1
SA HEALTH
South Australian Premier’s Nursing and Midwifery Scholarships 2014/2015
Reducing the impact on children whose parents have a mental illness-what can be adapted from overseas programs for use in Australia
Study Tour of Finland, Belgium & The Netherlands
Diane Becker & Tracy Semmler-Booth
17/11/2014
Report
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Contents Page
Executive Summary & Recommendations….………...………..2-5 Introduction ...6 Purpose of the Study Tour ...6-7 Background ...7-8 Objectives of the Study Tour ...8 Outcomes of the Study Tour ...8-9 Expected Benefits of the Study Tour ...9-10 Implementation in practice ...10 Dissemination of learnings in the workplace and beyond………..10 References ...11 Appendices………...12-13
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Executive Summary
This report by Diane Becker and Tracy Semmler-Booth describes the observations, key findings and recommendations learnt in September 2014, whilst undertaking an international study tour to investigate approaches and interventions in prevention, and early intervention for children of parents with a mental illness.
The study tour focussed on:
• Reviewing current interventions and treatments for children of parents with a mental illness;
• Examining treatments and interventions used in mother baby mental health units;
• Discussing policies and processes that have enabled services to roll out their family interventions nationally; and
• Training and staff development approaches were also investigated.
The authors of this report met with staff in Finland, Belgium and The Netherlands to discuss in detail some specific evidence based programs. Networks and professional links were developed with a view of undertaking further training enabling adaptation of interventions for the Australian environment. Mother baby inpatient and outpatient services were visited and outcome data reviewed.
The trip allowed us to learn about a number of beneficial interventions in a short space of time. We were able to identify some common themes that have impacted on the success of the development of family and child friendly practices throughout the 3 countries.
Tour summary
In the course of the study tour the following sites and countries were visited:
11 sites were visited across 3 countries:
Finland, Helsinki:
• Private Practice, Lappavaara Mental Health centre, Child Welfare Clinic at Vantaa Belgium:
• Gent - Sint Camillus Hospital, Centrum Moeder en Baby
• Kinderen van Ouders met Psychische Problemen/Children of parents with Psychiatric Problems, KOPP Flanders Family Platform
The Netherlands:
• Deventer – Mindfit
• Rotterdam - Erasmus UMC, Mother Baby unit
• Utrecht - Victas B, Centre for Addiction Medicine The Hague – PsyQ - Parnassia Bavo Group, Child Welfare Clinic - Centrum Jeugd and Gezin
During the course of the study tour the authors achieved the following:
• Met with 24 professionals
• Attended 2 seminar days organised for us so that we could meet staff and discuss programs
• Reviewed and discussed over 30 programs/therapies
• Had extensive discussions regarding 3 interventions
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• Had in-depth discussions about one therapy
Supports for whole of country prevention work
Legislation in Finland stipulates that when a parent has a mental illness the children’s needs for care and support need to be considered. Therefore a culture exists amongst services and staff that supports working with children and families. Good practice guidelines also state that parents must do the ‘Let’s talk about children’ intervention and that staff must be trained to provide this intervention.
All the services visited have had to overcome significant challenges to keep their services viable due to increasing economic constraints. From what we understand governments continue to support the need for this valuable intervention work in the three countries we visited.
It has been a long process for staff and patients to start understanding how mental illness symptoms may impact on children and the importance of offering a whole family service.
Services have worked together to allow this organizational change and all mental health and drug and alcohol services include a child perspective in discussion with patients.
Key findings summarised
Finland
• Public health prevention services are organised and funded by municipalities.
• The ‘Let’s Talk about the children’ intervention is used throughout the public health sector in Finland.
• Maternal and child welfare clinics have a large focus on mental health and wellbeing.
• Let’s talk is used in mental health settings, drug and alcohol dependence units, schools and prisons.
• Let’s talk is used early in treatment process
• Mental health services have worked with all other services to have organizational change and now all include a child perspective in discussion with patients.
• Outcomes: if you do let’s talk early the parent gets better quickly.
• School children 7 – 15 seen by school nurse and have school doctor checks regularly Belgium
• Chronotherapy - Light therapy is used for treatment of perinatal mood disorders
• Extensive follow up is provided by the inpatient unit once discharged from mother baby unit
• Intensive home visiting is an alternative to inpatient care
• Family mental health platform is a collaborative partnership between 8 family organisations, who provide care for families where a parent has a mental illness
• Family platform promotes the participation of family members in the different levels of policy, to improve the quality of care and to achieve family-friendly care.
The Netherlands
• Public health prevention services are organised and funded by municipalities.
• Community decides what they will budget for prevention and buy in services.
• Nation-wide approach to reduce risk for children and families where a parent has a mental illness
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• An extensive range of preventative interventions for parents and children/families exists
• Effect studies on many interventions show good parent and child outcomes
• Extensive outpatient follow up and day programs after inpatient admission to mother baby unit
• Drug and alcohol units have a child focus, do child checks, offer programs for children, offer day programs so parents can be with children before and after school
• Children of parents with a mental illness can have support up to 23 years of age
• Drug and alcohol services and mental health services work together to run groups for parents and families – 1 family 1 plan
• Most GPs have a mental health worker, this is a free service and there is a low threshold for referral
• Child Welfare Clinics use the Principle Signs of Safety, developed by Andrew Turnell (Australia)
• Chronotherapy - Light therapy is used pre and post natal from week 12
Key recommendations summarised
• Investigate evidence around light therapy for use in perinatal mood disorders, could this be useful in current practices.
• Permission has been granted from the Netherlands for us to use and teach the parent baby intervention. However, for this to occur we need to undertake further training and supervision. COPMI will allow us to do this. Therefore, it is recommended that our local health networks support us to undertake this intervention in our clinical work. Using this intervention will produce better outcomes for our families and allow us to teach the intervention to other practitioners. This report will be forwarded to our employers.
• Look at how to incorporate van Doesum’s Parent Baby Intervention for at risk postnatal families.
• Further discussion and investigation of European legislations in relation to supporting children of parents with a mental illness.
• The information on services offered to women after inpatient treatment be presented at our Mother baby inpatient team meeting.
• Advise our Child and Family Health Services (CaFHS) of the work being done overseas to incorporate a mental health and well being focus into child welfare clinics.
• Further investigate the possibility of training in some of the innovative interventions for example ‘squeak said the mouse’.
• Further discussion via Skype with Tytti Solantaus about adapting the ‘Let’s talk about the children’ intervention for use in schools through our work at COPMI.
• Increase promotion throughout health, education and welfare settings about the importance of supporting children when a parent has a mental illness.
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Introduction
Children of parents with a mental illness have a high risk of developing a mental illness during their lifetime (Beardslee 1998). The Netherlands has a nationwide approach with good outcome evidence, which helps to reduce risk for children and families. Investigating these interventions along with further training will allow for a comprehensive report to be developed that will be used for developing training packages and developing materials for use by Australian Infant, Child, Adolescent and Family Mental Health Association (AICAFMHA) and Children of Parents with a Mental Illness (COPMI) (see appendix 1). Both applicants are employed by a local health network and COPMI the national initiative that provides training and education for mental health providers.
Purpose of the Study Tour
The purpose of this study tour is to:
• Investigate the Netherlands comprehensive, evidenced-based, national prevention program which focuses on children of parents with a mental illness (COPMI).
• Develop a broad understanding of the Netherlands national prevention program and investigate the systems, policies and processes that have supported the Netherlands to roll out their family interventions nationally.
• Review the Netherlands approaches to training and workforce development that have improved the capacity of their services to respond to children and families where a parent experiences mental illness
• Meet with staff who are deliver training in the KOPP program a parent-baby intervention, for infants of mentally ill parents.
• Learn from the Netherlands programs to develop training materials to assist clinical staff.
• To establish networks and professional links with a view of undertaking training in the KOPP intervention if this program is adaptable for use in Australia.
• Review the mother-baby facilities and interventions at Belgium -Ghent Sint Camillus Hospital.
• Review the implementation of the Let’s Talk program in Finland –Helsinki, visiting sites and Tytti Solantaus author of the program.
The Netherlands’ programs have been developed with over twenty years of evidence of positive outcomes for supporting children of parents with a mental illness. This multi component program includes a wide set of interventions that addresses evidence based risk factors and protective factors with no similar program available in Australia. The interventions are for children of all age groups, parents and families.
The Finland program ‘Let's talk about the children’ developed by Tytti Solantaus’ (2010) is an intervention focusing on children and offers support to children and parents in parenting with a mental illness. The Let’s Talk intervention will be launched as a new e-learning program in 2014 – 2015 financial year by COPMI Australia.
Page 7 of 14 Our aim is to introduce a similar training program through our work at Australian Infant, Child, Adolescent and Family Mental Health Association (AICAFMHA)/COPMI Australia and at our local health networks.
AICAFMHA was established to help meet the needs of professionals and people with lived experience of parental mental illness and their children. AICAFMHA actively promotes the mental health and wellbeing of infant, children, adolescents and their families. AICAFMHA secured funding from the Australian Government in 2002 to implement the COPMI national initiative and has continued to support the initiative. COPMI has established an international reputation as a centre of excellence for promoting better mental health outcomes for children of parents with a mental illness.
Background
There is significant evidence pertaining to the risks of children of parents with a mental illness. They have higher rates of behavioural, developmental and emotional problems (Beardslee et al., 1998). The importance of family centred principles is considered to be crucial for positive outcomes for children and families.
Children who are at risk of depressive disorders should be targeted for evidenced based preventative interventions (Beardslee et al 2003). Currently in Australia, many of the international family based parenting interventions which have evidence of good outcomes are not implemented by practitioners.
Current literature shows that:
• The prevention and early intervention of mental disorders in childhood is critically important, both to improve children’s mental health, and to help prevent the onset of mental disorders in adolescence and adult life (RANZCP 2010).
• The mother-infant interaction is the key mechanism through which maternal depression affects short and long term consequences for the child (RANZCP 2010).
• Children of parents with a mental illness have a high risk of developing a mental illness during their lifetime (Beardslee et al 2003).
• Current evidence advises that intervening early in a child’s life (when parental mental illness can have the greatest impact) helps to improve child outcomes (RANZCP 2010).
• Infants of mothers with depression represent a population at high risk for intergenerational transfer of psychopathology (Van Doesum, Hosman & Riksen- Walraven 2005) risk of depression, anxiety disorder, and alcohol dependence (Weissmann et at 1997).
• Symptoms of illness and the adverse effects of medications can affect quality of attachment often resulting in insecure or disorganised attachment (Cooper & Murray 1997).
• Many studies have reported on the adverse effects that parental mental illness has on children. Infants of depressed mothers show fewer emotions, the mother may exhibit intrusive parenting, be less involved, less responsive, more hostile, and irritable (RANZCP 2010).
• Parents with psychosis can have compromised parenting caused by lack of
motivation, symptoms, lack of sleep and medication side effects (Kowalenko, Mares, Newman, Sved-Williams, Powrie & Van Doesum 2012).
• Evidence shows that the onset of many adult psychological problems originate in
Page 8 of 14 childhood as behavioural and emotional problems (Bowlby 1951).
• Prevention is likely to have its greatest impact in young children because of the considerable potential to reduce long-term, as well as short-term issues (Murray &
Cooper 1997).
• Mental disorders have been reported to have caused the highest burden of disease among children (Kowalenko et al 2012).
The evidence concludes that the best preventative interventions for preschool children include family support and parenting interventions. They have been shown to prevent the onset of emotional and behavioural issues. (Webster-Stratton, 1998; Sanders et al, 2008;
RANZCP, 2010).
Objectives of the Study Tour
Learn about the KOPP parent baby intervention and ‘Let’s Talk about the children’
intervention by spending 2 days meeting with staff at Mindfit, in Deventer, The Netherlands and 2 days meeting with staff in Helsinki.
Identify how the ‘Let’s talk about the children’ intervention was established as regular practice throughout the Finnish public mental health sector.
Expand knowledge of innovative, evidenced-based interventions used at different developmental stages for children of parents with a mental illness, during our study tour to the Netherlands, Belgium and Helsinki.
Review the Netherlands approaches, (through exploration and consultation), to training and workforce development that have improved the capacity of their services to respond to children and families where a parent experiences mental illness, during our study tour.
Identify processes and strategies which have enabled the Netherlands to roll out their family interventions nationally. This will be achieved by investigating the systems, policies and processes that have supported this initiative.
Investigate different interventions and therapies used within mother infant mental health units.
Outcomes of the Study Tour
We have learnt that Finnish legislation supports working with children of parents with a mental illness. The existence of this legislation has been instrumental in the ‘Let’s Talk about the children’ intervention being widely accepted and utilised as a prevention method.
We have expanded our knowledge of the ‘Let’s talk about the children’ intervention.
We have expanded our knowledge about innovative evidenced based preventative interventions for children of parents with a mental illness in Finland, Belgium and the Netherlands.
Page 9 of 14 We have expanded our knowledge of inpatient and outpatient interventions, therapies and services in Gent and Rotterdam. The extensive follow up offered after admission provides excellent support and ongoing therapy that has good outcomes for families. It is very comprehensive compared to what is offered in South Australia.
We have gained knowledge on training and workforce development practices as well as implementation processes (successes and difficulties encountered) used in the countries visited. Successful implementation was achieved in these countries was achieved by:
• Legislation stipulating that children whose parents have a mental illness must receive support and follow up.
• Nationwide collaboration through the Trimbos institute who also provide training, resources and research
• Municipalities are responsible for deciding preventative health measures and therefore community involvement in decision making (e.g Family Platform – Gent)
• National networks established and meet 3 times a year
We had exposure to new therapies and interventions not used within Australia at this time.
Examples include: (see appendix 2)
• KOPP Parent Baby intervention
• Children’s support groups
o ‘Squeak said the mouse’ for 4-7 year old
• Parallel Parent groups
• Family Talk
• Child Talk
• Chronotherapy
We developed strong relationships with expert practitioners and researchers which will allow us to further expand our knowledge and expertise in the areas of perinatal, child and adult mental health.
We have organised to have ongoing supervision via Skype from the Netherlands if we are successful in introducing any of the clinical interventions learnt.
Expected Benefits of the Study Tour
Our improved knowledge about evidence based interventions for families where the parent has a mental illness, the application of these interventions means that we can apply this new knowledge to our own practice.
With ongoing support and supervision we can introduce KOPP parent baby intervention firstly into our own clinical practice and then to others in the field.
Access to clinical supervision by international leaders to benefit our practice.
Scoping opportunities to investigate the possible application of training materials within SA/Australian context via AICAFMHA/COPMI.
Page 10 of 14 Increased knowledge which can be disseminated to other practitioners regarding the available evidence based interventions for children and families where a parent has a mental illness.
Improved knowledge of the practical application, training and implementation of the Netherlands interventions as a nation wide process.
Enhanced ability to write and organise training programs for ongoing workforce development. Intervention and training gaps identified.
Implementation in Practice
We will seek permission from our local health networks (LHN) (Northern Adelaide Local Health Network & Women’s & Children’s’ Health Network) to introduce the evidence based interventions in our own clinical practice by:
• Presenting findings to LHN unit managers/ hospital executive
• Providing evidence based outcome data from the services using the interventions
• Establishing how this can be achieved within current budget, workforce, time constraints and current scope of practice
We will discuss how our learning’s can benefit our COPMI work by:
• Presenting findings to management /executive board
• Showing outcome data around the implementation and training in interventions
• Establishing how this can be achieved within current budget
• Applying for grants focussing on workforce development and for providing mental health interventions
• Organising further training and supervision so we can implement interventions and plan training in the Australian environment
Dissemination of learning’s in the workplace and beyond
We presented our study tour findings at the Helen Mayo House conference on 17th November 2014.
We plan to utilize the learning’s to develop a proposal for future training options for AICAFMHA/COPMI. Funding has been sort to undertake this work. Permission has been obtained by the authors who developed these interventions.
Tracy Semmler-Booth will present her findings to the Lyell McEwin Hospital, Women and Children’s divisional executive team and ask for permission to use the new interventions in her current clinical work.
Diane Becker will present her findings at a Helen Mayo House multidisciplinary team wards round/meeting and at the Nurses meeting on 24th November 2014 and seek permission to use the new interventions in her current clinical work.
Page 11 of 14 The authors have submitted an abstract for the COPMI/FaPMI Special Edition – Advances in Mental Health and have been asked to submit an article for Interaction a midwifery education journal for February 2015.
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References
Beardslee, W. (1998). "Prevention and the clinical encounter." American Journal of Orthopsychiatry 68(4): 521-533.
Beardslee, W., T. R. G. Gladstone, et al. (2003). "A family-based approach to the prevention of depressive symptoms in children at risk:evidence of parental and child change."
Paedatrics 112(2): 119 - 131.
Bowlby, J. (1951). Maternal care and mental health. World Health Organization Monograph (Serial No. 2) pp 13.
Kowalenko N, Mares SP, Newman LK, Sved Williams A, Powrie R & van Doesum K.
(2012)Family matters: infants, toddlers and preschoolers of parents affected by mental illness.
MJA Open 1 Suppl 1: 14-17.
Murray L, Cooper PJ. (1997) “Postpartum depression and child development”. Psychol Med.;27(2):253-60.
Sanders, M.R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., & Bidwell, K.
(2008). Every Family: A population approach to reducing behavioral and emotional problems in children making the transition to school. Journal of Primary Prevention, 29, 197-222.
Solantaus T, Paavonen EJ, Toikka S, Punamäki RL. (2010) Preventive interventions in families with parental depression: children's psychosocial symptoms and prosocial behaviour. Eur Child Adolesc Psychiatry.:1-10
The Royal Australian and New Zealand College of Psychiatrists (2010). Prevention and early intervention of mental illness in infants, children and adolescents: Planning strategies for Australia and New Zealand, 2010. Melbourne, The Royal Australian and New Zealand College of Psychiatrists: Report from the Faculty of Child and Adolescent Psychiatry. Viewed online 3rd January 2014. https://www.ranzcp.org/Files/ranzcp- attachments/Resources/College_Statements/Position_Statements/ps56-pdf.aspx
Van Doesum, K. T. M., Hosman, C. M. H. and Riksen-Walrave, J.M. (2005). "A model-based intervention for depressed mothers and their infants." Infant Mental Health Journal 26(2):
157-176.
Weissmann, M.M., Warner, V., Wickramaratne, P., Moreau, D., & Olfson, M. (1997).
“Offspring of depressed parents – 10 years later. Archives of General Psychiatry, 54 (10), 932-940.
Webster-Stratton, W., & Hammond, M. (1998). Conduct problems and level of social competence in head start children: Prevalence, pervasiveness, and associated risk factors.
Clinical Child and Family Psychology Review, 1, 101-124.
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Appendix 1
COPMI outline of National programs
The COPMI (Children of Parents with a Mental Illness) is a national initiative funded by the Australian government. COPMI develops information for parents, families, children, and professionals. Information is developed with the goal of fostering better mental health outcomes for children of parents with a mental illness. COPMI develops training courses and resources for professionals to support families. Resources are developed with the assistance of persons who have a lived experience and in consultation with researchers and service providers in the field of mental health.
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Appendix 2
Let’s Talk intervention
‘Let’s Talk About Children’ (Let’s Talk) is a brief, evidence-based intervention that trains professionals to have a 2-3 structured discussions with parents who experience mental illness about parenting and their children's needs.
The aim is to make these conversations a routine part of the alliance between parents and professionals. The wellbeing and development of children is discussed and how the children understand the parent's mental illness and its possible effects.
Let’s Talk is suitable for professionals in adult mental health settings, primary health care, non-government organisations, child mental health and child and youth services.
Let’s Talk supports healthy parent-child relationships and promotes protective factors for the child’s wellbeing. There is no equivalent service available in South Australia.
KOPP Programs
KOPP Programs (Kinderen van Ouders met Psychische Problemen/ Children of Parents with Psychiatric Problems) are a range of programs established as preventative and early interventions to support children whose parents have a mental illness. There are a variety of programs running in the Netherlands including: KOPP parent baby intervention (see below), Let’s talk (see above) and Child talk. There are a variety of children’s groups for children of various ages. Squeak said the mouse is a program for 4-7 year olds. Other groups exist for ages 8-12, 12-16, 16-25, and 25+. All groups support children who have a parent with a mental illness. Groups provide: support, encourage expression of feelings, teach coping skills, help with self esteem and help children to communicate their feelings. There are also numerous parent groups that run parallel with the children’s groups that support parenting. Groups supporting children are not available in South Australia.
KOPP Parent Baby intervention
The Parent Baby intervention is an early intervention program for depressed parents and their infants. It comprises of 8-10 home visits where the parent infant interaction is videoed.
A multidisciplinary team analyse the video tape focusing on parental sensitivity to the infants needs and cooperation versus interference. The home-visitor then chooses strategies to achieve these goals and fine tunes the intervention to the parents needs. For example helping parents to expand communication behaviours, encourage partner support, cognitive restructuring, baby massage and practical support. This intervention has been introduced in the Netherlands as part of a national multi-component programme to reduce the risk of psychiatric and social problems in the children of parents with mental illness.
There is no equivalent service available in South Australia.
