Hope, Meaning and Continuity: The Development of Interventions and Partnerships with Families Facing

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Hope, Meaning and Continuity The Development of
Interventions and Partnerships with Families
Facing Depression Vancouver, British Columbia
May 2009
William R. Beardslee, MD Department of
Psychiatry Childrens Hospital Boston Harvard
Medical School
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Children are ...

• the embodiment of a familys hope for the future
• central to a familys narratives

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Engage Parents

• Understand the context and culture of the
  parents life
• Align resources to support parenting
• Obtain treatment for parents when possible
• Consider extra engagement for depressed parents
• Focus on hope
• Engage parents in existing programs
• Address context and risk factors for parental
  depression
• Develop partnerships

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The child is the bearer of whatever the
futureshall be At this center his
incomparable tendernessto experience, his
malleability, the almost unimaginablenakedness
and defenselessness of this wondrousfive-windowed
nerve and core.

• James Agee, Let Us Now Praise Famous Men

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The pediatrician can regard the family as
carrying the chromosomes that perpetuate the
culture and also form the cornerstone of
emotional development.Beardslee Richmond.
Mental Health of the Young An Overview
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Prevention

• Prevention requires a paradigm shift
• Mental health and physical health are inseparable
• Both health promotion and prevention need to be
  considered together
• Prevention requires long term shared
  responsibility for the future of children

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Recent Developments in Prevention Science

• Advances in developmental neuroscience
  genetics, neuro-imaging
• Developmental plasticity
• Profound influence of the environment on genes

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Key Areas for Preventive Intervention I New IOM
Prevention Report

• Early childhood interventions daycare, nurse
  home visiting
• Interventions to support parenting
• Social skills training
• Coordinated interventions in communities
• - substance abuse
• - smoking

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Key Areas for Preventive Intervention II

• Social skills training
• Interventions for family distress parental
  depression, bereavement, divorce
• Classroom based interventions

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Comparison to 1994

• Greater emphasis on dissemination and
  implementation
• Greater attention to systems as well as to
  individual intervention
• Greater number and quality of trials
  demonstrating positive outcomes

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The Child and Multiple Influences
6 5 4 3 2 1
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The Child and Multiple Influences Key to
Diagram

• 1 Child
• 2 Parents - Primary Caregivers
• 3 Schools, Day Care - Child-Centered
  Institutions
• 4 Health Care Systems - Care For Parental
  Depression
• 5 Sociopolitical System i.e., Unemployment,
  Stigma
• 6 Culture - Resources and/or Religious and
  Ethnic Attitudes Toward Mental Illness

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Depression Is . . .

• a family calamity, often profoundly
  misunderstood.
• a rearrangement of neurotransmitter function.
• a chronic smoldering illness.
• often the result of social injustice and
  adversity.
• a DSM-IV diagnosis.

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Risks for Depression

• General (Risks for many disorders)
• Exposure to trauma
• Poverty
• Social isolation
• Job loss
• Unemployment
• Family breakup
• Loss of community
• Dislocation / immigration
• Historical trauma

• Specific
• Extensive family history of depression,
  especially parents
• Prior history of depression
• Depressogenic cognitive style
• Bereavement

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Four Stories - Four Journeys In Making Sense of
Loss and Trauma

• The individual story and journey
• The family story and journey
• The caregiver story and journey
• The community/culture/faith journey

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Characteristics of Resilient Youth

• Activities - Intense Involvement in Age
  Appropriate Developmental Challenges - in School,
  Work, Community, Religion, and Culture
• Relationships - Deep Commitment to Interpersonal
  Relationships - Family, Peers, and Adults Outside
  the Family
• Self-Understanding - Self-Reflection and
  Understanding in Action

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Resilience in Parents

• Commitment to parenting
• Openness to self-reflection
• Commitment to family connections and growth of
  shared understanding

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Component Studies

• 1979 - 1985 Risk Assessment - Children of
  Parents with Mood Disorders
• 1983 - 1987 Resiliency Studies and Intervention
  Development
• 1989 - 1991 Pilot Comparison of Public Health
  Interventions
• 1991 - 2000 Randomized Trial Comparing
  Psychoeducational Family Interventions for
  Depression
• 1997 - 1999 Family CORE in Dorchester
• 1998 Narrative Reconstruction
• 2000 Efficacy to Effectiveness

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Seven Different Implementations of Family
Depression Approach

• Randomized trial pilot Dorchester for single
  parent families of color
• Development of a program for Latino families
• Large scale country wide implementation Finland
• Head Start Program for parental adversity /
  depression
• Blackfeet Nation Head Start
• Costa Rica
• Collaboration with other investigators in new
  preventive interventions

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Criteria for Intervention Development

• Compatible with a range of theoretical
  orientations and to be used by a wide range of
  health care practitioners
• Strong cognitive orientation
• Inclusion of a family as a whole
• Integration of the different experiences of a
  family, that is, parents and child(ren)
• Developmental perspective

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Core Elements of the Intervention

• Assessment of all family members
• Presentation of psychoeducational material (e.g.,
  affective disorder, child risk, and child
  resilience)
• Linkage of psychoeducational material to the
  familys life experience
• Decreasing feelings of guilt and blame in the
  children
• Helping the children develop relationships
  (inside and outside the family) to facilitate
  independent functioning in school and in
  activities outside the home

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Figure 1. Average Adult Child-Related Behavior
and Attitude Changes By Group Across Time
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Preventive InterventionFirst Session Part I

• Introduction, parental history and consensus
• a. Framing the intervention
• - explanation of purpose of intervention
• - time-frame for intervention
• - focus of meeting for each session
• b. History taking
• - elicit history of illness from the identified
  patient
• - emphasis on most recent period (depending on
  nature of illness, either most recent episode or
  past year)
• - dramatic changes in nature of or reaction to
  illness are noted

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Preventive InterventionFirst Session Part II

• Introduction, parental history and consensus
• c. Identification of familys main concerns and
  defining goals for the intervention
• d. Establishment of the therapeutic alliance and
  collaborative nature of the intervention
• e. Understanding of familys experience
• f. Obtain permission to talk with treating
  therapist

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Six Principles for a Successful Family Meeting

• Pay attention to the timing of the meeting.
• Gain commitment to the process from the entire
  family.
• Begin by identifying specific major concerns and
  addressing them.
• Bring together and reknit the family history.
• Plan to talk more than once.
• Draw on all the available resources to get
  through depression.

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Narrative Project for FamiliesWho Sustained
Changes

• The emergence of the healer within
• The need to understand depression anew across
  development
• Childrens growth
• Vicissitudes of parental illness

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Making Peace and Moving On Becoming Part of the
Story Again

• Seeing the Continuity and Ones Place in It
• Becoming Part of the Story Again
• Developing the Process of Self and Family
  Understanding

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Our Research Team

• Co-Principal Investigators
• Roxana Llerena-Quinn, PhD
• Rachel Shapiro, LICSW
• William R. Beardslee, MD
• Research Associates
• Frances Colon, LICSW
• Melinda Bravo, PhD
• Ane Marinez Lora, PhD
• Principal Investigator
• Eugene DAngelo, PhD

• Consultants
• Martin LaRoche, PhD
• Ana Ortiz, PhD
• Ester Shapiro, PhD
• Andrew Richards, PhD
• Donna Podorefsky, PhD
• Tracy Gladstone, PhD
• Center for Mental Health Service
• Nancy Davis, PhD

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What helps parents cope with depression?

• Focus on the children
• Visualizations. Envisioning a better future
• Prayer, songs, religion, church community,
  spiritual healing
• Support groups
• Helping others, sharing information
• Focusing in the present viviendo de dia a dia
  (living day to day)
• Not giving up seguir la lucha
• Alternative medicine
• Humor al mal tiempo buena cara yo no lloro,
  yo me rio

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Collaborators in the Finland Project

• Maarit Alasuutari, PhD
• Paivi Aronen, MD
• Tytti Solantaus, PhD
• Sini Toikka, MSS

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Finland Systematic Implementation of
Large-Scale Program for Children of the Mentally
Ill

• Dr. Tytti Solantaus
• Use of a family of well specified interventions
  with common principle
• Support from scientific governmental and
  clinician leadership
• Commitment to place trained individual in all
  clinics
• Stage sequential process

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Finland Phase I

• Support from central Health Ministry
• Support from Finnish Academy of Science
• Public health campaigns for clinician leaders /
  administrators
• General public health campaigns

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Finland Phase II

• Training I
• Plan to train master trainers in pairs
• 15 day per year, 2 year training program
• Certification of over 20 master trainers
• Use of original manual and rewritten manual

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Finland Phase II

• Training II
• Expansion of families to include families with
  severely ill children
• Expansion to include medical illness
• Additional curricula
• child development/parenting education
• child psychiatric assessment and referral
• child protection

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Systematic Countrywide Intervention

• Finland
• Holland
• Australia
• Norway
• Nordic Form

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Head Start Family Connections Project

• Principle Investigators
• Catherine Ayoub, R.N., Ed.D.
• Caroline Watts, Ed.D.
• William R. Beardslee, M.D.
• Project Director
• Mary Watson Avery, M.S.

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Four Principles

• Teaching approach
• Plan for dissemination
• Central aim of building resources and cooperation
  with Head Start staff, especially with teachers
  and families
• Evolving partnerships

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The Family Connections Approach

• Emphasize the positive ways that all parents can
  enhance their parenting and their interactions
  with Head Start.
• Foster engagement with Head Start among depressed
  parents
• Incorporate a program for getting appropriate
  treatment
• Enhance parents childrens classroom
  interactions through consultation, teaching and
  support for Head Start staff.

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Core Elements and Key Strategies

• Core Elements in Both
• providing hope
• developing family understanding of depression
• enhancing child and family resilience
• referral for treatment as needed
• engagement with health care systems

• Key New Strategies in Family Connections
• younger age (0-5)
• Head Start center-based
• primary intervention with teachers
• focus not just on parent-child interactions but
  on
• - child to child interactions
• - teacher to child interactions
• - teacher to class interactions
• 0-5 child development knowledge base

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Family Connections Partnership

• Training support for staff
• Partnerships for referral networking
• Consultation/intervention in the classroom
• Stress support groups for parents
• Expanded home visitation consultation
• Preventive relational friendship building for
  children
• Example sessions that relate to mental health
  with an emphasis on depression

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Training Module I

• Benefits and challenges of engaging parents
• Perspective taking
• What is depression

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Reaching out to families facing adversity

• What is depression?
• How does it affect the work of Head Start?
• What can be done?
• - knowledge
• - skill
• - understanding
• - commitment

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Practical ways to build resilience in children

• Supporting child learning
• Relationships
• Imagination
• Membership in the community

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Practical ways to build resilience in families

• Understanding culture and resilience in families
• Understanding strengths in families
• Helping families name their strengths

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What is depression? And where does it come from?

• Empty
• Unemployment
• Too many demands put on you
• Home work
• Being a single parent
• Low self esteem
• Hopelessness
• Confusion
• Forgetfulness
• Left out

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How do we see resilience in families?

• Attitudes with humor
• Togetherness
• Strong family and community support
• Parents attending school
• Being alone
• Memories
• Courage
• Good communications/ability to see both sides
• Patience
• Spirituality
• Guilt and shame

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How do we see resilience in the community?

• Communications
• Entrepreneurs
• Community support of each other
• Listening
• Very strong spiritual support
• Ceremonies
• Project HOPE
• Prayer chains
• Taking it a day at a time
• Acceptance

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• Of all the forms of inequality, injustice in
  health care is the most shocking and inhumane.
• Martin Luther King, Jr.

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Recommendations / Intervention Adaptation

• Pair highly specific, measurable outcomes with
  broader vision.
• Have specific goals for positive change for
  families, for caregivers, and for systems.
• Support for staff time and space for
  reflection.
• Make advocacy a fundamental part of research and
  practice.
• Shared ownership Significant change occurs when
  families or caregivers can make the interventions
  their own.
• Look for partnerships.

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SummaryEngage Parents

• Understand the context and culture of the
  parents life
• Align resources to support parenting
• Obtain treatment for parents when possible
• Consider extra engagement for depressed parents
• Focus on hope
• Engage parents in existing programs (Head Start,
  Early Head Start, Nurse Home Visitation)
• Address context and risk factors for parental
  depression

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References

• Beardslee WR. When a parent is depressed How to
  protect your children from the effects of
  depression in the family. Originally published
  in hardcover under the title, Out of the darkened
  room When a parent is depressed Protecting
  the children and strengthening the family, by
  Little, Brown and Company, June 2002. First
  paperback edition, December 2003.
• Beardslee WR, Wright EJ, Gladstone TRG, Forbes P.
  Long-term effects from a randomized trial of two
  public health preventive interventions for
  parental depression. Journal of Family
  Psychology, 2008, 21, 703-713.

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References

• DAngelo EJ, Llerena-Quinn R, Shapiro R, Colon F,
  Gallagher K, Beardslee WR. Adaptation of the
  preventive intervention program for depression
  for use with Latino families. Family Process, In
  Press.
• Podorefsky DL, McDonald-Dowdell M, Beardslee
  WR. Adaptation of preventive interventions for a
  low-income, culturally diverse community.
  Journal of the American Academy of Child and
  Adolescent Psychiatry, August 2001, 408,
  879-886.

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References

• National Research Council and Institute of
  Medicine. Preventing Mental, Emotional, and
  Behavioral Disorders Among Young People Progress
  and Possibilities. Committee on Prevention of
  Mental Disorders and Substance Abuse Among
  Children, Youth, and Young Adults Research
  Advances and Promising Interventions. OConnell
  ME, Boat T, and. Warner KE, Editors. Board on
  Children, Youth, and Families, Division of
  Behavioral and Social Sciences and Education.
  Washington, DC The National Academies Press.
  2009. On line http//www.nap.edu/catalog.php?rec
  ord_id12480

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References

• Avery MR, Beardslee WR, Ayoub CC, and Watts CL.
  Family Connections Project at Children's Hospital
  Boston. Introduction, Readiness Guide, Training
  Modules, Short Papers. and Lessons Learned.
  Produced with the support of an Innovation and
  Improvement Project grant from the Office of Head
  Start, Administration for Children and Families,
  US Department of Health and Human Services, and
  through local partnerships with ABCD. 2008. On
  line http//eclkc.ohs.acf.hhs.gov/hslc/ecdh/Menta
  l20Health/Resources20and20Support20for20Famil
  ies/Parent20Support20and20Resources/FamilyConne
  ction.htmTrainingModules