Parental-Group Interventions for Parents of Children with Mental Health Problems Admitted in a Tertiary Care Center: An Experience from India.

BACKGROUND: Families play a critical role in their children's development and learning. Parents' understanding of their child's illness has a significant impact on the parent-child relationship and helps them to have realistic expectations.
OBJECTIVES: The objective of this study is to understand the use of parental-group intervention for making parents understand the problems of the children and to develop skills to deal with the problems.
METHODS: A six-session parental-group intervention module was developed and tested. Data from the group session were collected for 6 months and have been analyzed.
RESULTS: Majority of the parents appreciated the intervention program as it led to skill-building and understanding of the mental health problems among children. Demonstration was liked most of the parents (74) parenting skills and stress management (71 parents); 68 parents liked session on school-related issues; 60 parents liked session on developmental disorders; 54 parents liked session on emotional and behavioral problems.
CONCLUSION: Group-based parenting programs are found to be effective in improving the overall psychosocial health of parents and the emotional and behavioral problems of children and adolescents as a result of better parenting. Copyright:

INTRODUCTION

Child and adolescent mental health issues have a high prevalence in the form of internalizing (emotional) and externalizing (behavioral) problems and developmental disorders[1] which most often have their implications into adulthood[2] and psychosocial implications in the form of occupational, financial, and relationship difficulties.[3] Mental health disorders in children create a significant burden on public health, resources, and workforce of low- and middle-income countries.[14]

A large body of research provides strong evidence that parents and the home environment are the most influential forces in shaping children's early learning.[56] Parents' understanding of their child's illness has a significant impact on the parent–child relationship, helps them to have realistic expectations from their child, which, in turn, helps the child to regain psychological health.[7] Group work with parents can be in the form of parenting training which can be accommodated as part of the inpatient care[8] Parenting programs are described as “focused short term interventions aimed at helping parents to improve their relationship with their child, preventing or treating a range of emotional and behavioral problems.”[910]

The researchers note that the involvement of parents in the treatment improves the behavioral and emotional problems of children.[11] Group-based parenting programs are seen as one of the most cost-effective methods to empower parents with better mental health and learning skills.[1112] A number of recent systematic reviews, published by the Cochrane Database of Systematic Reviews, suggest that group parenting programs are moderately effective in improving maternal psychosocial health and the emotional and behavioral adjustment of infants and toddlers and older children.[211]

Group interventions for parenting programs usually are based on one or more theoretical approaches, generally involve the use of a manualized and standardized curriculum and a range of techniques such as discussion, role play, watching the video of case vignettes, with the ultimate aim of improving the knowledge, skills, and parenting practices of parents.[213] Group-based parenting programs have shown to generate a range of benefits from improving the psychosocial health of parents and to reduce the emotional and behavioral problems of children.[211]

Keeping in mind, the dearth of Indian literature on the effectiveness of group-based psychosocial intervention for parents and the lack of availability of standard modules of parent interventions in group settings, the aim of the study was to document the feasibility of indigenous group interventions addressing the psychoeducational needs of Indian Parents having Children with Mental Health Problems.

METHODS

The current study adopted a descriptive research design. 25–30 new admissions occur during every month; families would stay for 15–20 days for in-patient care. The sample consists of parents hailing from urban and rural areas who took in-patient care for their ward. During 6 months period, 105 parents who volunteered were recruited for the study to test the feasibility of the group intervention program. It was only 85 parents who participated in all six sessions; some parents withdrew from the program as their wards got discharged and some were not comfortable in the group format. As parental-group intervention was provided as part of the in-patient care program, it was encouraged for all parents to participate; nearly 80% of the parents receiving in-patient care for their wards participated in the group intervention program. The parental-group intervention is a more structured format that was provided for the parents while they were taking in-patient treatment for their ward. Parents of children with mental health problems (CHMP) (below the age of 16 years) who volunteered were included for the group session. The parent-group intervention is delivered as part of the treatment program for in-patients in the child and adolescent psychiatry unit of NIMHANS, Bengaluru. These group interventions were conducted twice a week on a regular basis. Each session lasted for 90 min. The 6-month report from July 2013 to December 2013 was analyzed for the current paper.

The groups were heterogeneous in nature, parents speaking Hindi and South Indian languages, and children with all types of mental health problems were included, and the group was open in terms of the number of participants who join or leave the group in each session, depending on the varying period of admission. Parents speaking languages other than Hindi and South Indian language were not included as we did not have translators to translate during the sessions. One hundred and five parents participated in the study, 85 parents completed the full program, some discontinued as their wards got discharged, and some withdrew as they were not comfortable with the group format.

The group intervention was structured into six session format as given in Table 1.[7] These six sessions were organized to address the parents of CMHP. The group facilitation followed a multimodal approach and aimed at improving the knowledge, attitude, and skills of parents or caregivers through psychoeducation, behavior modification, and stress management. Family members attending all the six sessions were asked to answer a few questions for example which session they liked most? What was their learning's? Whether the advice/instructions given during the session were useful? The participants were asked to rate usefulness, satisfaction on a 10-point scale, 0 indicating the session as not at all useful/not satisfied and 10 as very useful/satisfied. Suggestions were asked to improve the session further. Frequency distribution was used for presenting data.

Table 1

Parental-group intervention module

Session number	Topic	Approach/model	Content
1	Child and adolescent mental health issues and general principles of management	Psycho-education	Normal development, broad categories and subtypes of disorders, manifestations, course, treatment, role of parents
2	Childhood developmental disorders and management	Psycho-education Supportive Behavioral modification (social learning, operant conditioning)	Types, symptoms, targets, home-based training, supportive services
3	Emotional and behavioral problems in children and adolescents and management	Psycho-education Problem solving Behavioral management Supportive	Disorders, manifestations, behavioral techniques, day structuring and reinforcements, parent-child interaction, quality time
4	School related issues	Problem solving	Understanding problems at school, causes, types of school and curriculum, learning disability versus mental retardation, classroom management of problem behaviors, parents as advocates
5	Parenting skills and stress management	Supportive	Healthy communication patterns, effective child rearing practices, relaxation, social support, adaptive strategies
6	Demonstration - video vignettes, role plays	Social learning	Watching video vignettes or participating in simulation exercises related to behavioral modification exercises with children, speech therapy, play therapy, etc.

RESULTS

A total of 105 parents enrolled for the group interventions, of which 85 parents completed all the six session and expressed their opinion. Both fathers and mothers participated in the group intervention. The children are spread across all age groups; however, boys seem to have received the in-patient services substantially more than girls (69.5% compared to 30.5%) [Table 2].

Table 2

Socio demographic details of the participants in the parental group intervention prorgamme

Group sessions
Variable	Frequency (%)
Total number of group intervention programs	6
Number of parents attended
Fathers	41 (39.1)
Mothers	61 (58.1)
Others	3 (2.8)
Age of children
1-4	15 (14.2)
5-8	23 (22)
9-12	33 (31.4)
13-16	34 (32.3)
Sex of children
Boys	73 (69.5)
Girls	32 (30.4)
Nature of primary psychiatric condition
Internalizing	30 (28.5)
Externalizing	29 (27.6)
Developmental disorder	27 (25.7)
Severe mental illness	19 (18.0)

The diagnoses of the child were divided into four broad categories; developmental disorders such as autism spectrum disorder, intellectual disability, speech delay (25.7%) followed by externalizing disorders such as attention-deficit/hyperactivity disorder, conduct symptoms (27.6%), internalizing disorders such as anxiety, dissociation, depressive symptoms (28.5%), and severe mental illnesses such as schizophrenia, bipolar affective disorder, and psychosis (18%) and more prevalent in the higher age group of 13–16.

The parents attending the program reported that they liked the sixth session on demonstration (74) through role play, as they were able to demonstrate their learning's and their participation made their learning effective. This was followed by parenting skills and stress management (71). Around 68 parents have reported that they liked session on school-related issues; 60 parents said that they liked session on developmental disorders; 54 parents reported that they liked session on emotional and behavioral problems among children; 48 parents liked session on the principles of management and child and adolescent mental health [Table 3].

Table 3

Usefulness of parental-group intervention program

Particulars	Frequency
Session they like most
Child and adolescent mental health issues and general principles of management	48
Childhood developmental disorders and management	60
Emotional and behavioral problems in children and adolescents and management	54
School-related issues	68
Parenting skills and stress management	71
Demonstration - video vignettes, role plays	74
Learning - understood about
Stress reduced - meeting other parents with children having mental health problems	85
Greater learning from other parents	62
Disciplining children	82
Being consistency while parenting	74
Importance of teaching children with developmental problems	60
Quality time for children	83
Learning difficulties in children	74
Dealing with parenting burden	53
Realistic expectations with the children	47
Role of schools	49
Remedial education and its importance	68
Whether the advice/instructions given were useful?
Yes	77
Not that useful	8
Mean score on usefulness	7.43
Suggestions for improvement
More sessions on alternative days/every day	52
More demonstrative sessions	76
More discussion	46
Using audio video materials while discussion	40
Generic topics like child-rearing/parenting styles/reinforcement etc., need to be given importance	68
Parents’ overall satisfaction about the group interventions on a scale of 0-10
Mean score	7.84
Parents’ satisfaction on the materials used for discussion (power point) on a scale of 0-10	6.83

All 85 parents have informed that they learned about stress reduction strategies and expressed happiness that they were able to meet other parents (65) with similar mental health issues so that they learn from each other. Eighty-two parents learned about disciplining children, using positive regards, and negative reinforcement as a mode of changing behaviors. Seventy-four parents learned about being consistent in parenting, realized about inconsistency in parenting as the root cause for the behavioral problems. Eighty-three parents understood the importance of quality time, 74 parents understood about learning problems, simplifying the learning, need for remedial education (68 parents). Fifty-three parents have learned the need for dealing with their burden, how to share their burden with the family members. Forty-seven parents understood that they need to have realistic expectations. Forty-nine parents realized the importance of schools in promoting mental health, and they felt important to interact with teachers. The mean score of the usefulness of the session was 7.43 and 77 parents liked the sessions which was scored as more than 5 on the scale.

Parents provided few suggestions to improve group intervention, 52 parents felt that the sessions need to be planned either on alternative days or every day so that all six sessions can be completed in a week. Seventy-six parents liked demonstration, wanted demonstration in every session. Forty-six parents felt more discussion should be encouraged in smaller and same language groups; 40 parents felt that more audio/video materials to be used. Sixty-eight parents suggest to include more generic topics such as child-rearing, parenting styles, and different methods of reinforcements.

DISCUSSION

Groups become a platform to facilitate learning through observation, listening, and participation and functions as a network of support and cohesion for parents.[14] Hence, it also becomes essential that research and practice are evidence based. The parental education program was designed carefully according to parents' needs and interests. Similar views have been shared by Barlow et al., and Kendrick et al., and Oncu et al.,[21516] in the research.

The caregivers benefit from generic knowledge enhancement in child and adolescent mental health to more specific issues of illness and management rather than keeping it unstructured. Barlow et al.[211] Kendrick et al.;[15] Hoard and Shepard[17] also in their research study conclude that structured group intervention program would be more effective in imparting knowledge and skills for parents to deal with their children.

In a systematic review on the effectiveness of group-based parenting programs for the improvement of emotional and behavioral adjustment in children[171118] have found that group-based parenting programs equip parents to deal with the emotional and behavioral problems. Hoard and Shepperd[17] have defined parent education as a systematic education given to parents by experts to contribute to their children's development; the same was adopted for the current study. Through effective parental training programs, parents can be able to learn how to behave with their children, how to manage problem situations, how to respond, and how to communicate with their children appropriately.[1119]

The therapeutic alliance has been found to be a major contributory factor to the effectiveness of psychosocial interventions.[19] Friedlander et al.[20] in their model of therapeutic alliance focused family therapy mention four core dimensions that facilitate positive changes, namely, “(1) engagement in the therapeutic process, (2) emotional connection to the therapist and other group members, and (3) safety within the therapeutic system, and (4) shared sense of purpose within the group.” The same was observed in the current study, wherein parents actively involved in the discussion, group facilitation were open and learning from each other and their involvement in the group demonstrated their commitment. In the experimental study conducted by Levy-Frank et al.[21] found that the participants of a therapeutic alliance focused intervention group frequently mentioned themes describing changes relating to illness than those of a psychoeducation intervention group.

Eliciting engagement is one of the essential requirements for any group interventions, 85 parents engaged in the group work intervention program and gave their feedback after the end of six sessions, and group members actively involved in the discussions and learned from each other and became support for each other, which resulted in mutual resource enhancement for the parents. Navaneetham and Ravindran, Janardhana and Ravindran in their studies[78] have also found that groups have a good platform to ventilate their feelings, would learn from each other, group members would act as a supportive mechanism. Parents reported having better knowledge and skills in understanding mental health problems in their children and felt equipped to respond to the needs of children. Similar benefits have reported by Barlow et al.[211] Bunting[22] Salveron et al.[23] in their systematic review, evaluating the effectiveness of brief group-based parenting programs and found that intervention groups showed significantly better outcomes in improving the emotional and behavioral adjustment of children, produced short term significant improvement in the parental psychosocial well-being, where “stress” and “confidence” showed statistically significant improvement even at 6-month follow-up.

In the present study, parents reported that they learned skills in managing the behaviors in children, and they look forward for more such role-plays so that they gain skills in handling situation. Similar findings have been reported by Furlong et al.[2] in their scientific review of randomized control trials and quasi-randomized control trials of group parenting programs for reducing or dealing with the improving behavior problems in children aged 3–12 years, state that group parenting programs “have the potential to help parents develop parenting skills that improve the behavior of their young children” in the short term, and also aid in improving parental mental health. Group-based parenting programs have provided sufficient evidence in improving psychosocial health in parents, parent-child interaction, and parent responsiveness.[11] They provide the opportunity for parents or caregivers to obtain sound understanding, emotional ventilation, supportive interactions, participatory learning, and experiential sharing which cumulatively facilitate the process of behavioral and attitudinal modification, hence benefiting the treatment process in turn.

Parents were able to understand better when the Behavioral Modification techniques were demonstrated through the role plays.[7811] Patterson et al.[24] in their study found that parents were able to realize the importance of modifying behavioral problems in the children. Parenting and family interaction variables have been found to explain 30%–40% of child antisocial behavior. “When inconsistent and harsh parenting practices with little positive parental involvement and poor supervision are associated with increased risk of conduct symptoms, positive parenting (involving positive expressed emotions) has been shown to significantly associated with high child self-esteem and social and academic competence” as said by Kumpfer and Alvarado.[25]

Through the evolution of more adaptive parenting styles, parent–child interaction processes and skill acquisitions in training and behavioral management, parents become efficient trainers or co-therapists for their wards, hence improving the treatment outcomes. Group work with parents becomes a medium to reduce the emphasis from biological model and pharmacological lines of treatment to a more holistic approach where external environmental factors and psychosocial modes of management are also appreciated and given adequate importance.

Limitations

The findings presented here are solely based on the few open-ended questions. The next step could be devising a scale/instrument and assessing the benefits of group-based parenting programs as perceived by the participants. The group being multilingual, considerable time is spent in translation into respective languages so that each participant gains a fair understanding of the ongoing discussions. Furthermore, the group addresses the diverse range of childhood and adolescent mental health issues, hence to be sensitive to the needs of each parent or caregiver, the group follows flexibility in discussions and themes rather than rigidly adhering to a structure. Hence, the attempt was made through this article to describe the perceived benefits of a group-based parenting intervention than translating the outcomes into quantitative data. The benefits of such group interactions were not tested, to be long lasting.

CONCLUSION

Researchers and practitioners have found parental-group interventions be an effective medium of improvements in the mental health problems of their children. Large-scale studies, documentation of results and experiences, program evaluations, standardization of culture-sensitive intervention modules, the amalgamation of qualitative and quantitative research methodologies, and indigenous literature development could go a long way in the creation of evidence base and strengthening of group-based psychosocial interventions in the field of child and adolescent mental health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.