Transcript Health and Youth Matter

“When A Parent Is Depressed –
How Can We Help?”
Presentation by
William R. Beardslee, MD
Department of Psychiatry
Boston Children’s Hospital and Harvard
Medical School
“The child is the bearer of whatever the future
shall be … At this center … his incomparable tenderness
to experience, his malleability, the almost unimaginable
nakedness and defenselessness of this wondrous
five-windowed nerve and core.”
James Agee,
“Let Us Now Praise Famous Men”
“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”
“If you always do what you’ve
always done, you’ll always get
what you’ve always got.”
~ Albert Einstein
Health care reform must challenge
existing paradigms and develop new
paradigms.
Envisioning the Future
 What should a heath care system look like
that fully meets the needs of families ,
incorporates prevention and treatment, and
reflects cultural competence and cultural
humility?
IOM 2009
5
Outline
1. Overview
2. Prevention of mental illness
3. Parental depression
4. Resilience
5. Preventive interventions – Family Talk
6. Recent work
6
Prevention of Mental Illness

Family-centered care

Prevention of mental illness and problem
behavior

Population level impact
Implementation and dissemination

Chronology of International Collaboration
I – The Beginning
2000
World Mental Health Association and the Carter Center – first combined
meeting on mental health prevention. Many countries already have
program components underway. Ongoing work of COPMI in Australia.
2001-Present
Effective Family Programme in Finland, Dr. Tytti Solantaus.
2002
WMHA (London) – International group focus on children of the mentally
ill formed including Australian representatives.
.
Chronology of International Collaboration
II
2002-Onward
Numerous programs for children of the mentally ill in Holland, Sweden,
Norway, Finland, Denmark, and other countries.
Numerous conferences and meetings within countries, at the Nordic
Forum, and in other places internationally.
2009
Second bi-annual meeting of international COPMI organization –
Adelaide, Australia. Development of extensive collaborations between
Drs. Beardslee and Solantaus, Australian COPMI and Australian
psychiatrists on interventions. Australian COPMI release of key training
website materials.
.
Chronology of International Collaboration
III – 2012 to 2014
2012
Vancouver, British Columbia. Third bi-annual COPMI meeting
2014
Fourth biannual meeting of the COPMI group, Berkeley, California.
Conference in Malmo, Sweden.
Preventive Opportunities
Early in Life



Early onset (¾ of adult disorders had onset by
age 24; ½ by age 14)
First symptoms occur 2-4 years prior to
diagnosable disorder
Common risk factors for multiple problems and
disorders
11
Mental Health Promotion
Aims to:


Enhance individuals’
– ability to achieve developmentally
appropriate tasks (developmental
competence)
– positive sense of self-esteem, mastery,
well-being, and social inclusion
Strengthen their ability to cope with adversity
12
Preventive Intervention
Opportunities
13
A Central Theme

“The scientific foundation has been created
for the nation to begin to create a society in
which young people arrive at adulthood with
the skills, interests, assets, and health habits
needed to live healthy, happy, and productive
lives in caring relationships with others.”
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-V diagnosis.
A series of recent meta-analyses
demonstrate that in both adults and
children, a significant number of
episodes of major depression
can be prevented.
Preventive Interventions
Promising preventive intervention strategies exist. They
include, for the most part:
• Treating the parents
• Providing help with parenting
• Using a two-generational approach
Some also directly involve children.
Depression Prevention
Examples: IOM Report
1. Family Talk - Beardslee, et al., 2009
2. Prevention of depression - Garber, et al.,
2009 –moderated by acute parental
depression
3. Parent/Child Coping Session - Compas
and colleagues
4. Mothers’ and babies’ program - Munoz
IOM 2009
18
Emerging Findings from the
POD Study
We demonstrated in a sample of over 310
youth significant prevention of episodes of
major depression using a cognitive behavioral
group intervention at 9 months, 33 months,
and, most recently, at 60 months.
Across both reports and in a variety of
different risk situations, very strong
evidence exists for the value
of parenting programs.
20
How do we see resilience in individuals?
How do we see resilience in families?
Characteristics of Resilience in
Civil Rights Workers




Capacity for anger and continuous working
Capacity to have a vision for the future and also
to work actively in the present
Deep commitment to human relationships
Self- and shared understanding
Family Talk 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 – Countrywide programs in
Finland and at least five other places; Project FOCUS with
the Navy; Family Connections
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
Resilience in Parents

Commitment to parenting

Openness to self-reflection

Commitment to family connections
and growth of shared understanding
Core Elements of the Intervention
1.
Assessment of all family members
2.
Presentation of psychoeducational material (e.g., affective
disorder, child risk, and child resilience)
3.
Linkage of psychoeducational material to the family’s life
experience
4.
Decreasing feelings of guilt and blame in the children
5.
Helping the children develop relationships (inside and outside
the family) to facilitate independent functioning in school and in
activities outside the home
Seven Modules
1. Taking a history
2. Psychoeducation and the family’s
3.
4.
5.
6.
7.
story
Seeing the children
Planning the family meeting
Holding the family meeting
One week follow-up, check-in
Long-term follow-up
Six Principles for a Successful
Family Meeting
1.
Pay attention to the timing of the meeting.
2.
Gain commitment to the process from the entire
family.
3.
Begin by identifying specific major concerns and
addressing them.
4.
Bring together and reknit the family history.
5.
Plan to talk more than once.
6.
Draw on all the available resources to get through
depression.
Narrative Project for Families
Who Sustained Changes – SelfReflection Over Time
1. The emergence of the healer within
2. The need to understand depression
anew across development
•
Children’s growth
•
Vicissitudes of parental illness
Different Implementations of the
Family Talk Approach
1.
2.
3.
4.
5.
6.
Randomized trial pilot – Dorchester for single
parent families of color
Out of the Darkened Room – a book for families
about how to overcome parental depression
Development of a program for Latino families
Large scale approaches – collaborations in
Finland, Holland, and Australia
Head Start – Program for parental adversity /
depression
Blackfeet Nation – Head Start – Family
Connections
Different Implementations of the
Family Talk Approach
(continued)
6.
Costa Rica
7.
Collaboration with other investigators in new
preventive interventions – Project Focus;
Chicago city-wide training; family-strengthening
intervention in Rwanda; web-based training –
FamPod.org
8.
International collaborations – COPMI
9.
Urban Institute Project – policy interventions for
depression among young poor mothers
Latino Team
Latino Adaptation

Familismo

Allocentric orientation

Kinds of separation in immigrant families


Differing involvement of parents and children in
the mainstream culture
Immigration narrative
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”
FAMpod Home Page
http://fampod.org
FAMpod Collaborations
Primary Care Implications
 Screening and referral are useful when
available referral sources have been
identified.
 Attention to the system in which primary
care occurs and its ability to deal effectively
with depressed parents are as important as
any particular intervention.
 A primary care physician is in the best
position to provide family-centered
preventive care for depression and to
facilitate treatment.
Clinical Implications
 Working with parents who are depressed
as parents first is essential.
 Elicit the parents’ concerns both about
himself/herself and about the children.
 Brief parenting interventions and referral
of children for evaluation are also helpful.
 Follow-up is essential.
Importance of Narrative
 Attention to the family narrative and what
has been disrupted is important in helping
the family get back on track in reestablishing rituals and having regular
conversations.
Key Ongoing Themes
from IOM Work
 Major depression can be prevented
 How to ameliorate the effects of poverty
 Encouragement of nurturing environments
 How to incorporate family prevention
perspectives under the ACA
43
IOM Forum on Promoting
Children’s Cognitive, Affective
and Behavioral Health
A focus on implementation and dissemination
of health promotion and prevention strategies.
The first forum dealt with effective
parenting interventions.
Co-chairs:
Dr. C. Hendricks Brown
Dr. William R. Beardslee
44
http://www.iom.edu/Reports/2014/Strategies-for-Scaling
-Effective-Family-Focused-Preventive-Interventions.aspx
Core Principles Across Projects

Self-understanding and shared
understanding

Individual and shared narratives.

Self care and shared support

Long-term commitment to long-term
partnerships - several years at a minimum

Shared values
In all these projects, families have become
our partners and our guides. We are deeply
grateful to them and thank them for their
extraordinary courage in confronting adversity
and for their willingness to help us
co-construct these interventions.
Thank You …

For more information, please contact:
[email protected]

Materials for Head Start parents and teachers about resilience
and depression available at
www.childrenshospital.org/familyconnections

Web-based training in Family Talk and other resources available
at www.fampod.org

Perry DF, Miranda J, Ammerman RT, and Beardslee WR.
Depression in mothers: More Than the Blues – A Toolkit for
Family Service Providers. 2014, Washington, DC. Substance
Abuse and Mental Health Services Administration. [On-line]
http://store.samhsa.gov/product/SMA14-4878
References
1.
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, 2002. First paperback edition, 2003.
2.
Beardslee WR. Commitment and Endurance: Common
themes in the life histories of civil rights workers who stayed.
Am J Orthopsychiatry, 1983, 53(1), 34-42.
References (continued)
3.
Beardslee WR, Ayoub C, Avery MW, Watts CI, and O’Carroll KL.
Family Connections: An approach for strengthening early care
systems in facing depression and adversity. Am J Orthopsychiatry.
2010, 80(4), 482-95.
4.
Beardslee WR, Brent DA, Weersing VR, Clarke GN, Porta G, Hollon
SD, Gladstone TRG, Gallop R, Lynch FL, Iyengar S, DeBar L, and
Garber J. Prevention of depression in at-risk adolescents: Longerterm effects. JAMA Psychiatry, 2013, 70(11), 1161-1170. doi:
10.1001/jamapsychiatry.2013.295. Available on-line in PubMed
PMCID: PMC 3978119.
References (continued)
5.
Beardslee WR, Solantaus TS, Morgan BS, Gladstone TR, and
Kowalenko NM. Preventive interventions for children of parents with
depression: International perspectives. MJA, 2012, Open 1 Suppl 1,
23-27.
6.
Beardslee WR, Gladstone TRG, and O’Connor E. Transmission and
prevention of mood disorders among children of affectively ill
parents: A review. JAACAP, 2011, 50, 1098-1109. {On-line]
www.jaacap.org.
7.
Beardslee WR, Lester P, Klosinski L, Saltzman W, Woodward K,
Nash W, Mogil C, Koffman R, and Leskin G. Family-centered
preventive intervention for military families: Implications for
implementation science. Prev Sci, 2011. DOI: 10.1007/s11121-0110234-S. [On-line] Open source publication:
http://www.springerlink.com/content/8265h1k18u4x77nr/fulltext.pdf
References (continued)
8.
Biglan A, Flay BR, Embry DD, and Sandler IN. The critical role
of nurturing environments for promoting human well-being. Am
Psychol. 2012. 257-271.
9.
Cuijpers P, Beckman ATF and Reynolds III C. Preventing
Depression: A Global Priority. JAMA, 2012, 1033-1034.
10.
Cuijpers P, von Straten A, Smit F, Miahlopoulos C, and
Beckman A. Preventing the onset of depressive disorders: a
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Psychiatry, 2008, 165(10), 1271-80.
11.
D’Angelo EJ, Llerena-Quinn R, Shapiro R, Colon F, Gallagher
K, and Beardslee WR. Adaptation of the preventive intervention
program for depression for use with Latino families. Fam
Process, 2009, 48(2), 269-291.
References (continued)
12.
Garber J, Clarke GN, Weersing VR, Beardslee WR, Brent DA,
Gladstone TRG, DeBar LL, Lynch FL, D’Angelo E, Hollon SD,
Shamseddeen W, and Iyengar S. Prevention of depression in at-risk
adolescents: A randomized controlled trial. JAMA, 2009, 301(21),
2215-2224. [On-line]
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2737625.
13.
Golden O, Hawkins A, and Beardslee WR. Home visiting and
maternal depression: Seizing the opportunities to help mothers and
young children. Urban Institute. 2011.
14.
Howell E, Golden O, and Beardslee W. Emerging opportunities for
addressing maternal depression under Medicaid. Urban Institute.
2013 [On-line] http://www.urban.org.
References (continued)
15.
Merry SN, Herrick SE, Cox GR, Brudevole-Iversen T, Bir JJ,
McDowell H. Psychological and educational interventions for
preventing depression in children and adolescents. Cochrane
Database of Systematic Reviews 2011, Issue 12. Art. No.:
CD003380. DOI: 10.1002/14651858.CD003380.pub3.
16.
Munoz RF, Beardslee WR, and Leykin Y. Major depression can be
prevented. Am Psychol. 2012. 67(4). 285-295.
17.
Podorefsky DL, McDonald-Dowdell M, & Beardslee WR.
Adaptation of preventive interventions for a low-income, culturally
diverse community. JAACAP, 2001, 40:8: 879-886.
References (continued)
18.
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. Mary Ellen
O’Connell, Thomas Boat, and Kenneth E. Warner, Editors. Board on
Children, Youth, and Families, Division of Behavioral and Social
Sciences and Education. Washington, DC: The National Academies
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http://www.nap.edu/catalog.php?record_id=12480.
19.
National Research Council and Institute of Medicine. Depression in
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identification, treatment, and prevention efforts. Washington, DC:
The National Academies Press. 2009. [On line]
http://www.nap.edu/catalog.php?record_id=12565.
References (continued)
20.
Perrino T, Beardslee W, Bernal G, Brincks A, Cruden G, Howe G,
Murry V, Pantin H, Prado G, Sandler I, and Hendricks Brown C.
Towards scientific equity for the prevention of depression and
internalizing symptoms in vulnerable youth. Prev Sci. 10/2014; DOI:
10.1007/s11121-014-0518-7.
21.
Perry DF, Miranda J, Ammerman RT, and Beardslee WR.
Depression in Mothers: More Than the Blues—A Toolkit for Family
Service Providers. 2014, Washington, DC: Substance Abuse and
Mental Health Services Administration. [On-line]
http://store.samhsa.gov/product/SMA14-4878.
22.
Yoshikawa H, Aber JL, and Beardslee WR. The effects of poverty on
the mental, emotional and behavioral health of children and youth:
Implications for prevention. Am Psychol. 67(4).2012, 272-284.