|Year : 2017 | Volume
| Issue : 4 | Page : 352-358
Functions of a group-based parenting program for parents of children with mental health issues-some observations from a tertiary care center
N Janardhana, Divya Ravindran
Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka, India
|Date of Web Publication||17-Nov-2017|
Department of Psychiatric Social Work, NIMHANS, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Child and adolescent mental health issues have a wide prevalence and cause serious burden and stress to the psychosocial health of parents and caregivers. Psychosocial interventions have proved to be useful adjuncts to pharmacological treatment in childhood psychiatric conditions because of their long standing nature and psychosocial implications. The present paper aims to identify and enlist the benefits of one such group-based parenting program practiced in a mental health services inpatient setting. The paper borrows from the experiences and observations of a psychiatric social worker who has considerable experience in conducting such group sessions. The material recorded here helps in understanding that parents and caregivers perceive benefits of significant magnitude from regular group session inputs, which help them to deal with the mental health issues of their children, and which also turn out to be a source of support.
Keywords: Group intervention, group function, parenting
|How to cite this article:|
Janardhana N, Ravindran D. Functions of a group-based parenting program for parents of children with mental health issues-some observations from a tertiary care center. Indian J Soc Psychiatry 2017;33:352-8
|How to cite this URL:|
Janardhana N, Ravindran D. Functions of a group-based parenting program for parents of children with mental health issues-some observations from a tertiary care center. Indian J Soc Psychiatry [serial online] 2017 [cited 2021 Jan 21];33:352-8. Available from: https://www.indjsp.org/text.asp?2017/33/4/352/218594
| Introduction|| |
Child and adolescent mental health issues have a high prevalence in the form of internalizing (emotional) and externalizing (behavioral) problems and/or developmental disorders, which most often have their implications into adulthood, and psychosocial implications in the form of occupational, financial, and relationship difficulties.,, Mental health disorders in children may create a significant burden on the public health, resources, and manpower of low and middle income countries such as India who have higher proportion of children and adolescent population, in some countries reaching up to 50%.,
Families play a critical role in their children's development and learning. 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. The responsiveness of parents to their children and the manner in which parents talk with and teach their children are important determinants of children's later wellbeing and development., Group-based parenting programs are viewed as one of the most cost-effective methods to empower parents with better mental health and skills as future therapeutic agents for their children, as well as to improve the behavioral and emotional outcomes of treatment.,
Parenting programs are typically focused, short-term interventions aimed at helping parents improve their relationship with their child and preventing or treating a range of problems including emotional and behavioral problems. Parenting programs are based on the premise that interventions that promote caring, consistent, and positive parenting are central to creating safe and supportive environments for children. Research has documented that the risk of child maltreatment is heightened when parents lack necessary child-rearing skills, social supports, and knowledge of child development. Thus, parenting programs are often designed to increase parental knowledge of child development, assist parents in developing parenting skills, and normalize the challenges and difficulties inherent in parenting.
Effective parenting in itself is a skill, where parental psychosocial functioning, well-being, and mental health determine to a significant extent the quality of parent–child interaction and “later psychological health of the child.” Research evidence suggests that “parenting plays an important role in helping children to be well adjusted” and parenting programs are effective in improving the behavioral and emotional adjustment of children as well as parental psychosocial health.,,,,
A number of recent systematic reviews, published by the Cochrane Database of Systematic Reviews, suggest that group parenting programs are moderately effective in the short term in improving maternal psychosocial health  and the emotional and behavioral adjustment of infants and toddlers  and older children. There is also evidence to suggest that they are effective in improving outcomes for both teenage mothers and their children.
Parenting programs may differ in their form of delivery (individual, group, or family systems), settings, focus or objectives, and the theoretical approaches underpinning them (behavioral, cognitive behavioral, etc.). Group-based parenting programs are considered one of the most cost-effective and beneficial methods of delivering knowledge, skills, and competence to parents and may use various strategies such as discussions, role plays, group activities, and audiovisual aids for the same.,
| Materials and Methods|| |
The current paper aims at enlisting and deliberating upon the benefits, as reported from participatory observation and experience, of conducting group-based psychosocial intervention programs for parents or caregivers of children and adolescents treated in an inpatient care setting. These benefits of group-based parent programs as per observations and parent reports are translated as functions served by group work as a method of service and treatment delivery in child and adolescent psychiatry.
The following material reported on the functions of group intervention for parents with children with mental health issues is drawn from the authors' experience, participant observation, and beneficiary feedback of conducting group-based parent intervention programs for a period of more than 3 years. The parent group work mentioned here is 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, Bangalore, Karnataka, India. Outpatient and inpatient services are provided by well-established multidisciplinary team consisting of consultants from the departments of Child and Adolescent Psychiatry, Clinical Psychology, and Psychiatric Social Work. Children along with their parents are admitted in the ward for providing treatment and psychosocial interventions for the children and their families. While they are admitted in the hospital these groups are conducted biweekly for a duration of 45 minutes to 1 hour in the inpatient ward for children and adolescents. The target group is the parents or caregivers of these children and adolescents (below 16 years of age) who were admitted in the inpatient ward for treatment, and their average stay in the ward would be 3 weeks.
The group is heterogeneous in nature in terms of 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 is multimodal in approach, although relies heavily on psychoeducation, supportive interactions, and behavioral strategies to manage mental health issues in children and adolescents. All the children are assigned to individual therapist for understanding the child and provide intervention; psychoeducation also would be provided in addition to group interaction. The group work is conducted as an adjunct intervention to other need-based psychosocial and pharmacological interventions carried out as part of treatment and care. The reports are recorded by the psychiatric social worker and psychiatric trainees biweekly. The reports were analyzed for a period of 18 months from May 2013 to October 2014. The voices of the group members were elicited to determine the functions of the group interventions. The same has been presented as functions of group interventions. The group members were encouraged to participate in the discussions and share their experiences of providing care for their child with behavioral and developmental disorders, and group members were able to give tips for the parents by sharing their experiences and acted as therapeutic and messages were well received by parents.
Functions of the parent group intervention program
The group because of its inherent participatory nature, focus, and facilitative process, serves the following functions in delivering child and adolescent mental health services:
Therapeutic alliance, being an intervention which is not merely solution focused, the current group intervention examined therapeutic alliance as one of the foundations on which work for handling the challenges of psychologically-impaired offspring was built. The group functions on the foundation of a positive therapeutic relationship were built and maintained between the parents and the group worker. The latter being one of a constant participant and facilitator is enabled to develop a good rapport, confidence, and trust among the target population. Through information dissemination, facilitation of focused discussions, and sharing, the group worker builds an environment which helps parents or caregiver to develop trust, favorable attitude, and engage better in their wards' treatment process.
The group interventions would be successful when it elicits engagement from the members during the group discussions and take responsibilities for their growth. Sustainability of knowledge is known to be achieved through participatory methodologies. The group worker, being more of a facilitator, leads the group by the principles of “guided group interaction” and “progressive program experiences” through the process by which parents or caregivers realize the potential and imperative role they play in the treatment outcomes of their children. This realization of healthy engagement in the recovery or development process of their children evokes most of the times an inclination and motivation in the parents or caregivers to engage or contribute effectively in the treatment.
Because the group consists of members dealing with similar kinds of issues relating to their children, it facilitates the parents or caregivers to empathize with and learn from each other's experiences. The group worker, through guided interactions, facilitates expression of experiences, emotions, doubts, concerns, hopes, and plans for the future from the participants, which provides them a potential venue of deriving emotional and psychological support, as well as an opportunity of relief through ventilation. The group also helps members to realize the necessity, identify, and enhance the social support around them for better stress management.
The group intervention focuses significantly on provision of need-based and appropriate information on childhood psychiatric disorders and management to the family members, which in turn would bring about favorable behavioral and attitudinal changes for the benefit of the child. Group psychoeducation becomes one of the most cost-effective methods for information dissemination, redressal of myths and misconceptions, clarification of doubts, allaying fears or concerns, and empowering parents with the requisite tools for informed decisions and rightful implementation of management techniques.
The group-based intervention focuses, through sessions, on shaping behavioral changes in parents through various behavioral principles and concepts of appropriate reinforcements, effective communication skills, consistent disciplining, etc. Parents are taught the rationale and use of various behavioral strategies such as shaping, modelling, ignoring, quality time, contingency management, limit setting, differential and reinforcers, as well as the application of principles through various audiovisual presentations, video vignettes, and discussions, which boost their confidence and understanding in implementation. Enhancing the parents' competence in behavioral and cognitive behavioral strategies also aids in greater self-reliance, independence from the treating professionals, and bringing down “doctor shopping” in search of solutions.
When parents develop competence at behavioral management and better understanding in the psychosocial management of various childhood psychological conditions, they are empowered as effective agents of change and become more self-reliant in facilitating the process of improvement or recovery. Thus, these parental outcomes help in contributing to the manpower for care of functionally disabled children and adolescents, helping a great deal to reduce the burden on mental health personnel.
| Discussion|| |
The abovementioned deliberations emphasize the use and development of group-based parent interventions as a cost-effective method to enhance the knowledge, attitude, and practices of the population, whom the children and adolescents are greatly dependent on. Groups become an effective platform to facilitate learning through observation, listening, and participation. It also functions as a network of considerable support and cohesion for parents or caregivers who experience similar problems. Hence, it also becomes essential that research and practice are sharpened to aid in the growth and development of this effective methodology into an evidence-based, standardized practice.
Therapeutic alliance has been found to be a major contributory factor to the effectiveness of psychosocial interventions., Friedlander et al., in their model of therapeutic alliance focused family therapy, mentioned four core dimensions that facilitate positive changes, viz., (1) engagement in the therapeutic process, (2) emotional connection to the therapist and other group members, (3) safety within the therapeutic system, and (4) shared sense of purpose within the group. Levy-Frank et al., in their experimental study, found that the participants of a therapeutic alliance focused intervention group (TAFI) significantly more frequently mentioned themes describing changes relating to illness than those of a psychoeducation intervention group.
Eliciting engagement is one of the functions of the group; group members become actively involved in discussions and learn from each other and become support for each other. This process results in mutual resource enhancement. The parents reported having better knowledge and skills in understanding mental health problems of their children and felt equipped to respond to the needs of children. Similar benefits have been reported by Barlow et al. and Berling  in their systematic review of eight randomized controlled trials 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. Barlow et al., in their review of 48 studies, found that group-based parenting programs 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.
Group interventions have been proven to be an effective tool for psychoeducation. Similar views been expressed by McFarlane  in his multifamily group model, advocating for providing knowledgeable support to the family members of severely mentally ill, as well as aiding them in treatment and rehabilitation. Levy-Frank et al. who also compared the efficacy of a therapeutic alliance focused individual intervention and family psychoeducation intervention in group format found that participants of the latter reported that “implementation and information provided contributed to change.”
Parents were able to understand better when the behavioral modification techniques were demonstrated through role plays. Patterson  in a study reported that parents were able to realize the importance of modifying behavioral problems in 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 parenting involvement and poor supervision are associated with increased risk of conduct symptoms, positive parenting (involving positive expressed emotions) has been shown to be significantly associated with high child self-esteem and social and academic competence., Hence, it is suggested that the interventions which would equip the parents or caregivers with the requisite knowledge and skills to bring about favorable attitudinal changes can go a long way in helping them to adopt behavioral strategies to manage the difficult behaviors and emotions of children and adolescents.
The parents attending group intervention programs reported to have empowered with information, and equipped with better skills in dealing with their children. Group-based parenting programs typically involve the “use of a manualized and standardized programme or curriculum and are aimed at increasing the knowledge, skills and understanding of parents.” Through theoretical underpinnings, like that of social learning, operant conditioning and a range of behavioral and cognitive behavioral strategies, the group becomes a venue for parents to learn through listening, observation, discussions, and clarifications. This in turn helps to develop better competence and engagement in their training to be future cotherapists or trainers for their children.
Group interventions created a platform for parents to vent their feelings and learn from the experiences of others. Middleman and Wood  in their book on “Skills for Direct Practice in Social Work” have proposed four conditions for group work. The group facilitator should focus attention on helping the group members become a system of mutual aid; must understand the role of the group process itself as the primary force responsible for individual and collective change; seek to enhance group autonomy; help the group members experience their groupness.,
Implications for research
Though there are studies that allude to the effectiveness of group-based parenting programs, they are not methodologically or outcome-wise sufficient to comment on the extent to which groups are effective over long periods of time and in eliciting specific benefits, as per the approach followed or any particular outcome measure such as psychosocial well-being or parenting practice. Hence, large scale trials covering larger population size, longer follow-up periods, specific outcome measures, multiple target groups, and respondent self-reports on benefits as well as relying on both qualitative and quantitative methodologies would help a great deal in building database and evidence for the role of group-based psychosocial interventions in the primary, secondary, or tertiary prevention of mental health disorders among children and adolescents, as well as promotion of mental health and competence among the persons involved in caregiving or treatment.
Implications for practice
Evidence base for various approaches (theoretically or strategically) which could be adopted for knowledge, behavior, and attitude outcomes could aid in devising and development of standardized curriculums or manuals to be implemented in group-based psychosocial interventions for parents or caregivers of children and adolescents with mental health issues. The programs need to be conducted long-term with periodical monitoring and evaluation for studying long-term benefits as well as for sustainable results. Customizing the modules to language, culture, and needs of the target group, would help in incorporating the element of sensitivity into a people-based psychosocial intervention such as group work. Similar groups can be tried in outpatient departments for the families coming for follow-up. The group interactions can be planned before they meet the consultant. The group meeting needs to be structured, open group, and more psychoeducation approach would benefit the parents. Parents of different age groups and different economic background would be better group composition, such that cross learning and the experiences can be different and creates a platform for them to learn.
The observations presented here are solely based upon the experiences of the group worker and informal discussions with the group participants. The next step could be devising an instrument and assessing the benefits of group-based parenting programs, as perceived by participants. The group work mentioned here has its own limitations as it functions within a nonstatic inpatient setting where members enter and exit the group with no fixed number of sessions attended. 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. Moreover, the group addresses 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 qualitatively describe the perceived benefits of a group-based parenting intervention than translating the outcomes into quantitative data. The benefits of such group interactions was not tested; in order to be long lasting, similar booster groups meetings are required either at the outpatient or inpatient setting.
| Conclusion|| |
Effective and healthy parenting in itself being a challenging task warrants greater competence, patience, and skills in the face of childhood psychological difficulties. Parents need to be sensitized and helped a great deal through knowledge and adaptive parenting practices during the phase of what is nothing short of a crisis for them for dealing with mental illness or disability. Group-based parenting interventions become one of the most cost beneficial, effective, and experientially rich methods of delivering the requisite knowledge and skills to the long-term caregivers of challenged children and adolescents with special needs. Hence, mental health professions and personnel also need to enhance their tools, methods, and expertise in working with groups and group dynamics for far reaching, faster, and better treatment outcomes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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