradford.nhs.uk/what-we-do/pregnancy-early-years/toolkit/ ) including: an operational guide through the service design process; an implementation and monitoring guide; and an evaluation framework. The evaluation framework incorporates implementation evaluations to enable understanding of intervention performance in practice, and quasi experimental approaches to infer causal effects in a timely manner. We also offer strategies to harness routinely collected data to enhance the efficiency and affordability of evaluations that are directly relevant to policy and practice.These strategies and tools will help researchers, commissioners and service providers to work together to evaluate interventions delivered in real-life settings. More importantly, however, we hope that they will support the development of a connected system that empowers practitioners and commissioners to embed innovation and improvement into their own practice, thus enabling them to learn, evaluate and improve their own services.