Parenting Stress Among Caregivers of Children With Bipolar Spectrum Disorders

X- vs. Y-chromosome influences on human behavior: a deep phenotypic comparison of psychopathology in XXY and XYY syndromes

BACKGROUND

Do different genetic disorders impart different psychiatric risk profiles? This question has major implications for biological and translational aspects of psychiatry, but has been difficult to tackle given limited access to shared batteries of fine-grained clinical data across genetic disorders.

METHODS

Using a new suite of generalizable analytic approaches, we examine gold-standard diagnostic ratings, scores on 66 dimensional measures of psychopathology, and measures of cognition and functioning in two different sex chromosome aneuploidies (SCAs)-Klinefelter (XXY/KS) and XYY syndrome (n = 102 and 64 vs. n = 74 and 60 matched XY controls, total n = 300). We focus on SCAs for their high collective prevalence, informativeness regarding differential X- vs. Y-chromosome effects, and potential relevance for normative sex differences.

RESULTS

We show that XXY/KS elevates rates for most psychiatric diagnoses as previously reported for XYY, but disproportionately so for anxiety disorders. Fine-mapping across all 66 traits provides a detailed profile of psychopathology in XXY/KS which is strongly correlated with that of XYY (r = .75 across traits) and robust to ascertainment biases, but reveals: (i) a greater penetrance of XYY than KS/XXY for most traits except mood/anxiety problems, and (ii) a disproportionate impact of XYY vs. XXY/KS on social problems. XXY/KS and XYY showed a similar coupling of psychopathology with adaptive function and caregiver strain, but not IQ.

CONCLUSIONS

This work provides new tools for deep-phenotypic comparisons of genetic disorders in psychiatry and uses these to detail unique and shared effects of the X- and Y-chromosome on human behavior.

Psychological well-being and needs of parents and carers of children and young people with mental health difficulties: a quantitative systematic review with meta-analyses

QUESTION

For parents of children and young people (CYP) with diagnosed mental health difficulties, what are the levels of parents' well-being and psychological need?

STUDY SELECTION AND ANALYSIS

Medline, PsycINFO, EMBASE, AMED, CINAHL, Web of Science and Cochrane Library of Registered Trials were searched from inception to June 2023.

INCLUSION CRITERIA

parents of CYP aged 5-18 years with formal mental health diagnosis. Data were extracted from validated measures of well-being or psychological needs with established cut-off points or from a controlled study.

FINDINGS

32 of the 73 310 records screened were included. Pooled means showed clinical range scores for one measure of depression, and all included measures of anxiety, parenting stress and general stress. Meta-analyses showed greater depression (g=0.24, 95% CI 0.11 to 0.38) and parenting stress (g=0.34, 95% CI 0.20 to 0.49) in parents of CYP with mental health difficulties versus those without. Mothers reported greater depression (g=0.42, 95% CI 0.18 to 0.66) and anxiety (g=0.73, 95% CI 0.27 to 1.18) than fathers. Narrative synthesis found no clear patterns in relation to CYP condition. Rates of parents with clinically relevant levels of distress varied. Typically, anxiety, parenting stress and general stress scored above clinical threshold. Quality appraisal revealed few studies with a clearly defined control group, or attempts to control for important variables such as parent gender.

CONCLUSIONS

The somewhat mixed results suggest clinical anxiety, parenting and general stress may be common, with sometimes high depression. Assessment and support for parents of CYP with mental health problems is required. Further controlled studies, with consideration of pre-existing parental mental health difficulties are required.

PROSPERO REGISTRATION NUMBER

CRD42022344453.

Burden Experienced by Primary Caregivers of Children With Psychotic Disorders and at Clinical High Risk for Psychosis

BACKGROUND

Despite the existing research exploring caregiver burden in adult psychosis, few studies have examined the experience of providing care to children diagnosed with psychotic disorders (PDs) and those identified as having clinical high risk for psychosis (CHR-P).

AIM

This study measured the level of burden in caregivers of children with PD and CHR-P and examined associated risk factors, including social support, caregiver-child relationship, severity of illness, and frequency of psychiatric hospitalizations.

METHODS

A total of 56 caregivers completed validated measures and provided demographic information. Measures included the Zarit Burden Interview, the Multidimensional Scale of Perceived Social Support, the Behavior Assessment System for Children, Third Edition, Parenting Relationship Questionnaire-Child and Adolescent Form (BASC-3 PRQ-CA), and the Clinical Global Impression-Severity scale.

RESULTS

The majority of caregivers were women (86%), mothers (84%), White (63%), married (66%), working full-time (50%), college-educated (79%), and whose mean age was 45.7 years (SD = 8.09). Nearly half of the caregivers (45%) reported a high level of caregiver burden, 39% rated their burden in the mild to moderate range, and 16% reported little to no burden. There was no significant difference in mean burden between PD and CHR-P groups. Higher caregiver burden was associated with lower levels of social support (r = -.408, p = .002), lower levels of parenting confidence (r = -.514, p < .001), higher levels of relational frustration (r = .612, p < .001), and higher severity of illness (r = .316 p = .025).

CONCLUSIONS

These findings underscore the critical unmet need for support for caregivers of children with PD and CHR-P. Applications to clinical practice are discussed.

Functional Alterations in Patients with Bipolar Disorder and Their Unaffected First-Degree Relatives: Insight from Genetic, Epidemiological, and Neuroimaging Data

Bipolar disorder (BD) profoundly affects cognitive and psychosocial functioning, leading to a significant illness burden on patients and their families. Genetic factors are predominant in the onset of bipolar disorder and functional impairments. This disorder exhibits a strong family aggregation, with heritability estimates reaching up to 80%. Individuals with BD often experience impaired functioning, especially in significant areas such as physical performance, sleep, cognition, interpersonal interactions, socioeconomic status, family and marital relationships, work and school performance, well-being, and life expectancy. However, patients with different subtypes exhibit significant heterogeneity in social functioning, cognition, and creativity levels. There are notable differences in psychosocial and cognitive function in their unaffected first-degree relatives (UFR) who do not suffer but may carry susceptibility genes compared to healthy control (HC) without a family history. The observations indicate common genetic structures between BD patients and their UFR, which results in varying degrees of functional abnormalities. Therefore, this article mainly provides evidence on cognition, creativity, and psychosocial functioning in patients with BD and their UFR to provide a more comprehensive understanding of this critical topic in the field of BD. By integrating various findings, including clinical data and neuroimaging studies, our article aims to provide insights and valuable information for a deeper exploration of the pathogenesis of BD and the development of more targeted therapeutic strategies in the future.

Comparing self-reported quality of life in youth with bipolar versus other disorders

OBJECTIVES

This study benchmarks quality of life (QoL) of youth with bipolar disorder (BD) against healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders. The relative impacts of depressive, (hypo)manic, mixed, and externalizing symptoms on QoL are tested for youth with BD.

METHOD

In total, 657 youth completed the Schedule for Affective Disorders and Schizophrenia for Children (KSADS), the KSADS depression and mania scales, the Parent General Behavior Inventory (PGBI), and the Child Behavior Checklist (CBCL). Youth-reported QoL was determined by the Revised Children Quality of Life Questionnaire (KINDL) and was compared to healthy youth, youth with chronic medical conditions, and youth with other psychiatric disorders.

RESULTS

Youth with BD reported poorer QoL overall and on most subscales compared to healthy youth, youth with chronic medical conditions, youth with behavior disorders, and youth with other non-behavior/non-mood disorders. QoL in youth with BD did not differ significantly from QoL in youth with unipolar depression. Parent-report and interview-rated depressive symptoms were associated with decreases in Total QoL and all QoL subscales except Family. Externalizing symptoms were associated with decreases in Family QoL and increases in Friend QoL, and (hypo)manic symptoms were associated with increases in Emotional Well-Being QoL.

CONCLUSIONS

Depressive symptoms may drive the decline in QoL causing youth with BD to rate their QoL worse than healthy youth, youth with chronic medical conditions, and youth with behavior disorders, but not worse than youth with unipolar depression.

X- vs. Y-Chromosome Influences on Human Behavior: A Deep Phenotypic Comparison of Psychopathology in XXY and XYY Syndromes

Do different genetic disorders impart different psychiatric risk profiles? This question has major implications for biological and translational aspects of psychiatry, but has been difficult to tackle given limited access to shared batteries of fine-grained clinical data across genetic disorders. Using a new suite of generalizable analytic approaches, we examine gold-standard diagnostic ratings, scores on 66 dimensional measures of psychopathology, and measures of cognition and functioning in two different sex chromosome aneuploidies (SCAs) - Klinefelter (XXY/KS) and XYY syndrome (n=102 and 64 vs. n=74 and 60 matched XY controls, total n=300). We focus on SCAs for their high collective prevalence, informativeness regarding differential X- vs. Y-chromosome effects, and potential relevance for normative sex differences. We show that XXY/KS elevates rates for most psychiatric diagnoses as previously reported for XYY, but disproportionately so for anxiety disorders. Fine-mapping across all 66 traits provides a detailed profile of psychopathology in XXY/KS which is strongly correlated with that of XYY (r=.75 across traits) and robust to ascertainment biases, but reveals: (i) a greater penetrance of XYY than KS/XXY for most traits except mood/anxiety problems, and (ii) a disproportionate impact of XYY vs. XXY/KS on social problems. XXY/KS and XXY showed a similar coupling of psychopathology with adaptive function and caregiver strain, but not IQ. This work provides new tools for deep-phenotypic comparisons of genetic disorders in psychiatry and uses these to detail unique and shared effects of the X- and Y-chromosome on human behavior.

Emotion regulation, parental stress and family functioning: Families of children with disabilities vs normative families

Childhood disability is a major challenge for families. The aim of the present study was to explore differences between families of children with disabilities and normative families, analyzing the association of emotion dysregulation with relationship satisfaction, through parental stress and interparental conflict, using supportive dyadic coping by oneself (SDCO) as a moderator. For a sample of 445 Romanian parents, results showed higher levels of parental stress and interparental conflict and lower relationship satisfaction in families of children with disabilities compared to normative families, as well as a direct relationship between parental stress and relationship satisfaction and a stronger direct effect for SDCO with relationship satisfaction. For normative families, SDCO moderated the relationship between emotion dysregulation and parental stress, and for families of children with disabilities SDCO interacted on the link between emotion dysregulation and relationship satisfaction. Only families of children with disabilities presented indirect effects between emotion dysregulation and relationship satisfaction through parental stress, moderated by SDCO. These effects increased in impact as the use of SDCO was higher. Conditional indirect effects by SDCO were also found for the link between emotion dysregulation and relationship satisfaction through interparental conflict for both families, with this effect being higher in families of children with disabilities. These findings highlight the need to implement specific programs that can adjust to the needs of these families, strengthening parents' emotional competencies, as well as stress and conflict management abilities.

Paediatric bipolar disorder and its controversy

OBJECTIVES

Paediatric bipolar disorder - bipolar disorder occurring in prepubertal children - is a diagnosis subject to considerable controversy. Whilst historically considered to be very rare, proponents since the 1990s have argued that mania can present differently in children and, as such, is much more common than previously thought. Such proposals raise questions about the validity of proposed phenotypes and potential risks of iatrogenic harm.

METHODS

I critically examine the construct of paediatric bipolar disorder using Robins and Guze's (1970, American Journal of Psychiatry126, 983-987) influential criteria for the validity of a psychiatric diagnosis. I review, in turn, evidence relating to its clinical description, delimitation from other conditions, follow-up studies, family studies, laboratory studies, and treatment response.

RESULTS

Across domains, existing research highlights significant challenges establishing the diagnosis. This includes significant heterogeneity in operationalising criteria for children; variable or poor inter-rater reliability; difficulty distinguishing paediatric bipolar disorder from other conditions; large differences in rates of diagnosis between the United States of America and other countries; limited evidence of continuity with adult forms; and a lack of evidence for proposed paediatric phenotypes in children at genetic high-risk of the condition. Laboratory and treatment studies are limited, but also do not provide support for the construct.

CONCLUSIONS

Evidence for the more widespread existence of paediatric bipolar disorder and its various proposed phenotypes remains weak. The ongoing popularity of the diagnosis, most evident in America, may reflect social pressures and broader limitations in psychiatric nosology. The uncertainty around the diagnosis highlights the need for careful longitudinal assessment of children potentially affected.

Early Family Intervention for Youth at Risk for Bipolar Disorder: Psychosocial and Neural Mediators of Outcome

BACKGROUND

The impairing neurodevelopmental course of bipolar disorder (BD) suggests the importance of early intervention for youth in the beginning phases of the illness.

OBJECTIVE

We report the results of a 3-site randomized trial of family-focused therapy for youth at high-risk (FFT-HR) for BD, and explore psychosocial and neuroimaging variables as mediators of treatment effects.

METHODS

High-risk youth (<18 years) with major depressive disorder or other specified BD, active mood symptoms, and a family history of BD were randomly assigned to 4 months of FFT-HR (psychoeducation, communication and problem-solving skills training) or 4 months of enhanced care psychoeducation. Adjunctive pharmacotherapy was provided by study psychiatrists. Neuroimaging scans were conducted before and after psychosocial treatments in eligible participants. Independent evaluators interviewed participants every 4-6 months over 1-4 years regarding symptomatic outcomes.

RESULTS

Among 127 youth (mean 13.2 ± 2.6 years) over a median of 98 weeks, FFT-HR was associated with longer intervals prior to new mood episodes and lower levels of suicidal ideation than enhanced care. Reductions in perceived family conflict mediated the effects of psychosocial interventions on the course of mood symptoms. Among 34 participants with pre-/post-treatment fMRI scans, youth in FFT-HR had (a) stronger resting state connectivity between ventrolateral PFC and anterior default mode network, and (b) increased activity of dorsolateral and medial PFC in emotion processing and problem-solving tasks, compared to youth in enhanced care.

CONCLUSION

FFT-HR may delay new mood episodes in symptomatic youth with familial liability to BD. Putative treatment mechanisms include neural adaptations suggestive of improved emotion regulation.

Mood Instability in Youth at High Risk for Bipolar Disorder

OBJECTIVE

Mood instability is associated with the onset of bipolar disorder (BD) in youth with a family history of the illness. In a clinical trial with youth at high risk for BD, we examined the association between mood instability and symptomatic, psychosocial, and familial functioning over an average of 2 years.

METHOD

Youth (aged 9-17 years) with major depressive disorder or other specified BD, current mood symptoms, and a family history of BD were rated by parents on a mood instability scale. Participants were randomly assigned to 4 months of family-focused therapy or enhanced care psychoeducation, both with medication management as needed. Independent evaluators rated youth every 4-6 months for up to 4 years on symptom severity and psychosocial functioning, whereas parents rated mood instability of the youth and levels of family conflict.

RESULTS

High-risk youth (N = 114; mean age 13.3 ± 2.6 years; 72 female) were followed for an average of 104.3 ± 65.8 weeks (range, 0-255 weeks) after randomization. Youth with other specified BD (vs major depressive disorder), younger age, earlier symptom onset, more severe mood symptoms, lower psychosocial functioning, and more familial conflict over time had higher mood instability ratings throughout the study period. Mood instability mediated the association between baseline diagnosis and mother/offspring conflict at follow-up (Z = 2.88, p = .004, αβ = 0.19, 95% CI = 0.06-0.32). Psychosocial interventions did not moderate these associations.

CONCLUSION

A questionnaire measure of mood instability tracked closely with symptomatic, psychosocial, and family functioning in youth at high risk for BD. Interventions that are successful in reducing mood instability may enhance long-term outcomes among high-risk youth.

CLINICAL TRIAL REGISTRATION INFORMATION

Early Intervention for Youth at Risk for Bipolar Disorder; https://clinicaltrials.gov/; NCT01483391.

Parental Expressed Emotion, Parenting Stress, and Behavioral Problems of Young Children with 22q11.2 Deletion Syndrome and Idiopathic Autism Spectrum Disorder

This study examined the associations of parents' expressed emotion (EE) and parenting stress, with behavioral problems of children with 22q11.2 deletion syndrome, idiopathic autism (iASD) and typically developing (TD) children. Parents of children aged 3-8 years completed the five-minute-speech-sample (FMSS), parental stress index and children behavioral checklist. Parents' FMSS-EE-criticism was higher among parents of children with 22q11DS and iASD compared to parents of TD children. FMSS-EE scores predicted children's behavioral problems, above and beyond parenting stress. The associations between FMSS-EE, parenting stress and children's behavioral problems were consistent across 22q11DS, iASD and TD children. These findings highlight the need for targeting parents' EE and parenting stress as integral elements in the screening and prevention of behavioral problems of young children with 22q11DS and iASD.

The relationship between the plasma proinflammatory cytokine levels of depressed/anxious children and their parents

Recent studies suggest immune function dysregulation in depression and anxiety disorders. Elevated pro-inflammatory cytokines may be a marker for immune system dysregulation. No study assessed the correlation between the levels of cytokines in children and adolescents with depression/anxiety disorders and their parents. In this study, 92 children and adolescents (mean age 13.90 ± 2.41 years) with depression and/or anxiety disorders were treated with fluoxetine. Blood samples were collected before initiation of treatment. One hundred and sixty-four of their parents (mean age 50.6 ± 6.2 years) and 25 parents of healthy children (mean age 38.5 ± 6.2 years) also gave blood samples. Plasma levels of three pro-inflammatory cytokine (TNF-α, IL-6, IL-1β) were measured by enzyme linked immunosorbent assays (ELISA) and compared between depressed/anxious children and their parents. We also compared cytokine levels between parents of children with depression/anxiety and control parents. Mothers of depressed children had higher TNF-α levels than mothers of controls. No significant difference was detected in the fathers. A positive correlation was found between the IL-1β levels of the depressed/anxious boys and their mothers. No such correlation was observed in the fathers. Our conclusions are that higher levels of proinflammatory cytokines may indicate immune system activation in mothers in response to the distress associated with having depressed/anxious offspring. The correlation between IL-1β levels in the mothers and their depressed/anxious children may indicate familial vulnerability to depression and anxiety. Our observation highlights the need for a better understanding of sexual dimorphism in inflammatory responses to stress.

The longitudinal relationship between child emotional disorder and parental mental health in the British Child and Adolescent Mental Health surveys 1999 and 2004

BACKGROUND

Research suggests parental psychopathology has an adverse effect on child mental health. However, due to the interactional nature of parent-child relationships and with a high rate of emotional disorders reported in school-age children, it is important to know whether the effect is reciprocal.

METHODS

We explored the longitudinal relationship between child and parent mental health in the British Child and Adolescent Mental Health Surveys (N=7,100 child-parent dyads) and their three-year follow-ups. The Development and Well-Being Assessment with DSM-IV diagnostic criteria was used to measure child psychiatric diagnoses, while parental mental health was assessed using the General Health Questionnaire. Multivariable logistic regression was used to explore the longitudinal association between child emotional disorder and parent mental health.

RESULTS

Parents of children who had an emotional disorder at baseline were more likely to have poor mental health three years later compared with parents whose children had no psychiatric diagnosis (33.3% versus 16.7%; crude odds ratio=2.52; adjusted odds ratio=2.19, 95% CI=1.58 to 3.05, p<0.001). Children of parents with poor mental health at baseline were more likely to develop an emotional disorder three years later compared with children whose parents had good mental health (5.2% versus 2.5%; crude odds ratio=2.08; adjusted odds ratio=1.63, 95% CI=1.18 to 2.25, p=0.003).

LIMITATIONS

The findings of this research are limited by the survey data collected, the measures used and survey dropout.

CONCLUSIONS

We detected a bi-directional relationship between child and parent mental health, suggesting that effective intervention for one individual may benefit other family members.

Parental Monitoring Predicts Depressive Symptom and Suicidal Ideation Outcomes in Adolescents Being Treated for Co-Occurring Substance Use and Psychiatric Disorders

BACKGROUND

Comorbidity of substance use disorders (SUDs) with mood disorders and other psychiatric conditions is common. Parenting processes and family functioning are impaired in adolescents with SUDs and mood disorders, and parent/family factors predict intervention response. However, limited research has examined the relationship between parent/family factors and mood symptom treatment response in adolescents with comorbid SUDs and psychiatric conditions.

METHOD

This study examined the predictive effects of parenting processes and family functioning on depressive symptoms and suicidal ideation (SI) in a randomized controlled trial of integrated cognitive-behavioral therapy vs. treatment as usual for 111 adolescents with comorbid SUDs and psychiatric disorders. Measures of parenting processes, family functioning, depressive symptoms, and SI were completed at baseline and 3-, 6-, and 12-month follow-ups. Exploratory analyses involved mixed-effects regression models.

RESULTS

Across treatment conditions, depressive symptoms and SI improved over 12 months. Family functioning domains of family roles (d=0.47) and affective involvement (d=0.39) significantly improved across treatment conditions over 12 months. Higher baseline parental monitoring predicted improved trajectory of depressive symptoms (d=0.44) and SI (d=0.46). There were no significant predictive effects for baseline family functioning or other parenting processes (listening, limit setting).

LIMITATIONS

Limitations include the modest sample, attrition over follow-up, and generalizability to samples with higher rates of mood disorders and/or uncomplicated mood disorders.

CONCLUSIONS

Parental monitoring may be an important prognostic indicator of depressive symptoms and SI in adolescents with co-occurring SUDs and psychiatric conditions, and therefore may be useful to assess and target in treatment, in addition to family functioning.

Early-onset bipolar disorder, stress, and coping responses of mothers: A comparative study

BACKGROUND

Providing care and nurturance to a child with bipolar disorder (BPAD) is a challenging task for parents, especially mothers. In Indian contexts, mothers are the primary caregivers of ailing children and they have to keep intrafamily situation stable, which makes their role more stressful.

OBJECTIVES

The objective of the study was to assess maternal stress and coping in mothers of adolescents with BPAD.

MATERIALS AND METHODS

This study was a comparative one and carried out on sixty mothers of adolescents; of which thirty were adolescents with BPAD, and the remaining thirty were the mothers of normal adolescents. The participants were selected purposively as per the mothers' age and education level, and the socioeconomic status of the families they belong to. Sociodemographic and clinical data sheet, Parenting Stress Index/Short Form (PSI/SF), and Brief COPE were applied on the mothers for data collection.

RESULTS

Mothers' of the BPAD adolescents reported higher scores in the both PSI/SF and Brief COPE.

CONCLUSION

Mothers of the adolescents with BPAD tend to perceive high level of stress and they also use maladaptive coping more in dealing with stressful situations.

The Greater Houston Area Bipolar Registry-Clinical and Neurobiological Trajectories of Children and Adolescents With Bipolar Disorders and High-Risk Unaffected Offspring

The aims of this article are to discuss the rationale, design, and procedures of the Greater Houston Area Bipolar Registry (HBR), which aims at contributing to the effort involved in the investigation of neurobiological mechanisms underlying bipolar disorder (BD) as well as to identify clinical and neurobiological markers able to predict BD clinical course. The article will also briefly discuss examples of other initiatives that have made fundamental contributions to the field. This will be a longitudinal study with participants aged 6-17 at the time of enrollment. Participants will be required to meet diagnostic criteria for BD, or to be offspring of a parent with BD. We will also enroll healthy controls. Besides clinical information, which includes neurocognitive performance, participants will be asked to provide blood and saliva samples as well as to perform neuroimaging exams at baseline and follow-ups. Several studies point to the existence of genetic, inflammatory, and brain imaging alterations between individuals at higher genetic risk for BD compared with healthy controls. Longitudinal designs have shown high conversion rates to BD among high-risk offspring, with attempts to identify clinical predictors of disease onset, as well as clarifying the burden associated with environmental stressors. The HBR will help in the worldwide effort investigating the clinical course and neurobiological mechanisms of affected and high-risk children and adolescents with BD.

Effects of family-focused therapy on suicidal ideation and behavior in youth at high risk for bipolar disorder

BACKGROUND

Youth who are at clinical and familial risk for bipolar disorder (BD) often have significant suicidal ideation (SI). In a randomized trial, we examined whether family-focused therapy (FFT) is associated with reductions in SI and suicidal behaviors in high-risk youth.

METHODS

Participants (ages 9-17 years) met diagnostic criteria for unspecified BD or major depressive disorder with active mood symptoms and had at least one relative with BD type I or II. Participants were randomly allocated to 12 sessions in 4 months of FFT or 6 sessions in 4 months of psychoeducation (enhanced care, EC), with pharmacotherapy as needed. Clinician- and child-rated assessments of mood, suicidal thoughts and behaviors, and family conflict were obtained at baseline and 4-6 month intervals over 1-4 years.

RESULTS

Participants (N=127; mean 13.2±2.6 yrs., 82 female) were followed over an average of 105.9±64.0 weeks. Youth with high baseline levels of SI who received FFT had lower levels of (and fewer weeks with) SI at follow-up compared to youth with high baseline SI who received EC. Participants in FFT had longer intervals without suicidal behaviors than participants in EC. Youths' ratings of family conflict significantly mediated the effects of treatment on SI at follow-up.

LIMITATIONS

Family conflict was based on questionnaires rather than observer ratings of family interactions.

CONCLUSIONS

Family psychoeducation with skill training can be an effective deterrent to suicidal thoughts and behaviors in youth at high risk for BD. Reducing parent/offspring conflict should be a central objective of psychosocial interventions for high-risk youth with SI.

Quality of Life in Family Caregivers of Adolescents with Depression in China: A Mixed-Method Study

PURPOSE

In this study, we investigated quantitatively the quality of life (QoL) and its influencing factors among Chinese family caregivers who care for adolescents with depression (AWD) and we explored qualitatively their care-giving experiences.

METHODS

The study was a mixed method with convergent parallel design. The sociodemographic characteristics, QoL, caregivers' burden, family functioning, positive and negative affects were assessed by using questionnaires on 240 family caregivers of AWD in China. Twelve of these family caregivers were interviewed by using a semi-structured guide to explore their care-giving experiences.

RESULTS

The mean score among family caregivers of AWD for physical QoL was 65.18 and 59.42 for mental QoL, which was significantly lower than the Chinese norms for QoL. Multiple regression analysis demonstrated that course of disease of AWD, caregivers' educational qualification, family functioning, positive affect and care-giving burden accounted for 57% of the variance in physical QoL. Suicide history of AWD, caregivers' educational qualification, negative affect, positive affect, care-giving burden and family functioning accounted for 54% of the variance in mental QoL. Four major themes of the care-giving experiences emerged: lack of knowledge about depression, being overwhelmed emotionally with psychological burden, the devastating impact of illness on family, and the perceived benefits of care-giving.

CONCLUSION

The QoL among family caregivers of AWD in China was low. It is necessary for health-care professionals to pay more attention to the QoL of family caregivers who care for AWD.

Using the Multiphase Optimization Strategy (MOST) framework to test intervention delivery strategies: a study protocol

Background

Delivery of behavioral interventions is complex, as the majority of interventions consist of multiple components used either simultaneously, sequentially, or both. The importance of clearly delineating delivery strategies within these complex interventions—and furthermore understanding the impact of each strategy on effectiveness—has recently emerged as an important facet of intervention research. Yet, few methodologies exist to prospectively test the effectiveness of delivery strategies and how they impact implementation. In the current paper, we describe a study protocol for a large randomized controlled trial in which we will use the Multiphase Optimization Strategy (MOST), a novel framework developed to optimize interventions, i.e., to test the effectiveness of intervention delivery strategies using a factorial design. We apply this framework to delivery of Family Navigation (FN), an evidence-based care management strategy designed to reduce disparities and improve access to behavioral health services, and test four components related to its implementation.

Methods/design

The MOST framework contains three distinct phases: Preparation, Optimization, and Evaluation. The Preparation phase for this study occurred previously. The current study consists of the Optimization and Evaluation phases. Children aged 3-to-12 years old who are detected as “at-risk” for behavioral health disorders (n = 304) at a large, urban federally qualified community health center will be referred to a Family Partner—a bicultural, bilingual member of the community with training in behavioral health and systems navigation—who will perform FN. Families will then be randomized to one of 16 possible combinations of FN delivery strategies (2 × 2 × 2× 2 factorial design). The primary outcome measure will be achieving a family-centered goal related to behavioral health services within 90 days of randomization. Implementation data on the fidelity, acceptability, feasibility, and cost of each strategy will also be collected. Results from the primary and secondary outcomes will be reviewed by our team of stakeholders to optimize FN delivery for implementation and dissemination based on effectiveness, efficiency, and cost.

Discussion

In this protocol paper, we describe how the MOST framework can be used to improve intervention delivery. These methods will be useful for future studies testing intervention delivery strategies and their impact on implementation.

Trial registration

ClinicalTrials.gov, NCT03569449. Registered on 26 June 2018.

Validation of the Caregiver Skills (CASK) scale in Catalonia: Concordance between caregivers in attitudes and behaviours

OBJECTIVE

The aim of this study was to validate a Spanish version of the Caregiver Skills scale (CASK) in a sample of eating disorder (ED) caregivers. A further aim was to examine the concordance/discrepancy between them (namely, between the mothers and fathers of ED patients).

METHOD

Two hundred sixty-five ED caregivers were recruited from ED centers in Catalonia, Spain. Confirmatory factor analyses was used to test the factorial structure of the CASK scale. Cronbach's α was used to measure internal consistency of the CASK scales. A comparison of the CASK measures between respondents (mothers and fathers) was conducted using generalized estimating equations.

RESULTS

Confirmatory factor analysis of the Spanish version of the CASK corroborated the strong factorial validity of the 6 factors of the original CASK questionnaire. Mothers and fathers did not differ significantly on CASK overall and subscale scores. There was however less concordance between parents on the bigger picture (ICC = 0.28) and biting your tongue (ICC = 0.08) subscales.

CONCLUSIONS

The CASK is a valid tool to assess ED-related attitudes in Spanish-speaking caregivers. Furthermore, caregivers and patients alike could stand to benefit from interventions focused on improving areas such as ED beliefs, effective communication, quality of life, and emotional distancing.

Predictors of caregiver burden in mothers of children with leukemia and cerebral palsy

OBJECTIVE

Caring for a sick child can lead to considerable burden in the caregiver. Comparative studies of burden in mothers of children with different types of disorders are rare.

METHODS

We assessed levels of and risk factors for burden in mothers of children with leukemia (n: 70) or with cerebral palsy (CP) (n: 69). Subjects were recruited from two hospitals in Ankara.

RESULTS

Levels of burden or depression were not different between groups. Burden was predicted by the presence of depression in the mother and severity of illness in both groups. In the leukemia group, mothers reported higher burden if the child was male or younger; no such relationship was observed in the CP group.

CONCLUSION

Our results show that type of illness has an effect on levels of burden. Mothers of children with leukemia should receive more attention, especially if their child is male or younger, to take preventive measures against burden.

Developmental evaluation of family functioning deficits in youths and young adults with childhood-onset bipolar disorder

BACKGROUND

Childhood-onset bipolar disorder (BD) is a serious condition that affects the patient and family. While research has documented familial dysfunction in individuals with BD, no studies have compared developmental differences in family functioning in youths with BD vs. adults with prospectively verified childhood-onset BD.

METHODS

The Family Assessment Device (FAD) was used to examine family functioning in participants with childhood-onset BD (n = 116) vs. healthy controls (HCs) (n = 108), ages 7-30 years, using multivariate analysis of covariance and multiple linear regression.

RESULTS

Participants with BD had significantly worse family functioning in all domains (problem solving, communication, roles, affective responsiveness, affective involvement, behavior control, general functioning) compared to HCs, regardless of age, IQ, and socioeconomic status. Post-hoc analyses suggested no influence for mood state, global functioning, comorbidity, and most medications, despite youths with BD presenting with greater severity in these areas than adults. Post-hoc tests eliminating participants taking lithium (n = 17) showed a significant diagnosis-by-age interaction: youths with BD had worse family problem solving and communication relative to HCs.

LIMITATIONS

Limitations include the cross-sectional design, clinical differences in youths vs. adults with BD, ambiguity in FAD instructions, participant-only report of family functioning, and lack of data on psychosocial treatments.

CONCLUSIONS

Familial dysfunction is common in childhood-onset BD and endures into adulthood. Early identification and treatment of both individual and family impairments is crucial. Further investigation into multi-level, family-based mechanisms underlying childhood-onset BD may clarify the role family factors play in the disorder, and offer avenues for the development of novel, family-focused therapeutic strategies.