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Group work intervention for the parents of children with mental health issues admitted in the Tertiary Care Center

Objectives: The objective of this study was to develop a structured curriculum for a group-based parenting program for parents/caregivers of children or adolescents treated in the inpatient child and adolescent mental health unit of a national health institute. Methods: Data from group session reports of 3 years of conducting group-based parenting programs in the same setting were analyzed and prominent themes of discussions were shortlisted before finally arriving at a six-session group parenting program module. Results: A six-session intervention module was designed by psychiatric social workers experienced in group work. The content followed combination of various theoretical approaches and methodologies ultimately aiming in improving the overall knowledge and understanding of parents or caregivers on various child and adolescent mental health issues, and enhancing their skills and competence in dealing with various emotional and behavioral problems in children. Conclusion: Group-based parenting programs are found to be effective in improving the over psychosocial health of parents and the emotional and behavioral problems of children and adolescents as a result of better parenting. Development and standardization of culture appropriate group intervention curriculums would help in the development of this cost effective method as a medium of change.


INTRODUCTION
Parental understanding of their child illness can have a significant effect on the parent-child relationship, with consequences for the later psychological health of the child. Group work with parents can be in the form of parenting training. Parenting programs are described as "focused short-term interventions aimed at helping parents improve their relationship with their child, and preventing or treating a range of emotional and behavioral problems." [1][2][3][4][5][6][7] The authors in their scientific review note that the involvement of parents in the treatment and improvement of the behavioral and emotional problems of children using behavior modification techniques began in the 1960s and it was only in the 1970s that group-based parenting programs were initiated. [4] Group interventions for parenting programs usually are based on one or more theoretical approaches, typically involve the use of a manualized and standardized curriculum and a range of techniques such as discussion, role play, watching video of case vignettes, with the ultimate aim of improving the knowledge, skills, and parenting practices of parents. [3,8] Group-based parenting programs have been shown to generate a range of benefits from improving the psychosocial health of parents to reducing the emotional and behavioral problems of children. [3,4,[9][10][11] This review shows evidence of the short-term benefits of parenting programs on depression, anxiety, stress, anger, guilt, confidence, and satisfaction with the partner relationship. The findings suggest that further input may be needed to support parents to maintain these benefits. [3,8,11,12] In the dearth of Indian literature on the effectiveness of group-based psychosocial interventions for parents or caregivers of children with mental health issues and lack of availability of standard modules of parent interventions in group settings, it was found that documentation of the process of development of one such indigenous intervention would benefit the practice and future of the psychosocial interventions in child and adolescent mental health. The current paper aims to elucidate the process of development of a structured curriculum for the group-based parenting program evolved from more unstructured and flexible group work practiced in the inpatient child and adolescent mental health services setting of a hospital.

METHODS
The components of the structured group-based parenting program were derived from the review and analysis of the group work reports of a 1-year period spanning from June 2011 to May 2012. The parent group work which became the founding platform of a more structured group work was being delivered as part of the treatment program in the inpatient treatment facility of the child and adolescent psychiatry unit of the National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India. These groups were conducted biweekly for 45 min-1 h in the inpatient ward for children and adolescents. The target group was the parents or caregivers of these children and adolescents (below 16 years of age) who are admitted in the inpatient ward for treatment.
The groups were heterogeneous in nature, in terms of the childhood mental health issues addressed and languages used, and open in terms of the number of participants who join or leave the group in each session, depending on the varying periods of admission. The group maintained a very flexible format where the themes and focus of discussions evolved mainly from the nature of disorders and needs of the participants that presented on a particular day. It mainly depended on discussions, brainstorming, reflections, information dissemination, and supportive interactions for the process. The group work was conducted as an adjunct intervention to other need-based psychosocial and pharmacological interventions carried out as a part of treatment and care.
Thirteen months group worker report was analyzed to derive at the prominent recurring themes during group-based parenting program. The themes were enlisted and further shortlisted and filtered down into a structured module of six sessions. These sessions were organized to best address the parenting needs of children with mental health difficulties. The curriculum followed a multimodal approach and aimed at improving the knowledge, attitude, and skills of parents or caregivers through psychoeducation, behavior modification techniques, personal stress management, and therapeutic alliance.

RESULTS
It can be noted from the above table that both fathers and mothers have almost equal or substantial representation in the group programs. The children also are adequately spread across all age groups; however, boys seem to have received the inpatient services substantially more than girls (70% compared to 30%) [ Table 1]. The various diagnoses they carried were divided into four broad categories, where some fell into more than one category at times due to equally important comorbid conditions. Developmental disorders such as autism spectrum disorders, mental retardation, and speech delay contributed to the major burden of psychiatric conditions (31%) followed by externalizing disorders such as attention deficit hyperactive disorder, conduct symptoms (28%), and internalizing disorders such as anxiety, dissociation, depressive symptoms (23%), and severe mental illnesses such as schizophrenia, bipolar affective disorder, and psychosis (21%). Severe mental illnesses were more prevalent in the higher age group of 13-16 [ Table 2].
The prominent recurrent themes that emerged through analysis of 1-year data of group-based parenting sessions could be enlisted as follows.
Most of the themes mentioned above evolved naturally from the needs and nature of the groups that participated in terms of the prominent diagnoses and ages of children. These themes were then discussed among eight psychiatric social work professionals who have experience in conducting these group programs for the past 10 years. The themes were sorted into six areas which are included in the six sessions. The group module given below provides information on topics for discussion, approach used in the session, and contents covered during the session. The details are given below [ Table 3].

DISCUSSION
In a systematic review on the effectiveness of group-based parenting programs for improvement of emotional and behavioral adjustment in children. [1,[3][4][5] It is noted that current evidence from controlled trials points toward the successful use of parenting programs in a secondary or tertiary preventive role; however, what would be required is the wide implementation of them in the primary prevention of mental health problems and the promotion of mental health. By 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. [10][11][12][13][14] As defined by Hoard and Shepard, [15] parent education is systematic education given to parents by experts to contribute to their children's development.
Furlong et al. [16] in their scientific review of randomized control trials and quasi-randomized control trials of group parenting programs for 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, and some outcomes associated with physically abusive parenting. [1,3,4,[10][11][12][17][18][19] Literature provides sufficient evidence that group-based psychosocial interventions in the form of parenting programs could generate effective results in the improvement of mental health issues among children and parents as well as help in skill development, favorable attitude, and promotion of overall psychosocial health. They provide 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. Janardhana and Nardev [20] and Janardhana and Parthasarathy [21] have also found that groups would be a good platform to ventilate their feelings, would learn from each other, and group members would act as supportive mechanisms while conducting group interventions for caregivers of persons with schizophrenia. Through evolution of more adaptive parenting styles, parent-child interaction processes, and skill acquisitions in training and behavioral management, parents become efficient trainers or cotherapists 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 similar views been shared by Barlow et al. (2005;2011) and Leung et al. (2003).
Most of the group-based parenting programs today follow one or other theoretical approaches (behavioral, cognitive-behavioral, etc.) and also may differ in the thrust areas such as psychoeducation, building therapeutic alliance, and bringing about behavioral modifications. Parental education program should be designed carefully according to parents' needs and interests. The topics should be discussed deeply and some methods such as introducing of case studies, role playing, and discussion or brainstorming about creative parenting should be used. The current exercise of developing a six-session curriculum was in view of inculcating the felt needs of the target group and introducing better structure into the intervention as a result of which the inputs could be systematically designed and delivered eliciting better commitment, engagement, and participation from the parents or caregivers. The caregivers could benefit from generic knowledge enhancement in child and adolescent mental health to more specific issues of illness and management rather than keeping it unstructured. Dimond and Hyde Barlow (2001;; 2016); Kendrick et al.; Hoard; and Shepard 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.
The sessions being multimodal in approach and strategies, aim at holistic impetus as far as possible targeting improvement in knowledge, skills, and competence in use of behavioral and cognitive behavioral strategies. Similar views been reported by Furlong et al. and Dimond and Hyde in their research paper on behavioral and cognitive group-based parenting programs for early-onset conduct problems and behavioral problems.
At the same time, the group workers were flexible and would be sensitive to the situational differences as the target group is open and heterogeneous in nature.
Since the content and methodologies have evolved from 1-year data and experience of conducting group parenting programs in similar population, the present curriculum aims to be sensitive to the culture and needs of the population it addresses. The module hence designed could be implemented over a period in the target group and create avenues for further experimental studies and randomized control trials to evaluate its efficacy and reliability to replicate results in similar population outside inpatient services.

Implications for practice
Systematic reviews have established that group-based parenting programs have a substantial role in improving  Kendrick et al. 2008). The findings of the various randomized controlled trials reviewed in such articles highlight group-based parenting programs as an effective and strength-based medium of knowledge, skill, and treatment delivery. Hence, it is advocated that child and adolescent mental health services imperatively enhance and standardize the practice of conduct of such groups for greater sustainability of expected treatment outcomes.
There is a need for development of standard modules or curriculum specific in approaches or target outcomes, which once established in reliability and validity through experimental studies, could aid in the training of functionaries who could carry on these parenting programs on a long-term basis. Focus on primary prevention and promotion of mental health through conduct of group work in the larger community levels and diverse cultures would help in curbing the child rearing issues and burden on parent mental health at the primary levels.

Implications for research
Most of the randomized control trials which test the efficacy of group-based parenting programs in relation to various outcome measures establish only short-term effectiveness due to the brief interventions, short duration follow-up, and lower sample size. Further longitudinal experimental designs need to prove long-term benefits and ability to replicate the results in larger populations and wait list or control groups. Various culture sensitive and focused modules or curriculum need to be standardized to improve mental health services and multidisciplinary practice.
"Large scale trials of the effectiveness of parenting programmes" (Barlow et al., 2012a) as suggested would help in exploring their role in primary prevention of child and adolescent mental health issues. Associations between various parenting styles, familial or environmental factors, and different childhood mental health issues could be explored to identify the thrust areas of parent management training.

CONCLUSION
Researchers and practitioners have found group work and group-based parent support programs to be an effective medium of improvements in childhood mental health issues and management. Large-scale studies, documentation of results and experiences, program evaluations, standardization of culture-sensitive intervention modules, amalgamation of qualitative and quantitative research methodologies, and indigenous literature development could go a long way in creation of evidence-based and strengthening of group-based psychosocial interventions in the field of child and adolescent mental health. Healthy parenting being one of the essential prerequisites to positive child mental health, involvement of parents as agents of change and support becomes essential in child and adolescent mental health services.

Financial support and sponsorship
Nil.