Parenting and family interventions in lower and middle-income countries for child and adolescent mental health: A systematic review

BACKGROUND

Given the protective effect of nurturing caregivers and families for child and adolescent mental health, there is a need to review and synthesize research evidence regarding the effectiveness of parenting and family interventions in low and middle-income countries, including humanitarian settings. To advance practice, further understanding of the active ingredients of such interventions and implementation factors that lead to effectiveness are essential.

METHOD

This systematic review, an update from a previous review, included studies on any parenting or family intervention for children and adolescents aged 0-24, living in a low- or middle-income country, that quantitatively measured child or adolescent mental health outcomes. We searched Global Health, PubMed, PsychINFO, PILOTS and the Cochrane Library databases on the 9th July 2020, and updated on the 12th August 2022. Risk of bias was assessed using an adapted version of the NIH Quality Assessment Tool. We extracted data on: effectiveness outcomes, practice elements included in effective interventions, and implementation challenges and successes.

MAIN FINDINGS

We found a total of 80 studies (n = 18,193 participants) representing 64 different family or parenting interventions, 43 of which had evidence of effect for a child or adolescent mental health outcome. Only 3 studies found no effect on child, adolescent or caregiver outcomes. The most common practice elements delivered in effective interventions included caregiver psychoeducation, communication skills, and differential reinforcement. Key implementation strategies and lessons learned included non-specialist delivery, the engagement of fathers, and integrated or multi-sector care to holistically address family needs.

PRELIMINARY CONCLUSIONS

Despite a high level of heterogeneity, preliminary findings from the review are promising and support the use of parenting and family interventions to address the wider social ecology of children in low resource and humanitarian contexts. There are remaining gaps in understanding mechanisms of change and the empirical testing of different implementation models. Our findings have implications for better informing task sharing from specialist to non-specialist delivery, and from individual-focused to wider systemic interventions.

Feasibility and acceptability of phone-delivered psychological therapy for refugee children and adolescents in a humanitarian setting

BACKGROUND

Refugee children are at high risk of mental health problems but face barriers to accessing mental health services, a problem exacerbated by a shortage of mental health professionals. Having trained lay counsellors deliver therapy via telephone could overcome these barriers. This is the first study to explore feasibility and acceptability of telephone-delivered therapy with refugee children in a humanitarian setting.

METHODS

An evidence-based intervention, Common Elements Treatment Approach, was adapted for telephone-delivery (t-CETA) and delivered by lay counsellors to Syrian refugee children in informal tented settlements in the Beqaa region of Lebanon. Following delivery of t-CETA, semi-structured interviews were conducted with counsellors (N = 3) and with children who received t-CETA (N = 11, 45% female, age 8-17 years) and their caregivers (N = 11, 100% female, age 29-56 years) (N = 25 interviews). Thematic content analysis was conducted separately for interviews with counsellors and interviews with families and results were synthesized.

RESULTS

Three themes emerged from interviews with counsellors and four themes from interviews with families, with substantial overlap between them. Synthesized themes were: counselling over the phone both solves and creates practical and logistical challenges; t-CETA is adapted to potential cultural blocks; the relationship between the counsellor and the child and caregiver is extremely important; the family's attitude to mental health influences their understanding of and engagement with counselling; and t-CETA works and is needed. Counselling over the phone overcame logistical barriers, such as poor transportation, and cultural barriers, such as stigma associated with attending mental health services. It provided a more flexible and accessible service and resulted in reductions in symptoms for many children. Challenges included access to phones and poor network coverage, finding an appropriate space, and communication challenges over the phone.

CONCLUSIONS

Despite some challenges, telephone-delivered therapy for children shows promising evidence of feasibility and acceptability in a humanitarian context and has the potential to increase access to mental health services by hard-to-reach populations. Approaches to addressing challenges of telephone-delivered therapy are discussed. Trial Registration ClinicalTrials.gov ID: NCT03887312; registered 22nd March 2019.

What drives change in children receiving telephone-delivered Common Elements Treatment Approach (t-CETA)? A multiple n = 1 study with Syrian refugee children and adolescents in Lebanon

BACKGROUND

Although the evidence-base for mental health and psychosocial support (MHPSS) interventions in humanitarian settings is growing rapidly, their mechanisms of change remain poorly understood despite the potential to improve the effectiveness and reach of interventions.

OBJECTIVE

This study aimed to explore the mechanisms or factors that drive change in a modular transdiagnostic telephone-delivered mental health intervention, Common Elements Treatment Approach (t-CETA).

PARTICIPANTS AND SETTING

Participants were Syrian refugee children and adolescents living in tented settlements in Lebanon.

METHODS

We used a multiple n = 1 design, drawing on secondary data from 9 children who completed t-CETA during a pilot randomized controlled trial.

RESULTS

Children with historical war-related trauma were more likely to show significant improvement across symptom clusters by the end of treatment compared to children presenting with depression related to daily living conditions. Children also showed fluctuating symptoms during the early stages of treatment (engagement and cognitive restructuring) but significant decline in symptoms after the trauma module (prolonged imaginal exposure) and depression module (behavioral activation). Salient external life events identified were starting or dropping out of school, working, change in living conditions, family conflict and the October Revolution; and interpersonal factors of parental engagement (with or without full attendance) and counsellor skills in building rapport were also identified as having an impact on treatment success.

CONCLUSIONS

Implications of our findings are discussed in terms of integrating active ingredients into MHPSS programming, and building on parental and multi-sector involvement in child and adolescent mental health care in humanitarian settings.

The culturally and contextually sensitive assessment of mental health using a structured diagnostic interview (MINI Kid) for Syrian refugee children and adolescents in Lebanon: Challenges and solutions

Elevated rates of mental health difficulties are frequently reported in conflict-affected and displaced populations. Even with advances in improving the validity and reliability of measures, our knowledge of the performance of assessment tools is often limited by a lack of contextualization to specific populations and socio-political settings. This reflective article aimed to review challenges and share lessons learned from the process of administering and supervising a structured clinical interview. We administered the MINI International Neuropsychiatric Interview for Children and Adolescents (MINI Kid) and used the Clinical Global Impression (CGI) severity scale with N = 119 Syrian refugee children (aged 8-17) resident in ITSs in Lebanon. Qualitative data were derived from supervision process notes on challenges that arose during assessments, analyzed for thematic content. Five themes were identified: (1) practical and logistical challenges (changeable nature of daily life, competing demands, access to phones, temporary locations, limited referral options); (2) validity (lack of privacy, trust, perceptions of mental health, stigma, false positive answers); (3) cultural norms and meaning (impact of different meanings on answers); (4) contextual norms (reactive and adaptive emotional and behavioral responses to contextual stress); and (5) co-morbidity and formulation (interconnected and complex presentations). The findings suggest that while structured assessments have major advantages, cultural and contextual sensitivity during assessments, addressing practical barriers to improving accessibility, and consideration for inter-connected formulations are essential to help inform prevalence rates, treatment plans, and public health strategies.

Family systemic psychosocial support for at-risk adolescents in Lebanon: study protocol for a multi-site randomised controlled trial

Background

Adolescents growing up in communities characterised by adversity face multiple risk factors for poor mental health and wellbeing. There is currently a scarcity of research on effective approaches for preventing and treating psychological distress in this population, particularly in humanitarian settings. The powerful impact of the home environment and family support is well known; however, approaches targeting the family are seldom developed or evaluated in such settings. We developed a brief family systemic psychosocial support intervention to be delivered through existing child protection systems with non-specialist facilitators. This paper outlines the study protocol for a randomised controlled trial of the intervention in Lebanon.

Methods

We will conduct a single-blind hybrid effectiveness-implementation multi-site RCT comparing the locally developed systemic family intervention to a waitlist control group for families residing in vulnerable regions in North Lebanon and Beqaa governorates (including families of Syrian, Palestinian, and Lebanese backgrounds). Outcomes on a range of family, adolescent, and caregiver measures will be assessed at baseline (T0) and post-intervention (T1), and at a 3-month follow-up for the treatment arm (T2). Families will be eligible for the trial if they are identified by implementing organisations as being medium-to-high risk for child protection concerns and have one or more adolescent aged 12–17 who demonstrates significant psychological distress on a self-report brief screening tool. Families will be randomly assigned to a treatment or a waitlist control condition. Families in the waitlist condition will receive a group version of the programme after completion of the study, to allow us to assess feasibility, acceptability, and preliminary indications of intervention effects of this modality. The primary outcome is reduction in overall adolescent-reported psychological distress over time, with post-intervention (T1) as the primary endpoint. Secondary adolescent-reported outcomes include family functioning, psychosocial wellbeing, and emotional regulation difficulties. Secondary caregiver-reported outcomes include parenting style, family functioning, psychological distress, and emotional regulation difficulties.

Discussion

This trial will provide the first assessment of the effectiveness of the family systemic psychosocial support intervention for use in Lebanon, with important implications for the use of systemic, low-cost, non-specialist interventions for this age range.

Trial registration

Local registry:

National Mental Health Program, Ministry of Public Health, Lebanese Republic. Registered on 19 October 2021

Lebanese Clinical Trial Registry LBCTR2021104870. Registered on 13 October 2021

Global registry: ISRCTN ISRCTN13751677. Registered on 1 November 2021

Neighbourhood effects on psychotic and depressive symptoms in the context of religious sectarianism in Northern Ireland: A data linkage study

BACKGROUND

The incidence of psychotic disorders is higher in ethnic minorities groups. The 'ethnic density effect', in which living in a neighbourhood with a low own-group proportion increases the risk of psychosis, is one explanatory factor. The density effect in the ethno-religious and sectarian context of Northern Ireland has been found to be reversed, particularly for Catholics, in which there is harmful effect of high own-group density areas. This is partly explained by high urbanicity, deprivation and unemployment, but is otherwise not well understood.

AIMS

This study aimed to examine the density effect at the level of symptomology (positive and negative psychosis symptoms and depressive symptoms) in a representative sample of people with a first episode of psychosis in Northern Ireland.

METHOD

Data linkage methodology was used drawing on data from the Northern Ireland First Episode Psychosis Study (NIFEPS) and the 2001 Census of Northern Ireland.

RESULTS

In total, 223 people between the ages of 18 to 64 were included in the study. A significant density effect was found for Catholics for total psychosis scores, but not for positive, negative and depressive symptoms, nor for general psychopathology, after adjusting for individual and area characteristics. The model accounted for just over 12% of the variance. No effect was found for Protestants.

CONCLUSION

The findings suggest that the density effect for Catholics is unrelated to the core features of psychosis (hallucinations, delusions and anhedonia) but rather to broader cognitive and emotional disturbances and area deprivation. Explanations of exposure to social adversity and inequality are proposed, with implications for public mental health and social policy.

Disseminating evidence-based research on mental health and coping to adolescents facing adversity in Lebanon: a pilot of a psychoeducational comic book 'Somoud'

Background

Despite advances in the evidence base and scaling up of mental health and psychosocial interventions for children and adolescents affected by conflict and adversity, a theory-practice gap remains, with limited translation of research findings to affected communities.

Methods

In order to disseminate findings from a review on mental health and coping for children and adolescents, a psychoeducational comic book ‘Somoud’ was developed and piloted with adolescents and their caregivers in Lebanon, using a qualitative Grounded Theory approach.

Results

In total, 10 participants (5 adolescents, 5 parents), took part in the study. Using Thematic Content Analysis, 6 themes were identified; 1) psychoeducation versus misinterpretation, 2) balancing depth with accessibility, 3) aesthetic appeal, 4) contextual relevance and realism, 5) daily stressors, and 6) parental and social relationships.

Conclusions

The findings demonstrate the importance of cultural and contextual piloting of psychoeducational content, and the potential usefulness and accessibility of a comic book format to disseminate information to adolescents. Data from the pilot was used to inform the development of a new version of ‘Somoud’ for sharing with adolescents in Lebanon. Further research is required to establish the effectiveness of the psychoeducational book as a ‘self-help’ tool, and to further improve knowledge exchange between researchers and communities.

Unmet need for mental health medication within the migrant population of Northern Ireland: a record linkage study

BACKGROUND

Migrant populations are particularly at risk of not receiving the care for mental ill-health that they require for a range of reasons, including language and other barriers to health service access. This record linkage study compares, for migrant and settled communities, the likelihood that a person in Northern Ireland with poor mental health will receive psychotropic medication.

METHODS

A cohort of 78 267 people aged 16-64 years (including 1736 migrants) who reported chronic poor mental health in the 2011 Census records was followed for 15 months by linkage to a centralised prescribing data set to determine the rates of pharmacological treatment. Logistic regression analyses quantified the relationship between psychotropic medication uptake and migrant status, while accounting for relevant demographic and socioeconomic factors.

RESULTS

Overall, 67% of the migrants with chronic poor mental health received at least one psychotropic medication during the study period, compared to 86% for the settled population; this equates to an OR of 0.32 (95% CI 0.29 to 0.36) in the fully adjusted models. Adjustment for English proficiency did not significantly alter these models. There was also considerable variation between individual migrant groups.

CONCLUSION

Although this study suggests substantial unmet need for treatment of poor mental health among the migrant population of Northern Ireland, further qualitative studies are required to better understand how different migrant groups respond to mental ill-health.

First-generation migrants' use of psychotropic medication in Northern Ireland: a record linkage study

PURPOSE

There is a recent and growing migrant population in Northern Ireland. However, rigorous research is absent regarding access to mental health care by different migrant groups. In order to address this knowledge gap, this study aimed to identify the relative use of psychotropic medication between the largest first generation migrant groups in Northern Ireland and the majority population.

METHODS

Census (2011) data was linked to psychotropic prescriptions for the entire enumerated population of Northern Ireland using data linkage methodology through the Administrative Data Research Centre Northern Ireland (ADRC-NI).

RESULTS

Lower prescription dispensation for all psychotropic medication types, particularly antidepressants (OR = 0.35, CI 95% 0.33-0.36) and anxiolytics (OR = 0.42, CI 95% 0.40-0.44), was observed for all migrant groups with the exception of migrants from Germany.

CONCLUSIONS

It is likely that the results reflect poorer access to services and indicate a need to improve access and the match between resources, services and the health and social care needs of migrants. Further research is required to identify barriers to accessing primary care and mental health services.

Antidepressant medication use among working age first-generation migrants resident in Finland: an administrative data linkage study

BACKGROUND

A higher risk of common mental health disorders has been found for first-generation migrants in high income countries, but few studies have examined the use of mental health care. This study aimed to identify the level of antidepressant use amongst the largest first generation migrant groups resident in Finland.

METHODS

This cohort study used record-based data linkage methodology to examine the hazard of antidepressant use between migrant groups in Finland using Cox proportional hazard models. Data was derived using socio-demographic and prescription data from Statistics Finland and the Finnish Population Registry. The cohort included a random sample of 33% of the working age population in 2007 (N = 1,059,426, 49.8% women, 2.5% migrants) and dispensed antidepressant prescriptions from 2008 to 2014.

RESULTS

After adjustment for socio-demographic characteristics, results show higher antidepressant use for female migrants from North Africa and the Middle East compared to the Finland-born majority, a similar level of use for migrants from Western countries, and lower use for migrants from other non-Western countries.

CONCLUSIONS

The gender and country of origin dependent use of antidepressant medication is discussed in terms of socio-political and cultural between-group differences. Recommendations are made to address inequalities in accessing services, particularly for migrants from non-Western countries.

Antipsychotic medication use among working-age first-generation migrants resident in Finland: An administrative data linkage study

Aims: Higher incidence of psychotic disorders in high-income countries for migrants compared with the settled majority has been well established. However, it is less clear to what extent different migrants groups have accessed and utilised mental health care. This study aimed to identify the hazard of antipsychotic medication use in the largest migrant groups in Finland, compared with a Finnish-born comparison group, using high quality datasets maintained by Statistics Finland and Social Insurance Institution Finland, and linking socio-demographic and -economic characteristics to antipsychotic prescription purchases. Methods: The study draws on a representative sample of 33% of the adult working-age population of Finland in 2005 ( n = 1,059,426, 50.2% male, 2.5% migrant). The use of antipsychotic drugs was followed-up from 2005 to 2014. Results: The results show that the hazard of antipsychotic medication purchases differed between migrant groups, with a higher hazard for migrants from North Africa and the Middle East before socio-economic adjustment (men HR 1.19, 95% CI 1.04–1.37; women HR 1.37, 95% CI 1.12–1.66), and a lower hazard for all migrant groups after adjustment for socio-economic characteristics compared with the Finland-born population. Conclusions: The findings suggest that attention should be paid to the lower use of medication for psychotic disorders in some migrant groups, as well as the potential role of social disadvantage for migrants from North Africa and Middle East.

The Mental Health of Migrants in Northern Ireland

BackgroundResearch has shown that the health of migrants can vary dramatically from the health of the settled population of their countries. Whilst migrant health has been studied in other areas of the UK, it is especially important to research the mental health of migrants in Northern Ireland specifically, due to the country’s unique mental health situation. ObjectivesThis study aims to assess the mental health of migrants in Northern Ireland as compared to the settled majority population, both by way of reported poor mental health, and psychotropic prescription medication uptake. MethodsThis study uses a cohort of 1,019,769 people in Northern Ireland, taken from the 2011 Census of Northern Ireland and the BSO Enhanced Prescribing Dataset (2011-2014). The migrant population of Northern Ireland is described in terms of demographic and socioeconomic factors, and logistic regression models are used to analyse the relative risks of reporting poor mental health and uptake of psychotropic medication within the migrant population as compared to the settled population. FindingsThe results show that migrants were significantly less likely to report poor mental health than the settled population of Northern Ireland, when adjusted for demographic characteristics, socioeconomic factors, and reported poor physical health. Migrants were also significantly less likely to use any form of psychotropic prescription medication than the settled population. ConclusionsThese findings are in concordance with most research conducted in other countries. The roles of the healthy migrant effect, the salmon bias, stigma, and lack of access to healthcare are discussed as possible reasons for the percieved migrant mental health advantage. However, such a dramatic difference between the health of migrants and the settled population of Northern Ireland may be due, in part, to certain limitations of the datasets used.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The mental health and wellbeing of first generation migrants: a systematic-narrative review of reviews

BACKGROUND

First generation migrants are reportedly at higher risk of mental ill-health compared to the settled population. This paper systematically reviews and synthesizes all reviews on the mental health of first generation migrants in order to appraise the risk factors for, and explain differences in, the mental health of this population.

METHODS

Scientific databases were searched for systematic reviews (inception-November 2015) which provided quantitative data on the mental ill-health of first generation migrants and associated risk factors. Two reviewers screened titles, abstracts and full text papers for their suitability against pre-specified criteria, methodological quality was assessed.

RESULTS

One thousand eight hundred twenty articles were identified, eight met inclusion criteria, which were all moderate or low quality. Depression was mostly higher in first generation migrants in general, and in refugees/asylum seekers when analysed separately. However, for both groups there was wide variation in prevalence rates, from 5 to 44 % compared with prevalence rates of 8-12 % in the general population. Post-Traumatic Stress Disorder prevalence was higher for both first generation migrants in general and for refugees/asylum seekers compared with the settled majority. Post-Traumatic Stress Disorder prevalence in first generation migrants in general and refugees/ asylum seekers ranged from 9 to 36 % compared with reported prevalence rates of 1-2 % in the general population. Few studies presented anxiety prevalence rates in first generation migrants and there was wide variation in those that did. Prevalence ranged from 4 to 40 % compared with reported prevalence of 5 % in the general population. Two reviews assessed the psychotic disorder risk, reporting this was two to three times more likely in adult first generation migrants. However, one review on the risk of schizophrenia in refugees reported similar prevalence rates (2 %) to estimates of prevalence among the settled majority (3 %). Risk factors for mental ill-health included low Gross National Product in the host country, downward social mobility, country of origin, and host country.

CONCLUSION

First generation migrants may be at increased risk of mental illness and public health policy must account for this and influencing factors. High quality research in the area is urgently needed as is the use of culturally specific validated measurement tools for assessing migrant mental health.