“when a parent is depressed – how can we help?” presentation by william r. beardslee, md...
TRANSCRIPT
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“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
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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 unimaginable
nakedness 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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“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.
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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
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Outline
1. Overview
2. Prevention of mental illness
3. Parental depression
4. Resilience
5. Preventive interventions – Family Talk
6. Recent work
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Prevention of Mental Illness
Family-centered care
Prevention of mental illness and problem behavior
Population level impact Implementation and dissemination
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Chronology of International Collaboration I – The Beginning
2000World 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-PresentEffective Family Programme in Finland, Dr. Tytti Solantaus.
2002WMHA (London) – International group focus on children of the mentally ill formed including Australian representatives.
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Chronology of International Collaboration II
2002-OnwardNumerous 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.
2009Second 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.
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Chronology of International Collaboration III – 2012 to 2014
2012Vancouver, British Columbia. Third bi-annual COPMI meeting
2014Fourth biannual meeting of the COPMI group, Berkeley, California.
Conference in Malmo, Sweden.
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Preventive OpportunitiesEarly 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
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Mental Health PromotionAims 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
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Preventive Intervention Opportunities
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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.”
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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-V diagnosis.
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A series of recent meta-analyses demonstrate that in both adults and
children, a significant number of episodes of major depression
can be prevented.
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Preventive InterventionsPromising 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.
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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
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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.
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Across both reports and in a variety of different risk situations, very strong
evidence exists for the valueof parenting programs.
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How do we see resilience in individuals?
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How do we see resilience in families?
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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
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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
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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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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
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Seven Modules
1. Taking a history2. Psychoeducation and the family’s
story3. Seeing the children4. Planning the family meeting5. Holding the family meeting6. One week follow-up, check-in7. Long-term follow-up
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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.
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Narrative Project for FamiliesWho Sustained Changes – Self-Reflection
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
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Different Implementations of the Family Talk Approach
1. Randomized trial pilot – Dorchester for single parent families of color
2. Out of the Darkened Room – a book for families about how to overcome parental depression
3. Development of a program for Latino families
4. Large scale approaches – collaborations in Finland, Holland, and Australia
5. Head Start – Program for parental adversity / depression
6. Blackfeet Nation – Head Start – Family Connections
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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
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Latino Team
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Latino Adaptation Familismo
Allocentric orientation
Kinds of separation in immigrant families
Differing involvement of parents and children in the mainstream culture
Immigration narrative
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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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FAMpod Home Page
http://fampod.org
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FAMpod Collaborations
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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.
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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.
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Importance of Narrative
Attention to the family narrative and what has been disrupted is important in helping the family get back on track in re-establishing rituals and having regular conversations.
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Key Ongoing Themesfrom 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
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IOM Forum on Promoting Children’s Cognitive, Affective
and Behavioral Health
A focus on implementation and disseminationof health promotion and prevention strategies.
The first forum dealt with effectiveparenting interventions.
Co-chairs:
Dr. C. Hendricks BrownDr. William R. Beardslee
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http://www.iom.edu/Reports/2014/Strategies-for-Scaling-Effective-Family-Focused-Preventive-Interventions.aspx
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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
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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 usco-construct these interventions.
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Thank You … For more information, please contact:
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
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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.
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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: Longer-term effects. JAMA Psychiatry, 2013, 70(11), 1161-1170. doi: 10.1001/jamapsychiatry.2013.295. Available on-line in PubMed PMCID: PMC 3978119.
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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/s11121-011-0234-S. [On-line] Open source publication: http://www.springerlink.com/content/8265h1k18u4x77nr/fulltext.pdf
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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 meta-analytic review of psychological interventions. Am J 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.
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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.
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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.
18.
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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 Press. 2009. [On line] http://www.nap.edu/catalog.php?record_id=12480.
19. National Research Council and Institute of Medicine. Depression in parents, parenting and children: Opportunities to improve identification, treatment, and prevention efforts. Washington, DC: The National Academies Press. 2009. [On line] http://www.nap.edu/catalog.php?record_id=12565.
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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.