Trajectories of mental health problems in children of parents with mental health problems: results of the BELLA study

The cost-utility of an intervention for children and adolescents with a parent having a mental illness in the framework of the German health and social care system: a health economic evaluation of a randomized controlled trial

BACKGROUND

Children of families with a parent with a mental illness have an increased risk of developing social and mental health problems resulting in decreased quality of life. Therefore, children and adolescents living in families with a parent with mental illness are regarded as a target group for preventive interventions. To date, only a few economic evaluation studies for interventions directed at preventing the intergenerational transmission of mental health problems exist. In this investigation we estimated the cost utility of an intervention for the support of children and adolescents with a parent having a mental illness from the perspective of the German health and social care system.

METHODS

We randomly assigned a total of 214 families with 337 children and adolescents to the intervention (INT) group (108/170) or the control (TAU) group (106/167). Families in the intervention group received on average eight intervention sessions (50-90 min) over 6 months. We estimated total cost of illness by means of the Children and Adolescent Mental Health Service Receipt Inventory (CAMHSRI) over 24 months. For the estimation of Quality-Adjusted Live Years (QALYs) we applied the KIDSCREEN-10. For estimating the incremental cost-utility of the intervention compared to treatment as usual we used the net-benefit approach.

RESULTS

We estimated the annual cost of illness amounting to € 3784.59 (SD € 8581.11) in the TAU group and € 3264.44 (SD € 9431.89) in the INT group. The annual cost difference between INT and TAU was € - 516.14 (SE 1124.95) which was not significant (p ≤ 0.05). We estimated the average QALY to be 0.759 (SD 0.073) in the TAU group and 0.763 (SD 0.072). The QALY difference between INT and TAU was 0.0037 (SE 0.0092) which was not significant (p ≤ 0.05). The incremental cost utility ratio (ICUR) indicated that the gain of one additional year in full health by means of the intervention was associated with the saving of € 139.49. However, the stochastic insecurity of the ICUR did not allow a unique decision about the cost-utility of the intervention.

CONCLUSIONS

More information on the economic value of the intervention for families with a parent with mental illness in comparison to treatment as usual in Germany is needed.

TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT02308462; German Clinical Trials Register: DRKS00006806.

Longitudinal Pathways from Parent Internalizing Symptoms to Parent and Youth Emotion Functioning

The current study utilized mediation analyses to examine how parental symptoms of depression and anxiety impact child emotion regulation (ER) and emotion stability (ES) through parent emotion functioning, parenting, and the coparent relationship. 564 parents of children between 3 and 17 years (Mage = 9.47; 54.4% male) were recruited via Amazon's Mechanical Turk across three time points: baseline (Wave 1), 4 months (Wave 2), 8 months (Wave 3). Mediation results demonstrated that symptoms of parent depression at Wave 1 predicted worse coparent relationships and decreases in parents' ability to identify their own emotions at Wave 2. Symptoms of parental anxiety at Wave 1 predicted decreases in positive parenting and an increased tendency to have negative secondary emotional responses, impulse-control difficulties, and difficulty accessing emotion-regulation strategies at Wave 2. Additionally, symptoms of parental anxiety at Wave 1 directly predicted lower child ER and ES at Wave 3. However, no significant indirect pathways were identified between parent symptoms and child ER and ES. Sensitivity analyses examined the effects of three youth developmental stages (i.e., early and middle childhood and adolescence), as well as parent gender (i.e., mother and father), and found no significant differences across groups. Thus, even at non-clinical levels, parental symptoms of anxiety and depression may negatively impact parenting, parent regulation, and the coparent relationship, while parental anxiety symptoms may contribute to lower child ER and ES.

Behavioral Outcomes of Children with Same-Sex Parents in The Netherlands

Same-sex parents face substantial stressors due to their sexual orientation, such as experiences of prejudice and prohibitive legal environments. This added stress is likely to lead to reduced physical and mental health in same-sex parents that, in turn, may translate into problematic behavioral outcomes in their children. To date, there are only a few nationally representative studies that investigate the well-being of children with same-sex parents. The current study takes a closer look at children’s behavioral outcomes, reported by a parent, using an adapted version of the emotional, conduct, hyperactivity, pro-social, and peer problems subscales of the Strengths and Difficulties Questionnaire (SDQ). We take advantage of unique data from the Netherlands based on a probability sample from population registers, whereby findings can be inferred to same-sex and different-sex parent households with parents between the ages of 30 and 65, and with children between the ages of 6 and 16 years (62 children with same-sex, and 72 children with different-sex parents). The findings obtained by coarsened exact matching suggest no significant disadvantages for children with same-sex parents compared to different-sex parents. We contextualize these findings in their wider cultural context, and recommend a renewed focus in future research away from deficit-driven comparisons.

Associations Between Mental Health Problems in Adolescence and Educational Attainment in Early Adulthood: Results of the German Longitudinal BELLA Study

Mental health problems (MHP) in adolescence are a major public health concern of the 21st century. Global prevalence estimates range between 10 and 20%. Most MHP manifest by adolescence and persistence rates are high, often accumulating further impairment in early adulthood and beyond. We analyzed data of N = 433 participants from the German longitudinal BELLA study to examine whether MHP in adolescence negatively affect educational attainment in early adulthood. Externalizing and internalizing MHP among adolescents aged 11-17 years were assessed at baseline using the Strengths and Difficulties Questionnaire. Educational attainment was assessed at the 6-year follow-up based on level of education, failure to attain the expected level of education, and dropout from vocational or academic training. Findings from logistic regression analyses suggest that more pronounced externalizing MHP in adolescence predict a lower level of education in early adulthood. We did not find a corresponding effect for internalizing MHP. Adolescents with higher-educated parents were less likely to attain a lower level of education themselves and less likely to fail in attaining their expected level of education. Our findings support that educational attainment presents a central channel for intergenerational reproduction of education and forms an important pathway for upward, but also downward social mobility. The current study emphasizes school as a central setting to implement measures to prevent onset and persistence of MHP and to foster equal opportunities in education.

Parents With Mental Illness: Parental Coping Behavior and Its Association With Children's Mental Health

The relevance of coping behavior for the individual's own mental health has been widely investigated. However, research on the association between coping of parents with a mental illness and their children's mental health is scarce. In the current study, we address the role of several parental coping strategies and their relation to child psychological symptoms. As part of the German randomized controlled multicenter study CHIMPS (children of mentally ill parents), parents with mental illness completed questionnaires on illness-related coping and child mental health symptoms. Children's diagnoses of a mental disorder were assessed with diagnostic interviews. The sample comprised n = 195 parents with mental illness and n = 290 children and adolescents aged 4-18 years. We conducted mixed models to investigate the associations of parental coping strategies with internalizing and externalizing symptoms as well as the diagnosis of a mental disorder in children controlling for sociodemographic factors and parental symptom severity. Parental coping characterized by religiosity and quest for meaning was significantly associated with fewer mental health symptoms and lower odds of a mental disorder in children, whereas a depressed processing style was related to increased internalizing problems in the children. Coping behavior in parents with mental illness is a relevant factor for the mental health of their children and should be considered in preventive interventions.

The Relationship Between Mental Health Problems and Systemic Family Dynamics Among High School and University Students in Shaanxi Province, China

Objectives: The present study aimed to correlate relationships between systemic family dynamics and mental health and to explore family factors that influence adolescent mental health in Shaanxi Province, China.

Methods: A cross-sectional survey was conducted to sample adolescents aged 12–23 using a questionnaire including Self-rating Scale of Systemic Family Dynamics, Symptom Checklist-90 Revised, and general demographic.

Results: More educated parents in white-collar employment and higher family income were associated with better mental health and better family dynamic scores. The total score of family dynamics was positively correlated with mental health scores. The generalized linear mixed model found that poorer mental health was associated with increased age, being in senior high school, having a father in a blue-collar profession, and SSFD square. The structural equation modelling suggested that this is largely a mediated effect via those characteristics impacting family dynamics, which in turn affect mental health.

Conclusion: Family dynamics may be an important contributor to adolescent mental health. Education and interventions aimed at improving family dynamics may be useful for reducing the prevalence of mental health problems amongst adolescents.

Trajectories of health-related quality of life in children of parents with mental health problems: results of the BELLA study

PURPOSE

Children of parents with mental health problems (CPM) have an increased risk for impaired health-related quality of life (HRQoL). This study aims at investigating the age- and gender-specific course of HRQoL and at exploring predictors of HRQoL in CPM based on longitudinal data (baseline, 1-year and 2-year follow-up) of a German population-based sample.

METHODS

Longitudinal data from the German BELLA study was analyzed (n = 1429; aged 11 to 17 years at baseline). The SCL-S-9 in combination with the cutoff for the General Severity Index (GSI) from the longer SCL-90-R served to identify CPM (n = 312). At first, we compared domain-specific HRQoL according to the KIDSCREEN-27 in CPM versus Non-CPM. Focusing on CPM, we used individual growth modeling to investigate the age and gender-specific course, and to explore effects of risk and (personal, familial and social) resource factors on self-reported HRQoL in CPM.

RESULTS

Self-reported HRQoL was reduced in CPM compared to Non-CPM in all domains, but in social support & peers. However, a minimal important difference was only reached in girls for the domain autonomy & parent relation. Internalizing and externalizing mental health problems were associated with impaired HRQoL in CPM. Self-efficacy, social support and family climate were identified as significant resources, but parental mental health problems over time were not associated with any investigated domain of HRQoL in CPM.

CONCLUSIONS

Adolescent female CPM may be especially at risk for reduced HRQoL. When developing support programs for CPM, self-efficacy, social support and family climate should be considered, HRQoL and mental health problems in CPM should be addressed.

"We're in good hands there." - Acceptance, barriers and facilitators of a primary care-based health coaching programme for children and adolescents with mental health problems: a qualitative study (PrimA-QuO)

Background

11.5 % of girls and 17.8 % of boys are affected by a mental health problem (MHP). The most prevalent problem areas are behavioural problems (girls/boys in %: 11.9/17.9), emotional problems (9.7/8.6) and hyperactivity problems (4.8/10.8). Primary care paediatricians are the first in line to be contacted. Nevertheless, even for less severely affected patients, referral rates to specialised care are constantly high. Therefore, a major statutory health insurance fund introduced a Health Coaching (HC) programme, including a training concept for paediatricians, standardised guidelines for actions and additional payments to strengthen primary care consultation for MHP and to decrease referrals to specialised care. The aim of this study was to examine how the HC is perceived and implemented in daily practice to indicate potential strengths and challenges.

Methods

During a one-year period starting in November 2017, a series of guideline-based interviews were conducted by phone with HC-developers, HC-qualified paediatricians, parents and patients (≥14 years) treated according to the HC programme. Paediatricians were selected from a Bavarian practice network with a total of 577 HC qualified paediatricians. Parents of patients with the four most common MHP diagnoses were approached by their health insurance: [World Health Organization, 2013] developmental disorder of speech and language [Wille N, et al., 2008] head/abdominal pain (somatoform) [Holling H, et al., 2003-2006 and 2009-2012] conduct disorder [Plass-Christl A, et al., 2018] non-organic enuresis. 23 paediatricians, 314 parents and 10 adolescents consented to be interviewed. Potential participants were selected based on purposeful sampling, according to principles of maximum variance. All interviews were recorded and transcribed verbatim. Two researchers analysed the transcripts independently of each other. Structuring content analysis derived from Mayring was used for analysis.

Results

11 paediatricians, 3 co-developers, 22 parents and 4 adolescents were included. Families were generally satisfied with paediatric care received in the programme’s context. The HC supported paediatricians’ essential role as consultants and improved their diagnostic skills. Lack of time, financial restrictions and patients’ challenging family structures were reported as major barriers to success.

Conclusion

The HC programme is perceived as a facilitator for more patient-centred care. However, structural barriers remain. Starting points for improvement are further options to strengthen families’ resources and expanded interdisciplinary networking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-020-01344-1.

[Preventive and therapeutic interventions for children of mentally ill parents]

Preventive and therapeutic interventions for children of mentally ill parents Abstract. The risk of developing mental disorders increases markedly in children of mentally ill parents. Several risk factors have been identified and become possible targets of preventive and therapeutic interventions. Numerous studies investigated the efficacy of these interventions, which are very heterogeneous regarding content and methodology. One part of these studies focuses on infants of depressed and substance-addicted mothers; the other part focuses on children and adolescents of parents suffering from various mental disorders. Today, we have several meta-analyses at our disposal which yielded small effect sizes concerning the development of psychological symptoms or disorders in these affected children. The current review reveals a lack of high-quality studies, and analyses on cost-effectiveness are also needed. The preventive and therapeutic interventions now available show inadequate efficacy to effectively improve the situation of these children and adolescents. Future research is needed to develop and implement cost-effective interventions as well as high-quality studies to investigate the efficacy of these interventions.

Associations Between Secondhand Smoke and Mental Health in Korean Adolescents

This study assessed secondhand smoke exposure among nonsmokers and examined its association with mental health in Korean adolescents. We used the 14th Korea Youth Risk Behavior Survey in 2018 to extract data and analyzed 60 040 adolescents through three secondhand smoke exposure categories: home, school, and public places. Mental health included stress, insufficient sleep, depressive symptoms, and suicidal ideation. Secondhand smoke exposure was reported at 23.0% for home, 20.0% for school, and 51.4% for public places. Secondhand smoke exposures were associated with stress insufficient sleep, depressive symptoms, and suicidal ideation. Furthermore, in the stratified analysis, secondhand smoke exposure was related to poor mental health in both nonsmokers and smokers. Based on the results, we concluded that Korean adolescents may experience poor mental health symptoms from being exposed to secondhand smoke.

Intergenerationale Transmission psychischer Auffälligkeiten unter Berücksichtigung von Geschlechtereffekten

Zusammenfassung. Hintergrund: Kinder psychisch kranker Eltern sind eine Hochrisikogruppe. Eine mütterliche Erkrankung scheint sich stärker negativ auf die Nachkommen auszuwirken als eine väterliche Erkrankung. Ob sich die Auswirkungen auf Mädchen und Jungen unterscheiden, ist unklar. Fragestellung: Ziel der Studie ist die Klärung von Geschlechtereffekten bei der intergenerationalen Transmission psychischer Auffälligkeiten. Methode: Es wurden N = 267 Familien untersucht, indem die Depressions- und Angstsymptome von Müttern und Vätern mit einem latenten Wachstumskurvenmodell über vier Messzeitpunkte (zehn Jahre) modelliert wurden. Die Überprüfung erfolgt mittels Strukturgleichungsmodellen. Ergebnisse: Es wurden Zusammenhänge zwischen elterlichen und kindlichen Auffälligkeiten gefunden. Dabei steht eine väterliche depressive Symptomatik stärker mit jugendlichen externalisierenden Auffälligkeiten in Verbindung als eine mütterliche depressive Symptomatik. Mädchen entwickeln tendenziell mehr als Jungen internalisierende Auffälligkeiten bei psychisch belasteten Eltern. Schlussfolgerung: Zukünftige Studien sollten Mütter und Väter gleichermaßen einbeziehen. Weiterhin sollten verstärkt Transmissionsmechanismen inklusive möglicher Mediatoren mit Berücksichtigung des elterlichen und kindlichen Geschlechtes untersucht werden.

Prevalence of emotional and behavioral problems and subthreshold psychiatric disorders in Austrian adolescents and the need for prevention

PURPOSE

Epidemiological data are crucial to plan adequate prevention strategies. Thus, this study aims at obtaining the prevalence of mental health problems (MHP) and subthreshold psychiatric disorders based on a representative sample of Austrian adolescents.

METHODS

Adolescents aged 10-18 were recruited from Austrian schools. Emotional and behavioral problems were determined using the Youth Self-Report (YSR); the point prevalence of subthreshold psychiatric disorders was assessed using structured diagnostic interviews. Sociodemographic variables including socioeconomic background, migration status, family structure, and place of residence were obtained. In addition, a non-school sample (unemployed adolescents, and child and adolescent psychiatry patients) was included to enhance representativeness and generalizability.

RESULTS

3446 students, 37 unemployed adolescents, and 125 child and adolescent psychiatric patients provided analyzable YSR data sets. In the school sample, 16.5% scored in the clinically relevant range, while internalizing problems were more prevalent (17.8%) than externalizing problems (7.4%). These prevalences increased by 0.7-2.0% when the non-school sample was taken into account. A low socioeconomic status (SES) and living in single parent families were associated with higher problem scores. Regarding the interviewed sample (377 students and 407 parents), subthreshold psychiatric disorders were observed in 12.7% of students. 92.5% of them have not yet received any kind of help.

CONCLUSIONS

A significant proportion of Austrian adolescents are at risk for MHP. A non-responder analysis indicates that the observed prevalence may be even underestimated. These findings emphasize the urgent need for targeted prevention, especially for reducing anxiety and depressive symptoms and for adolescents in disadvantaged families.